We dont do that in america. I know. Because theres a huge distance between that kind of invasion and the stuff im talking about, which is stuff that we can control. We can control muni. We can arguably vote bart. Theres a huge difference between monitoring people on their cell phones that we do not do and will not accept in our culture and what you are recommending. Can you bring that together quickly now, sir. 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 want you isolated and so this is really critical because thats where a lot of the infections are happening because people have mild illness. Theyre out and about and contaminating surfaces, infecting people and people dont realize theyre becoming infected from somebody because you cant tell when somebody has mild symptoms. One thing well be pushing for, our Public HealthSurveillance System, we only receive at the Health Department positive tests. We dont receive all of the negative tests. So, for example, what they did in santa clara, they looked at the negative tests and they found that 11 people showing up with influenzalike illness, 11 of them tested positive. Thats a high number. We need to have a Surveillance System so we need to make testing reportable by law so i can tell you what proportion of ilis are covid because that lives us an important idea of what is happening. So testing is critical and what was the other one . It was about essential workers . The tradeoff in terms of further than what we do. Thats the other one that we really struggled with, but we know because of unaffordable housing in the city, the vast majority of our workforce lives outside of the city. And so, we need them. We need this army of workers here with us, whether theyre cleaning sros or whether theyre an epidemiologist. We need them and want them to get here safely and so the Public Transportation plays that important role. , including police, fire, Public Safety and all other Public Workers that have to commute here. Just based on the orders today in terms of the essential workers, theres more than just police, fire and others that are deemed essential. Correct. Theres a whole bevy of people that are essential workers that need access to Public Transportation. So what i would say, work wig the sfna, are there things we can do in terms of the drivers or the other workers that are there, kind of informing people as they go in whether it means ensuring people are doing social distancing . Are there other things we can do to manage our public Transportation System in a more healthy way . Youre absolutely right and i think the most important thing is going to be social distancing and environmental disinfection and educating everybody when they go in and out of transportation to actually, youll notice that i cleaned the platform before i put my books down. So its really developing a super awareness. I wont touch that. Developing a super awareness of how you can become infected and it has to go, also, into transportation, as well. I guess my point is a little bit more refined in the sense that because of your position and because of your direction and because of the directives that you can give, working with our bart board and with our sfmta, could you give specific instruction because we have a lot of essential workers that are still in the city that would be redeployed to help with this and also as a part of this containment strategy as people are getting on and off Public Transportation. Yeah. Im not sure what is there a specific intervention youre thinking about . Giving them the instructions on what to do and having additional people . Right now on a munibus, you only have the driver, for example. Does it make more sense to have an additional person on there to make sure people are doing the appropriate thing . Anything that adds to the effort, absolutely, and i think thats one of the challenges, is that, yes, when you sit down and resign when you sit down and resign a process, you will discover that, yes, we need more people to do those types of things. I havent sat down and thought about resigning transportation, but there are people that specialize in just those types of things. Theres scientists that are called implementation scientists and their sole mission is understanding the science of behavioral change. How do you understand how people interact to optimize the Behaviour Change that you want . And there is a team of implementation scientists at ucsf looking at these types of questions. The challenge that we have is that hours matter. And so this is where these things, where even though we have implementation scientists, well have them look at, for example, how to help people stay at home and what are the barriers and unable enablers tot home . How can we use evidence to do that . Unfortunately, if we dont work fast enough, it may help us a few months from now but not today. Besides that, is there something the sfmta and staff can do now, ensuring people arent sitting next to one another . Absolutely. Right now its going to be social distancing, disinfection, making hand sanitizers available and all of the real basic things and not asking people to push so, for example, ill give you an example, these doors right here, right, these doors should be open, right . You should at least have one door open so people can walk in and out without touching surfaces. If you have 500 people here, you have 500 people touching a common surface and you could have infected 500 people with one door. Isnt that muni . Thats my point. Thats my whole point. Up have to really sit down and design the system so that people are minimizing supervisor ronan heard my speech, minimizing contact with surfaces and so its not just my voluntary contact. Its designing the environment so that they dont have to make that decision, right . If a door is open, you dont have to push it. And if you have hundreds of people going through a door and a hundred people are pushing it, thats 100 exposed people. You have to take that mindset. I guess that would be my last thing, through the chair. But this is a lot of work. Everything that im describing is a lot of work, including the social distancing, having ads, having all of it resigned so that youre making it safe for essential workers to come to work. Thank you. So supervisor peskin . Thank you, president yee. On your example of the door, we walk into city hall and that door is closed and that one is using the same handle for this building. So everyone just echo that and Everyone Needs to be thinking about their workplace and thinga door or wearing a glove or washing your hands, thats absolutely essential. And i think obviously there are things like testing that we, as a body may not have access to. We made a big step yesterday in having folks shelter in place and probably the single biggest thing we can do is to consistentlily anly get the wor. I will say the mayor and folks who spoke at the press conference yesterday, i think, delivered a very clear and strong message. So i think there is good messages and some of the materials we share do that. And i guess its partly a comment and partly a question because im curious whats in the works on this. But we in this body, i think, are particularly connected to our constituents and have the ability to get the word out in substantial way. What i dont see happening more broadly in terms really getting the word out around the importance of all of the measures that youre talking about is robo calls, standardized emails coming from every department and every supervisor and frankly, everyone who ever ran for office in this town and whether they won or not, to their lists. And phone trees and phone banks. I mean a lot of the things that many of us did to get elected here in this body are the ability to reach out to thousands of people. Doing that, i think amber alert on the phones, i dont know if thats an option of getting forced communications to cell phones. We talk about buses and i agree with supervisor safaye of having someone on the bus to walk through the bus but signage. Instead of advertising product, lets put stuff up thats jarring and talks to people about these issues. So i think theres a huge amount we can do and i think it has to happen really quickly and i think the more our offices and