San Francisco Chronicle - (Sunday)
Bay Area shutting down as virus rages
Restrictions return as hospitals near limits
Nine months into the pandemic, much of the Bay Area is nearly back where it started: sheltering at home, laid low by a virus that’s proved bitterly hard to contain.
The coronavirus by most metrics is more threatening now than at any other point over the past year. For the first time, Bay Area hospitals are on the cusp of being overwhelmed, a scenario that public health authorities have warned about since the spring. And despite weeks of increasingly severe restrictions on people’s work and social lives, this most recent surge has swelled to record peaks, seemingly unabated.
And so on Friday, five Bay Area counties announced a shutdown again, ordering the most restrictive shelterinplace edicts since March on the lives of nearly 6 million residents. The first measures go into effect on Sunday evening, and they will stay in place until
Jan. 4.
“This is a hard way to close what’s been a really hard year,” said Dr. Matt Willis, the Marin County health officer, in a news briefing with his colleagues to announce the new shutdowns.
The five counties — San Francisco, Alameda, Contra Costa, Marin and Santa Clara, plus the city of Berkeley — opted to move ahead of the state stayhome order that requires regions to shut down if their hospital intensive care capacity falls below 15%. The Bay Area is still above that threshold, at over 21%, but the health officers said they were too concerned to wait for the state order to take effect.
The orders are very close to the Bay Area’s March 16 shelterinplace directives, which were the first in the nation. The new orders ban outdoor dining, close hair and nail salons and tattoo parlors, and shut down zoos and playgrounds. Stores can stay open but at 20% capacity. Schools can open as long as they already had permission.
Public health and infectious disease experts said that, in hindsight, it was almost inevitable that the Bay Area would end up under another stayathome order. Everyone knew the fall and winter were going to be rough — that the colder weather would drive people indoors where the virus spreads more easily, and that people would be eager to gather with friends and family over the holidays.
Still, the Bay Area had successfully fought off two waves. And few experts anticipated an endofyear surge quite this dramatic. It’s raced across the entire country at once, driving infections to new peaks from coast to coast, even in places like the Bay Area that had earlier success. A record number of people are hospitalized in the United States — more than 100,000 as of Friday — as well as in California and the Bay Area.
Public health experts warn that California is on the cusp of running out of space and resources to treat people in intensive care, whether they suffer from COVID19 or any other serious illness or injury. Both the Southern California region, which includes Los Angeles, and the San Joaquin Valley will be subject to the state lockdown orders beginning Sunday night after ICU capacity in those regions fell below the 15% threshold. The situation in the San Joaquin Valley is particularly stark: ICU capacity fell from 14.1% reported on Friday to 8.6% on Saturday.
The situation has never been more dire, officials say.
“If you’re not working to stay ahead of this virus, you’re falling far, far behind. The measures we’ve tried so far simply haven’t bent the curve the way we needed them to,” San Francisco Mayor London Breed said in a news briefing on Friday. “This is perhaps the final test we face as a city in this pandemic.”
As the Bay Area regresses to a response akin to the earliest days of the pandemic — applying once again the bluntest and most painful tools to stop the surge — experts and civilians alike are asking: Will another shelterinplace order be enough to save lives?
But they’re also wondering: Does it go too far? ***
It’s now clear that this latest California surge began in midOctober, but these trends often are difficult to see in the moment. The first notable action to intervene and try to slow down cases in the Bay Area was Oct. 30, when San Francisco officials announced that they were pausing plans to expand indoor dining.
Ten days later, counties started shutting down parts of the economy again. San Francisco closed indoor dining on Nov. 13. Three days after that, Gov Gavin Newsom pulled his “emergency brake” and ordered most of the state into the mostrestrictive purple tier in California’s pandemic blueprint. That move banned indoor dining, along with indoor places of worship, gyms and museums. It placed strict capacity limits on malls and retail stores. Less than a week later, Newsom added a 10 p.m. to 5 a.m. curfew to the purple tier restrictions.
But cases and hospitalizations have continued to blow up in the more than two weeks since. It’s possible, public health experts said, that the earlier restrictions blunted infections and helped slow down the pandemic, but clearly not enough. The Bay Area averaged more than 2,200 cases a day in the past week — nearly double the average two weeks ago. Statewide, 20,000 cases a day were reported last week, up 70% from two weeks ago.
Hospitalizations climbed alarmingly fast too — up 82% over the past two weeks for the Bay Area, and 90% for the state.
And the “Thanksgiving effect” from cases tied to the holiday is still to come, said Dr. George Rutherford, an infectious disease expert at UCSF. “If you stopped transmission tomorrow, we still have three weeks of people in the pipeline for the ICUs. That’s just — yikes,” he said.
No one wanted to go back to sheltering in place, public health officials said. But targeted, piecemeal restrictions that were effective in slowing down the summer surge weren’t working this time.
“Things we’ve done here have worked in the past, but they’re not perfect,” said Dr. Nicholas Moss, the Alameda County health officer. “We’re not getting enough mileage out of them for what we’re facing right now.”
Maybe this wave, fueled by a national crisis, had grown too big for a less aggressive approach, public health experts said. Maybe it could no longer be contained with precise, surgical tools — it needed a sledgehammer.
And maybe people are too exhausted to keep up with a more measured attack, experts said. The cascade of restrictions, sometimes coming on backtoback days, often differing from one county to another, had become almost impossible to track.
“It’s decision fatigue. What will drive people mad is the daily changes,” said Dr. Robert Wachter, chair of the Department of Medicine at UCSF, in an interview before the counties announced a new shelterinplace order.
“Trying to be too clever and get this precisely right hasn’t worked,” he said. “We’re past the point of wishful thinking.” ***
The Bay Area’s original stayathome order was by almost all accounts wildly successful. It squashed the burgeoning outbreak, holding cases to a plateau that is now clearly the low point in the pandemic.
But the size of the pandemic going into that order was absurdly small compared to what the region faces now. When the first order was put in place the week of March 15, the Bay Area was reporting fewer than 100 cases a day. The case count is 20 times higher now.
The March shutdown also had broad support. All of the Bay Area’s health officers backed it. And residents, terrified of a mysterious new disease that had only recently been named COVID19, understood the need for dramatic action.
Nearly 10 months later, individuals are battered by the economic fallout and social isolation, and business owners are feeling resentful. Even some public health and infectious disease experts have started to question the wisdom of another shelterinplace order.
Only six of the Bay Area’s 10 health officers have signed on to the new directive. The remaining four said they didn’t yet share their colleagues’ immediate concerns about intensive care capacity, or that they believed they could control the current surge with restrictions already in place.
Dr. Bela Matyas, the Solano County health officer, said Wednesday that he wasn’t convinced people would adhere to another stayathome order. So far they haven’t been deterred by curfews or other restrictions. They’ve been told for months that they should avoid social gatherings, but those actions are still driving local cases, he said.
“What’s been worrying me over the last several weeks is the governor keeps increasing restrictions and doubling down, and it’s not making a difference,” Matyas said. With another shutdown order, the county will force the same financial burdens on small businesses and people who lose their jobs, “but the public has made it clear that they have no intention to abide by those kinds of restrictions again,” he said.
Dr. Monica Gandhi, an infectious disease expert at UCSF, said she was baffled by the new shelterinplace orders, which don’t take into account much of what scientists have learned about the virus and how it’s transmitted. She doesn’t agree with shutting down most outdoor activities — including dining, but also playgrounds and gatherings among people from different households.
Those things are largely lowrisk, she said. And evidence supports the relative safety of venues like hair and nail salons too.
“I don’t think we needed to go back to where we were in March. I think playgrounds shouldn’t be closed, they shouldn’t forbid people from getting together outdoors,” she said. “It is too draconian. It doesn’t account for the nine months of research. We’re still acting like we don’t know how this is spread.”
Her UCSF colleague Dr. Kirsten BibbinsDomingo, vice dean for Population Health and Health Equity, also doesn’t have much enthusiasm for another shelterinplace order, but she said she understands why it may be necessary. There’s too much virus in the community, and trying to identify and prevent the riskier activities hasn’t worked — it’s just upset and angered people, she said.
“We’ve spent too much time over the past several weeks arguing about curfews or closing this business or that, and it’s distracted us,” she said. “There are sharks in the water, and we have to get out of the pool now. It’s just that simple.”
Like many others, BibbinsDomingo said she is hopeful this will be the last big surge. With vaccines on the way, this shelterinplace order could be the final plea for people to do as they’re told and hunker down to save their communities.
“Can we collectively do what we need to do for a few weeks to months? Because if we get to the new year and through to the spring, we are legitimately in a situation where life can move back to normal,” she said. “We don’t want to be here, but we can get through it. There is light if we can do this for a few more weeks.”