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The Nebraska Coronavirus Fairy Tale

Let me start out by saying in the clearest terms possible: WE ARE SEVERELY UNDERESTIMATING THE NUMBER OF CORONAVIRUS CASES IN NEBRASKA. Everyone knows this, especially our leaders. And yet they are choosing to base their policy decisions on a deeply flawed measure. A test we are severely restricting the use of to very specific people. This is resulting in what is likely an extreme underestimation in the number of actual coronavirus cases.

Nebraska is one of four states with the least stringent directives from state and local leaders on social distancing measures. This might seem reasonable if you look at the total reported number of cases for our state, which currently stands at 81 confirmed. Because of these seemingly low numbers, Nebraska has been cited in national news pieces as an example of a state that could FURTHER ease restrictions by Easter. I am writing today to explain why this would be a grave and deadly mistake for Nebraskans. 

Every single time mayors or the governor use only laboratory confirmed case numbers to make policy decisions, they are asking all of us to participate in theater. They want us to suspend our disbelief, ignore everything we know about the availability of testing in Nebraska, and to believe in this fairy tale that there are only 81 cases in Nebraska and only 3 in Lincoln. And this wishful, magical thinking is very tempting.  It would be so convenient for me, for all of us, to suspend our disbelief in what we know to be true about the unavailability of testing and to go about shopping at grocery stores, getting takeout, going to parks, etc. Certainly many of us have curtailed our daily lives greatly at this point, isn’t what we are doing now, today, enough? The answer is no. Until we have a dramatic increase in the number of tests available to doctors and begin testing widely in Nebraska, WE HAVE NO IDEA the extent of the spread here. It is not conservative to base social distancing directives on a flawed system of testing that we know is deeply underestimating that actual number of cases, it is dangerously RECKLESS.

Although much of my research now is on inequalities in STEM education, I was trained as a health sociologist with an emphasis in quantitative methods and certificate of specialization in policy analysis where I focused most of my course taking specifically in health policy and epidemiology. As a social scientist, we are particularly cognizant of measurement error. Basically, there is something true out in the world, and we have different tools to measure it. When we are measuring things like feelings and attitudes, as you can imagine, there is a lot of error in our estimates. Humans are not great reporters, and surveys are not the most accurate tests. Nevertheless, we are able to measure and assess models predicting really squishy things like depression, trust, implicit biases, self-esteem, etc., ad nauseam.

Everyone, including scientists, knows that no test is 100% accurate, that all tests have some error, but science can estimate error and account for it. 

Our politicians are behaving as if the coronavirus testing in Nebraska is a perfect measure of the true coronavirus prevalence in Nebraska. It is not. It is not AT ALL. In fact, in the same press conference where a city or state leader bases their policy decisions on this EXTREME undercount of cases, we have public health officials explaining that we have extreme restrictions on WHO WE TEST because we have a critical shortage in the number of tests we have available. So although the test itself is pretty accurate, when you systematically refuse to test people, then there is systematic error in the reported prevalence.  Do you have to give away your firstborn child to be tested? No, but for a lot of people it feels that way because the guidelines are that stringent. What are the guidelines? People receive priority testing if they have symptoms and are in high risk populations (healthcare worker, childcare worker, children in childcare) OR if they have history of travel or came into direct contact with person who has had a lab confirmed case.  Because of this, gobs of people are being turned away without being tested.    

I have a dear friend and former student who is VERY SICK today. She is at home. She has asthma. I am really freaking worried. She has lost her sense of taste and smell, has a high fever, a dry cough, trouble breathing, she became sick suddenly after her daughter has been experiencing the exact same symptoms. Her daughter has type I juvenile diabetes and asthma has been very sick for the last 5 days. In fact, because she was having trouble breathing, and given that her immune system is compromised to some extent, they called their doctor’s office and were recommended to go to the ER the day before yesterday (before her mom’s symptoms began).

At the ER her daughter received two swabs and was tested for influenza, but not coronavirus. The ER docs said her oxygen was good. I am not sure if they did a respiratory panel or not, but it is my understanding that even people on a ventilator must screen negative on a resp. panel before being tested for coronavirus. Why? Because there aren’t enough tests. The lack of testing materials is so dire that they are beginning to test multiple swabs at the same time to save materials. If the test with 5 swabs comes back negative, they are all cleared, if they are positive, they must test all five individually. This is smart and good and necessary given the lack of available test in Nebraska, but it is less accurate (more false negatives) and it doesn’t solve the problem that almost nobody qualifies to actually get tested in the first place.

So, back to my friend who is home quarantined and sick with her family of 5. Neither her nor her daughter have received the coronavirus test. Apparently the nurse and doc at the hospital were very apologetic because it is extremely likely that they have the virus. They are to behave as if they do. They are presumptive positive. They have not traveled or been in direct contact with anyone else confirmed to have the virus, which means they are both likely cases of community spread. But if you listen to our leaders, we only have one case of community spread in Lincoln.

So how many cases of community spread are there in Lincoln?  The truthful answer is we don’t know. Instead of reporting this, and tracking presumptive cases, our leaders are telling the public, and making public health decisions based on the faulty assumption that it is only one.   A community spread case is a case that we can’t link to travel or to another laboratory confirmed case. These are SCARY. They mean the virus is spreading freely in the community and it is not contained at all. I want the reader to take note of something:  the definition of community spread (no travel and no known contact with a lab confirmed case) is part of the criteria for being eligible for testing.  If you aren’t in a high risk group then you have to have traveled or been in contact with someone who has a confirmed test. That means our testing criteria is systematically undercounting the prevalence of community cases IN PARTICULAR. Someone presents who is not in a high risk group (see above) and they haven’t traveled and haven’t been in direct contact with anybody with a confirmed case is EXCLUDED, A PRIORI, FROM RECEIVING A TEST.  This is not just error, this is systematic error, and it is extremely dangerous for our community because we are undercounting the most alarming cases.  

So what should leaders base policy on?  First of all, with a lack of laboratory testing, we need other measures.  My first suggestion would be to do what the New York City Health Department does and track flu-like symptoms.  This would be imperfect because we still do have some flu cases (they are tapering off) but based on historic data we can get a better sense of what the true prevalence of corona virus in the community is without laboratory testing.  I would also suggest tracking presumptive positive cases. These are the cases where they have tested negative for influenza, tested negative for respiratory panel, and they have the majority of the symptoms like my friend and her daughter.  These will have error too, some of them probably have another virus and not corona virus and without testing we don’t know.  But again, we can weigh this against all the facts and make sound decisions realizing there is error in every measurement we use.   If we use mutiple measures then we can triangulate and come up with a better estimate of the true prevalence in our communities.  Relying on one systematically faulty measure is foolish. This status quo, only having the political will to act on laboratory confirmed cases, is not conservative, it is not prudent, it is theater.  We all know there are more cases out there, and we know this because PEOPLE ARE BEING DENIED TESTS. So our politicians need to cut the political theater and they need to have the moral courage to act.  Err on the side of saving lives, not saving businesses, and not your re-election chances.