In LA, ambulances circle for hours and ICUs are full. Is this what Covid-19 has in store for the rest of the country?

LOS ANGELES — The situation here is dire. Every minute, 10 people test positive for Covid-19. Every eight minutes, someone dies. Ambulances circle for hours, unable to find ERs that can accept patients. Hospitals are running out of oxygen. ICU capacity is at zero. Patients lie in hallways and tents. Emergency room nurses have more patients than they can handle — sometimes six at a time.

The National Guard has arrived, not to help treat patients, but to manage the flood of bodies. As Los Angeles County approaches its millionth case of Covid-19, doctors describe their wards as war zones. Even the gorillas at the San Diego Zoo have gotten sick.

Just why did conditions deteriorate so badly in Southern California? And do the overwhelmed hospitals here offer a glimpse of what other regions may soon face as case counts rise steeply and a seemingly more infectious strain takes hold? Or did the unique and long-standing vulnerabilities of the nation’s second largest city conspire to ignite this current “surge on top of surge” that so many had feared but few predicted would get so bad that residents would be urged to refrain from entering grocery stores and, in some cases, to wear masks even while they are at home.

Like the city itself, the answers are complex — and also a bit perplexing.

When the novel coronavirus emerged in the U.S. last winter, LA County officials issued strict mask and stay-at-home orders so quickly they beat the virus back even as cases surged in New York and elsewhere. But that early success did not last.

“With the first wave, LA was the poster child on how to do things right,” said Leo Beletsky, a professor of law and health sciences at Northeastern University who is based in Los Angeles. “Then we blew the lead.”

The city’s early success may be one reason things are so bad right now. “What happened in New York is that people got very scared and they behaved,” said Karin Michels, who chairs the department of epidemiology at the UCLA Fielding School of Public Health. “We did so well, people started to relax, and they stopped following the rules.”

Many also hoped spread in LA would be buffered by year-round warm weather that allows activities to continue more safely outdoors. But winter has come to Los Angeles too, and while it may not be freezing here, the early darkness forces many indoors.

For many epidemiologists, this county with its population of 10 million and host of social inequities that fuel viral spread was always waiting to explode. “I never understood why people ever thought we could contain it,” said Paula Cannon, an expert on viruses and professor of microbiology and immunology at the Keck School of Medicine of USC. “Once it got into the general community, it became a forest fire with embers everywhere.”

“To me, it’s simple math,” she added. “Once the virus is out there, the numbers just keep going up and up and up.”

Early on, many experts thought LA’s notorious sprawl might be protective. They were wrong. LA doesn’t have a majority of residents living in and sharing elevators in dense high-rises like New York. But what the county has may be worse: a large population, a high rate of poverty, and, in some neighborhoods, the nation’s highest rate of severe overcrowding.

It’s also home to the nation’s largest population of Latinos, an ethnic group that has seen Covid-19 death rates in LA County increase a staggering 800% in recent months.

“We in California have to face the fact that our Latino communities, overrepresented among frontline workers, have never seen a decline in cases and deaths the way other groups have. That means there has always been a rip-roaring brush fire in those communities,” said Kirsten Bibbins-Domingo, an internist and expert on health inequities who chairs the department of epidemiology and biostatistics at the University of California, San Francisco.

The virus has laid bare many of the city’s vulnerabilities, and also its shocking inequalities. While the stereotype of LA is celebrity mansions on hillsides, its reality is overcrowded neighborhoods where entire families may squeeze into one-bedroom apartments or converted garages, settings where essential workers often live with older relatives, and social distancing is impossible.

“We don’t have a monopoly on poverty or overcrowding, but those issues are very acute here.” Beletsky said. “Over time, the virus found its way into the fissures of the city and exploited the many challenges the city faces.”

Epidemiologists are quick to point out that every city has similar risks and, therefore, could see their own “megawaves” of infection. But with vaccination now underway, and masking more commonplace, other cities may be able to avoid the fate of Los Angeles, which saw cases surge at the worst possible time, during the peak of holiday travel and gatherings.

Bibbins-Domingo’s city, San Francisco, has seen far lower case and death rates, something many attribute to the city’s better adherence to masking, strong public health infrastructure, and extensive network of social supports. While San Francisco has developed innovative programs to place those infected with the virus into hotel rooms to help stop spread within households, LA’s Project Roomkey, an attempt to use hotels to shelter the unhoused and prevent the spread of Covid-19, has seen less than 2,000 of its promised 15,000 rooms occupied.

But epidemiologists note that San Francisco County is also wealthier than LA County, and much smaller. While LA’s high case and death rate — 281 deaths were reported Wednesday — can seem shocking, it’s important to measure that against the county’s large population, Beletsky said. “Just the sheer number of people here makes our numbers look dire,” he said. “That said,” he added, “things are really bad.” Though there are counties in Texas, Wyoming, Montana, Oklahoma, and North Carolina with higher daily case rates, LA’s is about twice the U.S. average.

One issue that has Los Angeles health officials especially concerned is the lack of available ICU beds, which means that people who have other medical issues, like strokes or trauma from car accidents, may not receive care they need and that hospitals may soon need to triage care resources and refuse care to some; ambulances have already been told not to transport patients with little chance of survival.

That shortage is occurring in part because California had relatively few hospital beds even before the pandemic, as part of a trend to shift more care to outpatient settings. Despite being one of the nation’s wealthiest states, California is among states with the lowest number of hospital beds per capita — just 1.8 beds for every 1,000 people, compared to four beds in Mississippi. “The margin is razor thin. That’s why it tipped so quickly,” said Bibbins-Domingo.

Despite the lockdown here, mobility and cellphone data show Angelenos are out and about at higher rates than people in many other cities. ”Even when we call it a lockdown, we are not doing it the same way New York was,” Bibbins-Domingo said. Part of this may be that many people have to keep working outside the home, and often commute long distances to do so.

But many, whether suffering pandemic fatigue or to make a statement, are clearly flouting the restrictions. People are still gathering, holding large parties, and many are not wearing masks. Both Orange County and LA have been the site of multiple MAGA anti-mask rallies. And it’s not just those on the right who are flouting the rules. “A lot of people who refuse to mask or practice social distancing are not just the quote, unquote Trumpers,” Beletsky said. Many, he noted, are residents of wealthy enclaves like Pacific Palisades and Malibu, which have some of the state’s lowest child vaccination rates.

“It’s the hippie, organic, pure wellness attitude, which really is a white privilege, free-rider issue — they don’t have to vaccinate their kids because everyone else will. This is where the left and right gets really jumbled.”

These same people, who flouted rules and hold maskless parties in their elegant homes, “end up spreading the virus to their staff who are Black and brown and use public transportation,” he said.

Beletsky also lays some blame for the surge on inconsistencies in public health messaging, such as the closure of beaches early in the pandemic even as indoor dining continued. “One of the most absurd things they did was close the beaches and pull people out of the water. What could be less risky than surfing?” he said. Los Angeles public health leaders also pulled an abrupt turnaround in December, closing playgrounds, but then opening them a few days later after an outcry from frustrated parents and legislators who noted that poorer children often did not have their own backyards or private space in which to play.

What’s next for the city? Despite everything, there is some optimism that the worst could be over in a few weeks or months, especially because people are being vaccinated, albeit at a pace slower than desired. State officials reported this week that high hospitalization rates may have plateaued.

Everyone here is closely watching numbers. In something of a calculus of hope, Cannon keeps several running Covid lists: 41 of her close contacts have been infected by the coronavirus, and four have died. But 18 and counting have been vaccinated.

What remains worrisome is a potential new surge in cases caused by a variant of the virus that has been detected in California as well as other states; LA County Public Health Director Barbara Ferrer said she expected it to be the dominant strain in Los Angeles by March. The question is whether a higher infection rate of the new variant — if that is proven to be the case — can be outpaced by a massive vaccination campaign. “I’m quite worried,” Michels said. “We’re running against the clock.”

To help, health officials have converted Disneyland into a mass vaccination center for Orange County residents and are working on converting Dodger Stadium, where a million Covid tests  have been administered since May, into a site that could vaccinate 12,000 people a day once operational. The conversion takes away testing capability at a time when 1 in 5 Covid tests has been coming back positive and demand for testing remains sky high. “It pits one thing against the other, and those are the kinds of things that make LA, with its sheer numbers, so challenging to think about,” Bibbins-Domingo said.

Cannon said now is the time for people to hunker down, try to keep a distance from any people not in their households, go back to sanitizing door knobs and cellphones, and double down on wearing masks, even if they don’t think they are individually at high risk. “It’s the time for people to stop thinking about themselves,” she said, “and start thinking about protecting the city they love and the people in it.”