Life in Los Angeles was breaking down. Three weeks had passed since the city had shuttered all public venues to contain the outbreak. More than 1,100 people were sick, 26 had died, and the rates of infection and death continued to rise.
Acting on the advice of a special committee made up of prominent physicians, chiefs of police, and the State Board of Health, city leaders ordered all schools, colleges, churches, theaters, bars, and performance venues to immediately shut down and to stay closed until further notice. Ten thousand placards announcing the order were printed and posted throughout L.A., and the city’s chief of police vowed to enforce it to the letter.
The emergency ward of the county hospital was besieged by patients. L.A.’s fire stations were quarantined after 80 firemen came down with the disease. Scores of inmates were stricken at the East Side Jail. Members of the public demanded that inbound trains be inspected at the state line. Department stores were barred from holding special sales for fear of drawing a crowd. Elevators were not allowed to fill up to more than 50 percent of their capacity. The public was warned against riding in crowded buses and trains. Prominent business leaders complained that the order was more drastic than the situation required. Hollywood theater owners were on the verge of revolt over their mounting losses.
The events described above occurred during the Spanish Flu pandemic of 1918, when L.A. was on lockdown for nearly two months after hundreds of Angelenos succumbed to the mysterious virus, the deadliest plague in history. As the city mobilizes against a brand-new pandemic, scientists say the lessons of a previous century might provide a worst-case road map of what 21st century Los Angeles could experience. The scope of infection of the coronavirus is still light-years away from the influenza pandemic of a century ago. All the same, its cataclysmic possibilities are darkly reminiscent of its 20th century predecessor.
The coronavirus hit L.A. with record speed. The Chinese government publicly confirmed the coronavirus outbreak December 31. The first cases hit America a month later. By early March, state health officials had identified six newly confirmed cases of the flulike illness COVID-19 in 48 hours. On March 4 a team of prominent physicians and elected officials assembled outside the Kenneth Hahn Hall of Administration in downtown Los Angeles to declare a state of emergency. The officials were quick to counsel against panic but said big changes could be in the offing. “What we are saying…is that the potential public health risk is elevated and significant,” warned Mayor Eric Garcetti.
Barbara Ferrer, the director of the L.A. County Department of Public Health, told the throng of assembled reporters that the public should prepare for the possible closure of schools and businesses and the placement of restrictions on crowd sizes at sporting events, concerts, and other public gatherings. The county health department is one of the largest agencies of its kind in the nation, a world-class $1.3 billion operation with nearly 5,000 employees. Ferrer says her department has urged parents to prepare for the possibility that their child’s school will close and called on business owners not to penalize employees who call in sick. Her staff has also briefed large-venue operators on the health benefits of holding events without spectators.
Ferrer, who previously served as the executive director of the Boston Public Health Commission and received her Ph.D. in social welfare from Brandeis University, has the soothing manner of a therapist, at once gentle and direct. She endorses some mild, if anxiety-provoking, social-distancing measures to prevent infection, from using verbal salutations instead of handshakes to maintaining six feet of distance from the people in one’s proximity.
As of early March the spread of the new coronavirus had prompted the lockdown of vast areas of China and imposed far-reaching restrictions in terms of movement on people in northern Italy, South Korea, Singapore, Iran, and Japan. Though an outbreak is occurring in Washington state, and a spate of infections has been reported in Northern California, no resident of Los Angeles has yet contracted the virus from a local source. [As of March 12, the Department of Public Health reported two community-spread cases.] But if there is an explosion of local transmission, would Ferrer, as the top health official in the county, consider the kind of unprecedented control China is imposing on Wuhan?
“We don’t envision a scenario where we would lock down an entire city or jurisdiction, but I don’t rule anything out,” Ferrer says. “There are a lot of steps we should try before we get to lockdown, but everything has to be on the table. We need to understand what the route of transmission is and where the virus has gotten hold.”
Since COVID-19 is a new disease, there is no vaccine or medication for it, and no one has built up an immunity to the virus. So the constant drip of new cases in Los Angeles has contributed to mounting anxiety. Meanwhile the virus has already had an impact on significant sectors of the local economy.
On the same day the state of emergency was declared in L.A. County, the April release of the new James Bond flick, No Time to Die, was delayed until November, at an estimated $30 million loss to the film’s producers. It was another moment in an escalating series of bad omens for an industry whose foreign box office was already in free fall before the coronavirus began appearing in its backyard.
As more and more Angelenos avoid public places, and travel and tourism ebb, economists fret about the financial impact on the city if its residents avoid malls, movie theaters, and restaurants for any prolonged period of time. Spin class studios wonder if the bikes are properly disinfected. Metro riders fear the potential virulence lurking on a crowded bus. Companies worry about the malady being spread in the conference room. A sniffle from a rideshare driver can make a customer feel like a passenger on the quarantined Diamond Princess cruise ship. “Coughing in public these days is like shouting Allahu Akbar,” tweeted the author Hassan Hassan.
“Social distancing” has become the new buzzword of the current crisis. Not surprisingly, residents of the city’s wealthier zip codes have taken the challenge to heart with the assistance of concierge doctors, chartered planes, germ-free hideaways, and “urban air marks” that come equipped with five layers of filtration and an “ultrasmooth and skin-friendly finish,” as The New York Times reported. But what does social distancing look like for the nearly 60,000 men and women who bed down on the streets of greater Los Angeles every night? Los Angeles is home to more than 1 million undocumented immigrants, the linchpin of the local service and manufacturing sectors. Their understandable reluctance to seek medical treatment threatens to thwart education efforts and to exacerbate the spread of the virus in immigrant communities.
Los Angeles health officials are hoping that technology will be a useful tool in their battle against the virus. Advances in telecommuting, telemedicine, and an explosion of telephone apps for everything from child care to dog walkers will surely make isolation easier and mitigate the likelihood of infection. But financial and racial disparities will play a major role in determining who gets isolated and who is left in harm’s way. “You’ve got a problem in L.A.,” says Stanley Deresinski, an infectious disease physician at Stanford Health Care. “There’s a lot of people here who live from paycheck to paycheck and who don’t get paid if they don’t go to work, and their work doesn’t allow for things like telecommuting. There are going to be real difficult choices being made at that point. If you’re wealthy, you can isolate yourself much more easily than if you have to scrounge for your meals.”
Los Angeles interviewed two dozen top health care providers, politicians, and medical experts for this story. They all expressed concern about the possible toll of this outbreak, and said the shortage of accurate, vetted information has hampered efforts to curtail it. “Until we have enough data to understand how quickly it spreads and how severe the symptoms are and what the case fatality rate is, we all worry,” says Anne W. Rimoin, an epidemiologist at the UCLA Fielding School of Public Health who studies Ebola in Africa.
How easily people transmit it, how ill it can make otherwise healthy people, how long it will last, what balance the government will strike between public health and global markets are questions that will determine whether and to what degree the coronavirus will transform L.A.
“You always try to balance disruption to society and economic life to the country versus the medical necessities of trying to prevent the spread of infection,” says Zachary Rubin, chief of the health care outreach unit of the county’s Acute Communicable Disease Control Program. “You want to do everything possible, but there are a lot of things you can do without grinding everything to a halt.”
On February 26 federal authorities announced the nation’s first locally transmitted case of coronavirus, an elderly woman from Solano County who had contracted it from an unknown source. By then, two months into the global health crisis, health officials were experiencing a come-to-Jesus moment. Until then, the main focus of the government was to prevent the virus from breaching America’s borders. But a flurry of new cases across the country rendered that strategy obsolete, says Max Lau, a scientist who models infectious disease dynamics at Emory University. “You were starting to see people testing positive for this who had none of the supposed risk factors. They never stepped foot in China or Italy,” he says.
“COVID-19 has a reproduction number of 2.3, meaning on average each person infected with the virus will spread it to 2.3 others. The reproduction number of the Spanish Flu was 1.8,” says John M. Barry, the author of The Great Influenza: The Story of the Deadliest Plague in History. “So if you’ve actually got 2.3, that’s incredibly explosive.”
His concerns are echoed by Harvard epidemiologist Marc Lipsitch, who predicts that in the coming year 40 percent to 70 percent of the human race might be infected with the coronavirus that causes COVID-19. Since early February, a team of 900 L.A. County nurses under the guidance of the Centers for Disease Control and Prevention have been screening and interviewing travelers returning to Los Angeles International Airport from China and tracing the contacts of local patients who have contracted the virus. It was shoe-leather epidemiology: find everyone they’ve been in contact with, hunt each one of them down, and determine if they are at high or low risk for infection. The county eventually set up a call center for nurses and support staff to keep tabs on more than 3,000 travelers from China who the CDC had designated for surveillance.
The first confirmed case in L.A.—a man returning from China to LAX with his wife and toddler—was detected in the airport screening process in January. Emergency responders descended on the airport, wearing goggles, gloves, N95 masks, and surgical gowns. They put a mask on the coronavirus patient and transported him to Cedars-Sinai. Although he fell gravely ill at the hospital, the man ultimately recovered.
The patient had 50 close contacts in the United States who were all advised to isolate themselves and adhere to monitoring protocols during a two-week incubation period. “Do the math,” Ferrer says. “One case: 50 close contacts. Imagine what happens when there are ten or 20 cases.”
Three days after the Solano County patient was diagnosed—and as the virus was rapidly spreading throughout the Pacific Northwest—the L.A. County health department broadened its criteria for diagnostic testing to include instances of local transmission for the first time. The change was included in a new set of guidelines that urge health care facilities to review their emergency plans and procedures “in the event of widespread COVID-19 transmission in LAC.” “The focus initially was at LAX,” says Marc Eckstein, the medical director and commander of the EMS bureau of the Los Angeles Fire Department. “Now it can be anywhere.”
When Dr. David Eisenman went to dinner in Chinatown recently he witnessed a striking altercation between a panicked customer and a masked restaurant employee. Eisenman is a UCLA medical professor who lives and surfs in Marina del Rey. He has a joint appointment to the Fielding School of Public Health, where he directs the Center for Public Health and Disasters. “So I’m in Chinatown having dinner, and the guy behind the counter has a surgical mask on. [The customer] sees it, and it creates this crazy dynamic. ‘Why are you wearing a mask? Does that mean you’re sick? Should I be wearing a mask?’ He’s wearing a mask as a worker because he is frightened,” Eisenman says. “We’re all wearing these masks because we’re frightened.”
Despite the citywide run on face masks, medical experts warn that they are inadequate to prevent infection. The masks made of rectangular cloth with loops that fit around the ears are too porous. The industrial N95 masks work better, but they are impractical, expensive, effective mostly for preventing sick people from infecting others, and must be thrown away after one use. There is also a shortage of them in California hospitals, which is why the state announced in early March that it was going to start distributing them from a stockpile of emergency reserves.
“Eat More Onions!” was the slogan for a supposed natural remedy for influenza in 1918. Others included bloodletting, whiskey, quinine, chicken soup, laxatives, and Vicks VapoRub. The remedies sought to ward off coronavirus have been just as fanciful. Tens of thousands of WhatsApp users have recently been receiving messages about fake cures for the outbreak that include garlic, saltwater, and a type of tea, The Washington Post reported. Tito’s Vodka recently sent out a tweet dissuading its customers from using the product as a hand-sanitizer replacement. Televangelist Jim Bakker was recently chastised by the New York attorney general for marketing a $175 “coronavirus cure.” And L.A. medi spas are touting an immune-system boost obtained from an amino acid compound in peptide injections as a way to fight off the virus.
Others have tried to elude contagion by staying away from Asian neighborhoods and businesses. L.A.’s Chinatown has been desolate since January, and Koreatown has not lagged far behind. “We’ve heard from Chinese businesses and markets that people are not patronizing the businesses. And there’s a lot of discrimination. People are experiencing bullying because they’re Chinese or Asian,” says county health director Ferrer. “It’s already had an economic impact.”
In February a Korean Airlines flight attendant was diagnosed with the virus after she spent time in Los Angeles. An anonymous rumor spread on a South Korean messaging app alleged that the flight attendant visited several Koreatown restaurants during her one-night stay in L.A. The Consulate General of the Republic of Korea in Los Angeles later debunked the claim, but Korean restaurants across the city suffered a major drop in business. “If it goes on like this, entire neighborhoods will be shuttered,” warns one Chinatown businessman.
Experts are also worried that rumors of an outbreak could target vulnerable populations in L.A. like undocumented immigrants or the homeless. President Donald Trump has floated the possibility he will close the U.S. border with Mexico as a health precaution, though no cases of coronavirus have been traced back to Mexico. Medical experts have criticized Trump’s statement as unhelpful since Mexico has far fewer confirmed cases than the United States. Spreading fear among immigrant groups carries real health risks should someone feel too afraid to report symptoms of the virus and possibly end up infecting more people. “There’s been too much misinformation spreading around,” says county Supervisor Hilda Solis. “And, as we expected, it’s cultivating fear and leading to racial profiling.” Of equally serious concern to health officials is the impact of the virus on the local homeless population, which might be at greater risk of contracting the virus as well as spreading it. The most effective ways to avoid infection—hand washing, personal hygiene, not touching contaminated surfaces, social distancing if feeling sick—are largely unavailable to tens of thousands living unsheltered. Not only could the homeless be at greater risk of infection, says UCLA’s Eisenman, they’re also at risk of getting very sick or dying from the illness because many have chronic conditions that are not being cared for, so they lack stamina or immune response.
The county is working with shelter operators to create social distancing in the event a resident is diagnosed with coronavirus, Ferrer says. One option, if the person is mildly symptomatic, is to isolate them in a hotel. Technical assistance at shelters and interim housing facilities will help minimize contact between sick and uninfected people. Officials are relying on street teams of social workers and medical practitioners and other community groups to help inform the unsheltered homeless population about how to spot an infection and seek proper care. “Most people don’t spend a long period of time in proximity to the homeless,” Eisenman says. “I’m not worried about my risk from them, but I am worried about what we’re doing to keep them from getting sick and dying.”
What would a full-blown outbreak of COVID-19 in Los Angeles look like? For the most visual (and visceral) answer, look no further than a Hollywood disaster movie, says Stanford Health Care’s Deresinski. “I think the movie Contagion is great,” he says, referring to the 2011 Steven Soderbergh thriller. The film depicts the worldwide medical community’s frantic efforts to find a cure for a terrifying virus, which emerges from an outdoor Chinese food market. For obvious reasons the film has been trending on streaming platforms in recent weeks. “If you watch that movie, it’s pretty good in terms of describing what would happen in the case of an epidemic with a virus that is much more lethal than what we’re talking about here,” Deresinski says.
The worst-case scenario in L.A., according to Eisenman, is that the trickle-down effect of cuts to the federal health budget renders hospitals unable to manage the outbreak. In the most severe cases, when the coronavirus causes swelling in the lungs, patients can require a breathing machine or respirator to keep them alive. “The worst-case scenario,” he says, “is hundreds of people across L.A. who are severely ill needing an ICU bed and possibly a respirator. And that’s a real problem because we just do not have the respirator or ICU capacity in the county to add a thousand more patients and also take care of the patients we already have in the ICUs.”
Fear of the coronavirus can overwhelm the health care system much faster than exponential spread of the pathogen. Flu season in L.A. continues into the spring, and hospitals worry that people who mistake the flu for the coronavirus will stampede into emergency rooms, sucking up finite resources for reassurance that they aren’t really sick—the hypochondriac patient population has a name in epidemiology, the “worried well.” “The number of people who are worried well compared to actually at-risk people can be five or six times the number,” Eisenman says. “So flooding of ERs and clinic phone lines is a real issue.”
“Schools likely would close in the affected areas,” says Deresinski. “Anything associated with bringing people together would be avoided —things like Lakers games, Clippers games, baseball when the season starts—if there were really a widespread epidemic going on at that time.” [Since this interview, the NBA suspended its season.]
Ultimately, L.A.’s response to the coronavirus threat will be largely dictated by the L.A. County Department of Public Health, which has the legal power to order quarantines, isolations, and even lockdowns, as it did in 1918. But according to Dr. Jonathan Fielding, who ran the county health department until he retired in 2014, health officials are very reluctant to mandate disruptive measures unless they are absolutely necessary. During his tenure, Fielding managed the response to a rash of global health emergencies, from the anthrax scare in the wake of 9/11 to the bird flu pandemic of 2005 to the deadly swine flu that struck millions of Americans in 2009.
Fielding says health officials are trained to respond to public health emergencies with almost military precision. “The first step in dealing with a crisis like this is setting up a clear hierarchy of responsibility with clear objectives and somebody at the top. People from virtually every county agency are involved. Commands would give the goals of operational objectives for 24 hours or eight hours.”
When his department mobilized against the bird flu, Fielding helped organize clinics for a massive immunization effort. But he believes the coronavirus will be more difficult to contain. “Even in the worst-case scenario, a government lockdown of Los Angeles would be too difficult,” he says. “Our borders are just too fluid. China has an authoritarian state that’s able to do things that would not be very successful or accepted here.”
L.A. may be a long way off from imposing the drastic measures that were adopted by Beijing or in L.A. during the influenza outbreak, but there’s no question that life here has already been transformed. Gyms, hotels, airlines, and movie theaters have experienced precipitous declines in visitors. Restaurants are reporting significant drops in business. Supermarket and pharmacy shelves have been stripped bare of such pestilential essentials as toilet paper, bottled water, and face masks. Businesses across the city are axing long-planned conferences and cutting travel to a minimum. Fashion shows and concerts have been canceled, and, according to the LGBTQ website Them, even the city’s drag queens have been declining to perform.
If the virus continues metastasizing at its current pace, experts say schools could shut down for months, like they already have in China, Japan, and Iran. If that happens, L.A. school officials are prepared to move classrooms online. But that will do nothing to address the pressure on parents who will have to stay home from work if they cannot find alternate supervision for their kids.
Ultimately, as UCLA’s Eisenman points out, the social implications of this outbreak will likely be more consequential than the medical ones. Shortly before we went to press with this story, Eisenman sent me a series of texts noting the new ins and outs in L.A.
Out: classrooms, malls, coughing in public, hot yoga, Equinox, public transit, Uber Pool, office meetings, libraries, restaurant dining, Coachella? In: surfing, hiking, FaceTiming with your therapist, books, board games, good wine, hand-wash dispensers, Peloton, hygge, car culture. So, not great but not all is lost either.
“Thankfully, we can still go hiking and in the mountains, and still go to the beach,” he concludes.
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