Bay Area reopening taking step backward
Response: S. F. may pay price for curbing pandemic well
The decision to launch San Francisco’s attack on the coronavirus — perhaps the most aggressive pandemic response in the United States — can be traced back to February, before the city had reported a single case of the new disease.
Dr. Grant Colfax and his team at the Department of Public Health had been watching the numbers blow up exponentially, first in Wuhan, China, then Italy, and then much closer at a nursing home in the state of Washington. Mayor London Breed declared a state of emergency on Feb. 26. San Francisco
reported its first cases on March 5. The city, along with five Bay Area counties, shut down March 17.
Those earliest actions set a tone that’s carried over the eight months since, including the announcement Tuesday that the city was reinstating some restrictions. San Francisco now is widely heralded as one of the rare success stories in the United States, where the pandemic response has been among the worst in the world. But with success comes a question: At what cost?
“We recognized that there was no jurisdiction that was saying, ‘ We acted too quickly and too aggressively,’ ” Colfax said in an interview Friday, of the city’s earliest conversations about the pandemic. “We knew we needed to be ready. We needed to get out early and do everything we could to get ahead of the virus, which we knew was coming.”
As the United States staggers under its most crushing wave yet, with an average of about 100,000 new cases a day reported last week, San Francisco is better positioned than most places to hunker down and dodge another surge.
But no one can say with certainty how long this pandemic will rage, even with one or more vaccines on the near horizon. Surely it will be well into 2021, maybe through most of the year. And, increasingly, health and community leaders wonder what the final ledger will show when the victories are weighed against the collateral damage in economic and secondary health consequences.
“Clearly our response has been excellent in terms of one thing: COVID19. But I think our singlemindedness will end up doing us harm,” said Dr. Monica Gandhi, medical director of Ward 86, the HIV/ AIDS clinic at San Francisco General Hospital, and a UCSF infectious disease expert who has written about the role of face coverings in slowing spread of the coronavirus.
“It is now 10 months into the pandemic,” she said. “It is time to start having other dialogues.”
Picture of success
Coronavirus cases have spiked in San Francisco over the past few weeks, echoing trends across the country. Colfax said Tuesday that the city could surpass its summer surge peaks by the end of December if it doesn’t act aggressively now to curb transmission. The city is reporting about 9 cases a day per 100,000 residents as of Tuesday, triple the rate from a month ago.
But even with the recent upticks, San Francisco still has enviably low case counts compared to many other large cities. Its hospital capacity has never been truly tested, its intensive care units never overrun. Its positive test rate, a key marker of the spread of disease, has consistently been the lowest of any large county in the state.
Most remarkable is San Francisco’s fatality rate: At about 17 deaths per 100,000 residents, it’s the lowest among all major cities in the U. S., by a wide margin. The nextlowest death rate is Seattle, with about 36 deaths per 100,000 residents.
Since March, 151 people have died of COVID19 in San Francisco. Though each death is hard, that’s an astoundingly low number for a city of 870,000 people. As Dr. Robert Wachter, chair of the UCSF Department of Medicine, has pointed out: If the United States had San Francisco’s death rate, about 50,000 Americans would be dead instead of nearly 240,000.
“To do as well as we’ve done, everything had to have been working,” Wachter said. “The guidance that we’ve gotten from the mayor and from the public health officials has been terrific. And not just what’s codified in the rules, but the bully pulpit — Grant Colfax coming out and saying, ‘ This could go really sour, folks. We need to be careful.’
“The biggest danger for San Francisco all along has been complacency and being too self congratulatory,” he said.
The city’s triumphs in the pandemic are attributed to several factors, primarily the early and aggressive public health response, including the first shelter in place order in the nation, and a commitment to slow reopening ever since. San Francisco paused its reopening plans last week when cases and hospitalizations began to creep up, and on Tuesday it reinstated some restrictions for the first time since the pandemic began.
San Francisco also came into the pandemic better placed than many other cities to handle a public health crisis. It has strong ties with a highly regarded academic partner in UCSF. It has a politically homogeneous population that trusts science. It has a history of working with community groups to battle earlier crises, most notably HIV/ AIDS.
The low fatality rate can in part be attributed to one factor: Laguna Honda. It’s the largest staterun skilled nursing facility and has not reported a single COVID19 death, despite an early outbreak among staff and residents. Indeed, while nursing home deaths have made up 40% to 60% of all COVID19 fatalities in some counties, in San Francisco they’re only about a fifth.
The city has done “a very thorough job” of protecting the elderly and vulnerable, said Dr. Rajiv Bhatia, a former deputy health officer with the San Francisco Department of Public Health, who has been critical of coronavirus lockdowns in some communities. He said he thinks San Francisco has gone too far at times, but “what they did at Laguna Honda, and not just there — that should be a lesson,” he said.
Shutdown side effects
Bhatia isn’t convinced, though, that the San Francisco model would work elsewhere, or that the city yet knows the final toll in terms of secondary health and economic fallout.
“When you impose a lockdown, you have a responsibility to monitor its negative effects, and monitor them just as vigorously as you’re monitoring COVID cases,” Bhatia said. “That hasn’t happened.”
Of note, Bhatia signed the controversial Great Barrington Declaration, a document that promotes herd immunity and states that pandemic related restrictions could have “devastating effects on shortand longterm public health.” Most infectious disease and public health experts have criticized the document as irresponsible and lacking in evidence.
But many public health experts agree that it’s important that cities like San Francisco pay close attention to the effects of longterm shutdowns.
San Francisco already had more overdose deaths this year than any time in recent history. Care of people with HIV is slipping. Doctors worry about missed cancer screenings and skipped childhood vaccinations.
Communities of color, hardest hit by the coronavirus, are still carrying an unfair burden of illness in the pandemic plus other health consequences, advocates say.
Though San Francisco moved faster than many other cities to shift testing to neighborhoods with the most cases, community leaders say they still feel like they have to fight for resources.
“Obviously, relative to the rest of the country, there are a lot of things we can be proud of as a city. But there is a lot that is left to be desired in terms of the response,” in particular with the Latino community that has been hardest hit, said Jon Jacobo, chair of the city’s COVID19 Latino Task Force.
“I’ve been disappointed at the inability to move at a faster velocity,” he said. “This is just a pervasive problem that we’re confronting.”
Aside from the public health effects, more than 150,000 jobs have been lost, and thousands of businesses have closed. More than 50,000 students in San Francisco Unified haven’t returned to their classrooms yet. Many older adults living alone or in residential care facilities are suffering from isolation and associated mental health problems.
“When you take a public health system and clinical system and go all hands on deck for one particular health issue, obviously something falls by the wayside,” said Dr. Kirsten Bibbins Domingo, vice dean for Population Health and Health Equity at UCSF.
Future with the virus
San Francisco has done remarkably well in its response so far, she added. That means the city now “has the luxury to do the hard retrospective analysis and plan better for the future.” By keeping such tight control of the pandemic, San Francisco can take calculated risks, perhaps pilot programs like school reopenings that other regions could learn from, she said.
“I hope we don’t go back to shutdowns,” she said, “and that we understand the consequences of those decisions.”
Colfax, too, wants to avoid further shutdowns or economic setbacks. Part of the reason he’s stressed a gradual reopening and acted quickly when cases started to climb is so he never has to take the city backward and impose new restrictions — though he and Mayor Breed did just that on Tuesday.
He said he’s receptive to criticism and understands people’s concerns about the repercussions of sheltering in place. He’s eager to return students to their classrooms, he said. He wants to open more of the economy. He doesn’t like telling San Francisco families that they should consider having Thanksgiving over Zoom, and he understands that social distancing is hard on people’s mental health.
“The COVID pandemic is going to have health consequences above and beyond COVID itself. We’ve seen that across the country, I think we’ll see it regionally and locally, as well,” Colfax said. “It’s a matter of trying to mitigate the collateral effects.
“The issue is if COVID19 got out of control,” he said, “all these things would be worsened by magnitudes greater.”