Monique LeSarre, the doctor who directs the Rafiki Coalition for Health and Wellness, sat at a folding table at the entrance to the testing tent. In the nineteen-eighties and nineties, when Rafiki helped Black residents devastated by H.I.V. get care, the organization was known as the Black Coalition on AIDS (B.C.A.); as H.I.V. treatment improved, B.C.A. changed its name and broadened its services. “When I heard about the outbreaks in the Bronx and Detroit, I knew this was going to hit our Black neighborhoods,” LeSarre told me. Like Havlir, LeSarre lived through San Francisco’s H.I.V. epidemic and has connections and expertise from that period. To combat the stigma and general ignorance around H.I.V., community organizers like LeSarre, as well as politicians, health officials, and doctors of all kinds, built an infrastructure of trust and communication connecting the city’s government, universities, and marginalized communities. This network has been invaluable during the coronavirus pandemic. In places such as Texas’s Rio Grande Valley, where poor and minority communities are more alienated from their local governments, it has been nearly impossible for health officials to mount a humane and targeted intervention, and cases have surged.
In such interventions, the last mile is crucial. Kim Rhoads, a cancer researcher and associate professor of epidemiology and biostatistics at U.C.S.F., and Kevin Epps, a community-outreach coördinator and documentarian—he is known for his 2003 film “Straight Outta Hunters Point”—brought to Havlir’s team an intimate knowledge of the southern neighborhoods of San Francisco, as well as a wide range of contacts, built over decades, who could spread the word. “If you don’t have community buy-in, there’s always going to be a level of distrust that makes these things almost impossible to run,” Rhoads told me. Over the course of a week, Epps executed what he called a “guerrilla marketing campaign” in District 10, which includes Hunters Point, Bayview, and Sunnydale. “This was door-to-door, posters, putting it out on social media,” Epps said. “I even was out on the corner with a bullhorn.” Epps combatted rampant misinformation. “Early on, a lot of Black people had heard they couldn’t get the virus,” he said. “Even more didn’t want to sign up for testing because they heard Google was running it and thought all their information was going to get stolen.” (The testing sites run by Havlir and her colleagues used Chan-Zuckerberg BioHub/U.C.S.F. labs; Verily, a research organization that is operated by Google’s parent company, runs most of the testing in the Bay Area.) “They’ve all known me for years,” Epps concluded. “That got through some of the trust issues.”
By May, the testing-trace-and-isolate efforts mounted by U.C.S.F. and the Latino Task Force had tested 3,953 people, isolating many of them at a time when the first wave was at its most dangerous. The testing had side benefits: it included a world-class community-based communications effort, designed to inform non-English speakers, and spurred the creation of a new municipal program, Right to Recover, which offered wage replacement to workers who needed to stay home. During the same period, the city’s health department, working at Laguna Honda and other S.N.F.s, was able to take direct action to safeguard an unusually high proportion of the metro region’s most vulnerable elderly residents. All of this happened in a part of the country that had shut down early enough to prevent massive viral spread. But the shutdowns weren’t the end of the response; they were the beginning.
The testing effort drew a map of infection in San Francisco; that map illuminated not just the physical location of the virus but the socioeconomic dynamics of its dispersion. It showed that infections among people who could work from home were relatively rare. Instead, most transmission took place in poor neighborhoods, or in workplaces where people huddled together: nursing homes, restaurant kitchens, meatpacking plants. Differences in case numbers reflected the distribution of certain kinds of workers and workplaces. Berkeley had a low infection rate partly because it had done a good job with its S.N.F.s, but it also helped that there were so few of them. A city is more likely to beat the coronavirus if the indigent elderly who live in understaffed S.N.F.s and the poor essential workers who attend to them cannot afford to live there. Berkeley, in effect, had priced out the worst of the pandemic.
East Palo Alto, known locally as E.P.A., is a good example of a Bay Area city that has suffered during the pandemic without the shield of gentrification. Situated between the marshy south end of San Francisco Bay and the wealthy communities of Menlo Park and Palo Alto, it is home to about thirty thousand people; although it’s just a few miles from Stanford’s campus, no well-funded projects headed by superstar epidemiologists took place within its borders. Its history is deeply intertwined with the story of race in the Bay Area. In the nineteen-thirties and forties, Japanese-American farmers lived on its land; after they were placed in internment camps during the Second World War, Black domestic workers moved in, and for the next fifty years East Palo Alto was a Black city. In the sixties and seventies, Nairobi College, a radical training space for Black and Latino youth inspired by the Third World Liberation movement, was run out of private homes and meeting spaces there. East Palo Alto was devastated by the crack epidemic—in 1992, it was called “the murder capital” of America—and the Black population was eventually replaced almost entirely by working-class Latino immigrants. Latinos now make up more than sixty per cent of the city’s population. The majority are undocumented, and many are essential workers. E.P.A. residents live so close to Facebook’s headquarters, in Menlo Park, that some have taken to stealing the bikes that Facebook employees use to get around campus and tricking them out.
“We’re last in census response and last in voter turnout,” Walfred Solorzano, an East Palo Alto city clerk, told me. “And we’re first in coronavirus.” In early July, at a time when a surge in COVID cases had prompted Governor Gavin Newsom to shut large parts of the state back down, I went for a bike ride around East Palo Alto with Solorzano and a couple of his friends. We started off in Jack Farrell Park, where protesters had painted a mural of George Floyd on one of the concrete walls. The park was surrounded by single-story, single-family homes, most of them fenced off from the street and in disrepair. “Lots more people live in these houses than you’d think,” Solorzano said. “Families living in garages, stacked up inside the houses. So when one of them gets sick with corona, everyone’s gonna get it.”
We headed out toward the industrial flats, on the shores of the bay, passing the new office buildings that housed Amazon’s Web Services operation. On our right was the former site of Whiskey Gulch, once the city’s main street and night-life district; it was now a modern corporate fortress, with gated parking, a bottleneck entrance, and two large, beige buildings bookending a Four Seasons Hotel. Because of the lockdowns, the site was completely empty. “All of this is in E.P.A., but on their Web site they say it’s Silicon Valley. It’s like they’re ashamed to be associated with the city,” Solorzano said. “This space used to have the Nairobi Cultural Center here, and all these old businesses that meant a lot to the people who have been here a long time.”
As we biked, Solorzano summarized the state of testing in East Palo Alto. More Latinos had been getting tested, having been persuaded by word-of-mouth campaigns. Still, he said, many people, especially African-Americans, were hesitant. “I think they might feel this apathy,” he said. “They’ve just seen every promise get broken, and maybe they’re just giving up.” This hopelessness has extended into the winter. East Palo Alto’s test-positivity rates have hovered around fifteen to eighteen per cent, which is roughly five to six times higher than the surge that shut San Francisco back down this winter; at times, rates have reached thirty per cent.
After beginning its response with broad, early shutdowns, San Francisco and its surrounding cities and counties faced a challenge. How do you manage a pandemic in a city where some people can afford to tutor their kids in pods, have all their groceries delivered, and leave the city at a moment’s notice for houses in Tahoe, on the northern coast, or even in Hawaii, while others live in tent cities? Confronting the pandemic required the coöperation of young, relatively affluent residents who could work from home; it also demanded targeted interventions among low-income essential workers, immigrants, the poor, and people in nursing homes. San Francisco, perhaps more than any other city in the country, has particularly stark gaps between these groups.
“It’s not been easy,” Mayor Breed told me, when I asked her about the city’s response in Latino neighborhoods, where people fear that coöperating with health officials will ensnare them in an immigration dragnet. “There’s definitely a trust issue there. I can’t control ICE. I can only control what we’re able to do. We’ve made it clear to people, whether for the census or for testing, that we don’t share information with ICE and that we’re there to provide support, but that message takes a lot of work.” Kim Rhoads explained the other side of the problem: communicating the inequalities of the pandemic to white voters. “It’s so complicated,” she said. “We don’t want it to be called a Latinx disease here, so we have to be very careful about that.” She added, “You can’t just say that the Latinx community is contracting the virus without explaining exactly why. You have to say who is still going to work in food plants, who are the essential workers in kitchens and delivering groceries.” To describe the racial inequalities of the pandemic, she concluded, is also to risk “inciting the worst anti-Latinx sentiments.”
In the coronavirus’s winter wave, San Francisco and the Bay Area have not been spared. Infection rates, while still comparatively low, have spiked; for the first time since the start of the pandemic, I.C.U.s and emergency rooms are inching toward full capacity. But the approaches used in the spring and summer—hyper-localized targeting; an emphasis on the hardest-hit communities; the coördination of disparate resources in hospitals, clinics, academia, the community, and government—are just as relevant now. You still have to look for the virus. Having found it, you can suppress its spread; you can also, in the months to come, vaccinate at-risk populations.
After finishing up their studies in San Francisco, the U.C.S.F. team went across the bay to Alameda County. In an initiative led by Alicia Fernández, a physician and researcher, they set up testing sites in Deep East and West Oakland, both traditionally Black neighborhoods, and Fruitvale, a majority-Latino neighborhood that, despite being situated in the center of the relatively calm Bay Area, had some of the highest test-positivity rates in the country. In Fruitvale, the researchers determined that the epicenter of the outbreak wasn’t the Latino community in general but a group of Mayan workers from Guatemala who speak the indigenous Mam language. Rhoads and her colleagues believe that these sorts of specific insights, which are currently vital for testing, isolation, and education, will also be needed when it comes time to distribute vaccines. The U.C.S.F. team has learned to fine-tune its testing efforts; it has discovered, for instance, that, while scheduled-mass-testing sites work well within Latino and Asian neighborhoods, Black residents in Oakland are more likely to visit pop-up testing sites. “The same issues with testing are going to be present with the vaccine,” Rhoads said. “A lot of health-care institutions and even research universities have this vision that, if they provide it, people will come. That’s just never been true, and it’s certainly not going to start being true now. We need to meet people where they are.”
The architects of San Francisco’s coronavirus response may find a receptive ear in the Biden Administration: three U.C.S.F. faculty members, with a broad combined range of expertise, from biostatistics to emergency-room management, will serve on the President’s coronavirus advisory board. But it’s worth asking if any top-down effort can replicate the city’s success in a country that now averages more than two hundred thousand new confirmed cases per day. Even the best plans require basic infrastructure; in San Francisco, much of that infrastructure had been put in place long before the pandemic arrived. It is difficult, in a matter of months, to build bridges between minority populations and local governments, or to fix long-standing problems with understaffing in privately run nursing homes. Around the country, even well-intentioned test-and-trace programs have struggled to reach vulnerable people who, afraid of the government, do not want to share their names and contacts with a stranger on the phone. While Operation Warp Speed, the Trump Administration’s effort to produce and distribute a vaccine, has found success, no similar effort has been aimed at the protection of nursing homes, which, nine months into the pandemic, still account for forty per cent of COVID-19 deaths nationwide. (In individual states, the figure has sometimes risen to more than seventy per cent.)