A potent combination of factors, from shutdowns to masks to our acceptance of vaccines, helped save lives in the region
Six-hundred-fifty-thousand Americans would still be alive.
If the United States had the Bay Area's death rate from COVID-19, 350,000 people would have died so far — not 1 million, the astounding number of deaths the country will reach this month, about as many as the entire population of San Jose.
How did the Bay Area avoid the worst of the virus's wrath? While good fortune and good health played a role, new analysis makes clearer than ever the advantage bestowed by the region's whole-hearted embrace of public health restrictions and vaccines.
Our lockdowns, masking and social distancing helped us to a death rate among the country's lowest even before vaccines became widespread. When it was time to get jabbed, we lined up — and an already low rate plummeted to a level seen almost nowhere else in the United States.
In other words, the Bay Area behaved — and reaped the rewards.
“It wasn't all behavior, but mostly behavior,” said Dr. Bob Wachter, who leads UC San Francisco's medical de- partment. “In the Bay Area and California generally, policymakers took it very seriously, acted responsibly and people listened.”
The Bay Area News Group analyzed more than two years of state and regional COVID death and vaccination rates, and census, health and mobility data to explore how and why the Bay Area and California stood out from the pandemic pack. The numbers tell the story — loudly.
• THE BAY AREA'S DEATH RATES ARE AMONG THE VERY LOWEST IN THE COUNTRY >> The region's five biggest counties all place among the 10 lowest death rates for U.S. counties with more than
500,000 residents, with San Francisco and San Mateo the lowest of all. Contra Costa ranked fifth lowest, Alameda ninth and Santa Clara 10th, according to data through May 7, the most recent available.
• CALIFORNIA, TOO, COMPARES WELL >> The Golden State has the 12th lowest death rate in the country and ranks better than its three closest large-state peers — Texas, Florida and New York. An additional 119,000 U.S. lives would have been lost if the entire country had New York's death rate, and 146,000 at Florida's. Texas fell just under the U.S. rate. In contrast, 241,000 more people would have lived if the nation had fared as California did – less than half of the Bay Area gap, but significant.
• WE OVERCAME OUR INHERENT DISADVANTAGES AND CAPITALIZED ON ONE NATURAL ADVANTAGE >> As an international travel hub with close ties to Asia, where the virus originated, the Bay Area began the pandemic with the odds against it. Our relative age was not in our favor, either. But if you're looking for one pre-existing factor that positioned this region to endure a pandemic, try health, particularly our low obesity rate.
• NO REGION OR STATE MAKES A MORE CONVINCING ARGUMENT FOR THE POWER OF VACCINES >> California kept its death rate below the national average even before vaccines became widely available, but since May 2021, that rate – like the Bay Area's – has plummeted, to less than half what it was before. Florida, by comparison, actually saw its death rate increase post-vaccine, one of 16 states to claim that dubious distinction. Looking to explain the difference? The five largest Bay Area counties have a vaccination rate near 82%, California's is 72%, and Florida's just tops 67%. In the U.S. overall, 17 states have vaccination rates under 60%, and all but one of them have higher than average death rates since May 2021.
None of these comparisons are meant to suggest that the Bay Area's success at withstanding COVID would have been simple or even possible to replicate elsewhere, though there's little doubt that many high death-rate states could have done better. Nor should we be too enthusiastic about our own achievements; even in California, with a relatively low death rate, total fatalities since the start of the pandemic have now topped 90,000.
At an average of about 400,000 a year, COVID deaths vastly exceed the U.S. annual tolls of about 92,000 fatal drug overdoses, 45,000 gun deaths and 41,000 fatal automobile crashes. For the second year in a row, the virus was the third-leading cause of death in the United States behind heart disease and cancer. But no infectious disease approaches its toll.
Once compared to “a flu,” COVID-19 quickly blew past that flawed analogy. Between 2010-20, influenza killed about 12,000 to 52,000 Americans a year.
COVID deaths also outnumber the 656,505 American soldiers killed in battle — in every U.S. war combined.
Still, many in the medical field, such as Catherine Troisi, an infectious disease epidemiologist with UTHealth School of Public Health in Houston, feel like the American public hasn't fully grasped the gravity of COVID-19.
“Why,” she asked, “does nobody seem to care about 1 million deaths?”
Different from the beginning
From the start, the Bay Area took the risk of death seriously.
The alarm sounded just after we learned the term COVID: The region recorded the state's first cases and the country's first official death from the virus — a 57-year-old San Jose woman who died on Feb. 6, 2020. And then, we shut down — a move that at this point is an oft-told and much-debated tale.
Research shows just how pervasive the region's sense of caution was — and how long it has lasted.
At the peak of the pandemic's first winter surge in January 2021, the Bay Area was the strictest in the country in following social distancing rules, according to anonymized GPS data compiled by TOP Data, a market research agency. The average resident here interacted closely with just under two people a day — far fewer than Los Angeles (3.12), New York (4.78) and Miami (8.15).
State-level data compiled by the Institute for Health Metrics and Evaluation tracking people's mobility from cell phone data and compliance with mask requirements from surveys shows Californians consistently have distanced and masked as much or more than residents in other large states.
“If the public hadn't taken public health so seriously and trusted for the most part what we were telling them to do,” Santa Clara County Health Officer Dr. Sara Cody said, “we'd obviously be in a very different place.”
The payoff? For the first 15 months after COVID emerged in the United States — the period before vaccines became widespread, when minimizing exposure was the only way to avoid the virus — only seven states had a lower death rate than the Bay Area. Because of high death rates in Southern California and the Central Valley, California's advantage was far smaller — it ranked 22nd.
Critics said early on —
and continue to say today — that the health leaders' efforts to contain the virus went overboard. California saw the nation's highest unemployment, and the state's prolonged classroom closures — the tracking company Burbio ranked it 50th among states for the amount of in-person learning provided in 2020-21 — stunted its children's education.
“Public health is not about a single disease,” said Martin Kulldorff, a biostatistician with the Brownstone Institute who co-authored the controversial Great Barrington Declaration arguing against lockdowns, social distancing and mask mandates in favor of measures targeting those most vulnerable to COVID-19.
Kulldorff and other critics don't just think the cost of California's caution was too great. They also argue the public health measures weren't effective — suggesting death rates are influenced more by factors like age and pre-existing health issues than masks and vaccine restrictions.
“Comparing raw (death) rates is misleading since COVID mortality is extremely age-dependent and the average age varies greatly between states,” Kuldorff said.
But the Bay Area News Group analysis found that age does little to explain this region's accomplishment.
Did age make a difference?
Throughout the pandemic, COVID-19 deaths have consistently been concentrated among the aged. Three out of four victims nationwide were 65 or older. Fewer than one in 100 were younger than 30.
Yet as powerful as those numbers are, it's difficult to make a case that age explains much about which regions fared better against COVID, and which fared worse.
Nationwide, only three of the large U.S. counties with the 10 highest COVID-19 death rates — Montgomery, Ohio; Nassau, New York; and Jefferson, Kentucky — had a percentage of older residents higher than the national average.
Among states, seven of those with the 10 highest death rates had more senior citizens than average. But so did half of those with the 10 lowest rates.
The Bay Area's share of 65-and-older residents is higher than California's, and just above the national average. If anything, our age made our COVID experiences slightly worse, on a relative basis, than they would have been otherwise.
“Even if you adjust for a somewhat older population,” Wachter said, “the math still works out that you have excess deaths compared with what you'd see if you mirrored the Bay Area's performance.”
Population health
More than age, a region's overall health did appear to align closely with its COVID death rates, the Bay Area News Group analysis found. And health definitely works in the Bay Area's favor.
One powerful influence on mortality is healthy living conditions, which California gauges through its
Healthy Places Index, assessing access to health care, clean air and water and other factors. Here, the major Bay Area counties top the statewide list, corresponding to the region's low COVID-19 death rates. The lowest scores were in the southern and central parts of the Golden State, which also had the highest death rates.
There are many other conditions — obesity, diabetes, chronic lung disease — that also put someone at higher risk of dying from the virus. The CDC suggests obesity is the most significant, tripling the risk of hospitalization. It is linked to impaired immune function, reduced lung capacity and higher risk for ailments like diabetes and heart disease that make severe COVID more likely.
That tracks closely with death rate comparisons. Of the states with the 10 highest death rates, eight have high obesity rates of 35% or more. But none of the 10 with the lowest death rates do.
Within California, none of the Bay Area's nine counties had a high obesity rate and six were below 25%. Southern California, with a death rate 2½ times higher than the Bay Area, has far worse numbers: Just one of the seven major counties — San Diego — was under 25%. Imperial County had by far the highest obesity rate in Southern California at 36% and also the Golden State's highest death rate. If the entire country had Imperial's death rate? More than 1.5 million Americans would have perished by now.
Vaccinations
Looking back at the blur of the last 2½ years, Contra Costa County Health Officer Dr. Ori Tzvieli said one thing stands out to him as the difference-maker in the Bay Area's fight against COVID-19.
“The most important factor,” he said, “was our population was eager and willing to go out and get vaccinated.”
Though their effectiveness has waned some against the latest variants, particularly in the battle against infection, vaccines have consistently made the virus much less deadly. Unvaccinated people were 10 times more likely to die of COVID-19 in February during the omicron wave than
the vaccinated, 16 times more likely in August during the delta surge and 18 times more likely in May 2021, the CDC has determined.
Of 140 counties in the United States with over 500,000 people, 16 have vaccination rates over 80%. All five of the Bay Area's large counties — Santa Clara, San Mateo, San Francisco, Alameda and Contra Costa, in that order — are in that top group.
One of the pandemic's most tragic statistics is the number of deaths after Americans had the opportunity to get a COVID vaccine. More than 400,000 Americans have perished since shots became readily available to all adults by May 2021.
The Bay Area News Group's analysis found states that embraced vaccination, such as California, New Jersey and Massachusetts, saw death rates decline sharply, while those where many shunned the shots saw modest declines or — like Florida, Ohio and West Virginia — even increases.
And the well-vaccinated Bay Area? Its low numbers dropped far lower. The region's COVID death rate of 33 per 100,000 since May 2021 is smaller than any state's. It is less than half that of the entire state of California, one-fourth the death rate in Texas, and one-fifth that of Florida.
Ultimately, what the Bay Area did saved lives.
Ali H. Mokdad, professor of health metrics sciences at the University of Washington's Institute for Health Metrics and Evaluation, says there is no doubt. His institute published a widely followed model that projected the virus's impact throughout the pandemic and forecasted how much worse it would be without masks, social distancing and vaccines.
More than luck and a population's age and health, Mokdad said, “the variation” in death rate “is due to behaviors and vaccination rates.”
Not that it was always easy or popular. The vast majority of the Bay Area's nearly 8 million residents supported the pandemic measures, but the ones who didn't vilified the region's public health officers so viciously at times that Santa Clara's Cody needed police protection. Today, she admits she sometimes wished her bosses would fire her.
But all these months later, as the Bay Area reflects on its experience amid a national tragedy, Wachter calls the differences in mortality rates “really quite profound.”
They “can't be explained by weather or pre-existing health conditions or age,” Wachter said. “They're mostly explained by behaviors and policies. That adds to the tragedy that many hundreds of thousands would be alive today if the rest of the country mirrored what the Bay Area did.”