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Essential, Sick and Marginalized: Latinx people represent nearly half of all COVID-19 cases in the City

This report is published in two parts. Part 1 reviews the City’s timeline of response in the first three months of the COVID-19 outbreak and existing data on Latinx workers as essential workers in the City. Part 2 hears directly from six essential Latinx workers who contracted COVID-19 in San Francisco while on the job during the initial lockdown phase and about their experience seeking and accessing help when they were sick. 

Compared to other large cities, San Francisco has fared remarkably well in limiting infections since the first novel coronavirus cases were reported three months ago. The early shelter-in-place order issued across five Bay Area counties, including San Francisco, on March 16 was crucial to this outcome. In the last two weeks, the curve of daily confirmed COVID-19 cases and the number of patients hospitalized in acute care and intensive care units started trending down in the City. Last week, on May 28, Mayor London Breed drew a new timeline and plan for safely reopening San Francisco. This hopeful turn in the epidemic restrictions, however, came with strict health orders that indefinitely extended the shelter-in-place order and made wearing facemasks mandatory outside. 

For the rest of the year, the valve on health order restrictions will open and close; it will be touch and go, depending on the rise and fall of infections in the weeks to come. Officials will need to collect and share as much information as possible about the virus and how the virus is moving within our communities for everyone to be on board with the next steps. Lessons must also be swiftly gleaned from the first wave of contagion in San Francisco in preparation for a possible, or perhaps inevitable, second wave, including who has been most impacted by the virus and why.

Source: Data SFGov

According to City data, as of June 1, 43 lives have been lost to the novel coronavirus. Ninety-three percent of these deaths involved people with one or more underlying health conditions, and 46.5 percent of those deaths are of Asian people. The specific health conditions of those lost lives have not been made known, but the Center for Disease Control (CDC) informs, based on currently available information and clinical expertise from across the country, that older adults and people of any age who have serious underlying medical conditions, such as chronic lung disease or moderate to severe asthma, serious heart conditions, diabetes, severe obesity, chronic kidney disease undergoing dialysis, liver disease, and immunocompromised conditions, might be at higher risk for severe illness from COVID-19. Yet, in San Francisco, deaths have taken a toll on people in the prime of their life: 23 percent of lives lost were in the 31-40 age range, 19 percent among 18-30 years old, and 18 percent in the 41-50 age range. In other words, 60 percent of all lives lost have been of young to middle aged people. 

Nationwide—worldwide—the virus has yet to be fully understood. For example, is it just a respiratory illness or also a cardiovascular disease, which would explain why it severely aggravates the health of those with diseases like diabetes, and not only those with underlying respiratory illnesses. The medical jury is still out, and as a result, so is a consensus on the most effective course of treatment. Prevention, therefore, is the first line of defense when combatting a new epidemiological event like COVID-19.

Prevention measures have unfortunately and disproportionately failed the Latinx community of San Francisco during the initial crisis. Per City data published on June 1, Latinx people represent 47.4 percent of all cumulative COVID-19 confirmed cases in the City since the start of March, despite representing only 15 percent of the City population. This percentage has been steadily increasing, even as the contagion rates have slowed down and testing rates gone up. 

Understanding the timeline of the outbreak in San Francisco and taking stock of the government’s preparedness and capacity to deal with an epidemic can help explain why the Latinx people continue to be overexposed to COVID-19. The role of Latinx workers, both documented and undocumented, as essential laborers in the City is also a clear factor to consider.

On May 28, the shelter-in-place order was indefinitely extended in the City. The City must provide a better response to all essential workers going forward, but especially, right now, to the Latinx community in order to beat back the spread of the virus within this community and protect Latinx people against grave health and economic consequences and greater social marginalization. 

Timeline of the Outbreak in San Francisco

Acknowledging the high volume of travel to and from mainland China, the government of San Francisco began preparing for the appearance of the COVID-19 disease on Jan. 21 by activating the Operations Center of the Department of Public Health (DPH). The Operation Center supervises and coordinates health and medical responses in the epidemic. Preventive measures were also issued instructing the public to wash our hands, cover our sneezes and coughs, and stay home if we felt sick. 

Six days later, on Jan. 27, the Department of Emergency Management (DEM) opened its Emergency Operations Center (EOC). The EOC coordinates government responses during an active disaster. The DEM, in general, supports government agencies to ensure that essential public services are provided after a disaster, and that they are prepared to accelerate post-disaster, long-term recovery and reconstitution. DPH toolkits published online have a decisive post-disaster outlook, and one best suited perhaps to unpredictable events such as earthquakes that can affect infrastructure. The City’s capacity to avoid the disaster that struck—an epidemic—required a decisive preventive response to contagion. Prevention requires widespread testing and contact tracing to contain the spread of a virus. 

On Feb. 25, Mayor Breed issued a “declaration of a local emergency,” which legally allowed the City greater agility in mobilizing resources, accelerating emergency planning, staffing response centers, and coordinating agencies, among other actions. No Coronavirus or COVID-19 cases had yet been reported in San Francisco, but it was only a matter of hours or days given that other Bay Area counties had begun announcing infections from community spread: Santa Clara and Sonoma County were followed a week later, on March 2, by confirmations of cases from community spread in San Mateo. 

In other words, these cases were unrelated to travel to China, the patients were unrelated to each other, and had no prior contact with any known carriers of the COVID-19 virus. The virus had already moved from person to person, away from the originally infected person or community, and it was no longer possible to trace the original source of the novel virus. For San Francisco, and the Bay Area at large, this was bad news. It meant that many unidentified cases had been missed and the transmission of the virus could no longer be checked at its source. It was in circulation and spreading. 

On March 3, Twitter told its Bay Area employees to start working from home. The next day Facebook and Google followed suit. The corporate and financial offices of downtown San Francisco shutdown in tandem. 

In coordination with the CDC and as part of the existing national influenza surveillance network, the San Francisco DPH Laboratory (SFDPHL) began testing for COVID-19 on March 2. Three days later, the first two cases of COVID-19 in San Francisco were confirmed: a 90-year old man in serious condition, and a 40-year old woman in fair condition being treated at two different hospitals. They had contracted the virus through community transmission. On March 8, the City confirmed a total of eight cases. In the days that followed, San Francisco’s Health Officer escalated health recommendations: large events were cancelled of over 100 people, vulnerable populations were urged to limit outings, businesses asked to limit employee exposure, and the public was urged to practice social distancing and hand washing. A variety of social security measures were also put into motion, including a moratorium on evictions, penalty waivers for delinquent payments on water and power, and funding for homeless shelters and SROs. 

On Monday March 16, 11 days after the first COVID-19 cases were identified in San Francisco, the Health Officer of San Francisco issued a shelter-in-place order to further limit the spread of the disease. The order, one step down from a full emergency lockdown, allowed residents to leave home only for essential businesses and travel, and listed a series of essential businesses that would remain open. 

The shelter-in-place order was a coordinated action of Health Officials across five Bay Area counties of the order, and in it saved lives, it undoubtedly saved lives. Consider that New York City issued a similar order on March 20, but by then, it was reporting 2,952 new daily cases and 29 deaths per day with numbers exponentially climbing. 

Two weeks after tech and corporate workers were ordered to work from home by their employers, essential workers continued to work harder than ever, commuting on the empty streets of San Francisco. For the first time, we woke up to learn who beyond first responders were essential workers: garbage collectors, restaurant workers, delivery people, tow-truck drivers, construction workers, grocery cashiers, and transport drivers to name a few. We could finally name them for what they were: essential to the day to day functions of the City, whether documented or undocumented. And yet, they are among the lowest paid.

On March 17, Dr. Grant Colfax, the head of DPH, explained to the Health Commission of the Board of Supervisors that the SFDPHL’s capacity to test and contact trace for COVID-19 was very small, compounded by a lack of CDC testing kits. The DPH initiated a process of establishing a testing plan with UCSF to track the availability of tests (including at private labs) to understand who, how many and where people were being tested. Tomás Aragón, the Health Officer of the City, at the Board of Supervisors meeting that day also stressed that the real spread of the virus in the City was unknown due to the lack of testing. On March 24, the City’s Health Officer ordered private and public labs in San Francisco to report complete COVID-19 testing information to the DPH.

Available testing also followed mandatory CDC guidelines which prioritized symptomatic healthcare workers, seniors and people with underlying chronic or immunocompromised conditions. Testing was next made available to people who showed severe symptoms: a fever with acute respiratory illness, such as a cough or difficulty breathing, requiring hospitalization. In other words, if a person came in with a fever or cough or shortness of breath but didn’t require hospitalization, a test was denied and they were sent back home. The obvious problem with this approach was that cases went undetected, even when people felt ill enough to ask for help at a public hospital. 

Access to testing for COVID-19 became a test of privilege. By mid-March, those with health insurance or the means to cover the out-of-pocket expense could get a doctor’s order for a test in a private medical facility in the Bay Area such as Stanford, Kaiser, John Muir Health, and Forward. The rest would have to wait until March 23, when the first free tests for active COVID-19, without doctor’s orders, were made available in the Bay Area at the Hayward Fire Station. Drop-ins were still heavily screened according to CDC guidelines.

While around the globe the sick overwhelmed hospital capacity and the death count rose exponentially, each day that followed in San Francisco seemed to bring a new positive response from the City government: nurses were expeditiously hired, relief provided for artists, the City bought N95 masks, and hotel rooms were available for those ill with COVID-19 who needed to quarantine. 

The City response appeared gloriously successful and forward-thinking, except for two events: a worrisome outbreak at San Francisco’s largest nursing home, the Laguna Honda Hospital, at the end of March, followed by an outbreak in San Francisco’s largest homeless shelter, the MSC South. On April 13, the City confirmed that 90 residents and 10 staff members of the MSC South homeless shelter tested positive for COVID-19. The news came after weeks when experts relentlessly lobbied for and Supervisors urged the Mayor to shelter the 8,000 homeless residents of the City in empty and available hotel rooms to reduce the spread of the disease. Instead of solving homelessness, Mayor Breed went with her longstanding stance against housing the homeless of San Francisco, no less in the middle of a historic pandemic. 

It was in the days of public outrage over the MSC South outbreak that questions also arose about whether the virus lurked undetected among the Latinx population of the City. The questions began when Unidos en Salud—a partnership between UCSF, the Latino Task Force for COVID-19, DPH, and the District 10 (D10) community—announced that the second densest census tract in the City and the highest with a significant Latinx population had been selected for a first-of-its-kind COVID-19 testing effort from April 25-28. As a resident of the tract, I reached out to Unidos en Salud asking about the spread of the illness in the Mission District and specifically that tract, but my questions were deflected with a canned answer about researchers needing a densely populated census tract. I sensed, as many others probably did, that there was “gato encerrado,” something fishy going on. We didn’t wait long for answers. 

In advance of the Unidos en Salud testing dates, on April 20, the DPH released a “Map of the Coronavirus Impact in the City by Zipcode.” The 94110 zip code, which covers a vast part of the Mission District, since then continues to show the highest number of COVID-19 cases, and the third highest density of cases in the City. In San Francisco, the Latinx population is most heavily concentrated in the Mission District, but also in the Tenderloin District and Excelsior District. The north and south corridors of the Mission District overlap with the 94103 and 94112 zip codes, respectively. The 94103 zip code mostly covers SOMA but also the north edge of Mission District. This zip code then and now continues to have the highest density of COVID-19 cases in the City. The 94112 zip code that carries south into the Excelsior and Outer Mission sustains the second highest number of COVID-19 cases. 

In releasing the map, the City informed that of 1,216 confirmed COVID cases up to April 20, Latinxs represented 25 percent of the positive cases. Unidos en Salud cited a higher statistics: “~34% of COVID-19 cases (with known race/ethnicity, as of April 18th) are in Latinx population, despite Latinx people comprising only ~15% of SF’s total population.” Unidos en Salud further confirmed that 80 percent of the hospitalized coronavirus patients at San Francisco General Hospital were Latinx, where generally, Latinx people comprise 30 percent of the hospital population. The statistics were alarming.

Before then, the City released data on the Coronavirus epidemic piecemeal, and information about the impact on the Latinx community had been entirely unknown. If not for the Unidos en Salud study, how long did the City plan on withholding statistical information literally vital to the health of the Latinx community? How many cases could have been avoided if the Latinx community had been better informed of the developing situation? The City officials acted recklessly in failing to disclose the spread of the virus among the Latinx population in real time. As of May 31, the total number of confirmed coronavirus cases in San Francisco have more than doubled, and the Latinx population now represents 47.3 percent of all COVID-19 confirmed cases in the City of San Francisco. 

In four days of testing, Unidos en Salud increased the total number of COVID-19 tests in the City by 29 percent, and days later released initial results from that one census tract: out of nearly 3,000 people tested, 62 people tested positive for active COVID-19. While seemingly low, the 2.1 percent infection rate was 2 percent above the city reported rate at the time. Moreover, of those who tested positive 95 percent where Latinx and 90 percent of those positive cases represented people who could not stay at home to work. The results highlighted the role that Latinx people were playing as essential workers, as well as their economic vulnerability that impeded them from staying at home. 

A 2017 survey by Mission Promise Neighborhood of 584 households with children in the Mission District shows that in the year prior, two in five families had gone without basic needs, including housing, health care, food and child care. Seventy-seven percent of the 447 respondents to questions on household income were earning less than $35,000 a year with 30 percent living below the federal poverty threshold at the time. At the time, almost all families were spending more than half their income on rent, with food related expenses being the next highest expense. Unemployment among these families was nearly four times that of the City rate, with 21 percent of working parents working more than one job to make ends meet. This snapshot of the Mission Latinx families provides a worrisome outlook for a community today simultaneously facing an epidemic and economic depression.

Following up on the Unidos en Salud results, the Bay Area Equity Atlas analyzed data from the 2014-2018 American Community Survey provided by the Center for Economic and Policy Research that describes the characteristics of essential workers in the nine-county Bay Area. The data shows 1.1 million essential Bay Area workers account for 28 percent of the region’s workforce. Among these essential workers, people of color are overrepresented: 66 percent of essential workers were people of color, even though only 58 percent of all workers were people of color. Of all essential workers in the Bay Area, 43 percent are immigrants, and 31 percent of essential workers are Latinx (even though Latinx people are 21 percent of all Bay Area workers). 

A further breakdown by specific essential industries shows that Latinx people represent a majority percentage of essential work in construction, cleaning and waste management, grocery, convenience and drug store, domestic services, trucking, warehouse and postal services, and agricultural work in the Bay Area. In regards to women, the Bay Area Equity Atlas found that “Latina workers make up one- tenth of the labor force, but nearly half of all domestic workers (47 percent), 37 percent of building cleaning services/waste management workers, and 23 percent of childcare and social services workers.” 

By the numbers, the extended City and State shelter-in-place order place the brunt of our survival needs square upon the shoulders of essential workers of all stripes, and their labor exposes them the most to contagion. In the case of San Francisco, it is the Latinx population, both documented and undocumented that is most impacted by illness in the City, physically and economically, whether out of exposure to the illness or lack of income, without any fallback resources. 

The restrictive access to existing testing in the City left Latinx essential workers overexposed and under-attended. The City did not expand access to free testing at its two CityTestSF to essential workers (without a requirement for a doctor’s referral) until early May. Now that the City has significantly expanded its number of free and accessible testing to anyone who lives or works in the City, Latinx people as a percentage of cumulative COVID-19 cases continue to go up.

There are lines of over 500 people a day at the various food pantries in the Mission District. These families with mixed or undocumented immigration statuses are ineligible for most of the federal and state relief funds and unemployment benefits. In any case, the one-time $500 City or state handouts for undocumented works cannot adequately compensate their high-risk labor or their economic losses after falling ill to COVID-19 for playing an essential role in sustaining our quality of life in San Francisco. The virus, even when it has not made them ill, but left them unemployed, is leading the Latinx community towards extreme poverty.

These days, we protest the humanitarian homeless crisis in the City. We protest the legacy of police brutality and inequity against the Black community. But we must also protest the disproportionate suffering of the Latinx community and other people of color as they bear the brunt of the disease in the City as essential workers. Echoing the Bay Area Equity Atlas recommendations, the essential working class of San Francisco needs to be supported by guaranteeing its basic human rights to living wages, paid and expanded sick leave, safe working conditions. free testing and free health care, facilitated by culturally appropriate methodologies, and stable housing, through eviction moratoriums, cancelled rent, mortgages, and utility payments

It’s the only humanitarian way forward. 

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