Did California make the pandemic worse through its policy choices?
California was the first to lockdown in the US and has had the most stringent policies regarding testing, case definitions, hospitalizations and deaths, but did California’s policy choices make the pandemic worse?
California’s Bay Area counties issued a stay-at-home order in mid-March 2020, following suit with Italy’s Lombardy region that had also locked down in early March in an effort to contain the perceived viral outbreak in that area of northern Italy. California was the first to do so in the U.S.
Shortly after the Bay Area counties issued their orders, the entire state went on lockdown pursuant to Governor Newsom’s shelter-in-place order.
While California’s case counts and hospitalization rates have been high compared to other states in absolute terms, its case levels and its mortality figures have actually been quite low. This is because California is by far the most populous state in the nation, with over 40 million people.
Figure 1 shows how California compares to other states when adjusted for population. California is, in fact, 36th on the list, with only 13 states doing better than it in terms of mortality. Vermont and Hawaii are doing the best in terms of lowest mortality levels.
Similarly, California’s case levels are quite low compared to other states, at 4,887 cases per 100,000 people. This is better than all but 16 other states (again with Vermont and Hawaii doing the best).
California’s cases, hospitalizations and mortality have tracked very closely with testing levels, as Figure 2 below shows.
But it’s highly important to understand how tests, cases, hospitalization and mortality are defined in order to understand what these data mean.
California has, as the speed of its lockdown reactions described above would suggest, been hyper-reactive to the perceived threat of the pandemic.
News accounts have highlighted California’s limited hospital and ICU capacity and this has been the primary justification for the new rounds of lockdowns starting in December.
Let’s look specifically at hospitalizations for a moment to get a better picture of why California has had such a problem with limited hospital and ICU capacity this winter.
The spike in hospitalizations and limited ICU capacity is clearly a very serious issue because as hospital and ICU beds fill up there is far less recourse for treating new patients, staff become overwhelmed, logistical issues regarding treatment of Covid patients become very serious, and many other issues.
However, I’m going to examine California’s stated hospital admission policies and its related Covid testing policies in order to shed some light on why California has been having such issues.
California’s high hospital and ICU problem has occurred in large part because in many cases hospitals have adopted Covid-19 testing and observation policies that require that any admission be tested for the virus and observed for at least 14 days, and only when two (yes, two) negative daily tests are obtained will the patient be moved or discharged.
Here’s the stated policy from the Department of State Hospitals (DSH), which runs six public hospitals, suggesting why these hospitals are having such a problem with hospital and ICU capacity (emphasis added): “DSH has also implemented Admission Observation units for patients returning from outside medical facilities or who are newly admitting to our hospitals. Patients when admitted to these units will be observed for signs and symptoms of COVID-19 for a period of at least 14 days and receive serial testing for COVID-19. After this period, if they are negative for COVID-19, they will be moved to their regularly assigned treatment unit.”
Cottage Health, which runs a dozen not-for-profit hospitals and urgent care clinics, has a similar testing policy for all admissions:
Cottage Health has many precautions in place to protect patients and staff:
Pre-screening all patients entering the Emergency Department and using isolation precautions if symptoms are consistent with COVID-19.
Screening with temperature checks of physicians, staff, and anyone who enters the hospitals.
COVID-19 testing for every patient admitted to the hospital.
COVID testing for patients prior to a scheduled surgery or procedure.
Requiring face masks for staff and visitors upon entry, to be worn at all times in clinical areas and public areas.
Limiting visitors to help prevent exposure and maintain social distancing.
Using protective equipment based on infection control best practices.
Providing staff training and education on COVID-19 care and infection prevention.
Using specialized care units for patients with COVID-19, separate from those admitted for other conditions, with specific precautions and negative pressure airflow for infection prevention.
Scripps, which runs dozens of hospitals and clinics in San Diego County, has similar policies, but adds some distinctions in terms of Covid-19 symptoms.
To make sure you get care safely, we are taking the following precautions:
Screenings for everyone entering our facilities
Required face coverings for all physicians, staff and patients
Curbside check-in option and social distancing in waiting rooms
Rigorous cleaning and disinfection for all facilities and equipment
Dedicated entrance and isolated zones for patients with coronavirus symptoms
A piece looking at similar policies in Singapore stated as a matter of fact that U.S. hospitals were generally following the policy of two negative Covid-19 tests before transfer out of Covid-19 wards or discharge from the hospital.
The World Health Organization did early in the pandemic suggest two negative tests before discharge was prudent. However, this guidance changed in May of 2020 to a recommendation for no testing and instead a focus on symptoms.
Testing all patients who are admitted to hospitals makes a lot of sense as a Covid-19 precautionary measure — if symptoms are showing and if the tests are reliable. Unfortunately, we’ve learned that the various coronavirus tests are all extremely problematic. I wrote a detailed essay on this topic here, but the quick summary is that the PCR tests and antigen tests (the two types of tests for testing patients in a hospital setting) often return 90% or even higher false positives or non-infectious positives.
This is, to make it entirely clear, a catastrophically bad level of false positives. And these issues are vastly exacerbated when testing people without symptoms (asymptomatics).
The purpose of these tests is to identify infectious people and to quarantine or otherwise isolate them, in a hospital setting or not, and of course to treat them if treatment is needed. But when tests are returning 90% or more late non-infectious positives, or simply false positives in large numbers (as is the case in many circumstances), these tests are fundamentally failing in their stated purpose.
This very high level of non-infectious positive PCR tests is occurring because of two fundamental issues: 1) a high level of false positives and false negatives due to inherent problems with the tests in terms of the genetic sequences not being truly unique to the new virus; 2) the tests are being applied in such a way that 90% or more are detecting either tiny non-infectious viral loads (size matters a great deal in terms of how sick a person gets and how infectious they are) or, in the large majority of cases, just dead viral RNA fragments from a defeated infection or an attempted but failed infection, which aren’t infectious to the patient or anyone else. And, again, these issues are far more significant when testing asymptomatics because the prior probability is so much lower when there are no symptoms.
The science has become clear on this cycle threshold and infectiousness issue in the last six months, but our policies have not been adjusted to reflect this new science and it is a very important part of understanding what has happened and how to get the pandemic behind us.
In light of these hospital admissions and retention policies and the highly inaccurate tests, it seems that California has significantly exacerbated its hospital and ICU problems through policy choices.
There are also significant financial incentives for hospitals to overstate Covid cases, which impact private hospitals and long-term care homes more than non-profit hospitals, that I won’t delve into here because the factors already discussed do the lion’s share of explaining how California got into such a mess regarding its hospital and ICU capacity.
A later essay will examine the financial incentives in more detail but this piece examines the incentives that led to the debacle we’ve witnessed in the nursing home setting, in California and nation-wide.
