conditions that impact a woman's right to decide when the time is right to be a parent and that includes domestic violence and because many women are in relationships where they are intimate partner violent and that prevents them for example from taking birth control and all kinds of other issues and so i want to say that i am really happy to see that domestic violence and reproductive justice are integrated in a way that are going to serve women. >> for sure. >> i had a quick question and not a quick question, could you go to the last slide? so the thing in the bottom, is that relation to pregnancy? >> no it is not. >> that is just a general. >> that is just gift different and the two about them are not related to pregnancy and those

are women of child bearing age but not related to pregnancy and they are just stating that women for various reasons don't go to the doctor. >> >> we ever looking at a vast number of those that are present able and prevention oriented chronic diseases and i am wondering how the health department is use and do you use a gender frame and do you use, a social disparity frame when you are determining what kind of prevention efforts you are going to spending the city

dollars on and how does that process work? >> i don't know if i am the best one to answer how we spend the money. >> we are rying to align the department in the areas of heart disease for sure, because it crosses over, alcohol, and committee for the women as well as there are other areas and you want to align the department so that they were all focus and particularly on the african american health disparity issue. and to be able to focus the health department and we are two billion dollar organization and to provide the incredible amount of healthcare service and we are trying to align our institutions and all of our services to focus on this issue that lifts that health status, and by, insuring that the health department is aligned

and focused and give the special attention that the african americans have the best healthcare in the health department and they will move that throughout the city wide as soon as we get our own services in mind and we would love to share that with you and the efforts that we are making in those areas and we do work out of a lens in terms of looking at the population that is in greatest need, of the full attention of the health department and so we will share those documents to your director association that you are and happy to come and talk to you about the progress in that area. >> okay. >> is your position of chronic diseases separate from maternal? >> yes, and our maternal child and health is in our network area, and particularly because of our nursing services. and we have a whole public health division that is run by our director, and public health, area, and in particular, our health officer and we can also give you our

structure of how we are reorganized and so we have done and we are not doing the disease specific any more where we have the hiv area and chronic disease altogether and particularly with the progress and the attention to hiv and also, and the other areas and so we are trying to really focus on the fact that people do have multiple diseases and how we look at that from the hol list tick way to the comment. >> and do you use the gender lens. >> today that was very clear to me is how do we do that? i wanted to skt staff to look at that through the woman's area. in fact, i think that this commission may be able to go in a new direction on that as well. >> commissioner jung >> i want to see where they are going for the health officer if

you have any comments? >> one of the challenges that we have is that average we are healthier than most places in california and than most places in the country, but when you look and when you look at our data what really stands out is really the health and akties and the disparities and we notice that in general we are healthier than everybody else but addressing the disparities in the city is where the focus should be, and well, i will admit to you that we don't really take and we have heard

>> i am thinking about it in terms of obesity prevention and i think that over weight and obesity for women, for girls in particular is different for boys and i don't see that is an area, when we are drilling down into, and not necessarily, a disease, or a health related, and that effects women, primarily, such as breast cancer, or even, and so we are looking at chronic disease and we know for years, and the health disease and we assume that it applied to women and we are learning a lot of things and i would like to encourage you to continue to use that lens on the diseases that maybe don't seem like they are maternal. or women diseases. >> i agree with you, thank you so much. >> commissioner?

>> i just had a couple of questions in follow up, to what commissioner ackerman questions were. one, it would seem to me in looking at the rate of death due to these issues around heart disease, and the department and the health department out reach, and initiatives that were described by the director garcia. and is there a economic piece to this? in terms of i am just going to talk about or it is just straight talk for me, okay? and it was stressful for be a black woman in san francisco. and it is especially stressful if you are under economic duress, we are less than 6 percent of the population, this is a round up in terms of the population, and in 1991, i believe that we were around 13

percent of san francisco, population, and we are now less than half of that. and we have been exiting san francisco for a variety of reasons, most of which are because of the economics. and so, i would speculate that the health issues have not really diminished greatly, and certainly, there are some triumphs through the departments initiatives over the years. but nonetheless, the numbers continues to be very stagnant. and so, is there any particular one, is there any particular initiative between the health department and those working on the economic development issues, in the city. in order to help improve and elevate the status in the quality of life, for the

segments of our population and most specifically black families or black women? you are stressed in having strokes and heart disease and other particular health challenges much due to stress. much due to lack of access to healthy diet. and much less i would imagine also, access as less. and by limited resources. and also, some others barrier and so the way that i read this, is that perhaps, the economic factors for once, and certainly there are other factors but the economic factors are also a cause or a factor in this and how does the health department, work in conjunction with those persons or those agencies that seek to

provide economic security, for san francisco? so that is it. >> a couple of areas, one is that we are closely working with our housing authority, and those new developers, for the sf sites. and there is a whole workforce development component to that. and particularly for young people and that are living in these areas and also, the families. and so they are very involved in the development of the health component to that. but i see that as a major focus is really looking at the families in some of the sunny dale areas and the hill area and so we have been very focused on the dedicated staff who are working with the redevelopment programs, the workforce development and the programs. and particularly in those areas. >> and i have just one last question. >> and thank you for that. >> because, we are talking before in terms of the zip codes, where the people are

existing and you have described some of those public housing areas. do we have any indication in terms of these numbers the ages of the women that are largely representative of this 113.8 percent, and on this chart. and would or do we know that they have resided in those areas in the city that have undergone the environmental clean up. and so in other words, in the neighborhood, and in the naval point and the bay viewpoints, and the naval yard area? exposure to the environmental yeah toxins that exist there and is there a correlation that one can speculate? and arrive that there is a

correlation of sorts because the neighborhood that you have mentioned are in proximity to that. >> right. >> and so, it happens that, and it seems to me that there will be have to be more than what i have described just the stress of being existing and the economic challenges and etc., and if there is something happening that is going to be an actual environment itself. >> let me turn this over to the doctor and he has been involved in the environmental pieces of the bay view, and the naval shipyard and in fact we have a epidemiologist who has worked on it for 20 years. >> great. >> you are asking a really good question. what i first came to the health department in 1996 that was my first job with the work in the bay view and the work with the african community at looking at exposure assessments and one of them and the questions of the correlation between the exposures and the out come that is hard to prove, statistically

and that there is an association and we definitely know is that when you look in san francisco, in that neighborhood, especially associated primarily, with the race, with african americans that they have higher, rates of all the chronic diseases and i have been following the vital statistics from now until now, and you are right, it is very it is the disparity is huge, and persist ant and one thing that we did not show you, is that we have the other data that really breaks this down and looking at men and women and there is the disparities across the leading causes of premature death for men and women with african americans have the highest one of the things that you will notice is that for african american men, the out come that you see tend to be a little bit more socially determined. violence plays a big role for african american men and at one point there is a lifetime risk of 1-13, if you were born in the bay view you had a rate of

1 in 13 dying from homicide that is how bad it used to be. when you look at women, it is differently and more of them have a component that could be prevented through the access and the primary care and screening and for example, we see the lower rates of breast cancer in african american women but we see the higher rates in breast cancer and mortality, they are more likely to die of breast cancer and so you do see these differences in the group and we know that that is definitely there and even if you look outside of the bay view you continue to see those. and in the environmental focus, we focus on insuring a safe environment and making sure that they are on level across the zpaoe that is really the best that we can do. and it is hard to statistically

infer causalty. and i want to just ask, one question, generally, and i guess as a model for the places that we are embarking on now, and due to the fact that we prior to most of our nations most of our fate had a strategy for the universal health coverage, do we have the capacity to take a look at the data from when we embarked on a presentive model? using our clinic system as well? verses what is happening now with the implementation of the aca and have any lessons that might come out of that, that are particularly relevant for a future prevention? >> and i will have the deputy director also respond to what she knows of the data, but i can tell you that we are not facing but many other counties are facing. and also, doing all of the out reach necessary to get the people into the medical homes

we did that over seven years ago and it has proven to i believe, we will show that the cost will be lower too, because we took care of a lot of the chronic disease issues and when the first got the medical homes and one of the issues that we are facing now is the affordability factor where the people are enjoying and even though the healthy san francisco is not an access system and they do have the mandate for the own insurance programs and we are facing the affordability factor of those who were paying incredible more amount than when we are federally mandated to give an insurance program for finding that difficulty and that transition and we have a whole study that we are trying to accomplish to look at that to see how we can mitigate some of those concerns and i wondered if you want to add more to that? >> good afternoon, commissioners, i am the deputy director here and i don't want

to add too much more except to say that we did an analysis of the healthy san francisco program. and healthy san francisco as director garcia said is a coordinated care program and it provides a primary care medical home and access to especially and presentive and hospital services when needed to an individual who is inrolled in the program it looks like health insurance and go to the medical home and get referred to whatever and the services that they need and pay a fee, based on the income, and on a monthly or a quarterly basis and so it looks like health insurance but it only works in san francisco and it is health insurance, we have had that in place since 2007. because we had that program in place, we have not experienced the same lack of access to care that other communities in the state and in the country have experienced and so when they did a review of the healthy san francisco program, they found the lower rates of the preventable hospitalizations among the healthy san francisco population compared to uninsured people elsewhere and so it does have an impact so it

does have an impact on preventing unnecessary emergency room use and hospitalization. >> commissioner jung >> thanks, again for the presentation, and i just want to follow up. and a couple of sublts here, one is if you look at this census and we get a clear census on two gender and of course, as we continue to evolve, we know that gender is not necessarily a (inaudible) thing and so a lot of times, sometimes the woman became invisible and buried in these data and even though a lot of the issues shared by the transwomen, especially the transwomen color and especially transwomen who live in poverty

or near poverty and very similar to those of you know like the women, that would just talked about. and but these data are nowhere to be shown because a lot of times we also experience such a high rates of violence, that they are discouraged to engage in the system. so i think that one thing that is really helpful, for us, is answer changing the way that we are collecting the data on gender identity instead of checking the basketballsing box we are going to use the two question approach and so we might be able to capture the better data, you know, around a more ininclusive women community, that we served. and so, that is helpful to me. but, with the hope there are challenges as well and because, like we have been working so much in the silo and in the various different departments, and when we look at the more more morbidity and when we had

the hiv report, homeless women, usually have poorer health out come as well when it comes to hiv and late stage diagnosis and, so how do we really, make this truly, intersectional and how do we create a system that respond to the need before it turns into a crisis. and so that it is a community that is near and deer to me and i think that we hear a lot about our concerns and when it comes to the dark women, who delay care, you know, like what exactly is the reason and i think that that is really where we need to find out and i remember once upon a time when i was very involved in the woman's health, and conferences like child care with the big factor for many women.

not to mention, you know, a trans... (inaudible) but because of the budget cuts a lot of times, these services get cut. so when you ask the women to juggle between choosing taking care of the children first or taking care of themselves first a lot of women will opt for taking care of the family first. those are the narratives that we need to include i will juster jump in and say, that commissioner soo has been pointing to child care as a very important factor in woman's economic and i am so glad to hear it here, also, health, likes sf san francisco, and generally and so i am here to just, second and applaud, commissioner soo's focus on child care. >> we move.

>> yes, commissioners i believe then, that because some of the topics that we are taking it were actually in the enf and i am anxious to hear what in fact, the department has done on these status of women. and would you call the next item? >> yes, item 2 d, top issues and dr. emily murase will be presenting on this you. >> i think that we asked that there was no public comment on the previous item sf. >> no. i had not received public comment on that item >> thank you. >> good evening, commissioners and thank you very much for this opportunity to talk briefly about the focus that

our department has had. and i want to acknowledge former health commissioner, and police commissioner and health commissioner, who occupied this position, previously and i also commenting on how much i admire your health director barbara and the commissioner honored her, with the human rights award in 2011 and as was mentioned by the president will be honoring dr. katherine doda at our event on monday and you should have received an invitation to that and you will be joining the friends of status on the commission of women on monday. >> so i want to touch on five key issues as human trafficking and domestic violence, and family violence, and the status of girls and healthy mothers. >> so, at the department, we take a human rights approach to the violence against women and rooted in the un convention, on all forms of discrimination against women. and international bill of

rights for women and that has been ratified by 186 out of 193 un member states, and with the exception of the united states. we are among the 7 countries that have not signed on including iran, and lo, and south sudan and tonga but this was not good enough for the women of san francisco and in 1998 san francisco became the first city in the world to enact a local ordinance with the principals, and this forms the framework that guides our work and we are privileged to have amy who is the city attorney at the time who drafted much of the language for that ordinance. and so with any human rights, framework and freedom from violence is a human right. our first topic, trafficking in

san francisco. we have a rebounding economy and a growing population and immigrant population and hospitality industry. we see all forms of trafficking here in san francisco, sex and labor trafficking, child and adult domestic and international trafficking. and our entire community affected and there is a link between human trafficking and smuggling and drug and, money laundering and organized crime and all of these lead to increased crime in gang activity and child exploitation and public health problems. so what would you guess the annual income of a pimp, 640,000 tax free and the

calculation goes something like this. four women, we understand, from the county that a typical quota is ten tricks a night, we are talking about a street operation gets you to $730,000, and you take off some money for expenses food, housing and clothing and you get to something like $650,000. i mean this is one person, controlling four women and so it is lucrativ. >> the mayor has shown tremendous leadership on this issue and convened a mayor's task force on human trafficking beginning 18 months ago and the purpose is that the (inaudible) will over see a victim approach to effectively intervene in the human trafficking situations and focus on the long term solutions to this problem. and the task force is a combination of city agencies including the department of public health and the human

services agency, and the criminal justice, agencies but also, the service providers, such as asian women, and market street, youth services. so what has this task force accomplished so far? >> we have developed a data tracking tool, human trafficking is a largely invice able crime and we are trying to make the invis able, visible. and then, the enforcement of the massage parlor regulations have been beefed up thanks to the police department and the commissioner, mary and i actually joined your inspections team to go in to massage parlors in and around china town and these inspections are important sxh in one instance a female decided to leave the parlor suspected of sex trafficking

after speaking with police inspectors she packed up her stuff and left. but it was clear to us that the inspections require many more resources to provide a comprehensive victim centered approach that is cultural competent, and the only language folks there were volunteers and so you theed to have paid language proficient out reach workers and it would be help follow to have service providers also who can make available referrals and we also need many more services to address the needs of human trafficking survivors, the sad part of that was that we didn't know where this female went to, because there is not a place to go for human trafficking it is likely that she ended up back in the massage parlor. >> the state law requires a noticing, including the hot line number in all bars, bus stations and train stations and

emergency rooms. so we conducted a campaign to 700 affected businesses and i want to thank the dph massage marlor