Dr. Robert M. Wachter
Like a wildfire spraying hot embers, the coronavirus pandemic is now flaring in communities around the country, with growth curves in New Orleans, Michigan and Illinois that resemble those of 10 days ago in New York City — which in turn mirror those of early 2020 in Italy and Wuhan, China.
But California — and particularly San Francisco, where I live — appears to be following a different course, with relatively low rates of COVID-19 cases and mortality. In San Francisco, there are few signs of an imminent spike. Our experience may hold lessons for the rest of the country, especially on the importance of aggressive public and corporate steps to promote social distancing.
As recently as March 10, the rates of confirmed coronavirus infection in New York City and San Francisco were roughly the same: New York City had seven cases and San Francisco had 14. On Monday evening, New York City had more than 38,000 confirmed cases and 914 deaths; San Francisco had over 374 cases and six deaths.
At my hospital, the University of California, San Francisco Medical Center, we have been caring for eight to 14 patients with confirmed COVID-19 at a time, with a few new admissions each day. At comparably sized academic health centers in New York City, the COVID-19 census has been in in the hundreds and, tragically, all of these hospitals have seen scores of deaths.
A tale of two cities and the coronavirus
Some commentators, noting the sharply divergent growth curves in New York and San Francisco, have wondered whether the differences relate to testing, which has been more readily available in New York than in California. Testing might explain a small part of the difference in the sheer number of cases reported (that is, assuming patients with relatively mild symptoms are more likely to be tested in New York than in San Francisco). But it wouldn’t explain the profound differences we’re seeing in hospitalization and death rates. Anyone sick enough to be in a hospital would be tested in both locations.
So what explains this tale of two cities, and two regions?
While it is difficult to attribute the difference to any one factor, it seems likely that early action by political and corporate leaders made an enormous difference. On March 16, the mayors of San Francisco and the five surrounding counties issued orders mandating that all citizens “shelter in place” — stay at home for all but essential needs such as shopping for food or receiving health care. With this order came the closure of restaurants, bars, gyms and many businesses.
A statewide order from California Gov. Gavin Newsom came three days later. Illinois and New Jersey issued similar orders on March 21. By Monday, two weeks after San Francisco acted, there were statewide orders in at least 30 states.
Perhaps just as important, by the first week in March, many of the Bay Area’s information technology giants, including Apple, Google and Facebook, were directing their employees to work from home. The work-from-home orders increased the degree of physical distancing for tens of thousands of people in the region, which lowered the chances of viral spread. Such actions underscored a message that reverberated throughout the region: These companies were taking the threat seriously.
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There could be other ways to explain San Francisco’s relatively small number of cases. The density of the city is lower than that of New York (28,000 residents per square mile; San Francisco is the second-most dense city at 18,000). But other less dense cities, such as Detroit and New Orleans, have been hit far harder.
Underlying medical conditions could play a role. Lungs compromised by smoking, and the diabetes and cardiovascular disease that can come from obesity, likely contribute to higher rates of hospitalization and death in those who do become infected. San Francisco’s rates of smoking and obesity are significantly lowerthan the national average.
Our COVID-19 luck may not hold
And maybe some of it was luck. After all, Seattle resembles San Francisco in many ways (population density, links to China, a thriving technology industry) and it became the first American hot spot, as the coronavirus tore through a nursing home in Kirkland, Washington. Yet the state of Washington now has among the lowest rates of new cases of COVID-19 per capita in the country — evidence that, once that city experienced its initial flurry of cases, a concerted public and corporate response mirroring the one in San Francisco paid dividends.
While we in San Francisco are allowing ourselves a bit of optimism, it’s entirely possible that our luck won’t hold. We are keeping a close eye on a 750-bed nursing home with six infected health care workers and one infected patient. Significant spread there could rapidly change the narrative in our city.
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Riskier still would be complacency. If we let our guard down, begin resuming our normal activities too soon, and fail to aggressively implement appropriate testing and quarantine procedures, we risk having our successes be the seeds of later tragedies.
I suspect, though, that this will not happen. The citizens, politicians and health care workers in San Francisco are watching the horrors unfold in many parts of the country with a mix of sympathy and fear. The actions of our people and our leaders, both political and corporate, demonstrate that social distancing can work — if it is enacted early, adhered to religiously and continued until such time it is no longer needed.
In San Francisco, we were lucky enough to have leaders who took seriously the lessons from prior pandemics, the science of infectious disease epidemiology and the experience of other countries hit first by the coronavirus. In the COVID-19 pandemic, we can only hope that San Francisco emerges as an example to other parts of the country, and the world.