Why is the virus spreading here at its current higher level now? I don’t know exactly, but it appears to me that there are 3 major factors. In order to understand what’s going on completely with transmission risks, we don’t have the resources to do case-control studies. We don’t have the wherewithal to do case-control studies given the enormous burden on all the staff at the health department at this time, but we can take some educated guesses based on patterns that we are seeing here. 1. The virus appears remarkably, even surprisingly, transmissible. At pretty much every point over the last 6+ months, I’ve been surprised, and impressed, at how capable this virus is at moving itself between people. It spreads in households like wildfire and it spreads in other indoor environments too. It seems to be everywhere we look. I know this is hard, we’re all exhausted and frustrated by having to take precautions, but the implication of this fact is that you can’t let your guard down, or be careless, even once, especially if you are at high risk. 2. Fundamental structural failures of the US economy are being laid bare by the pandemic. These structural issues seem to be a major cause of the transmission we’re now seeing, at least in San Mateo County. Many elements of the US economy can be viewed as illogical, even immoral in my opinion, in that so many people are forced to live lives of economic desperation, live pay check to pay check, are not paid a living wage, live with no workplace safety nets, like healthcare, like paid sick leave, or other wage protection programs. While these structural issues are illogical in good times, they are downright inexplicable in times of a pandemic. These structural problems are at such a massive scale, they can not be ignored. A majority of people we are seeing infected now are front line workers (people who allow the rest of us to eat, and have electricity, and have our garbage picked up, etc), live in crowded multigenerational conditions, live with lack of trust in, and in fact have downright fear of, government. Remember to stem the spread of this very transmissible virus, people who are infected need to be separated from others (isolation and quarantine), not go out in public, and not go to work while they are infectious. Try getting compliance with isolation and quarantine when the infected person is the breadwinner for the family and the family will be out on the street if they don’t go to work. And when they go to work they will, perhaps, interact at that job with you. There is not enough enforcement capacity in the world to stop this from happening. The implication of this is that the current business focused restrictions will do little to stem the spread of the virus when the spread is exacerbated by these conditions. This requires rapid policy and systems changes at every level of both public and private sectors, from the feds on down, and from the largest corporations to the smallest business. We need to see much more work in this area, and we need to have less reliance on business sector closures and restrictions, beyond getting businesses to do the basic transmission control measures. Failure to fix some of these issues will prolong our collective pain. 3. Complacency is the other majority factor enabling spread. This is either born of belief systems (this is all a hoax, this isn’t that bad for me, let’s go to a party and get infected), or born of just not paying attention. Many, many of our infections are related to fairly small gatherings of family and friends. Birthday parties, picnics, eating at restaurants with mixed households, etc, without the basic precautions being taken. Most of these gatherings are innocent, no doubt, not intending to spread the virus, but they do spread it, and with far reaching implications. Please note, your seemingly innocuous get togethers are driving the spread and are a major reason why you can’t go to a restaurant, why you can’t go to the gym, why you can’t go get your hair cut, why kids can’t go to school. Until, or unless more people get this fact, we will continue to be stuck in the situation we are in. To get out of this situation depends on all of us. Our collective best course of action: No gatherings outside of immediate households, use facial coverings extensively, and social distancing. — Scott Morrow, MD, MPH, MBA San Mateo County Health Officer Please read or reread previous statements to get a better understanding of where we find ourselves today and actions you can take to protect yourselves and your family: https://www.smchealth.org/coronavirus-health-officer-updates.