Category Archives: global pandemic

Shelter-in-Place?

If elites have long harangued lower classes for continuing behavior that continued to spread disease, interpretation of the spread of illness has rarely divided so strikingly along separate interpretations. It is as if life or death matters were open to public debate: rarely have reactions to an infection been able to be received so clearly along partisan lines. While reaction to COVID-19 were long cast in partisan terms by the President, our Fearless Leader of Little Empathy, as far overblown, the surprise was perhaps that even as the data grew, and the exponential growth of infections in American cities began, the decision to announce Shelter-In-Place directives in hopes to “flatten the curve” shuttering non-essential businesses with increased fears of overloading public health facilities.

Faced by drastically uneven hospital bed capacities in individual states, reflecting existing fears of hospital bed capacities for intensive care units or floor beds, and deepening fears of needs to add increased beds across the nation, to confront a major public health emergency. Using different scenarios of increased needs for beds based on infection rates, a relatively moderate need for beds: infection of a fifth of the population in six months would compel expanding existing capacity for beds in multiple western states already hard-hit form infections, like Washington and California, east coast states, including Massachusetts and New York, and Midwest’s like Ohio, Michigan, and Minnesota, and many pockets of other states, including Louisiana. Actual fears of such an impending emergency of public health emergency —

The Upshot/New York Times/March 17, 2020

–grows even sharper if one allows oneself to imagine an expansion of infection rates to 40%–not unheard of for the highly infectious novel coronavirus–over the same six month period:

.The Upshot/Interactive Version/March 17, 2020

1. Even as “Shelter-in-Place” measures sought to staunch the spread of infections across the nation, the uneven nature of the measures adopted by state governors, mayors, and counties suggested a fragmenting of the nation, as the governors of many states reacted to the issuance of shelter-in-place orders or stay-at-home directives by declaring their separate rule of law, in the words of Alabama’s Governor, “we are not New York state, we are not California–right now is not the time to shelter in place.”

Shelter in Place Measures Confined to Bay Area/Washington Post, March 15

Yet if the confirmed infections of the novel coronavirus seemed concentrated in preponderance in Louisiana, California, and New York, the virulence of its transmission was far more widely distributed, Philip Bump created a simple overlay to show, and the readiness of imposing measures of restriction were often resistant to accept school closures, or shuttering bars and restaurants as a means to restrain the virus’ spread.

httpsPhilip Bump, Washington Post, March 17 2020

Such choropleths are poor indicator of concentration and dispersion of infection, or of the “hot-spots” early watchers of the novel coronavirus hoped to isolate, folks commuting from counties of identifiable outbreaks created an immediately far more complicated map of viral dispersal, often crossing state lines and state jurisdictions at the very start of March, as work commuting alone bled from 34 counties into 1,356–even into Mississippi!

County-to-County Commutes from Confirmed Cases of Coronavirus COVID-19/March 3
BRENNEJM, r/dataisbeautiful/

Despite some a lone call the President impose a national shelter-in-place order, but the response of asking for a collective sacrifice would be hard to imagine. But the animosity that Trump revealed to any governors who tried to impose a policy of social distancing has intensified a new sense of federalism, as the increasing opposition that President Trump has directed toward Governors who have responded with attempts to enforce social distancing led, mutatis mutandis, to a new call for “liberating” states from social distancing requirements, President Trump announced April 21 that “We are opening up America again,” with great content, heralding an “opening” across twenty states comprising two-fifths of the nation’s population, if partial reopening are only slated in eighteen states.

But how could one say that the need for social distancing was not increasingly important, in a nation where health care is not only not accessible to many, but that hospital bed capacity is uneven–and would need to be ramped up to serve the communities–

–but that many areas are distant from ready testing, diagnosis, or indeed the ability for easily accessible health care? What is COVID-19, if not a major wake-up call for disparities in public health and medical access?

New York Times

–and many regions suffer severe health care professional shortages, that have been obscured in the deep shortages of health professionals, according to Rural Health Info, who have revealed these gaps in the following infographic, but many towns in each county remain difficult to get to hospitals in time in cases of emergency or need.

2. The legitimacy offered to “re-opening” states for business channeled a rousing sense of false populism across the nation, courting possible onset of a second wave of infections by easing llocal restrictions on social distancing–although testing is at a third of the level to warrant safe a transition, several governors claim “favorable data” to justify opening shuttered businesses. But when @RealDonaldTrump retweeted an attack on public safety measures against COVID-19 that were enacted in California and other states to slow airborne viral infection that labeled the closures of bars, restaurants, and theaters as revealing local states’ “totalitarian impulses” in the face of COVID-19, as having effectively “impaired the fundamental rights of tens of millions of persons” and flagrantly abrogating constitutional rights and natural liberties: the endorsing of a tweet of former judge, Andrew Napolitano, of an open “assault our freedom in violation of Constitution” demeaning sheltering policies as”nanny-state rules . . . unlawful and unworthy of respect or compliance,” inviting the sort of social disobedience, encouraging the stress-test on our nation that the pandemic poses be generalized?

COVID-19 Infection Rates in United States/New York Times/March 27, 2020

While the calls to prevent violations of the U.S. Constitution have grown in recent weeks from March to April, it makes sense to question the validity of an eighteenth-century document to a public health emergency–or to abilities to respond to a zoonotic disease of the twenty-first century. Never mind that such arguments ignore the reserving of rights of state governors in the U.S. Constitutions Tenth Amendment to protect the safety, health, and welfare of the inhabitants of their territory, is the ability to manage state health not a calculus for public health officers, rather than a partisan debate? There is a despicable false populism and rabble rousing in decrying “nanny-state rules” as “unlawful and unworthy of compliance,” and covers for “assaults on freedom” as a Lockeian natural right. Yet in retweeting such charges and denigrating policies of social distancing as “subject to the whims of politicians in power,” President Trump perpetuated the notion that medical consensus was akin to an individual removed from public concerns. In doing so, Trump echoed the opinion of a member of his own Coronavirus Economic Advisory Task Force, Heritage Foundation member Stephen Moore, to protest “government injustices” echoing false populist calls to “liberate” Michigan and Minnesota from decrees of Democratic governors. As Moore called for further protests, opening a group, Save Our Country, dedicated to agitating for the reopening of states, out of concern for the “abridgment of freedom” of sheltering in place.

The call to arms over a rejection of social distancing emphasized the translation of the pandemic into purely partisan terms, and echoed the partisan resistance to the states-right discourse of a rejection of health care, using the panmdemic to divide the nation along party lines.

3. The weekend before SIP was announced in the East Bay, my daughter’s High School suspended, and I snuck out in the mask-free days for a Monday morning coffee at my favorite café, where my friend Mike caused some consternation in line by ordering through his black 3M facemask. The mood was survivalist and grim, but we stopped outside our local Safeway, as if to provisions before an impending lockdown, looking for half-and-half. Staring me in the eyes, Mike said with some resignation that the massive mortalities in northern Italy were our future in a week at most, as the spreading waves of infections migrated crosscountry, approaching in something like a delayed real time; the question was only when “It’s gonna happen here.

What was happening across the Atlantic Ocean was trending not only on social media, but was being attentively followed by epidemiologists like Dr. Cody, apprehensive of the state of development of pubic health across the entire East Bay.

The Public Health Officers in the region had been haunted by the vision, alerted by the tangible fears of the Santa Clara Public Health Officer, Dr. Sara Cody. That very day, Cody was convening the coming early Monday morning, gripped by a sense of panic for a need for action, as the public drinking festivities of St. Patrick’s Day loomed, and as Chinese health authorities curbed travel and cancelled New Years celebration, even if its airborne communication was doubted, in hopes to contain an outbreak that still seemed centered in its largest numbers in Wuhan province–

Quartz, January 22, 2020

4. It was if we were watching in real-time image the global ballooning of COVID-19 infections in the Bay Area feared was on its way to Silicon Valley, or the entire Bay Area, as the virus traveled overseas. The lockdown that had begun in northern Italian towns in a very localized manner from late February when a hundred and fifty two cases were found in Turin, Milan, and the Veneto, had, after all, only recently expanded to the peninsula, filling Intensive Care Units of hospitals or transforming them to morgues. Although elegant graphics provided a compelling narrative, with the benefit of retrospect, that “Italy’s Virus Shutdown Came Too Late,” the interactive story of a “delayed” shutdown after the February 24 shutdown of sites of outbreak within days of the first identification of an infection in Milan, across two “red zones” around Italian cities, and the March 3 cordoning of larger areas.

February 24, 2020 Lockdowns in Northern Italy
Lockdown in Response to COVID-19, March 8 2020

The reluctance to impose a broader shutdown over the northern economy created a tension between commerce and public health that led to a late ‘shutdown’ of the movement across the peninsula by March 10 to prevent infection risks, haunted by public health disaster.

Multiplication of COVID-19 Cases in Italy, February 27-March 12, 2020 BBC

Fears of the actuality of a similar public health disaster spreading under her nose led Dr. Cody to convene a quick check-up with local public health officers to see if they registered a similar alarm, and what policy changes were available across a region whose populations are so tightly tied. And the need to convene a mini-summit of Public Health Officers to take the temperature of willingness to recommend immediate public policy changes was on the front burner, as one looked at the huge difficulty of containing the outbreak in Italy–often argued to not have been responded to immediately enough, but revealing a full public health response that the Bay Area might not be able to muster, as Italy’s hospitals were flooded by patients with infections and was on its way to become the site of the most Coronavirus deaths.

Vivid fears a growth of COVID-19 filling the hospitals and emergency rooms after St. Patrick’s Day–an event for a far larger audience contracting the aggressive virus–led Dr. Cody to arrange a group call among the Public Health Officers in San Matteo and San Francisco early Monda. Dr. Cody had broad epidemiological training was rooted in an appreciation of contagious disease–including contagious diseases outbreaks like SARS, H1N1 influenza, and salmonella, and had worked on planning for public health emergencies and completed a two yer fellowship in Epidemiolgoy and Public Health, managing E. coli outbreaks as an Epidemic Intelligence Service Officer with CDC. Fears “crystallized” quickly of a scenario of similarly exponential rise in case loads making Silicon Valley a new epicenter outbreak of an epidemic overwhelming the public health services. As she quickly contacted Public Health Officers in San Francisco and San Matteo, to contemplate a response, by March 8, a lockdown in all Lombardy and other states was declared, as COVID-19 cases multiplied, in a chilling public health disaster replicating the lockdown in China.

In contrast to the uncertain public health numbers from China, as the city’s airport, highways, and rail stations, images of massive mortality from health care disasters in Italy were haunting and suddenly far closer in space, even if cases of viral infection were already reported in each province, Macao, Hong Kong, and Taiwan–revealing a global pandemic that linked place to a global space in ways difficult for some to get their minds around. The honesty that came out of Italy was an alarm.

The Bay Area health authorities were looked with apprehension at the arrival of St. Patrick’s Day celebrations, after the exponential growth of infections from COVID-19 in the region: Dr. Mirco Nacoti had just published an eye-catching account of the catastrophic conditions of Ospedale Pap Giovanni XXIII in Bergamo that weekend, describing the levels of general contamination of caring for COVID-19 patients, for whom over two thirds of ICU beds were reserved, and filled a third of 900 rooms in thd peer-reviewed NEJM Catalyst; he described phantasmagoric scenes of a hospital near collapse as patients occupied mattresses on the grounds, intensive care beds had long waiting lines and with shortages of both masks and ventilators, and poorly sterilized hospitals became conduits for the expansion of diseases. The clinical model for private care incapacitated, as patients were left without palliative care; a surge of deaths in overcrowded wards overtook China’s community-based clinics at such higher death rates of 7,3% Italian doctors plead felt incapacitated by the surge of cases overflowing at intensive care units from March 9-11 as a model for mass infection, before COVID-19 was declared a pandemic.

The desperation of a staged re-enactment of Michelangelo’s Pietà of L’Espresso were a few weeks or so off. While the spread of infections in our region had not yet begun, ant eh below photoshoot by Fabio Buciarelli did not appear until April 5, we were still formulation the desperation of confronting the ravages of disease we lacked time to develop any reactions, processing current or impending mortality rates.

Fabrizio Bucciarelli/COVID-19 Pietà. 5 aprile 2020, L’Espresso

The danger of trusting scientific modeling, or data, and fostering deep suspicions of trusting data on confirmed infections, or modeling that suggested the danger of failing to practice social distancing.

5. Decisions to “shelter in place” promised to “slow the spread” of COVID-19 transmitted widely in group settings, and able to create a public health disaster in the Bay Area, and was quickly followed by Santa Cruz county. After the growth of cases in Santa Clara county–whose rates of infection doubled over the weekend to 138 as of Monday–the absence of a any national restraining order save a suggestion to social distance, as Seattle cases of infection had grown to 400–and some 273 cases of infection had appeared over th weekend, despite limited testing availability.

The clear eventuality of a public health disaster, after a directive closing bars, night clubs, and large gatherings, as well as many school closures in San Francisco and the East Bay–where my daughter attends Berkeley High, whose doors shuttered on March 13; Los Angeles’ mayor, Eric Garcetti, closed bars, gyms, movie theaters, bowling alleys and indoor entertainment on late Sunday night, as Gov. Newsom encourage all elderly to self-isolate immediately. The 6.7 million in the Bay Area early agreed on the need for a “shelter in place” order as a basis to control the spread of COVID-19 that had been discovered in the region on March 16, 2020, anticipating the nation by some time.

The closure of all non-essential businesses in the seven counties sprung from the epicenter of Santa Clara county–Silicon Valley–but included affected a much larger area of commuters, no doubt, across an interlinked region of commuting far across the northern state to twelve other counties.

The cases in Italy would only grow, creating a textbook case of the exponential expansion of illness that killed a terrifying number of physicians in hospitals on the front lines against its expansion, as the arrival of medical supplies and medical viral specialists from China increased the logic of the lockdown as a response to its spread.

The evident stresses on the health care system of Lombardy, where a terrifying number of physicians on the front line contracted the virus and died, in the wealthy region of Lombardy, distanced the disease whose effects were projected or distanced onto China, and provided a clear scenario that Cody understood could be repeated, with even worse consequences, in the crowded population and limited health facilities of Santa Clara County: her own close ties to public health authorities in Italy made the exponential growth of cases from February 21 across the peninsula seem a preparatory run-through for a future disaster, as China was sending increasing medical supplies and specialists to Italy in a global story as a pandemic was declared in China March 11; northern provinces were declared under lockdown March 8 quickly extended to the nation, as a spike in 1,247 cases were found on the previous day.

When Cody urgently alerted San Francisco Public Health Officer, Dr. Tomás Aragón, to discuss the fears of a new epicenter of COVID-19 spread in Silicon Valley, they did not start by contemplating their authority to issue a legally binding directive to shutter businesses in the region. But as they discussed consequences of the exponential increase in Santa Clara County and the greater danger of facing an analogous overwhelming of pubic health hospitals as in Italy, haunted by a danger of a similar scenario overwhelming public health, and Cody’s tangible fear, Aragón floated the idea of a shutdown, acknowledging their authority of acting without permission of governors.or mayors or county supervisors; the call touched on a series of calls to debate options, including the most dramatic — a lockdown order–which seemed the only certain means to enforce isolation and social distancing haunted by the image of the increased diagnosis of COVID-19 across the Italian peninsula that would indeed only be publicly released March 18. Two days later, Governor Newsom expanded the policy to the entire state; the time lag meant that by late April, almost half of all infected with the novel Coronavirus in California were found in Los Angeles County, and were facing the prospect of overloading its public health system and hospitals.

Diagnoses of COVID-19 in Italy/ Ministero di Sanitá, March 18 2020

The influence of the health care provider Kaiser Permanente was unseen, but the preventive agenda of the health provider can be seen in a sense in the shadows of this quick consensus among six Public Health Officers. But the qyuick defense of the decision–soon followed by dozens of states since–suggests the prominence of Kaiser Health Care in the dynamic of emphasizing preventive health care, and in anticipating epidemiological spread. Cody’s brave insight into the fact that northern Italy provided a rehearsal for the public health disaster, shifting from the ban on mass gatherings to a concerted effort to isolate millions, was less apparent to the nation.

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