Monday, May 18, 2020

St Louis Relaxes Restrictions: Sociocultural Patterns of the Covid-19 Pandemic


Tomorrow the Covid-19 restrictions in St Louis City and County will be relaxed. The state of Missouri was one of five states that “opened for business” on May 4, which nearly all health professionals said was too early. The City and County now open, two weeks later, but also before the numbers justify it, before testing and contact tracing are in place, so that we risk having another flairs-up. But there are many uncertainties: will people really be willing to go to restaurants? How much difference will wearing masks make? Will most people actually be willing to wear a mask in public?


I spoke with a former secretary in Hong Kong by phone on May 1st, and she was horrified at the Covid-19 situation in the US, and worried for my safety. I realized in talking with her that the news media portrayed a picture that makes the situation seem perhaps worse than it is, though since Hong Kong has only had 1,053 cases and 4 deaths, in a population of about 7.4 million, the situation in St Louis City and County is indeed much worse: with a population of only 1.32 million, we have 5,918 cases and 431 deaths. More importantly, my county reported 51 new cases today, and 4 more deaths. Many worry the pandemic will just pick up again.

Americans live much more spread out than do people in Hong Kong; single family homes are the rule. Americans can easily shop at supermarkets and only go out once every 8-10 days to buy all their groceries (I go to one store, with a shopping list, wearing a mask, and can be in and out in about 30 minutes). I go to a nearby park to exercise, either running (OK, mostly walking) or on bike. The chances of me getting sick are as close to zero as possible.

In Hong Kong, I lived in an apartment building, on the 7th floor. Most people have to take a bus or train to get anywhere. Elevators, public transit, and crowds on the street, all these add to the risk. This is part of the reason why Hong Kong is working so hard to completely eliminate the virus from the city.

Eliminating the virus was probably never possible in the US. It came from many different directions (via Wuhan, via Italy, via Paris) and was spreading locally before authorities were even aware of its existence. Hong Kong could close its borders, particularly the border with China, but there is no border between states in the US. Trump floated the idea of quarantining the New York City metropolitan area, but it was impossible to do, so he dropped it. The US also has never had the public health infrastructure (e.g. contact tracers, local government personnel) in numbers sufficient to do contact tracing in an epidemic.

Of course, add to that the string of failures of the US government: failure to have PPE stockpiled, failure to plan for an event that would affect the entire country at once, and the failures with the tests. A friend who is a nurse tells me her hospital is still recycling N95 masks, even though they were designed to be single use disposable. The story of the failure of the US response is very clear and was documented early on (see Atlantic story from back on March 21 here, Vanity Fair here, and WaPo here, for example.)

In addition to the different geography of the cities and areas, there is the history of epidemics. Having experienced SARS (and MERS, for Korea), East Asians were not only better prepared but also on the lookout for the next epidemic. Here LINK is a fascinating article about the Taiwanese doctor who went to Wuhan in mid-January, when the outbreak was still not well understood. But he was cautious and informed enough to decline his Chinese hosts’ invitation to dinner in a restaurant. Smart move. And of course, Taiwan’s vice president is an epidemiologist, so they had a real scientist in charge.

In the US, the speed of officials’ responses depended on many factors, including their historical experience with epidemics, but also how much the officials were willing to listen to scientists. Charles Duhigg has written an interesting article contrasting the different ways officials communicated the danger in Seattle and New York. Though the outbreaks emerged at about the same time, the Republicans and Democrats in Seattle were able to agree on a common message and “let the scientists take the lead,” resulting in a much more controlled outbreak in Seattle. San Francisco’s mayor Breed was initially criticizes for overreacting, but hassince won praise for her quick action.

It is amazing to me how uninformed most Americans are about testing and contact tracing, the two features necessary to contain the virus. The Q&A on NPR’s Corona Virus Update for May 2nd shocked me when a nurse who had gotten sick asked how they could trace who gave her the virus. The journalist had to explain that contact tracing was not tracing who she got it from, but who she might have exposed before she was symptomatic. If a nurse does not know that (and the radio host also sounded surprised), then clearly this is not a well understood idea. People also do not understand error rates and the limits of testing. It is more than a little depressing that a comedian like John  Oliver has a better grasp of the issue (and the importance of testing) than most politicians. Many are worried that states are relaxing social distancing before testing and contact tracing are up to a level that can suppress any new outbreaks. 

Hong Kong is being extremely cautious; only residents are allowed to enter the territory, and they have to be tested upon arrival and do a 14 day home quarantine (checked with a digital wrist band; see video here and Twitter feed here); though restaurants never completely closed, schools have been closed and administrative staff at my old university were taking turns staffing the office, one person at a time, until May 4th, when offices were back at full strength. Even the Cheung Chau Bun Festival (ironically, a celebration of the end of a late 19th century epidemic) was restricted and ultimately cancelled for the first time in 100 years, for fear that crowds might spread the virus, even though Hong Kong had reported no new cases for 10 of the previous 16 days and nearly all the new cases were from travelers coming home to Hong Kong. Of course, it is also true that the Bun Festival procession has been an occasion to mock government leaders, so it is possible the authorities were “especially cautious” to avoid being insulted. But in general, people seem to accept that the government policies are medically necessary. (As an aside, I heard an amusing incident in a recent Planet Money podcast where the journalist asked a restaurant manager in Beijing if most people supported the government’s restrictions on restaurants and she laughed and said “next question.” It is really pointless to ask such questions in the Mainland.)

So Hong Kong is relaxing restrictions, allowing people to gather in groups of eight instead of four, and allowing gyms and movie theatres to reopen on May 8. Schools will restart in late May.

But St Louis, and much of America, is opening up only because the peak has been avoided. In no way has the epidemic been controlled, and Michael Osterholm of CIDRAP says not one of the 42 states that have relaxed their restrictions have met the conditions originally set by the White House for Phase 1 reopening. All are responding to political pressure.

The economic problems caused by the epidemic are very real and severe. But many of the workers who are being asked to go back to work are worried that they might get sick, and that they could infect their family. A group called HealthB4Wealth is actually protesting the opening, calling it premature. And the head of the STLMetropolitan Covid-19 task force admits that political pressure led to settingan earlier date. (Note that the previous link is to the St Louis American, a newspaper serving the African American community. It is not a coincidence that the group got more and earlier coverage there.)

It dramatically obvious that poor people are suffering much more tragic outcomes from this pandemic. Blacks and Latinx get the virus, and die from it, in higher numbers (see here). And medical anthropologists would not be surprised. In fact, the journalists who broke the story of the disparate racial impact of Covid-19 for Chicago’s WBEZ have been researching how class and race affect health, so they were thefirst to realize that though Blacks make up 29% of Chicago’s population, theyrepresented 70% of deaths by early April. Days later, it emerged that the first twelvepeople to die in St Louis City were all Black. Since then, the press has stopped reporting the race of the dead, but several reports have said that most are African Americans.

Of course, there is nothing genetic about this. Blacks and Hispanics are more vulnerable because many are poor, so have had less medical care, and often eat high calorie diets because they are cheaper, so they end up with hypertension and diabetes, which make the outcome of Covid-19 infection much worse.

In addition, many of the so-called “essential workers” who could not work at home are minorities, so they have been more exposed, and therefore more likely to get sick. I was on a call recently when someone suggested African Americans were less likely to “social distance” or follow the rules; I think this is absurd. I heard of a wealthy family in the suburb of Chesterfield (83% white, 11% Asian, 4% Black) that tried to hold a party for a graduate last week. The 30 cars on the street gave them away, and the police came and told everyone to leave. I would be willing to bet that the rich are more likely to believe the rules don't apply to them, or that they are safer than the rest (which, in some ways, they are--that is privilege).

Because “essential workers” still have to go to work, often by taking a bus or train to get there, they continue to get exposed, and to spread the virus to family members. It is not a coincidence that 33 MetroTransit workers have tested positive for the coronavirus, and two have died. Wealthier and non-minority people can work and hide in their homes and remain safe. A recent article in the Boston Review examines the shameful history of racism in St Louis, and the role it plays in the Covid-19 epidemic. 

What is frustrating, to me, is to see people who push for the economy to “reopen” without realizing that they are relatively privileged and protected, but a) still vulnerable, and b) can infect others. The Atlantic recently had an article that argued “Georgia’s brash reopening puts much of the state’s working class in an impossible bind: risk death at work, or risk ruining yourself financially at home. In the grips of a pandemic, the approach is a morbid experiment in just how far states can push their people.”  Non-Americans often do not realize that “essential US workers often lack sickleave and health care – benefits taken for granted in most other countries.”  That results in people going to work even when sick, because they or their family need the money, or because they fear being fired if they miss work. That is not a way to fight a pandemic.

Some who are frustrated by the government restrictions even go so far as to claim the whole coronavirus is a hoax. One such person wrote a screed on my NextDoor feed today, claiming that no one is actually dying of it. I’d like to think she was drunk, but I fear she was just watching too much Fox News. When the epidemic began, it was emphasized that “we’re all in this together.” But now, the racial fault lines, and political fault lines, are growing wider. Journalists already commented in early March on the early partisan division, but now it has become particularly toxic (NY Times 1 March and The Atlantic 20 March). 

Some people even refuse to wear masks, viewing the imposition of masks a threat to their freedom. One NextDoor post replied to a polite message that mentioned wearing a mask this way: “Your demand that someone else wear a mask to allay your fears is a pernicious form of bullying, so please knock it off.” Fortunately, the original poster replied politely again:
I wasn’t demanding that anyone wear a mask, simply asking for people to wear masks as a courtesy to others, and to help stop the spread of the virus. No reason to be afraid of the virus, just be cautious and aware of it. However, your response seems a little on edge. Maybe I’m just reading it wrong, tone isn’t always well conveyed over the internet. But if you are feeling on edge, let me know if you need someone to talk to. I would be happy to help

This is a good example the American individualist, who thinks that he/she should be able to do whatever they please, and don’t understand how their actions can impact other people. If it was not so self-centered and childish, it might be funny, but in a pandemic, it’s alarming. Here’s another example just in from NextDoor:
...And all I want to do is go to the pool.  I have read two articles stating it is safe to swim in the ocean and indoor pools.  None saying it is not safe.

Open up the country.  If business owners don’t want to open yet, then don’t open.  If people don’t want to go out yet, then don’t go.  If employees are afraid to go back to work, there are 36 million waiting for a job.  We are adults.  We have seen what this virus can do.  We have been told 20 times a day how to keep ourselves safe.  We are adults, let us make the decision about where we go when. 

I sympathize with her frustration, also because the rules are different in different states; Pennsylvania did not allow gardeners and outdoor construction, while most states did. Still, the naivete of this author stunning. It is true that articles say pools are safe, but all the articles also say that the dressing rooms, toilets, and poolside are all places where contagion would be likely. And if she gets infected, it is not just her that is affected: she will go to stores and the supermarket, and could infect others, especially the pool staff and other “essential workers” who cannot protect themselves as well as she may be able to. So it is not just a matter of everyone deciding for themselves what risks they are able to accept. American notions of freedom and liberty seem to prevent some people from understanding how they are tied to others in webs of relations.

The expensive consultants McKinsey just sent me a report which says:
Uncertainty about the continuing spread of the coronavirus makes people fear for their health and their lives. Uncertainty about their livelihoods makes them cautious about spending. Under high uncertainty, business leaders find it impossible to make reliable plans for investment.
This uncertainty is toxic for our economic recovery.
The objective now must be to crush uncertainty as soon as possible.
Good luck with that. Uncertainty will be with us for a long time. And states can “open” their economies, but will customers go back to restaurants and movie theatres? How much of a difference will masks and handwashing make, especially if some people actively refuse to comply? There is plenty of uncertainty, and it is likely to last quite a while.