Transcripts For SFGTV Planning Commission 20240712

There are four of you and there is quorum, i will text the commissioner to see if she needs help. President bernal with the quorum present, we move on to the next item. The approval of the meetings of the minute of september 1st. Wrong date, im looking at the minutes. The minutes of the meeting of september 15. Upon reviewing the minutes and without amendment, do we have a motion to approve or any amendments from the commissioners . So moved. Second. Before you all vote there is nobody on the Public Comment line, so there is no need to take Public Comment. I can take a roll call vote, commissioner. President bernal yes. Commissioner green yes. Commissioner chung yes. Commissioner chow yes. And lets see if okay, i will call her as we move into the next item. That looks like the minutes passed. The next item is the directors report. Director colfax. Good afternoon. The director report, grant cocolfax. One item of note, september 30, state department of Public Health released details regarding a Health Equity metric to help continuing efforts to move effectively as to fight covid19. And really, in order to move to a tier of lower risk, county will need to meet an equity metric or disparities in covid transmission to advance to the next less restrictive tier. Counties with a population greater than 106,000, which obviously San Francisco is one of those rates in the most disadvantaged neighborhoods do not fall significantly behind the overall Positivity Rate and submit a plan that disproportionate populations. So were working with the state in regard to this. Were currently in the orange tier. Right now, were the only bay area county in the orange tier. And to the best of our ability, we determined that our Health Equity metric is also in the orange tier. In terms of other items related to covid and beyond, im pleased to confirm with the commission, the board of supervisors passed the fiscal year 2021 budget. Changes based on the budget that you saw here a number of meetings ago. Also with regard to equity investments, mayor london breed announced 28 million effort to expand covid19 support for San Franciscos Latino Community. This is work that will include the specific investments on the part of Public Health and also other city agencies. Regard to the Public Health investments, theyll include increasing testing, increasing more communitybased Contact Tracing and partner notification. And very importantly, prevention efforts, especially around important messages with regard to maskwearing and other steps, as well as letting people know that help is available, that no one in San Francisco will go without help, including and especially during this covid19 pandemic. And then we continue with the reopening process. I will provide some Additional Information with written detail with regard to that in my presentation. Finally, just to highlight as a followup with the school reopening. Open online dashboard that is available to School Administrators and to parents to determine so they can tell where their school stands in the process of the reopening approval process. Its called our reopening dashboard. That has been positively received by the School Administrators and parents. And finally, just to say that one of black africanamerican Health Initiatives film entitled working to eliminate health daas parities within the disparities has been excepted for screening during the Film Festival at the Virtual Meeting at the end of this month. At the end of the director report, there is a quite a bit of media coverage. Im available for any commissioners questions and again, there will be a more detailed covid19 update. The doctor is here to provide Additional Details with regard to that. Thank you. President bernal thank you, director colfax. Before we move on to commissioner questions, mark, any Public Comment on the directors report . There is no one on the line at all. Any questions or comments for the director . Commissioner chow yes. Thank you for your report, dr. Colfax. And i was curious that the bill that was signed by governor newsome about adult residential facilities named a number of facilities that here in San Francisco and your report was closed. How many remain in San Francisco that this might help protect or at least give about a halfyear warning about the changes that might occur . I dont have that number at my committed to memory, commissioner, but we can certainly provide you with that information. I dont know if dr. Hammer is present and we can follow up with that number very soon. Thank you. We can get that number to you. President bernal commissioners, any other questions . Director colfax, one question. I know we had heard from you and dr. Aragon in previous presentations even though we meet the criteria here in the state, that some of the numbers such as our really high degree of testing and the formula that the state use indicate that perhaps we should be taking more of a cautious approach than what is allowed in the state tier were in. Are we still in that posture . Yes, thats right. And we can talk about that more in the update, but were using the local data to determine how to report. Weve been very much focused on what is needed based on our data. What is the state provide the framework, but remember we can be more restrictive than the state. And in general, weve been more cautious than the state has necessarily permitted. President bernal great. Thank you. Commissioners, any other questions before we move on . All right. If not, well move on to the covid19 update. Are we ready with slides. Thank you. Grant colfax. Director of health. Dr. Aragon is available for additional any questions and obviously, its welcome if he would like to add more details. Apparently 11,57 cases of covid19 in the city. Unfortunately, 111 deaths. This is a population characteristics of our positive cases and, again, highlighting the inequities that i describe in the directors report with regard to the latino population representing 50 of cases. The age group you can see here that this has been somewhat of a shift. Weve been getting increasing number of younger people diagnosed with covid19. I will say that particularly with regard to the less than 18 age group, we may see increases in this one, because children will be returning to school. So there could be more transmission as well as more testing as a result of that. And this week we also announced that our city test sf, popup sites testing children under the age of 13, thats been positively received by the Community Members. So well continue to watch those numbers. You see the other characteristics of the cases. A little bit higher among male prevalence and so far in the homeless in the population experiencing homelessness, a relatively small proportion, 3 . And about 5050 between Community Transmission and known contact. Then the Sexual Orientation of cases. Its here on the far right bottom of the slide. Next slide. Again, this is the data comparing our jurisdiction to other similar jurisdictions in terms of cases, death rates per 100,000, testing rates. San francisco continues to do very well. Near the top in the things that wed like to be doing well in terms of tests and near the bottom in terms of deaths compared to other jurisdictions. Our key indicators, these are local health indicators. As of this morning, you can see the hospital indicators, the first three, Hospital Capacity are low rate of covid19 hospitalizations. Our case rate which has stubbornly high for many weeks, in the red zone, is now down to orange. Thats a very much growing in the right direction. Testing numbers, 4500 tests over the last seven day average. Our Contact Tracing, this has been slowly climbing. Were at 83 and 85 . Then our p. P. E. And d. P. H. Remains strong at 100 capacity for 30day supply. This is our hospital occupancy curve for people with covid19. The darker blue lines are the intensive care unit on that given day. The light blue lines are the medical surge beds and the total is located at the top of that. The curve flattened in may and june. We had a peak in late july. Were starting to go down again. Things levelled off in september. Were bouncing between 65 and 75. Im rounding here, cases. And were seeing a decrease again, so were watching this carefully. And as we enter the fall and winter, were concerned about transmission and were opening more activities, the more permissive in terms of businesses opening with protocols in place, including the masking, social distancing, masking when possible, but at the same time we know this virus increases when activity increases. So were watching these metrics carefully. Were also concerned about flu season and ensuring our hospital capaci capacity. I will say in the southern hemisphere, what has been interesting, some of the flu the data from the flu has been less concerning than other years and thats because with more precautions that people with taking to prevent covid19, there is less flu transmission. We are telling everybody, this is certainly the year to get a flu shot. Every year, but this year is more important than ever. So this is our reproductive rate slide. This is again the number for the reproductive rate, if the reproductive rate is two, that means for every one person infected, two people become infected. 5 means for two people infected, only one person becomes infected, so the infection slows down. Reproductive rate of 1 means youre in neutral territory for every new person infected, a new person is infected. Remember the goal of covid19 control is to get that reproductive rate less than one. Youve seen from other data how important that is. Were at. 92. Right now, our best estimate remember this is an estimate. This is based on thousands of data that we provide to our colleagues at ucsf and u. C. Berkeley. That is the average estimate that those simulations come up with. The lighter blue lines are the intervals, you can see up to the 95 conference interval. Its possibly were slightly above 1 right now, but its more possible were at. 92. Next slide. In terms of our reopening, i just want to make note that dr. Aragon and the outstanding team, including the City Attorney, the info and guidance people. One of the things that i do want to emphasize here, were not dealing with the hospital surge, thank goodness, that we were so concerned about early on. That is certainly a plausible scenario still, but the reopening work is also a tremendous amount of work for the department, for the many people who go through the info, the guidance, the lepehel helpe directives. Its good were focused on this right now, but it takes hours of time. I would say that the Health Orders are very detailed and very much based on the best evidence that we have available. So these are some of the highlights with regard to reopening the indoor dining, indoor bars with food. The indoor movies, houses of worship, indoor malls and then we do hope that we will be opening playgrounds in mid october as well. But you will see that there are a number of activities still to be determined and, again, per commissioner bernals comment earlier, we are reopening more slowly than the state would currently permit, so were taking a cautious approach and were looking carefully for signs of a surge that may overwhelm our health care system. There is a lot of focus on testing. I wanted to give a visual representation of the city and county s. F. Testing sites that we expanded. This map looks similar to the map i showed you in terms of the prevalence of covid19 in the city. Really being concentrated in the tenderloin, the mission and then in the southeastern part of the city. Youll see that we have expanded our Testing Capacity along those corridors. We have the two city test websites, embarcadero and soma, those have been established since april. We have Community Clinics in green that many of them do popup testing. They have varying capacities. They are not only d. P. H. Clinics, but there are other partners in the clinic core consortium. We have our mobile sites. These purple dots on the map do not represent sites that are up every day, but they show where we go during the week. We have two sites that have total capacity of doing 500 tests a day in this regard. So quite an expansion of testing and an expansion of testing where the virus is most prevalent, including in the Latino Community and neighborhoods. They have high numbers of latino residents. Next slide. So i believe youve seen this slide before, but this is data from august. Well provide you with data from september once its analyzed, but this is just looking at the popup sites, the purple dots on the map, compared to the sick sites. Youll see high rates of participation and positivity among the latino clients at our popups and thats significantly different from the fixed sites in embarcadero and soma. Remember, the fixed sites were established early on in the pandemic. The goal was for them to provide barrier testing, especially for city workers and other people who were working during shelter in place, so they continue to serve a purpose, but the Positivity Rate is at these two sites and you can see were focusing our efforts into the popup to concentrate our testing efforts Going Forward in populations with the high Positivity Rate. And with this is also data. These are data from our alternative testing sites. So these are at d. P. H. Clinics. Youll recall we set up these sites early on in the pandemic. You see march 7 was when we started the testing sites. And these include the Southeast Health center, maxine hall health center, San Francisco hospital and well see that theyve done a number of tests over over 21,000 tests and 34 of those clients have identified as latinx. You can see here that our Positivity Rate is high among our latinx clients and they are we are reaching the population most affected by covid19 at our alternative testing sites. These sites are for the most part, dropins. People can make appointments. They can for the most part tested children from the pandemic. Im pleased to say were expanding capacity at these sites very soon, so we will be able to serve even more patients and clients than weve had previously. This is data that do show that within the d. P. H. System we are reaching populations most at risk for covid19. And this is just emphasizing that with regard to over time, at our alternate testing sites at d. P. H. , our average Positivity Rate has been 13. 5 . You can see its a bit of a lot going on. The lines are the number of tests done a day. The jagged lines are the Positivity Rate on any given rate. And the blue line is the Positivity Rate over a 7day average. Youll notice that in april we had a very high Positivity Rate that was likely because we were really focusing on people testing who had symptoms, so we obviously had a higher yield there. But you can see that the Positivity Rates still remains pretty high going into almost the beginning of this month. Next slide. And then i did want to one of the big efforts that weve focused on is isolation and quarantine sites. And providing people isolation and quarantine opportunities because we all know, despite the fact that some people in this country are not doing this, isolation and quarantine is very key to ensuring that the person gets the support they need. These are people so who have availed themselves of the hotels free of charge. And nearly half of the clients have of the isolation and Quarantine Hotels have been identified as latino or latina. A number of people avail themselves of these hotels. Nearly half of them had an apartment or home, suggesting they werent able to isolate or quarantine safely in their residence. So just what i hope is Interesting Data for the commissioners to review. Finally, i just wanted to this is a slide from ja marks, one of our in charge of advanced planning at covid command. And this is just looking at the reproductive rate of the virus over that second surge. Im sorry, that straight blue line, im not sure that is as accurate thats my arrow. Sorry. Disregard what i just said. That reproductive rate surged up to almost 1. 3 in late june and early july consistent with that concern about the second surge. Then we saw the reproductive rate drop down to. 8 where it was in may and early june. Then we are seeing it creep up just now to the. 92 level. We really demonstrated i think in San Francisco with this re productive rate, the decrease in rates, the subsequent decrease in hospitalizations, that weve developed a feedback where when there is high transmission and disease, people who are able i want to emphasize this because not everybody is able to do this but people who are engage in less risky behavior. And people who are not able to, its often for socioeconomic reasons or housing reasons. But in general, we think that people are able to engage in less risky behavior do so. The lower transmission of disease is a result. Humans have sometimes challenges in terms of being adherent to all the social distancing and masking requirements that this does demand. We get a higher transmission of disease and the cycle repeats itself. As we reopen, the goal is to keep the Risk Behavior as low as possible. And well continue to hope that if there is a feedback, that were able to catch it in the rick behavior increased stage Risk Behavior increased stage so we dont overwhelm our health care systems. I think this is going to be our balance that were going to have to try to hold during the ongoing pandemic. And so we have a vaccine and more importantly, communities at risk and hopefully entire populations actually receive a safe and effective vaccine. That completes my presentation and dr. Aragon is available for questions. Please raise your hands if you have any questions for director colfax or dr. Aragon . Commissioner chow . Commissioner chow yes. This is more for just as a comment. I know we were given the line to the interface consult, meeting that dr. Aragon held with the council and i just wanted to commend him for the work he was doing there. I think it demonstrated the enormous work hes been doing in all sectors. And that was just one sector in which he was working with the our churches and our communities. There needs to be about a dozen dr. Aragons i think. And he certainly has been fulfilling all of the need of a health officer. We can be very proud of that. I wanted him to know that i thought he did a very commendable job with the community in regards to the religious issues that were raised in terms of the worshipping facilities. Thank you. Dr. Aragon, ive unmuted him, in case you want to comment back. Yes, sir. Thank you for the feedback. I really appreciate it. Sorry i could not be there in person. I had trouble logging into web x so i had to call in. I wanted to say i heard positive reactions to your conversations with the faith community. Commissioner giraudo yes. I do have a question. When i know weve talked in the past about trying to have a summary of the that is readable for the Health Orders. My concern is that were moving ahead for Health Orders that involve children and families, if they can be if the communication can be simple. Ive had so many questions at our center on the Health Orders related to going to school, to playgrounds, et cetera. So i just encourage you as the next set of Health Orders goes forward, to please help the communication to be a little more clear so that the families arent reading it just on s. F. Gate. I appreciate it and i know so would my staff and many of the parents i deal with. Just to say were working with the joint Information Center in an effort to make these to realize what your request and what the commission has requested. Commissioner giraudo i appreciate it. Thank you. Commissioner green i would like to third the compliment of dr. Aragon. Youve done a great job. Two questions. One involves by the way, apropos giving the information to the public, i think the slides show capacity, 10 , i think that is excellent and really clear, but ive been asked by some of the patients ive spoken to what happens if certain organizations or facilities are, in fact, not following the order. I take care of a lot of pregnant women and i think families about to have children are extremely anxious that, you know, if theyre going to walk into a restaurant, or a market, that indeed all the distancing orders are being followed to the letter. And i dont know what to tell them about what to do, in fact, if theyre concerned that maybe the orders arent being followed. I wonder if you could elaborate on that. You said something really important about how the public stepped up and if you look at the way it shifted, once the word is out that we need to dial it back, the community has done that and so have the businesses, working together and pulling together. I was wondering, what lessons can be learned from the little surge we had in july . In other words, some of the restrictions that we began in april or march were still in place in july. And so im wondering what lessons we can learn from that as we move forward to this time as you stated is going to be more vulnerable because of confounding issues like schools and the flu season and so forth . So i wonder if youd elaborate and in particular how the public can redouble the efforts to ensure we stay in the category we are in that multicity list of terrific outcomes . Yes, commissioner green, i can start and then maybe dr. Aragon can fill in the answers on the enforcement. So i think there are a couple of things we learned. One, we know that if we educate and get the message out that things are getting worse, not only does the community respond, but the virus responds. Right . So we now have several data points that say the messages that go out, people respond and it is the virus is actually quite malleable and responsive to changes in behavior. The other thing i think we really focused on in learning about the virus is how important masking is. And there seems to have been a dramatic increase in masking in San Francisco. So i think people are getting the messages. Now people in crowded conditions and multigenerational households, i think that is a really key piece. And i think as we reopen one of the balances of our messaging is to say, you know, in this new era, its about reducing risks. There is often not such there are few circumstances where there is no risk and people need to think about their own sort of risk tolerance and risk factors for covid19. And then the last thing i think we have really been focusing on ensuring, where it is allowed for people to gather, its in very small groups so we avoid as much as possible the large outbreaks. So if somebody is in a particular vulnerable risk group for acquiring covid19, or for a poor outcome from covid19, i think that person the way that person may think about taking different activities on now that were reopening, just because were reopening doesnt mean that people necessarily should throw themselves into every aspect of this, right . So i think its really trying to provide the right to provide the prevention messages and the education and also understand that this is not sort of a onesizefitsall approach, that people need to be aware of the risk and make their own decisions. And have the Data Available to help them make that informed decision. And dr. Aragon, i defer to you for any additional insights which im sure youll have and the enforcement question. The quickest way for people to report is to call 311. And 311 will take any complaints. And they will it will get routed, the information will get routed to the Covid Command Center. At the Covid Command Center we have Community Education response team. Thats a Multidisciplinary Team that includes Law Enforcement as well as the City Attorney. And they will go ahead and respond to that focusing on education and supports of the site where this is happening. But thats the quickest way. Tell them to call 311. Everything gets logged in and tracked so things dont get lost. Commissioner giraudo thank you very much. When can they expect to hear back . In other words, is there feedback for the individual concerned about followup . That, i dont know. Im not sure how that happens. Id have to look into that and get back to you. Commissioner giraudo great. Thank you. President bernal thank you. Any other questions . I did have a quick comment and question. First of all, dr. Aragon, director colfax, pleased to see the stubborn new cases per population number go lower. I know thats been a challenge for a while as well as our Case Investigation and Contact Tracing numbers going up. I did have a question about the testing sites and particularly the number of folks in the late late Latinx Community. There is an element of geography for the proportion of people who are tested are from the Latinx Community. But besides geography, are there other factors that are explored, where driveup is not accessible to people on foot, whether were providing language. Are there other factors that could potentially be contributing to that really significant difference in the proportion of people tested from the Latinx Community . Yeah, i think there are a number of things. So as we expand our low barrier focus community testing, its been clear that the sites south of market and the embarcadero sites, which you test very large it numbers of people. There are a couple of things. One, they require an online appointment. So there is accessibility question there. There is also been barriers with regard to the language access, which were working to correct. And so that is a key component. And then there is not the Wraparound Services approach that we do have at our popup sites that has really provided so much by the community partners, right . So i would say that those sites are a very you know, theyre walk through or drive up and you get your test you make your appointment on line, walk up, get out and get the results and there is not that wraparound approach we know is so key for so many people and their families. So thats why as we expand, were really driving these low barrier testings in the community. The popup sites that are agile and able to follow not just follow, but basically go to where the virus is, and then just according to what our data are telling us. So i think both of these testing sites both of these testing models have value to the overall covid19 response, but clearly the expansion needs to be more focused on the low barrier, Community Centred and Community Driven testing. Thank you. It appears we do not have any other comments or questions. Actually, commissioner chow and green put their hands back up. President bernal they did. Sorry about that. Commissioner chow sorry. I actually had about two or three questions which dont need to be answered right now. One was to note that well, first to note that and, therefore, a request, that within the alternative testing sites and im pleased to see there were a percent that had increase away from what was the average in the agent and the nay asian and native american and Pacific Islander community. And in these alternative sites, they were like 610 , which is above the norm throughout the rest of the city for the community. So actually, that just brought back to my mind, im wondering if we actually know any more now or are trying to find out why our asian death rate is still higher even though there are lower numbers and, therefore, per 100,000, the death is still a little higher. And that also seems to be true in other parts of the country. And so not asking for an answer today, but trying to see if we were also looking into that to see if we are we could understand that a little better, especially with the fact that we have about a third of the asians here in the city. And they continue to be interested in this. And there continues to be discussion that we dont test enough asians. Im not sure thats true, but on the other hand, i think were in a position in which we probably should be doing a little more studying on that population to try to understand it as it seems to be a phenomenon a little mixed throughout the country, but still in general shows that there is a higher incidence within the Asian Community and the p. I. Community particularly. The second question that i would like some clarification in the future. In regards to the potential coming back and what the city is preparing to do for that again, not an answer for today but not to lose sight of that, we run a very large airport and the question is whether or not our Health Department is involved with airport safety and health. And what we might be doing about it. And we certainly have heard what is happening in terms of other airports. And a variety of things that seemingly is occurring even at San Francisco airport, offering direct covid testing in two of the airlines right now. The potential of whether or not like in other places im not sure that we do temperature testing or anything like that. But wondering if we actually are working with the airport to determine the health policies. I would think we are. And what those might be. So, those are just areas i thought we could help look at in the coming meetings. Thank you, commissioner. Well certainly provide answers and more details in the future on those three areas. Thank you, commissioner chow. Commissioner green . Commissioner green yes, i think its a kind of a correlate to what commissioner chow was saying. I would find it helpful to see the slide presented with the incidences of positive testings in various populations, if we could get more information about out of how many of the asian population i realize people are being tested here that work in the city but it might be helpful to have that context. Along with that, i would be curious to see more granular information. I think what you presented about the latinx was so helpful. More granular information about the populations in general, especially those tested at the permanent site, because the words are out, there are certain sites, pier 30 and 32, people are aware of the sites. Yet when you go online for testing, there is a lot of barriers, insurance information, even if you speak english, to getting through that entire series of questions. I dont know that they can be streamlined, but there is certainly a lot of data, because they ask birth date, gender, race and zip code. I would be curious to know if there is anything to learn from that information and get a sense of the denominator of our population. Yeah, thank you, commissioner green. Something that the team is working on very much. We have that we show that for the a. T. F. Sites, because those are our network sites. We have through epoch that data readily available. Across the system, its considerably more challenging, but the team is on it. I know some of the sites arent run by d. P. H. And i wonder if they have the capability of pulling that data, because they do ask for a lot. Yeah. We can certainly bring that back once the team the data team has completed the analysis and has a better understanding of what the limitations of the data are and what we are able to show. Commissioner green thank you. Commissioners, any other questions or comments for director colfax or dr. Aragon . If not, we can move on to the next item. Which is resolution honoring tosan boyo. Id like to recognize dr. Susan ehrlich, c. E. O. Of the general to present. Hello, commissioners. President bernal, commissioners, dr. Colfax, i am so grateful for this opportunity to celebrate tosan boyo, who until very recently was our wonderful chief operating officer for the past three and a half years. Before i read the resolution, i just wanted to say a couple of things. First, that ive been fortunate to know and to work with tosan boyo for most of the time between 2014 and now. We worked together first at san matteo Medical Center and then he joined us here about a year after i started. He and i have really grown together as Hospital Executives and for that, im truly grateful, because he is, indeed, a very special person and this is a wonderful recognition for him. What the resolution doesnt say about him and part of what has made him a very special part of d. P. H. , he has a very deep sense of purpose. And that purpose grew from his family roots in many nigeria, ae clinic where his father worked. He has that drive to get things accomplished in all areas hes overseeing and more. With that, those things are outlined here in the resolution. I would just like to read that to you. Honoring tosan boyo, m. P. H. , whereas tosan boyo, has served the San Francisco department of Public Health at zuckerberg general as the chief operating officer for three and a half years, and whereas mr. Boyo has dedicated his career to building and refining Population Health initiative by providing a unique perspective about the impact of Public Policy and Health Care Delivery on the wellness of communities, especially vulnerable populations, and whereas mr. Boyo has humility, empathy during his tenure, and as chief operating officer, mr. Boyo oversaw 12 departments with over 850f. T. E. S and where he developed implemented and led the Strategic Initiative to ensure that the hospitals Capital Program met the needs of the s. F. G. Patients and team members, and whereas mr. Boyo was a key leader in successfully implementing the Electronic Health record, epoch, by leading the system during the inaugural period. And whereas mr. Boyo led and championed the equity journey by empowering the organization to discuss race, equity, diversity, and inclusion through the hospitals Equity Council. And whereas mr. Boyos passionately led and built the Equity Council to address disparities and system racism, by bringing team members across the network. And whereas he has served as chief of operations as San Francisco covid19 command center during the pandemic and successfully deployed disease prevention, Health Facility surge management and Public Health compliance Health Orders. And whereas mr. Boyo was Board Certified in health care management, and whereas mr. Boyo served on the board of directors for the youth center, a 125yearold Nonprofit Organization providing Mental Health and social services for families in california, now therefore be it resolved that the San Francisco Health Commission honor tosan boyo for his many years of outstanding services, contributing to the health of all san franciscans and wishes him well in all endeavors. Hes a pretty remarkable person. Thank you so much for honoring him. Thank you, dr. Ehrlich. Do we have any Public Comment . No one on the line, so no Public Comment. President bernal thank you. Id like to recognize any of my colleagues who would like to add to that fitting and thoughtful tribute to tosan boyo. I would like to say in particular with regard the the covid19 command center, the pandemic has asked so much more of all of us and the commission is very, very aware of the incredibly hard work that has been layered on top of the normal work and leadership that the Department Team has been engaged in, for him to take on this Critical Role within the command center. Were so grateful for that, for his leadership and for his hard work and commitment. And just as with everyone in the department, he went so far above and beyond in that role. Thank you very much. Commissioners, would you like to we have commissioner green. Commissioner green well, i would just like to add that i have learned so much. One of the most wonderful parts of being on this commission has been watching the team at the general work. And ive watched tosan boyo as a leader, a presenter, a philosopher. As someone who really listens and really responds. As a great consigli tore, educator and partner. Everything that has been written about systemic racism, i think he brought about his own personal experience, the piece about his own personal experience was the most moving thing i have read as ive tried to read and educate myself and ive shared it with everyone i can find. Its emblematic of how thoughtful he is, how beautifully he expresses ideas and how much progress when someone of his caliber leads an organization. I know how much everyone will miss him. And i just want to thank him so much for everything hes taught me. And what a wonderful opportunity its been to watch him in action and interact with him. Im really going to miss him. Thank you. Commissioner chow . Commissioner chow thank you. I wanted to also add my compliments and certainly my strong commitment to this resolution honoring mr. Boyo. As the chair of zuckerberg San Francisco general, i recognize that he brought to life the Equity Council. And he made the question of equity that was added to the pyramid and part of true north, a very real issue. Not just his own person, but how he was taking on the issue for everybody. He made it so that it became as important as, of course, we know it is. And he was able to do that without rancor and always with humility. And yet with a firmness that i think brought out the very best of the people he worked with, his colleagues, to actually continue the journey to equity. He never shrank away from a failure of the system. Its a remarkable team. And were going to lose a remarkable person. Thank you, commissioners, chow and green, who i know have had the opportunity to work with mr. Boyo through the general j. C. C. Next id like to recognize commissioner christian. Commissioner christian hi. I just want to say as the newest member of the commission, newest arrival to this team, i am not exaggerating when i say that each time i have an opportunity to speak with or hear about or learn about members of the department of Public Health, the team at zuckerberg, the doctors and all the executives and the staff, the things that people are doing and the things they have done and the way theyve watched through the world. Its just unprecedented. I cant tell you how deeply sorry i am that im not going to have the chance to learn more about you and the work that youve done here personally. But i just did want to say that i regret the chance im not going to have to work with you. And im going to find that general piece that dr. Green mentioned and other things youve written and wish you the best of luck in everything you do. I want to thank as a citizen of the city for all that you have done. Thank you, commissioner christian. Director colfax, anybody else would like to say anything before we have mr. Boyo come up and say a few words . Thank you, commissioner bernal. I actually have been told about tosan boyos remarkable abilities before i came back to the department. So when i was fortunate enough to rejoin, he was one of the first people i asked to meet with and everything that had been said about him was what became and i think more so as he continued to do such an outstanding job in the hospital and as he responded to covid19. I think his contributions to the citys response cant be underestimated, both as incident command and also as the leader of the operation operations at covid command. Hes been in this since the very beginning. And just so pivotal to our response. Id also say that he an ability to inspire teams to engage, to focus on work, but also maintain a perspective. [please stand by] and the way she raised me to be the man i am today. I am a product of her. And serving San Francisco during the past it has been a privilege of my career, especially being part of public command and thank you to director colfax for, you know, asking me with air quotes to lead this event centre because it genuinely was a privilege of my career. The privilege of my career to do that. It is the most important thing i have ever done and i hope it is the most important thing i ever do. If it is not, that means the world is going to be very challenging in the future. Thank you for everything and i will never forget any of this. I am tremendously grateful to have served this city. Thank you, everyone. Thank you. We will miss you very much and where we under less challenging or isolated times, will be handing you a framed copy of your resolution and lining up to shake your hand and take a photo and express our appreciation in person. While we cant do that, we hope you are feeling this from all of the scan our appreciation of your leadership and hard work and how much we will miss you. Mark will arrange to get the resolution to you as well. Thank you again, on behalf of the entire commission. Best of luck. Please stay in touch. Thank you, everyone. I appreciate it. There is an issue of voting on this resolution. Thank you, mark. Would you like to go ahead and call the role . Actually, a motion needs to be put forward and then i need to have a second. Then i will be happy to do roll call. We are all caught up on this. That is my job. Thank you. By so move the resolution. I second. All right. Thank you. I will do a roll call vote. [roll call] have i missed anyone . That is everyone. Thank you, all. The item is passed and your comments are very heartening. We will of course, miss you. Thank you. All right, we will move on to the next item. The laguna honda Hospital Gift fund budget. Sir, you kind of skipped a few. There is general Public Comment. I can note there is no one on the line. We can skip that. Item seven is report back from the finance committee. Thank you. I grabbed the wrong piece of paper. Its good that i am backing you up. Thank you. Commissioner ciao, would you like to offer the report back . Yes, thank you. I had the privilege and in the absence of commissioner chung, to chair the meeting. We undertook the business. The consent calendar included a number of programs, which were basically extensions of already existing programs. Note however there was a large contract to health right 360 for its continuation as providers for the city who receive reimbursement mostly through our Behavioral Health in direct [indiscernible] it is a continuing contract of ours. We will have an additional 5. 250 million that will be given for a Covid Community wellness initiative. This merges very nicely to the discussions that we had earlier in regards to covid. We will be putting out contracts , the proposal for contracts from Community Organizations who will be working with the community on covid wellness programs. This is a new program. Otherwise, the remainder of the contract are fairly routine and we would ask for a consent of that contract. We have a number of new contracts. I think they are worth noting. One was a contract for security of our assistance. It could be Computer Systems with data way u. S. , which is actually a continuing contract with a Previous Company before, but now they have now spun off this as a u. S. Company and its scope is to assure security for the d. P. H. s all of the d. P. H. Information. So there is the contract for 1. 15 million. The second one is, again, related greatly to covid and it is Laboratory Corporation of america for doing covid testing. In addition to covid testing, hoping they wouldnt need a contract of five years to do covid testing, it also does include the fact that it could be valuable as a backup for its other very large range of Testing Services that it does. It is its a contract before you also. The committee is recommending this. The third contract is very interesting. It precludes services up to six months at laguna honda. It appears that the pouring of the new kitchen that was built as part of the lead buildings that laguna honda actually was built under in order to be a lead building is actually failing and for that reason, it has to be replaced. It has been 10 years. And the replacement, it does require that in order to do this major replacement, they have already done one or two patches and there is still a fourth to go. This one is up to six months. The kitchen will be out of service and amazingly, then they will have to supplement 800 peoples meals three times a day over this period of time. This contractor his Foodservice Partners and while they apparently were the only bidder, they actually come with very high credentials of serving a number of kaiser hospitals already and they are a local and the fact that their headquarters are in south San Francisco. They apparently have a dietitian they can prepare the different meals that are necessary for our residents at laguna honda. That is a contract that while the year and three months is the extension of the contract, the implementation and the time that is thought to be required will be up to six months and it is a contract for about 3 million including a contingency of 211,000. The latitude are actually part of an as needed contract of maintenance people. In this case, the steam cleaning and it would be for a vendor for steam cleaning under the contract and then a approval of the vendor table. There is actually a vendor table that the department can use for different types of Craft Services that our own employees are not able to do and we need to approve that vendor service. That is the fifth item on our new contract list. The Committee Also was actually able to see evaluations of the previous contract under the contract report, which was a request from the previous meeting, and the department did a wonderful job in being able to show the evaluations that were in place for these continuation contracts under the contract support. The finance and planning committee, therefore, is recommending these for their approval. We are happy to answer any questions at this point in time. Market, are there any requests for Public Comment . No Public Comment yet. Okay. Commissioners, any questions or comments . If not, do we have a motion to approve . Motion to approve for the consent calendar. Is there a second . Yes. [roll call] thank you. It passes. All right. We will move onto the next item, which i could not wait for. That is the laguna honda hospital have to fund budget modification. We have mr. Fraser. Hello, commissioners and dr. Colfax. I am so happy that you are were looking forward to my presentation. I am the Program Manager at laguna honda hospital. The hospitals hospital hospitalwide gift Fund Management policy requires that the budget be approved by the Health Commission, as well as any modifications to that budget we call it a special funding request. You may remember you approved our budget back in august. Today rerequested 25,000 increase to the budget to fund our holiday gift program. That program is a longstanding tradition and had been funded by the friends of laguna honda through inkind donations. We are currently prohibited from receiving donations. Timelines are very tight and we must proceed immediately. Our ask is for 25,000 and i want to explain to you that the gift fund is a continuing fund. Its different from your normal government appropriated funds. You can think of it more as like a savings account. We have a balance of 2. 5s million. The budget request would bring the budget to the year at 465,000 i am prepared to take any questions you may have. There is no Public Comment. Are there any questions or comments . No Public Comment. Commissioners, any questions or comments . If not, seeing no Public Comment thank you, mr. Fraser. Do we have a motion to approve the budget modification . So moved. I make the motion to approve the modification to the fund. Is there a second . Second. Great. Mark, call the role. Yes, sure. [roll call] commissioner ciao, can you give me your answer, please . Yes. [roll call] thank you. The item passes. Thank you. And thank you to mr. Fraser and everyone for all of the comfort you bring to our residents at laguna honda through your work on the gift fund. Thank you very much. All right. Moving on to the next item, we have our annual report with dr. Susan philip. Dr. Philip . Everyone can introduce themselves. They will start. And then dr. Scott and dr. Philip. Thank you, yes. Good afternoon. I am the director of h. I. V. Surveillance. And fideli and for todays presentation, the report was released last month and then [indiscernible] they will provide an s. T. D. Update. Next will be the live feed. There are a number of new diagnoses in 2019 that climbed to 166 which would present a decline compared to the 13 decline in the previous year. Since 2010, the diagnoses have declined by 65 . It fluctuated but remained relatively stable. About 16,000 people are living with h. I. V. At the end of 2019. And almost 70 are over the age of 50. These are San Francisco residents. Many of them have moved out of San Francisco. We estimated there are about 13,000 who live with h. I. V. And live in San Francisco. Based on their most recently available address information, we are aware they were not aware they were initially diagnosed. The h. I. V. Diagnosis rate per 100,000 population. The lines here are four men and the other lines are for women. Women have much lower h. I. V. Diagnosis rates than men and black men have the highest rates closely followed by latino men. Black women also have the highest diagnosis right among women. The rates for black women are similar to black white men. For asianPacific Islander men, the rates increased but remains low. Next, please. We closely monitor trends and new diagnoses for select populations. [indiscernible] these populations have a decline in new diagnoses in 2019 after an increasing or leveling trend between 2015 and 2018, which is encouraging. However, two populations, people over 50 and trans women had an increase in both the number of diagnoses. The number for people over 50 increased from 27 to 34. And for trans women, it increased from seven to 13. And for people over 50 diagnosed in 2019, there appears to be more trans women, men who have sex with men, and asianPacific Islanders than those diagnosed in previous years. The increase could be due to the increase age in h. I. V. Populations or lower crack use, especially among trans women. Next, please. The causes among that for those with h. I. V. Is the leading cause of death. It includes overdose and [indiscernible] the proportion of h. I. V. Related deaths has been declining over time from 40 9 to 35 . In 2018, 29 of deaths are due to h. I. V. Related causes. Next, please. For multiple causes of death, which include both the underlining and the contributory causes of death, individuals may have more than one cause of death. Poverty is the second most common cause of death after h. I. V. And in transmission category, we see that black people who ingest drugs are disproportionately affected by these common causes of death. Next, please. So this slide shows the continuing of care among purses persons newly diagnosed. Care is defined as having the h. I. V. Test. [indiscernible] this is a brave achievement. 81 people diagnosed were suppressed. The majority were suppressed within six months of diagnosis. Next, please. We see that time continues to improve. From diagnosis, to first care, from initiation and from art to virus suppression. This is calculated by the starting art within seven days of diagnosis. Increased from 16 in 2014 to 50 9 in 2018. It decreased from 54 days in 2015 to 35 days in 2018, which is likely due to improved art management and increasing use of the inhibitorbased regimen that lead to faster virus suppression overall, they will increase from 2015 to 46 days in 2018. Next, please. By race and ethnicity. Virus suppression has decreased badly among white and asianPacific Islanders. Black had the highest median virus suppression in 2017, which is 103 days. It decreased by more than half in 2018 to 47 days, which is similar to that. People who ingest drugs took much longer to achieve virus suppression and in other risk categories. Remains high in 2018, which is 133 days. People experiencing homelessness have a high, median high virus suppression in 2016, but it drops significantly in 2016 and continued to decline at a slower pace, similar to nonholistic people. Next. We also want to look at virus suppression among People Living with h. I. V. , which is a Larger Population than the new diagnosis. Overall, 75 People Living with h. I. V. Were suppressed in 2019. Virus suppression rates are lower among women, black, latin x. , middle aged groups and people who inject drugs. People dont born outside of the u. S. And only 39 of the homeless were suppressed in 2019 next. In this report, we added new data to adding these rates as social determinants of health. We did not have individual indicators for these. They had the highest diagnosis rates in 2018. These rates are associated with these social determinants of health. This population accounted for 21 of new diagnosis in 2018 and 18 in 2019. It is a sickness of it significant proportion of new diagnosis. [indiscernible] they have lower aids survival rates and lower linkage to virus suppression. Next. This is my last slide. In summary of care incomes by health and status by the way, the animation feature is disabled. It may look very busy to see all the information together. The first four indicators are among people newly diagnosed with h. I. V. And the last three indicators are among People Living with h. I. V. In general, people experiencing homelessness have worse care outcomes compared to [indiscernible] these care outcomes improve from 2017 to 2018 and 19 for both groups. We see more improvement among the homeless. This requires review in the collection of followup information. We may not have updated housing information in 2018 or 2019, specifically for those who are homeless in 2017. But we know at a population level that those who were housed have better h. I. V. Care outcomes than the homeless. Linkage to care and receiving art among new diagnosis, which are the indicators with the checkmark are similar between the homeless and nonhomeless. Viral suppression is considerably lower among the homeless, even among People Living with h. I. V. In care, the last indicator, which includes people who have one lab test during the year, for example, 71 of virus suppression among the homeless. This suggests that the care and the compliance and comorbidities there are challenges for People Living with h. I. V. Who experience homelessness to achieve virus suppression. In conclusion, we see new diagnoses continuing to decline. There is linkage to care and virus suppression continues to improve. The disparities remain, but to a lesser degree compared to previous years. This is all very encouraging. However, due to covid19, we face these challenges in maintaining h. I. V. Testing and managing h. I. V. Care. We will continue to monitor the trends using h. I. V. Surveillance data to see how this affects new diagnosis and viral suppression in 2020. Dr. Scott will talk more about the impact of covid19 on prevention and tried Care Services. Thank you so much for your presentation. Just a note to our commissioners and anyone viewing in the public , we will be taking questions and comments from commissioners between each section, then we will take any Public Comment at the end of the full presentation. Commissioners, do you have any questions or comments on her presentation . I would like to say that looking at the progress that has been made, particularly since 2010 is extraordinary and there are so many people across the department who are responsible for that. Thank you, dr. Sue for your work and leadership. We keep expecting to see a leveling off of our reduction in new cases every year, but it seems we still are seeing significant reductions well disparity while disparity still exists, particularly concerning transgender women. Thank you so much for your presentation. If we do not have any comments or questions, we can move on to dr. Scott. Thank you. Thank you. Thank you for allowing us to come and give an update. It will really focus on what has happened during covid because it has changed so much for our h. I. V. Care and prevention. Next slide. So one shelter in place went into effect, most of the clinical and c. B. O. Sites shut down and moved to a more virtual platform. There was a big disconnect between a lot of the support that our patients get in the community and from clinical settings that was significantly impacted. Experiences it was an impact on covid19 and on prep. And overall, there was a dramatic decline on h. I. V. Testing for People Living with h. I. V. A decrease in viral suppression as an example and a strong concern particularly for Homeless Individuals who already have a disparate outcome of it becoming worse. We have seen some rebound of these indicators, but hasnt come back to where it was yearoveryear. We still have more work to do, but i wanted to give you a sense of where we are currently. Next slide. This is for the laboratorybased h. I. V. Testing from four labs that reported positive and negative test results. As you can see, between 2019 and 2020, there was essentially a stable in february and then there was a drop with the largest drop in april at 54 . Half the number of tests were done the year prior. Next slide. We also saw that the number of positive tests remain about the same, but we were seeing about half to a third the number of positive tests that we had in the past. I think we also saw this in city clinic for s. T. I. Where the individuals who might have had a risk or an exposure might be more likely to come into care, with the overall number of positive tests has gone down, even though the percentage is about the same. Next slide. And then when we look at community, there is a lot of testing in our communities. Unlike laboratory testing, we saw a peak in the decline. There was a 91 decline in the pointofcare h. I. V. Testing that happened april of this year after the shelter in place orders went into effect, and as of july, its still about half the number of tests that were done the year prior. Next slide. And then when we look at different facilities, we can see that across the city, both within the d. P. H. And others, which is our Large Community setting in the castro that you saw the massive dip in h. I. V. Testing, and then you saw this rebound at a shelter in place order. It hasnt gone back to where it was yearoveryear. A sort of flattened out so we havent seen the same level of increases. Overall, we are still 2040 lower than we were last year in terms of testing. Next slide. We have seen a similar, but not a profound dip that occurred in april and there has been more of a rebound unless of an overall reduction number of tests yearoveryear. We saw this peak in june where theres a lot of ketchup catch up that was happening and people who were due for laboratory testing. Its still maintain was maintained at a lower level compared to what we have seen in the last year. Next slide. And at ward 86 specifically, they looked at an analysis of all the patients and the virtual visits model and worked at looking at [indiscernible] it accounted for some of the demographic and clinical factors associated with viral suppression. The odds of not being viral suppressed were about 30 higher post covid compared to precovid period, particularly the vulnerable or those who are homeless, and they were more likely to be on suppressed post covid as well. We also had the worst viral suppression among black patients , but this did not change after covid. Next slide. At magnet, they have one of the largest prep clinics in the country and this slide is just in blue emblematic of the decrease of services that happened in april of this year in response to shelter in place. There was approximately a 90 drop in the testing Prep Services and not as much of a change, other than a much lower proportion of services for People Living with h. I. V. But really, it is a significant hit for the Prevention Services that were not clear initially whether they qualified as essential services, as well as a need for social distancing and clinical settings. It really drove down a lot of the testing and prep followups that were happening at magnet in particular. Next slide. As part of the response to covid , there has been a lot of effort to increase communication and so since march, there were daily bulletins posted onto the homepage. Initially outlining a lot of the impact of covid from other People Living with h. I. V. Are at risk for h. I. V. These were distributed widely through electronic means. There was a Community Forum on safer sex and covid that was organized with bridge h. I. V. And several local communitybased organizations. And then there was a virtual town hall in collaboration with ward 86 for People Living with h. I. V. To address concerns in the community, particularly around care, access to care and the impact of covid on People Living with h. I. V. Given the concerns around increased complications with people who are immunocompromised. Next slide. There is a subcommittee that is working to address the provider concerns of the epidemic evolves and as i mentioned, it was not clear whether or not initially the Prevention Services in particular qualified as essential services under health quarters. It was really an effort to clarify and provide clear guidance to the c. B. O. And other prevention providers in particular around how to provide services safely and develop resources for home testing, for example, options for people to minimize clinic visits and looking at low barrier approaches to delivering some of the services. Zoom doesnt work for everyone, but are there other ways to continue to provide services in a safeway. Next slide. And then off on policies side, there has been, when the shelter in place occurred, all the clinics closed due to activation many of the people were activated for Covid Response. And also in response to ensuring that staff are safely in these clinical settings. But as a shelter in place has been lifted, there is a need, in particular because of the Prevention Services that have been declining, to reopen and provide care for young people particularly and so this curbside care model was discussed at the last meeting around expanding services for youth, including some of the Nonclinical Services that are essential for a lot of the vulnerable truth in the city. And then there is the task force , the Housing Task Force addressing homelessness and the differential and disproportionate impact on people experiencing homelessness in San Francisco. Next slide. I will defer to the commission if they have questions about that section before talk about ending the epidemic. Commissioners, you have any questions or comments . First of all, thank you for your accomplishments. This is incredible work. I guess i had two questions that are more statistical. I was wondering, given this effect of covid19 on testing and so forth and virus suppression, how you plan on looking at these statistics yearoveryear. In other words, have you thought about how you would correct the unique drops that we see this year so you can see what have been incredibly successful on tread lines trendlines in this condition . I guess, you know, the corlett to that is do you anticipate any increased Disease Burden and we do know not we do not know what the winter holds. I think it will be disproportionate among our populations that are are ready at higher risk of having worse outcomes. And many of the prep clinics, for example, prescriptions were extended for another three months or six months and people miss to the test. But if they stayed on prep, they still maintain high levels of protection. For individuals who might be experiencing difficulty adhering to prep, they might continue to have sexual risk and might discontinue prep. We are seeing that in the clinic there is no question that we will see a decrease in our case findings because the h. I. V. Testing, for example, is a cornerstone of our prevention for Public Health response. It has been negatively impacted by covid. I defer to link for any statistical adjustments that might be made. I also think the highvolume, easy access testing as part of our Public Health h. I. V. Prevention response. That has gone down. There is a concern that it will undercut these efforts we will really try to counteract that as much as we can buy supporting, encouraging and facilitating testing Prevention Services to be restarted and reoffered in maybe a different approach. And for People Living by h. I. V. , ensuring that disruption of care is minimized so, how do we bring for whom zoom doesnt work, into the clinic with capacity where they can also where they could meet their needs . It will not be businesses usual for anyone post covid. But how do we maintain the success that we have had . I think that we are trying to figure out what the best approach for that is. There is no question it will impact our income. All right. Thank you. Commissioner christian . Thank you. Thank you for this presentation. Looking at the viral suppression , the left bullet point had worse viral suppression but did not change after covid. Could you help me understand exactly or why you think it might be, or i am understanding this did they have worse viral suppression, but it did not change after covid. Can you help me understand . There was a disparity that we were looking for. And there was a new disparity that arose post covid and there were disparities that existed that were sent. It existed at ward 86 and it did not worsen. It is about how poverty impacts the ability to maintain adherence in viral suppression and how income and competing needs impacts, particularly for a black individual and for black men in the city. It was present precovid. There was a change seen in the data. So, i mean it was deeply distressing that it was so bad when there were normal Health Situations and it didnt get any worse after covid. Yeah. I totally agree. There has been efforts both at ward 86 and to address this through black health and focusing on what are the ways that we need to adjust and change our care model to meet the needs of black patients, and particularly, black male patients given the disparities we have. I am one of the providers there and there is a nurse, as well as another medical provider working on what are the models that we will shift to try to remove these disparities. Describing them, i agree, they are not positions. We need to have a proposed solution and monitor our outcomes and be held accountable for how we do or do not address those disparities. Right. Systemically it is such a nightmare at base level. It could not get any worse after this pandemic started. As someone who is fairly new to hearing about this level of statistics, it is very distressing. Yeah,. I completely agree. I completely agree with commissioner christian and hope this is something we can hear reports back regularly as we get continued data from getting 20. Next we will go to commissioner dorado. On adolescence . And whether when the access for the youth in the clinics is going to restart. It is not able to see anybody. And what is there a timeline to reopen the clinics and have access for the youth . I know there has been discussions around the timeline for reopening. I know that allie is on the line im not sure if there are updates on this. But if we dont, we can get the timelines and at the information back to you. Okay. Thats great. I appreciate it. Two of the clinics at balboa and burton, i mean those schools are probably not going to open until at least january or february and [indiscernible] thank you. I would appreciate the information. I can speak to that a little bit. Would you like some information now . Just followup would be great i would appreciate it. Okay. The long and short is we are slowly reopening clinics that were closed just because of concerns about air circulation and deployment of staff for the activation. We have a timeline now for reopening as we are able to deactivate some of the clinical staff and bring them back to the clinic once we determine that the sight is safe. Okay. Thank you. Thank you. Commissioner ciao . Thank you for this presentation. Thank you. The first thing i was concerned about was it appears you are still working with the City Attorney to try to assist the input for Community Clinics to be able to feel comfortable in doing h. I. V. And s. T. I. Services i am wondering and im not quite sure they determine to these essential in the beginning and the prevention could be in question. That is just one thing. When you were describing this in the last few minutes, i became similar i have some similar concerns. It is a phenomenon not just that it was h. I. V. , but everywhere. There has been, in general, a resurgence of visits back from [indiscernible] they put this into get to the baseline again. Im wondering if part of that, and you are starting to convey that some of these people are potentially no longer here. Some of them may not need visits because youve extended their medication. And i guess the real bottom line is, how are we going to try to figure out the real impact that you are discussing here in terms of the fact that, you know, intuitively, it will probably get worse in the sense that there are bound to be some people who dont feel like they will get services or didnt feel like the services were as easy to access as before. There is a factor here in which a number of people had continued my cheek medications. Others may not need prep perhaps because of social distancing and isolation. And others have moved out of the city. All of this has been confounding any sort of a normal study, and i recognize as you are having a good look at this, whether or not there is some sort of clarity or some sort of timeframe that maybe we can sort through between people who have stayed on treatment, what havent actually been followed up by us, people who [indiscernible] that is not even asking the question of how many people should have been tested that didnt get tested, right . And the complexity of this. Im wondering what some of your thoughts are in terms of us being able to sort it out. Its something we can take a look again as the commissioners have asked, suggesting they get a followup on this. Well be following this closely and be happy to present an update when we have new data. The way that i have been thinking about it is its a spectrum from prevention through care for h. I. V. There are individuals whose risks change and they dont need prep anymore so they dont need to be on prep and they decide that they made a decision that they dont want to be on prep and they dont go in for visits. And then there are people who are unable to access prep, for example, because they cant get into their visits and they have continued risk and they have breaks in their medication. I think there are people who have who are living with h. I. V. Who are adhering and are able to come in every six months to a year anyway, so it hasnt been a disruption. In particular there is a lot of drop in services that have been for people who are on the margin and those really got disrupted. Its not easy to get into any of the buildings or any of the clinics on the hospital campus, for example. Many places providing support are no longer open. I think we will need to make take a systematic look. There is already a large outmigration of People Living with h. I. V. In San Francisco. And i know it was accelerated during covid. It is a densely populated urban centre. People are moving towards more space and suburbs and other more rural areas in response to covid i think we are, particularly from the surveillance team, there is the ability i have been following up with individuals. And within the prep clinic, there will be a lot of utility i know that is an effort at magnet to provide outreach and educate people. It has been clarified that prevention and Care Services are essential and that has been disseminated to the communitybased organizations and clinics to provide clarity. It is getting communicated into the community. It will be a big next step. Thank you. We appreciate getting feedback on this and to see where we are all standing. Thank thank you. Commissioner green . [please stand by] to that followup testing. So there are people who have been discontinued, not refilled if they havent come in and that is not true. Because, you know, i know well have a lot to learn about level Risk Behavior that occurred during the shelter in place and over the pandemic. It appears as looking at the testing data for example, the bigger institutions like the general or ucsf and other Hospital Systems are bouncing back if terms of their testing. Are we seeing a similar bouncing back of the communitybased organizations that are engaged in prevention and other kinds of services and if not, is there any kind of support that the Department Needs to provide to them . I think it is going to be difficult in the spaces and how its around ensuring staff safety and social distancing and the types of things is going to change the volume that can happen in the clinics. So we are starting to see that and i know that there are efforts to sort of think about doing things differently with home testing for example. So that individuals can do their testing at home. Or dropin testing where there is minimal contact with staff unless there is a need for a discussion for like Sexual Health or other clinical needs. So, yes, things are opening up. Theyre not at the same level they were and there are unique barriers i think that communitybased organizations have that hospitalbased systems can better mitigate. Thank you. Commissioners, any other questions or comments for dr. Scott before we move on . May i make a comment. Director colfax, yes, thank you. I wanted to thank them for their presentations and i think one of the key pieces about this is that our Institutional Response to covid19 has been driven by our institutional memory with h. I. V. And the work weve been doing. The commissioner saw the vaccine presentation two weeks ago. The doctor who has been leading the vaccine efforts, while there are differences, vast differences in how theyre transmitted, i think going to the inequity were seeing here, we need to ensure were doing everything we can to prevent and mitigate very similar inequities that were seeing across the nation and to some extent, hopefully. And just a reminder that while these our focus on these Infectious Diseases is often in the health care system, these are often also socioeconomic and social factors that are at play here with regard to the social determinates of health. At the same time were talking about getting to zero in San Francisco and im hopeful well be talking about getting to zero covid19 infections. Sort of book ending these departments. Thank you. Thank you, director colfax. Commissioner christian . Commissioner christian thank you. Dr. Scott, this is a late question and maybe it might be best answered by dr. Seo, but it is kind of a prep question and follows on the last couple. Looking back at slide 4 if my notes are correct, where the doctor told us that the slide is titled trends and new diagnosis in select populations and that for transwomen, it had increased to 13 . And my notes say lower by transwomen. And my question is why. Were talking your thoughts of why, were talking about the social determineates of health that exist and disparities that drive that. And then you just mentioned the impact of the closing of communitybased organizations on people and how obviously people who rely on them and who are at greater disadvantage than many others are suffering because of this. Do you think that has something to do with the increase in new diagnosis in transwomen . So, i think so if i remember that slide correctly, i think it went from 2 to 7 among transwomen and the absolute number was from 6 to 13. So we have definitely seen a rise in transwomen, new diagnosis among transwomen. This would have been data before the covid19 impact on all of our care and Prevention Services. But, yeah, prep is prep uptake among transindividuals has been lower than snm which is the comparative group. Its not about awareness. Its not about knowledge that prep exists, its about all the other things that are necessary for an individual to take prep, including what is a perspective of prep among peers and other Community Members. There has been more and more data around the impact of prep and hormones. So there is a concern among the community that prep can negatively impact gender hormones and there is more and more data coming out that it does not negatively impact hormone levels. Actually gender performing hormone levels reduce, but not to the point where we think there is increased risk of h. I. V. And there is also where people access prep and is it available in the clinics where the individual might receive gender affirming care. So there is a lot of, think, going back to the social determinates, there is also high rates of poverty and other social determinates are driving the lower uptick of prep among transwomen compared with other groups. Particularly among smn in San Francisco. And could you describe some of the efforts that are being made to overcome as much as possible these barriers . Yeah. So there was a study called the stage study that was really about providing peerbased social support and clinical support for transindividuals, specifically transwomen, to access prep within San Francisco. And it was within several of the transclinics, those providing transspecific care and one in the east bay. Here at bridge h. I. V. , we actually created a clinic here as well for the city, because there were barriers that were people were encountering accessing care that was delaying their ability to initiate prep. So we wanted to provide a very low barrier access strategy for transwomen to access to access prep. So those are some of the efforts. There has been a lot of communitybuilding, Community Education, provider training, provider support, increasing both provider and client awareness around prep for transwomen and also dissemination of the information that we have about the impact of prep on gender forming hormones and the fact that the data do not indicate there is a negative impact. So making sure that we communicate that. And there is an effort here at bridge h. I. V. To develop a prep clinic specifically for transindividuals and focus on transwomen. And well being doing a study which is focused in supporting prep among transwomen using a peer support and genderforming hormone service model. And that will be done here at bridge h. I. V. Commissioner christian thank you. Can you say a little bit about how the Community Education, how youre getting the message out there is no negative effect on the gender forming hormones . So there was during covid similar to the Community Education forum we did around Sexual Health in covid, there was one focused specifically on transindividuals, highlighting transwomen. And talked about prep and talked about the data that was many of the investigators are based this San Francisco have done looking at the impact of prep on gender forming hormones. Disseminating it through the community, disseminating it through the peers and peer navigators that worked within the study, that worked within the community as well as the ucsf has a center of excellence, so leveraging that and using social media and strategies to get the word out as the study come out. There was one at aid 2020 by dr. Bob grant that also has been communicated through the channels. And the Community Connections and connections peer connections are really driving most behavior in general is based on connections to other people. So leveraging those connections have been built to disseminate information from trusted sources. Commissioner christian thank you so much for your answers to my question and thank you so much for your work. Thank you, commissioner christian. Thank you very much, dr. Scott for your presentation as well. I think we can move on to the next section that dr. Philip. I think this is still me. Still you, okay . Thank you, dr. Scott. Thats all right. In line with our getting a zero effort, there is a National Ending the Epidemic Initiative and we actually here are thinking about it in ending the epidemic, plural, because we have an epidemic of h. I. V. , hepc that we want to have as one of our Guiding Principles. The goal is to reduce h. I. V. Infections by 75 by 2025 and 90 by 2030. And so this is a cdc Planning Grant that was implemented for funding on august 1st and there is work to hire new staff. And the grant is actually five years, so it goes through 2025. And these are the Guiding Principles so Health Equity and Racial Justice eliminating stigma and discrimination, ensuring barriers are as low as possible. And valuing the experience and providing peerdelivered services, so very much in line with what weve done in getting to zero and very much compliments the work that getting to zero has already been doing in the city. So im going to go through some highlights and happy to take additional questions. So, this is currently were finalizing the plan with the Community Planning council, getting to zero, ending hepc, as well as several programs. And we said this is inclusive of sti. And then expanding Community Engagement with communitybased organizations like aids project of the east bay within the Latinx Community, as well as the transcommunity and people who inject drugs and those experiencing homelessness. And this is just a summary that this is the prevention dollars from the cdc. As i said, it started in august 1st. Goes for five years. Its about there are two sections, component a and component c, totalling about 2. 7 million. Next slide. And these are some of the planned activities. So its really organized in these principles of diagnosing individuals, treatment, tracing, and prep. And so im just going to highlight a couple of items for each of these. And talk about them. So the take me home is a home h. I. V. And sti Testing Program that was done in collaboration with building healthy online communities, which is a group out of the San Francisco aids foundation in collaboration with emory university. And this was a homebased h. I. V. Testing. There were ads placed for free that ran from april through july. There are about 150 people who ordered a kit. There is over 260 kits selected. 20 never tested for h. I. V. Before. These are home h. I. V. Selftests, so these are essentially anonymous tests. And they were an effort to create low barrier. They were mailed to individuals, but date of birth and Social Security was not collected, so there was not an opportunity to do a surveillance match, because that would have created a new barrier for individuals. There were no h. I. V. Tests reported positive tests reported to the Health Department, but this is an ongoing study and there are surveys done, so well hopefully have more and more data about this program and how well it works. So within the treat rubric, its really around expanding services for people who are coming out of incarceration. And then working with stabilization rooms and a support team for individuals who might be living with h. I. V. And diagnosed and treated for hepc, or have a recent sti diagnosis. Prevent is really about prep and there is multiple components around prep, including an effort within the San Francisco zuckerberg General Hospital to increase prep scaleup. And there are a lot of individuals coming in both at risk for from injection drug use as well as sexual risk, and there was no prep discussions that were happening in the hospital until there was effort to use that as a moment to educate individuals about prep and to start initiate prep in the hospital and then discharge individuals. That program has been ongoing and there is going to be data hopefully available next month or two around the amount of prep initiations that were able to be initiated, reaching communities that have been relatively low uptake of prep particularly among individuals experiencing homelessness. And then there are several other expansion programs around both prep as well as syringe services. These are focussing on cluster. A big part of this is developing a cluster and outbreak Response Plan that needs to be multijurisdictional. As i tell folks in soma and i can get to west oakland faster than the campus and were mobile and our communities are overlapping with other jurisdictions and how do we ensure we can respond to clusters that might cross jurisdictions . So this is really working closely with our local jurisdictions as well. So actually ill end there. And ill turn it over to susan philips. If the commissioners have questions, im happy to take them. Thank you, dr. Scott. Commissioners, any questions before we hear from dr. Philip . All right, seeing none, dr. Philip . Thank you, president bernal, commissioners, and thank you so much for the opportunity to present along with my colleagues as part of this really Important Panel and discussion. And i think its really important to recognize while were each speaking from our individual teams perspective in which we have expertise in individual areas, i think you heard from the last portion of the presentation, were thinking about this work holistically and understanding there is so much overlap in the work we need to do to improve disparities and improve Sexual Health overall. Next slide. So you heard a little bit about the aids foundation and the great work they do and the clinical services. I wanted to make sure youre also aware that we have have Wonderful Services as well at city clinic, which is the only municipal clinic run out of the department. And city clinic operates 36 hours a week. Its our Sexual Health Services Clinic or the city and county of San Francisco. And in 2019, we saw that 15,000 visits, 64 of the visits were by people of color. And really important Sexual Health work in an integrated way happens with the team at city clinic. In 2019, there were 741 initiations that happened at the visit. There are 120 patients in 2019 that were served in extremely low barrier and in 2017, they diagnosed about 16 of the overall declining amount. So, again, that sort of comprehensive approach is so important. But as we had heard previously at city clinic, magnet, other care sites, the visit levels decreased and are not back up to preshelter in place levels. What the clinics have tried to do is focus on urgent Sexual Health care needs. Have had limited asymptomatic sti screening and that has been a gap. We tried to fill it with creative ways. Some of which you heard from dr. Scott. Extending the refills for prep. And really, moving and pivoting to telehealth which hadnt been done before and trying to manage syndromes as people describe them to us. So here, this is really just looking at the data from city clinic, but the same pattern weve been talking about. During shelter in place, the visits dropped by twothirds. Even after the shelterinplace were seeing half the visits because of the need to have spacing, the ventilation issues and so on in the clinic. Next slide, please. And so this is not just a city clinic because chlamydia and gonorrhea tests in all San Francisco residents are reported to the Health Department by law, we see here those reported cases among San Francisco residents have dropped had dropped as well during shelterinplace. This is happening in all providers and we see that drop has continued over time. Its the same story youve been hearing with h. I. V. Is true and the others as well. And in addition, to having the challenges of people not being able to get in to be seen, in addition weve had shortages that have recently been announced and noticed. Shortages of testing components. So for chlamydia and gonorrhea, the implication test, which are the recommended test sites, have been in short supply and we received a Dear Colleague letter from cdc about this earlier last month. The reason for this, like the visit changes, are tied to covid19 as a lot of the National Production lines have been moved over to try to accommodate this immense need for covid19 testing. So we have been able to order alternate, so the testing we have done at city clinic has not been interrupted or the Public Health laboratory. And were working with other selfhelps to assess for shortages there as well. Cdc has recommended certain priority groups that are higher risk for chlamydia and gonorrhea, including women under the age of 25 and men who have sex with men, and then patients who present. Were in the midst of planning a Health Advisory as we do assessment of other Health Systems and what theyre experiencing. Next slide, please. And the concerns, just as with h. I. V. , this decreased access is not going to come back to everyone equally and well be worsening the existing health disparaities which are higher rates among h. I. V. In people of color. This graph is looking at chlamydia tests performed over time. We see that drop off in march and extending into april. It really seemed to affect all racial ethnic groups at the same time, but what we see, we see the orange line which represents tests among white patients increasing above some of the other ethnic groups. So again these are efforts we have to monitor and think about ways to creatively decrease these access and testing gaps. So some of the ways weve been trying to do this is again this telehealth model we had not previously done. Selfcollection of swabs and specimens in different routes, including new Generations Health center. People have done a Curbside Pickup and dropped off their specimens for testing. Home testing as we just heard about from dr. Scott. And then working with the Health Network to really measure the screening in any primary care visits that do occur, so chlamydia screening in women under 26. And cdc has been putting out guidance on management, which ideally, we want to get the test and get a diagnosis, but if not, if people just present with discharge, we have ways of treating them even if we cant get the test wed like to. Our top priority and the last time i was able to present to you, this was also a concern. Congenital syphilis. This is the most devastating outcome of the nonh. I. V. Stis resulting in neonatal. And these cases are increasing in the United States and california. These are generally among very Vulnerable Women with history of substance use, people experiencing homelessness and a lack of prenatal care. The cases are rising among women in San Francisco. While cases among men comprise over 90 of the cases, the number in women while still small has been increasing. And from 2017 to 18 we saw they increased 84 among women. And so that led to our activation of the command of structure in 2019 and that was at the point we went from 62 to 114 cases among women. And unfortunately, its continues to increase. We see racial and ethnic disparities with the women diagnosed with syphilis as well. With black africanamerican women disproportionately impacted here. The thing about syphilis among women, congenital syphilis, that treatment with penicillin cures syphilis and prevents genital syphilis. So our primary goal within std and within our disease intervention specialists at the moment for std is to ensure extreme for 100 treatment for 100 of effected women. This is showing the bars by year, the numbers in grey of women that were assigned as cases for followup for treatment and then the percent in blue that were successfully treated by the link team. The navigation to care, which is a team that works on the syphilis and h. I. V. You can see that as the numbers increased greatly, i can assure you the team did not grow in proportion to the number of cases, but they through really great work, have managed to enable treatment for over 90 of the women. And, of course, our goal is 100 . And we are thinking of new ways to increase that percentage further. So again to reinforce, our cases overall of congenital syphilis are quite low compared particularly to some of our other challenges in california and other areas of the United States, which have very, very high case numbers and case rates. But, again, because each of these is a potentially tragic loss of life or health, we want to do everything we can to prevent all cases of congenital syphilis. We went from zero cases in 2018, to four cases in 2019. And through the period of time we have one case. But weve had three additional cases since then in the third quarter, so it remains a strong concern. Next slide, please. And this is a busy slide that has a lot of dense important data. This was put together by one of our outstanding epidemiologists. Its looking at cases among pregnant women from 2018 to 2020. There were 27 such cases during this time and you can see by the shading of blue, the grouping by year. And then the most important line is right below that with the circle, the pregnancy outcome. A solid blue circle means there was a case of congenital syphilis averted. The pregnant woman was able to receive treatment in time within 30 days of giving birth, which averts syphilis in the infant. Red is unfortunately a case where that did not occur and congenital syphilis was diagnosed in the baby, either because there was a Clinical Evidence of congenital syphilis in the child or because it met the definition of being treatment less than 30 days at the time of birth. Then grey is where there was either therapeutic or spontaneous abortion. The single circle, that is green with the white inside, means that at this point in time, the mom was treated but had not yet delivered the infant. And if you look at some of the risk factors going down the rows there, lacking prenatal care is overwhelmingly associated with the cases of congenital syphilis seen in San Francisco. Experiencing homelessness is quite common and using methamphetamine. So again, speaking to the vulnerability of these women and new ways of working and new partnerships that will be needed to avert cases and try and reverse this trend. So again, this is why we had the activation in 2019. This started as a health alert in may. And we started the activation june 3rd and it went through the end of the year. Next slide. And it was truly a partnership between many areas in d. P. H. , both in the Health Network and the Population Health division, including the offices of Health Equity. Dr. Bennett was a leader in this work as well. You can see the many areas within both the network and ph. D. That were involved in trying to do this. It was an unprecedented effort up to that point. Now were seeing a much larger scale activation citywide, but this was a really important effort to get a lot of key partners together. So you know, now post activation, i can tell you what we accomplished. So it went it was meant to transition into an a3 process in january, but then covid came along. We did make breakthroughs. We have a result of the work, a new partnership with team lilly. Its led by doctor simon and others and it specializes in prenatal care to women with bare seeking care. Through grants, were funding team lily and working with them. Rapid syphilis testing has been rolled out in jail health and street medicine. And that partnership has been wonderful. Along with team lily and the disease investigation specialists, theyre going to be instituting case conferences to talk about women and making sure we can offer syphilis screening to women and follow up with prenatal care and medicine. These multidisciplinary case conferences are important because there are so many avenues of care that are needed to ensure treatment in these women. And linking them to the other services they need. And then another thing that was done through the team and jackie mcbright, a very experienced std specialist is testing information and approaches with women experiencing homelessness to see what type of messages appeal to them. We worked very closely with dr. Luke john day at zuckerberg San Francisco General Hospital and were making plans to really think about syphilis screening among women that came into the Emergency Department and care. We were limited about our timing because this was when being rolled out. Then new reports that look indepth at syphilis in women are happening every quarter. As i said, we were in the process of switching from a structure that served us well into a more a3 response. I want to switch a little bit to talk about innovation in the last two slides. So really, the reason that weve had such profound success with h. I. V. Is because of biomedical prevention of h. I. V. Both with preexposure prophylaxis and the profound imi im impact on the field and getting to zero. We would need that. A vaccine would be wonderful, but other approaches are important. There are preliminary data to say that this medicine seemed to reduce the incidence of chlamydia and syphilis. That was enough of a signal to really warrant trying to do a study, a larger study. So this is a study doxy pep that is going to be done among 780 people who were assigned male at birth. Either living with h. I. V. Or on h. I. V. Prep. Men who have sex with men. And theyll be randomized to getting doxy sigh clean after sex oar not. And were enrolling in San Francisco at ward 86 and also at city clinic. And dr. Scott, dr. Butch binder and the team is led by dr. Stefani cohen. Dr. Connie from washington. This is really exciting. Well get to see if this biomedical intervention does work to reduce syphilis and chlamydia. And theyre going to be evaluating for safety of taking doxy longterm. The reason that women are not being enrolled in the study is because doxy can have bad impacts on a fetus if a woman happens to be pregnant. So this initial study is limited to people assigned male at birth. And then finally another exciting innovation. I think well hear about this more from director armstrong when she speaks in an upcoming system. Planned both by leadership and ncah, upsf, Population Health, and i think its really very exciting to bring together Community Members to engage in conversations about how institutions can really enable people in this work of reproductive justice and how we can become client focused and better provide the services and embrace the goals together. So im really looking forward to this and well be sure to share information with you commissioners as the date comes a little bit closer and those plans are finalized. I believe that is my last slide. So thank you very much for the opportunity. To be with you and share these information with you and present alongside my colleague. Thank you, dr. Philip. Commissioners, questions for dr. Philip . Commissioner green . Commissioner green thank you for this wonderful information. I guess i had two questions. One is, can you touch points that brought the pregnant female syphilis patients in. I think out of the five that are the bad outcomes, three were homeless and two were not. And i wonder, you mentioned clinics and so forth. Is there anything you can learn or any information we can gain based on when they actually entered the system . And another system that comes from earlier in the presentation, you talked about telehealth and selftesting, yet, those two elements, you know, have significant barriers. I was wondering if there is a particular population that you think would be most amenable to approach through those means or you know how youre kind of directing your resources to try to get the greatest effect given the limitations of trying to reach populations . Yes, absolutely. Thank you, commissioner green. For the telehealth and selftesting, what has been shown in studies and in other jurisdictions have been that gay men and other men who have sex with men do take up those routes and are able to use them. As i said, we still have over 90 of our syphilis patients among men. I dont want to down play Offering Services to gay men in San Francisco. And that is very important. And speaking of some of these creative avenues to do that will be help. Ful. We also want to see if young women, adolescent women will be amenable to vaginal swabs and taking that route. As you said, the intensive work we want to do in person, in conjunction with street medicine, our colleagues at General Hospital and other will most likely be best served in working with a very vulnerable population of women that have limited prenatal care before delivering. In fact, for a large portion of those individuals that did end up being diagnosed with syphilis and having an infant that was diagnosed with congenital syphilis, there was not touches to the system ahead of time. Like during their pregnancy. Were doing case conferences to try and look for opportunities, you know, to intervene and make sure that providers throughout the city know about this. Of women with syphilis, about a third of them are served by our own San Francisco Health Network, so its really wonderful that our colleagues there are as engaged as they are. Because we need to look together for any opportunity to do that. Were hoping that street medicine because theyre so proactive and have relationships and out in communities of unsheltered people, might be able to enable us to try to offer screening if we know that someone is might be pregnant or others know people that might be pregnant within their social networks or nearby. And then having lily be able to really offer that clientcentred prenatal care to whatever extent the person is able to engage in it is also wonderful. So were hoping that this model will be helpful in preventing what is happening before that people present in labor and we dont have a chance to do anything before. Thank you. Commissioner chow . Commissioner chow yes. Dr. Philip, thank you for your presentation and also wanted to ask as you mentioned that youre still emphasizing obviously the stds that are in males and gay males, but at the same time as we heard earlier in previous years, the rise of std was also in the young. And so the project that was described, the integrated h. I. V. Program, would seem to be targeting the h. I. V. Population. How are you looking at also being part of that as and at the same time also as you did with the congenital program, how would you then continue to also concentrate on the black and young male std rise . Absolutely, commissioner chow. Yes, so we are we are trying to understand what the best ways are to continue to deliver services so that young people have access. And you know, we have also been watching to see if youth are going to which clinics theyre going to. And i think that the plan weve heard about from dr. Hammer to roll out or to reopen the clinics will be helpful in that regard. And i think, again, these ideas of nontraditional ways of doing screening and low barrier ways of doing screening are also important. I previously talked about our great work with our amazing partners at services and pratt and her team. They have been also really champions of trying to do rapid gonorrhea and chlamydia testing within jail populations as well. So i think there are several ways in which were trying to move the work forward. It becomes much more challenging in the time of covid, as all of our work is. And so were continuing to refine and try to improve that within the limitations, spacing and needing to have patients per hour at clinic. We dont have all the answers and were trying to work with partners with expertise and also hear from community as to how they would like us to. Thank you. I know that well continue to look forward to not only this collaboration, but also the emphasis of trying to reduce overall std rates in the city. With the new innovative ways that youre thinking of, and some of that will come from the experience working with the h. I. V. Project there, too. So well look forward to Additional Information as we get more reports. Thank you. Thank you. Thank you, dr. Philip. Commissioner chow. Any other questions from commissioners . Dr. Philip, i did have a question. Its for you and all of your colleagues. I view San Francisco as having the best second to none health and surveillance. And every year, particularly when we get these reports from you and your colleagues, we find encouraging things. We find evidence of the great work that theyre doing and areas that we need to refocus our efforts. Given were nine months into 2020 and this is no year like any other, is there an Inflection Point where we will use the Data Collected from this year and what is happening in terms of Risk Behaviors and other things so we can adjust our strategies accordingly but do it more quickly and more in realtime . Yes. I think that is very much very much needed. And you know finding exactly what the Behavioral Changes have been, i think we may also need to rely on some of our academic colleagues and others who are able to dig into that more. I will tell you that my team and i weve been focussed on what we know the structural barriers are as a result of covid. I think all of the pieces, as you said, have to come together. And without sort of all those pieces, we wont know if we see the decline in syphilis for 2020 or 2019 what that means. And i think none of us would feel reassured by that and i think wed want to really understand dive more into the different aspects of the data you have. Knowing that is going to be somewhat limited by the data that was reported to us and the fact that a lot of our leadership is involved in the Covid Response, which is really important. Our epidemiologists are community experts. And our disease intervention specialists as well are leadership. So its balancing all of those things which is a constant challenge, but were our team is up to it, so were going to keep working at it. I know you are. It ties back to one of the points made in dr. Scotts presentation, which is a great concern, that black patients have worse viral suppression, but it has not changed in covid. So what can we learn from that and how that may provide useful ways to address the fact that black patients do much worse in the suppression. Because as we know, viral suppression is not just an issue of patient outcomes, but community outcomes. Absolutely. And i think that, you know, understanding that all the Sexual Health outcomes and hepc, theyre all tied together. Theyre the same structural barriers and underpinning of racism throughout, that we are all going to be working together and using these federal dollars to find new ways of improving our work and thats our Constant Mission and pledge. Great. Thank you, dr. Philip. Commissioners, do you have other questions or comments . Mark, any Public Comment . There still remains no one on the Public Comment line. Ive remained hopeful, that, unfortunately we do not have anyone. Dr. Philip, dr. Scott, dr. Hsu, thank you for your presentation. I look forward every year. Thank you so much for that. All right. Moving on to the next item. Other business. Commissioners, any other business . All right. Seeing no other business, welcome move on to item 12, which is a brief update on the joints Conference Committee from zuckerberg San Francisco General Hospital. Pardon me, did i miss somebody . Or if not, commissioner chow . Commissioner chow thank you. Briefly, we did do a routine study, routine reports on the regulatory affairs. We also received a very comprehensive presentation on zuckerbergs quality programs and data. The enormity of over greater than 100 measures that we have with maybe six or seven different types of reporting agencies that they go to. And its implications. It was a very good presentation and i think that we might be able to distribute that to our commissioners here. Action items included the approval of the Laboratory Medicine rules and regulations, intervention radiology, standardized procedures and we had a closed session where we did review our work and passed the credentials report. So put that into my report. President bernal thank you. Mark, any Public Comment . No Public Comment, sir. President bernal commissioners, any questions for commissioner chow . If not, the next item which is consideration of a closed session. Do we have a motion to move into a closed session . So moved. Second. Commissioner, roll call vote. Commissioner chow yes. Commissioner green yes. Commissioner christian yes. Commissioner giraudo yes. President bernal yes. Before we move out of open session, i want to thank all of the d. P. H. Staff that joined us and provided excellent presentations today because we may not be seeing you when we reopen briefly to adjourn. So thank you. If everyone wil closed or not disclose the discussions from the closed session. I move not to disclose the discussions during the closed session. Do we have a second . Second. Thank you. All right, roll call. Commissioner green yes. President bernal yes. Commissioner christian yes. Commissioner giraudo yes. Commissioner chow yes. Thank you. President bernal moving on to the next item, 14 which is adjournment. We will enter a motion to adjourn. So moved. Second. Commissioner christian yes. Commissioner green yes. Commissioner chow yes. President bernal yes. Thank you, everyone. Thank you. And the city of San Francisco would like your assistance, the Board Meeting is now called to order. Due to covid19 Health Emergency and given the Public Health recommendations issued by the city and county of the San Francisco Public Health, and governor newsome, and the restrictions on the teleconference. We will be virtually with all members and staff participating today via teleconference. And to ensure the safety of the board, the staff, and the members of the public. Now Public Notice for this meeting and on the web page we ask the public to participate remotely by writing to the board or leaving a voicemail message. For all comments received in advance of the meeting we have received and we appreciate these comments. While Technology Allows us to hold these meetings via teleconference, it may not be as seamless as it would like to be. There will be gaps in some airtime, staff at times the staff transitions between the speakers and the callers. Know that we are doing the best that we possibly can and we ask for your understanding and patience as we are all learning this new way of working together. A reminder to the Board Members to mute themselves to minimize the background noise. Board members will have to remember to unmute themselves to comment. Again, were going to ask everyone to be patient as we make these adjustments. Madam secretary, roll call, please. Clerk [roll call] we do have a quorum. President bridges . Number two, communications. Due to the covid19 Health Emergency and t due to the covid19 Health Emergency and to protect the Board Members, and the employees and the public, the system is closed. However, members will be participating in a meeting remotely. This precaution is taken pursuant to the local state, and federal orders directives and orders. The Board Members will attend Via Video Conference and the meeting will be to the same extent as they are physically present. Public comments are available on each item on this agenda on channel 26 and sfgovtv. Org and we are streaming the number across the screen. Each speaker will be allowed two minutes to speak. Comments are opportunities to speak during Public Comment period and are available via phone, by calling 4156550001, and access 4165792433. And then pound and pound again. When connected you will hear the meeting discussion, and you will be muted and in listen mode only. When your item comes up, press star, 3, to be added to the queue. And call from a quiet location and speak clearly and slowly and turn down your tv or radio. Alternatively you may submit Public Comment in either of the following ways. Email to Public Commentat sfgovtv. Org. And Public Comment lines 4154877220. And Public Comment via email or by recording it will be included as part of the official file. President bridges . Okay. At this time the board will be going into closed session. The board will begin with general Public Comment for no earlier than 2 00 p. M. Well take Public Comment and were going into closed session at this time. Madam secretary, please open up the phone lines for Public Comment. Clerk members of the public who wish to provide Public Comment on this item should call 1 415 6550001. Access code 1465792433. And then pound, and then pound again. If you havent already done so, press star, 3, to line up to speak. The system prompt will indicate that you have raised your hand. Wait until the system indicates that you have been unmuted and you may begin your comments. Please state your names and make your comments. You will have the standard two minutes to provide your comments. Moderator, do we have any callers on the line . Madam secretary, there are no callers on the line. Thank you. Hearing no callers, Public Comment is now closed. President bridges . Commissioners, please join me in closed session in this meeting now. Thank you very [roll call] fbz. Clerk we have a quorum. Motion is in order to vote whether to disclose the discussion held in closed session under San Francisco administrative code section 67. 12a. Commissioners, may i have a motion whether to disclose or not to disclose . Ill make a motion not to disclose. Second. Second. It has been moved by commissioner casciato and seconded by commissioner driscoll. At this time, well take Public Comment. [inaudible] please press star, three to be added to the queue. If you are already on hold, please wait until the system indicates you have been unmuted. Moderator, are there any callers on the line . Operator madam secretary, there are no callers on the line. Clerk thank you. Hearing no calls, Public Comment is now closed. President bridges . Thank you, madam secretary. Again, it is moved by commissioner casciato and seconded by commissioner driscoll that we not discuss the matters held in closed session. Madam secretary, a roll call vote, please. [roll call] clerk you have four yeses. Motion passes. President bridges . Thank you, madam secretary. Next item, please. Clerk item number 6, general Public Comment. Commissioners, i received one Public Comment. In the september Board Meeting, you agreed to invest 300 million into an investment called alanis. Its in mostly european securities. Our pension fund is over diversefied, high risk, high cost, low liquidity investment. To quote warren buffet, wise diversefication is only warranted if investors do not understand what theyre doing. Thats the end of his Public Comment. Thank you, mr. Hughes, for submitting that comment. Madam secretary, please open the phone lines for general Public Comment. Clerk members of the public who wish to provide Public Comment should call 4156550001, access code 1465792423, then pound, and pound again. When connected, you will hear the meeting discussion but mutes and in listening mode only. When your item comes up, dial star, three to be added to the speaker line. Best practices had to calling from a quiet location, speak slowly and clearly, and keep your microphone muted. Madam operator, do we have any callers on the line . Operator madam secretary, we have no callers on the line. Clerk thank you. Madam pra madam president , we have no public callers on the line. Thank you. Madam second, next item, please. Clerk item 5, approval of the minutes of the september 9, 2020 retirement Board Meeting. May i have a motion . So moved. May i have a second. Yeah. Second. It has been moved by commissioner chiu and seconded by commissioner casciato that we adopt the minutes from the september 9, 2020 retirement Board Meeting. Well take Public Comment at this time. Please press star, three to be added to the queue at this time [inaudible] moderator, are there any callers on the line . Operator madam secretary, there are no callers on the line. Clerk thank you. Hearing no callers, Public Comment is closed. President bridges . Thank you, madam secretary. Roll call vote, please. [roll call] if. Clerk by a unanimous vote, the motion passes. President bridges . Item number 6, action item, consent calendar. Consent calendar. Lets [inaudible]. Id just like to ask about item number 6e. 6e, commissioner casciano . Yes. Yes. That would be what would be exhibited in the board packet, and also, they could present an oral presentation of the conference, also, if they wanted to at this point. Okay. So were just moving it from the back end to the you know, what weve gotten is, in the last couple months, just moved it from the back end to the front end of the agenda, correct . No. The comments the good of the order comments are still at the end of the meeting. This is just for approved it used to be approved travel and attendance at conferences, but the board policy requires that a board member present, you know, a review of the agenda. So this does not replace the good of the order. The good of the order no, i didnt mean that. I didnt mean good of the order at all. We used to have it the back end we used to have the copy of the form, and thatll be included in this item 6e . Yes, thats correct. So the form will be included, and when we make a motion for the minutes, if anybody wanted to make a motion regarding the minutes, this is where they do it . Thats absolutely correct. Okay. Ill make a motion to approve it. Commissioner casciato, to approve the consent calendar . Thats correct. Okay. Second. Okay. We have a motion and a second to approve the consent calendar. Public comment, please. [inaudible]. Operator madam secretary, we have no callers on the line. Clerk Public Comment is closed. President bridges . Yes. Roll call vote, madam secretary. [roll call] clerk we have four yeses. Motion passes. President bridges . Thank you, madam secretary. Next item, please. Clerk item number 7, discussion item, annual esg update. Thank you, madam secretary. At this time, mr. Coaker, ill let you make the introductions of the members that will be presenting the usg updates. Thank you, president bridges. [inaudible] collaborating with others on esg initiatives, and hiring a director of esg investing. Andrew collins was hired in such a position a few months later, and andrew was tasked with building a factbased data driven, researchintense approach dedicated to carbon related investment reps, and he has been doing so sense. We hired ann, who was hired a few months ago. There is a series of six recommendations. Five are action items, and one is an update. Recent initiatives have included staff making an ambition, staying in ambition to become Carbon Neutral by 2050, and that well have an annual update and Strategic Review every five years. Well ask kurt to provide additional context, and then, well turn it over to andrew. Thank you. We hired andrew about 2. 5 years ago, and i dont know that we intended to have six items presented at one Board Meeting. So the consequence, andrew has a lot of work to be done leading up to the october Board Meeting. I do want to acknowledge the vost amount of work that he did and that adrian did. Adrian only joined six weeks ago. I do encourage everyone to read these. We have six different topics. The discussions here are quite thorough. We have one discussion item, five action items. Well begin with our annual esg update, which will provide a little bit of sfers update in the e. S. G. Space and then provide the three pillars of our e. S. G. Program, which are ownership, investments, an area that i think weve made extraordinary progress in across all Asset Classes at sfers, and then finally, discussion of our collaboration efforts with the public at large. Well then turn to four action items that both have been our targeted divestment companies which have included tobacco companies, sudan, oil and coal, and well end with an update on our Climate Action plan and actions forward. So andrew, ill turn program o year. And just want to start out, i guess, with a few comments and observations about whats happened more broadly in the e. S. G. Discipline in the last year. Like everything, its been an interesting and hectic year between the Economic Impacts and volatility in the markets due to covid, and the shutdown, the massive social movements calling attention to issues of systemic racism and inequity, and then, more recently, the wildfires in california and throughout the state, all of these things really intersect with a lot of the e. S. G. Themes that we look at in the investment process. And given everything, if i had to look at one theme of the year to highlight, i think it would be the social pillar, the s within e. S. G. Has certainly gotten a lot more focus from companies and investors over the last year. I think over a decade, decade and a half of a lot of focus on Environmental Issues and certainly corporate governance, as we think about Worker Welfare in the light of expectations around being an essential worker, certainly, employee pay, benefits, issues of diversity and inclusion in the workforce, corporate culture, i think these things have come into much clearer view for a lot of corporations and investors over the last year. And really, instead of turning away from any e. S. G. , the efforts, i think weve seen everybody lean into them and realizing even during a period of stress and market stress. These issues are really important. This continues to come up with our managers, as well, as we talk about it with them. At the same time, you know, climate has still been a big a big theme for the year, and the year actually started, interestingly, with a letter to c. E. O. S, where we talked about funding due to climate risk, and how that will affect investments in the economy over the longterm, and black rock, as one example, given their size and an assess manager, black rock updated its voting policies around climate risk. These are meaningful steps that that have occurred over this period. And, you know, corporate actions have also progressed a lot in terms of climate change. Youve seen a ton of Companies Making netzero commitments by 2050, and these are not Just Companies that have minimal environmental impact, these are Companies Like shell and b. P. , the largest corporations in the u. S. Like dominion have made commitments around the upcoming Carbon Neutral, and Greenhouse Gas emissions neutral. Microsoft went so far as to say that theyre going to invest 1 billion to negate their Carbon Footprint that theyve ever invested in the company. I think the social factors have become more and more important. So ill ill start here with just a reminder of our, you know, e. S. G. Beliefs, and a bit of history of our e. S. G. Policy. Our core belief is that e. S. G. Factors can and do influence outcomes in nearly every investment that we wake, but how they do so is typically w nuanced in each case. We really take what id say a principled approach to e. S. G. Considerations and not a prescriptive approach to e. S. G. We began the effort quite sometime ago in 1988, when we first had our social Investment Policies thats evolved a lot to an e. S. G. Policy that kurt described has these three pillars of active ownership where we think about influencing public equity outcomes in our portfolio management, voting our proxies, we integrate e. S. G. Considerations into oush manager selection process, and our ongoing relationships with those managers and then e. S. G. Collaboration and information, where we work with other stakeholders in the financial community, certainly with our wi beneficiaries to communicate with e. S. G. Ill provide a little bit of an overview of what weve done in 2020. Ill skip over these slides for now, but its a history of e. S. G. Over the last 20 years, if folks want to take a look at that at some point. 2020 here and ill try to make this screen a bit bigger here so folks can see it. Hopefully, thats a bit better. For 2020, i really want to highlight, i guess, four things, four focus areas from the last year. One, bill mentioned we announced the ambition that the trust become netzero by 2050. This was, you know, an important step in really expanding our view of climt risk among publicly traded oil and gas classes and climate risk among publicly traded oil and gas classes and thinking about climate risk that goes much further than just thinking about our exposure to oil and gas companies. Two, we continue to support and expand our engagement on climate risk, where we acted either as a lead engager or even in a supporting role with over 20 Companies Oil and gas companies, utilities companies, where we, you know, sat down with those companies, provided input that shapes policies around decarbonization targets, enhanced transparency around e. S. G. Practices. Third, wed like to highlight that we continued to prioritize board diversity, and that was thr through our voting efforts and engagement. We voted against the chair of nominating government committees of roughly 3,000 companies that had fewer than 20 women on the board, and we voted against entire boards where there were no women on the board this year. So those were updates to our voting policy. We continued our engagement efforts through a 30 coalition, and, you know, i think those were very successful in the four companies that we engaged with through those efforts, and we were really asking, you know, those companies, you know, two main things. One was to think about actually adding additional women to their board and then second was to ask them to think about updating their corporate charters to actually implement things like the winnie rule, which commits them to not commit to adding additional women to their board but considering a diverse search and looking for diverse candidates when doing that search. Next, and looking forward a bit, weve joined a partnership with three other california pensions calstrs, calpers, and lucera. This is a reminder that our efforts are not focused just on gender but on race and ethnicity as we engage with companies, and thats part of our corporate and governance belief, workforces that are reflective of society at large tend to perform better over the longer term. And the fourth area to really talk a bit about is our e. S. G. Investment management pillar. We really deepened our e. S. G. Engagement with our own external managers, and this is across Asset Classes. So not only are we conducting e. S. G. Due diligence when we make a new recommendation to invest, but we really have to take a step back on some of our core relationships in the private equity allocation and the absolute return program and have sent questionnaires and engaged in conversation with those managers around their own e. S. G. Integration practices, and i think have had some really, really productive conversations there, where weve learned a lot. Theyve asked for input, and weve learned about how theyre shaping their e. S. G. Program Going Forward. We also have, in our Public Equity Program and fixed income program, weve begun a deep dive in engaging with our managers around climate risk, and thats part of our netzero by 2050 ambition. A starting point there is we send a details questionnaire around climate risk and then had deep dive conversation around that. Again, a lot of really constructive learnings from those engagement efforts, partneri partnering the e. S. G. Teams partnering with the investment teams. So well turn to slide 7 here now, talk a little bit more about other active ownership activities that i didnt just touch on. Progress over the last year, you know, started with an update to our learning guidelines. Remember where i said we strengthened our voting requirements around board diversity, but other shareholder proposals related to human capital, gender pay gap proposals that come to shareholder votes, and we took another way that we look at remuneration packages and really revised some of those core aspects to plant a stake in the ground where we believe there should be proper remuneration for proper performance by companies and c. E. O. S. So with respect to that, we ended up voting against 22 pay on [inaudible] proposals, were continuing to scrutinize excessive executive compensation thats not linked with performance. In terms of engagement activities, i mentioned those we had with climate risk, with oil and gas companies. Weve also engaged some retailers like Dicks Sporting Goods and walmart on firearm retail practices through a partnership that we have with calstrs and other active asset managers. Those have been really productive, as well, to think about how do you responsibly and safely participate in retail of firearms . And then, we also had a, you know, several other conversations throughout the year. Things ranging from sitting down with pork and beef Processing Company to talk about their Covid Response and Worker Health and safety, sitting down with a big three audio o automaker to think about their services there, professional lobbying firm around professional lobbying and disclosures. And those are things that well do if they arrive if there are particular votes coming up if theres opportunities to partner with other investors on those efforts. Well now move onto the second pillar here, e. S. G. Investment. To some degree, this is the core of our e. S. G. Program, supporting the investment teams Due Diligence ongoing monitoring of our investment manager relationships. As i said, weve really strengthened that, not only at the Due Diligence phase, but also, as we think about ongoing relationships that we have with managers, where we may invest fund after funds, and have tried to engage and build relationships around e. S. G. To learn what those practices are and form, you know, our own views of their investment approach and style. [please stand by] so some of that is just the overall efficiency from and then Revenue Growth occurring in the overall economy, but weve decarbonized faster. Why is that so . A couple of things are going on. One is that we are underweight to the most carbon intensive sectors, and you can see this in the chart on the right. The darker lines are our portfolio weight and then the dotted lines are the index weight. So the utilities, materials and energy sector. So we are underweight to sews te sectors, so thats improves our carbon weight. Some of the most carbon efficient sectors. So those two factors that underweight and overweight contribute significantly to our reduced Carbon Footprint. The second thing was at the boards direction we invested 1 billion of our equity portfolio to two sectors that had reduced Carbon Footprints versus their benchmarks. Thats the Goldman Sachs strategy and the Global Equity strategy, both of those have resulted in additional Carbon Intensity reductions against our benchmark. One thing interestingly that we looked at this year was actually, you know, any short positions we had in our public equity portfolio and the Carbon Footprint associated with that part of the portfolio. And not by design, but as it turns out, our portfolio is overweight, the portfolio is overweight, and this is in aggregate, right, to high carbon sectors, like utilities and materials, and then even within other sectors, there are greater short positions in more carbon intensive companies, and thats true in the real estate sector, its true in the technology sector. So this is, you know, further reducing our exposure to carbon risk, if you want to think of it that way, through those positions. If we look beyond the public equity and fixed income portfolio, were really limited by data. But one thing weve tried to do in the report is show from a sector perspective our allocation to the three most carbon intensive sectors, and in aggregate, if we look at our overall, the overall sfers portfolio and compare that to a 70 30 portfolio, we are significantly underweight utilities and materials and have [indiscernible] sustained energy exposure. If you think of using assumptions and averages, we would have a much lower aggregate footprint, most likely in the absence of data which doesnt exist to just think about exposure there. Every project we do, we look at our investment exclusions that weve put in place since 1998 with tobacco and weve works with msci to license some customized indices so we can have some sort of model on what impact those may have on planned returns and risks since we put those in place. Basically what we do is we licence an index that excludes the companies that weve excluded. We compare that to the generic msci index and we assume that any gains or losses were reinvested with, you know, the same allocation that we had to each asset class. Over time, you know, our portfolios shifted, of course, over those many years for different reasons. So this relies on some assumptions to get a good sense of, as we said, a positive or negative impact. As you can see, in aggregate its been negative. Thats been really driven just by tobacco exclusion that weve had in place since 1998 that was, you know, sometimes positive, sometimes negative, but really just due to compounding effects, mostly that in aggregate has cost about 88 million over that time period. In aggregate, the other exclusions can be said to be negligible or contributed positively. We have assumed over the last year, you know, a negligible but positive interaction from all of those exclusions that you can see in that final column year over year impact fy19 to 20. The chart just shows sort of the volatility of those relative returns look like over time, and you can see that theyre in different time periods they contribute in different ways. one moment please . We continue to be very engaged with series, they coordinate the climate 100 initiative and the carbon Asset Working Group we participate. Ive mentioned the 30 coalition and the council of Institutional Investors is a longtime membership that weve maintained and we participate in their events and take advantage of their resources. As well, ive also mentioned the principles for responsivelyian firearms industry. Civilian firearms industry. We continue to do transparent and conduct esg reporting through presentations like this, publishing materials, updating earlier in the year or, you know, later if you think about our next report on our proxy voting and shareholder activities and we did a policy refresh, as you all recall, last fall and the beginning of this year on the esg policy and the proxy voting guidelines, and then built out the esg section or reference in the Investment Policy Statement as well. So i will close there, put my first slide up here. But thats the update, program update. Im happy to answer any questions there dive in. As you know, this is not a voting item. Commissioner thanks, andrew. Did you have anything to add to that . Commissioner maybe just one or two questions. The platform that andrew just described has become a valuable working tool for Institutional Investors around the country. In addition, as andrew described, in each of our investment recommendations now for quite some time weve been including an esg assessment in every recommendation, and also over time weve seen the volume and the depth of that assessment has also increased [indiscernible]. So you will have seen those now for probably the better part of a year. Thank you. I would like to ask a question of andrew. Please. [indiscernible]. Andrew, how would you describe how the state of esg is you know, weve gone through periods where theres been a lot of activism, but where would you say that the movement has grown to or settled at right now and moving forward are we making Good Progress . Are we on good lines . Are we in conflict . Will we have any conflicts or will we have more collaboration moving forward here . Yeah, i think i would say more of the latter. Its a great, great question. But certainly i think, you know, particularly last year where i think Investor Expectations and corporate expectations are around a lot of esg practices, those social factors that i mentioned but also the Climate Action youre seeing, sort of in the absence of any regulation, shows a lot of alignment with, you know, investor views and corporate views and actions. So it has been highly collaborative. Again, there have been fewer shareholder proposals introduced at Public Companies over the last year, and a lot of this is actually, you know, due to the fact that companies are willing to engage with investors constructively in order to address esg concerns, which is really good to see. Weve also seen an explosion of esg efforts outside of the public equity and fixed income Asset Classes. So, you know, the private Equity Industry is doing a lot to address esg factors in their own portfolios, but also looking internally at their own firms and talking about, you know, how to think about esg risks, opportunities there, in the way that they run their own firms. So i would say, you know, a lot more work to do on a lot of challenging issues, but very constructive, in my view. Thank you. Yesterday i had the opportunity to be able to watch for about an hour and 21 minutes the apple rollout, apples rollout of their new products. And one of the things i was impressed with is that they focused on their new buildings, apple campuses and their production lines that they were Carbon Neutral, they said, were one point was 450 tons of carbon monoxide, the equivalent of taking 10,000 cars or more. They made some points about what products theyre using to produce their phones, et cetera. So i was pretty impressed. Do you think thats would you say thats a common thing . Is that special to apple, or is that a common thing for some of the other companies . With the hesitation of sort of commenting on whether a company is a leader or not, i think i will say that there are a set of companies that are sort of taking leading efforts to integrate these considerations into Product Design and Building Management and workforce management. I think, you know, as i sort of alluded to, the Tech Industry has really planted a stake in the ground. Many of the Largest Tech Companies have made commitments around Carbon Neutrality, and that includes their products, their supply chains, their own building operations, and weve seen this i think, you know, in response to a couple of things one is their own employees and wanting to be a good Corporate Citizen to attract and maintain the best employees, as more and more employees care about these issues and the corporations that they work for and, two, that the customer base, you know, customers have access to more and better data on this, they care about it, theyre willing to make purchasing decisions around esgrelated issues. And then third is just, you know, resource constraints. You know, a company like apple relies on a lot of, you know, materials from that can be resource constrained and still operating efficiently using recycling, securing access to materials like cobalt that have esg [indiscernible] is important for them. Thank you. Adrian . Commissioners, you have questions for andrew on the update on esg . Just a quick question from me, and that is whether, andrew, youve been presenting in front of other audiences at all about what the sfers esg portfolio looks like and what weve been doing . Yes. I do present to, you know, peer paragraph how its actually groundbreaking in many respects compared to other Pension Plans and i think those kinds of things are important just to make sure that we put that message out there. Certainly. Yeah, im happy to, if you have ideas on that, im happy to take that input. Andrew, i want you to know, ive sent this document to all five of my advisors as examples of what a wellmanaged plan does with esg. Its a very welldone document. Thats great. Andrew, i wanted to ask, and its good to see that the 22 different [indiscernible] because i notice something that [indiscernible] for the last five or six years and i know its been a huge component of the push. Has there been resistance, though, on that front . Because it moves but it moves slowly. But im not sure whats happening there. There have not you know, there continues to be a pretty low rate of [indiscernible] for executive compensation, and i think its been perhaps less of an investor focus area over the last several years. I think what will be interesting to think about is, you know, Going Forward into this 2021 proxy season is executive compensation in light of, you know, covid and layoffs and restructuring, and i think, you know, you will see probably pushback from investors around compensation that seems you know, may be in line with performance over the past year period, but also, you know, when wages have been cut or layoffs occurred with workers. Exactly. Yes, i would be curious to see data around that. The other thing you talked about was the Climate Action 100 and [indiscernible] and various initiatives. Have we seen any of our other managers join this, the Climate Action 100 . I know [indiscernible] was probably one of the first instances. I would hope more managers would be feeling that. We do have other managers that are both participants. We have other managers who