Department of Medicine Chair Dr. Bob Wachter kicked off Thursday’s Grand Rounds by asking panelists to recollect when the severity of the coronavirus pandemic dawned on them.
For Dr. Kirsten Bibbins-Domingo, chair of UCSF’s Department of Epidemiology and Biostatistics, it was the cancellation of an NBA game .
“That is when the things that I had been saying were more than, ‘Oh, Mom is just the doctor who is always worried about everything’ to ‘something really different has happened,’” Bibbins-Domingo said.
Dr. Peter Chin-Hong, professor of medicine in UCSF’s Division of Infectious Diseases, noted the docking of the Grand Princess cruise in Oakland as a metaphorical turning point. “Literally, it was on our shores,” he said.
For Dr. George Rutherford, professor of epidemiology and biostatistics at UCSF, the turning point came that first week of January. “The first sequence came out and you could tell that it was a beta coronavirus..” In twenty years, he said, beta coronaviruses SARS and MERS had been responsible for two pandemics. “I thought ‘ruh-roh,’ in the immortal words of Astro.”
As more data emerged from Wuhan, China, and community transmission became evident, Rutherford became more worried about the possibility of a major pandemic, especially around January 10, 2020, when evidence of asymptomatic transmission began emerging.
As the pandemic spread in the United States, racial disparities were clear from the start. Bibbins-Domingo said that it was “pretty clear” that “all the patients we were seeing [at Zuckerberg San Francisco General Hospital] with covid were Latino patients.”
She described this evidence of inequity as an early drive into Covid-19 research at UCSF, citing studies by Dr. Diane Havlir and Dr. Carina Marquez in the Mission District.
“It was pretty clear in reading that, you know, everyone who studies pandemic knows that this is what’s going to happen. Poor people, poor communities, communities that lack resources defined in a variety of different ways, oftentimes bear the brunt of a pandemic,” Bibbins-Domingo said.
The striking health disparities of covid alongside the recent killing of George Floyd catalyzed a national reckoning with racial injustice, a conversation which “became the focal point nationally because we were all at home, watching these images, at the same time, on the screen,” Bibbins-Domingo said, not because this kind of violence was new.
Chin-Hong was also “blindsided” by the hate and violence against Asian communities that emerged throughout the pandemic.
Though the World Health Institute anticipated anti-Asian discrimination in its early push to rename the disease to Covid-19, “political leaders still use, you know, ‘Kung flu’ and ‘Chinese virus,’ and that’s fuzed so much hate and violence,” Chin-Hong said. He witnessed an Asian man almost being run down in the street because of coronavirus-related racism. “It’s still persisting, and in the Bay Area,” he said.
Wachter and Rutherford went on to draw parallels between the marginalization of certain groups, especially the LGBTQ+ community, during the HIV/AIDS crisis, and the covid pandemic today.
Rutherford also noted other similarities between covid and HIV/AIDS: early on, nobody knew how the viruses were transmitted, there was resistance to advice regarding the disease, and politicians were “flubbing it” at a national level. The biggest difference he saw is that the Centers for Disease Control and Prevention “failed to ride to the rescue,” in the case of covid, he said.
Chin-Hong also noted the CDC’s absence from the early days of the pandemic. Typically, the CDC rolls out updates about prevention and therapeutics in this kind of situation. Instead, he, his team, and other clinicians were turning to places like Twitter to crowdsource information about treatments. He also described being “incensed” at the politicization of masks, hydroxychloroquine, and testing.
Bibbins-Domingo highlighted how politicization of different issues colored both the national and local contexts, describing receiving “vile, repulsive” messages from individuals who didn’t like her conversation with a reporter about the importance of masks. She pointed to local health officials who were forced to step down for instituting health measures, such as one in Orange County.
Rutherford pointed out that San Francisco today has had 420 deaths, while there were 3,000 deaths here in 1918 as a result of the influenza pandemic with the same mitigation measures.
“So, when people say to me, ‘How could you have done this?’ I say, ‘well, what’s your vital status? Are you alive or dead?’ Right. You’re alive,” Rutherford said.
Bibbins-Domingo said the reason for San Francisco’s low death rate per capita is “multifactorial,” and that many factors in San Francisco worked in its favor to contribute to the low death rate. And, she noted, disparities still exist.
Chin-Hong attributed the city’s success in part to the political homogeneity of the Bay Area and the willingness of Bay Area counties to work together from an early stage.
Asked about their optimism moving forward, the panelists had several different responses.
Bibbins-Domingo is “middle of the road,” highlighting issues of equity as a source of pessimism, especially as vaccine distribution continues in an inequitable way. “Our failure to focus on equity has been the reason we’ve not had as good a response as we think … ” she said. “The virus is always hanging around … in communities that we have not really invested in.”
Chin-Hong said his optimism gas tank “is about three-quarters full and one-quarter empty,” again pointing to equity as a concern. His focus was more global, however, noting that with more variants in places all over the globe, we cannot solve this issue until everyone is protected.
Rutherford was more pessimistic, calling himself “about a quarter happy” and describing “reckless” behavior in places like Texas (where masking and social distancing mandates have been lifted) that are “going to hold the rest of us back.” Not only do these actions create opportunities for more complex variants, but Rutherford said we will not be able to “get back to normal” until our trading partners worldwide have the pandemic under control.
Though 80-percent herd immunity is a “great short-term goal,” California is not going to build a massive wall around its borders. “We need to act as part of a United Group of States and a larger group of countries that are our trading partners,” Rutherford said.
Chin-Hong said his pessimism comes from what we don’t know, especially concerning variants. Though he is optimistic about Merck’s successful oral treatments, the entire world will not be vaccinated a year from now, and the disparities between countries will only continue to grow.
“We’re not going to eliminate covid,” he said. The question is whether it will settle into an annoyance or something else.
“If I’ve got my two shots already, Peter; what’s the chance I never need another one?” Wachter asked.
Chin-Hong’s answer was swift and blunt: “zero.”
There are, however, reasons to be optimistic. Bibbins-Domingo pointed to innovations regarding homelessness and other community investments, as well as partnerships formed between city governments and communities.
Her hope is that these are not forgotten once the threat of the pandemic is no longer in front of us, but that governments continue to address the ongoing health needs of these communities.
Rutherford wants to set up early warning systems that were dismantled by USAID in October 2019, and believes that fully vaccinating the world will take “a couple more years,” requiring the development of a universal vaccine for beta coronaviruses or “chasing variants all the time.”
“Internationally there’s…going to be a ton more work to do,” he said. Even domestically, he said there could “easily be a winter surge if we don’t get enough people vaccinated easily.”
Though Wachter said UCSF has come through the pandemic with “flying colors” in terms of the care and work of its members, “We’re not completely out of this yet, we’ve got a while to go in the world. It’s an awfully big world out there.”
See our previous Grand Rounds coverage here.