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Vigilance Had a Three-Month Shelf Life
On March 1, California seemed destined to be pummeled by the coronavirus. America’s most populous state has large, crowded cities and a diverse population, and travel between it and Asia and Europe is prodigious. Seattle, another West Coast hub, had just become the first U.S. city to be hit by the virus, and a cruise ship crawling with COVID-19 was about to enter San Francisco Bay.
Three months later, California had weathered the virus’s first storm. By June 1, the state had experienced a total of 115,000 cases and 4,200 deaths. In contrast, New York State, its population half that of California, had seen 372,000 cases and 29,900 deaths, not counting thousands more who died at home. Had California’s per capita mortality rate equaled New York’s, 55,000 more people would have died.
I and others dubbed it the “California miracle.”
A month later, the miracle has evaporated. Case and hospitalization rates in California have doubled since early June. Although mortality rates have lagged, deaths will invariably follow. So will finger-pointing. How did the Golden State manage to screw things up after such a promising start? California’s experience shows that doing the right thing matters—but gives you no special privilege when you stop doing it.
A lot went right in the early months. California had good leadership (by mayors, health officials, the governor, and corporate CEOs, many of whom told their workers to stay home well before the state’s stay-at-home order on March 19), good citizenship (among residents who accepted the restrictions as legitimate and prudent, with little give-me-liberty-or-give-me-death bluster), and plain good luck.
Why luck? In February and early March, when testing was scarce and Californians were all flying blind, the state somehow avoided a super-spreader event in a nursing home or at a parade or choir practice. This meant that COVID-19 was not out of hand when the state shut down, and things remained under control until it reopened.
But the surge in cases beginning in mid-June showed that California’s luck had run out.
The decision to end the shutdown and ease restrictions on businesses, a process that began on May 8, was not unreasonable. When a new pandemic breaks out, the whole point of stay-at-home orders is to give a region’s health-care system time to build capacity, so it can better handle a modest uptick in cases after those orders are lifted. And during the relatively benign months of March, April, and May, California acquired masks, gloves, and other protective equipment; added hospital and intensive-care beds; and expanded its ability to conduct testing, contact tracing, and disease monitoring. The drugs remdesivir and dexamethasone were proved to be moderately effective. By Memorial Day, the state seemed poised to be a model of reopening successfully, just as it had been a model of a successful lockdown.
But that’s not what happened. As Californians left their homes and returned to work, as well as stores, restaurants, bars, and gyms, the state experienced surges in case numbers far larger than anticipated. Of course, states such as Arizona, Florida, and Texas, whose leaders were more cavalier about safety measures than California’s, fared correspondingly worse. (See chart) But that offered little solace as California’s per capita confirmed-infection rate caught up to and surpassed that of the nation as a whole.
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While the decision to lift stay-at-home orders might have seemed reasonable, the virus was soon spreading—and not just in newly reopened businesses. A huge outbreak occurred at San Quentin prison in Marin County after infected prisoners were transferred there from a Southern California facility. A surge of infections in Imperial County on the Mexican border was associated with cross-border traffic. The virus is undeterred by walls.
The broader problem, however, was that too many people heard “We’re starting to open” but missed the next part: “… and we have to do it safely.” Safety meant that people needed to continue to maintain their distance from one another, reliably wear masks, and avoid large crowds. As shelter-in-place rules were relaxed, too many people—particularly, but not exclusively, young ones—interpreted opening up as permission to return to their pre-coronavirus life. They grew complacent. And with complacency came sloppiness.
This is understandable. Maintaining vigilance for months on end is hard, particularly when you’re not hearing ambulance sirens wailing through the night or seeing refrigerated morgue trucks outside your hospitals. COVID-19 came to be seen as a New York problem, and Californians let down their guard.
Several other factors explained the surge, none of them unique to California. While the state is reliably blue, it has plenty of right-wingers who seem to believe that wearing a mask is a sign of weakness or party disloyalty.
Moreover, the messaging about masks was muddled, partly because the science was incomplete—the value of masks in preventing the coronavirus’s spread is far more evident now than in March—and partly because early concerns about having enough masks for the health-care system discouraged public-health officials from recommending them to lay people.
Those who didn’t want to wear masks in June found validation in March’s ambiguity. But to argue that a mask is unnecessary because Anthony Fauci or the surgeon general or the World Health Organization said so several months ago is ridiculous. I’ve yet to hear a patient in the ICU say, “I don’t want you to give me remdesivir or dexamethasone, because you told me in March that you weren’t sure they worked.” Science evolves, and reasonable people evolve with it.
Regardless of the reason Californians lowered their defenses, the virus seized the opportunity. The coronavirus doesn’t care that you had a terrific March and April, nor is it interested in who you vote for, that you don’t like the look or feel of masks, or that you’re desperate to get your job back and see your friends. It is interested only in whether it can find a warm, moist home in the back of your throat or nose. And, in June, too many Californians made those parts of their anatomy available to the coronavirus.
If in fact the shelf-life for vigilance in the U.S. is only about 3 months, new surges may occur in the fall in previously hard-hit regions such as the Northeast—unless residents remember to stay afraid. California and other parts of the country could be fated to live a deadly game of COVID-19 ping-pong for the next year or longer.
Another lesson from California is that the state’s failure to normalize coronavirus-safe behavior—much as it has normalized seat-belt requirements and smoking bans—sets the public up for failure. If we’re going to try to open up our world, we need a vigorous and creative campaign to persuade people to act safely. Having Gavin Newsom or even Donald Trump tell you to wear a mask will not be as effective as having sports and media influencers do so. The home of Silicon Valley and Hollywood has led the nation in addressing climate change and second-hand smoke. If any state can figure out how to promote safety during a pandemic, California can. For now, though, California’s surge shows that good governance is no guarantee of durable success, and that Americans’ greatest enemy may well be complacency.
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ROBERT M. WACHTER is a professor and chair of the department of medicine at UCSF. He is the author of The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine's Computer Age
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