Dr. Monica Gandhi knows what San Francisco will be remembered for during the pandemic: It’s the city’s low mortality rate, claimed by San Francisco officials as a testament to the wisdom of an early shutdown.
But, while Gandhi would be the first to acknowledge the blessing of fewer deaths, she looks at the lower mortality rate and sees something other than prescient city officials. The main factors, she argues, “are our privilege and the wealth in this city.”
Wealth, she said, allowed much of San Francisco to shelter in place. Weeks before the city shut down, many tech companies had already sent their workers home.
Such not-so-fast correctives to popular narratives have become increasingly common in San Francisco’s pandemic sphere. Sometimes the assertions land as zingers, other times as matter-of-fact reminders, but nearly all come from a group of female UCSF researchers — most of them women of color.
If not for their dazzling resumes, flawless manners, and white lab coats, they might be confused with community activists. And, in a sense, they are, although their activism is shaped by academic pursuits and reams of data. Insofar as San Francisco’s pandemic year has proved exceptional in any way, it has, in no small part, been in the individual voices and collective activity of these women. Each is a role model for legions of other young women interested in science. Together they’re a powerful example of the benefits of diversity.
Gandhi, Dr. Kirsten Bibbins-Domingo, Dr. Diane Havlir, Dr. Kim Rhoads, Dr. Alicia Fernandez, and Dr. Carina Marquez — a young epidemiologist who, like Fernandez, lives in the Mission — are all researchers who have pushed against entrenched narratives over the last year. Their prominence in Covid debates and research owes nothing to an old-boys network. Instead, they are women who have seized the initiative, each of them helping to change the way UCSF and the city have responded to the crisis.
They generally research within their academic pods — calling on a bevy of scientists in their labs or departments —but sometimes they co-author reports. Havlir and Gandhi wrote early on about the Achilles Heel of asymptomatic transmission, that made controlling the virus all the more difficult. The editorial in the New England Journal of Medicine was based on data from a Mission District study also signed by Marquez, Gandhi and others. Last month, Bibbins-Domingo and Havlir teamed up to argue for a vaccine distribution strategy based on geographic hotspots.
Often, said Bibbins-Domingo, the motivating question is, “What do we have that we can put together with other people to really try to drive the agenda?”
That a strong cohort of women researchers was able to address the pandemic was not an accident, said Fernandez, the director of the UCSF Latinx Center of Excellence, who has devoted her research to looking at health inequities. The onset of Covid coincided with the advance of women propelled by the first wave of diversity in academia. Already, Fernandez and others had senior positions that gave them a certain freedom to act on “a huge crisis unfolding on our watch.” In many cases, their backgrounds made that crisis personal.
They watched as Zuckerberg San Francisco General Hospital filled up with immigrants and residents who spoke their language or looked like them. The women wasted no time. “All of us just went to work on this,” Fernandez said.
To Rhoads, a professor of epidemiology and biostatistics who has done fieldwork in testing and vaccinations in San Francisco’s and Oakland’s Black communities, their biggest impact has been a change in how policymakers have approached the crisis. Traditionally it was top-down. Now, increasingly, it’s bottom-up.
“The old way presumes that we already knew everything,” said Rhoads. That’s over. “It doesn’t work. It marginalizes too many people. It causes us to lose perspective on what is possible if we’re so busy saying what you know.”
The new way is bottom-up research — talking to and working in communities most impacted by the crisis.
“If different voices with different kinds of leaders had not emerged specifically around UCSF’s Covid initiative then we would have been doing the same thing,” added Rhoads. “That’s the value of diversity — we’re not doing the same thing right now.”
Fernandez agreed and added that all of the partnerships with community-based organizations has given both the academy and grassroots groups a new appreciation for one another and the power in collaborating. “I think — I hope — that is here to stay,” she said.
Epidemiology attracts activists
Marquez, who has worked throughout the crisis with Havlir on the Mission-based studies, said that what attracted her initially to epidemiology was the intersection of science with social justice issues. That was also a powerful lure for her more senior colleagues.
Dr. Gandhi describes that intersection as hardwired into infectious diseases, which are not simply the interaction between host and pathogen. Instead, there are “three interactions — host, pathogen and disparities — the social determinants of health.” This means, she said, that every policy has to be examined for its impact on disparities.
When the city closed playgrounds and outdoor dining in early December, for example, Gandhi and Bibbins-Domingo made it clear that such moves might be counter-productive — and particularly hard on the low-income residents already bearing the brunt of the virus. Gov. Gavin Newsom conceded – it’s unclear exactly why – and overturned the directive. Mayor London Breed followed suit.
“For my colleagues, this is often personal,” said Bibbins-Domingo. “This is health equity; it’s something that people are willing and able to talk about openly.”
Gandhi, who is also the medical director of the HIV Clinic at SFGH, known as Ward 86, agreed. “The entire reason I entered HIV is that I grew up in a place (Utah) where I felt different and stigmatized for something I couldn’t control, which was the color of my skin.”
Nowadays, she sees marginalized people facing the worst of Covid. “It’s actually very simple to shut down pathogens,” she said. So in this crisis, the wealthy stayed home, but the poor had to leave home to work. Similarly, in a cholera outbreak, the poor have less access to clean water and in HIV, the poor are harder to reach, sometimes because they are homeless or suffer from an addiction. It is breaking transmission in the impacted communities that is crucial to any successful fight against a pandemic, Gandhi said.
And demonstrating the impact of inequities for scientists means gathering data. Gandhi and her fellow researchers realized “that we have to use whatever we have within our power that can help policymakers make the right decision.”
Ignore us? More data coming.
When policy lagged behind research, which has happened often with the city’s approach to Covid, the researchers just worked harder.
Early on, for example, when the Department of Public Health appeared to ignore research of Havlir and Marquez that indicated more testing needed to be done in the Latinx community, the two researchers and the Latino Task Force alliance known as Unidos en Salud simply continued piling up the data. Dismissing it became impossible.
And, at public forums, they cautioned (very graciously) against an outlook that was too optimistic. When Mayor London Breed and UCSF’s chair of medicine Dr. Bob Wachter toasted San Francisco’s mid-summer lull in cases, Dr. Havlir politely pointed out that it was perhaps unwise to celebrate so early. By fall, the city was again awash in the virus, and the toasting ceased.
They don’t always agree with their male colleagues. Early on, Wachter, not only UCSF’s top doc but a big social media personality (as is Gandhi), penned a Jan. 3 Washington Post op-ed calling for delaying the second dose of vaccine in favor of vaccinating as many as possible with a first dose. Bibbins-Domingo was more cautious.
Her glasses slightly askew — giving her the look of an amiable and confident class brain — she asked aloud on Zoom and other forums whether that wasn’t a problem for two reasons: messaging and the data on hand.
Then Bibbins-Domingo and Wachter moved on. They disagreed, but that is the point of open collegial relationships and it is also what has been interesting to watch as researchers – none Covid-19 experts a year ago – have become increasingly familiar with the spiked virus. Wachter stepped back from the eight weeks he first proposed to second-dose a delay of two weeks, which is within the delay CDC now allows for, if needed.
“I am pushing this a bit less hard than I was, because the rollout has started accelerating,” he wrote in an email. “And, with the prospect of the J&J vaccine being added to the mix, I suspect that we’ll have enough vaccine within a couple of months.”
By January, Bibbins-Domingo was at work on a new study with Fernandez and others looking at death rates among Latinx residents in California. It showed that excess deaths were 31 percent greater than might normally be expected, and that food and agricultural workers were particularly hard hit. Since then, she’s published six more papers or editorials.
Marquez, a junior member of the faculty who, like the others, has also published throughout the crisis, watches her senior colleagues in awe. “It’s inspiring to be part of a group and to work with really action-oriented people,” she said.
Her own work, she added, has benefited from Havlir’s counsel and from being pushed to take on speaking roles and leading her own research projects in Uganda and the Mission. The jump from academia and teaching to becoming a principal researcher, she said, is a big one, and having the advice and counsel of her senior colleagues has been critical to her success.
But, like those senior colleagues, Marquez also notes how few doctors of color are represented in the academy, and she relishes the time she is spending at the Mission testing sites to encourage young pre-med volunteers to enter the fray. “I can count the number of faculty [of color] on my hands,” she said. “As we’re all addressing inequities it’s really important to have people of color, women of color, at the table and shaping this work.”
Fernandez and the others could not agree more. Fernandez wrote recently in CalMatters how Covid has exposed the state’s need for more Black and Latinx physicians. She’s hopeful that the role she and others have played in influencing Covid policy will teach an enduring lesson. “I think having a more diverse academic workforce — the value of that — is also clearer to people in a way that it wasn’t.”