In late June, Santa Cruz County Health Officer Dr. Gail Newel announced that pandemic restrictions on using the county’s beaches would be lifted. Her justification for the change in policy astonished many in and outside Santa Cruz County. It was the kind of thing that public officials may often say among themselves in private settings, but rarely into a live microphone.

“It’s become impossible for law enforcement to continue to enforce that closure,” Newel said at a press briefing. “People are not willing to be governed anymore in that regard, and we want to recognize that by removing that restriction.”

Whether she intended to or not, Newel exposed a stark and uncomfortable truth about the spread of Covid-19 in Santa Cruz County and around the country. Given what science has determined about the virus’s infectious behavior, it can be controlled, but only insofar as individuals control their own behavior. In this case, the good news is that “We the People” can still exercise considerable freedom of choice, and public officials sometimes have no choice but to respect that. Unfortunately, that’s also the bad news.

Covid-19 infection rates are dramatically increasing locally and nationally—though, significantly, not so much internationally. As of July 3, the per-day average of new confirmed cases was at an all-time high in Santa Cruz County (the same is true statewide and nationally). That increase represents a spike upward from a dip in new infections in early June, a trend characterized by many in public health as a reversal of relatively successful efforts to control the virus in April and May.

As Newel all but admitted, governments are limited in what they can do to control public behavior. So officials are left to turn to whatever power they might have in the realm of moral persuasion.

Though the messages coming from governments and public health agencies have evolved since the initial U.S. outbreak in March, they have remained consistent for a couple of months now in effective preventative measures: social distancing, face coverings, and no sustained unprotected interactions with others outside the household.

A. Marm Kilpatrick, a disease ecologist at UCSC, has taken a lead role in local efforts to communicate the urgency in taking action against Covid-19. “It’s no mystery how people are getting Covid-19,” he says, “and we can all avoid it if we want to. You and I can do a bunch of things that are going to make almost all of us safe—the main exception to that are people whose bosses are not being helpful and making them work in close quarters together, or those who can’t avoid contact because they are in health care.”

A LOT TO LOSE

But the message may not be getting through. Kilpatrick points to the correlation between the spike in infections and states’ efforts to reopen their economies. He says that too many people took the fact of reopened business as a signal to relax. “The reopening of businesses is not happening because we’re all good and fine now or that the virus is gone. It’s only going to continue if we take actions in the opposite direction. We can have restaurants. We can have our jobs. We can have all the things we enjoy, if we just keep our between-household contacts short, or protected, or outdoors. But if we don’t, we’re actually going to lose all those things that we’ve just regained.”

Family physician Catherine Sonquist Forest is an associate professor at UC San Francisco’s Natividad Family Medicine Residency program and sits on the board of the Santa Cruz-based nonprofit Encompass Community Health Services. She also helped lead an effort to supply masks and other protective equipment to essential workers in the early days of the pandemic. “I believe that everything we did when we were in lockdown,” she says, “was predicated on being able to respond properly when we let up on lockdown.”

Last week, Gov. Gavin Newsom announced what amounts to a rollback of the economic reopening, ordering a new round of mandatory restrictions on bars, restaurants, movie theaters and other spaces in 19 counties in California. Santa Cruz County, which is not on the new restricted list, has a lower rate of confirmed cases than Monterey County and neighboring counties in the Bay Area. As of July 3, Santa Cruz County’s rate was 50 infections per 100,000 people, well below the state’s metric for alarm (100 infections per 100,000 people).

Even with relative local successes, health care experts are still touting the four mitigations that have been shown to slow infection: 1) maintaining at least six feet of distance from people not in the same household, 2) using face coverings within that six-foot radius, 3) having social interactions outdoors instead of indoors, and 4) keeping high-risk contacts brief, a few minutes at most.

Kilpatrick says the failure of the abstinence-only approach in sex education proves to him that prohibitions against out-of-household contact will probably not work. “It’s summer. The weather is nice. People have a desire to get together. That’s natural. It’s going to happen. Let’s just acknowledge it’s going to happen and direct people to do it in a safe way.”

The idea that everyone is going to follow all safety protocols all the time is simply unrealistic, he says.

“I want people to realize that they can break some of these rules, as long as they keep the other ones,” says Kilpatrick. “If that means you want to see friends you haven’t seen in three months, no problem. Go for a walk outside in a park, where you can walk a few feet ahead or behind them. If you’re not able to get that kind of space, throw a mask on. If you want to sit and have coffee, fine. Go find a picnic table where you can sit five or six feet apart. We have pretty good science to allow for that kind of behavior, and it’s not super high-risk.”

MESSAGING MISTAKES

If the message about masks and social distancing is not getting through, say some health-care officials, it’s because that message contradicts what the public was told early on in the pandemic, when the focus was on washing hands and disinfecting surfaces, and people were told to resist buying masks in order to keep frontline health-care workers supplied. Early public messaging also discouraged anyone feeling mildly ill to seek immediate medical help, in order to prevent a panic run on hospitals and clinics.

“One of the big challenges and frustrations we’ve had,” says Kilpatrick, “is that it’s really hard to reverse messages. Once you say one thing—especially if you push it for a while—it’s very hard to un-say that thing. I think we’re better at learning than un-learning. That’s been super, super tough. And we still have a slog ahead of us.”

Epidemiologist Will Forest worked at the county health office before his retirement in 2018. He said county leadership is doing a “better than average job,” but county leaders were relying too heavily on advice from the federal Centers for Disease Control and Prevention, which was not recommending masks for the general public in the early days of the pandemic. “That was foolish and destructive,” he says.

While Kilpatrick is focused on public behavior, Forest is thinking about the issues in diagnosing Covid-19. Forest believes doctors and medical professionals should rethink their attitudes toward testing as the best means for diagnosis. He says testing is not only unreliable, but usually happens well after the period of most likely infection.

“We should be diagnosing people on the basis of symptoms and immediately isolating them, identifying their contacts, and quarantining their contacts,” Forest says.

Doctors have learned Covid-19 is most infectious right at the first onset of symptoms, and even a few days before onset. “Now, if you look at yourself or anyone you know,” says Forest. “When do we go to the doctor? Not the first time we cough, but after a couple of days as it’s getting worse and it’s not going away. (With Covid-19), that’s the point at which the most infectious period has already passed. The worst damage, the most transmission of the disease, has already occurred. Add to that, the doctor doing a test, maybe it’s tomorrow or the next day. The test results come back in a couple of days, maybe five days, at which point, the person is practically non-infectious by then. If you wait for the testing, you’ve missed the entire opportunity for major intervention, regarding transmission to other people.”

Doctors and epidemiologists tend to talk a lot about the unknowns of Covid-19, mostly what is not known about the long-term effects of the infection on those who survive it. “This is a new virus, and no one can predict how it will react in their body,” says physician Catherine Sonquist Forest, Will Forest’s wife. 

Another unknown is exactly how a widespread infection might put even more pressure on already stressed social structures in housing, employment, and health care. Also unknown is whether those who survive will have a lasting immunity, and the percentage of the populace needed to attain herd immunity. The unknown Will Forest is focused on is how many Covid-19 cases are unreported and not counted in official statistics.

“Covid-19 deaths are going unidentified,” he says. “I’m pessimistic. It’s going to get worse before it gets better, because it’s not being taken with the seriousness it deserves.”

“What we need to do,” says Catherine Forest, “is to be able to act very quickly to minimize outbreaks, to save lives and to minimize illness. And minimizing illness is a worthy goal. We’re not just trying to eliminate deaths, we’re reducing suffering in all its forms.”

A SURVIVOR’S STORY

Catherine Forest has a particular intimacy with that kind of suffering—because she is a Covid-19 survivor.

In May, Catherine says, she “got quite ill. I was in isolation for three weeks. And my family was in quarantine for two.” Her symptoms began with a cough followed by a sudden descent into fatigue and chest tightness. Soon, she lost her sense of taste and smell, followed by a headache that lasted two weeks.

“She’s a very energetic person,” Will Forest says of his wife. “The way I knew something was very wrong was that after about four days isolated by herself in our bedroom, she was not complaining about not being able to do anything. The level of fatigue that this illness creates was so great that an absolute dynamo was not only able to sit in her room doing next to nothing, but felt OK about it.”

“It’s been an interesting ride to balance these things,” says Catherine. “The direct experience of having what is called a mild case of the disease that took me out of commission for about a month, and I’m still not well. And also, with the perspective of a physician and a public health professional who has been thinking about what we should be doing in order to move through this until there is a time when we can manage outbreaks and protect one another.”

What happens when a dangerous infectious disease comes into the home of an epidemiologist and a prominent physician?

“We’re a household of five people,” says Will, “and we were able to essentially quarantine from each other in our house. But that’s because we have the privilege of having a house where we can do that, large enough for each of us to isolate ourselves. And I think of what it would be like for people living in more crowded conditions, or people who are essential workers and can’t separate themselves from society. And it really brought home to me the disparity between my privileged life and the life of so many other people in this country and the world.”

Almost two months after her first symptoms, Catherine is still struggling to get back to something like normal. She’s gone from being an avid hiker to not being able to walk a city block without gasping for breath.

“I know a person who got sick a week before I did, and died,” she says. “And they were my age, and healthy, with my level of education. And they did not survive this virus. I’m here now, and I’m not any better than they were. I’m a healthy person. I exercise. I meditate. I am not overweight. I am the person who had good odds. And I did survive. But you can say the same for the person I know who didn’t survive.”

“She had what they call a mild case,” says Will Forest. “Even the mild cases are really severe, and can have big impacts. People think it won’t affect their lives much. They are wildly, wildly wrong.”