Updated on December 7, 2020 at 1:07 p.m. ET.
IOWA CITY, IOWA—Nick Klein knew the man wasn’t going to make it through the night. So the 31-year-old nurse at the University of Iowa ICU put on his gown, his gloves, his mask, and his face shield. He went into the patient’s room, held a phone to his ear, and tried hard not to cry while he listened to the man’s loved ones take turns saying goodbye. When they were finished, Klein put on some music, a muted melody like you might hear in an elevator. He pulled up a chair and took the man’s hand. For two hours that summer night, there were no sounds but soft piano and the gentle beep beep beep of the monitors. Klein thought about how he would feel if the person in the bed were his own father, and he squeezed his hand tighter. Around midnight, Klein watched as the man took one last, ragged breath and died.
“I still don’t know if I’ve fully processed everything that’s going on,” Klein told me the day before Thanksgiving, as we talked about what the past few weeks and months at the hospital have been like. And with COVID-19 infections skyrocketing in his state, he added, “I don’t know when I will.”
To visit Iowa right now is to travel back in time to the early days of the coronavirus pandemic in places such as New York City and Lombardy and Seattle, when the horror was fresh and the sirens never stopped. Sick people are filling up ICUs across the state. Health-care workers like Klein are being pushed to their physical and emotional limits. On the TV in my parents’ house in Burlington, hospital CEOs are begging Iowans to hunker down and please, for the love of God, wear a mask. This sense of new urgency is strange, though, because the pandemic isn’t in its early days. The virus has been raging for eight months in this country; Iowa just hasn’t been acting like it.
The story of the coronavirus in this state is one of government inaction in the name of freedom and personal responsibility. Iowa Governor Kim Reynolds has followed President Donald Trump’s lead in downplaying the virus’s seriousness. She never imposed a full stay-at-home order for the state and allowed bars and restaurants to open much earlier than in other places. She imposed a mask mandate for the first time this month—one that health-care professionals consider comically ineffectual—and has questioned the science behind wearing masks at all. Through the month of November, Iowa vacillated between 1,700 and 5,500 cases every day. Between November 23 and November 29, the state’s test-positivity rate reached 50 percent, according to data compiled by Reuters. Iowa is what happens when a government does basically nothing to stop the spread of a deadly virus.
“In a lot of ways, Iowa is serving as the control group of what not to do,” Eli Perencevich, an infectious-disease doctor at the University of Iowa Hospitals and Clinics, told me. Although cases dropped in late November—a possible result of a warm spell in Iowa—Perencevich and other public-health experts predict that the state’s lax political leadership will result in a “super peak” over the holidays, and thousands of preventable deaths in the weeks to come. “We know the storm’s coming,” Perencevich said. “You can see it on the horizon.”
Warnings from doctors like Perencevich are what prompted my visit to Iowa City, a college town in eastern Iowa that serves as a sort of liberal sanctuary in a mostly red state. The city is home to the University of Iowa, and also to its public teaching hospital, which employs 7,000 people and has more adult ICU beds than most other state hospitals. I spent two days there just before Thanksgiving, interviewing doctors and nurses outside the brick walls of the hospital in the frigid November weather, standing six feet apart in the front garden or, when it rained, near a vent shooting out warm air on the building’s south side. Through the glass windows of the lobby, I watched as nurses in face shields pushed sick people around in wheelchairs. Once, I stepped inside to thaw and was startled by how quiet it was, and how the silence belied the suffering going on just a few floors above.
The first cases of the coronavirus in Iowa were recorded here in early March, when a group of infected locals returned home from an Egyptian cruise. As cases rose, Reynolds closed schools for the rest of the school year and most businesses for about two months. But by May 15, she’d allowed gyms, bars, and restaurants in all of Iowa’s 99 counties to open up again. She did not require Iowans to wear a mask in public, ignoring requests from local public-health officials and the White House Coronavirus Task Force and arguing that the state shouldn’t make that choice for its people. “The more information that we give them, then personally they can make the decision to wear a mask or not,” Reynolds said in June. She also wouldn’t require face coverings in public schools, where she ordered that students spend at least 50 percent of their instructional time in classrooms. When Iowa City and other towns began to issue their own mask requirements, Reynolds countered that they were not enforceable, undermining their authority. (The governor’s office did not respond to multiple requests for comment for this story.)
The rest of the summer and early fall brought on a mix of business closings and reopenings in counties around the state. (Complicating the picture, a data glitch at the Iowa Department of Public Health deflated case numbers in late summer.) Infections exploded in meatpacking plants, where managers were allegedly taking bets on how many workers would get sick. After students returned to schools and universities in the early fall, Iowa had the highest rate of COVID-19 infections in the country. In October, when Iowa was in the thick of community spread, Reynolds showed up, maskless and smiling, at a campaign rally for Trump at the Des Moines airport. (Her let-them-get-sick attitude toward the pandemic hasn’t been unusual among Republican governors, though there have been exceptions, including Mike DeWine of Ohio and Larry Hogan of Maryland.)
By November, the number of new COVID-19 cases in Iowa was higher than at any other point in the pandemic, and as many as 45 Iowans were dying of the disease every 24 hours in a state of just 3 million people. Outbreaks were reported in 156 nursing homes and assisted-living facilities in Iowa, and the virus ran rampant in the state’s prisons.
Doctors have been warning for weeks that the state’s health-care system is close to its breaking point. The University of Iowa hospital reached a peak of 37 COVID-19 inpatients in April, but by Thanksgiving, it had 90. That number may not seem overwhelming until you consider that COVID-19 patients require dozens of staff and that many spend weeks or months in hospital care. To meet the demand, administrators have had to reschedule hundreds of nonessential surgeries and converted multiple wards into COVID-19 units. Doctors told me that they’re already short on ICU beds, and are having to decide which critically ill patients receive one. There are not enough specialists to oversee common life-support techniques, such as extracorporeal membrane oxygenation, or ECMO, for people with severe cases of COVID-19.
And the University of Iowa hospital is actually in a better position than many others in the state. Smaller institutions, which have fewer specialized doctors and fewer staff overall, are being overwhelmed across Iowa, and many face bankruptcy, in part because they’ve been forced to cancel elective procedures.
Worst of all, health-care workers are sapped. They are used to death. But patients don’t usually die at this pace. They don’t usually die in this way, with tubes sticking out of their throats and sucking machines clearing the mucus from their lungs. They don’t usually die all alone.
Joe English, a 37-year-old respiratory therapist, spends every day traveling between hospital units, hooking up seriously ill COVID-19 patients to ventilators or ECMO machines. When there’s nothing left to be done, English is the one who turns off those machines; he’s done so at least 50 times in the past few months. “What I’m seeing [among health-care workers] is just frustration, desperation,” English told me. “People have been acting like we’ve been fighting a war for months.”
There is a name for this feeling, says Kevin Doerschug, the director of the hospital’s medical ICU: moral distress, or the sense of loss and helplessness associated with health-care workers navigating limitations in space, treatment, and personnel. Just a few weeks ago, a man in his 30s with no medical problems arrived in Doerschug’s unit with a severe case of COVID-19. After a week on a ventilator, the man’s health had greatly improved. Nurses removed his breathing tube, and his vitals were stable. But just a few hours later, the man was dead. “Our whole team just sat down on the ground and cried,” Doerschug told me outside the hospital, his voice muffled by his mask and the sound of the heating vent. Trauma like that compounds when a hospital fills up with critically ill patients. “The sheer enormity of it—it’s just endless,” Doerschug said.
What makes all of this suffering and death exponentially more painful is the simple fact that much of it was preventable. A recent New York Times analysis clearly showed that states with the tightest COVID-19 restrictions have managed to keep cases per capita lower than states with few restrictions. Reynolds is in an admittedly complicated situation. She, like other governors, is facing enormous pressure to protect people’s livelihoods as well as their health. But a mask mandate is free. And failing to control the virus is, unsurprisingly, very bad for business. “We want to take care of people ... It shouldn’t be this hard, and that makes us mad,” Dana Jones, a nurse practitioner in Iowa City, told me. “There are people to blame, and it’s not the patients.”
When Reynolds finally announced a spate of new COVID-19 regulations on November 17, the rules limited indoor gatherings to 15 people, and required that Iowans wear masks inside public places only under a very specific set of conditions.* Four of the doctors and nurses I interviewed laughed—actually laughed—when I asked what they thought of the new regulations. The policies will do basically nothing to prevent the spread of the virus, they told me.
State lawmakers’ response to Reynolds’s handling of the pandemic breaks down along partisan lines. “She’s done a good job balancing people’s constitutional rights with a few restrictions that have been commonsense,” Representative Dave Deyoe, a Republican from central Iowa, told me, arguing that tighter restrictions in more liberal states haven’t led to lower death rates. Although this is a common argument among Iowa Republicans, it’s an unfair one. Many Northeast and West Coast states have had more total deaths because they were badly hit by the virus early in the pandemic, before strong measures were put in place. In the past seven days, Iowa’s death rate has been at least twice as high as that of New York, New Jersey, and California.
Democrats in Iowa believe that Reynolds’s inaction has always been about politics. Early on, she’d assumed an important role making sure that Trump would win Iowa in the November election, State Senator Joe Bolkcom, who represents Iowa City, told me. “She did that by making people feel comfortable” about going out to eat, going to bars, and going back to school. “She mimicked Trump’s posture” to get him elected. Ultimately, Reynolds was successful in her efforts: Trump won Iowa by 8 points. But Iowans lost much more.
Iowa’s problem is not that residents don’t want to do the right thing, or that they have some kind of unique disregard for the health of their neighbors. Instead, they looked to elected leaders they trust to tell them how to navigate this crisis, and those leaders, including Trump and Reynolds, told them they didn’t need to do much at all. (Although some residents have certainly deliberately ignored the advice of public-health experts.) “When our strategies are not consistent with CDC evidence, when we are not adhering to even the advice of the White House task force, it raises questions in people’s minds on the seriousness of the pandemic and the validity of the mitigation strategies,” Lina Tucker Reinders, the executive director of the Iowa Public Health Association, told me. “People don’t necessarily know what the right thing to do is.”
Which means that not only are health-care professionals tasked with saving sick Iowans’ lives, but it’s also fallen on them to communicate the truth about the pandemic.
Before last spring, Brian Gehlbach told me he was decidedly not a “social-media person.” Now, though, the 51-year-old critical-care physician spends hours on the weekends carefully crafting long Facebook posts about COVID-19. He writes about masks’ effectiveness in preventing the virus’s spread, attaching illustrations and graphs as evidence; he offers warnings about the precarious state of Iowa’s intensive-care units; and he patiently unpacks the concept of the tragedy of the commons. (Occasionally he throws in a photo of his cat for levity.)
Gehlbach told me about his weekend routine while we sat outside the hospital on a cold park bench, as the straps of his mask pulled down on his ears, making him look like a gray-haired elf. In his posts, which are public and in many cases widely shared, Gehlbach never mentions Trump or Reynolds by name, and he doesn’t refer to Republicans or Democrats. Framing the pandemic around partisan politics makes Iowans tune out, he says, and right now, health-care workers desperately need them to listen. “I just feel compelled to try to reach as many people as I can so that we can save lives, so they won’t have regrets, so we have beds, so that my colleagues will suffer a little bit less,” Gehlbach told me.
The crisis in Iowa’s hospitals could be improved in a matter of weeks if Iowans started wearing a mask whenever they leave the house and stopped spending time indoors with people outside their households. But doctors posting diagrams to Facebook can do only so much, Gehlbach acknowledges. Without state leadership on board, none of those changes will happen. “The endgame of uncontrolled spread is a choice between massive death and suffering and overflowing hospitals, or shutting things down,” he said. “This is the equivalent [of] choosing between death or amputation—when you could have had an earlier surgery, which would have been painful but would have prevented this scenario from developing in the first place.”
Reynolds needs to order bars closed and restaurants to move to takeout only, at least until the surge is over, public-health experts told me. Reynolds and other state leaders could frame mask wearing and self-isolation as a matter of patriotic duty. “We need to make the right thing to do the easy thing to do,” Tucker Reinders said.
An end to the pandemic is in sight: The United States is mere weeks away from being able to vaccinate health-care workers and vulnerable members of the public. It would be helpful if, when it’s time to distribute those vaccines, local hospitals were not on the verge of collapse. But right now, Iowa is on a disastrous path. Experts expect to see a spike in COVID-19 cases in the state roughly one week from now, two weeks after the Thanksgiving holiday. That spike will likely precede a surge in hospitalizations and, eventually, a wave of new deaths—maybe as many as 80 a day, Perencevich, the infectious-disease doctor, estimates. Add Christmas and New Year’s to the mix, and Iowans can expect to see nothing less than a tsunami, Perencevich says.
Every day after work, Klein, the ICU nurse, goes for a run. He laces up his sneakers and follows the trail along the river through City Park and past the disc-golf course, a three-and-a-half-mile loop around town. He runs even if he’s already bone-tired after a 12-hour shift, where he spends all day on his feet. He runs because it’s the only way he can process his emotions these days.
Klein won the DAISY Award, part of a national nursing recognition program, for his “ultimate compassion and kindness” in refusing to let his patient die alone over the summer. But since then, Klein has sat with more dying Iowans as they’ve taken their last breaths, including two the week before Thanksgiving. His biggest fear now is the coming holidays, and more nights spent silently in the ICU, holding the hands of Iowans who did not need to die this way.
*This article previously misstated Iowa's limits on indoor gatherings.