it's more positive than negative and some other opportunities to think about how we can move forward and within what we have coming down from the state. i heard a lot of willingness from the people here today to work collaboratively with the administration towards solutions. actually identifying where the needs are, doing this in, think, a collaborative way and a lot of conversation about funding. i heard someone say we'll go up to sacr sacramento. i hope be can join you with that and that city hall is part of pushing sacramento to give more and let us know how we can do that and then we should be looking at local funding. i agree with that, how city hall can do more. prov w has passed, part of free city and not doing enough. i agree that most people voted

thinking that the large majority would go to city college and that's not happening right now. there was an article in the chronicle about a sale of a building that facebook will be in, that they basically used a loophole and only turned over 49% of the building and a as result, the city is losing out on $16 million of taxes we would have gotten through the real estate tax and that could cover what we're talking about here. there is a ton of money in the city and a ton of resources. if we don't have it in the budget that we have here in city hall, we need to go out and access it and use it for institutions like city college and directly for city college because this is so critical for how we have an equitable city with access an opportunity and enrichment and spirit and joy and happiness. that is so critical if we'll be

a san francisco that is what we say we are, which is a place that is for everyone, where everyone can be themselves and be there for each other and that's what we're fighting for. thank you for staying the entire time, chancellor. when we have department heads here and we have a hearing, they leave way before public comment for you to listen to everybody and i think it's important and i know you're exited t exit commig with them. thank you to all.

we need a motion and second to file this hearing. >> and this hearing is filed and our meeting is adjourned. thank you.

[♪] >> coming to san francisco on june 11th, the earthquake safety his fair from 10:00 a.m. until 4:00 p.m. as the auditorium at 99 grove street. meet with contractors, design professionals professionals, engineers and architects, along with city agencies and hundreds of booths on the main floor. attend one of the workshops at 11:00 a.m. the seismic safety strategies study. what you need to know is the city strengthens buildings 240 feet high and higher, and to get ready to the next -- for the next big one. 12:00 p.m., changes in the updated citywide vacant

commercial storefront ordinance. 1:00 p.m., comply with the accessible business entrance program to enable everyone to enter your business. 2:00 p.m., home modelling process made stress-free, meet the experts and understand the permit review issuance and inspections process. 3:00 p.m., making the best use of the accessory dwelling unit and legalization program to at affordable housing. learn from these three workshops at the june 11th d.b.i. earthquake safety fair, and begin to get ready for the big one by taking immediate steps to protect both family and property we hope to see you there, so register now. [♪]

>> everything is done in-house. i think it is done. i have always been passionate about gelato. every single slaver has its own recipe. we have our own -- we move on from there. so you have every time a unique experience because that slaver is the flavored we want to make. union street is unique because of the neighbors and the location itself. the people that live around here i love to see when the street is full of people. it is a little bit of italy that

is happening around you can walk around and enjoy shopping with gelato in your hand. this is the move we are happy to provide to the people. i always love union street because it's not like another commercial street where you have big chains. here you have the neighbors. there is a lot of stories and the neighborhoods are essential. people have -- they enjoy having their daily or weekly gelato. i love this street itself. >> we created a move of an area where we will be visiting. we want to make sure that the area has the gelato that you like. what we give back as a shop owner is creating an ambient lifestyle. if you do it in your area and if

you like it, then you can do it on the streets you like.

>> i will call the roll. the meeting has begun. [roll call] the second item on the agenda is the approval of the april 16, 2019 minutes.

>> commissioners, the minutes from april 16 are in your hands. if you'd like to review them and make any comments you have before we adopt the minutes from the 16th meeting. is there a motion to adopt? >> so moved. >> second. >> any further comments? >> i've not received public comment requests for this item. >> ok. all those in favor signify by saying aye? >> aye. >> and commissioners, we have some folks who want to make public comment who are employees and on the job on their break and so the president has agreed to change the order of items and we will take general public comment as our next item. >> that is correct.

>> and everyone who's making public comment today, please know that i have an egg timer. everyone has two minutes. and when the buzzer goes off, that means that your time is up. the first person is jill duncan or joe duncan. and the second one is nato green. >> good afternoon, distinguished members of san francisco health commission. my name is joe duncan. i'm a registered nurse at san francisco county jai. i'd like to start by thank youing for creating resolution number 19-5. incarceration is a public health issue. too often we see the most vulnerable members of our community locked up. the mentally ill, those with substance abuse and the homeless brought in.

with the guidance of dr. lisa pratt, we have updated our medical assistance treatment for substance use disorder. we have expanded our roles in methadone maintenance program. our alcohol protocols have been revamped and are much more aggressive in combating the alcohol withdrawal symptom. we started -- we are starting and continuing medications, psychiatric medications at a much faster rate and decreased the use of safety cells and increased our 5150 send outs. it is an unfortunate reality that the jails have become a de facto primary care setting for some people. but it is also an opportunity and opportunity to reach a segment of the population that generally otherwise goes ignored, shunned or, worse, forgotten. i applaud you in your resolution but ask that you not

look so far in the future that you forget the work that needs to be done. >> could you please identify yourself, for the record? >> joe duncan, registered nurse. >> thank you, joe. next speaker. >> wait a second for the documents to be circulated. my name is nato green. i'm the -- i work for s.a.u.10-1. i'm giving you two documents. so i just discovered that one of them has a copy problem and there is a key page missing. but you have it already, so the first document says at the top

the zuckerberg trauma center vacancy report march 2019. you got this last month at the joint commission of the health commission that deals with vacancies. the page that is missing, but you already have it, what it says is it deals with vacancies and at the top of the page it says for classification of registered nurse 2320, that there are 68f.d.e.s worth of nursing vacancies in the hospital. if you look at the other page that i gave you, that says d.p.h. budget versus actual is another document that the department has generated that shows actual d.p.h. budget and utilization. so, for instance, what it says in the second box on the right cold sum in fiscal year 2017-2018, the budget per diem nurses was $27 million at zuckerberg general and the actual expenditure was $62 million. so, these are both d.p.h.

documents. they cannot both be true. it is not possible for there to be only 68 nursing vacancies while the department is spending $62 million a yore on per diem nurses. the explanation, the only possible explanation is that the budget document is wrong. the actual utilization of nursing labor in the hospital is much higher than what is currently reflexed in the budget and so what we have is a trauma center that is running on temps. and the city hasn't said that as a matter of policy. but that is the case. that we have 400 f.t.e.s right now of nursing labor being performed by temp nurses who -- when it should be done by people with full-time civil service jobs. this has far-reaching consequences for scheduling, for operations, for overtime,

for trauma response, for disaster preparedness and the city needs to fix its fundamental hiring problems to budget staff and hire full time civil service nurses based on the operations of the institution. thank you. >> that is all the requests that i received. >> call the next item. >> sure. item three is the director's report. >> good afternoon, commissioners. i have a number of updates. it has been pretty busy. if you'll bear with me. there are a couple of items that are of high policy significance that are not included in the report but because of their importance i want to high light them at the beginninging and follow up with written materials at the next meeting. but what i wanted to update you on the federal health and human services rule on the conscious protections for health care workers, which was released on may 2.

it's a rule that would allow health care providers to refuse to provide medical services, such as abortion and assisted suicide based on religious or moral reasons. there will also be guidelines to punish health care institutions should they refuse to comply with the rule and including loss of -- potential loss of federal funds. this regulation is expected to go into effect in 60 days. and last week, dennis herrera, the san francisco city attorney, announced a lawsuit against the new regulation. and additional lawsuits are also expected and we, the department, will be working closely with the city attorney to review potential impact before the rule goes into effect. so, we're working on preparing for this and also following obviously both the lawsuit and any implications there isof very closely. there is also on may 3rd, this is regard to a draft rule and

changes to public charge. and on may 3 there was a report leaked that the d.o.j. is drafting regulations to expand the category of people who could be subject to deportation on the grounds that they use public benefits and are a public charge. currently, legal permanent residents who are dedicated to be public charge can be deported. but historically this has been very rare. the draft rule of broadened public benefits to be considered under public charge discrimination, this includes s.s.i., snap, also known in california as calfresh, and section 8 housing vouchers, medicaid and others. it would allow for deportation of legal permanent residents who have used public benefits within five years of admission. many of the details of this draft rule are still to be determined and it is expected to undergo continued revision. but we'll be following this very closely as i expect to

know a number of community stakeholders will be as well as other city departments and will provide you with an update there. turning to the written section of the report, i just wanted to update you. we're now less than 100 days to epic go live and the department staff are working hard to ensure success of the go live. and we've -- training of 500 super users will begin next week. and there will be training for over 9,000 people provided this summer. going to an issue that has been particularly pertinent to communities where health equity is an a issue, we're actually partnering -- the health department is partnering with sfmta and the community living campaign to expand eligibility

for a paratransit plus which will allow people in the neighborhoods who serve the health center to access paratransit to access their appointments. this has been something that both clinicks have heard from their community boards and from community stakeholders that transportation is needed. the pilot project will -- we hope that it will improve health outcomes by removing spatial barriers to transportation particularly for low-income individuals who are otherwise unable to make their appointment. and the pilot includes an evaluation and will include future expansion of this important program. and we estimate a pilot that will serve about 1,000 people a year at the two clinics. going to h.i.v. work, there are two awards to highlight here. bridge h.i.v., which is our research arm of the h.i.v. work was awarded a five-year grant of approximately $2.5 million

by the n.i.h., national institutes of health, to conduct a research project that explores online pharmacy delivered exposure prophylaxis through a mobile online application. it is one of most prevention interventions we have and looking to continue to scale up so this is looking at access -- how to improve access points for people most at risk. again, a health equity intervention, since we know particularly among communities of color, there's been lower access to prep compared to other communities. and the population health center for learning and innovation received a five-year $4.5 million cooperative agreement from centers for disease control to continue delivering capacity building assistance to the h.i.v. prevention workforce. and this new award will allow the learning innovation center to offer technical assistances to 33 c.d.c. funded health departments. so taking the san francisco

model as it were and trying to work with others to help expand our evidence-based and community focused approach. and just a few more items. san francisco received a platinum level walk-friendly community designation. this was tonight third time a community has received the honor of -- in the program's 10-year history and really emphasizes the city's commitment to prioritizing pedestrians and to create safe, comfortable and inviting spaces to walk and this was in partnership with vision zero, sunday streets and the health impact assessment work which really helped us determine what needed to be changed with other city departments to improve the walkability of the city. so, it is not only a safety issue, but a health issue and providing people with this opportunity to be -- to get outside, to stretch, to engage. really has benefits for the

physical mental health safety equity and in the environment and on our economy. so, sort of a multisystem win for walkability in the city. another thing to highlight with our work is gender health. san francisco presented the 2019 national transgender health summit. at the 2019 transnational health summit in oakland, san francisco was well represented, including through the department. general health san francisco led the development of at least nine conference presentations and collaborated with key community stakeholders, providing multiple insights through the public health lens. in addition to their outstanding presentations in the medical and policy realms i want to recognize two outstanding workers.

project affirm acknowledged to nur with a health provider of the year award to support the service and health and well-being of the transgender and nonbinary communities and project affirm awarded kathy agulair for advocacy work to the local transgender community. so very proud of the acknowledgment in the awards for the staff. the last thing, one of my favorite items on this list is that on the 2*79, the randall museum of san francisco invited the health department to run a booth educating people about mosquitos in celebration of bug day. the staff worked with hundreds of kids that visited the museum that day. in addition to being a nuisance, mosquitos spread many diseases, including west-nile virus, dengue, and zika. our health staff held up a jar full of the mosquitos after

making sure the lid was on tight. so, educating across the community, across with regard from policy at the federal level to mosquitos at the museum level, we're doing the work in keeping with our mission and vision. thank you. >> thank you. my questions from the commissioners. >> i just wanted to commend the department again for the outreach again into the restaurants in china town. there's been a partnership and it looks like it is going to be a growing partnership with the community and the community leaders. >> absolutely. thank you. >> thank you. >> next item. >> thank you, commissioners. i'll note that there is no public dmoenlt that item.

item five is a report back from the finance and planning committee. >> good afternoon, commissioners. the finance and planning committee met at 2:00 p.m. this afternoon and we considered a few items and we added one contract report and a total of nine contracts. to the consent calendar. if you wonder why there is only five bullet points, because if you look at the last bullet point, it says six new contracts. wasn'ting of the new contracts worth mentioning is the new contract with makeeson corp thracing provides pharmacy distribution services, you know, which means that they are our providers to deliver all the different types of medications that we use, you

know, in hospitals, in public health clinics, and even in jail. and it is interesting to know that, you know, we're getting discounts when we bow in bulk. that is good to know. i think that, you know, when we move forward, we see this coming up as a separate item because before it was, like [inaudible] in the budget where we don't really see that anywhere listed separately at all when we approve contracts. we values a presentation of the charity report for 20 -- >> 2017. >> yeah. 2017. [inaudible]. >> any other comments or

questions? ok. item six is the consent calendar which includes the contracts that were reviewed at the finance and planning committee meeting today. >> all you need to do is vote on this item, is that correct? >> yes. >> all those in favor? >> yes. >> [inaudible]. >> great. thank you, commissioners. item seven is an action item, the cancellation of the july 2, 2019 meeting due to the july 4. >> this item is in our hands. do i have a motion? >> so moved. >> second. >> signify by saying aye. opposed? >> there is no public comment for that item. item eight, please -- please excuse my clerical error. it is a discussion item.

the resolution in support of the 2019 community health needs assessment. you all will hear this item today and discuss the resolution. you'll vote on it at the may 21 meeting. >> good afternoon, commissioners. my name is dr. thomas. i'm a director of the population health division and a health officer. in a couple of minutes, you'll hear a presentation from our amazing staff. they will be presenting the 2019 community health needs assessment. one thing i want to point out is that on the document that you had on page five, you'll sew that there are a lot of people that participated on making this possible and this is through the san francisco health improvement partnership and one thing that is important to us is that you see the report really connects the dots with the focus on racial equity and poverty.

i wament the co-chairs to make a couple of comments before the presentation. they are both co-chairs and want to say a couple of words and important thing is that this is really a strong collaboration with the community. >> good afternoon, commissioners. i just want to emphasize the fact that you should be very proud of this work product. this is the result of months and months of work. but all the hospitals, ucsf, d.p.h., the school district come together every month. our major product every three years is the community health needs assessment. the next step is the implementation plan. so, this is just about the needs. the next step, part two of this

is the chip, or the implementation strategy. we'll be bringing that back to you when we complete that. >> good afternoon, commissioners. so, one of the things that has happened with the chna which is a regulatory requirement for our hospitals is to issue this every three years. just coming to present a report of needs stopped short. and so what we need to do with the implementation plan and this body that represents many sectors to actually do a strategic plan to move the needle so we're not coming back in three years, highlighting the same priorities. indeed, this particular time we have two additional which is -- has a lot more visibility, which is really the problem of homelessness. and also the problem in our community around trauma and violence.

we look forward to bringing our ideas and our plans to impact those five areas in addition to behavioral health, access to care and healthy and active living. so, we appreciate your adoption of this chna. thank you. >> good afternoon, commissioners. i'm going to start my presentation first. that is not it. mark, where do i find it at? thank you. >> it's ready. so my name is michelle kinn.

i'm an epidemiologist with the department of public health in the population health division. my presentation will focus primarily on the data collected as part of the assessment -- part of the chna. however, before i get into the data, i'm going to provide you a lick of background which was already partially covered. the chna identifies the health of san franciscans and the factors that influence health. we complete this assessment once every three years in collaboration of sfhip who you already heard from and informs the community health improvement plan. we also use this document to support our work internally and provide it to the community to use as well. data is collected through three means a. community health status assessment, which is traditional data analysis. a review of existing assessments which collects day the and viewpoints as well from other researchers, community groups and d.p.h. itself that

put out a report so we can use lie that work and we also do direct community engagement. the chna includes an immense of data. it includes more than 170 data elements covering not only disease but also risk factors and social determinants of health. variable selection was guided by the modified barhigh framework, which is shown here. the following presentation provides only one way of cutting through the day the and i encourage you to look at sfhip.org where all the data is available. the leing cause of death in san francisco are predominantly chronic diseases with cardiovascular diseases and cancers alone accounting for 40% of all deaths. however, in the top 10 are alsos drug use and inflew went -- influenza and pneumonia. the vertical axis is the number of deaths. those points which are higher

up is more deaths and those over the dotted line are those 10 leing causes of de. while the leading causes of death are determined solely on the number of deaths, years of life lost is a measure that accounts for the age of death. and so the number goes up both as the number of deaths increase but also as the age of those who died decreases. in the graphic, the size of the dot is the magnitude of death caused. in fact, 17 of the 20 leading causes of death are also leading cause of premature death. the horizontal axis is the average age of death and when looking right to left, we see despite contributing relatively few deaths, drug abuse and suicide are increasingly important cause of death.

this figure disaggregates the data and examines leading cause of premature data by sex, race and ethnicity. doing so reveals health disspareties as well as the causes important to minority populations. it shows that for black african americans, premature death rates are highest for all causes. and liver cancer, h.i.v., prostate cancer and breast cancer appear now in the top 10 causes of premature death. on average, asians in san francisco expect to live the longer at 87 years while black african american and pacific islanders live 11 to 15 years less with a life expectancy of only 72 to 76 years. black african american males have seen the greatest improvements in life expectancy since 2005.

while chronic diseases versus behavioral health issues do tend to kill later in life. we know that by definition, people are sick with chronic diseases for years or decades before dying. while we do not have prevalence measure, we do have data on hospitalization, which reflect prevalence, but other factors like access to care. looking at hospitalizations for diabetes, heart failure and hypertension, we see that in general, [inaudible] start to eke pa up when people are 30 or 40. however, against black african americans, rates soar early in the 30s and 40s and rates for black african americans in their 30s or 40s are compared to those -- others who are 30 years older. in fact for diabetes, rates are higher amongst young black african americans than they are for anyone else. at any age.

[please stand by] -- it's lower than the rates seen in california overall or the healthy people 2020 goal, young adults, low-income residents and people of color

and men are disproportionately affected and have not seen the same gains. low-income residents are twice as likely to smoke and men three times as likely. and a survey of new moms reveal while rates have decreased and the rates are relatively low, black mothers are more likely to smoke before or during pregnancy. and while the rate of cigarette use amongst san francisco high school students as well as is 4%, there's a risk of nicotine addiction as 27% have used electronic smoking devices. overall the rate of binge drinking among high school students is 8%, however, the rates vary and 25% of white students binge drink. marijuana is very prevalent with more than a quarter of the students reporting smoking and, again, that rate varies based

with 40% of latin and almost 60% of black african american students smoking marijuana. and 11% of high school students report using -- abusing prescription drugs and 8% report using methamphetamines and other drugs. again, similarly, the students most at risk are black african american, latin and white. mental health including substance use is come know and help may be hard to get. 23% of adults report needing help. 7% of adults report psychological distress and that number is three times higher for low-income residents. depression is the most common mental health condition with the number of hospitalizations exceeding that seen for hypertension or asthma. and the rate of hospitalization

increased 20% between 2012 and 2016. rates of hospitalization are highest among young adults and black african americans and the tenderloin and sonoma neighborhoods. and depression with pregnant women have consequences for both the mother and baby and 14% of pregnant women report depression. and women with only a high school education are three times more likely to report depression than are women with a college degree and 25% of the lower income mothers experience depression. and among sfdu high school students, 26% report prolonged sadness and 10% report suicide ideaization. rates are higher amongst the middle school students with filipino and latin students having especially high rates. while not shown here the rates are elevated amongst students identifying as bisexual, gay or

lesbian. violent crime rates are high in san francisco and rates exceed those seen in california. crime rates and emergency room visits due to assaults are higher in black african american and pacific islanders and latin americans are more likely to experience violent crime. it's the fifth leading cause for black african american men and eighth with latin men. and not surprisingly residents in eastern neighborhoods and people of color are less likely to feel safe in their neighborhoods. despite city-wide decreases, a large disparity in the rate of trauma treatment exist for black african american children where there's a 17 higher time rate as compared to asian and pacific islander children or white children. while the magnitude is less

there's also elevated rates of non-treatment amongst latin children. the majority of cases of child maltreatment are a result of neglect. and commercial exploitation of children is a problem in san francisco. the victims of commercial exploitation are mainly transgender women and people of color. one-third of victims are from the bay area. and minors account for a third of the victims said trafficking. and healthy eating, and the diets of many san franciscoians do not meet recommendations for vitamin and water and exceed the maximum recommendations for salt, fat and sugar. low-income and black african american and latin residents are more likely to not meet recommendations as well as residents in san francisco's southeastern neighborhoods and treasure island. two-thirds of children and teens iand pregnant women eat less thn

five servings of vegetables or fruit in a day. over a third of all adults and two-thirds of high school students consume soda regularly and the majority of black african american and latin residents eat fast-food regularly and a third consume soda regularly. not having enough food or resources for healthy food is prevalent among the students in public school and low-income residents and pregnant women and housing insecure adults and older adults and persons with disability. up to this point we have looked at data points in the causes of the leading causes of premature mortality, but what circumstances contribute to not eat willing? it's not being physically active and using harmful substance or poor mental health. why do we see disparity in the approximate causes? to understand the causes, i have reviewed models like the one published by the world health organization which shows the

individual, social and environmental risks to mental health over a life course. so far in today's presentation we have seen a number of risk factors for mental health and substance use including neighborhood, family, and trauma, poor nutrition and ill health. while additionally we'll see some data points on social inequities and socioeconomic status and difficulties at school and employment. while i'm not going to show you models for healthy eating and physical activity and violence today, each of these models includes the same risks, or many of the same risks, safety and adequate resources and incarceration and mental health. this figure shows data on select social determinants of health. and life over the life course and you have true -- while this data does not show determinants of health, inadequate resources

and unjust criminal system and housing instability and more build up in a community and lead to the consistent health disparities that we see. and while expressed upon repeatedly, it's to show the tradeoffs that residents must make. one in four san franciscoians live below the poverty level and for family of four that is equating to about $50,000, but about $120,000 is needed for a family of four. and with the cost of child care and rent, which for many consume more than 50% of the household income we can see that many won't have the resources necessary to buy healthy foods and take time to go to the gym and any other requirements to live a healthy life. living healthy can be expensive. in addition to the direct effects of poverty, inequality has been shown to have effects

on health and community. and in san francisco the wealthiest 5% of households earn more than 15%, 16 times the poorest 20% of households. this inequality is especially pronounced when viewing data by race and ethnicity as the median income is $111,000 and that of black african americans is a mere $28,000. so that is the end of my presentation for today. and if you want there's a website where the rest of the data is included. >> thank you, there's one public comment request that we have received. yes, former commissioner.

>> thank you, commissioners. it's always wonderful to bit get this report because then we can think differently and now the two new priorities being raised are, you know, with homelessness and that's really important for our community as has been stated. i just want to have you to consider for the strategic plan to include social factors, determinants of health, like where people are with their heart problems or their cancer and it makes a difference. and unless we have at least a chart and so in my two minutes i can say that if you could look at slide 12, 10 and 7, when you're developing the strategic plan that in chart 7 you are looking at the risk factors. and unless you find a way of integrating rather than separating out social determinants which include high

incarceration for people in certain locations in our community, then you will medicalize their condition but not include the social determinants. so if they're in jail, for example, or they're in bayview and that's not integrated in any sort of way in your charts, then the separation doesn't make much difference between high blood pressure for people over 70, of which i'm one. and somebody who spent 12 years in and out of the jail or in and out of tents going to jail. somehow we have to figure that one out. so that's what i would say since it's already been said that -- because i'm focused on the jails and you're now taking this up. i just encourage you to look at that way of doing it and i'm sure that the epidemiologist and the activists and the committee can figure out a way to do this.

thank you. >> thank you. now, commissioner, you have any comments? commissioner. >> thank you for the report. i guess that you know that in some ways i'm always beating the dead horse because transgender communities are so small, a lot of times it's not showing up in any of the data. and that's where the concern comes in. because if we use these datas to make a str strategic plan, then transgender people would never make it into the strategic plan. and i'm surprised that we don't have any footnotes on the student health risk, you know, of the suicide rates or even contemplating suicide.

because, like, it's lgbt students are high, and i would doubt that transgender students would be any lower than they are. so i'm not trying to be hyper critical, but as a transgender woman i'd like to see, you know, like improvement plans that includes me in there somewhere, not just, you know, survivors of, like, human trafficking. thank you. >> commissioner john. >> so i will make sure that we do follow up on that and we can put that -- >> i know that if we're looking at it, whether it's the statistically significant -- sometimes it's hard to arrive to any conclusion. but having a footnote makes a whole lot of difference in the community. >> thank you for pointing that

out. i had, first, one question -- which is on the executive summary and it's mostly a query on information. under health needs, you speak about san francisco gaining access to health care with 10,000 fewer residents, in 2017, compared to 2015. is that insurance or is that insurance plus our health access in healthy san francisco that you're talking about? because it's not clear to me. >> it's the combination. >> so it is a combination? >> i believe that it is a combination. >> i think that because you continue to say that 3.6% of the population does not have insurance, so i think if we're looking at the report, at the executive level, it would be good to clarify that this was health access including insurance and healthy san

francisco. because otherwise it seems to imply that we're only talking about insurance. that was just a gray point. and we should get credit for closing that gap, i agree. thank you. now -- now i'd like to really thank the page 5 people which has been pointed out, as participating in the program -- or i should say in the steering committee and in all of the other aspects of the development of this report from so many places. and i think that it really shows -- i'm just amazed at the amount of data and also to put six charts into one powerpoint. and sometimes even more as it flips back and forth. but it doesn't even do justice to what is in the report in terms of the richness of the data. the part that i find concerning

is that the data can help us to inform what our situation is today. and, of course, we need to know that and we need to know what the needs are. and i'm reminded that we have had similar reports done not quite as extensively or even exhaustively, and in such detail and with such great quantification. and -- and we at that time on those instances -- and these were pre-dating our population health accreditation and all, so they were, you know, important reports and often put out by the hospital console or put out as a consortium or a collaboration. and off of that data we then felt enthused about what would happen next.

and in the following years almost nothing happened. i do have hope that because of our accreditation process that we then are required to not only find an action plan but to get to outcomes after the action plan that are then reported back to us. because we have seen action plans -- we have seen attempts even on the various iterations of a needs assessment to try to evaluate where we were and then they sort of ended. and i'm hoping that all of the work that has gone into this will really begin a new phase of our success in getting -- not only to the needs which you have now shown, and then narrowing down into action plans, but to produce outcomes. to some extent you have shown

some of the outcomes from the last three years. you have shown improvement in some of the black and -- the black communities' disparities and others. but i just have a plea that after these years that we really would like to continue to see that kind of information come out. and i commend you for putting that into this report. and from the last three years we had done something. and i'm just making a plea that we really make that an even bigger goal, not only do we have plans to try to address our disparities and our needs, but that we have plans to tell us how well we've done and what we're going to do from that. and not just find a new set of goals that we want to do. thank you. >> commissioner. >> i was just saying thank you. >> well, i want to commend you for this amazing report and for

the detail and clarity. it's a remarkable report and it was just a pleasure and an honor to be able to read it. i'm just wondering, you know, you have identified a lot of obstacles but a lot of opportunities here as well. and spin boarding off what commissioner chau was saying, do you see anything that was a quick win? of these various issues that you're facing and various strategies, you might decide to initiate. anything here that you think that within a year you could say, gee, we have really done something meaningful? i was looking at the w.i.k. program in particular. some of these things will be huge challenges and others will be easier to accomplish. what do you think? >> i'll mention a couple and michelle may have additional ones to add. we know that, for example, there are evidence-based strategies that you can implement that we can spread. and one of them, for example is the family partnership that you're probably familiar with that by using nurse practitioners and working with

kids, high-risk pregnant -- first time pregnancies and first year in life has a huge impact and saves money. and we're not reaching everyone that we can. so there's things like that where if we invest we can expand and do more. and the other one is going to be important for us is that we actually for me is almost a logistical supply chain problem which is really around food insecurity. we have as a city, we have the wealth to do this and so we can close the gap and we are starting, for example, with pregnant moms, and making pregnant moms that are housing insecure and making sure they get access to food. and we can close that gap and keep it closed and move on to high priority groups. so there's things that as a city we have to just make -- make it happen. those are two that just come off the top of my mind. there's other ones. my wife works with the school district and there are great programs like making schools into trauma sensitive schools

because it's a big issue of kids that come in with early child adverse experiences that can have an impact and by intervening in the schools. several schools are part of it and we could do more in that area. is there anything more that you would like to add? >> and i would add, talking to the commissioner's comments as well that we haven't mapped well what we have done and the asset and th the asset assessment is missing. and so some things are ongoing like tomas has mentioned. >> and i forgot to mention and the health commission endorsed this, and the incarceration of the public health problem, there's a team of people working on this. and i think is a great opportunity for us to really focus in on a really concrete thy and to look at that path --