The one-year anniversary of the Bay Area's first shelter-in-place order passed on Wednesday, with Bay Area health experts expressing optimism that the pandemic is in its end stages.
Alameda, Contra Costa, San Francisco, San Mateo, Santa Clara and Marin counties and the city of Berkeley issued identical orders on March 16, 2020, announcing they would go into effect the next day and ban all non-essential gatherings and travel while shuttering businesses across the region.
The order in the seven Bay Area jurisdictions came three days prior to Gov. Gavin Newsom issuing a statewide shelter-in-place order.
Santa Clara County Health Officer Dr. Sara Cody said last month that the virus's early concentration in the Bay Area necessitated the region's early action.
"On Feb. 4, 2020, Santa Clara County had two of the 11 positives in the entire country. So we had 20 percent of the positives, but were only submitting 5 percent of the specimens," Cody said during Joint Venture Silicon Valley's State of the Valley event last month.
"Of course, the minute we began testing ... every signal that we saw showed us that we were in trouble," Cody said.
At the time the order was issued, health officials around the Bay Area had confirmed around 260 cases of the virus, including three deaths.
That case count, however, was obscured by a widespread lack of testing kits and equipment like swabs. The federal government also fumbled its initial roll out of test kits, dispersing kits with a failure rate of 33%.
Tests were also limited to people with symptoms who had been referred by a doctor, but some likely cases still fell through the cracks.
Dr. Jeanne Noble, an emergency medicine specialist with the University of California at San Francisco and the COVID-19 response director for UCSF's Emergency Department, recalled treating a patient who had just arrived in the city from Italy with COVID-19 symptoms like a fever and a cough but could not access one of the limited number of tests.
"That's an incredible gross mismanagement of an infectious pandemic," Noble said of the federal government's failure to rapidly disperse working test kits.
San Francisco Director of Public Health Dr. Grant Colfax described issues at the time like the lack of personal protective equipment for health care workers, let alone regular citizens, as "incomprehensible" compared to the state of the pandemic at the time.
"I remember, distinctly, calls in April about how are we going to clean the face masks of the front-line workers," Colfax said in an interview this week.
Cody and Colfax said the counties involved in the shelter-in-place order agreed on the necessity of acting quickly in spite of how disruptive the order would ultimately be.
"This was really about not overwhelming the health care system and slowing the spread of the virus so that we were able to manage it," Colfax said. "We didn't know at the time if it was possible."
Colfax, who previously worked as the San Francisco Department of Public Health's HIV prevention director and was a top HIV and AIDS policy advisor to President Barack Obama, said the city's intent on early action was due in part to memories of the HIV epidemic in the 1980s, noting that they city was not going to wait for the federal government to take preventive action in the pandemic's early days.
It also quickly became apparent that the novel coronavirus would be different than previous outbreaks like H1N1, Zika and SARS based on how quickly it could overwhelm health care systems like those in China, Italy and Kirkland, Washington.
"It became very apparent that the most vulnerable populations are going to be affected very rapidly if we didn't get things under control," Colfax said.
Noble suggested that, in hindsight, the best virus mitigation tactic may have been a well-enforced mask order rather than the blunt instrument of a shelter-in-place order had there been enough face coverings for non-health care workers at the time.
"Knowing what we did then, (the shelter-in-place order) was a very reasonable and, I think, dramatic and bold and important move," she said. "I think that what we didn't do is focus on what was really the most important aspect of preventing spread, and we are still not united as a nation behind ... universal masking."
While some counties had already done so, the state did not mandate mask wearing until June, when Newsom ordered residents to wear face coverings in public spaces and when social distancing was not feasible outdoors.
"If we had just immediately adopted our best mitigation measure, which is universal masking, I think we would have had more of an impact than we did in stopping the spread," Noble said.
The order as originally announced was set to last through April 7. Subsequent extensions combined with the state's order meant the Bay Area would not begin lifting shelter-in-place restrictions and reopening businesses until early summer.
Cody said that, in retrospect, the initial shelter-in-place order was the easiest phase of the pandemic, despite few tools being available to local health officials.
The difficulties only cropped up once state and local officials began planning to reopen certain businesses and deem some activities safer than others.
"It started to become complex as soon as things settled down, because then the clamor to open things up and to resume normal life started to become rather loud," she said.
Varied approaches to reopening and regulation across the greater Bay Area's 11 counties also led to a break-up of the coalition that initially enacted the order, according to Cody.
Those variances included funding support for public health in the Bay Area, as well as across the state and country at large.
Colfax described San Francisco as a city that has historically invested in public health while Cody credited Santa Clara County for its support for public health.
Still, she described the pandemic as having to build public health infrastructure on the fly due to a lack of resources like data systems and trained workers at the state and federal levels.
"We all talk about building a plane while flying and how difficult it is," she said. "But responding to this pandemic has really felt like building a whole fleet while trying to form them in formation."
Cody and Colfax both agreed that the public health strategy in the year since the initial shelter-in-place order has gradually changed from defense to offense, due in large part to the ever-expanding availability of vaccines.
The Bay Area has also successfully weathered three surges in cases while preventing large-scale health care breakdowns and gaining vital information about transmission of the virus, giving health experts cautious optimism about managing the virus going forward.
"I really do think we are well into the beginning of the end of this," Noble said. "Unless we have big problems from states that have abandoned their masking too soon ... I think we have every reason to be optimistic."
Cody largely agreed, with the caveat that the devastation wrought by the pandemic will linger once people can return to pre-pandemic activities.
"I think that we do have a chance to return to a normal, but this has been like a national trauma," Cody said of the past year. "We're not going to be the same."