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California marked a dark stage this week, surpassing 11,000 deaths from COVID-19 and 600,000 cases. With the coronavirus epidemic still raging in many parts of the state, Gov. Gavin Newsom is tipping between tightening restrictions in some places and canceling them in others.
California’s plan to reopen businesses and schools, like that of many other states, now depends on using the county-specific case count to determine whether a county has sufficiently controlled the spread of the coronavirus.
The problem with this approach is that it hides the reality that the pandemic is playing out like the story of two Californias. A single county can contain these two Californias in communities a few miles apart, but public policy has failed to recognize this difference, with devastating consequences.
In one California, many people have the financial and social resources to protect themselves from exposure to the coronavirus and to weather the economic storm. Although life is disrupted and the future uncertain, they know few who have died from COVID-19.
In the second California, severe illness and death from COVID-19 is a relentless daily occurrence, as is growing new anxiety over hunger, homelessness and economic devastation.
These two Californias are linked by essential, low-wage workers in sectors such as agriculture, restaurants, groceries, and child and senior care, who risk illness and death to provide the services that all Californians cannot live.
These lucky Californians of the first group ignore the struggles of the second at their peril. To stem the tide of viral transmission and safely reopen important sectors of the economy, we must prioritize the needs of Californians most affected. Our inability to provide and enforce basic protection in the workplace and workers, especially those who fall ill, undermined early efforts to flatten the curve of the pandemic.
Across California and the country, the lack of protective measures in the workplace has brought the virus back among low-wage workers, whose overcrowded housing creates an environment that favors transmission to entire households. California’s pre-existing crisis of an extreme shortage of affordable housing for low-wage workers has created a powder keg pandemic.
Latin Americans and black Californians make up 63% of the state’s low-wage workers and have the highest age-adjusted COVID-19 mortality of all Californians, three to four times that of white Californians, the death often occurring at a young and middle age. Despite this disproportionate toll for nearly half of California’s population, the public health response in neighborhoods with Latin American or black populations and in predominantly Latin American counties has been terribly slow.
To address this inequality, we must change our understanding of the pandemic and transform the framework of what we measure, how we measure and how we respond. Counties are currently reporting case counts in the past 14 days, with rates below 100 per 100,000 population being used as the threshold for reopening schools and various economic sectors. But these are averages that cover huge disparities between communities with very low rates of viral transmission and those with high transmission.
San Francisco surpasses the state’s reopening threshold, with 175 new cases per 100,000 population, but rates are ten times higher in the eastern part of the city in neighborhoods with higher numbers of Latino or black residents compared to to the western part of town. Latino residents of San Francisco make up just 15% of the city’s population, but account for more than half of its cases. The Los Angeles County rate is 300 per 100,000, with nearly ten times the rate differences between the cities of El Monte, which is 69% Latino, and Santa Monica, which is 13% Latino. Latino.
Focusing only on averages risks imposing equivalence in the public health response at a time when more is actually needed in communities with higher transmission: more testing, more tracing, more support for HIV. isolation. And linking the average to reopening may actually discourage more case finding in poorer communities where low-paid workers reside.
Counties can and should report on the specific neighborhoods and demographic groups with the highest transmission rate over the past 14 days, and should be held accountable for reducing these trends over time. This is the only way to ensure that resources are directed to the communities that need them most.
Developing meaningful metrics requires that the tests be universally available. The persistent evidence of subtesting in communities with the highest transmission is particularly perverse. And parameters such as average number of tests per day or average positivity rates make no sense if they represent improved access and higher testing (and retest) rates in communities where transmission is the most common. weaker.
We need increased availability and fewer barriers to testing in all of our communities, but especially in those most in need and least in resources. This means testing that doesn’t require an email address, broadband access, car, insurance, or a trip across town. Rigorous testing should be followed by effective case investigation and contact tracing, ideally carried out by public health staff recruited from affected communities. It helps build the confidence required to be successful.
We need more workplace protections for essential workers, including adequate personal protective equipment provided by employers, increased occupational studies and monitoring, and strict enforcement of health ordinances to minimize occupational exposures. We also need to provide job protection and financial support that allows sick workers to self-isolate and self-quarantine without losing pay, as has been attempted in some counties in California, including more recently in the hard-hit Alameda County. We need to provide temporary housing, such as hotel rooms, where infected people can isolate themselves to protect others in their households from the virus.
We cannot afford to look away by using measures that cover up the deep suffering in low income neighborhoods and counties in our state. Our two Californias are linked and together we must face our double health and economic crisis.
Kirsten Bibbins-Domingo is Professor and Chair of the Department of Epidemiology and Biostatistics and Associate Dean of Population Health and Health Equity at UC San Francisco. Margot Kushel is professor of medicine and current director of the Center for Vulnerable Populations at UC San Francisco.
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