Thread by @Bob_Wachter

1/ Covid (@UCSF) Chronicles, Day 104

Let’s talk California. Until recently, our state managed to do so well that our experience has been dubbed The California Miracle. But let’s say it clearly: The Miracle is over. The sooner we acknowledge that, the better off we’ll be.

2/ In many of the surging states, including TX, AZ, and FL, one can easily point to leadership malpractice by governors and other politicians. They doled out misinformation about Covid and failed to require evidence-based practices, like masking, to prevent spread. Unforgivable.

3/ California is different: our leaders acted responsibly. And Californians mostly did too.

But around Memorial Day, standards were relaxed, people (yes, mostly young ones) got complacent, and – after a string of lucky breaks – our luck ran out. Now it’s our time.

4/ Let’s start at the beginning. In late Feb, there was every reason to believe that CA – huge, diverse, fairly dense, w/ lots of travel to/from Europe/China – would be slammed. In fact, when I launched these tweets in mid-March, I fully expected to be chronicling an apocalypse.

5/ But we made it through 3 mths remarkably unscathed. On June 1, CA had ~100,000 total cases & 4,000 deaths. In contrast, NY State, with half our population, had ~370K cases & 30,000 deaths. “The California Miracle” narrative was born; I contributed to it nyti.ms/2Zo3b9o

6/ Leaders in CA, from the governor (who ordered shelter-in-place on March 19, the first state to do so), to mayors and public health officials, to tech CEOs (many of whom told workers to stay home in early March), were much praised for acting decisively. They deserved it.

7/ There was some luck as well – we never had a big super-spreader event or a massive nursing home, plant, or prison outbreak, the kind of things that created conditions for surges in NY & elsewhere.

As @nytimes just quoted me nyti.ms/2Zj6Lla, our luck has just run out.

8/ Early on, CA citizens acted responsibly, w/ precious little anti-mask nonsense & no armed protestors agitating for opening up. CA and its counties enacted sound re-opening plans, with metrics for further opening and spelled-out criteria for retrenchment bit.ly/3dNDLHo

9/ In May, all states – red and blue – began opening up their economies. It’s easy to apply the retrospecto-scope now… but the CA plan seemed perfectly reasonable to me, particularly since the state was doing so well, and we had geared up our testing & contact tracing programs.

10/ With re-openings, a bump in cases was expected (that’s the nature of The Dance bit.ly/34Ryhsk), but few (including me) expected it to be so fast & widespread. While it’s mostly concentrated in red states, blue states that dodged the first bullet are getting hit too.

11/ While it’s easy to pin the new surges on feckless politicians, CA offers a bit of a controlled experiment: even in a state with mandatory masking & a sound re-opening plan, things went sour. Covid wins again: demonstrating that good leadership is crucial, but not sufficient.

12/ Before blaming it on “the people,” let’s not let politicians – & I’m talking Trump – off the hook. If you’re young, bars are open, & you’ve heard mixed messages re: masks, it’s natural that some would say, “I don’t know whom to believe, but I hate masks so I’m going without.”

13/ So even in CA, with masking & distancing mandates, many people got sloppy. On top of that, our lucky streak came to a screeching halt. One horrific example is San Quentin prison, just north of SF, where the number of infected prisoners just topped 1000 n.pr/3gbo0fc

14/ CA’s surge doesn’t match AZ, TX, or FL’s… yet. And – while we’re seeing more hospitalizations – mortality has not climbed… yet. But mortality is a lagging indicator – these new cases are sure to ultimately translate into many deaths, as the cases move to higher-risk groups.

15/ It’s worth comparing CA (on L) w/ TX (R). While CA got most of the nat'l press for being a star pupil, TX # 's were equally good. This, of course, is an inconvenient truth for those who prefer a simple narrative that attributes everything to clueless, right-wing politicians…

16/ …or to a caricatured view of the populace that says that everybody in CA acts perfectly & everybody in TX is a careless ignoramus. Without forgiving @GovAbbott of Texas for awful leadership (hear The Daily on this: nyti.ms/2ZkobxY), the facts are more nuanced.

17/ Here are the numbers: CA is so vast that our # ‘s are sum of multiple different epidemics, and some regions (incl. SF) continue to do OK. But overall, the past 2 weeks are bleak: new cases doubled, hospitalizations ↑43%, ICU pts ↑37%, & test positivity rate from 4.4%→5.5%.

18/ SF not surging, but warning signs. @UCSFHospitals 16 pts, 5 on vents; ~double 2 wks ago. In SF, cases and hospitalizations up; most of bump in hospital pts is transfers from elsewhere. Forgive the metaphor, but if somebody sneezes in LA, we’ll ultimately catch a cold in SF.

19/ As @GavinNewsom said today, 19 CA counties (~70% of state population) now on watchlist because of surges. Bars closing in ~15 counties (incl. LA, Orange). Imperial returning to SIP, LA beaches closing bit.ly/2AfESlD. Expect more use of “dimmer switch” in coming wks.

20/ The message from the governor was crystal clear: if we don’t turn things around, we may find ourselves back to widespread shelter-in-place soon. It wasn’t a @NYGovCuomo-esque “Don’t make me come down there” moment bit.ly/3dL3qAL, but the resolve was unmistakable.

21/ Trust is key, and Newsom & CA mayors have mostly earned it. Here's a fun PSA on masks from past 4 governors, GOP & Dems (incl. Ahnold) bit.ly/3eWHaW1. This kind of thing will be harder to do in red states, since it’ll involve a lot of walking back past fictions.

22/ As I said last week, we enter this crisis in better shape than we were in March (Fig again below). We’re catching the surges early through testing (not ICU admits), we have some effective treatments, & we’ve built hospital, ICU, & PPE capacity. We should feel good about that.

23/ I don’t know about you, but in March I was scared; now I’m mostly depressed – depressed that we’ve collectively allowed this to happen, depressed that the light at the end of the tunnel may prove to be an oncoming train. But if any state can turn this around, I’d bet on CA.

24/ Stay safe and do the right thing. It’s not too late – California can once again get this thing under control.

No grand rounds this week. So back Friday – I hope with some better news.