WEBVTT - Imagining The New Normal 0:00:15.396 --> 0:00:23.916 Pushkin from Pushkin Industries. This is Deep Background, the show 0:00:23.956 --> 0:00:27.436 where we explore the stories behind the stories in the news. 0:00:27.996 --> 0:00:33.316 I'm Noah Feldman. Throughout the long run of this pandemic, 0:00:33.716 --> 0:00:37.716 we've been running episodes to keep you our listeners informed 0:00:38.156 --> 0:00:42.116 about the latest changes in the emerging science of COVID, nineteen, 0:00:42.796 --> 0:00:47.716 treatments appropriate to it, and public health responses available for 0:00:47.836 --> 0:00:50.596 dealing with it. As the country has gone through a 0:00:50.716 --> 0:00:55.196 substantial third wave of the virus, and as hospitals, especially 0:00:55.276 --> 0:00:59.396 in the Southeastern United States, are coming dangerously close to capacity, 0:00:59.716 --> 0:01:01.836 we thought it was the right time to have another 0:01:01.876 --> 0:01:05.876 conversation about this topic, and particularly on what looks like 0:01:05.956 --> 0:01:08.596 it will emerge as the new normal in the wake 0:01:08.676 --> 0:01:12.556 of the variant. Here to discuss this with me today 0:01:12.796 --> 0:01:16.476 is doctor Susan Philip. She is the health officer for 0:01:16.516 --> 0:01:19.556 the City and County of San Francisco. I wanted to 0:01:19.556 --> 0:01:22.876 talk with her in particular because San Francisco's COVID response 0:01:22.956 --> 0:01:25.996 is in many ways a model for major American cities. 0:01:26.476 --> 0:01:30.716 Nearly eighty percent of the eligible population is fully vaccinated there. 0:01:31.076 --> 0:01:34.276 Just last week, San Francisco made news by becoming the 0:01:34.356 --> 0:01:37.476 first big city in the us to require proof of 0:01:37.596 --> 0:01:44.036 vaccination to get into restaurants, gyms, recreation centers, or any 0:01:44.036 --> 0:01:46.956 event at all with more than a thousand people. Doctor 0:01:46.956 --> 0:01:49.876 Philip wields the power to write health orders for the city. 0:01:50.276 --> 0:01:53.196 She's been at the front lines of determining the right 0:01:53.276 --> 0:01:58.396 policy responses to the challenges of the current moment. Doctor Phillip, 0:01:58.476 --> 0:02:05.156 thank you so much for being here. I'm really looking 0:02:05.196 --> 0:02:09.756 forward to delving deeply into the complex po see questions 0:02:09.756 --> 0:02:12.836 that you're managing every day and your very important job. 0:02:13.756 --> 0:02:15.796 To start the conversation, I thought we should try to 0:02:15.836 --> 0:02:18.636 just do some level setting on the state of play 0:02:18.636 --> 0:02:22.996 of the science, recognizing that this is a moving target 0:02:23.116 --> 0:02:25.236 and that science is not an exact science when it's 0:02:25.316 --> 0:02:28.556 constantly getting data at every given moment. But I want 0:02:28.556 --> 0:02:31.876 to start by asking you about the Israel data that 0:02:31.956 --> 0:02:36.996 seemed to suggest the need for booster shots at least 0:02:36.996 --> 0:02:40.556 for people sixty and over and potentially for more people, 0:02:41.316 --> 0:02:45.316 and how you think about that question of boosters interacting 0:02:46.036 --> 0:02:50.196 with the broader question of the different variants delta and beyond. 0:02:50.716 --> 0:02:52.556 Thank you and thank you very much for having me 0:02:52.716 --> 0:02:56.556 today to speak with you. So you know, the news 0:02:56.596 --> 0:03:00.276 coming out of Israel, and science just recently that shows 0:03:00.316 --> 0:03:04.116 that a proportion of their hospitalized patients are are actually 0:03:04.156 --> 0:03:07.356 fully vaccinated is concerning, and I think that goes along 0:03:07.396 --> 0:03:10.996 with the data that ADC and other agencies in the 0:03:11.076 --> 0:03:14.676 US have shared that really is more of the step 0:03:14.756 --> 0:03:18.876 before that looking at immunologic response and seeing that decline 0:03:18.996 --> 0:03:23.036 over time in some of these post approval studies of 0:03:23.076 --> 0:03:26.316 people that have been vaccinated, and I think those together 0:03:26.516 --> 0:03:30.876 are leading to this conversation about boosters and when we 0:03:30.956 --> 0:03:33.836 do those in the United States and what that looks like, 0:03:33.876 --> 0:03:35.876 and that of course raises a whole set of other 0:03:35.956 --> 0:03:39.556 questions about the timing of doing that as opposed to 0:03:39.716 --> 0:03:42.756 getting first doses to as many people as possible. But 0:03:43.196 --> 0:03:46.876 that data seems to be increasingly clear that over time 0:03:47.476 --> 0:03:51.116 there does seem to be a decrease antibody response immune 0:03:51.156 --> 0:03:54.636 response that, at least in Israel, such a very highly 0:03:54.716 --> 0:03:59.276 vaccinated country, we're seeing translate into some cases and certainly 0:03:59.316 --> 0:04:02.876 hospitalizations and some of their population. And the reason I'm 0:04:02.876 --> 0:04:05.796 asking about that is that if it were not for this, 0:04:06.236 --> 0:04:08.516 it would be possible to frame the discussion rightly or 0:04:08.516 --> 0:04:11.476 wrongly by saying, well, look, as soon as we can 0:04:11.476 --> 0:04:14.516 get as large a number of people as possible vaccinated. 0:04:15.196 --> 0:04:18.316 We can take on board that variance aside, we're just 0:04:18.316 --> 0:04:19.836 going to get back to normal, and then what we're 0:04:19.836 --> 0:04:24.196 basically debating is how fast, how slowly, what's the appropriate step. 0:04:24.796 --> 0:04:28.396 But it may be that this data suggests that it 0:04:28.436 --> 0:04:29.716 is not going to be as simple as that, that 0:04:29.756 --> 0:04:32.036 we're going to have to have rolling vaccinations even for 0:04:32.076 --> 0:04:35.716 those who are vaccinated, in order to avoid substantial amounts 0:04:35.716 --> 0:04:40.396 of breakthrough infection. So seen through that lens, now let's 0:04:40.436 --> 0:04:43.156 turn to sort of the incredible complexity that is your 0:04:43.196 --> 0:04:45.996 day to day life with the judgments that you have 0:04:46.076 --> 0:04:50.156 to make. Where do you currently stand in San Francisco 0:04:50.916 --> 0:04:57.996 on public places and access to those public places? Well, 0:04:58.036 --> 0:05:02.156 in San Francisco we do know that as everywhere, that 0:05:02.276 --> 0:05:04.996 vaccination is going to be the key, if not to 0:05:05.036 --> 0:05:08.596 getting back to full normalcy, at least to getting to 0:05:08.636 --> 0:05:11.996 a place where fewer people are getting infected and we're 0:05:12.036 --> 0:05:14.716 preserving the ability of our health system to take care 0:05:15.116 --> 0:05:18.556 of people that need care for anything COVID nineteen or otherwise. 0:05:19.036 --> 0:05:22.716 So in San Francisco, as of Friday, we have a 0:05:22.796 --> 0:05:26.196 health order that went into effect that requires that in 0:05:26.276 --> 0:05:29.716 indoor settings where food or drink are served, or in 0:05:29.756 --> 0:05:34.716 any type of fitness establishment, gyms, other recreation facilities, if 0:05:34.756 --> 0:05:38.196 they're indoors, people have to show proof of a full 0:05:38.276 --> 0:05:42.316 vaccination to access those spaces, and we also have that 0:05:42.396 --> 0:05:45.196 in place for any gatherings that are of a thousand 0:05:45.236 --> 0:05:48.356 people or more. So these are some of the ways 0:05:48.356 --> 0:05:51.036 in which we have a very high vaccination rate in 0:05:51.076 --> 0:05:53.676 San Francisco, but these are ways in which we want 0:05:53.716 --> 0:05:58.236 to encourage others to get vaccinated in order to access 0:05:58.316 --> 0:06:01.796 these spaces that we know are higher risk. Throughout the 0:06:01.836 --> 0:06:04.596 pandemic in the United States and worldwide, we've seen that 0:06:04.636 --> 0:06:07.396 these indoor spaces are among those that are highest risk 0:06:07.516 --> 0:06:11.116 or transmission led you to the conclusion, and I'm sure 0:06:11.156 --> 0:06:14.236 this is a complex conclusion that includes both scientific elements 0:06:14.276 --> 0:06:18.796 and policy judgments that places that don't primarily serve food 0:06:18.796 --> 0:06:24.156 and drink, like workplaces for example, would not be logically 0:06:24.316 --> 0:06:28.316 included in this current round of orders. You know, early 0:06:28.396 --> 0:06:31.236 on and throughout the pandemic, some of the news that 0:06:31.276 --> 0:06:35.196 came from the CDC, from the Morbidity and Mortality Weekly Report, 0:06:35.556 --> 0:06:39.396 which is their journal CDC puts out, really showed in 0:06:40.076 --> 0:06:43.276 rigorous case control studies where people are interviewed after they 0:06:43.316 --> 0:06:46.876 become positive, what their activities may have been in the 0:06:46.916 --> 0:06:49.796 weeks leading up to their testing positive, and then compared 0:06:49.836 --> 0:06:51.636 to a group of people that tested at the same 0:06:51.676 --> 0:06:55.196 time but tested negative. Really showed that the areas that 0:06:55.236 --> 0:07:00.676 I mentioned restaurants, bars, gyms, were among those most associated 0:07:00.756 --> 0:07:05.196 statistically associated with becoming positive. These sites are places that 0:07:05.276 --> 0:07:08.876 by definition, people are removing their face coverings, they are 0:07:08.916 --> 0:07:12.156 in contact with other people outside of their household, and 0:07:12.196 --> 0:07:15.756 so there are more aerosols, more virus particles in the 0:07:15.796 --> 0:07:19.596 air in restaurants, in bars, and you add into that 0:07:19.676 --> 0:07:23.076 in bars and some other restaurants, it's loud, it's crowded, 0:07:23.156 --> 0:07:26.876 people are leaning in closer to each other, and also 0:07:27.036 --> 0:07:31.196 with the addition of drinking and alcohol, people are talking louder, 0:07:31.316 --> 0:07:36.316 maybe more disinhibited talking to other people. So that explains 0:07:36.316 --> 0:07:38.076 a little bit about why the risk might be there 0:07:38.076 --> 0:07:41.636 in bars and restaurants. For fitness establishments, those have also 0:07:41.676 --> 0:07:45.636 been associated in several studies from across the country in 0:07:46.516 --> 0:07:50.836 outbreaks and increases, and there it's really again recognizing it's 0:07:50.876 --> 0:07:55.916 a respiratory aerosol transmitted virus that people's respiratory rates are up, 0:07:56.116 --> 0:07:58.956 they're breathing heavily, they're in an enclosed room with others, 0:07:59.236 --> 0:08:02.836 and that's why we see that elevated risk. Let's talk 0:08:02.876 --> 0:08:06.476 about the mechanisms that you might use to check that 0:08:06.556 --> 0:08:10.316 people have been vaccinated. As I understand it right now, 0:08:10.676 --> 0:08:15.476 you would accept the physical vaccination card. I'm imagining you 0:08:15.476 --> 0:08:17.916 would also accept someone's picture on their phone or their 0:08:17.996 --> 0:08:21.876 vaccination card or something similar to that. Have you, as 0:08:21.916 --> 0:08:27.276 a city yet flirted with vaccine passports or other mechanisms 0:08:27.316 --> 0:08:31.036 that might potentially be more reliable than a rather flimsy 0:08:31.076 --> 0:08:34.356 piece of cardboard or a photograph of said flimsy piece 0:08:34.356 --> 0:08:37.676 of cardboard. You know, we have not talked about San 0:08:37.676 --> 0:08:41.716 Francisco having its own version of New York's excelsure pass 0:08:42.276 --> 0:08:45.196 or anything like that. We do know that there are 0:08:45.476 --> 0:08:49.476 private companies and others who have been working on these, 0:08:49.556 --> 0:08:51.956 and so what we're trying to do is evaluate which 0:08:51.996 --> 0:08:55.836 of those would also be acceptable for businesses to use 0:08:55.876 --> 0:08:59.236 in San Francisco. For instance, the state also it's not 0:08:59.316 --> 0:09:02.596 a full vaccine passport, but what they have done is 0:09:02.636 --> 0:09:06.636 they allow people to access the state Immunization Registry and 0:09:06.756 --> 0:09:10.076 get on their phone a QR code and so their 0:09:10.196 --> 0:09:13.276 name and their dates of their vaccinations. One of the 0:09:13.316 --> 0:09:16.316 topics that is widely discussed but is not so widely 0:09:16.316 --> 0:09:20.276 discussed in the media, is the possibility of people falsifying 0:09:20.876 --> 0:09:23.876 vaccination records. Right. I mean, in the world of things 0:09:23.876 --> 0:09:26.316 that are hard to copy, and there are many in 0:09:26.356 --> 0:09:29.516 our world, your vaccination proof is not one of them. 0:09:29.916 --> 0:09:33.916 So somebody who wanted to spend ten minutes falsifying proof 0:09:33.916 --> 0:09:38.476 of vaccination presumably could do that extremely easily, and there 0:09:38.476 --> 0:09:42.396 would be absolutely no way for anyone to tell if 0:09:42.476 --> 0:09:44.236 that were the case, or not to say nothing of 0:09:44.876 --> 0:09:47.356 the person that a restaurant puts at the door, you know, 0:09:47.396 --> 0:09:49.956 the greeter whose job is now includes not only being 0:09:50.036 --> 0:09:51.196 nice to you and telling you how long the weight 0:09:51.316 --> 0:09:55.236 is going to be, but also checking your proof of vaccination. So, 0:09:55.716 --> 0:09:58.756 given that how much of what you're doing is sort 0:09:58.756 --> 0:10:01.236 of a signaling function to try to send to the 0:10:01.316 --> 0:10:05.436 public the feeling that you and San Francisco really expect 0:10:05.516 --> 0:10:08.436 people to be vaccinated, how much of it is you 0:10:08.476 --> 0:10:11.196 just calculate people are so moral that they would never 0:10:11.236 --> 0:10:14.436 lie about such a thing. How much you calculated people 0:10:14.476 --> 0:10:16.156 can't be bothered to do that, and it would just 0:10:16.156 --> 0:10:18.316 be easier for them to go and get vaccination than 0:10:18.356 --> 0:10:21.956 it would be to mess with a PDF. What's the 0:10:22.196 --> 0:10:24.516 as it were, actual thinking behind this, if you're willing 0:10:24.596 --> 0:10:28.436 to share it, sure, yes, I think that the way 0:10:28.476 --> 0:10:31.276 I have always thought about it, the health orders themselves 0:10:31.316 --> 0:10:34.316 are not enough to make the full impact. The health 0:10:34.396 --> 0:10:38.316 orders are important, but they're not sufficient. So the way 0:10:38.356 --> 0:10:40.716 we have always addressed this in San Francisco from the 0:10:40.756 --> 0:10:44.356 beginning is to be very visible, to make sure that 0:10:44.396 --> 0:10:47.516 we put out reasoning, that we share the science. And 0:10:47.556 --> 0:10:50.276 I think we're fortunate to work in a city where 0:10:50.276 --> 0:10:53.436 people are responsive to hearing about the science. They don't 0:10:53.516 --> 0:10:55.876 doubt that the virus is real, they don't doubt that 0:10:55.996 --> 0:11:00.156 vaccines work. So addressing really the importance of doing it 0:11:00.196 --> 0:11:03.956 for their own individual health, and then the health orders 0:11:03.996 --> 0:11:08.156 are important in driving up the understanding and the demand 0:11:08.596 --> 0:11:12.036 for vaccine, for people to understand that it's expected, that 0:11:12.076 --> 0:11:14.956 it's required, but this is the most important thing that 0:11:14.996 --> 0:11:16.916 they can do, and that this is going to have 0:11:16.956 --> 0:11:19.676 the most impact over time. So it's using this as 0:11:19.676 --> 0:11:22.196 another opportunity that gets a lot of attention. People are 0:11:22.276 --> 0:11:25.636 very focused on the vaccination mandates. The truth is we 0:11:25.676 --> 0:11:28.916 have the highest rate of full vaccination you know, of 0:11:28.996 --> 0:11:33.236 any city in the US, so the incremental increase in 0:11:33.316 --> 0:11:36.396 this is important. We want every single additional person to 0:11:36.436 --> 0:11:39.596 get vaccinated that we can. We have to marry that 0:11:39.596 --> 0:11:42.956 though with explaining why it's important, and then most importantly, 0:11:43.036 --> 0:11:46.916 we have to have highly accessible routes for vaccination in 0:11:46.916 --> 0:11:50.196 the city as well. The health order load is not perfect, 0:11:50.236 --> 0:11:52.396 as you said, but in my mind, the goal is 0:11:52.436 --> 0:11:54.436 not for it to be perfect. It's really to add 0:11:54.516 --> 0:11:57.276 cumulatively to all the work that we've been doing around 0:11:57.316 --> 0:12:01.356 increasing our resilience and our response to COVID nineteen. I 0:12:01.396 --> 0:12:04.516 think that you know, this requirement for vaccination in public 0:12:04.556 --> 0:12:08.396 spaces is the most recent vaccination requirement, but it's not 0:12:08.476 --> 0:12:10.556 the only one. It's not been. The first one that 0:12:10.916 --> 0:12:13.716 we actually put out as a health order was related 0:12:13.756 --> 0:12:17.436 to higher risk settings, settings in which the people that 0:12:17.476 --> 0:12:20.596 are within those settings are at higher risk for either 0:12:20.716 --> 0:12:24.956 severe illness or death. So that includes our acute care hospitals, 0:12:24.956 --> 0:12:28.076 our nursing homes, our jails, and so that was the 0:12:28.156 --> 0:12:31.276 first place where workers were required to be vaccinated. We 0:12:31.356 --> 0:12:35.676 do have an indoor masth mandate as well, So we've 0:12:35.676 --> 0:12:38.396 had that since the beginning of the month, and so 0:12:38.436 --> 0:12:41.156 we have both. Now we just have this newly implemented 0:12:41.396 --> 0:12:45.036 vaccination requirement in these certain public businesses as we talked about, 0:12:45.196 --> 0:12:48.356 but we do have in all indoor spaces a mask 0:12:48.476 --> 0:12:51.676 requirement as well. I think that the delta variant had 0:12:51.836 --> 0:12:57.076 introduced enough level of uncertainty to not be sure, even 0:12:57.076 --> 0:12:59.156 with our highly vaccinated city, what was it going to 0:12:59.236 --> 0:13:01.236 mean for our hospital system, what was it going to 0:13:01.316 --> 0:13:05.036 mean for people that had already been vaccinated. That we 0:13:05.556 --> 0:13:07.836 determined to do the mass mandate first because it could 0:13:07.836 --> 0:13:10.916 be implemented very quick CLEA and we had done it previously, 0:13:11.196 --> 0:13:16.316 and then work on this vaccination requirement. So going forward, 0:13:16.356 --> 0:13:18.076 what we're going to have to see is keep looking 0:13:18.356 --> 0:13:21.516 at our case numbers. They are coming down slowly, and 0:13:21.556 --> 0:13:25.116 we'll have to see if that continues and decide how 0:13:25.116 --> 0:13:27.236 we move forward. We are going to have to learn 0:13:27.316 --> 0:13:31.036 to live with COVID nineteen in San Francisco and elsewhere, 0:13:31.356 --> 0:13:33.716 but for now we do have both of those measures 0:13:33.716 --> 0:13:38.116 in place. Let's talk about the formulation that you just used, 0:13:38.156 --> 0:13:40.516 which is one that I think is very important that 0:13:40.636 --> 0:13:42.356 we're going to have to learn to live with COVID 0:13:42.436 --> 0:13:46.676 nineteen formulation. And I'd love to hear in more fine 0:13:46.716 --> 0:13:50.596 grain detail what you think that living with is going 0:13:51.116 --> 0:13:53.916 to look like. Let me make the con question concrete 0:13:53.916 --> 0:13:56.476 in the following way. You've got great uptake at eighty 0:13:56.476 --> 0:14:00.636 percent or so of eligible residence getting a vaccine. That's amazing. 0:14:01.196 --> 0:14:04.036 Let's say you got to ninety five, right, which is 0:14:04.036 --> 0:14:06.676 as close to perfect as anyone's going to get. And 0:14:06.756 --> 0:14:09.316 let's say the Delta variant still existed, because it's still 0:14:09.356 --> 0:14:12.396 going to exist, although perhaps it will have burned itself 0:14:12.396 --> 0:14:14.516 out in this latest round, but it or other things 0:14:14.556 --> 0:14:16.996 like it, we'll be back in the future. This doesn't 0:14:16.996 --> 0:14:19.436 seem like it's some outlying evolutionary development. It's a kind 0:14:19.476 --> 0:14:22.396 of to be expected and doubtless will be recurrent in 0:14:22.476 --> 0:14:24.676 various ways. We'll have to learn the names of lots 0:14:24.676 --> 0:14:29.596 of other Greek characters beyond Delta. So in that environment, 0:14:30.316 --> 0:14:32.836 does living with it basically mean that we would move 0:14:32.876 --> 0:14:37.236 towards a world where no mask requirements and we would 0:14:37.276 --> 0:14:39.276 just understand that there was a certain amount of breakthrough 0:14:39.316 --> 0:14:41.636 infection that was going to keep on happening in the 0:14:41.756 --> 0:14:45.516 light of future variants, and we will try to manage 0:14:45.516 --> 0:14:49.196 that and if it requires building more hospital beds to 0:14:49.276 --> 0:14:51.996 be prepared for those potential surges, will do that. Is 0:14:52.036 --> 0:14:54.276 that sort of what you're picturing. Well, I think what 0:14:54.436 --> 0:14:58.876 we'll picture is again continuing to take in any new information. 0:14:58.996 --> 0:15:01.196 You know, and as you pointed out earlier, this virus 0:15:01.236 --> 0:15:04.396 has done nothing if not keep throwing curveballs, and we 0:15:04.476 --> 0:15:07.076 have to adapt to what we might need to do. 0:15:07.396 --> 0:15:10.436 We were not talking about masks early on in the pandemic, 0:15:10.476 --> 0:15:13.836 and that was not in our culture as a country before, 0:15:13.876 --> 0:15:16.676 as it was in some other Asian countries, but it 0:15:16.876 --> 0:15:19.796 is something now. Are we going to have to mask 0:15:19.876 --> 0:15:23.116 completely going forward? I don't think that that's likely, but 0:15:23.236 --> 0:15:25.556 I do think that people may choose during cold and 0:15:25.596 --> 0:15:28.676 flu season in coming years to wear a mask. Hopefully 0:15:28.716 --> 0:15:31.036 people have a sense that if they're sick, they stay home. 0:15:31.356 --> 0:15:34.196 So there are some lessons I think from COVID nineteen 0:15:34.196 --> 0:15:37.756 that I hope do continue pass this current time. And 0:15:37.836 --> 0:15:40.956 I do think that there will be other challenges potentially, 0:15:40.996 --> 0:15:44.036 as you said, other Greek letters maybe coming at us, 0:15:44.076 --> 0:15:47.196 and then we will have to adapt over time. So 0:15:47.236 --> 0:15:48.916 what I'm hopeful is that we will get a high 0:15:48.956 --> 0:15:52.756 level of vaccination that that will continue. We'll understand if 0:15:52.756 --> 0:15:56.556 and when we need to continue having boosters of these vaccinations, 0:15:56.556 --> 0:15:58.796 and then if we need to adjust further, we will 0:15:58.796 --> 0:16:02.036 have to adjust. But I do think that we will 0:16:02.076 --> 0:16:04.196 eventually be able to peel away some of these other 0:16:04.316 --> 0:16:08.836 non pharmaceutical interventions like masking, and we've already peeled distancing 0:16:08.876 --> 0:16:12.876 away and have the vaccine really really hold the bulk 0:16:13.036 --> 0:16:17.236 of the work for keeping population safe. And you know, 0:16:17.276 --> 0:16:20.196 as a health officer, we're working at a population level, 0:16:20.396 --> 0:16:22.756 so we do know unfortunately that there still will be 0:16:22.796 --> 0:16:25.796 people that get infections and get sick. But what we're 0:16:25.836 --> 0:16:28.076 trying to do is really make sure that the bulk 0:16:28.116 --> 0:16:31.316 of the population is protected and that everyone has as 0:16:31.396 --> 0:16:33.876 much information as they might need to make decisions. But 0:16:33.996 --> 0:16:36.756 for right now, as we are working to get all 0:16:36.796 --> 0:16:39.596 of our populations as vaccinated as we possibly can, and 0:16:39.636 --> 0:16:42.036 we don't know where we'll end up with that, these 0:16:42.076 --> 0:16:44.036 are the additional protections that we want to have in 0:16:44.076 --> 0:16:47.396 place using the power of state law, the health officer 0:16:47.436 --> 0:16:49.436 authority to be able to do that. For the moment, 0:16:50.556 --> 0:17:03.596 we'll be right back where does rapid antigen testing, in 0:17:03.636 --> 0:17:06.716 your view, fit into this series of different measures that 0:17:06.756 --> 0:17:10.836 you're engaged in. I got my first wedding invitation post 0:17:10.916 --> 0:17:14.596 COVID today that noted not only that they wanted people 0:17:14.636 --> 0:17:18.116 to prove vaccination to attend the wedding, but also that 0:17:18.156 --> 0:17:21.156 they wanted people to get a rapid antigen test that day, 0:17:21.716 --> 0:17:23.876 not even a PCR test, you know, in the previous 0:17:23.916 --> 0:17:26.916 thirty six hours. And I, you know, thought maybe this 0:17:26.956 --> 0:17:29.356 is the new normal. There's an expense question, of course, 0:17:30.036 --> 0:17:33.836 but when you think about the various components of a 0:17:33.956 --> 0:17:39.276 preventive plan, testing surely is one of them. Prices have 0:17:39.356 --> 0:17:41.436 come down, although not as much as one would have 0:17:42.156 --> 0:17:44.836 hoped thus far. So how does testing fit into the picture? 0:17:44.876 --> 0:17:46.636 I mean, I think, to put another way, how we 0:17:46.716 --> 0:17:48.636 been discussing this at the beginning of the pandemic, before 0:17:48.716 --> 0:17:51.396 vaccines were available. A lot of our conversation would have 0:17:51.396 --> 0:17:54.716 been and we did these conversations on deep background, you know, 0:17:54.996 --> 0:17:58.156 the centrality of testing to a successful regime and the 0:17:58.276 --> 0:18:01.156 mechanisms that can be undertaken to make testing more efficient 0:18:01.196 --> 0:18:03.076 at scale. And yet now it doesn't seem to be 0:18:03.156 --> 0:18:06.076 as central to the at least to the Public Health Conversation. 0:18:07.396 --> 0:18:10.356 I think you're right. You're absolutely right. The testing remains 0:18:10.356 --> 0:18:14.076 really important when you think about schools which are opening 0:18:14.116 --> 0:18:17.676 soon in a matter of days. We still don't have 0:18:17.956 --> 0:18:21.796 authorization for vaccination for under twelve, but for twelve and over. 0:18:22.636 --> 0:18:26.556 Is San Francisco in its public schools requiring vaccination universally? 0:18:26.956 --> 0:18:29.596 You know, in San Francisco our schools opened last week. 0:18:29.676 --> 0:18:32.756 It was very exciting because we had not had all 0:18:32.796 --> 0:18:36.276 of our schools opened during the last year, and so 0:18:36.956 --> 0:18:40.276 we're encouraging them for twelve to seventeen. But they're not mandated, 0:18:40.636 --> 0:18:43.836 and the San Francisco Unified School District has a different 0:18:43.916 --> 0:18:47.396 governing entity. They don't fall under the mayor and the 0:18:47.436 --> 0:18:49.876 rest of the city department, so we work very closely 0:18:49.876 --> 0:18:52.036 with them, but they have a different decision making and 0:18:52.596 --> 0:18:56.236 policy approach and independent of the rest of the rest 0:18:56.276 --> 0:18:59.796 of us and independent of health officer or orders as well. 0:18:59.876 --> 0:19:03.836 They make decisions there, so they are supporting twelve to 0:19:03.876 --> 0:19:05.676 seventeen year olds and the rest of the city. Our 0:19:05.716 --> 0:19:08.516 Health Department is working closely with the Unified School District 0:19:08.556 --> 0:19:10.796 to be able to do that and have there be 0:19:10.916 --> 0:19:15.636 events where entire families can come where we facilitate vaccine, 0:19:15.636 --> 0:19:19.156 and we'll have increasing sites numbers of sites on school 0:19:19.196 --> 0:19:22.276 property to be able to get vaccination, but we're not 0:19:22.516 --> 0:19:27.236 requiring it yet. That was such a beautifully diplomatic answer 0:19:27.396 --> 0:19:29.156 that I almost don't want to draw attention to how 0:19:29.156 --> 0:19:32.156 diplomatic it was. It's a reminder that being public health 0:19:32.156 --> 0:19:34.956 officer of a city is not dissimilar from being, you know, 0:19:34.956 --> 0:19:36.796 an abassador with United Nations or something. You have to 0:19:36.836 --> 0:19:39.356 be careful in what you say. Let me try to 0:19:39.396 --> 0:19:41.076 parse it. I mean, what I heard you say is 0:19:41.076 --> 0:19:43.796 that the schools don't answer to you and they have 0:19:43.836 --> 0:19:47.636 a different policy. Without stating it. The natural implication I 0:19:47.716 --> 0:19:49.276 want to ask you to confirm this or deny this, 0:19:49.396 --> 0:19:51.756 but the natural implication when it might have been that 0:19:51.836 --> 0:19:53.916 you might have reached different decision if they were within 0:19:53.996 --> 0:19:56.636 your decision making authority. Let me use that to ask 0:19:56.676 --> 0:20:00.156 a further question. You know, across the country, this is 0:20:00.196 --> 0:20:03.116 going to be replicated a much greater scale, right, I mean, 0:20:03.516 --> 0:20:07.356 even within a progressive city like San Francisco, it's clear 0:20:07.396 --> 0:20:10.836 that there's some nuanced difference between different agencies at the county, 0:20:10.836 --> 0:20:13.836 at the city level, at the level of the education system, 0:20:14.956 --> 0:20:18.356 and nationally, we've got a huge range of variation all 0:20:18.396 --> 0:20:20.916 the way from where you guys are to you know, 0:20:20.916 --> 0:20:23.996 the governors who prohibited even not just as governors, but 0:20:24.036 --> 0:20:27.396 there were state laws passed signed by governors that prohibited 0:20:27.436 --> 0:20:32.996 mandatory masking. So the other very very grave extreme. When 0:20:33.076 --> 0:20:35.476 you think of this, not just in your role in 0:20:35.516 --> 0:20:37.876 San Francisco, but you know, your role as a national 0:20:37.996 --> 0:20:43.476 leader on questions of public health, are you worried about 0:20:43.516 --> 0:20:47.756 just the range, just the huge disparity of viewpoints that 0:20:47.796 --> 0:20:52.316 we're getting from governmental elected officials on these matters of 0:20:52.476 --> 0:20:56.156 life and death. You know, are these are matters, as 0:20:56.156 --> 0:20:59.356 you said, of life and death, these are public health matters, 0:20:59.396 --> 0:21:02.396 these are scientific matters. And it really has been troubling 0:21:02.436 --> 0:21:06.796 since the beginning of this pandemic how there had initially 0:21:06.796 --> 0:21:10.276 not been a national response. You would think that when 0:21:10.316 --> 0:21:13.396 there was a pandemic that there would be a coordinated 0:21:13.436 --> 0:21:15.476 response at CDC, would be at the forefront, and that 0:21:15.556 --> 0:21:20.356 we as local health department leaders would be responding to 0:21:20.396 --> 0:21:23.916 the same stimuli and not not really trying to do 0:21:23.996 --> 0:21:25.916 our own thing and come up with how we were 0:21:25.916 --> 0:21:27.556 going to get PPE and how are we going to 0:21:27.636 --> 0:21:30.436 do testing, and what was our approach going to be there. 0:21:30.756 --> 0:21:33.396 It's been better more recently, but I think that that 0:21:33.596 --> 0:21:36.876 set the precedent for there being such a diversity of opinion, 0:21:37.236 --> 0:21:41.116 and then this whole way of thinking that masks were 0:21:41.596 --> 0:21:44.716 a sham, that the virus itself was a sham, and 0:21:45.276 --> 0:21:50.516 the splittization of the response of the science of the 0:21:50.516 --> 0:21:54.076 health officials, many of whom my colleagues in California have 0:21:54.156 --> 0:21:58.476 received threats, have really been unduly harassed for just trying 0:21:58.476 --> 0:22:01.116 to do their jobs and save lives. So there is 0:22:01.156 --> 0:22:05.196 a lot there. It is really concerning last question. We 0:22:05.276 --> 0:22:07.996 mentioned the terrific rate of a vaccine uptake that the 0:22:08.036 --> 0:22:12.036 city has. Are there measures that you have of what 0:22:12.076 --> 0:22:14.676 those numbers look like for people who are not just 0:22:14.716 --> 0:22:17.636 poor but are actively homeless in the city, and do 0:22:17.716 --> 0:22:21.276 their numbers look comparable to the general population in terms 0:22:21.316 --> 0:22:25.396 of vaccine uptick. I don't know if we can pinpoint 0:22:25.436 --> 0:22:28.876 the exact numbers. We do know that they are generally 0:22:28.916 --> 0:22:31.836 lower than the general population. But what we've tried to 0:22:31.876 --> 0:22:36.556 do is make mobile vaccination available, allow people to drop 0:22:36.636 --> 0:22:38.716 in and get them at the sites where they get 0:22:38.756 --> 0:22:41.916 their usual services or care and we right now have 0:22:42.076 --> 0:22:45.196 mobile vaccination teams that are going out to work with 0:22:45.236 --> 0:22:48.716 persons experiencing homelessness, so they are a priority, and we 0:22:48.756 --> 0:22:50.556 do recognize that we're going to have to try different 0:22:50.596 --> 0:22:54.676 strategies to increase those rates among those populations in San Francisco. 0:22:55.036 --> 0:22:59.756 And have you gotten broadly speaking yet, the criticism from 0:22:59.876 --> 0:23:03.276 the civil rights community that would be might be worried 0:23:03.396 --> 0:23:09.076 that given differential vaccination rates when measured by socioeconomic state 0:23:09.436 --> 0:23:14.276 or by race, that a public vaccine mandate could look 0:23:14.356 --> 0:23:17.316 like it involves the turning away of a disproportionate number 0:23:17.356 --> 0:23:21.236