San Francisco Chronicle - (Sunday)
Virus holds upper hand
State struggling to regain control after spike in daily cases
For three months, California bent the curve.
Look at this miracle, said public health and infectious disease pundits. Admire this success, led by the Bay Area, in beating back the coronavirus that had overrun New
York City and devastated dozens of other cities around the world.
California basked. Then the virus rallied.
After months of gentle upticks and encouraging plateaus, the state reported recordhigh daily cases on June 22, then broke that record the next day, and again a few days later. The numbers of patients hospitalized and in intensive care have shot up over the past two weeks. California is reporting as many new cases a day as Florida and Texas and Arizona — states that never quite committed to sheltering in place the first time around.
On Tuesday, the day after
California reported more than 8,000 new cases, Gov. Gavin Newsom seemed to take the setback personally.
“We bent the curve in California once. We will bend the curve again,” he said at a news briefing in Pittsburg. “Mark my word: We will crush this pandemic. We will annihilate it.”
The next day, the governor announced he was shutting down bars, indoor restaurants, movie theaters and museums in 19 counties. The closures would last at least three weeks, to give counties time to reestablish control over their outbreaks. More counties could be added to that list in the coming days, he said.
Of course, California is not alone in this predicament. The entire United States is facing a critical moment in this pandemic. Already the world leader in case counts — with 2.8 million confirmed infections, or a quarter of the global total — the nation is reporting recordhigh new cases now, including 55,000 on Friday. Cases are trending up in most states, in some places alarmingly fast.
The Bay Area and California have been widely lauded for an early, aggressive response to the coronavirus pandemic and subsequent success of sheltering in place. The case counts climbed, but at a manageable pace. Hospitals were never overwhelmed. Morgues didn’t fill up. California has many more cases and deaths than most other states, but it’s also the most populous state, and the rates per capita weren’t as alarming.
But just a few weeks after letting people out of their homes and back to something approaching normal life, the California outbreak is swelling all over again. In addition to the climbing case counts, the state has more patients hospitalized with COVID19 now than ever before.
California, and the Bay Area in particular, may still be the nation’s success story, said infectiousdisease experts. This may be the best that the United States can hope for: constant vigilance and the political will to slow down and take stock when the virus begins to rear up.
“When it comes to fighting a pandemic, we suck,” said Robert Wachter, chair of the UCSF Department of Medicine, regarding the U.S. response to COVID19. “Our response was never going to be perfect. But I don’t think we needed to be this bad.”
Of California’s situation, Wachter added: “We should be disappointed, and I am. And we should be somewhat selfcritical.
“On the other hand, we made it through three and a half months with remarkably good performance,” he said. “What happened now is human, which is we let our guard down. We believed, ‘Look how great we’ve done, the virus never struck us, we got lucky, we dodged the bullet, it’s time to go out and live our lives.’ And that’s where things went off the rails.”
What’s happening across the state, Wachter and others say, is as much about a failed response as it is the wily nature of this new virus and the challenge of containing it in a country defined by free will and individualism. South Korea managed to drive its coronavirus cases down to nearzero. Italy, one of the first countries to be crushed by the pandemic, mostly has stomped out the virus.
The United States is not either of those places. It’s a huge, heterogeneous nation that is more politically and culturally divided now than at almost any other time, public health and infectious disease experts say.
And California, though it took a progressive stand against the virus, is still at the mercy of its federal leaders and its neighbors.
Even Santa Clara County, where the health officer acted faster and more aggressively than anywhere else in the country, where the government and residents supposedly did everything right, is stumbling to stay on top of its cases.
The county recorded more cases last week than at any other time in the pandemic — in fact, more cases in that one week than the entire month of April.
Its hospital numbers are picking up, too. It’s now on a state watch list for counties where the virus is threatening to run rampant. On Thursday, Health Officer Sara Cody said she was issuing a new health order that would reopen some businesses but leave certain “highrisk” venues — including indoor restaurants and bars — closed indefinitely.
“Santa Clara County was really on the front end of acting as quickly and decisively as possible. Which is partly what makes it so discouraging that, even in Santa Clara County, we’re seeing cases going up,” said Erin Mordecai, a Stanford biologist. “What could we be doing better, if they can’t do it?”
Mordecai pointed to many of the same limiting factors as Wachter and other infectiousdisease experts: Americans value their privacy and don’t like being told what to do, for starters.
But the response across the state also was hindered by deeply embedded structural challenges — racism and socioeconomic imbalances that put communities of color and lowwage workers at particular risk. It was always going to be nearly impossible to slow the spread of the virus to almost unreadable levels with pervasive systemic disparities unaddressed, Mordecai said.
Even though the outbreak was seriously dampened by sheltering in place, it never disappeared entirely. In the Bay Area, newly reported daily cases dropped below 100 only once since the stayhome orders took effect in midMarch. But public health officials believed they’d done the best they could, and they used those three months to shore up hospital and public health resources for what they anticipated would be a longhaul battle with COVID19.
“People in the Bay Area have done so much already. They did such extraordinary work sheltering in place,” said Susan Philip, director of disease prevention and control at the San Francisco Department of Public Health. “But people have been really pushed, potentially just to the limits of what they feel they can do, or are willing to do. It’s been mentally exhausting.”
Why cases are springing up across the state isn’t actually much of a mystery. Public health authorities warned that they’d see increases from reopening the economy, as people returned to work and began to interact with others more often.
And the state has dramatically expanded its testing, which is surely capturing many cases that would have been overlooked a month or two ago, especially among younger people with mild or no symptoms.
Some cases also may have come from the civil rights protests that exploded at the end of May, after the death of George Floyd while in police custody in Minnesota. No coronavirus clusters have yet been directly attributed to the protests in California, but public health officials have identified a few cases tied to them.
More significantly, starting around mid May — first with Mother’s Day, then Memorial Day — people began socializing more. They slipped out of their housebound isolation and started seeing friends and family. They crowded beaches in Southern California. They celebrated high school graduations.
In many places, they refused to wear masks.
“The mistake that we made, even here in the Bay Area, was that we didn’t anticipate human behavior. We assumed that people would be more responsible than they’ve been,” said John Swartzberg, an infectious disease expert at UC Berkeley.
He’s hopeful, though — for the Bay Area and California. Tens of millions of people were responsible enough in March, April and May to fend off disaster. He believes they can do it again.
Sheltering in place is the best defense against the coronavirus, but it can’t be maintained indefinitely. And once states began reopening, Americans weren’t going to sit well with the type of aggressive public health oversight other countries have employed to keep cases from rising again, authorities say.
So the answer is to proceed with caution, and to keep close watch on the earliest signs that the outbreak is surging. That’s not just climbing case counts, but more nuanced indicators, like the percentage of coronavirus tests that are coming up positive. If that number is ticking up, the virus is spreading more widely.
Deaths are stable in California, which is good news, of course, but it may just be a
matter of time before they climb again too, public health officials warn. Other red flags are flapping. Positive test rates are climbing statewide — up from just over 4% two weeks ago to 7%. State hospital numbers are up about 60% from two weeks ago; Bay Area hospitalizations have more than doubled.
Now is the time to take action and slow down, authorities say.
San Francisco’s positive test rate is only about 3% at the moment, but it was 1% three weeks ago. Cases are shooting up, and hospitalizations that had been dropping steadily for two months are surging again — the city has as many COVID19 patients in hospitals now as in early May.
When the first warning signs went off two weeks ago, San Francisco delayed the reopening of bars, hair salons, zoos and a few other sectors. Health official Philip hopes the city acted quickly enough that it can wrestle control again.
“The reason that some of our indicators went red is because we deliberately designed them to be very sensitive. We didn’t want to be behind the eight ball and knowing once our hospitals were almost at capacity that there is very little we can do about it,” Philip said.
The state as a whole has been a little more reckless, infectious disease experts said. The Bay Area counties are seeing nothing like the surges in parts of Southern California, including Los Angeles, where total cases passed 100,000 last week.
This is “the dance,” said Wachter — push and pull with the virus, trying to strike the balance between restrictive health policies that save lives and letting people go back to work and see one another again. The next two weeks will be critical, he said. The Bay Area and the rest of the state can wrestle control again, or it could spiral into chaos like New York City did early on.
“To beat this thing, it’s not just about what the rules are set by the state and county,” he said. “It’s the 100 decisions made by 40 million people every day. We went through a big test in March and we passed. We’re going to go through a big one now and we’ll see.”
“The mistake that we made ... was that we didn’t anticipate human behavior.”
John Swartzberg, infectiousdisease expert at UC Berkeley