Photo: Douglas Zimmerman/SFGATE
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Days after the first case of the novel coronavirus was reported in the United States on Jan. 21, San Francisco's Chinatown was preparing for its annual Chinese New Year festivities. With many people traveling between China and S.F. for the holiday, fears heightened that an outbreak could explode in this 24-block slice of the city. Mayor London Breed held a press conference reassuring the city it was safe to celebrate, and Breed rode in a car in the parade on Feb. 8.
Thousands turned out for events, but an uncontrollable outbreak never hit, and even after a July surge of cases in San Francisco, Chinatown continues to have among the lowest number of cases in the city.
After Sea Cliff, where fewer than 10 cases have been detected, Chinatown has the second-lowest count in the city with 28 cases, according to data from S.F.'s Department of Public Health. By comparison, three of the city's hardest-hit neighborhoods, the Mission District, Bayview Hunters Point and the Tenderloin have seen 980, 916 and 610 cases respectively.
Chinatown's low case numbers are perplexing. While the neighborhood is home to only about 15,000 residents, it's among the most densely populated areas of the city and known for crowded living conditions with seniors and families packed into single-occupancy residences (SROs), ideal conditions for the transmission of COVID-19.
S.F. public officials have said cramped conditions, with multigenerational families cohabitating in small quarters, have contributed to a surge in the Mission District, where the case rate stood at 207 positive tests per 10,000 residents as of Tuesday. In Chinatown, the case rate is dramatically lower — with 19 cases per 10,000 residents.
Health experts in San Francisco have noticed the trend, and they don't know exactly why the cases are significantly low in Chinatown, but they suspect it's due to a lack of testing and cases going undetected, or a result of residents embracing wearing masks early in the pandemic and following the shelter-in-place order with vigilance. At the Chinese New Year Parade, before the first case was detected in the city and long before any health officials encouraged face coverings, a handful of people wore masks, according to news reports.
“I don’t think we have enough information to know," said Dr. Kent Woo, executive director of the NICOS Chinese Health Coalition. "My guess would be it's some combination of both. We’ve done a little too good of a job of sheltering in place. We haven’t left home, and we haven’t even left home for the health care we need to get tested.”
The S.F. Department of Public Health provides data on the total number of tests implemented in the city but doesn't break it down on a neighborhood level. The exact number of people tested in Chinatown is unknown, but Woo said the rate of testing could be low as a result of a number of factors, including lack of education on testing in the Chinese language.
"We probably don’t have a true rate," said Woo. "The Chinatown population probably hasn’t been going out and seeking the test."
UC San Francisco helped test 4,000 residents in the Mission District at a free four-day community event in April and some 850 residents in the Bayview in May. Chinatown hasn't seen a widespread testing effort at this scale, but it has led the city in testing residents of SROs.
The Chinese Hospital, an acute care facility in the heart of Chinatown and the city's only remaining community-led hospital, spearheaded an effort to offer free testing in the SROs and follow up with contact tracing.
"We set up a hotline for them to call," said Dr. Jian Zhang, chief executive of the hospital. "If they have any symptoms, we do their testing right away. They can be quarantined so it doesn’t spread to other people."
Woo applauded the effort but said some residents were reluctant to receive testing. He noted that in one residence with 100 people, 40 said they would get tested but only 19 actually showed up.
“There needs to be a greater outreach and education to get the community to break down whatever barrier there is to actually go out and get the test,” said Woo.
Dr. Sunny Pak, director of the Chinatown Public Health Center, said the goal is to test more residents.
"The question is how to get it done effectively," Pak said. "The question is if we set up a testing site, will they come? They worry they may contract the virus at the testing site, the elderly may not want to show up. We see what has been done in the Mission District, and the question is, should we replicate that here in Chinatown? It’s complicated. It’s not that simple. It may or may not work, so we have to be very careful. We've been meeting many weeks to try to figure out how to do it."
Another hypothesis to explain Chinatown's low case rate is that the neighborhood's organizations and residents embraced social-distancing measures and mask-wearing guidance earlier than other neighborhoods, preventing widespread transmission.
San Francisco issued an order requiring face coverings in late May, but residents of Chinatown were using them as early as January and February.
Dr. Ben Lui with the nonprofit On Lok Lifeways explained the neighborhood's population has close ties with family members in China who experienced the 2003 SARS outbreak, during which the practice of wearing face masks became common.
"Even in non-pandemic times it's common for East Asians to wear face masks when they have a common cold because it’s considered rude to cough in public," said Lui, chief medical informatics officer at On Lok, an organization providing care to the elderly. "There are a lot of immigrants, people going back and forth, children of immigrants, there’s a comfort level with wearing face masks."
What's more, residents were in touch with family members in China who were in the throes of the coronavirus pandemic that started in Wuhan.
"It was rumored or said a lot of people with family in Asia had been advised by family in Asia to wear a mask before Dr. Fauci or public health officials said that," added Woo with NICOS.
Elaine Xhu who works at Fashion Bag & Gifts on Grant Avenue in Chinatown said she started wearing a mask from the start of the pandemic.
"For Chinese people being healthy is the most important thing," said Xhu. "Everybody in China, including my fiance, they started shipping me masks by air. My friends here, they all received masks from their family in China."
Chinatown has its own network of media and outlets, including the Sing Tao Daily and World Journal newspapers, and they helped educate the community early on in the importance of mask wearing, washing hands and keeping a distance from others. Zhang said education in the neighborhood started in January.
"That’s when we started converting the clinics into testing centers, started the hotline to educate people, worked closely with the Chinese media to educate the community and community leaders," said Zhang. "I think everyone thought the outbreak would be in Chinatown because of Chinese New Year and also we have a lot of residents going back to China so that’s why we did so much early."
The San Francisco Department of Public Health also began focusing on prevention in the neighborhood in January, distributing fact sheets to multiple organizations, health care providers and media; inviting community leaders to COVID-19 roundtables; and holding a parent forum in partnership the S.F. Unified School District to answer questions and concerns regarding the virus.
Another striking point in San Francisco's COVID-19 data is that the death toll in San Francisco reveals a disproportionately high number of deaths among Asian Americans.
In S.F., 26 of 61 people who have died due to complications with COVID-19 are Asian Americans, even though the group accounts for 10% of the total cases and about a third of the city's total population.
The city doesn't share the exact number of deaths in Chinatown, but notes in its data that it's less than 10, the same number in neighborhoods with higher rates of cases. "Our death rate is very high," said Zhang. "You notice almost half the deaths are Asian. I think that’s something we need to look at."
Compared to some other cities, such as New York City with more than 23,000 deaths, San Francisco's death toll has remained relatively low, though experts caution against drawing conclusions. But the high case-to-death ratio among Asian Americans isn't unique to San Francisco and exists in other parts of California and the country, according to recent research from the Asian American Research Center on Health, or ARCH.
"Wherever we could find evidence, we found that this pattern persisted," said Dr. Tung Nguyen, a UCSF professor of medicine and an author of the ARCH report.
For example, Nguyen said, in Los Angeles where 15% of the population are Asian Americans, 3.8% of cases and 16.84% of deaths were in this group.
Nguyen and his colleagues list possible reasons for the high case-to-death ratio among Asian Americans, including limited access to testing, higher rates of underlying health conditions, and an older population.
Most states and counties do not provide "data stratified simultaneously by race and age, but data from Santa Clara County suggests Asian American deaths are clustered among older adults, ages 80 and older," the report says. This could also be the case in San Francisco.
"Everyone wants to know why," said Nguyen. "You don’t know why unless you collect data. Across the country, they don’t collect good Asian American data. A lot of states lump them with Pacific Islanders. You need to do more sophisticated data collection so we can get more answers."
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Amy Graff is the news editor for SFGATE. Email her: firstname.lastname@example.org.