Since New Year’s, Sara Cody, the public health officer of Santa Clara County, had been watching the news coming out of China—the cluster of pneumonia cases linked to a wholesale seafood market in Wuhan. As infections were confirmed across Asia, Europe and North America, her unease grew. “What I remember most about January and February and even into early March,” says Cody, ’85, “was just this really unsettled feeling that we couldn’t see what was going on.”
Cody, who has held her post since 2013 and spent the preceding 15 years as deputy public health officer, had been preparing her entire adult life for the possibility of a pandemic: After earning her MD at Yale and completing an internal medicine residency at Stanford, she trained as an epidemic intelligence service officer with the Centers for Disease Control and Prevention. And yet she had never felt so concerned. With a population of 1,922,200, Santa Clara is the sixth-largest county in California and contains San Jose, the 10th-largest city in the United States. It is also the heart of Silicon Valley, home to many of the world’s tech giants, and—like other Bay Area counties—a point of frequent travel between China and the United States. “We didn’t have testing at the beginning,” Cody recalls. “Right up through February 26, the only way we could test was to get permission from the CDC and send a sample back to Atlanta. We were just in this really, really, really uncomfortable place.”
Though Santa Clara confirmed its first COVID-19 infection on January 31—in a man recently returned from Wuhan—Cody didn’t know whether the virus was spreading undetected in the community, since the CDC tested only after documented exposure. In February, as cases increased, she issued a recommendation to avoid crowds. By early March, she had placed restrictions on gatherings of more than 1,000 people. “On Friday, March 13,” she recalls, “it felt impossible that I would actually be standing up there saying that you couldn’t have a gathering of any kind if it was greater than 100, and I even got a little bit choked up during the press conference because it just really hit me what that meant. Over the course of the next 48 hours, I got to the place along with colleagues from around the Bay Area that actually that was far, far from sufficient and we were going to be in trouble.”
That Sunday, March 15, marked the tipping point when Bay Area recommendations and restrictions gave way to shelter-in-place orders—the first in the United States. The decision, announced the following day, would catapult Cody into the national spotlight and lead to controversies over the scope of the orders and their economic fallout. But the shelter-in-place decision wasn’t the work of Cody alone; rather, public health officials from six Bay Area counties and the city of Berkeley made it together. And though outlying counties followed suit, not all of their public health officers agreed on the path forward. They would have to address the needs and inclinations of people who, though living within the same region, have dramatic variation in population density, occupations, resources and culture. And they would have to do so while readying their health-care systems and most vulnerable citizens for a highly contagious and potentially lethal disease.
The Ides of March
“The actual shelter-in-place decision was made very quickly in a very short period of time,” says Erica Pan, ’92, interim public health officer of Alameda County, which is home to more than 1.6 million people and covers most of the East Bay. “It’s hard for people to remember now, with what I call COVID time,” she adds, searching her memory back to March 15, that Sunday unlike any she had experienced.
Over two decades, Pan had forged ties in Bay Area public health, directing units involved with bioterrorism, infectious diseases and emergency response. “Many of us have worked on planning for this exact scenario,” she says, having previously joined forces to ready the Bay for avian flu, H1N1 and Ebola. “A lot of the players are still the same, so we have really strong, collaborative relationships.”
March 15 began with an 8 a.m. conference call among Cody and the health officers of San Mateo and San Francisco counties to sync up policies on mass gatherings so as not to confuse the public. St. Patrick’s festivities were two days away and likely to facilitate the spread of COVID-19. “Santa Clara County had more cases than anywhere else in the Bay Area and the state at that point,” Cody says. “We’d had our first death on Monday.” She also now had data no other county possessed—from a small study carried out as soon as testing was available locally. “We tested a subset of people with influenza-like illness. If their swab was in the lab and they had tested negative for flu, then we used some of our limited testing capacity to test those swabs for coronavirus. We found that 11 percent of them were positive.”
At that point, Santa Clara had only 253 identified cases and less testing than Italy had had at that juncture, and yet in less than three weeks Italy had gone from a similar number of cases to more than 24,000 infections and 1,800 deaths. “We were comparing what we looked like and what Italy looked like [on the infection curve],” Cody says, “and realizing that we actually were not that far behind.”
‘I remember looking at some basic models of exponential spread and thinking, We actually don’t have that time. We just need to move. Eventually, everyone did get on board.’
The calls the morning of the 15th soon included three more Bay Area counties—Alameda, Contra Costa and Marin—as well as the city of Berkeley, which has its own health department. Pan recalls hearing Cody describe the speed at which COVID cases in Santa Clara were doubling: approximately every three days. “We’d already tried to do various mitigation measures that weren’t necessarily slowing it down,” Pan says, “and we needed to do something dramatic. It was really important to do it together. It would be much harder for any one of us to do it alone. We’ve seen data around how fast you can have exponential rise and how much of a difference it can make to intervene in a really fast and critical way.”
All day, the already exhausted health officers hashed out details, determining the scope of essential services like water, food, sanitation, transportation and health care, the wording of press releases and whether there was time to make the order effective the following midnight. They had lawyers outline the order and spoke with local elected officials.
A lot of the work, Cody recalls, involved the health officers’ getting to the same place emotionally so they could convince county leadership. “I remember there was a lot of discussion of ‘You guys are moving too fast,’” she says. “‘This is impossible. We can never get this done. Let’s stop and think about this and do this right.’ And I remember looking at some basic models of exponential spread and thinking, We actually don’t have that time. We just need to move. Eventually, everyone did get on board.”
Meanwhile, to the North . . .
Even within the nine counties of the greater Bay Area—the six in the initial shutdown pact and the three that ring the north—the months leading up to March 15 offered different lessons about COVID. Under the guidance of public health officer Bela Matyas, ’81, Solano, one of the outer counties, played a crucial early role in understanding the coronavirus.
Solano County lies along the north shore of Suisun Bay, with Napa to the west and Sacramento to the east. “Solano has distinct personalities in the northern part of the county versus the southern,” Matyas says. “The southern is more liberal, very much in tune with the Bay Area. The northern part is much more in tune with the Central Valley.”
Solano also includes Travis Air Force Base, where, in February, hundreds of passengers were quarantined when the State Department repatriated American citizens from Wuhan. More followed from the Diamond Princess and Grand Princess, cruise ships with coronavirus outbreaks.
‘I believe nature has already proved to us that for this disease, containment is impossible.’
Like Pan and Cody, Matyas had spent his career preparing for outbreaks, with three decades in public health and epidemiology. The testing of quarantined people transformed his understanding of COVID-19. “There was a much larger number who were not symptomatic but who were positive for the virus,” he recalls. “That’s important because, until that point, the quarantine approach at the federal level was to look for people with fever, and pretty much everybody else was let through.”
The situation, he realized, was far worse than most people knew. California was the premier port of entry for travelers from China. Thousands arrived daily, and if only symptomatic carriers were being stopped, then many infectious people had returned to their communities. “We were letting large numbers of people through while we thought we were containing it,” Matyas says. “Containment is trying to stop the disease, and mitigation is recognizing that you can’t and trying to reduce the harm it causes. I believe nature has already proved to us that for this disease, containment is impossible.”
On February 26, Solano County diagnosed the first case of community transmission in the United States. The patient first reported symptoms on February 13 but, lacking documented COVID-19 exposure, spent time in two hospitals before the CDC authorized a test. Health workers suddenly scrambled to find everyone who had been in contact with the patient. At one of the hospitals, they numbered 121. “Following the CDC guidance then in place”—self-isolation of any exposed person for two weeks—“would have resulted in the hospital having to shut down,” Matyas says.
But the test results from the exposed hospital workers shifted Matyas’s perspective on the disease. “Only three became positive,” he says, “and it was really clear by how they interacted with the patient that they had significant droplet transmission unprotected. There was just no evidence whatsoever of airborne transmission.”
People with respiratory infections exhale droplets filled with viral particles. With airborne diseases, after the droplets evaporate, the active virus can travel long distances in the air, as does measles, one of the most infectious diseases known. Droplet-borne viruses, however, remain most contagious while suspended in the droplets and commonly infect nearby people who inhale them or who touch surfaces on which the droplets have fallen.
“We looked at so many people, and we had a very clear understanding of who did become positive,” Matyas says, “and they all had had genuine extensive droplet exposures. That allowed us to convince the CDC to drop the airborne containment requirements.”
Until then, hospitals first had to confirm that a patient had COVID and then put that person into an airborne isolation room. But it was clear to Matyas that there soon wouldn’t be enough rooms in the country. “Instead,” he says, “we assumed everyone who comes in has COVID and [we] used universal droplet precautions with everyone with respiratory disease. Period.”
The strategy worked, with no further cases of COVID among the hospital staff. Given its success, Matyas sees it as part of a portfolio of mitigation strategies—including social distancing, wearing masks and banning large gatherings—that he would have preferred to shelter-in-place orders. Nonetheless, he said, “every one of these decisions was made with the best of intentions under very adverse conditions with very limited information.”
Flattening the Curve
After shelter-in-place, one thing became clear: California—and the Bay Area in particular—had far fewer infections than projected. In terms of cases per capita, California ranked 32nd in the country at the end of May. Whereas New York topped the list with 20,000 cases per million, California had only 2,850—despite having had the earliest known U.S. cases. In fact, on April 23, an autopsy report revealed that a 57-year-old woman in San Jose had died of COVID on February 6—the earliest recorded death in the United States. The CDC has since confirmed that the disease was circulating in California as early as mid-January.
‘It could have been a disaster here, but it wasn’t, and I think the reason it wasn’t was the seven health officers and the mayors and boards of supervisors.’
Whereas some commentators argue that the Bay Area was relatively unscathed because of less reliance on public transportation and lower population density, George Rutherford, ’74, MA ’75, professor of epidemiology and biostatistics at UCSF, dismisses this. San Francisco County, he points out, has the highest population density in California—18,808 per square mile compared with Los Angeles County’s 2,474—and yet it has had a far lower rate of cases (3,170 per million as opposed to 6,569 per million as of June 10) than L.A. County or, for that matter, many other lower-density areas of the country.
Furthermore, Rutherford explains that the Bay Area has some of the nation’s most racially and ethnically diverse counties (by some estimates, Alameda ranks first and Solano second)—and international travel to match. “There are tons of people here,” he says. “There’s tons of diversity. We have nonstop flights to Asia and Europe. It could have been a disaster here, but it wasn’t, and I think the reason it wasn’t was the seven health officers and the mayors and boards of supervisors. If you look at the original mortality projections, the United States was looking at between 1.7 and 2.2 million deaths, which we could still get to, by the way. That would have been in the absence of doing anything. The Bay Area is 2 percent of the population of the country. Two percent of 2.2 million deaths is 44,000 deaths, and 2 percent of 1.7 million deaths is 34,000. We’ve had 420.”
A Pandemic at Bay
Regional cooperation has kept cases low even in high-density areas.
The speed of the shelter-in-place order, Rutherford argues, was significant. The Bay Area enacted it four days earlier than Los Angeles. Four days, he explains, is long enough for a newly infected person to pass COVID-19 on to several more people, since it takes an average of 5.2 days to start showing symptoms and the person could be contagious 48 hours before that. Moreover, the Bay Area was relatively compliant. “You saw the pictures from Los Angeles the first weekend after the shutdown,” Rutherford says. “Everybody went to the beach. They didn’t get the memo about social distancing.” And according to online reservation site Open Table, restaurant attendance continued in Los Angeles and New York well after it had dropped off in San Francisco.
As for Solano and Alameda counties, new cases largely remained flat during shelter-in-place, whereas in Santa Clara County—predicted to be one of the hardest hit in the nation—the curve wasn’t just flattened; it was crushed. “I expected much more transmission in Santa Clara,” says Rutherford, “and the fact that there hasn’t been bespeaks their capacity.”
The Bay Area counties extended their mutual shelter-in-place orders into May; then, as reopening began, their paths started to diverge in response to local conditions—and sometimes pressures. “The problem,” says Matyas, “is that the public we are working with as a partner in all of this has demonstrated that it really has grown tired of restrictions on our lives. That pressure by the public is going to have a lot of power in the decisions around what to do going forward.”
Reopening, Pan believes, must be based on each county’s capacities: availability of testing, personal protective equipment, contact tracers (workers who find and inform everyone who has had contact with an infected person) and hospital beds. Though she has been working steadily for months, reopening has proved particularly stressful. “Early on I was running on adrenaline,” she says; now she spends days meeting with heads of schools, hospitals, industry, congregations and long-term care facilities. She evaluates whether contact tracing and quarantining infected people in hotel rooms could interrupt transmission. By some, she is criticized for reopening too slowly or violating civil liberties; by others, for moving too quickly since the virus is still spreading.
“We know about all the social determinants of health,” Pan says, “how important it is for our economy to restart, and all the health impacts when people aren’t working, when they can’t get food and when they have increased stressors.” And yet she also took a key lesson from the 1918 flu. “Cities that shut down quickly and early and that waited it out and didn’t reopen too early actually did much better in the long run as far as not only fatalities but also their economic recovery,” she says. A recent study by Drexel University School of Public Health estimates that in Alameda County alone, 60 days of shelter-in-place prevented 70,364 hospitalizations and saved 7,291 lives.
‘It’s hard in the moment to remind ourselves that it’s the pandemic that’s caused a lot of the economic devastation.’
On May 9, Pan received her most high-profile attack. Tesla CEO Elon Musk tweeted his intention to sue Alameda County for preventing the reopening of a factory. He characterized Pan as “ignorant . . . acting contrary to the Governor, the President, our Constitutional freedoms & just plain common sense!” Pan recalls how trying that moment was. “Ultimately, my job as a public health officer is to protect the health and safety of our community, including our workers, and we were trying to have a collaborative discussion around that. To have it inflamed very publicly in the media was extremely difficult. On the other hand, I’ve been lucky. I have seen colleagues across the state who are getting death threats. I’ve had some very nasty trolls, but I haven’t actually gotten any threats. But it was really hard to be personally attacked.”
It has also been hard, Pan says, to rarely see her husband and her fifth- and eighth-grade daughters. “They’ve been understanding and they’ve been proud, but . . . I’m getting emotional now. It’s been tough since the end of January.”
When she considers the outbreak in Alameda County, she reflects on how the pandemic struck New York. “They’re having to bring in refrigerated trucks since they don’t even have room in the hospitals with all of the deaths. I’m just really grateful we did not get there, and I’m confident we won’t. It’s hard in the moment to remind ourselves that it’s the pandemic that’s caused a lot of the economic devastation. It’s been wonderful to have people trust in our decision and authority to make these decisions, but it’s also been a huge amount of pressure, especially now when everyone has intervention fatigue. People want to reopen, but we want to do it safely and we definitely can’t please everybody.”
How the Bay Area reopens may be influenced by research funded through the Chan Zuckerberg Initiative, a company that Facebook founder Mark Zuckerberg and his wife, Priscilla Chan, established in 2015. The couple donated $13.6 million for two studies conducted through Stanford, UCSF and the Chan Zuckerberg Biohub. Led by Rutherford and Yvonne Maldonado, MD ’81, a Stanford professor of pediatrics and of health research and policy, the first study enrolled 4,000 Bay Area residents to test them monthly for COVID-19 and its antibodies.
‘We’ll provide data in real time to the counties so that they know the baseline rate of infection.’
“We’ll provide data in real time to the counties so that they know the baseline rate of infection,” says Maldonado. “This will inform them of areas at risk or where people are actually at lower risk, and will help them understand how they can keep moving forward or stepping back as we try to live through this unknown period.”
The second study, led by Stanford clinical associate professor of medicine Marisa Holubar, MS ’14, and UCSF’s Sarah Doernberg and Vivek Jain, MD ’03, enrolled 3,500 health-care workers negative for COVID-19 and is testing them weekly to determine the impact of the disease on medical personnel.
Rutherford also directs a program training 10,000 civil servants who can’t do their usual jobs to redeploy as contact tracers. “We have people from the city attorney’s office, the assessor’s office and city librarians—people from county and state governments—who will become the backbone of the contact tracing workforce,” he says.
Cody’s team has already begun contact tracing and is in discussion with Stanford associate professor of pediatrics Jason Wang about an innovation to scale it up: an opt-in smartphone app that would keep a 14-day record of Bluetooth interactions between phones and notify users of exposure.
However, given COVID’s often-silent nature, Matyas is skeptical that large-scale contact tracing will be effective. “Contact tracing serves an incredibly vital function in all outbreak investigation,” he explains, “but there’s a big difference between identifying those contacts who are in high-risk environments and focusing on them to protect the high-risk environments versus tracking down everybody who could have been possibly exposed in the last 14 days.” After Solano’s first community transmission, he points out, tracing for the patient, the three infected hospital workers and one family member spanned six counties and linked 350 people.
Matyas advocates prioritizing high-risk environments, as with the single nursing home where an outbreak caused a quarter of Solano’s confirmed cases and, he explains, all but six of its deaths. “You want to identify who among your community are apt to have a more severe outcome from the disease, and you want to protect them preferentially,” he says. “For the rest of the community, what you try to do is educate on how to minimize transmission of the disease.” After all, he points out, it’s a question of how best to protect public health given limited resources.
Since COVID’s arrival, Matyas has spent his days on conference calls at the county, state and national levels while continuing to oversee the work of his team on such programs as nutrition and health promotion. As for his home life, it is thinly separated from work, as his wife runs the public health laboratory. “It does help having a spouse who exists in the same basic environment,” he says. “The only thing that I’ve been really derelict in is walking my dog, so that has fallen to my wife with great consistency.”
Going forward, Matyas wants to prohibit high-risk activities such as concerts, trade shows and parties while allowing low- and medium-risk activities with precautions. “I firmly believe that if you can create an environment where you make transmission risk negligible, then you can operate. That doesn’t make me pro-business. That makes me pro-health, because unemployment is horrible for health.”
In Solano County, which has a third of Santa Clara County’s population density, time will reveal whether his approach is workable now that face masks are widely available. “We have to recognize that we’re dealing with something unprecedented, and it’s dynamic,” Matyas says. “People are genuinely trying to do the right thing. But there are different considerations in different circumstances, and there are really genuinely different cultures across the different counties in the state and reactions on the part of those communities reflect those cultures. I don’t think any of that’s wrong.”
Like her counterparts, Cody has struggled with the repercussions of shelter-in-place. “This is extraordinarily difficult,” she says. “In a perfect world, there would be a model where you can say, ‘OK, we understand that shelter-in-place has these economic harms and social harms, and we know how to translate that into a health metric, so we can measure the short-, medium- and long-term harms of food insecurity and poverty and jobs and exacerbations of mental health conditions, and now we can navigate the most protective path given all these terrible, terrible trade-offs.’ However, those sorts of conversions and models really don’t exist.”
As the country reopens, she has spoken publicly about the dangers of moving quickly, arguing that the impact of each phase should be studied before the next is implemented. Pausing for the longest possible incubation period after each round of restrictions is lifted—“at least 14 days,” she says, “and 21 days is even better”—would allow scientists to understand whether newly resumed activities spread COVID.
Thinking back to the Sunday she and the other public health officers decided to shelter-in-place, Cody says, “It was stressful, but it’s nothing compared to how complex it is now.” She is aware of people’s hardship, the political pressure, the fear of lasting economic damage. And she increasingly feels the impact on her husband and two children. “When I’m home, I’m so tired I can hardly speak,” she says. “My spouse is trying to work from home with kids trying to do distance learning. I’m never home. My family says it’s like I’ve been deployed to war.”
Images, from top: Courtesy Santa Clara County; Courtesy Solano County; Courtesy George Rutherford; Giorgia Virgili; Erin Attkisson; Norbert von der Groeben/Stanford School of Medicine
Deni Ellis Béchard is a senior writer at Stanford. Email him at firstname.lastname@example.org.