NRPLUS MEMBER ARTICLE T he bluest state’s public officials have been warning for weeks that California will be overwhelmed, given federal-government unpreparedness and the purported inefficacy of the local, state, and federal governments.
California governor Gavin Newsom has assured his state that over half of the population — or, in his words, 56 percent — will soon be infected. That is, more than 25 million coronavirus cases are on the horizon, which, at the virus’s current fatality rate of 1–2 percent (the ratio of deaths to known positive cases), would mean that the state should anticipate 250,000–500,000 dead Californians in the near future. Los Angeles mayor Eric Garcetti predicted that this week Los Angeles would be short of all sorts of medical supplies as the epidemic killed many hundreds, as is the case in New York City.
It’s been well over two months since the first certified coronavirus case in the United States, so one might expect to see early symptoms of the apocalypse recently forecast by Governor Newsom. Yet a number of California’s top doctors, epidemiologists, statisticians, and biophysicists — including Stanford’s John Ioannides, Michael Levitt, Eran Bendavid, and Jay Bhattacharya — have expressed some skepticism about the bleak models predicting that we are on the verge of a statewide or even national lethal pandemic of biblical proportions.
The skeptics may be right. As of this moment, California’s cumulative fatalities attributed to coronavirus are somewhere over 140 deaths, in a state of 40 million. That toll is a relatively confirmable numerator (though coronavirus is not always the sole cause of death), as opposed to the widely unreliable denominator of caseloads (currently about 6,300 in the state) that are judged to be only a fraction of the population that has been tested. The Iceland study, for example, suggests that half of those who are infected show no symptoms. Currently, even with fluctuating statistics, California is suffering roughly about one death to the virus for every 250,000–300,000 of its residents.
The rate certainly will go up each hour, and no doubt in geometric fashion, as the virus spreads. Yet we should remember that California loses about 270,000 lives to all causes every year — meaning, on any given day, around 740 Californians die. So far there is no published clear evidence that in January, February, and March more Americans have died from pneumonia-related diseases than in an average year. Note too that not all deaths attributed to coronavirus are the work of COVID-19 alone; they are often accompanied by advanced age and serious chronic conditions that may have soon led to death without any accompanying viral infection.
In contrast, as of Monday morning, New York State, with about half of California’s population, has about eight to nine times the number of deaths, and 20 times the per capita rate, at 60 deaths per million residents. In fact, California has a much lower per capita death rate than many of the nation’s largest states; for that matter, its per capita death rate is similar to that of nations that so far have mysteriously escaped the virus’s modeled wrath. Currently, California has lost fewer than 4 people per million, roughly between South Korea’s 3 deaths per million and Germany’s 5, which are both being studied as outliers. Of course, statistics change hourly, but for now California’s data remain mysteries.
Even at this midpoint in the virus’s ascendance, most believed that California would be faring far worse. And they have good reason for such pessimism. California in a normal year usually experiences the greatest number of deaths associated with the flu in the United States, and it ranks about midway among the states in flu deaths per capita. The state was hit hard by influenza unusually early in the first weeks of November, including a strain that at the time was characterized as probably not “A” but a rarer “B” — and on occasion quite virulent. A typical news story related, in early 2020, “California health officials have identified 16 outbreaks since the start of the flu season Sept. 29. Flu cases, hospitalizations and flu deaths are all higher than anticipated, according to the health department.” Many Californians complained late in 2019 of getting the flu a bit early, with flu symptoms that were somewhat different from the norm, at times including severe muscle aches, some digestive cramping, an unproductive cough, and days or even weeks of post-fever fatigue.
Forty-million-person California, in normal times — that is, until around or shortly after February 1, 2020 — hosts dozens of daily direct flights from China in general to San Diego, SFO, LAX, and San Jose, and in particular, since 2014, several weekly nonstop flights from Wuhan. Of the nearly 15,000 passengers who were estimated to be arriving every day in the U.S. on flights from China in 2019 and 2020, the majority flew into California. After the ban, there were thousands of Chinese tourists who remained in California and could get neither direct nor indirect flights home to China.
Travel forecasts from China for 2020, even amid the trade war, had estimated more than 8,000 daily arrivals in California. Two years ago, Los Angeles mayor Garcetti bragged that 1.1 million Chinese tourists had visited L.A. — more than 3,000 per day. The greatest number of foreign tourists to Los Angeles are Chinese, and the city is the favorite spot in America of all visitors from China. During the months of October, November, January, and February alone — before the travel ban — perhaps nearly 1 million Chinese citizens arrived in California on direct and indirect flights originating in China.
Moreover, researchers in Italy believe that the Chinese were not telling the truth about the origins or birth dates of the virus; they argue that COVID-19 was first loose worldwide in the middle of Autumn 2019 rather than in Winter 2020. Reuters recently reported:
Adriano Decarli, an epidemiologist and medical statistics professor at the University of Milan, said there had been a “significant” increase in the number of people hospitalized for pneumonia and flu in the areas of Milan and Lodi between October and December last year. . . . He told Reuters he could not give exact figures but “hundreds” more people than usual had been taken to hospital in the last three months of 2019 in those areas — two of Lombardy’s worst hit cities — with pneumonia and flu-like symptoms, and some of those had died. . . . Decarli is reviewing the hospital records and other clinical details of those cases, including people who later died at home, to try to understand whether the new coronavirus epidemic had already spread to Italy back then. . . . “We want to know if the virus was already here in Italy at the end of 2019, and — if yes — why it remained undetected for a relatively long period so that we could have a clearer picture in case we have to face a second wave of the epidemic,” he said.
In a recent Oxford study, a heterodox hypothesis was offered questioning the widely circulated study of Neil Ferguson, an epidemiologist with Imperial College London. He and his team had offered a worst-case projection of as many as 2.2 million American and 510,000 British deaths. Ferguson has now emphasized the low-end estimates of death rates in some of his modeling, for example, suggesting that maybe only 20,000 in Britain may die from the virus, given how Britain has taken actions to curb and treat it. In any case, other models from the Oxford authors offer far less pessimistic hypothetical scenarios. In one, they suggest that viral infections in the U.K. might have begun almost 40 days before March 5, which was the first confirmed death there. If that is true, they argue, then to square the current figures of transmission, perhaps 68 percent of the British population would have had to be already infected by at least March 19 — reflecting a herd immunity that will radically curtail future transmission. Of course, without widespread antibody testing alongside testing for current infections, no one knows the number of past and present infections. Regardless, the Chinese notion that the world was not seriously infected until mid February increasingly seems mathematically unlikely.
In the case of California, again, unfortunately, the state still should have had many things going against it, at least in terms of susceptibility to any pandemic infection that curbs its huge tourist and commercial travel with China. The state has the nation’s highest poverty rate (affecting over 20 percent of the population, or some 8 million people); the greatest number of homeless people, at somewhere over 150,000; and the most residents in the nation on some form of public assistance, one-third of the nation’s total.
Over a quarter of the state’s population was not born in the U.S. Until recent bans, many frequently went to and from their countries of origin. It has the largest number of non-English speakers in the U.S., suggesting that public dissemination of key information might become far more problematic.
The state is not especially healthy and rarely rates among the top ten states in terms of per capita health, by whichever metrics one uses. A decade ago, studies suggested that one in three admissions of those over 35 to California hospitals were suffering from either diabetes or pre-diabetes — a known risk factor for coronavirus patients.
California ranks near the bottom when we count the number of available hospital beds per 1,000 population, at about 1.8. Likewise, its number of active doctors per 100,000 is similarly unimpressive, about midway among state rankings, at 276 per 100,000 — versus Massachusetts’s high of 450 and Mississippi’s low of 191. In most surveys of nurses per 100,000 population, California ranks near last (664).
How, then, has California in the third month of known COVID-19 infections in the U.S. lost between 140 and 150 lives to it?
Again, a number of experts have offered hypotheses. Is it a question of the statistical anomaly — as some have suggested is the case for Germany, which similarly posts few total deaths from the virus — given differences in how countries and perhaps even states record the chief causation of death (i.e., are some places listing COVID-19 as the cause of death, even when the decedent suffered from underlying chronic conditions)? Is California experiencing a brief lull, in the fashion of Japan, which likewise has suffered few deaths so far but may be poised to suffer far more?
Is there a lag in ascertaining and determining deaths in a state that’s geographically huge and linguistically diverse, a lapse that will shortly cease, correcting such misimpressions with a radical increase in corona-associated deaths — as is now forecast for Japan and to a lesser extent Germany?
Did California’s Draconian shelter-in-place policies that antedated many of those in other states simply arrest (so far) what should have been by now a lethal epidemic?
Did California’s proverbial warmer weather slow down the virus? Did its suburban ranch-home lifestyle and the large open spaces in the Central Valley, Sierra Nevada, desert and northern counties make transmissions harder than it has been in, say, the high-density living of New York City?
Maybe and maybe not.
While testing tardiness might explain outliers in terms of California’s relatively small number of proven cases and lethality rates, it would not greatly affect accurate statistics of deaths attributed to the virus. If anything, as the number of known cases grows, the lower the lethality rate will likely appear.
While California adopted shelter-in-place policies on March 19, other states did the same about the same time. And visiting a California Costco on any Saturday morning is a reminder of current mob frenzies. After a near-record dry and warm January and February, the state has been unseasonably cold and wet for most of March during the epidemic’s spike. True, California encompasses an enormous area, but it also is home to the country’s largest population and thus still ranks about eleventh in population density among the states. Some districts in San Francisco and Los Angeles are as densely populated as East Coast cities.
One less-mentioned hypothesis is that California, as a front-line state, may have rather rapidly developed a greater level of herd immunity than other states, given that hints, anecdotes, and some official indications from both China and Italy that, again, the virus may well have been spreading abroad far earlier than the first recorded case in the U.S. —and likely from the coasts inward.
So given the state’s unprecedented direct air access to China, and given its large expatriate and tourist Chinese communities, especially in its huge denser metropolitan corridors in Los Angeles and the Bay Area, it could be that what thousands of Californians experienced as an unusually “early” and “bad” flu season might have also reflected an early coronavirus epidemic, suggesting that many more Californians per capita than in other states may have acquired immunity to the virus.
Here in Fresno County (1.1 million people), we are warned daily that we are the next hot spot. But as of late March, we’ve had no recorded deaths and only 41 known cases. The figure will no doubt multiply rapidly and geometrically, but it still seems incomprehensible that not a single death was attributed to the virus in its first 60 days of visitation. I live near the Kings County line in rural Fresno County (which is not so rural anymore, given urban sprawl from greater Fresno). There have been two recorded cases and no deaths among the county’s more than 150,000 residents.
We won’t know the answers until antibody testing becomes widespread enough to determine who has already been infected, and who carried the virus without symptoms, and who wrongly attributed symptoms to the flu or a bad cold. Or epidemiologists will have to go over average daily pre-coronavirus death rates in California to determine whether, in comparison with past years, the state had any per capita spikes in deaths in October, November, December, and January, or an increase in hospitalizations attributed to the flu.
In the meantime, for a few days at least, we are left with the California paradox. As with the apparent outliers of Germany, South Korea, and Japan, it reminds us that there are endless known unknowns about the origins, lethality, infectiousness, and patterns of travel of the coronavirus — and that today’s latest frightening statistical model is often superseded tomorrow by more realistic appraisals and theories, and then again rendered naïve by even more frightening new backlash models. Until now, without either widespread antibody or current-infection testing, the number of people who die from the virus in comparison to a given population base is about all we can rely on to determine the lethality of the disease. And in that regard, at least for a few days or weeks longer, California remains a mystery.