California locked down early and took the coronavirus seriously. Why are its cases still rising?

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Drive-up Covid-19 testing in Los Angeles. California is among the states that has seen flat or rising case numbers under stay-home orders. | Kevin Winter/Getty Images

How California finds itself in limbo despite doing many things right.

In late February and early March, when much of the United States wasn’t yet taking the coronavirus pandemic seriously, the state of California — the first place in the country to spot community transmissionlargely was.

Major tech companies in the state told their employees to work from home by the end of February or the first week of March. LA’s enormous TV and film industry largely shut down voluntarily in early March out of fears of spreading the virus among the hundreds of crew members and actors who circulate on sets every day.

Local leaders and the governor declared a state of emergency early in March while, in New York, Mayor Bill de Blasio was still infamously encouraging people to get out and enjoy themselves. For a while, the state was touted as a success story — and in some sense it is one. San Francisco, with only 36 coronavirus deaths, certainly deserves a victory lap. Statewide, the death toll has reached more than 3,000 in a state with 39 million people. If the country had managed the virus as well as the state of California did, America likely would have had far fewer deaths than the about 90,000 tallied so far.

But now, California is in limbo and is making very little progress toward an exit strategy. Case numbers aren’t falling, despite the lockdown. Testing is increasing, but too slowly. The state can’t meet its goals for contact tracing and isolating exposed people. The state’s guidelines for when to reopen look reasonable, but it’s not clear when (or if) they’ll actually be met.

This is bad news. It’s also jarring, because California has more resources, more public cooperation, and in many respects better leadership than most states. If all those advantages have nonetheless left the state with no real path to reopen, it seems as though most states should expect even worse. California’s experience illustrates just how vexing the coronavirus has been to deal with — and just how steep the challenge is for the country as a whole as it inches its way to a reopening that it hasn’t yet earned.

California’s public health leadership has been pretty good. It hasn’t been enough.

On March 20, when a statewide stay-at-home order was put into place across California (one had already gone into effect four days earlier in the Bay Area), about 1,000 cases had been detected in the state and about 20 people had died. The hope at the time was that the stay-at-home order would not just “flatten the curve” — causing new case numbers to grow more slowly — but crush it, getting case numbers much lower so that the state could safely reopen.

For weeks, public health officials watched to see if the stay-at-home order had worked. Case numbers in California grew more slowly than elsewhere in the country — but they did keep growing. The order, originally set to expire April 7, was extended through April, and then extended through May. (The state has inched — more slowly than most other states — toward opening low-risk businesses, with social distancing measures in place.)

Now there have been more than 75,000 cases reported in California. The first week in May had a spike in confirmed cases. The second week had even more, with cases at their highest numbers yet. That might be partially an artifact of improved testing — as more tests become available, more people test positive. But other indicators not dependent on testing aren’t that great, either. New deaths in the state have been effectively flat, at about 70 a day. The number of hospitalized coronavirus patients has also been effectively flat, maybe declining very slightly. (The state is not homogeneous; things look better in the Bay Area and worse in Los Angeles.)

That’s a problem. One of the hopes for stay-at-home orders was that they would cause significant declines in new case numbers, not just get to a plateau. Once new cases become relatively rare, states could set up contact tracing, isolation of confirmed and possible cases, and other less restrictive strategies for combating the virus.

That remains the best way out of lockdown, but those strategies are harder to implement when case numbers keep rising. The fact that California’s stay-home order didn’t decrease, or only slightly decreased, the number of new cases means that the road ahead will be a very hard one.

“The US was not able to reach suppression with our lockdown,” virologist Trevor Bedford wrote last week, “and so we’re left with agonizing decisions about how to keep society functioning while holding the virus in check.”

What went wrong? The best explanation is that California’s stay-home order, like many orders around the country, did not get the so-called R0 for the coronavirus to significantly below 1 (some preprints estimate it around 0.9).

Let’s spell that out. An R0 of 1 means that the average person with the coronavirus transmits it to about one additional person. Things won’t get exponentially worse, but nor will they start to improve. Over time, case numbers will stay relatively flat and “crushing the curve” will be out of reach. What this all adds up to is that, despite months of lockdown, case numbers are not going back down.

The California stay-at-home order still involves more face-to-face contact with other people than the lockdowns in places that successfully controlled the virus. California hasn’t adopted centralized isolation, for instance, which would let sick people avoid infecting family members, and has a large homeless population exempted from the stay-home orders.

A CDC estimate suggests about 50 percent of Californians were still leaving their homes regularly after the stay-home order. In Italy, by contrast, mobility fell 85 percent under their lockdown. “That’s still 50 percent” at risk of exposure and of transmitting the virus, UC San Francisco epidemiologist and infectious disease expert George Rutherford told the Los Angeles Times.

California is in limbo

If we take China’s statistics from Wuhan at face value — and, to be clear, while China is an authoritarian state with a long history of lying to the international community about infectious disease, there’s some virology data suggesting their numbers are in approximately the right ballpark — Wuhan’s comprehensive lockdown reduced the transmission of the coronavirus to an R0 of about 0.3. That means three infected patients will, between them, infect just one new person, so case numbers will drop fast.

“Big interventions in Wuhan, China, took about three weeks to start to reverse things. And then every day after the situation got better,” Johns Hopkins Center for Health Security director Tom Inglesby explained on March 23. Eventually, the virus was squashed, with China reporting no new internally transmitted cases. Now that they’ve started to reopen, they’ve found a few tiny clusters of more cases, but not many — letting the region focus its public health resources on each cluster as it appears.

New Zealand has done something similar. The country maintained one of the world’s strictest lockdowns while case numbers declined, and residents are now exiting lockdown with lots of capacity for testing and almost no new cases. The country estimates that R0 was 0.4 under lockdown.

That’s the path many US states likely were hoping they’d find themselves on when they issued stay-home orders in March. Instead, new confirmed case numbers suggest that many states — like California — entered a lockdown that was not strict enough to actually reduce case numbers and that instead produces a long plateau. (You can see this pattern in Nevada, Tennessee, Oklahoma, and South Carolina, for instance.) Successful suppression of the virus remains far in the distance.

And even worse, California has largely been unable to take advantage of the time the lockdown buys them to increase testing capacity, provide hospital workers with sufficient personal protective equipment (PPE), or establish large-scale contact tracing programs. The state’s much-praised leadership had a hard job ahead of them, to be sure — but they haven’t gotten it done.

In other words, the state is in limbo. Lockdown isn’t much improving things, but the state is increasingly itching to get out of it. Case numbers do not get better week to week despite the huge sacrifices of a lockdown. The situation will not improve until testing and tracing step up, which they did not meaningfully do in April and may be doing only very slowly in May.

“The whole point of this social distancing is to buy us time to build up capacity to do the types of public health interventions we know work,” Natalie Dean, a biostatistics professor at the University of Florida, told my colleague German Lopez. “If we’re not using this time to scale up testing to the level that we need it to be … we don’t have an exit strategy. And then when we lift things, we’re no better equipped than we were before.”

The fact that California is in this boat portends poorly for other states. California was praised early in the pandemic for having good public health leadership. It is a relatively wealthy state with unusually high state revenues, a strong medical system, and lots of biotech companies. If California can’t make it out of limbo, what does that mean for other states?

California hasn’t accomplished the things on their list of must-dos to reopen

California Gov. Gavin Newsom (D) said in April it would require contact tracing capacity, declining case numbers, PPE in hospitals and nursing homes, and 60,000-80,000 tests per day to consider reopening the state. That’s 150-200 tests per 100,000 residents.

But even this modest goal has been excruciatingly difficult to achieve. Throughout the month of April, testing in California mostly didn’t increase, stuck at just over 25,000 tests each day. In May, that has finally started to change, but at a glacial pace. Last week, the state averaged 34,000 tests per day. Overall, the state is in the bottom half of states in tests per capita, worse than Mississippi, as of May 11.

The progress has been uneven. San Francisco is currently conducting about 168 tests per 100,000 residents a day, while neighboring Alameda County, where I live, is testing just 28 per 100,000. Efforts to expand testing have run into difficulty on all fronts, “complicated by regulatory restrictions, supply constraints, and a shortage of trained personnel,” MIT Technology Review argued in early May.

Other experts have pointed to overreliance on commercial labs in March and April as an explanation for the state’s slow start. Whatever the exact cause, it’s clear that the political leadership wasn’t able to deliver on one of the most critical elements of a reopening plan.

When it comes to contact tracing, progress has been even slower. Mass hiring is needed to field the teams of thousands of contact tracers needed to reach out to people exposed to the virus. But all of April went by before California got started on substantially expanding its tracing ability. It is only in the last week that UCSF and UCLA announced plans to train 3,000 tracers a week.

And PPE remains in short supply at hospitals across the state — a reflection of worldwide shortages, to be sure, but still one of the problems the lockdown was supposed to help with and has not.

California isn’t alone in this. “[W]e all went into lockdown at incredible cost to ourselves right now, and to our kids in the future … and still six weeks go by and I don’t see huge improvements in testing capacity, in serology, in PPE, in hospital capacity. These things just haven’t happened,” the Center for Health Security’s Tara Kirk Sell said last week.

Much of the blame there lies with the federal government. By refusing to exercise any national leadership on testing, officials have left states trying to invent the right policies on their own. By seizing state shipments of PPE, they’ve made it much harder for states to get the equipment they need.

But ultimately, the White House has abdicated all responsibility for improving the coronavirus situation, and states can only be judged by how well they perform in the face of that abdication. California might have been one of the states expected to perform well. After all, Newsom, an established critic of Trump, seems to have been well aware he couldn’t expect any aid from Washington. Instead, he formed reopening pacts with many neighboring states, caused a stir by referring to California as a “nation state” in its own right, and has proceeded with adjustments to the state lockdown order while ignoring the president.

And yet, the state remains stalled, both when it comes to case numbers and when it comes to the other criteria for reopening.

Some states are seeing a decline in cases. What makes them different?

While California is stuck in limbo, some parts of the country have more promising statistics. Take Connecticut, New Jersey, and New York, the hardest-hit part of the country: In those areas, new case numbers, new hospitalizations, and new deaths dramatically declined (though Connecticut’s new case counts have leveled off in recent days). In the US overall, excluding those states, new confirmed case numbers haven’t been falling.

A chart of America’s diverging coronavirus epidemics.
German Lopez/Vox

What’s going on in the rest of the country is pretty clear: There’s a mix of “limbo” states like California with stagnant or slowly declining case numbers, and “trouble” states where case numbers are actually increasing.

But what’s going on in New York and New Jersey?

Their progress could stall. But one possibility is that the severity of the outbreak in those areas produced higher compliance with stay-home orders, which meant that R0 actually fell below 1. Another is that those states, by virtue of testing more, drove R0 down, and California might start to see the same results if officials ramp up testing to New York levels.

A more discouraging explanation is that, since something like 15 percent of people in those states have now been exposed to the coronavirus, it’s easier to reduce transmission. A similarly strict stay-home order to California’s will do more to reduce transmission in a state where many people have already been infected. That interpretation would suggest that states can only get out of limbo at a horrific human price: New York has lost more than 25,000 people to the virus, and tens of thousands of others may suffer long-lasting effects.

Overall, this paints a scary picture; lockdowns alone, no matter how long they last, won’t save us. All they can do is buy us time, which doesn’t matter if we don’t have the capacity to use it well. Even the early success stories are now floundering when it comes to that. Lockdowns are worth it if they buy us successful suppression. But they cannot possibly replace lasting suppression, no matter how much economic hardship you’re willing to permit. In limbo, we lose the economy and lose lives to the virus. There has to be a better way out.

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