As of this week, at least 21,000 New Yorkers are dead from Covid-19, with a few dozen added to the city’s count every day. More than 3,000 have perished in nursing homes, many more in hospitals. Some died at home. The most brutal toll came among those who were old, poor and in the outer boroughs.
The city’s deaths are 10 times those of Los Angeles County’s. They’ve surpassed the 16,000 lives lost in Italy’s hard-hit Lombardy region. In the UK, eight times as populous as New York City, about 37,500 have died.
With New York’s outbreak eclipsing others around the world, it’s logical to look for somebody to blame. The mayor, the governor, the president — a human foil for a microscopic villain. But that would be a simplistic approach to accounting for a new virus hitting a dense city, full of people who’d never faced a pandemic threat, enjoying a decade-long stretch of prosperity.
“There’s blame to go all around," said Jeffrey Shaman, director of the climate and health program at Columbia University’s Mailman School of Public Health. “We haven’t been confronted with an infectious-disease threat like this for 100 years."
There are glimmers of optimism emerging. The virus’s spread is slowing, and New York is moving toward the early stages of reopening by mid-June, Mayor Bill de Blasio said during a Tuesday news briefing.
But a crucial question remains for America’s financial and cultural epicenter: What went so wrong? Bloomberg reviewed past comments by those involved in the pandemic response, and asked the question of disease experts, the U.S. Centers for Disease Control and Prevention and de Blasio.
Here’s what they said about the major factors that led to New York’s outbreak.
1. Close the front door, leave the back open
Outbreaks can’t start without a spark. The U.S. shut down most travel from China on Feb. 2, when there were at least 14,000 cases there. But it left open travel from most of Europe until March 13. During that time, Italy went from two known infections to more than 15,000.
In the week ended March 13, 274,000 people arrived at New York-area airports from Europe, and another 174,000 came from the U.K. and Ireland, according to U. S. Customs and Border Protection’s New York field office.
“We closed the front door with the China ban, which was right," New York Governor Andrew Cuomo said on April 24. “But we left the back door open."
Using genetic analysis, it’s possible to trace the lineage of the virus like a family tree with branches around the world. One analysis, from researchers at the Los Alamos National Laboratory, showed that one branch emerged directly from China, with U.S. cases concentrated in Washington state. But a second branch of the virus grew in Italy, and was then imported to New York, rapidly becoming more prevalent.
“We tested people all through February, but it turns out we weren’t testing the right people," de Blasio said in an emailed statement. “It’s painful to think about how things might have been different had we been able to test someone returning from Europe a month sooner."
Jay Butler, the CDC’s deputy director for infectious diseases, compared the city to dry kindling in a wildfire.
“New York City is a global destination and had the opportunity for multiple introductions of a virus," Butler said in an interview. “Because of the amount of travel to New York, particularly related to the increase of disease in Europe, there were multiple sparks landing at once."
2. “Ride the subway, take the bus"
Wash your hands and cover your cough: That was the main advice given to New Yorkers early in the outbreak to prevent the virus’s spread.
“We want New Yorkers to go about their daily lives, ride the subway, take the bus, go see your neighbors," New York City Health Commissioner Oxiris Barbot said on March 2.
The mayor gave the same guidance. “From what we do understand, you cannot contract it through casual contact, so the subway is not the issue," de Blasio said March 3. Days later, he said, “It has to go from someone who is infected to another person directly into their mouth, their nose, or their eyes."
Health experts have now almost totally reversed that understanding. The CDC told people to begin wearing face coverings in public on April 3, at which point there were more than 5,000 new cases a day in New York. Later that month, the agency updated guidance to say that touching contaminated surfaces didn’t appear to be the primary mode of transmission. There have since been multiple case studies showing clusters of transmission in offices, at churches and other high-density settings.
“Hindsight is 20-20. If we knew everything we knew now, probably there would have been more intervention earlier, but we didn’t have that crystal ball at the time," said the CDC’s Butler. “Now we know people can be infectious before the onset of symptoms."
3. Perfect environment
With the virus’s easy transmission, New York’s shared spaces were a perfect vector to bring the infection from one family to another.
Subways and buses, concert halls, elevators, offices, crowded bars, apartment towers — while other U.S. urban areas have natural social distancing built into their structure through the prevalence of cars and less-dense buildings, New York is defined by crowding.
“In a place that doesn’t have a car culture, that relies on mass transit, there are more opportunities for it to get into households and move around," said Columbia’s Shaman.
A May 8 CDC report drew a similar conclusion. The agency noted that the four most dense counties in America are New York City boroughs. Combine that with public transit, three major transportation hubs and 1.6 million daily commuters into Manhattan, and it’s a perfect human mixing bowl.
In his emailed statement, de Blasio said the city’s mass transit system had been a major factor.
“New York’s subway system stands alone," de Blasio said. “New York City is different than Los Angeles and Seattle and pretty much everywhere else for how heavily the population relies on travel by subway. The subway has been a lifeline for our essential workers, but we also now know that prolonged, close contact during a commute may have been an issue long before we knew the virus was even in the city."
4. Slow to close
For all of New York City’s risk, its leaders moved late on shutting down the city.
Cuomo and de Blasio — who have had a long-running, often public feud — disagreed for days over how and when to act. The city closed the schools on March 15. Two days later, de Blasio raised the possibility of a stay-at-home order. Cuomo disagreed, saying it was the state’s decision and that he had “no interest whatsoever or plan whatsoever to contain New York City." On March 20, he announced that the state would shut all non-essential businesses, and told people to stay home.
Butler said those decisions are difficult at the early stages of an outbreak. “When we evacuate a city for a hurricane, we don’t do it based on when there’s something out off the coast of Africa," he said. “We do it when there’s much clearer visibility of when it’s going to happen. It’s much harder with an infectious disease, particularly a brand new one."
In hindsight, the city’s actions came late. The day the stay-at-home orders were announced, New York City reported 4,000 new cases — despite a significant shortage of testing. The outbreak was well into the acceleration phase. And with a bigger head-start, the virus kept growing in the city, with new cases peaking 17 days later on April 6.
5. Nursing homes
As the virus swept through nursing homes — and the city was in an urgent search for hospital beds — the question arose of what to do with elderly patients who recovered.
On March 25, the state made what now appears to be an ill-fated decision to send those people back to nursing homes once they were well enough to leave the hospital. Two months later, Cuomo said the state had followed the federal government’s guidance, and made the rules when the state was scrambling for hospital bed space.
“Is the best use of a hospital bed to have somebody sit there for two weeks in the hospital bed when they don’t need the hospital bed, because they’re not urgently ill? Cuomo said at a press briefing on May 20. “They’re just waiting to test negative."
Statewide, there have been 5,980 presumed and confirmed Covid-19 deaths in nursing homes and adult-care facilities as of May 24. New York has now changed its rules for sending patients back to the homes, saying hospitals can’t do so until a patient tests negative for the virus.
Unknowns and the Future
Even with the factors that made New York a hot spot, it’s still unclear why it got hit harder than other similarly dense areas. Also unknown are how weather, potential variants of the virus, testing and counting of cases and other factors play a role. And the outbreak is just now breaking over new hot spots like Brazil.
“It’s important to recognize the pandemic isn’t over yet," Butler said. “Some areas are going to be hit earlier than others."
Much of New York City’s risk from an outbreak remains. It will forever be a tightly packed city dependent on public transportation, defined by public spaces and close human interaction.
“What caused New York City to be hit so hard is something we’ll be studying for a long, long time," de Blasio said in his statement. “On the one hand, it’s frustrating to think of how things may have been different had we known any of this earlier. On the other hand, it’s informative as we move to reopen."
In its push to resume activity, the city and state are now considering how to stop the transit system from becoming a disease vector again.
“We anticipate just phase one is easily hundreds of thousands of more people going to work, and then phase two even more so," de Blasio said. “We still have to make sure that we don't end up with a lot of crowded subway cars and buses. It's got to be very systematic. You need the frequency of the service, you need the face coverings, you need some way to make sure that there isn’t overcrowding."
Shaman said he’s optimistic that some of the tools are in place to better manage the virus, but that the U.S. hasn’t succeeded so far — though to be fair, few countries have.
“We failed on both ends," Shaman said. “We disrupted the economy and haven’t controlled the disease."