COVID-19: A Time of Reckoning

  • 03/19/2020
  • Paul Rosenberg

By Paul Rosenberg, Senior Editor

Sunday evening, March 15, Los Angeles Mayor Eric Garcetti issued an emergency order in response to the Covid-19 pandemic, requiring the temporary closure of all restaurants for dine-in service, along with closure of bars and nightclubs that do not serve food, movie theaters and entertainment venues, bowling alleys and arcades and gyms and fitness centers. Cafeterias within hospitals, nursing homes and similar facilities were specifically exempt.

“We are all first-responders in this crisis,” Garcetti said. “I don’t take these steps lightly, but they are absolutely necessary — because our decisions today have the power to slow the spread of the virus and save lives.”

Merely slowing the spread may not be enough, experts warn. Much stronger steps may be necessary to prevent millions from dying as hospitals are overwhelmed with intensive care unit patients. But the closures signal a significant shift toward the necessary direction.

The next day, Los Angeles County followed suit with a similar measure, announced by Kathryn Barger, Chair of the Board of Supervisors, along with adopting Center for Disease Control guidance to limit public gatherings to no more than 50 people.

“We’re in a new stage of the response and everybody needs to help us,” said Dr. Barbara Ferrer, LA County Public Health Director, in a press conference announcing the new measures.

“Everyone must take precautions in everything you do and you must assume that you need to take these precautions everywhere you go. If something is not an essential activity, I urge you to please not do it,” she said. “In the absence of vaccines, social distancing is the best tool that we have. And that means that everyone has to help us avoid all non-essential activities.”

These measures capped a series of announcements from the state, county and city levels, increasing the intensity of social distancing measures designed to slow and reduce the spread of the disease. But they paled in comparison to six Bay Area counties, where officials issued a shelter-in-place mandate the same day, affecting roughly 6.7 million people for the next three weeks. Residents must stay inside, except to go out for necessities. This almost total lockdown is unique in the United States, but may be the only way to effectively control the virus, especially given the horrendous lack of testing, which means we’re fighting an enemy we can’t even see.

The basic reproduction number of the virus is about 2.5, meaning one sick person infects two or three people on average. At that rate, one infected person now will result in 244 infections about a month from now. But reducing the number of people everyone comes in contact with can bring that down significantly. At half that rate, there will only be four infections a month from now. At 40 percent of that rate, there will only be one. Below 40 percent, the virus starts to die out. If we can’t see who’s infected, a total lockdown may be our only option.

In response to a question, Ferrer noted that “up north some communities” had “been especially hard hit” with “a really astronomical increase in the number of cases over the last week in some of the northern counties.”

She went on to say, “At this point we don’t have the same trajectory as they have up north, and we’re doing everything we can in hopes that we can slow the spread enough not to be issuing orders for entire communities to self-quarantine.”

But publicly available figures don’t support this claim. While Bay Area counties currently have more cases per capita than Los Angeles — about four times as many — the increase in their number of cases is much lower. Santa Clara County has the most cases of any California county — 138 at the time Ferrer spoke, up from 45 a week before, more than three times what it had been. But LA County’s figure of 94 cases was up from just 17 a week before, an increase of more than five times.

In short, the Bay Area counties are not responding to a sharper increase in cases. Rather, they’re proactively dealing with an earlier rise in case levels, which has seen them taking more stringent measures for most of this month.

Los Angeles got its first taste of what was coming through the sharp decline in container traffic from China seen in February, but as is usually the case, what happens at the Port of Los Angeles doesn’t really register at city hall. Now, belatedly, both the city and county are taking action. But more questions than ever remain, about the virus, about how to fight it, and about how to handle the costs.

Contrary to what many assume, the best public health response will also be best economically, said Dr. Timothy Brewer, of UCLA’s Fielding School of Public Health, who also serves as chair of the board of directors for the Consortium of Universities for Global Health.

“The things we do to contain the outbreak will also minimize the economic impact,” Brewer said.

“If the government responds in a way that generates panic and anxiety, for example, not only will that probably facilitate the spread of whatever the pathogen is, it will certainly facilitate the economic consequences as well.” The repeated Wall Street sell-offs of the last three weeks seem to confirm this point.

On the other hand, Brewer said, “If the government and public health agencies are able to respond in ways that help communities to calmly and rationally deal with the outbreak, and provide the necessary knowledge, that will not only minimize morbidity and mortality, it will minimize the economic effects as well.”

This appears to be what’s happening in East Asia — not only with China, where it all began, but with Singapore, Taiwan and South Korea as well, even though China did everything wrong at first. So, if they recover from a disastrous beginning, there’s hope for us, too.

For one thing, Brewer questions predictions that 40-70 percent of the population could become infected. He noted that where the outbreak started, in China’s Hubei Province, “there have been about 68,000 cases in a population of around 60 million people.”

Even with a tenfold undercount, “That still puts you around one percent of the population where the outbreak started,” he said. The measures taken to stop the spread were severe. But Brewer cited a study in another Chinese province, Shenzhen, which found that even household contacts only transmitted the disease in 15 percent of all cases — less than one in six.

Another example Brewer cited was the 2009-2010 H1N1 avian influenza pandemic, which infected 61 million Americans, according to the CDC — 20 percent of the population. While they’re different viruses, “based on past pandemics it seems unlikely that 40 percent to 70 percent of the U.S. population will become infected with COVID-19,” Brewer said, “particularly as areas expand the implementation of public health measures to limit the spread of the virus.”

That’s exactly what Los Angeles is doing with these latest measures, which followed a week of rapidly spreading closures of venues and cancellations of events across America. But the Bay Area’s more stringent measures are likely to prove necessary, especially with such limited testing.

Another factor to consider is our most vulnerable populations — not just those over 65 or with chronic conditions like heart disease and diabetes, but those less protected from getting sick in the first place: the uninsured, the unhoused and the incarcerated are three substantial population groups at much higher health risk which are largely absent from other developed democracies. And because they’re so vulnerable, our whole society is vulnerable as well.

“We do not have routine healthcare available for the entire population, so that’s a huge vulnerability,” Brewer said.

“It means that people who get sick, we don’t have access to healthcare will not necessarily get the ability to be diagnosed, and isolated or treated. And that is going to facilitate spread in the community,” he explained. “So that’s probably our single largest vulnerability.”

It’s not just a matter of individual income levels, either. Whole communities are significantly under-served. “You see that and everything,” Brewer said.

“If you look at death rates from lung disease or heart disease or tuberculosis, if you compare West L.A. with South L.A., if you look at maternal mortality rates, there are huge differences,” he explained. “We have a number of areas where access to healthcare is just not at the level it needs to be, and that’s a big vulnerability for us.”

The incarcerated represent another huge vulnerability. “Jails are confined spaces, and confined spaces, especially spaces with poor ventilation, are conducive to transmitting respiratory infections,” Brewer said. “So, this potentially could be a very substantial issue for jails, and jails and prisons need to be thinking about how we are going to screen and protect our population.”

The U.S. has the largest incarcerated population in the world, including substantial numbers of people who are waiting trial, but can’t make bond, are elderly, serving long sentences, or are serving draconian sentences under mandatory minimum laws. Leaving these people where they are subjects them to enormous risk of serious illness or even death.

Similarly, the homeless are extremely vulnerable, as Ferrer herself noted. “Earlier this year we released some devastating mortality data around people who are homeless, and what we found was that on average, people experiencing homelessness live 20 to 30 years, less than everyone else,” she said. “Our aim is, as much as possible, to find places for them to go in and get sheltered.”

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