Los Angeles is applying disaster.
An explosion of COVID-19 patients has begun flooding hospitals and could soon force doctors to become rations. The number of available beds in intensive care units is rapidly declining to zero, as healthcare providers are urging people not to come to emergencies unless it is a matter of life or death.
“Ambulances circulate for hours in hospitals to find one who has a bed open so they can take their critically ill COVID patient to their air,” a doctor at a public hospital in LA County said last week, and the describes ‘apocalyptic’ scene. “We’re literally hanging on to a wire.”
And there are no signs of procrastination. The expectation is that the number of COVID-19 patients in hospitals will grow until January – or beyond Christmas travel and social gatherings will fuel the further spread of the virus.
If there is another wave within a few weeks, it will ‘lead to a vision of people in the corridor in northern Italy, in New York,’ said Mayor Eric Garcetti in an interview. “We’re about to do that.”
The serious situation has caused confusion and upset among Angelenos, many of whom are wondering if their sacrifices over the past nine months have been in vain. LA County was an early adopter of masks, quickly instituted home orders in March and November, and has so far kept its rate of coronavirus cases and COVID-19 deaths relatively low.
What went wrong then?
Interviews with 31 epidemiologists, health experts and public officials provide clues: LA was far more vulnerable to an extreme crisis than almost anywhere else in the country.
The trifles of fatigue, winter weather and holiday trips that led to more transmission of the coronavirus across the country also hit here – and became the match that ignited the fuel box.
The popular image of LA – hills on the hill, urban expansion and drivers combed in their cars – condemns the grim reality. LA County, home to more than 10 million people, suffers from high poverty and homelessness, large numbers of essential workers and some of the most densely populated neighborhoods in the country.
‘There is no city as big and complex as LA. The nearest can be New York. And we saw what happened in New York, ‘said Dr. Kirsten Bibbins-Domingo, an epidemiologist from UC San Francisco, said.
Experts also identify LA’s problems with rules that may appear inconsistent or arbitrary, as well as a confusing patchwork of policy in Southern California. Furthermore, the province is investigating whether a more contagious strain of the virus, which is spreading in the UK, may be partly to blame.
According to epidemiologists, LA has mostly taken the right steps and, with a little luck, managed to hold on to a crisis for months.
“Now, some of the luck is up,” Garcetti said.
November brought a boom
An increase in coronavirus cases that began in early November has put LA County officials on the lookout.
By Thanksgiving Week, 4,000 people tested positive every day, which was a record for the country at the time. Barbara Ferrer, director of public health in LA County, thought the numbers were likely to peak.
Then hit Thanksgiving.
“We realized, ‘Oh, my God. We are all traveling, like hundreds of thousands of people, ‘she said in an interview last week. “We got really scared at that point because we just knew in our core that we had a boom on top of a boom on top of that.”
LA County now has an average of 14,000 new cases of coronavirus per day.
The coronavirus rose throughout California in November, the start of an increase predicted months earlier. The progress reflects that of the flu pandemic in 1918, when the autumn peak was five times greater than that of spring.
The coronavirus is thought to thrive in colder, drier weather, making transmission more likely during this time of year. Short days in winter can also encourage people to spend more time indoors, where the virus can spread easily.
Until November, California avoided the violent outbreaks that erupted elsewhere in the country. Once the virus began to spread more, a higher percentage of the population was susceptible, experts say. Since Californians had not yet seen so much early destruction firsthand, they may have had the false belief that the pandemic was manageable.
“People get tired,” said Dr. Grant Colfax, director of public health in San Francisco, said. “It’s been ten months, and I think people started to let their hats down a little bit more, because we were relatively good.”
A high ‘social vulnerability’ score
After picking up the transfer in the fall, LA faced unique challenges.
LA County has a large manufacturing sector and two of the largest ports in the country – industries staffed by people working in the immediate area that can facilitate the spread of the virus. LA’s factories – where individual outbreaks have infected more than 400 people – have been a major driver of cases throughout the pandemic.
LA County also has a highlight “Social Vulnerability” Score as calculated by the U.S. Centers for Disease Control and Prevention, is a measure of how severe a region can be by a natural disaster or disease outbreak, based on factors that include average income, education, and housing status. The province’s score is worse than anywhere in the Bay Area or neighboring Ventura and Orange, suggesting that it will always be harder for LA to withstand a COVID-19 boom without fatal consequences.
“This is what came home: Los Angeles has the combination of poverty and density that causes a virus like this to spread much faster and be more devastating,” Garcetti said.
LA’s expensive housing market has also hurt the region. While density measures how many people live in a geographic area, another measure, known as ‘pressure flow’, follows how many people live in a house. Having more than one person per room, excluding bathrooms, is considered overcrowded.
But in LA, it’s common for a working class family of four, five or even more to share an expensive one-bedroom apartment.
Among the 25 largest metropolitan areas in America, LA has the highest percentage of overcrowded homes, according to data from the U.S. Census Bureau in 2019. Eleven percent of LA homes are considered overcrowded, compared to about 6% in New York and the Bay Area.
An analysis published in the Journal of the American Medical Assn in June. found that the chance of becoming ill due to the coronavirus is not significantly affected by the poverty rate or the density of a person’s environment, but clearly increases as the overpopulation increases. An infected home can have an infected person nowhere to isolate to prevent others from getting sick.
“The more people you infect and the denser people are housed, the more links there will be,” said Dr. George Rutherford, epidemiologist at UC San Francisco, said.
In a province as large as LA, the spread has become ‘exponential growth’, with each new person infected, making it more likely that others would become infected, Ferrer said. It is currently estimated that 1 in 95 people in the country are infected with the coronavirus.
“I do not think people listen”
Ferrer is now focusing on breaking the transmission cycle. Her department banned out-of-town restaurants and government officials issued a local home order lasting through the holidays. But she knows she’s lost some public confidence over the past few months.
In the spring “I drove to work every day, and there would be, like two cars on the road – no one was out. And we definitely do not have it this time, “said Ferrer. “I don’t think people listen that much.”
Ferrer said dissenting views of locally elected public officials that have emerged in recent months have defied compliance with regulations. Two members of the county’s board of supervisors, Kathryn Barger and Janice Hahn, excited the Department of Public Health for advocating a ban on eating outdoors. The three other supervisors and Garcetti supported public health officials.
“Once there is a sense that there is no unity – that we do not all speak with one voice – it also creates a different kind of confusion and in some cases has led to a major challenge,” Ferrer said. “This is a disaster for us.”
In San Francisco, where officials report that new daily cases of coronavirus are starting to flatten out, visits to retail and recreation sites are 55% lower compared to baseline, according to Google’s COVID-19 Community Mobility Report. In LA County, they are down just 24%.
Some experts suggest that LA’s declining compliance with public health guidelines may be due to overly strict rules that have sown distrust among a public that once complied with them. The recent controversial closure of playgrounds (later reversed) and the ban on small outdoor events, while keeping indoor retail businesses open, has led to criticism that decisions are driven by economics rather than public health considerations.
“Meetings with masks outside are a very low risk activity, and therefore it is wrong to limit them,” said Leo Beletsky, a professor of health sciences at Northeastern University. “There were a number of cases where restrictions were not carefully adjusted to the evidence and were not clearly communicated, which opened the door to misinformation.”
Ferrer and other experts defended rules to reintroduce a ban on most gatherings, pointing out that it is clear that when new people do not mix, new infections go down. However, she acknowledges that it is a complicated message to explain that activities that were considered OK a few months ago are no longer safe due to the large number of people who are ill.
Overall, the rules that apply throughout the pandemic have helped LA a lot, Ferrer said – a view many experts agreed with.
While LA’s case numbers are astronomical, it’s in part due to widespread testing, making it difficult to compare the region to other parts of the country, she said. When it comes to cumulative mortality rates, which are less affected by the availability of tests, 93 out of every 100,000 people in LA County died from COVID-19, less than the 134 in Illinois, 121 in Arizona and 103 in Florida. If LA County were a state, it would be about 28th in terms of mortality rate.
LA’s death toll remains far from the disaster of New York in the spring. New York City reported a total of nearly 25,000 COVID-19 deaths, compared to 9,400 in LA County.
But Ferrer knows that could change soon. The sound of sirens became a soundtrack for the holiday weekend in parts of LA, while hospitals were crowded with COVID-19 patients. Early data show high travel figures last week, indicating a devastating, even worse, boom.
Government Gavin Newsom has already ordered 5,000 suitcases, most of which are earmarked for Los Angeles County.