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How San Francisco Brought Its COVID Death Rate Down to Zero

No city in the country has had as much success keeping its residents safe from the coronavirus as San Francisco.

San Francisco's domed City Hall as seen from across an intersection in front of it.
San Francisco's city hall. The city's per capita death rate throughout the pandemic has been about one-fourth the size of Los Angeles and New York. (Alan Greenblatt)
Every Thursday for the past year, the 700 block of Alabama Street in San Francisco has been closed to traffic. It was the city’s first community-based coronavirus testing site and at its peak tested upwards of 500 people a day. Things have gotten a lot slower lately. While waiting, one volunteer walks up the block, sweeping the street by hand.

Nearly all the action has shifted three blocks away, to a vaccination site set up at a union hall. In its parking lot, residents sit carefully spaced on folding chairs, waiting 15 minutes to make sure they’ve had no adverse reactions. It was the first San Francisco site to offer vaccinations to children as young as 12.

“We don’t panic, we pivot,” says Valerie Tulier-Laiwa, coordinator of the Latino Task Force, which runs both sites. “We’re just continually reacting and responding.”
The same is true of the city as a whole. Arguably no city in the country has responded as successfully to COVID-19 as San Francisco. Its per capita death rate throughout the pandemic has been about one-quarter as high as Los Angeles and New York. Total deaths during the month of May could be counted on the fingers of two hands. Four deaths due to COVID-19 were recorded on Sunday, breaking a two-week streak of zero deaths.

New cases are now running below 2 per 100,000, or about 16 per day. More than 77 percent of the population aged 12 and up has received at least one dose of the vaccine, which means more individuals have been vaccinated within the 49-square-mile city than a fair number of states.
A sign in a city intersection that says "road closed."
Alabama Street is closed off to cars on COVID-19 testing days.
(Alan Greenblatt)
“The behavior of the people, which can only be legislated so much, tended to comport more with the major public health recommendations, more than anywhere in the country,” says Bob Wachter, who chairs the Department of Medicine at the University of California, San Francisco (UCSF). “There was a general consensus that this was serious and virtually no pushback on the kinds of restrictions that made the most sense from a public health standpoint.”

Yellow-and-blue safety warnings are ubiquitous all over town. San Francisco has benefited from a unified political response and a public health department considered one of the best in the nation. “There are many states, frankly, that don’t have the level of expertise that the San Francisco health department has,” says Art Reingold, an epidemiologist at the University of California, Berkeley.

For all that, Wachter says the city still got lucky. Citizens could have acted responsibly but the city might easily still have been “creamed” by superspreader events, he says.

“Some of it is due to really careful policy design and implementation,” says Paulette Cha, a research fellow at the Public Policy Institute of California, a think tank in San Francisco, “and some of it, frankly, is just dumb luck.”

San Francisco’s Many Strengths

San Francisco is a city of neighborhoods. Along commercial corridors such as West Portal and the Richmond District, seemingly half the parking spaces have been filled with wooden shelters to allow more space for outdoor dining. Thanks to the city’s gentle climate, staying outside has been an option all year.

The city has closed many streets to open up space for recreation, including the 3.5 mile Great Highway that runs along the Pacific Ocean. Cha says the city has benefited during the pandemic both from its density and “de-densification” as the city lost population over the past year.

With nearly 18,000 people per square mile, it’s almost impossible to step outside without bumping into neighbors. That helped get people in the habit of wearing masks, which city officials first recommended and then mandated as early as April 2020.

Even now, it’s rare to see anyone in public without a mask, even passing bicyclists or individuals walking dogs down empty streets at night. “Now there’s a social stigma for not wearing a mask,” says Ashwin Kotwal, a physician at UCSF. “It’s become a normal part of how we act outdoors.”

The city shed about 2 percent of its population over the past year. It also has lost a lot of its tourist trade. Plenty of storefronts in Chinatown are not just closed but boarded up. It’s easy to get a parking space at the Golden Gate Bridge visitor plaza, something decidedly not true during a normal spring.

The city’s army of tech workers have not only been able to work remotely but in many cases were ordered to do so, with companies such as Facebook and Twitter sending people home ahead of the city’s orders. Office leasing activity fell 71 percent in 2020.

“The business community, which is primarily the tech community, was completely on board,” Wachter says, “and sent signals to its workers that this was serious stuff.”

Staying in Sync

San Francisco has developed an ethos of compliance. The city gave just 12 percent of its vote last year to Donald Trump. “There were no cries to liberate San Francisco,” Wachter says. “There was pain, but there was a general consensus that this was the right thing to do.”

In much of the country, people live in jurisdictions where mask mandates and bans on indoor dining are just now starting to lift, while restrictions might have ended months ago just a mile up the road. That’s not the case in San Francisco.

San Francisco, which is both a city and county, has worked in concert with neighboring Bay Area counties. They were the first jurisdictions in the country to issue stay-at-home orders. California was the first state. “If San Francisco locked down hard and San Mateo County didn’t, that would not be a very successful effort,” says Cha, the PPIC research fellow. “They had a real incentive to work together toward a common goal.”

The city’s Department of Public Health took advantage of other local partners, forming an advisory committee of scientists from institutions including UCSF and Berkeley who have performed detailed studies and carefully tracked hyper-localized infection and hospitalization rates.

UCSF is an enormous medical complex. With more than 26,000 faculty and staff, it’s one of the largest employers in the city. Its protocols helped set the tone for a sizable share of the population. It also has lots of experience working with community groups. Muscles formed at the height of the HIV/AIDS crisis were ready to be flexed against the coronavirus.

A health care worker posing next to a patient who just got a vaccination.
Camika Robinson, who teaches in the Mission District, was feeling strong after receiving her vaccination. (Alan Greenblatt)

Night and Day Difference

A serious response against AIDS had to be kick-started by pressure from activists and the affected community. To some extent, the same was true regarding COVID-19.

The city’s initial testing center was set up at the Embarcadero — convenient to downtown but not residents of San Francisco’s southeast quadrant, where much of its non-Anglo population lives. The Latino Task Force, a coalition of community groups in the Mission District, formed the same week as the city’s shelter-in-place order. “We knew instinctively that the pandemic was going to hit our community,” says Tulier-Laiwa, “so what are we going to do about it?”

The task force had to fight City Hall to get sign-off and supplies for its Alabama Street testing site. It took months. The city was only willing to provide 100 testing kits per week, even though coronavirus cases were running especially high in the Mission. The task force began a media campaign to press for more help. A survey of residents co-sponsored by UCSF and the task force clearly demonstrated the need.

“If you have a 14 percent infection rate, you don’t just send buckets of water, you send the whole battalion,” says Jon Jacobo, health committee chair for the Latino Task Force. “You send everything you’ve got and you extinguish the fire.”

Jacobo still seethes with frustration about the city’s initial response last year, saying it failed the Latino community at the beginning of the pandemic. That’s all changed. After the task force secured the Laborers Local Union 261 Hall as a potential vaccination site, the Department of Public Health (DPH) signed off on it the same business day. A DPH official was there on a recent afternoon, training volunteers on how to conduct intake interviews.

Although Latinos in general and Mission District residents in particular have suffered far higher caseloads than the city as a whole, their infection and death rates are much lower than comparable neighborhoods in other cities. The three community sites set up by the Latino Task Force have provided more than 27,000 vaccinations. “It’s a night and day difference,” Jacobo says.

A man wearing a facemask standing on a sidewalk in front of a wall painted with cartoon figures.
In San Francisco’s North Beach neighborhood, stores are closed and foot traffic is light, but pedestrians remain masked. (Alan Greenblatt)

The City’s Other Problems

San Francisco’s relative success in staving off COVID-19 has not come without cost. San Franciscans from Mayor London Breed on down have been frustrated by the school district, which has allowed only a few days of classroom learning right at the end of term, in an apparent effort to secure $12 million in reopening funds from the state. An effort to recall school board members has collected more than 12,000 signatures.

Kotwal, the UCSF physician, published a study looking at the pain of social isolation and loneliness among Bay Area seniors during the pandemic. “We’re seeing long-term impacts on the health of older adults previously engaged in the community,” he says.

Last year, twice as many people died in San Francisco from drug overdoses than COVID-19. Homelessness has been a major problem for West Coast cities for years, but it’s grown more visible in San Francisco. Rather than hidden by overpasses, rows of tents now line many city sidewalks.

San Francisco has been one of the nation’s economic boomtowns over the past decade, but along with New York, it appears to have been especially hard-hit by the pandemic in terms of population loss and plummeting commercial and residential rents. Last year, major companies including Oracle, Hewlett-Packard and Charles Schwab all moved their headquarters out of the Bay Area.

But rents — and foot traffic — are starting to pick up again. San Francisco has continually reinvented itself since the Gold Rush days of the 19th century. There’s no reason to think it won’t remain one of the most vibrant cities in the country.

And it will come out of the pandemic as one of the healthiest cities in the country.

“It’s not been a 100 percent rosy story,” says Cha, “but the net effect has been that we’ve done pretty good on COVID.”
Alan Greenblatt is the editor of Governing. He can be found on Twitter at @AlanGreenblatt.
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