California marked a grim milestone this week, surpassing 11,000 COVID-19 deaths and 600,000 cases. With the outbreak of coronavirus in many parts of the state still raging, Govin Gavin Newsom alternates between restricting restrictions in some places and rolling them back into others.
California’s plan to reopen businesses and schools, like that of many other states, now depends on the use of county-specific case counts to determine whether a county has adequately controlled the spread of coronavirus.
The difficulty with this approach is that it obscures the reality that the pandemic is playing out as a story of two Californians. A single province may include these two Californias in communities only a few miles apart – yet public policy has not recognized 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 heat up the economic storm. Although life is disrupted and the future is uncertain, they know a few people who died from COVID-19.
In Second California, serious illness and death from COVID-19 is a relentless daily occurrence, as is a new and growing fear of hunger, homelessness, and economic destruction.
These two Californias are connected by essential low-wage workers in industries such as agriculture, food services, groceries and child care and elderly care, who are at risk of illness and death to provide the services that all Californians cannot live without.
Those lucky Californians in the first group ignore the fight of the second at their peril. To curb the tide of viral transmission and safely open up key sectors of the economy, we must put the needs of the most affected Californians first. Our failure to provide and maintain basic workplace and employee protection, particularly for those who are ill, has ignored early attempts to flatten the curve of the pandemic.
In California and the nation, the lack of workplace safety has brought the virus home to low-wage workers, whose overcrowding creates an environment that promotes transmission to entire households. The impending California crisis of an extreme shortage of affordable housing for low-wage workers has created a pandemic tinderbox.
Latino and Black Californians make up 63% of low-wage workers in the state and have the highest age-adjusted COVID-19 mortality rate of any Californian, three to four times that of white Californians, with deaths frequently occurring on young and middle age. Despite this disproportionate toll on nearly half of California’s population, the response to public health has been slow in neighborhoods where Latino and Black populations live and in counties that are predominantly Latino.
To address these inequalities, we need to change our understanding of the pandemic, and transform the framework of what we measure, how we measure, and how we respond. Counties currently report case counts over the last 14 days, with rates lower than 100 per 100,000 population used as a threshold for reopening of schools and various economic sectors. But these are averages that paper on enormous differences between communities with very low viral transmission farms and those with high transmission.
San Francisco exceeds the state threshold for relocation, 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 and Black residents compared to the western part of the city. The residents of Latino in San Francisco make up only 15% of the city’s population, but are more than half of their cases. Los Angeles County’s rate is 300 per 100,000, with nearly ten times the difference in rates between the cities of El Monte, which is 69% Latino, and Santa Monica, which is 13% Latino.
Concentrating solely on averages risks imposing equality in response to public health at a time when more is actually needed in communities with higher transmission: more testing, more traces, more support for isolation. And the average bond to resume may discourage more business-finding in poorer communities where low-wage workers live.
Counties can and should report on specific neighborhoods and demographic groups with the highest transmission in the last 14 days, and are held responsible for lowering these trends over time. This is the only way to ensure that resources are targeted at communities of vital importance.
Developing sensible measurements requires that tests be universally available. The persistent evidence of under-testing in communities with the highest transmission is particularly perverse. And metrics such as average number of tests per day or average positivity figures are meaningless as they represent improved access and higher tests (and re-tests) in communities with the lowest transmission.
We need increased availability and lower barriers to testing in all our communities, but especially in those with the highest need and least resources. That means tests that do not require an email address, broadband access, a car, insurance or a trip through the city. Robust testing should be followed by effective case research and tracking of contacts, ideally conducted by a public health employment agency hired from the affected communities. This helps build the confidence needed for success.
We need more workplace protection for essential workers, including adequate personal protective equipment provided by employers, increased professional studies and supervision, and strict adherence to health care requirements to minimize occupational burdens. We must also provide job protection and financial support that allows sick workers to isolate and quarantine without losing wages, as is the case in some counties throughout California, including most in hard-hit Alameda County. We need to provide temporary housing, such as hotel rooms where infected people can isolate to protect others in their household from the virus.
We can not afford to avoid our gaze by using metrics that hide the deep suffering of low-lying neighborhoods and counties in our state. Our two Californias are intertwined and we need to work with our twins to create health and economic crisis.
Kirsten Bibbins-Domingo is Professor and Chair of the Department of Epidemiology and Biostatistics and Vice Dean of Population Health and Health Equity at UC San Francisco. Margot Kushel is Professor of Medicine and the current Director of the UC San Francisco Center for Vulnerable Populations.
