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When Covid-19 crept quietly into Orange County by way of international air travelers from China in January of 2020 county health care officials knew very well this was not just another version of seasonal influenza. We’d already seen the pandemic wave sweep into Italy, Spain, and New York where the bodies piled up in cold storage trailers. In Orange County we should have been ready.
Instead, the county’s public health agency was conscripted by its board of supervisors to focus its attention on delaying and distracting the public from seeing this new virus in all its pandemic potential. OC leaders saw Covid-19 more as an economic disruptor, and sought political cover, for themselves, and for cities requesting non-disclosure of their first Covid-19 cases. Health bulletins went undisclosed to the public. Rising case numbers were undercounted for months. It cost us all precious time.
Now, a year into the pandemic it seems a good time to look back and take stock of the county’s response to this still ongoing health crisis. No better way to view it than through the prism of the OC Health Care Agency and the musical chairs of top leadership changes that occurred through the course of this pandemic.
From the very first case of coronavirus in California identified in Irvine, county government and its first Health Care director to face Covid-19, Richard Sanchez, sought to mute the Covid alarm by declaring in a January 25 press release “no evidence of transmission . . . with “minimal risk” to the general population. In an effort to protect certain prominent cities from “the stigma” and possible economic impact of a viral outbreak, HCA Director Sanchez refused to identify where the first confirmed cases were, any pattern of transmission, or even the type of individuals who were infected, at the request of those cities.
Under the watchful eye of the board of supervisors, OCHCA Director Sanchez suppressed public disclosure of viral spread and further slowed the rate of testing by ordering most testing under control of the agency to be sent back to CDC Atlanta for confirmation. He then went on to reinforce a general illusion of stability over the outbreak by saying, “In terms of testing capability, we feel we have sufficient numbers at this time.” When it finally came to light that a mere 1,124 test kits were available for the entire county in March, it was too late to contain the outbreak.
“Wholly inadequate,” was the way long time Orange County infectious disease specialist Dr. Michael Fitzgibbons described to this reporter the health care agency’s response to the onset of coronavirus in OC. “They did nothing to prepare the population. . . . or to mobilize us in the medical community. When [Covid-19] hit they even hindered those of us in the field who were thinking out of the box, even though there was no coordinated response coming from public health.”
This pattern of deception and delay established by Director Sanchez would be duly rewarded by the supervisors with his up-salary transfer to director of the county’s Cal Optima program. His replacement, longtime Deputy HCA Director David Souleles, tried to make up for lost time by attempting to expand the anemic Covid-19 testing network Sanchez had left behind, challenging the board of supervisors in April with his expansion plan including opening two much needed labs. He didn’t get very far.
The 16-year career public health officer would not keep his new job long enough to see any of those facilities open. It was too much too soon for those supervisors politically committed to the proposition that this epidemic was bad for business and would soon pass anyway. Souleles suddenly found himself leaving the agency for daring to put public health ahead of politics.
Board Chairwoman Michelle Steel led the charge against the state imposed pandemic lockdown by defending defiant business establishments who refused to shutter their doors to walk-in customers, ordering the HCA to actually stand down from enforcing Covid related restrictions on businesses.
In a June 11 press conference Supervisor Steel floated the unsubstantiated notion that
“Orange County is well on its way to getting out of this situation,” and later added with an unscientific flourish, “99% of Covid positive people don’t get sick anyway.” Supervisor Don Wagner joined in the county’s defiant stand against state pandemic restrictions. “It’s not the job of the health care agency to police the state orders if the business is complying with the county’s own orders,” he declared in a press release on April 28 announcing county’s own guidelines for reopening decidedly more relaxed than the state’s. “We’re not going to enforce either beach closures or those those business closures if they don’t run afoul of the county’s own guidelines. And if the governor would like to bring CHP out or call out the national Guard, the governor can do what he wants.”
Into this contentious environment, percolating down from the supervisors themselves, stepped medical manager for the agency Dr. Nichole Quick. As the agency’s chief medical officer she took a stand with the prevailing state public health stance that facemasks are an effective check on viral transmission, and issued a countywide public mask order as test positivity rates and hospitalizations soared in May. But her emergency facemask order flew in the face of Supervisors Steel and Wagner’s late April declarations that hospitalization rates had “flattened.”
A look back through the broader spread sheets of the state Department of Public Health data base for April-June, and even the county’s own data charts, as depicted in the above graph, identified no such prolonged “flattening of the curve,” as Supervisors Steel and Wagner had boldly asserted. Nor was Chief Medical Officer Quick impressed by the subterfuge.
“We follow the state guidelines,” Quick told the BOS in open session. “Our science comes directly from the CDC (April 24 Directive),” She told a May 5 BOS meeting. “Our own numbers are telling us we are seeing an increase in community transmissions, so it is medically necessary for people to cover their faces.” It may have been a science informed position, but it contradicted Supervisor Steel’s race to reopen the doors of commerce and her timeline for “returning the county back to normal.” Quick soon found herself on the receiving end of Supervisor Steel repeated criticism in open session over her stand on masking.
Favoring political interests over public safety, Supervisors Steel and Wagner enlisted the county’s two largest agencies to follow them into the breach of pandemic politics. OC Sheriffs’ Department partnered up by refusing to enforce Quick’s facemask order. “We are not the mask police, nor will we be,” declared OC Sheriff Don Barnes refusing to allow deputies to engage in any enforcement of Covid related health orders. Facing withering criticism from the Board, lack of support from internal and external county enforcement players, personal harassment and public death threats, Chief Medical Officer Quick was forced to resign at the end of May. OC supervisors quickly appointed public health administrator Dr. Clayton Chau, a behavioral psychiatrist, as the new Health Care Agency director. Mindful of the top level turnovers that preceded him, Director Chau made it clear early on he would dutifully “facilitate” (his word) the wishes of his BOS bosses. He immediately rescinded Quick’s mask order. Then a few days later sidestepped enforcement action against businesses defying Covid regulations by refusing to enforce related health and safety orders as “not our responsibility. . .these enforcement actions are outside of our licensed jurisdiction,” Chau declared at a July 9 press conference, even though just days before the agency’s own chief communicable diseases officer, Dr. Matthew Zahn had identified restaurants as the most troubling sources of Covid-19 transmission.
Director Chau went on to refer to a mysterious “legal determination” presented to him by county counsel to justify his stand down policy toward enforcement of Covid violations. But when asked to disclose the language or the legal basis for his refusal to enforce, his only response was, “I am not a lawyer.” Director Chau was then asked if his code enforcement officers had issued any Covid related citations to flagrant non-complying businesses. County CEO Frank Kim stepped up to the podium in Chau’s place to say “ all such violations are referred to state Covid strike teams. . .these guidelines are outside of our authority.” CEO Kim indicated Chau was in agreement. Chau nodded affirmatively.
The board had finally found their yes man.
Chapman University Law Professor Mario Mainero, with expertise in local government and state law, did disagree with Chau and his boss, CEO Kim. “Authority over the direction of a county health agency comes directly from the state codes,” Mainero told this reporter in November, “Health care agencies know what to do, they have the power directly from the state to enforce.” Professor Mainero points to State Health and Safety Code Section 101040 (a) . . . “giving the county health officer power to take any preventative measures consistent with the preservation of the public health.”
But the County of Orange had no interest in facemasks or any other state Covid restrictions that obstructed the county’s vision of itself as somehow “exceptional” in dodging the Covid bullet, and therefore ready to reopen for business. The Summer of 2020 would derail that illusion with a pandemic surge that peaked in July and revealed in its wake great disparities in the county’s public health response to the pandemic.
Testing and other Covid mitigating services in OC had been lacking from the beginning of the epidemic. “The county response was never well coordinated across the region,” says UCI Professor of Epidemiology Daniel Parker, who participated in some of that early outreach in the county’s response to Covid. “But even now, with not enough contact tracers to deal with this epidemic, it’s still a patchwork process . . .. We just never had a lot of boots on the ground.” Parker concluded, “We could have done better.”
The OCHCA’s early Covid response was so inadequate, partly because of its politically driven policies of its ill-informed resistance to mask wearing and social distancing, and its consistent lack of transparency with the public so pervasive the county was compelled to hire a PR firm to reestablish the agency’s connection with communities it had broken trust with. As the PR firm’s official marketing strategy admits, “The goal is to remove the invisible barriers between OCHCA . . . and the people,” in a scramble to get public acceptance for the coming vaccine push, and “create” as the strategy lays out, “a positive narrative showing the county and the health care Agency has a plan,” which, if it did have one, was obliterated by the Summer surge of 2020.
After the July surge that almost broke the OC hospital system, the supervisors’ campaign of promoting commerce over caution, politics over science, could no longer be delivered with the same swagger displayed by supervisors previously. But the systemic inequities built into the politics of public health in Orange County continued in subtler and more nuanced ways to perpetuate those inequities.
From almost the beginning of the pandemic large pockets of Covid transmission had been creeping into traditionally disadvantaged communities of the county and creating local viral hotspots that failed to get HCA’s rightful attention. This was largely due to an agency policy of averaging all local Covid positivity and hospitalization rates into an “aggregate” county total, blending all 34 cities into one county average, thereby creating the illusion of a low Covid count overall, allowing the county to overlook surging Covid hotspots in more disadvantaged communities, and county/ HCA officials to declare in a May OC Register article “No Red Flags” here, unless of course you were one of those unfortunate low income communities, that were “averaged” out of statistical significance and overlooked by county public health services. You knew who you were, and that Covid was quite real.
“Its hurting our community “ Santa Ana based Latino Health Access CEO America Bracho told the OC Register, after months of attempting to alert the county to spiking Covid counts in Santa Ana and Anaheim. “It’s not like it all got better. . .we still need more testing. . . But it’s not just access to testing,” Bracho insists, “It’s about having ongoing access to prevention and other health opportunities that don’t go away in a month. . . and the resources to maintain contact with our communities.”
The only way LHA could ensure ongoing health access and contact with its communities was to provide it themselves, with their own local volunteers, or Promotores, onto the streets and into the back alleys daily to provide residents access to testing, and beyond that, quarantine support with services, whatever that might require. The Promotores became, in effect, the county’s proxy outreach and engagement force on the streets, at least in Santa Ana and parts of Anaheim.
So where are county HCA’s own Outreach and Engagement teams, the “blue shirts” as they are called, on the streets today in these Covid times? In the area of contact tracing a May OC Register article revealed the agency had approximately 75 tracers on staff in the field. That number doubled through the Summer surge. But today the agency claims virtually all of its own tracing outreach has been retracted from the streets. “Except for certain county outreach in congregate settings. . . .case and contact investigation is no longer done on the streets by HCA,” states HCA Chief of Operations Mark Meulman. In fact, all agency outreach for Covid -19 contact tracing, Meulman acknowledged in a December memo, “is now done through CalConnect” (a telephonic referral service). In other words, it’s phoned in.
The scarcity of agency O&Es on the streets of Orange County is hardly new. But It took a pandemic to reveal the fault lines in this county’s health care system historically disconnected from its most needy populations, like the homeless, or the hidden underclass of poverty level families and RV nomads constantly on the move in OC. And now there are the overlooked and underserved communities crippled by Covid-19 the county failed to acknowledge early on.
It took a state edict and some very persistent local advocates to get the county and its public health agency to refocus on some of these disadvantaged communities ravaged by coronavirus, zip code by zip code, as Santa Ana’s America Bracho had advocated for since March 2020. But when Anaheim’s City Manager Greg Garcia attempted in June to release Covid data by zip code County CEO Frank Kim and HCA Director Chau told him not to share the data with the public, data county officials had been burying from public view since the onset of the pandemic.
It was the state’s new Metric-based Health Equity Initiative conceived early in the pandemic rolled out in the summer that finally imposed its will on counties, like Orange, by tying economic recovery to more equitable living conditions for those “forgotten” zip codes lost in the county’s “averaging” of Covid tracking data. Governor Newsom made it clear no county would be moving to a higher tier of economic reopening until these disparities in services within its underserved communities were corrected. In an October 5 press conference he spoke directly to counties like Orange in these words, “Leaving communities behind in order to game your testing and your case rates isn’t right. Our approach is to make sure we are doing justice to all communities and not just gaming the system to paint a rosy picture.”
Today, early pandemic denier Michelle Steel has moved on to greener political pastures. And Don Wagner no longer stands on street corners inciting anti mask protesters, but institutional inertia still grips this county’s response to Covid -19. Disadvantaged communities across Orange County still suffer disproportionately with coronavirus case counts and positivity rates 4- 8 percentage points higher than the county so called background “average.” And after a couple of months into a vax roll out aimed at the elderly 65 and older, only a quarter have been vaccinated, those percentages even lower among communities of color that need it the most.
Orange County Health Care Agency continues the take a backseat position on many critical public health fronts. County outreach remains sparse and ineffective on the streets, the promise of mobile medical triage vans going where the need is greatest, remains largely a myth. OCHCA to this day refuses to take a lead role in monitoring and following up on outbreaks on and around public school campuses “unless the outbreak goes community wide” states Director Chau. Again, a public health response two steps behind the virus, leaving the county intentionally blind to all but voluntary reporting by schools and parents of school children.
Rampant transmission continues to spread within our homeless shelters, jails, recuperative care and other congregate populations settings that have mostly gone poorly monitored and by HCA field teams typically responsible for oversight, particularly in a pandemic.
After all the PR push and millions spent on promoting “Health Equity” in Orange County most of county’s vaccine roll out has concentrated in so called super POD mega centers like the Disneyland parking lot, inconvenient for the working poor to get to, difficult for the first priority elderly to physically navigate, frustrating only for many who must sign up through the glitch-prone Othena website, until recently, accessible in English.
The second super POD was a drive-thru, but located in well to do South County, where far fewer outbreaks have occurred. And of the first few local pharmacy-based vaccine centers opened for business in OC, most are in the upscale locales of Irvine, Aliso Viejo, Yorba Linda, Brea, Newport and Huntington Beach. Much like the roll out of the first few OC coronavirus testing sites last year, these first pharmacy-based vaccine centers were typically far from actual epicenters of the pandemic in disadvantaged communities that, once again, lacked historic leverage with county leadership. Persistent viral hotspots like Santa Ana and Anaheim, representing 37% of the county population, continue to suffer with almost half of the county’s Covid case counts, and yet have received only 11% of the county’s vaccination allotments to date according to the California Healthy Places Index, which scores central OC communities as among some of the lowest “equity” rated tracts in the state.
This is no way to run a pandemic. As UC San Francisco Epidemiologist Kirsten Bibbins-Domingo puts it, “What does it mean to reach herd immunity when one part of the county might reach that goal. . . while another part doesn’t? People move across communities which means effectively we don’t have herd immunity anywhere, so the pandemic doesn’t end.” In Orange county where public health care has been historically blind for decades to the suffering of its disadvantaged, climbing out of these “public health “deserts” as Bibbins-Domingo calls them, need to be addressed first, not last.
Current Director Chau did not create this politically driven, inequitable public health system the HCA has become under the thumb of its county overseers. He just “facilitates” it, to use Chau’s own word, on behalf of his BOS bosses.
This county and its public health agency has handed out over $500 million of mostly Federal Cares Act pass-thru money to Covid relief and protection programs across the region. Yet in so many cases OC Health Care Agency was unwilling to monitor, track, enforce and ultimately ensure the public is actually being protected and served by this Covid relief funding.
Safe Dine OC, was a mini-grant stimulus stab at incentivizing businesses to adopt Covid- safe practices up to $5,000 reimbursement grants to over 2,300 restaurants across the county to keep their establishments Covid clean and health order compliant. But even here, our health care agency backed down from any kind of lead role in qualifying OC businesses as grant recipients or in monitoring restaurants for health code and grant compliance. This partnership between the HCA and the Orange County Business Council, conceived by the supervisors themselves, consigned the Health Care Agency to a “promotional role,” states OC register on August 7. “The agency will promote the campaign, but is not involved in . . . .compliance. The business council (OCBC) will be approving applicants,” the Register reported.
When asked in a press conference on August 6 why his health care agency was not at the center of this program monitoring compliance to Covid protocols, Director Chau responded “We ourselves do not have the staff or the resources at this time to administer the program.” The response was typical of HCA Director Chau’s leadership during the course of this crisis, deflecting responsibility away from his agency, reluctant to commit resources, and more critically, direct resources at crucial points in the pandemic, deferring time and again to undisclosed county “legal determinations” to justify inaction. This pattern of delay and deferral of public health engagement from the onset of this pandemic, enabled been by the BOS, has had its consequences.
County government’s incessant micro-managing of its health care agency into a secondary responder through the course of this pandemic has forced our hospital systems to bear the front line burden against this pandemic almost to its breaking point, when it should have been the county public health agency out there on the front line from the start in the streets testing, tracking, surveilling, isolating this virus spread, informing the public at every turn so it could be an active participant in the overall response that might have gone more equitably.
As we look to the promise of a new year and the hope that these new vaccines coming online will eventually overcome Covid-19, we must also remind ourselves we are still at a tipping point in this pandemic. This virus has the potential to surge again with every new variant, and the potential of taking our hospital system with it, should we become complacent to the health threat still among us.
We do have our vaccines now, and the formidable weapons of face masks and social distancing at our disposal too. Science and public health have provided us with at least these tools, if we are smart enough to use them.
Because this virus will be in our public spaces and on our doorsteps for months to come, we all bear some personal responsibility to protect those spaces. But we also expect and count on our public health agency to take a leadership role and step out onto the front lines in our defense, particularly among our most vulnerable and traditionally underserved communities where the need is most critical. Yet, in the county’s rush to vaccinate, testing has been allowed to languish, contact tracing essentially abandoned, and the Health Care Agency’s surveillance over the growing population of post Covid infected “long haulers” left debilitated and disabled by the virus, is not even on our public health officials radar yet.
There’s a reason, as Professor Mainaro pointed out, why health care agencies in California are bestowed authorities in a health crisis that come directly from the state, and not county government. A public health department must be able to act quickly, decisively, and independently of political influences in order to stamp out community born disease at its epicenters. That action was denied, delayed, and deferred here on Orange County for almost a year. As UCI epidemiologist Dan Parker has said, “We could have done better.” As chief epidemiologist for the county’s own Covid-19 Task Force Andrew Noymer has said, “We must do better.” The stakes are too high, our adversary too clever, for anything less.
As pandemic metrics begin to trend downward we lean into the possibility of a post Covid time. On the other hand, we could be just passing through the eye of the storm toward another variant-driven surge. It is yet to be seen if vaccines will prove to be the get out of Covid free card we are all banking on.
Either way, a full year into this pandemic should have given us some hard public health lessons to guide us into the future, if we are allowed to follow the science. We now know face masks and distancing work. Even the seasonal flu has been considerably dialed down this past year by mask wearing.
We also know that time is not on our side. The longer this pandemic rages in the bodies of the hospitalized, the asymptomatic, and the slow to recover “long haulers” alike, the greater the proliferation of these viral variants, imported and home grown, increasingly resistant to our first generation vaccines. The countywide public health response, therefore, must be faster and better coordinated, unencumbered by the politics of preferential treatment to some and inequity toward others. Resources must be more closely directed at the communities most threatened by the virus. That takes commitment, not just in dollars, or in PR campaigns, but in public health personnel and resources redirected at testing, tracing, and isolating the virus before hotspots become wildfires.
As the noted University of Minnesota epidemiologist Michael Osterholm has said, “Looking at the pandemic as giant waves surging over us may be the wrong metaphor. It’s really more like a wildfire spreading cinders across the landscape. Some will burn out and some will catch and spread quickly. We must be there where the fires are before they become firestorms.”
We cannot afford to wait for the politics to catch up to the science, as was the case in OC through most of 2020. Our current health care director must find the courage to take charge and take back control of his agency from the political and financial entanglements of his county overseers that have only served to slow our public health response thus far.
Director Chau must redeploy his outreach and enforcement teams back to the streets with renewed testing, tracking and neighborhood level vaccinating sites that reconnect with the communities most immediately at risk. This is understood at the state level and in many surrounding counties as health equity. But with Covid transmissions and mortalities still running many percentage points higher among our disadvantaged communities over the county average, the term remains little more than a slogan in OC.
If the current director of public health in Orange County cannot separate himself from long arm of county politics and recommit his agency as a frontline responder during a pandemic, he should step aside and allow medically grounded professionals within the ranks of the OC Health Care Agency to step forward. There are many capable career professionals left at the agency who could rise to the rapidly evolving challenges of a second year of Covid-19 and its emerging variants, with science and public health as their only metrics.
As much as we would like to be done with Covid-19, this virus is not done with us. As long as the active cinders of Covid-19 are still allowed to smolder in viral hotspots like Santa Ana, Anaheim, Fullerton and elsewhere in the County, none of us are beyond its reach. In other words, none of us are really safe, until we all are safely past these Covid times.
John Underwood is a working reporter and media producer in Orange County with extensive background in Orange County based news and public affairs in print, broadcast and online platforms. Past news organizations he has been affiliated with are National Public Radio, the Orange County Register, the OC Weekly and various other OC based news publications. His current documentary series NO FIXED ABODE focuses on channeling the voices of the OC homeless and can be viewed on the website losaltv.org
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