It’s troubling, if not surprising, to see covid-19 cases spiking across the American South and Southwest, where public officials delayed lockdowns, rushed to reopen businesses, or refused to require people to wear masks.
But what’s the matter with California? The nation’s most populous state was the first to enact statewide shelter-in-place rules, took decisive steps to build up the recommended testing and case tracing capacity, and has hammered the public health message on social distancing and masks.
Yet new cases are rising sharply in pockets throughout the sprawling state, even as they’re flat or falling across much of the East Coast. Positive tests over the last seven-day period have risen 45%, regularly topping 5,000 a day, Gov. Gavin Newsom said during a press conference on Monday. Hospitalizations and intensive care unit admissions are both up around 40% over the past few weeks as well, threatening to overwhelm healthcare systems.
In turn, Newsom has pressed Imperial County–the southernmost part of the state where skyrocketing cases have forced officials to move hundreds of patients to hospitals in neighboring areas–to fully reinstate stay-at-home orders. He’s also recommended or required more than a dozen counties to shut down their bars, including Los Angeles and Santa Clara, the home of Silicon Valley. Meanwhile, San Francisco’s mayor halted the city’s reopening plan on Friday.
So what’s driving the outbreaks in a state that supposedly did things right? Why weren’t its ambitious testing and contact tracing programs adequate in preventing the recent surge in cases?
“It’s not one thing, but four or five,” says George Rutherford, an epidemiologist at University of California, San Francisco, who is leading the university’s training program for the state’s contact tracing task force. “The state is so big—the population of California is larger than Canada—and there’s a lot of different things going on in different places.”
Health officials believe the state’s efforts to boost testing and rapidly track down infections is helping. California’s cases per capita – 567 per 100,000 – is well below states like Alabama, Arizona or Florida. And Rutherford says about 85% of the people known to have interacted with positive patients are returning calls or answering questions from the state’s contact tracers, who are tasked with tracking down possible infections and encouraging people to quarantine or isolate themselves.
But clearly not enough people are strictly following these recommendations, and others, from public health officials – sometimes due to carelessness, and sometimes due to financial strains and other constraints.
Here are some of the main drivers at work:
Throughout the state, Latinos make up the largest share of cases by far (56%) and deaths (42%), according to data from the California Department of Public Health. While Latinos make up 39% of the population, whites are a close second at 37%, but only represent 17% of covid-19 cases.
These infections appear to be concentrated within low-income communities, where people are often essential workers who can’t do their jobs from home, can’t afford to call in sick and may live in crowded housing conditions, according to information from contact tracing programs as well as other research and reporting. Language, immigration status and financial issues can complicate efforts to successfully reach infected patients or their close contacts in these communities, and convince them to isolate themselves for extended periods.
Early results from a covid-19 screening project in San Francisco’s heavily Hispanic Mission neighborhood found that 95% of those who tested positive were Hispanic or Latinx (the difference is explained here). And 90% of infected patients said they couldn’t work from home.
People are becoming cavalier
Another major factor is that people are ignoring safe practices, according to a state breakdown of counties experiencing rising cases. As regions relax stay-at-home rules, families, friends and strangers are increasingly gathering in homes, bars, restaurants and other venues. Too often, they’re not wearing masks or staying far enough away from each other, said Mark Ghaly, secretary of California’s Health and Human Services Agency, during the Monday press conference.
Los Angeles County has become the nation’s largest epicenter of the disease, with nearly 98,000 confirmed cases, according to Johns Hopkins University’s coronavirus tracking map.
The Los Angeles County Department of Public Health announced on Sunday that it would heed Newsom’s directive to shut down bars, noting that the region’s sharp increase in cases and hospitalizations directly coincide with the reopening of businesses a few weeks earlier. Those include breweries, pubs, wineries and other venues “where people remove their face covering to drink while they may be socializing with people not in their households,” the statement read.
“I implore that our residents and businesses follow the public health directives that will keep us healthy, safe and on the pathway to recovery,” said Barbara Ferrer, the county’s director of public health. “Otherwise, we are quickly moving toward overwhelming our healthcare system and seeing even more devastating illness and death.”
Explosions in prison cases
More than 2,500 inmates throughout California are infected with the coronavirus, amid major outbreaks in state and federal prisons. More than 1,000 prisoners and staff members have tested positive in San Quentin State Prison alone during the last few weeks, in an outbreak linked to the transfer of inmates from the California Institution for Men in Chino, where there are more than 500 active cases.
The spill over of patients into local hospitals has forced Marin County, where San Quentin is based, to pause its plans to reopen gyms, hotels and other businesses.
An influx of cases from elsewhere
There are a variety of other factors driving higher case counts as well, including increasingly widespread testing across the state (which totaled nearly 106,000 on Sunday), continuing outbreaks in nursing homes in several counties, and patients from outside California crowding into counties with better testing and treatments.
Part of what’s driving the soaring cases in Imperial County is the influx of positive patients from Mexico. State officials say they’re primarily US citizens, hundreds of thousands of whom live in neighboring Baja, crossing back in search of superior healthcare.
The different drivers may demand different interventions, health experts say. Officials need to take extra efforts to communicate with low-income Latino patient populations, and provide money, food, housing or other services to help them isolate while they’re infectious. (San Francisco has some programs like this in place, but clearly more is needed throughout the state.) Prison systems need to keep infected inmates isolated, and ensure they’re no longer spreading the disease across facilities. And nursing homes should test patients and workers more often, and step in more rapidly at the signs of an outbreak.
But pretty much all of this has been known from the start. Californians needs to recognize that the dangers haven’t passed, even as regions relax certain rules. Everyone still has to keep their distance from others, vigorously wash their hands and abide by the one public health decree that may help the most.
“Wear masks,” UCSF’s Rutherford says.