Peskin. Ill just call you. Supervisor preston. Just one question regarding some shelters that are not 24 hours, so, for example, in my district the first friendship emergency family shelter where folks have to leave at 7 00 in the morning i know that theres other shelters that dont operate 24 hours. And im curious if theres been any effort underway under the circumstances to try to have shelters that are less than 24 hours to be a resource during the day as well . Yes. Thank you for that question. I couldnt have scripted this discussion any better. We are working on that and trying to get all shelters that are currently not open 24 hours, including first friendship, to stay open and to provide three meals a day. So thats in the process and i dont know the status of that, but thats our intention is that all shelters stay open 24 7 and theres only a few that do not and so it shouldnt be too big of a lift. Thank you. President yee okay, i think that is it. Thank you very much,. Thank you very much. Clerk next dr. Odogon if you could come up and the question that we were asking for all of the Department Leaders is whether or not there is any programs that youre working on that havent been publicly been mentioned so that were aware of as we plan our legislative agenda and work with our constituents and our offices. So in my current role as the Health Officer good evening, i am the Health Officer of San Francisco. So in my current role as Health Officer, i have been thinking primarily strategically at a Population Health level and working with other Health Officers and other counties, studying what is happening in other countries. Learning from the experts that we have here in the bay area, to understand what strategies were going to do moving forward. And in terms of where were going, there was a question that was asked earlier about what can you do. The measures that we need to do are by our regular standards very drastic. And so the population is going to need the support, the social support, to really be able to endure endure everything that were going through. I wanted to just describe to you really briefly where the evolution of where we got to, and where we are today. Initially we started with travel restrictions to prevent introduction. As cases started coming, we focused on isolating cases and quarantine contacts. That body is called containment. Its an important strategy and a lot of what you hear about getting people into housing for isolation and quarantine, its absolutely critical. Super time intensive. And it has been limited by testing. The third one, the third area, is what people normally call mitigation and focusing on social distancing involving schools and workplaces and social gatherings. In the last few days, we had really been thinking and seeing what is happening in italy and really trying to understand what is the key strategy that we needed to implement so that we dont become what is happening in santa clara, and the Health Officer in santa clara said to us, you are a week ahead of us. You dont want to be where were at now a week from now. And just watching the explosion of this virus. And so a key strategy is to have people stay at home so they do not become exposed. And you reduce you reduce exposure except when you have to go out for essential services. And for us to be able to support that strategy it took it took we worked with the attorneys across the bay area and the idea is that how we keep people in place but have enough of the economy running that supports essential services so people can stay home safely and not have to go out and get exposed and to expose other people. So thats probably i would say that the things that were thinking moving forward is really thinking about how do we strengthen what were doing. What are the areas that we got wrong that we need to adjust. And so the continuing support that we have from you for supporting social services and social infrastructure is going to be really be critical. And the other thing that i want to point out is that i want to just share one more thing and that is one thing that i learned from sunday night that just now is stuck in my head is that hours matter. This virus, the way that it moves, is explosive. To give you an idea of how explosive this virus is, is that we have an iceberg. At the very top of the iceberg are the people that die. And then we have the people who are in the i. C. U. And then you have this iceberg that you cannot see. And we were not able to see any part of this iceberg because of our testing debacle that happened in the country. Thats increasing, which is great, but that iceberg that we cannot see is doubling every six days. That iceberg that we cannot see is doubling every six days. That means that its just going to explode like this and thats why the measures that were taking while they seem drastic its our only hope of trying to freeze that from growing any further so that people can people who are infected can recover. So that means how we move happens in days. Thats it. Sorry. President yee supervisor peskin. With the president s indulgence, doctor, do you think that were being aggressive enough . And what other steps would you suggest to this government that we take that were not taking now, sir . So youre asking a really good question. I would say that were in our approach, were close to what is happening in europe. Except that theyre being more restrictive on enforcement of shelter in place orders is my understanding. Okay, so lets talk about transportation. I am very concerned that the bay area regional Transportation System,bart, is moving a lot of nonessential people around this region. Not people who have to go three stops on the 38 or the 30 or name your bus line the 5. But people who actually do not need to move around the region, who are nonessential. Do you have a comment on that . Youre slielg absolutely rig. I would say that the Transportation System is a vulnerability, and to function we need the Transportation Systems to just get the essential workers here. But your point is absolutely correct. So if you had advice to the individual who is representing our local transportation property, the sfmta, who is sitting right there, what would your advice be . I would discourage people from doing nonessential travel, including local nonessential travel. How would you suggest that . Thats a good question. I would have to sit down and think a little more carefully about how wed do Something Like that. How would you suggest that for bart . With generally other than nurses, doctors and First Responders, does not need to operate at all. How would you suggest that . You know, for me i can think about it conceptually and id have to sit down with the City Attorneys and really understand the attorneys dont run this government and they just give us advice. I agree, i agree. But i would have to think about that. I know i can tell you what is happening in other countries. Yeah, what do they do in other countries . Theyre tracking your cellphone so they know when you move around, they know who you are and where you are, and you cant you cant move into certain spaces unless youve been cleared so they have a whole surveillance infrastructure electronic surveillance infrastructure to really monitor the movement of people. I know i had heard that somebody was telling me in france when somebody was on before they would leave their home, this is not verified and just told to me theyd have to put online why they were leaving and print something out and when theyre out and about they have to show police this is why im out on the street and im not staying home. So the chief Health Officer, what recommendations we dont do that in america. That in amer i know. But because theres a hugh distance between i agree. With that kind of invasion and the stuff that im talking about which is stuff that we can control. We can control mune and we canf arguably control bart. So theres a huge distance their cellphones that we do notd do and will not accept in our or culture. Wha and what you are recommending. Can you bring thahat together quickly now, sir. Hat together i would say the key issue is for us to minimize, to the extent possible, nonessential travel, including locally and we dont have a campaign to do that right now. Becausbecause what happens is tt this is so massive, so massive, that a lot of the enforcement happens from the peer pressure and they see what other people are doing. So at this moment, even for this order, we dont have a Massive Campaign yet to really, really enforce how important it is to not be out. As the chief Health Official of this town, who is not dr. Colfax, how are you relaying that to the mayor, to other officials in this town with the urgency that youre expressing to the elected body of San Francisco right now . Thats a great question. Today has been spent mitigating and trying to understand how the order applies or doesnt apply to them. You have gone through three steps we should take as a city and what would the three steps be . At this moment today, i would not do more than were doing today until because im being honest with you. Because i think, like i said, this started sunday morning as we started looking at putting everything together and it happened so fast. Started on january 28th and santa clara blew up and god bless you and your five colleagues and that precipitated to mayors. And we will probably in a few minutes actually take action to ratify our mayors order. But what three steps or one step or two steps, how would you step this up if you want to flatten the curve . Again, ilets say you wont w transport, we would have to figure out how to support people in place. If people cant get around, how will we support people . We need transportation so essential workers are able to move around. Thats one area. The other area that was mentioned earlier and i will tell you what i lose sleep over, i feel that we may be able to this broad measure may able to mitigate infection among the general population who is able to sheltener place, understand the issues, et cetera. And where i start losing sleep is that even if everyone there did a great job, our vulnerabilities are, again, we already know theyll be our condegrecongregate living and wn have an explosion in those populations. So those are areas i believe we need a lot more work in. But doctor, isnt our Transportation System congregate living . Its not congregate living. Again, to the extent that people separate in transportation ill just give you an idea, just because sometimes people dont understand this and this is from experts that study this. Is that its not just the contact its the contact rate, the distance and the duration. So, for example, in the models that have taken the covid, basically onethird or actually let me just put it to you this way. We cut up a pie into six pieces and two of those pieces, two out of six or onethird transmission occurs in the household. Because prolonged contact. And thats one of the reasons why congregate living is so critical. We know in sros, you have People Living in crowded conditions and multiple families in one room. Thats where infection can happen. Schools is onesixth and workplace is onesixth and the community in general, the community in large, when you put it together will be two pieces, two out of six or onethird. So its not it really depends on duration. Youre absolutely right about transportation. To the extent people are crowded, to the extent people send prolonged periods of time, the risk goes up. But if i hop on bart for a 20minute ride, thats different than living with somebody and being with them for hours or being in a restaurant where youre not just spending prolonged periods of time but youre doing a lot of exchange. So transportation is a vulnerability, but its also an essential infrastructure and well have to figure out how to tackle that one. So doctor, i will stop after this, and i dont want to be argue goargumentive, but you to, its exploding. Its not an airborne disease but a droplet disease and if i touch something and then improve touch my eye or my nose or my mouth, then i can get it. What im trying to talk to you about is the recommendations that you would make to the mayor, to this body or, actually, under state law in your absolute authority and weirdly enough and ive never had this conversation with anybody who has the powers that you actually personally have. There are no greater powers that a chief Health Officer has under state law. You actually dont have to come to us. You dont have to go to the mayor. These powers are actually held by you personally. So what i am asking you is what steps would you take if you tell jeff tumlin that you have to do this, as a matter of law, he has to do it whenever you issue the order. You are the most important individual person in this town as a Health Official. So the questions that im asking you are not arbitrary. Theyre not capricious, but theyre the most important questions that could be asked in public, in this town, at this time, noting that were doing much better than santa clara and much better than any other neighboring county. So let me tell you what ill try to explain this to you, but i spent a huge amount of time thinking about this. And so this is just a little diagram i drew today. We are you can put it on the overhead. This is a little bit embarrassing. But we have pulled every lever. We have pulled every lever and one thing i didnt mention of the levers we pulled, what were doing is beyond mitigation. Its actually called a suppression strategy. Were not just trying to flatten the curve. The idea behind flattening the curve is, from some of the papers estimate up to 80 of the population will become infected, up to 80 . The question is, do you want that 80 to get infected in a short period of time now or do you want it to be flattened out . Thats the mitigation strategy, the flattenthecurve strategy youve been hearing about. What weve embarked on is called a suppression strategy and its more impressive than the mitigation strategy. Thats the fourth one you see here and were trying to get the reproductive number less than one. Why are we moving in that direction . Because theres so much uncertainty. We dont know. There is a role we know its definitely droplet spread, when youre close by, in fine aerosoles and we are assuming that with asymptomatic infection, when you have 100 people of the susceptible, thats like dropping a match and it may be only a few matches, but its dropping a match on gasoline because everybody is susceptible. We have to learn to do it better and faster. At least with the modeling papers are telling us, for us to be successful, we would have to do this for more than three weeks, going on into months. So the question that these papers ask is that how do we begin, if were successful in doing the suppression strategy, how do you take your foot off that accelerator . That means that we would have to have a Public Health infrastructure that is able to do these other strategies that other countries are doing and doing well because they have an army of people that do Contact Tracing and quarantine. We havour Public Health infraste is so small that we dont have enough to do syphilis contact investigation. So we are down to the bare bones in Public Health infrastructure. These other countries have invested in the Public Health infrastructure, so they have all of the people to do, all of the contact investigation and case isolation, contact investigation and quarantine in following everybody, because we know that containment strategy works and we need a modern Surveillance System. We would need to do massive testing. We would want to test as many people as we can so that we can identify whos infected so we can isolate them. So those two components, containment and Surveillance System is really critical. We dont have that right now. We would need investments of them. On that depressing note hold on, sorry. The thing is to realize if youre looking at south korea, singapore, they are countrying that are doing this. So it can be done. Its just that we have to have the will to invest in the Public Health infrastructure thats required to be able to pull back on a very aggressive strategy until a vaccine becomes available because thats what were waiting for and thats not coming for at least a year. Supervisor safaye . So i think you said a lot of what i wanted to ask for. It sounds like from everything, all of the resource and reading ive done, we are taking the most aggressive measures, probably, in the united states. As of today, yes. So we are taking the most aggressive measures and what ive heard you say is, you need a little bit more time to understand how much suppression is working, and reading also today that the cdc and, also, the federal government is encouraging more private testing to the point where we might have at some point the ability to do thousands of more tests. Can you talk a little bit about that . With all due respect, to supervisor peskin, its important to talk about transportation where that could lead and where we are, but theres been a conversation about tradeoffs and what that could mean in terms of essential employees being able to get to where they need to go that dont necessarily have access to automobiles, right . Right. I think thats something youre weighing, so could you talk about the testing and the tradeoffs in terms of allowing the suppression to take time . Yeah, so testing is going to be, in my mind, will be very, very critical, especially for people that have mild symptoms, because oftentimes right now, as you know, as dr. Colfax said earlier, our testing is being reserved for people at higher risk and oftentimes we tell people just stay home and recover. We dont know what they have. We want to know what they have. We want our Surveillance Systems to know we want to be able to tell that person who has a mild illness, you dont have covid, dont worry about it, get better, go back to work. But if you do have covid, we absolutely