San Francisco first made headlines over its response to COVID-19 in late February.
There were no known cases of the new coronavirus in the city at the time — and only 57 confirmed cases in the United States as a whole.
But Mayor London Breed declared a state of emergency, making San Francisco the first municipality in the nation to take the step to free up resources for a pandemic fight health officials had said was coming.
A few weeks later, it became the first county in the United States to shut down, implementing a shelter in place policy on March 17.
The early action appears to have paid off.
According to analysis produced in early September by the city’s COVID Command Center and Department of Health, San Francisco has a wide lead among U.S. cities in terms of the lowest number of COVID-19-related deaths per capita.
As of early this week, city officials told Healthline that San Francisco was still averaging around 12 deaths per 100,000 people. The next lowest city, Seattle, was averaging in the mid-30s to low 30s.
San Francisco also appears to have the second-lowest cases per 1,000 people despite appearing to have the highest tests per 1,000 people.
Death rates can be unreliable because they’re sometimes updated weeks or months after the fact, but San Francisco’s quick response has long been recognized as contributing to its success relative to other cities.
An Atlantic article in April called the city “a national model in fighting the pandemic.”
A May investigation from ProPublica contrasted San Francisco’s response with New York City’s and found the early action paid off.
While some of the reasons for San Francisco’s relative success are likely unique to the city, others hold lessons other cities and counties can continue to apply, city officials say.
San Francisco is starting to loosen restrictions on businesses and public places, albeit much slower than other cities.
This next stage could hold lessons, too.
San Francisco isn’t just a city. It’s also a county.
That makes coordination a bit easier.
When COVID-19 cases were surging in California over the summer, that was mainly in the southern part of the state.
Los Angeles County stretches about 80 miles from beach, over the mountains, to the desert, covering dozens of cities and unincorporated areas.
“It’s harder to get them all on the same sheet of music. We don’t have that problem,” said Dr. Jim Marks, planning section chief for San Francisco’s COVID Command Center and the chief of anesthesia at Zuckerberg San Francisco General Hospital and Trauma Center.
Beyond the geography, San Francisco is small as major cities go. Even if there’s only one conductor, the fewer people and neighborhoods you’re trying to get on the same sheet of music, the easier it presumably would be.
San Francisco also has a progressive and well-educated population, which may contribute to what appear to be high rates of compliance with medical guidelines and recommendations.
“They’re kept informed, and they want to be informed and understand how the disease is transmitted,” Marks told Healthline.
And the city happened to be somewhat prepared for a situation like this due to past experiences and funding decisions.
“In some ways, we were set up for success,” Marks said. “We have a very well-funded and well-managed health department and are experienced in other pandemics, like HIV.”
The HIV crisis that spiked in the 1980s and 1990s gave the city experience with widespread testing, tracing, and public education campaigns, all of which apply directly to a much different disease right now.
It’s likely too late for other cities to implement new health department funding — or shrink to become their own county.
But some of those lessons from the HIV crisis and other aspects can likely still be implemented.
These include centralized command, disaster-ready workforce, an emphasis on education around masks, tracking of mask compliance, and a widespread but focused testing strategy.
The COVID Command Center in San Francisco may have focused the city’s efforts and provided transparency. The center took over the city’s downtown convention center during the pandemic, and at its peak had a fiscal year budget more than $500 million, according to Marks.
It’s been staffed by employees from throughout city government, pulled from their day jobs because they had earlier agreed to be designated as “disaster service workers” for a situation like this — or a major earthquake.
The command center has established what Marks calls a “data feed” with hospitals to assess their capacity and COVID-19 cases on a daily basis.
It also has developed and tracked indicators to define whether the city is meeting its targets, developed a surveillance program for nursing homes that includes mandatory testing, and found ways to protect vulnerable populations, such as the city’s large homeless population.
Marks said they have placed more than 2,000 people who are unhoused and been deemed especially vulnerable to COVID-19 in shelter-in-place hotel rooms.
They’ve also leaned on public health messaging to get compliance with medical guidelines. More recently, they’ve started tracking how much compliance they’re getting.
Marks thinks that education push about masking has been key, since, as he noted, “probably the single most important thing we can all do is be masked.”
The city posted signs and ads throughout town. In addition, actions such as painting physically distanced circles in the grass at popular parks may have helped drive home the seriousness of the situation.
Now, San Francisco has followed Philadelphia’s lead and hired contractors to try to walk around and record what percentage of people are wearing masks. They walk 39 routes in the city, Marks said, and so far have found compliance is 72 percent.
For context, recent estimates in Philadelphia range from 40 percent to the low 70s.
Marks noted that compliance is lower in some neighborhoods, and those neighborhoods also have higher case rates.
Like other cities, San Francisco also has universal access to testing. Marks said it has tested more than half of the city’s population and has the highest current testing rate of any California county.
He also said the city is focusing testing efforts on neighborhoods where cases are higher, whether that higher rate is due to mask compliance or not.
Other cities have appeared to have done relatively well, too.
Miami, for example, has experienced about 100 COVID-19 deaths per 100,000 people, but only about 1.6 percent of the people there who have contracted the new coronavirus have died from it.
That’s second only to San Francisco, at under 1 percent.
But Miami and other places in Florida are reopening back to prepandemic capacity and activity.
Zoran Bursac, PhD, chair of Florida International University’s department of biostatistics, has been working with other area researchers to maintain the Miami-Dade County COVID-19 Trajectory, which tracks patterns in COVID-19 statistics in Florida’s most populous county.
He said deaths due to COVID-19 there are now approaching the number of annual deaths due to cancer, but that “things are getting better and we’re expecting to see the trend from July to start going down.”
But while they had been seeing declines, Bursac’s current forecast is “keeping us flat where we’re at,” he told Healthline.
That’s because of a decision by the state government that overrules cities’ ability to react and adjust.
“Gov. (Ron) DeSantis just overrode everybody and went to phase 3 — bars and clubs at full capacity — took the ability from local municipalities to enforce mandates,” Bursac said. “So, we’ll see if there are any effects of this.”
San Francisco’s restrictions have been allowed to be more restrictive than the state of California’s and to last longer.
But the relative success of those policies hasn’t saved the city from pushback.
The U.S. Department of Justice, for instance, has called San Francisco rules limiting capacity in houses of worship “draconian,” and called for a rollback of the restrictions.
But San Francisco is starting to roll back some of the restrictions.
Indoor dining was allowed to resume on Wednesday, albeit with strict regulations and at 25 percent capacity.
Playgrounds reopened Monday, quelling questions from parents who wondered why they were still closed while adults’ indoor gyms had reopened with limited capacity a couple weeks earlier.
It will be a new test of whether the city’s track record of early and careful action can hold up once things start returning to something resembling prepandemic life.