It turns out it’s not just the kids who aren’t getting snow days this year. This week, we spoke with an executive at a health system hit hard by Wednesday’s Nor’easter, and asked how the system was faring with the expected 18 inches of snowfall. He replied that the medical group was as busy as usual.
With all the work this spring to expand telemedicine capabilities, clinic staff were able to reach out to patients the day before the storm, and proactively convert a majority of scheduled in-person clinic visits to telemedicine. “Normally we would’ve been closed, and most appointments rescheduled for weeks down the road,” he told us. Instead, they were able to keep most of those visits in their scheduled time slot.
“Now that we have a systemwide process for telemedicine, I don’t think we’ll have a reason for the clinic to take a snow day again.” It’s a clear win-win for the system and patients: patient care seamlessly goes on. It’s easy to see the many use cases for the ability to toggle between in-person and virtual visits. A parent is stuck at home with a sick kid, and can’t make her endocrinologist appointment? Moved to virtual! A patient has an unexpected business trip taking him out of town? Don’t cancel, let’s do that follow-up visit via telemedicine.
We’ve been worried about the slowdown in progress made on telemedicine as patients switched back to in-person visits across the summer and fall. The ability to continue patient care during a record-breaking snowstorm is a perfect illustration of why it’s critical not to “backslide” with virtual care: meeting patients where they are, regardless of circumstances, is an essential part of building long-term loyalty and care continuity.
The pandemic put nurses on the front lines of the battle against COVID-19 and caused shifts in the way they provide care.
During this year, nurses have adapted to increased adoption of telehealth and virtual patient monitoring, as well as constantly evolving staffing needs.
These factors — and others, such as the physical and emotional conditions nurses have faced due to the public health crisis — are sure to affect nursing in the years to come. Here, 10 healthcare executives and leaders share their predictions for nursing in the next five years.
Editor’s note: Responses were edited lightly for length and clarity.
Beverly Bokovitz, DNP, RN. Vice President and Chief Nurse Executive of UC Health (Cincinnati): In the next five years, as we continue to encounter a national nursing shortage, I expect to see additional innovative strategies to complement the care provided at the bedside.
One of these strategies will be some type of robot-assisted care. From delivery of medications to answering call lights — and completing simple tasks like needing a blanket or requesting that the heat be adjusted — we will see more electronic solutions. These solutions will allow for a better patient experience and help to exceed the expectations of our patients as customers.
Of course, nothing can take the place of skilled and compassionate bedside care, but many tasks could be automated — and will be — to supplement the professional nursing shortage.
Natalia Cineas, DNP, RN. Senior Vice President and Chief Nurse Executive of NYC Health + Hospitals (New York City): Nurses will continue to play a vital role in addressing the health inequities and social determinants of health among vulnerable populations as the nursing workforce itself becomes more diverse and inclusive. As the largest segment of the healthcare workforce — with some 4 million nurses active in the U.S. — nurses represent the faces of the communities in which they serve. As America becomes a more diverse and inclusive society, so too will the nursing profession become more diverse and inclusive. Currently, industry estimates indicate that between one quarter to one-third of all U.S. nurses identify as a member of a minority group, with between 19 percent and 24 percent of U.S. nurses identifying themselves as Black/African-American; 5 percent to 9 percent identifying themselves as Hispanic; and about 3 percent identifying themselves as Asian. The percentage of minority nurses has been rising steadily for the past two decades and is expected to continue to climb in the coming years.
Blacks and underserved minority populations face numerous genetic, environmental, cultural and socioeconomic factors that account for health disparities, and the impact is particularly visible in the areas of cardiovascular disease, diabetes, pregnancy and childbirth mortality, and cancer outcomes, as well as the enormous toll of the current novel coronavirus global pandemic, where communities of color have been among the hardest hit populations.
In New York City alone, statistics compiled by the city’s health department show Blacks and Hispanics together account for 65 percent of all COVID-19 cases; represented 70 percent of all hospitalizations due to COVID-19; and, sadly, 68 percent of all deaths caused by COVID-19. As demonstrated during this pandemic, in the future, technology such as telehealth and virtual patient monitoring will play a major role in the care of patients. There will be a vast need to address social determinants of health by educating and providing resources to allow utilization of this technology such as using “wearable tech” to monitor ongoing health issues, such as high blood pressure, diabetes, heart conditions and other chronic illnesses.
Ryannon Frederick, MSN, RN. Chief Nursing Officer of Mayo Clinic (Rochester, Minn.):Nursing research will experience extraordinary demand and growth driven by a realization that both complex and unmet patient needs can often be best served by the role of a professional registered nurse. Nurses are uniquely positioned to implement symptom and self-management interventions for patients and their caregivers. Significant disruption in healthcare, including increasing use of technology, will lead to a dramatic shift to understand the role of the RN in improving patient outcomes and implementing interventions using novel approaches. Nursing researchers will provide a scientific body of evidence proving equivalent, if not better, patient care outcomes that can be obtained at a lower cost than traditional models, leading to an even greater demand for the role of the professional nurse in patient care.
Karen Higdon, DNP, RN, Vice President and Chief Nursing Officer of Baptist Health Louisville (Ky.):The value of nursing has never been more apparent. Nurses have led the front line during this pandemic. In the next five years, we must be flexible and creative in establishing new models of care, specifically around roles that support nursing, such as assistant and tech roles. Creating roles with clear role definition, that are attractive and meaningful for nursing support will help build consistent, high-quality models for nursing to lead. This consistency, along with IT capabilities that enhance workflow, will better allow nurses to work at the top of their scope.
Karen Hill, DNP, RN. COO and Chief Nursing Officer of Baptist Health Lexington (Ky.): 2020 was declared the “Year of the Nurse” and this reality has never been more true than realizing the personal and professional sacrifices of nurses in dealing with issues surrounding the pandemic. The next five years will require nursing professionals to be flexible to address new, unknown emerging issues in all settings, to be open to new opportunities for leadership in hospitals, schools and communities and to use technology and telehealth to provide safer care to patients. Nurses need to evaluate our practices and traditions that are value-added and leave behind the task orientation of the past. We need to honor our legacy and create our path.
Therese Hudson-Jinks, MSN, RN. Chief Nursing Officer and Chief Patient Experience Officer at Tufts Medical Center and Tufts Children’s Hospital (Boston):Over the next five years, I expect that the support and retention of clinical nurses will become the top priority of every CNO and executive team, given nurses’ direct impact on supporting the business of healthcare. This will be particularly critical because there will be a concerning shortage of experienced clinical nurses as a result of advancing technologies increasing complexity in care, additional nurse roles created outside traditional areas, fierce competition for talent between large healthcare systems, aging baby boom workforce retiring at higher rates year over year, and a lack of sufficient numbers of PhD-prepared nurses working in academia and supporting higher enrollments.
I also believe that CNOs will be laser-focused on creating the practice environment that enhances retention of top, talented clinical nurses, and we will put a greater emphasis on the influence of effective nursing leadership in reaching that goal. In addition, I fully expect that nurses will be seen more as individuals with talents and experience than ever before — not just a number on a team, but rather a professional with specific, unique, talents that are highly sought after in competitive markets.
Finally, I anticipate that nursing innovation will blossom, given the exposure of the “innovation/solutionist superpower” within nurses during the pandemic. Philanthropy will grow exponentially in support of nursing innovation as a result.
Carol Koeppel-Olsen, MSN, RN. Vice President of Patient Care Services at Abbott Northwestern Hospital (Minneapolis): During the COVID-19 pandemic nurses have been working in difficult physical and emotional conditions, which may lead to significant turnover after the pandemic resolves. Nurses have a commitment to serving others and will persevere until the crisis is past; however, when conditions improve, many nurses may decide to pursue careers outside acute care settings. A possible turnover, coupled with a service economy that has been devastated, may result in large numbers of former service workers seeking stable jobs in nursing. Hospitals will have to be nimble and creative to onboard an influx of new nurses that are not only new to the profession but new to healthcare. Tactics to onboard these new nurses may include the use of retired RNs as mentors, instructor-model clinical groups in the work setting, job shadowing and aptitude testing to determine the best clinical fit.
Jacalyn Liebowitz, DNP, RN. Senior Vice President and System Chief Nurse Officer of Adventist Health (Roseville, Calif.): Over the next five years, I see nurses providing more hospital-based care in the home using remote technology. Based on that shift, we will see lower-acuity patients move into home-based care, and higher-acuity care in hospitals will increase. With that, hospital beds will be used at a different level. My bold prediction is that we will not need as many beds, but we will need higher acute care in the hospitals.
Nurses will learn differently. As we are seeing now, nurses have not been able to train in the traditional way. They are already using more remote technology to educate, onboard and orient to their roles. It looks and feels vastly different, and nurses need to be comfortable with that.
As for patient care, I think data that can be gleaned from wearable biometrics, and the use of artificial intelligence will help predict patient care on a patient-by-patient basis. Nurses will work with AI as part of their thought process, instead of completely focusing on their own judgment and assessment.
I also believe we are going to face a nursing shortage post-COVID for a few reasons. Due to the emotional and physical toll of responding to a pandemic, some nurses will decide to retire, and another group will leave based on the risks that go hand-in-hand with the profession.
As for patient care, we are going to collaborate differently. There will be more video conferencing regarding collaboration around the patient. And I think in the future we will see that the full continuum of care will include a wellness plan.
Debi Pasley, MSN, RN. Senior Vice President Chief Nursing Officer of Christus Health (Irving, Texas):I believe the demand for nurses will become increasingly visible and newsworthy throughout the pandemic. This could drive increases in salaries and numbers of qualified candidates seeking nursing as a profession in the medium and long term. The shortage will, however, continue to be a factor, leading to more remote work options to both supplement nursing at the bedside and substitute for in-person care.
Denise Ray, RN.Chief Nursing Executive of Piedmont Healthcare (Atlanta): Nursing schools will need to focus on emergency management and critical care training utilizing a team nursing model. While nursing has become very specialty-driven, the pandemic has demonstrated gaps in our ability to adapt as quickly utilizing a team model where nurses lead and direct care teams. By implementing a team model and enhancing education in the areas of emergency management and critical care, nursing can adapt quickly to the ever-changing environment.
Also, communication with patients and families will take on different dimensions with wider use of tele-therapeutic communication. Nurses will be leaders and liaisons in the process, connecting physicians, patients and patient families virtually.Nurses will play a key role in integrating patient family members as true patient care partners— making sure they have the information they need to serve an active caregiving role for their family members during and after hospitalization. We’ll also see more nurses becoming advanced nurse practitioners, playing an expanded role in all healthcare settings.
A quick stop at the local Whole Foods Market recently yielded surprising insights into the dilemma faced by physician practices in the COVID-era telemedicine boom.
The store location opened just last year, part of a brand-new residential and shopping complex designed for busy professionals. It’s larger than the old-style, pre-Amazon era stores, and was designed to integrate Amazon’s online grocery operations into the bricks-and-mortar retail setting. There’s a portion of the store set aside for Amazon “shoppers” to receive and pack online orders for pickup and delivery, along with an expanded array of convenience-food offerings for the app-powered consumer to scan and purchase.
But when COVID hit, the volume of online orders went through the roof, and the store hired a small army of Amazon shoppers (including one of our own adult children who’s on a “gap year”) to keep up with demand. The result has been barely controlled chaos—easily 70 percent of the shoppers in the aisles last weekend were young Amazon employees “shopping” on behalf of online customers. They’re all held to an Amazon-level productivity standard, which makes the pace of their cart-pushing somewhat frantic and erratic. And the discreet area at the front of the store for managing the Amazon orders has become a noisy hub, making entering and exiting the store problematic. Even the “regular” store employees at Whole Foods have begun to complain about the disruption caused by the Amazon fulfillment operation.
It’s acautionary tale for traditional physician practices and other care delivery organizations looking to “integrate” telemedicine into normal operations. Integration sounds great in theory, but in practice raises important questions:
1)What physical space should be set aside for delivering virtual care?
2)Should telemedicine work be done in a separate, centralized location, or in existing clinic space?
3) How does the staffing of clinics need to change to meet the demand for virtual care?
4) How can we flex staffing up and down based on demand for telemedicine?
5)If new staff are required, how will they be incorporated into the existing team—or should they be managed separately?
6)What operational metrics will they be held accountable for, and what impact will those metrics have on other operational goals?
If Amazon, a worldwide leader online, renowned for running tight, precision, productivity-driven operations, is having trouble figuring out physical-virtual integration at the front end of their business, imagine how difficult these challenges will be for healthcare providers. The sooner we start to dig into these issues and find sustainable solutions, the better.
On June 25, San Francisco Mayor London Breed was excited the city’s zoo would finally reopen after closing down for months in response to Covid-19. She visited the facilities, posting photos on social media with a mask on and giraffes in the background.
“I know people are eager to get back to some sense of normalcy, especially families and children,” she tweeted. And it looked like her city was taking a step toward it.
The day after the visit, Breed had to announce the sad news: San Francisco’s reopening plan — for the zoo and various other facilities, including hair salons and indoor museums — would have to be put on hold.
“COVID-19 cases are rising throughout CA. We’re now seeing a rise in cases in SF too. Our numbers are still low but rising rapidly,” she tweeted. “As a result, we’re temporarily delaying the re-openings that were scheduled for Monday.”
While state and local leaders nationwide were pushing ahead with reopening, Breed pulled back. “I listened to our public health experts,” she told me. “It’s hard. The last thing I want to do is go out there and say one thing and then have to say something else. But I think it’s important that people understand things can change. This is a fluid situation.”
The decision — taken weeks before California Gov. Gavin Newsom’s move to shut down risky indoor venues statewide in July — was emblematic of San Francisco’s cautious approach throughout the coronavirus crisis. The city joined a regional stay-at-home order in March, before the rest of the state and New York, which became a Covid-19 epicenter, imposed their own orders. It was also slower to reopen: When California started to close down indoor venues again, the order largely didn’t affect San Francisco — because the city never reopened bars and indoor dining, among other high-risk venues, in the first place.
By and large, the approach — aided by regional cooperation, with leadership from Santa Clara County Health Officer Sara Cody, and widespread social distancing and mask-wearing by the public — has kept cases of Covid-19 manageable. In the spring, California and the Bay Area saw some of the first coronavirus cases, but quick action since then has let San Francisco and the surrounding region avoid turning into a major hot spot.
The increase in cases this summer has exceeded the April peak and fallen particularly hard on marginalized groups, especially Latin communities. But that, too, seems to be turning around: New cases started to fall by July 20 — almost a week before the state as a whole began to plateau. San Francisco has maintained less than 60 percent the Covid-19 cases per capita as California, and less than 30 percent the deaths per capita. Its caseload and death toll are lower than other large cities, including Washington, DC, and Columbus, Ohio, and far lower than current hot spots like Arizona and Florida.
“It’s doing as well as it can, given what’s going on around it,” Peter Chin-Hong, an infectious disease expert at the University of California San Francisco, told me.
Experts and local officials say the summer increase in cases doesn’t take away from what San Francisco has done. What it shows, instead, is the limits of what a local government can do — and the risk of relying on a county-by-county, state-by-state approach to a truly national crisis.
“We have to accept that we are all interrelated in a pandemic,” Kirsten Bibbins-Domingo, an epidemiologist at UCSF, told me. “We have to help each other out.”
“We are not isolated; we are interconnected,” Grant Colfax, director of the San Francisco Department of Public Health, told me. “The virus exploits that very interconnectedness of our society. Without a consistent, robust, and sustained federal response that is driven by science … eventually things cannot be sustained.”
This is why, experts argue, federal leadership is so key: The federal government is the one entity that could address these problems on a large scale. But President Donald Trump has ceded his role to the states and private actors — what his administration called the “state authority handoff” and the New York Times described as “perhaps one of the greatest failures of presidential leadership in generations.”
That’s left cities and states to fend for themselves. San Francisco has made the best of it, with the kind of model that experts argued could have prevented the current coronavirus resurgence if it had been followed nationally.
“There’s a value to being cautious,” Bibbins-Domingo said. “Any type of reopening is going to come with some increase in cases. That’s what we are learning in the pandemic. That’s what the infectious disease experts told us was going to happen. Places that thought they could just reopen without caution have really paid the price for it.”
San Francisco’s leaders were ahead on Covid-19
Breed started to really worry about the coronavirus in February, when she saw a glimpse of the future.
Stories of overwhelmed hospitals in Wuhan, China, showed that Covid-19 could cripple health care systems. But Breed believed, she said, that San Francisco’s larger, more advanced health care system could handle the blow. Then her advisers and experts told her differently — that a situation like Wuhan’s really could happen in San Francisco if she didn’t act.
“The shock I got,” Breed said. “We have all these hospitals, all these places where we have some of the most incredible doctors and research institutions. So in my mind, I’ve always thought this is where you want to be if something happens. To be told that here’s what our capacity is, here’s what happens if we do nothing, and what we need to prepare for, it really did blow my mind.”
At that point, she concluded, “We need to shut the city down to make sure this doesn’t happen.”
The virus has been the biggest challenge yet for Breed, who first became mayor in 2017 when her predecessor died, before she was elected to the role in 2018, having previously served on the Board of Supervisors.
But Breed, with the guidance of the Bay Area’s public health officials, has consistently kept the city ahead on Covid-19. The day before Trump claimed, falsely, that coronavirus cases would go from 15 to nearly zero in the US, Breed on February 25 declared a local state of emergency over the virus. Three days before California imposed a stay-at-home order and nearly a week before New York state did, San Francisco County, with Breed’s full backing, on March 16 joined the five other Bay Area counties in issuing the country’s first regional stay-at-home order.
Breed was ahead of not just much of the nation, but her progressive peers as well. On March 2, she warned on Twitter that the public should “prepare for possible disruption from an outbreak,” advising people to stock up on essential medications, make a child care plan in case a caregiver gets sick, and plan for school closures. The same day, New York City Mayor Bill de Blasio, a fellow Democrat, tweeted that he was “encouraging New Yorkers to go on with your lives + get out on the town despite Coronavirus.”
New York City would go on to suffer one of the worst coronavirus outbreaks in the world, with its total death rate standing, as of July 29, at 272 per 100,000 people — more than 45 times as high as San Francisco’s rate of 6 per 100,000. (De Blasio’s office didn’t respond to a request for comment.)
San Francisco’s death toll is also fairly low compared to that of some other areas in California — a fraction of Los Angeles County’s 45 per 100,000 and Imperial County’s 103. San Mateo County, a Bay Area county that reopened more aggressively, has more than double the death rate, at 15 per 100,000. San Francisco looks even better compared to cities and counties beyond California — with less than a tenth the deaths per capita as Washington, DC, and about a sixth as many as Franklin County, Ohio, where Columbus is, and Fulton County, Georgia, where most of Atlanta is.
At the time of the initial stay-at-home order, Chin-Hong said, people wondered if Breed was overreacting. “Of course, in hindsight, she was very prescient. She knew what was coming.”
There’s good reason to believe that San Francisco’s early action, particularly its lockdown, helped. The research indicates that stay-at-home orders and similar measures worked, with one preliminary Health Affairsstudy concluding:
Adoption of government-imposed social distancing measures reduced the daily growth rate by 5.4 percentage points after 1–5 days, 6.8 after 6–10 days, 8.2 after 11–15 days, and 9.1 after 16–20 days. Holding the amount of voluntary social distancing constant, these results imply 10 times greater spread by April 27 without SIPOs (10 million cases) and more than 35 times greater spread without any of the four measures (35 million).
That’s not to say San Francisco performed flawlessly.
Even the experts who praised Breed simultaneously raised alarms about how the virus had disproportionately affected minority populations — with about half of confirmed Covid-19 cases affecting Latin people, even though they comprise about 15 percent of the local population. The city’s large homeless population is also a major point of concern, with a big outbreak at the largest local homeless shelter. These are the kinds of blind spots with Covid-19 that have shown up across the country — as minority groups, in particular, are more likely to work in the kind of job deemed “essential” — and San Francisco isn’t immune to them.
“Myself, just taking care of patients, I know that some of those patients are going back to work sick if they don’t have to be hospitalized,” Yvonne Maldonado, an infectious disease expert at Stanford, told me. “They can’t afford not to work.”
Local officials point out they have taken aggressive action to shield marginalized populations — creating support programs for them, fielding contact tracing calls in Spanish, and setting up more than 2,500 hotel rooms for the vulnerable, including homeless people. And the disproportionate case count for Latin people is from a baseline of cases that’s lower than other parts of the state and country with similar disparities. Out of 57 Covid-19 deaths in the city, only one was a homeless person.
Breed acknowledged the challenge, describing the city’s response to Covid-19 as a work in progress as she and other officials struggle with the uncertainty that surrounds a virus that’s still relatively new to humans.
“That’s hard,” Breed said. “We have to make the hard decisions. What we hope people will understand is why. We keep trying to call attention to what’s happening or could happen to any of us. It’s a constant struggle.”
That’s especially compounded by the massive sacrifices that people have to make as they’re forced to stay at home, potentially giving up income, child care, and social connections.
Breed is aware this is no easy task. On a personal level, she said, “I’m tired of being in the house. I’ll tell you that much.” She acknowledged that the shutdown has left many people struggling, “because their livelihoods are at stake, their ability to take care of themselves is at stake.”
But the alternative, she suggested, is much worse. It’s not just more Covid-19 cases, hospitalizations, and deaths — but harm to the economy if a major outbreak forces cities and states to shut down all over again. As a preliminary study of the 1918 flu pandemic found, the cities that came out economically stronger back then took more aggressive action that hindered economies in the short term but better kept infections and deaths down overall.
Experts echoed a similar sentiment. “Dead people don’t shop. They don’t spend money. They don’t invest in things,” Jade Pagkas-Bather, an infectious disease expert and doctor at the University of Chicago, told me. “When you fail to invest in the health of your population, then there are longitudinal downstream effects.”
Breed had a key ally in San Francisco: The public
Chin-Hong, who lives and works in the Bay Area, recalled a recent experience he had at the grocery store. With the place at full capacity, people were waiting outside the store in a line. One person joined the line without a mask on. People began to eye him disapprovingly. He grew visibly nervous, at one point pulling his shirt over his mouth. After a while, a store staff member came out and gave him a mask, which he quickly put on.
The story is emblematic of one of Breed’s key advantages as she has pushed forward with aggressive actions against the coronavirus: San Francisco’s public is by and large on board, with a lot of solidarity built around social distancing and masking.
“The politician is only as good as her constituents,” Chin-Hong said. “It’s a key factor in all of this.”
In some ways, the public was even ahead of Breed. In the weeks before Bay Area counties issued a stay-at-home order, major tech companies in the region, like Google and Microsoft, told employees to work from home. That partly reflects tech employees’ ability to work from home with fewer disruptions, but also a greater sense of vigilance for an industry with close ties to the countries in East Asia that saw Covid-19 cases earlier.
It wasn’t just the tech sector. Restaurant data from OpenTable shows San Francisco was starting to avoid dining out by the first week of March, while most other cities in the US saw at best small decreases, if any changes: On March 1, dining out via OpenTable was down 18 percent in San Francisco, compared to down 3 percent in Los Angeles, down 2 percent in New York City, up 2 percent in Houston, and up 21 percent in Philadelphia. From that point forward, San Francisco’s numbers steadily dropped, while much of the US fluctuated before the depth of the outbreak became clearer nationwide.
San Francisco has also been better than much of the country about mask-wearing. A New York Times analysis found there’s a roughly 60 to 90 percent chance, depending on the part of the city, that everyone is masked in five random encounters in San Francisco. In other parts of the US, including cities, the percent chance can drop to as low as 20, 10, or the single digits.
Even in California, it wasn’t guaranteed things would go like this. Orange County’s chief health officer resigned in June due to public resistance against a mask-wearing order. Sheriffs in Orange, Riverside, Fresno, and Sacramento counties said they wouldn’t enforce Gov. Newsom’s June order requiring masks in public and high-risk areas. With Trump and other Republicans suggesting that social distancing and masking requirements were part of a broader overreaction to the pandemic and an attempt at government overreach, and people genuinely suffering due to the economic downturn, San Francisco could have taken a very different direction.
We don’t know for certain why San Francisco’s public is more aggressive about precautions against Covid-19. One advantage San Franciscans have is many of them, particularly those in the tech sector and other office jobs, can work from home much more easily than, say, “essential” agricultural employees. The city also has close ties to East Asia, including China, potentially offering personal connections — and an early warning — to the first coronavirus outbreaks and the value of masking. San Francisco is also very progressive and Democratic, which helps as physical distancing, masking, and related measures have become politically polarized. Perhaps Breed’s more aggressive communication paid off.
Whatever the cause, there’s good reason to believe the public embrace of precautions helped the city. A review of the research published in The Lancet found that “evidence shows that physical distancing of more than 1 m is highly effective and that face masks are associated with protection, even in non-health-care settings.”
Again, it’s not perfect. Breed told me of a recent trip to a local store that was clearly far above the city’s reduced standards of capacity, with some of the staff and customers not wearing masks. “I was like, ‘What the heck is this? This is ridiculous,’” she said. “I called [the San Francisco Department of] Public Health, and they put a stop to it.”
More recently, Breed had to get tested for coronavirus after she went to an event attended by someone who reportedly knew they were positive. She used the moment to lightly admonish those who didn’t follow the recommended precautions: “I know people want to be out in public right now, but this disease is killing people. It’s simply reckless for those who have tested positive [to] go out and risk the lives of others,” she tweeted. “I cannot stress this enough: if you test positive, it’s on you to stay home and not expose others.” (Breed tested negative.)
But San Francisco’s public is seemingly better than much of the country at following the recommended precautions. Beyond Breed’s actions, that’s a potent explanation for why San Francisco has done relatively well — and why other parts of the state and country haven’t.
Local governments can only do so much about a pandemic
As successful as San Francisco has been relative to other parts of California and the US, it hasn’t escaped the recent rise in Covid-19 cases untouched. As of July 22 (the most recent reliable local data available), the city hit a seven-day average of 98 new cases a day — down from a peak of 120 several days prior but up from the previous peak of 48 in mid-April.
More than reflecting San Francisco’s own failures, experts said the upward swing in cases reflects the limits of what a local government can do when a virus spreads nationally and globally. When a virus can cross borders, there’s only so much San Francisco can do if its residents can drive an hour or two to a county where bars and indoor dining are open for service, or to meet with family members in an area that’s hit much harder by Covid-19.
“When you have different rules for different counties, it’s very confusing,” Maldonado said. “People lose the message.”
There are similar limitations to what even California can do. It can impose its own lockdown, but it has less control over cases from Arizona, Nevada, Mexico, or other parts of the globe. While the state has taken steps to build up its testing capacity — surpassing the benchmark of 150 tests per 100,000, which is the equivalent of 500,000 tests nationwide — it can only go so far if there are constraints around the country for testing.
The testing problem is especially acute now: With new outbreaks across the US, demand for tests climbed as supply constraints reappeared. That’s led to waiting periods of up to weeks for getting results back — making tests practically useless for confirming, tracing, and containing infections before they have time to spread.
But there are limits to what San Francisco or California can do if the bottlenecks for testing are originating in other parts of the country or world — whether they’re due to epidemics in Arizona and Florida, or because factories in the Northeast and South can’t produce enough swabs to collect samples or reagents to run tests.
“We need a national plan,” Cyrus Shahpar, a director at the global health advocacy group Resolve to Save Lives, told me. “In terms of the structures to improve the supply chain or procure more stuff for the whole country, that’s a federal level of support. You need that to be in place.”
The Trump administration, however, has explicitly left most of these issues for states to solve. The White House’s testing plan declared that the federal government is merely a “supplier of last resort,” leaving it to local and state governments and private actors to fix choke points along the testing supply chain. The New York Times explained this was part of a broader “state authority handoff” plan that would “shift responsibility for leading the fight against the pandemic from the White House to the states.”
To the extent the federal government has provided support, Trump has actively undermined it. When the federal government released a phased plan for state reopenings, Trump called on states to reopen faster — to supposedly “LIBERATE” them from economic calamity. After the Centers for Disease Control and Prevention recommended people in public wear masks, Trump said it was a personal choice, refused for months to wear a mask in public, and even suggested that people wear masks to spite him (although a recent tweet seemed to support masking). (The White House didn’t return a request for comment.)
In my interviews, local officials, health care workers, and experts repeatedly complained about the problems caused by federal inaction. Breed lamented that San Francisco, and California, couldn’t rely on federal support to get personal protective equipment for health care workers, particularly in the early stages of the pandemic. A San Francisco Department of Public Health spokesperson told me that testing took time to scale up while the federal government did little to address supply constraints, commenting that the mixed messaging and inaction from the federal government “are hampering local efforts to be as effective as we would like to be.”
Over time, even the once-proactive California let its guard down. As Gov. Newsom faced pressure from local governments and businesses to reopen the state quickly, he allowed counties to reopen at a quicker pace if they met certain metrics. That led to new outbreaks, particularly in Central and Southern California — each of which presented a risk of bleeding over to the Bay Area. As Bibbins-Domingo said, county-by-county variations “have not been helpful” for suppressing the virus in San Francisco or statewide.
California Health and Human Services Secretary Mark Ghaly said that, like everyone else, the state was still learning how to properly combat the pandemic. But he argued it does make sense to tailor local responses to Covid-19 to what’s happening locally — and that’s what the state tried to do as it let some counties move quicker than others, while keeping some oversight by enforcing certain criteria before counties moved ahead.
The state is still “figuring out … the balance between hundreds of different things,” Ghaly told me. That includes, he added, “how you support counties making local decisions while maintaining some level of cohesiveness at a regional and statewide level so we don’t erode gains.”
Still, the fractured nature of federalism doesn’t help for fighting a virus that ignores local, state, and national borders.
A recent study in Science backed that up. Running simulations for Europe, researchers concluded that better-coordinated action within the European Union can help suppress Covid-19 better than different countries acting in different ways. Drawing on that finding, the authors concluded:
The implications of our study extend well beyond Europe and COVID-19, broadly demonstrating the importance of communities coordinating easing of various [non-pharmaceutical interventions] for any potential pandemic. In the United States, [non-pharmaceutical interventions] have been generally implemented at the state-level, and because states will be strongly interconnected, our results emphasize national coordination of pandemic preparedness efforts moving forward.
That the US has by and large stuck to a state-by-state and county-by-county approach to public health — an approach that predates the coronavirus pandemic — can help explain, then, why the country has continued to fail to control Covid-19 in the same way countries with strong national plans and, in some cases, international cooperation haven’t. To this day, America reports among the highest rates of coronavirus cases and deaths in the world.
In that context, with outbreaks raging around San Francisco and California, there’s only so much any single local or state government could do. “When you look at success stories of countries on Covid, you had a strong central voice,” Chin-Hong said.
So while San Francisco has done a lot right, it will take the rest of the country adopting a similar approach for the city, the broader Bay Area, or anywhere else in the US to really be safe from the coronavirus.
Colleges And Universities Reverting To Online Instruction
On August 17, seven days after the start of in-person classes, the University of North Carolina at Chapel Hill announced that, due to a dramatic increase in Covid-19 on campus, all undergraduate classes would be held online for the remainder of the fall.Ithaca College and Michigan State pulled the plug on August 18. Two days later, N.C. State joined the club. More may follow. (The Chronicle of Higher Education maintains a live update feed.) In fact, only a minority of colleges and universities are still attempting fall instruction fully or primarily in person (about 25% at this writing).
Only time will tell if these rapid course changes were warranted and, of course, the answer may not be the same everywhere. Each institution is unique with respect to size, culture, infrastructure to provide online learning, and ability to cope with transmission.
What We Know About Infectious Diseases On College Campuses
In thinking about Covid-19 transmission on campus, it may be useful to know something about the science of epidemics among college students in general. There is a small scientific literature on disease outbreaks on campus. Campuses are special for several reasons. News photos of students lounging on green quads, engaged in late night study groups, or partying into the wee hours reminds us that if college is known for anything other than studying and college sports, it might be the unique gregariousness that attaches to what many people call the “college experience.”
Although outbreaks of infectious diseases on college campuses are routinely reported, there is little evidence that they are more explosive than in the general population. Outbreaks of directly transmitted diseases like measles, mumps, and whooping cough occur with some regularity and are typically contained through isolation and other public health measures. But, no study has been done to systematically examine how the campus environment differs from community-based transmission.
Influenza is a particularly interesting case because, like Covid-19, it is a respiratory disease transmitted directly through close contact and also has a short incubation period. Thebasic reproduction number (R0) is a measure of the explosiveness of an epidemic, with anything over R0 = 1 indicating the possibility of sustained transmission.
In 2014, CDC and academic scientists compiled a list of all estimates of R0 for influenza. While most estimates for the 2009 pandemic were between 1 and 2, estimates from some schools (not necessarily colleges or universities) were noticeably higher (2.3 for a school in Japan and 3.3 for a school in the United States), although other cases (Iran and the United Kingdom) were similar to the rest of the population.
Perhaps more importantly, a study in Pullman, Washington (home to Washington State University) estimated R0 of the 2009 pandemic flu to be around 6, which is two to four times larger than most other estimates. So there is some evidence that campus contagions may be more prone to outbreak than other places.
Since Covid-19 is typically much less severe in young adults than in older adults, another question that seems particularly important now is whether transmission among students remains primarily within the student population or readily spreads to the rest of the community.
In a measles outbreak at a university in China, the fraction of staff who were infected was not statistically different from the fraction of students. The total number of staff infected — three — was small, however, and it seems unlikely that this is the usual pattern.
A study of the 2009 influenza pandemic at the University of Delaware found that the risk of infection for people older than 30 was roughly half the risk of those that were 18 to 29.
An even more interesting aspect of the University of Delaware study is the association with student activities. Reports of influenza-like illness among students at a nearby emergency health center remained stable for almost a month after spring break. But cases increased almost five-fold following “Greek week”. In the final analysis, belonging to a fraternity or sorority doubled a student’s chances of being infected.
What’s Happening Now
This is concerning now as cases of Covid-19 are rising among college students nationwide. College leaders such as Penn State president Eric Barron, University of Kansas chancellor Douglas Girod, and University of Tennessee chancellor Donde Plowman have reproached students, especially fraternities and sororities, for ignoring guidance to avoid large gatherings.
Yesterday, J. Michael Haynie, Vice Chancellor for Strategic Initiatives and Innovation publicly excoriated students at Syracuse University for “selfishly jeopardizing” the possibility of in-person instruction this fall. “Make no mistake,” he wrote, “there was not a single student who gathered on the Quad last night who did not know and understand that it was wrong to do so.”
The science of Covid-19 tells us that students are vulnerable, just like everyone else. Although the evidence is somewhat thin, what there is points only in one direction: because of their specific social structure, college campuses are especially prone to outbreaks of infectious diseases. As in the rest of society, the only way to slow down the Covid-19 pandemic on college campuses is to reduce the rate of infectious contacts. There is too much value in the college experience to reduce it to partying, and it should not be squandered altogether for the sake of the party experience.