Iran's second wave of coronavirus infections is showing the rest of the world the 'triple threat' it needs to avoid

• Iran has reported more than 2,000 new daily coronavirus cases for the past two weeks — a sign the country is experiencing a second wave of infections.
• Global health expert Amir Afkhami said the spike in confirmed cases is the result of three factors: an erosion of public trust, testing delays, and lockdown restrictions that were rolled back too soon.

On May 2, Iran's number of new daily coronavirus cases dipped to its lowest point since March. It seemed the nation's outbreak was contained.

But Amir Afkhami, an associate professor of global health at George Washington University, didn't think so.

"Iran will likely be a major repository and major source of the spread of the coronavirus to the region in the months to come," he said during a webinar on April 16.

Afkhami turned out to be right: For the last two weeks, Iran has reported more than 2,000 new cases each day. On June 4, the country reported around 3,600 new infections — its largest single-day total to date. Unlike its initial outbreak, which was centered in the northern cities of Tehran and Qom, the latest outbreak is concentrated in Khuzestan, a southwestern province bordering Iraq.

Afkhami told Business Insider that a "triple threat" of factors facilitated high rates of transmission in Khuzestan: an erosion of public trust, testing delays, and the premature rollback of lockdown restrictions.

Other countries likely need to avoid these factors to prevent second waves of their own.

Distrust in Iran's public-health response

Iran's first two coronavirus patients tested positive on February 19. But Iranian physicians later told the New Yorker that they had seen evidence of coronavirus cases as early as December, and were told by hospital officials to keep quiet.

The virus soon began spreading among the nation's senior officials. The Iranian parliament closed on February 25 after a member tested positive. By the time it reopened on April 7, more than 30 members of had been infected. Iran's deputy health minister, Iraj Harirchi, and vice president for women and family affairs, Masoumeh Ebtekar, tested positive as well.

By mid-March, satellite images showed Iranian authorities digging mass graves presumed to be for coronavirus patients. The images suggested that Iran's outbreak was much larger than the official figures let on.

After closing schools, universities, and cultural centers in 14 provinces in late February, Iran imposed a nationwide lockdown on March 13, which included shuttering shops and public spaces. The government then reopened subways, buses, mosques, bazaars, and shopping malls in April as cases began to drop off.

But infections started to pick up again in May and reached an all-time peak in June.

Iranian health officials have attributed this recent surge to a lack of social distancing.

"My colleagues and the deputies of the ministry of health are working around the clock and traveling to one province every day to control this epidemic, but we are dealing with local issues and behaviors that could lead to the return of the peak of the disease," the nation's health minister, Saeed Namaki, said on June 1.

Iran's health ministry reported that same day that only 40% of the population was adhering to social-distancing guidelines at the time, compared to 90% at the start of the outbreak.

Afkhami said that's because people in Iran are wary of the government's advice.

At the start of the outbreak, Iranian President Hassan Rouhani told residents not cease social activities out of fear. Iran also didn't close down religious shrines until March 16.

"There was this constant subtext that any form of social distancing or any sort of precautionary measures that would call for restrictions in the religious life of the population or the economic life of the population was a foreign plot, primarily a plot by the United States, to either damage the prestige of Iran or destroy its economy," Afkhami said.

In March, Iran's supreme leader, Ali Khamenei — who has been leading the nation's coronavirus response — rejected humanitarian aid from the US. He later promoted a conspiracy theory that the US government had engineered the virus as a weapon against foreign adversaries. Afkhami said Iran's military was also "charged with a repressive political agenda" to "arrest people critical of the regime's coronavirus response."

Public-health experts tend to agree that trust in government is critical to containing an outbreak. A January survey from US News & World Report found that citizens in China and South Korea — two nations that swiftly contained their outbreaks — had substantially more trust in their governments than citizens in Italy or the US. Iran was not included in the rankings.

Afkhami said people may be fearful of adding to Iran's official case count.

"If you don't trust the government, if you feel that there can be potential repercussions for reporting illness, it's very hard to do disease tracing, to keep track of how an illness is spread, to implement adequate precautionary measures to prevent the spread of the disease," he said.

Many Khuzestan residents had lost faith in government long before the outbreak, he added.

"It's an oil-rich region in Iran's southwest which has a large ethnic, Arab, non-Persian minority, which has long complained of discrimination and balked at the central government's control," Afkhami said. "There's been a greater disregard for government-mandated public-health restrictions."

A reluctance to test and report cases

Iran has reported nearly 176,000 coronavirus cases and more than 8,000 deaths. That means it has the largest outbreak in the Middle East. But Afkhami said there's still widespread belief among public-health experts and Iranian parliament members that Iran's official figures are far lower than the reality.

"I believe there was a push on the part of the government to understate these numbers for political reasons to appear to both the domestic audience and to the international audience like they were in control of the situation," he said.

At the start of the outbreak, Afkhami added, a lack of testing likely caused cases to go unreported.

"Hospital workers and doctors I've talked to have not mentioned a lack of availability of tests," Afkhami said. Instead, he said, Iranian hospitals have felt pressure to report low numbers, which means only testing people when "absolutely necessary."

Public-health experts contend that widespread testing is essential to containing an outbreak.

Iran appears to have ramped up testing in the last month — which may help explain why cases have risen. The nation's health ministry reported that more than 1 million tests had been administered as of Sunday. Iran exported around 40,000 diagnostic tests to Germany in May.

Economic constraints led Iran to reopen too soon

Amira Roess, a professor of global health and epidemiology at George Mason University, said the recent case spike in Khuzestan is the product of reopening.

"It is likely that increases in cases are due to loosening of movement restrictions in the province," she told Business Insider.

Afkhami said Iran's brief lockdown wasn't enough to quell the virus in the first place.

"It opened the country up to soon in mid-April before adequate testing was implemented," Afkhami said. "This contributed to the spike in the last month."

He added that Iran was motivated to reopen due to economic constraints. Disruption to local businesses caused the nation's GDP to fall by around 15%, Foreign Policy reported.

"The country was already in an economic tailspin because of the ongoing US sanctions," he said. "I think there's a realization that opening up the economy can potentially lead to a second wave, can potentially lead to a significant surge in mortality, but they're willing to take that loss."

Iran reinstated a lockdown across multiple counties in Khuzestan on May 10, but the move may have come too late.

"We're probably going to see an increase in the number of cases in the coming months," Afkhami said. "I think the worst is yet to come."

Lessons for other countries

Afkhami said Iran's "unscientific approach" to containing the outbreak sets it apart from many other countries.

"I do believe it was a significantly botched case," he said. "Politics was basically at the forefront of the decision-making."

But some similarities are playing out in other countries.

An investigation from the Associated Press recently revealed that China delayed the release of critical information, including the discovery of the initial outbreak and the country's first death, for several days. Epidemiologists have estimated that coronavirus cases in China, Italy, and the US, may be 10 times larger than the current data suggests due to limited testing capacity, testing errors, and difficulty tracing asymptomatic cases.

In the US, President Donald Trump has suggested that testing is "overrated."

"If we did very little testing, we wouldn't have the most cases. So, in a way, by doing all of this testing, we make ourselves look bad," Trump said on May 6.

Public-health experts have also suggested the US might be easing lockdown restrictions too soon. Data compiled by the New York Times suggests that cases are on the rise in nearly half of US states.