How hidden cases, testing blunders and political missteps doomed NYC's COVID-19 response

When New York's first cases of COVID-19 were announced at the beginning of March, attention was focused on China as the source of the threat.

But preliminary research now suggests dozens of patients with genetic markers of the virus that can be traced to Europe may have been spreading it across the city as early as late January — a key factor that led New York to become the epicentre of the outbreak in the U.S.

The first identified case of community spread in New York, a lawyer from the suburb of Westchester, is linked to more than 100 other COVID-19 cases. So the likely spread from dozens of other unknown cases put New York behind the eight ball right from the beginning, said Dr. Eric Cioe-Pena, director of global health for Northwell Health, a non-profit network that runs hospitals and research and testing facilities in the state. 

"It became kind of a losing game. We were already on the wrong end of the curve and time was no longer our friend," said Cioe-Pena, noting that scientists are still studying the origin of these cases, including how the Westchester lawyer contracted the virus.

"As we were learning about this virus, how it was transmitted, about the asymptomatics, it was already raging in New York."

Experts say a lack of available testing, poor screening at the city's international airports and a dense urban area combined to bring New York to its knees, forcing millions into isolation and pushing hospitals to the brink. 

With more than 15,000 probable and confirmed deaths due to COVID-19, New York City has the fifth highest recorded death toll in the world, behind only Italy, Spain, France and the U.K.

Early disadvantage

That such a high number of probable cases went undetected early on put New York at a disadvantage compared to cities on the West Coast, which had fewer initial cases and locked down sooner, said George Rutherford, the head of infectious disease and global epidemiology at the University of California, San Francisco.

"When New York started off, they had 200-plus chains of transmission going on, whereas out here in the West, we had six, seven, eight, something like that," he said.

In California, health officials have determined the earliest death they can trace to COVID-19 came on Feb. 6, indicating the virus was likely in the region in January.

A study from Mount Sinai Hospital in New York links the city's first cases to Europe and other parts of the U.S. — not to China, where the virus originated — and suggests the virus was possibly circulating in late January. The research is what's known as a preprint study, meaning it has yet to be peer reviewed by independent experts. 

"Basically, the virus was already in the population and there was already community transmission before we even realized that we needed to do this social distancing," said Elodie Ghedin, professor of biology and global public health at New York University. 

An estimate from researchers at Northeastern University, shared with the New York Times, suggests that by March 1, New York City may have had in excess of 10,000 cases.

"It stands to reason that there was community transmission occurring in New York that we didn't know about," said virologist Dr. Angela Rasmussen of Columbia University. "Because New York is so densely populated, there's the opportunity to really amplify that and have it go out of control."

A failure of testing

Cioe-Pena said the initial lack of testing infrastructure meant health officials were unable to keep on top of the spread, contributing to New York's inability to control the outbreak.

Early stumbles by the U.S. Centers for Disease Control and Prevention meant states and municipal officials didn't have access to large numbers of tests, so they were limited to testing only the sickest patients, and it would take days to get results back.

"It was already too late for us to scale up testing. We had already missed the boat on that," Cioe-Pena said.

By March 5, the city was monitoring 2,773 people in home isolation, and Mayor Bill de Blasio was calling on the federal government for more help with testing. It would be more than two weeks before Gov. Andrew Cuomo issued the shelter-in-place order. 

Rasmussen said such an order may have come sooner had the city had the ability to test more proactively for COVID-19, as well as antibody testing to detect those who'd already had the illness.

"I think that was definitely a missed opportunity," she said.

As of Thursday, officials said there were more than 138,000 confirmed cases of COVID-19 in New York City, but that number misses the mark because, from the beginning, people with mild symptoms were told not to get tested.

"It wouldn't surprise me if at this point in time, we have probably close to a million New Yorkers who have been exposed to COVID-19," said Dr. Oxiris Barbot, New York City's health commissioner. 

Political missteps

Not knowing the true footprint of the virus may have given elected officials a level of misplaced confidence early on. In the beginning of March, New York state and local officials sought to reassure the public even as the virus was apparently spreading silently throughout the population.

On March 11, Mayor de Blasio was still advising healthy city residents to continue socializing.

"People should go out and continue to live life, should go out to restaurants," he said.

Officials at the city and state level also clashed over everything from closing schools to postponing New York City's St. Patrick's Day parade. Containment measures focused on the suburbs, not the city.

A statewide stay-at-home order was announced on March 20 and went into effect two days later. California, following earlier measures implemented by some of its jurisdictions, shut down on March 19. 

"I still think that the response was too slow at the federal level, at the state level, at the city level," Ghedin said.

Gov. Andrew Cuomo, now widely praised for his steady demeanour during the crisis, also sounded a confident note on March 5, saying, "We have the best health-care system in the world here." 

Cuomo on Friday reacted to the recent research, saying it offers a valuable lesson for future pandemics, that an outbreak on the other side of the world can and will travel fast.

"When you look back, does anyone think the virus was still in China waiting for us to act two months later?" Cuomo said.

He pointed out that between January and when the state shut down in March, there were 13,000 flights from Europe to New York, bringing in 2.2 million people.

Cuomo said the ban on travel from China to the U.S. on Jan. 31 was appropriate, but the European travel restrictions on March 14 came too late. 

"We closed the front door with the China travel ban ... but we left the back door open." 

No easy choices

Nonetheless, New York officials were facing difficult choices, Ghedin said. She points out, for example, that the mayor and governor clashed over when to close schools, in part because of the large number of students who rely on the school system for free or subsidized meals. 

"As a virologist and as an epidemiologist, of course my first thought was, 'You have to close the schools.' But it's hard when you start weighing all these other elements that are important in a society." 

Dr. Tom Frieden, the former head of the U.S. Centers for Disease Control and a former New York health commissioner, told the New York Times that stronger quarantine measures a week or two earlier could have reduced the death toll by 50 to 80 per cent. 

However, as Cioe-Pena points out, shutting down New York City simply wasn't an idea people could wrap their heads around at the time.

"This is something that was conceptually inconceivable in February, for an American city the size of New York to lock down."