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Sunday was supposed to be a rare day off for Dr. Tomás Aragón after weeks of working around-the-clock.
Instead, the San Francisco public health officer was jolted awake by an urgent 7:39 a.m. text message from his boss.
“Can you set up a call with San Mateo and Santa Clara health officers this a.m., so we can discuss us all getting on the same page this week with aggressive actions, thanks,” said the message from Dr. Grant Colfax, director of San Francisco’s Department of Public Health.
“Will do, getting up now,” Aragón responded.
It was March 15, two days before St. Patrick’s Day, a heavy partying holiday and nightmare scenario for public health officials.
The novel coronavirus was spreading stealthily across the San Francisco Bay Area and public health officials were alarmed by the explosion of deaths in Italy and elsewhere around the globe. Silicon Valley would be next, case counts indicated.
Until then, they had primarily focused on banning mass gatherings. But they knew more had to be done — and wanted to present a united front.
Within a few hours of the text, Bay Area public health leaders jumped on a series of calls to debate options, including the most dramatic — a lockdown order that would shutter businesses, isolate families and force millions of residents to stay home.
They decided they had no choice. And they were able to move swiftly because they had a secret weapon: a decades-long alliance seeded in the early days of the AIDS epidemic that shields them from political blowback when they need to make difficult decisions.
Together, they would issue the nation’s first stay-at-home order, likely saving thousands of lives and charting the course for much of the country. Three days later, Gov. Gavin Newsom followed with his own order for California. New York came next, as have dozens of states since.
“This was one exhausting and difficult day for all of us,” Aragón later wrote in his journal. “We all wish we did not have to do this.”
Now, officials nationwide are weighing how to lift isolation orders as the rate of COVID-19 transmission slows — and protests against the orders mount. The Bay Area is again poised to lead, but with a warning: All of this could be for naught if it isn’t done right.
The coalition of county public health officers didn’t set out to lock down the Bay Area that fateful Sunday morning in mid-March. But as they discussed the exponential increase in Santa Clara County cases, where the hospitals were becoming overwhelmed by infected patients falling ever sicker, what they needed to do “started to crystalize,” said Dr. Sara Cody, the county’s public health officer.
“It felt huge to me,” she recalled, “because I knew how disruptive it would be.”
Elsewhere in the region, diagnosed cases were sparse. But decades of experience had shown the health officers that while they represent different jurisdictions, they are one region when it comes to infectious diseases. “We knew that it would be a matter of time before that was our experience,” said Dr. Matt Willis, Marin County’s public health officer, who contracted COVID-19 days later.
Cody told her colleagues that Italy was under siege, and her county was just two weeks away from a similar fate. If she could have locked down sooner, she told them, she would have.
“That was compelling,” said Dr. Lisa Hernandez, the public health officer for the city of Berkeley, which had not yet recorded any cases of community transmission. “We knew there was going to be St. Patrick’s Day parades and celebrations, so the timing was critical.”
Dr. Scott Morrow, California’s longest-serving public health officer, who heads operations in San Mateo County, said he also felt the urgency. “We thought, ‘Yes, the clock is ticking,'” he recalled.
County health officers in California have immense power to act independently in the interest of public health, including the authority to issue legally binding directives. They don’t need permission from the governor or mayors or county supervisors to act.
Even for this group, though, with all its collective strength, telling millions of Californians to shelter in place seemed risky at first. But the health officers involved had grown to trust one another, even if they don’t always see eye to eye.
For instance, they currently disagree on whether to require residents to wear face coverings. Some counties, including San Francisco and Marin, are requiring them in public, while others, like Santa Clara, are not.
On the first Sunday morning call, Aragón floated the idea of developing a coordinated recommendation that Bay Area residents stay at home. By the next confab, Cody, Santa Clara County’s health official, made the case that for social distancing to work, it had to be an order.
“Sara Cody was the courageous leader!” Aragón later wrote in his journal.
So forceful a move can be unpopular, but evidence shows it can also be the most effective, in the absence of treatment or a vaccine. “Here’s the rub on these methods — they only work if you do it really early,” said Dr. Howard Markel, a medical historian at the University of Michigan and an expert on the 1918 flu pandemic.
“When you do a quarantine, you stop the commerce, you stop the flow of money,” he said. “But on the other side of that are those whose lives are saved.”
This isn’t the group’s first pandemic. The alliance, formally called the Association of Bay Area Health Officials, was born in 1985 in the early days of the AIDS epidemic.
Dr. David Werdegar, who became health officer for San Francisco that year, was analyzing AIDS data for surrounding counties and asked their health officers to join him for dinner at Jack’s, an old bordello-turned-political hangout in the city that has since shuttered.
Most of the infectious disease research was happening in San Francisco at the time, but HIV was spreading, and one city couldn’t fight it alone.
“It was important that we share all the information we had,” said Werdegar, now in his 80s and retired.
Dr. Robert Melton, a former Monterey County health officer, said that working for nearly two decades with Bay Area public health giants taught him tremendous lessons. “Camaraderie is important in maintaining the energy to be able to focus on the common good, through good and bad,” he said.
That close-knit relationship among the 13 health officers — representing counties stretching across a large swath of Northern California from Napa to Monterey — continues to this day. Collectively, their public health actions touch about 8.5 million people.
They meet monthly and communicate regularly on Slack, a messaging app. Their diverse backgrounds and expertise, especially in an era of funding cuts, provide a deep well of public health knowledge from which to draw. Together, the group has joined forces to combat youth vaping, air pollution and measles outbreaks.
And they have also tackled various influenza scares, which is why they had an emergency response blueprint at the ready when cases of what would later be called COVID-19 first cropped up in Wuhan, China.
“We spent a couple years as a region thinking about pandemic planning, and that really helped us come a long way thinking about these policies for COVID-19,” said Dr. Erica Pan, the interim health officer for Alameda County.
So when they jumped on the call that Sunday, they were already in mid-conversation about how to respond. They brought their lawyers and, working into the predawn hours, translated their lockdown plan into legalese, one that would be enforceable with fines and misdemeanor charges.
They would make prime-time announcements across the region the next day, alongside elected officials. “This is not the moment for half-measures,” said San Jose Mayor Sam Liccardo. “History won’t forgive us for waiting an hour more.”
At first, the stay-at-home order applied just to the “Big Seven” counties surrounding the San Francisco Bay, whose officers peeled off from the larger group to issue it first. They shared their model ordinance with the others, who quickly followed.
Dr. Gail Newel, an OB-GYN and Santa Cruz County’s health officer, is not an infectious disease expert. She has relied heavily on the group’s expertise throughout her career, and especially now.
“It’s this incredible bank of knowledge and wisdom and experience that’s freely shared among the members,” she said. “And the whole Bay Area benefits by that shared knowledge bank.”
Roughly one month after they made the unprecedented decision to close the local economy, the risk seems to have paid off. It will be years before researchers have fully analyzed its impact, but officials across the Bay Area are cautiously optimistic. Others haven’t been so lucky.
Though there are important differences between the two regions, New York City, which issued a stay-at-home order four days after the Bay Area, saw its hospitals completely overwhelmed and had recorded more than 14, 600 deaths as of Monday.
By comparison, the counties represented by the alliance have documented more than 215 deaths and hospitals haven’t been overtaken by a surge. In fact, hospitals brought online specifically to accommodate an overflow of patients are sitting largely empty.
Even within California, communities that waited to issue lockdown orders have emerged as COVID-19 hot spots, including Los Angeles, where Mayor Eric Garcetti followed suit three days after the Bay Area.
Internally, some of the Bay Area health officials have wondered if they made the right call. But “anytime I have any doubt, I just read another news report from New York or Detroit or New Orleans,” said Dr. Chris Farnitano, Contra Costa County’s health officer.
And the close-knit band is already undertaking its next task: reopening the economy without causing another spike in cases.
Before the orders are lifted, the officials say there must be rapid, widespread testing across the population. They want to hire disease investigators by the hundreds, if not the thousands, to trace the virus and quarantine those who have been infected. And until there is a vaccine, they may ask people to wear masks in public and continue social distancing, even in bars, restaurants and schools when they reopen.
“I was concerned that we might get a lot of resistance and it might get interpreted as alarmist and overreach,” said Marin County’s Willis. “Time has shown that it was really a vital step to take when we took it.”