-- and you've got two minutes. >> caller: i'm cynthia and a pharmacy student from ucsf. and i really appreciate the progress that our city has been done with, like, the vaccine rollout and the policies like that. but i just wanted to touch base on some aspects regarding the mental health problems for covid-19. i learned that the new senate bill 855 was passed in september of last year and it was a great step towards expanding coverage for mental health and substance use disorder diagnosis and treatment in the state. especially with covid, which has brought a lot of mental health issues for many families and people who are isolated. and i was aware that sfpdh has increased a budget for covering

more urgent care services to make it easier for people to use, including services like the street crisis response teams and the mobile response teams which are great resources. but in light of the increase in the demand for mental health services during this pandemic, i think that the city should expand the accessibility of mental health service and its associated information especially to the elderly population. while these mobile response teams may be convenient to younger adults or college students, there might still be barriers for the elderly population. as much as the information and guidance is on covid and vaccines are important and readily available, i do think that mental health resources can also be included in those official information documents and they are distributed to nursing homes, assisted living facilities, and, you know, just other general public for them to

reach out so that people can be aware of these mental health services being available to them. yeah, and that's all of my comments. thank you so much. >> clerk: thank you very much. all right, anyone else? this is the last call. >> thank you for your comment. >> that is the last hand for general public. >> president bernal: thank you, mark. we'll move on to the next item which is a report from the community and public health committee. the chair commissioner suzanne dorado. commissioner? >> thank you. we have -- we had an excellent committee meeting and the -- we had two topics to discuss. and the first is the racial equity toolkit.

this is a little different than what the committees have been asked to do in the past, which is to approve something that has been put together and then forwarded for commission approval. with the racial equity toolkit and the -- not only the white paper but an example presented by dr. bennett, which was excellent, we are asked to, in fact, to choose it, work with the -- work with dr. bennett in going forward and then recommend it to the health commission. so it will be a little different. it's a work in progress. and we are excited to participate in putting the tools together.

and what we have asked dr. bennett is to put together a worksheet for the -- for the tool. and it will be at this point based on the framework which is the government alliance on race and equity framework, the gare. and that worksheet that would be part of any program or contract will be presented to the next month's finance and planning committee as part of the gare meeting. and commissioner christian and myself will join the committee at 3:00 for a further discussion of the tool. so that we are all together in

working on it and any questions will be at that particular time. so that is -- that is exciting and going forward. our second item on the agenda was the acknowledgement of the land in san francisco, and professor corderro was kind enough to help us and to talk us through it. and there was a wonderful job in putting together the acknowledgement document. we have asked with input that since this is the department of public health and the health commission, that, in fact, within the document as well as in the title will be referenced

health equity. and what -- so it's more than just land acknowledgement, but also what we do is in health. so that will be reformatted with those changes and brought forward to us. and then we will recommend it to the full commission. that was our -- it was a very -- a great committee meeting. so i don't know if any of the other commissioners would like to add to what we -- what i have stated. >> president bernal: anyone? mark, do we have any public comment on this item? >> clerk: folks, if you want to make comment on item 6, the report back from the public health committee, please press star, 3.

no hands up, commissioners. >> president bernal: thank you, mark. and thank you commissioner giraudo and the members of the committee. i tried to attend the meeting today. i'm not a normal member of that committee and i was very interested in the topic. and i unfortunately had network difficulties and i was fading in and out but i look further to getting more updates as it comes into the full commission. so, thank you. >> clerk: a hand has popped up. is it okay to go ahead and do that? so i will unmute you and let us know that you are there, please. >> caller: hello? >> clerk: yes, actually, before you begin i have to read a statement to make sure that we're all on the same page. the numbers have the opportunity to make comment for up to two minutes. the public comment process is designed to invite input and feedback from individuals in the community, however, the process does not allow questions to be

answered in the meeting or for members of the public to engage in back-and-forth conversation with the commissioners. note that the commissions do consider comments from the members of public when discussing an item. i will put two minutes on the clock and you can begin your comment. >> caller: yes, thank you. i'm calling about looking for policy to be written to protect tenants. the state has policy that was implemented starting january 1st to protect the employees. and my building has had several cases of covid and the employees, young and healthy people, were sent home the same day before the end of shift. but my building which is low-income people, but we have newborn babies to elders and english second language and all kinds of barriers and marginalized people, we have never been informed. you know, and the people with covid are not -- it's not

enforced to be isolated and quarantined. and our manager in our building is without masks. so we're constantly at risk. and we only have one front door and two elevators and i'm a person that is at high risk myself and i have it posted on my door. and they keep finding excuses to come in. so i was looking for some guidance from d.p.h. to protect -- and this is public money too -- it's subsidized -- to protect, especially -- well, all renters. and especially low-income renters whose rent is subsidized by the city of san francisco. so that's my concern, and i love the information guidance department. i think that they could probably find some good stuff out there, and models elsewhere, maybe, and even one that protects employees. i wish it applied to tenants, you spend more time at your residence than at your work

site. so yeah, i would, you know, definitely an equity issue. this is low-income housing. and so, anyway, thank you. that's my concern. >> clerk: thank you, caller. i'm going to mute you. if you -- i'm actually getting a note from dr. noonan that there's a document and resources to help with them. i'm going to call and give you my work email and if you can write that down and email me i will try to get this information to you. mark.morewitz@sfdph.org and i will repeat that slower. mark.morewitz@sfdph.org. you can also find us on the health commission website, on

the d.p.h. website under the health commission because i'd like to follow up. that's all of the comments, commissioners. >> president bernal: thank you, caller and thank you, mark. any other comments or questions before we move along to our next item for action? >> i did have one after commissioner giraudo's report on the native indian -- the native peoples resolution. they are going to try to look at the issues of health equity and i wanted to know also what might be the process in which they would receive input into the resolution from other commissioners? >> president bernal: thank you, commissioner chow. >> we are aware of that, and

with professor giraudo and with mark, we're reaching out to other native groups -- native american groups. so this is inclusive. and not as well. so this will -- again, it's a work in progress. and well aware of the need for a reach out. and all agreed. and so the language has been worked on. >> president bernal: thank you, commissioner chow and giraudo. we can move to the next item for action which is a resolution to honor dr. tomas aragon who left us as the city to bring his leadership to the state level. and i would like to recognize director colfax.

>> hello, directors, sorry. i was having some connectivity issues. so i just wanted to introduce this resolution to celebrate drd a mentor and an incredibly wonderful leader with firm commitments to public health, his integrity has led us through this covid-19 pandemic locally. and i'm just slighted that he's gone on to be the health state director and also sad that he's left san francisco. but he's taking the san francisco approach and the san francisco values, which he in

some part, in large part, helped to drive a culture of health in san francisco to the state. and i think that will be reflective of everything that he's going to do moving forward. so very excited and i'm honored that the commission is recognizing dr. aragon for his visionary leadership and his commitment. >> president bernal: thank you, director colfax. mark, would you read the resolution. >> clerk: whereas tomas aragon has a thoughtful leader between 1996-2020, and dr. aragon's long tenure with the d.p.h., served in the following leadership roles. director of chronic disease epidemiology, director of community health epidemiology, and disease control. and the health center and urgent care physician, deputy health

officer, and population division director and health officer. and whereas health officer dr. aragon led the design and implementation of public health programs and policies to ensure the effectiveness of the mandated functions of the local government and force the local health orders and ordnantses and communicate it regularly with public health issues with the health commission, the board of supervisors, mayor and san francisco residents. and whereas director of the population health division, dr. aragon was responsible for the vision, the commission strategy, the leadership, and the administration of the division which implemented the core public health services across the city. this included successfully earning and maintaining the accreditation for the d.p.h. and whereas dr. argon also had a productive 29-year history with the university of california teaching faculty, the principal investigator and clinician. and during the covid-19 pandemic, dr. argon worked

tirelessly with city and community leaders to shape san francisco's response through the development of health orders and ordinances and guidances, always striving to protect the health of all san franciscans. whereas dr. argon had humility and compassion during his d.p.h. tenure and whereas dr. argon is known to have a deep understanding of public health theories and mathematical models in addition to a wealth of on-the-ground public health experience. and whereas dr. argon is a proud native san franciscan and also a proud father. and whereas the health commission congratulates dr. argon as being named with the california department of public health and with governor gavin newsome. therefore be it resolved that the health commission honors tomasj. argon for his many years of outstanding service krnting to the health and well-being of all san franciscos and wishes him well in all of his

endeavors. >> president bernal: excellent job on the resolution, mark. before we move on to commissioner comments, do we have any public comment? >> clerk: folks on the public comment line, would you like to make public comment? press star, 3 no hands up, commissioners. >> president bernal: all right, commissioners, any comments on the resolution? i will step in to take the privilege to say that we are so grateful to dr. aragon for his leadership. he really in response to the pandemic, set a foundation for san francisco that is based on data and aligned with our values and has really helped to bring us to the place that we are today as a leader in the nation in responding to the pandemic. and we also know that we are in -- continue to be in excellent hands with acting health officer dr. susan philip

and dr. colfax and his entire team as well. but i have learned so much from dr. aragon during my time on the health commission. and i'm so grateful for that. and i look forward to continue working with him for many years to come. so thank you for that. commissioners, do we have other comments? i see commissioner chow. >> commissioner chow: yes, thank you, and i echo everything that you have just said but i wanted to also personally thank dr. aragon for all of the years that we've been able to work together. and to be able to develop a strong population health division and to have accomplished within that division the accreditation agenda that we were all striving for and working for to show that we do meet all of the standards and exceed them. i think that he's exceeded expectations that i even had concerning how the division

would function. he's always been very kind with that. i thank his own staff and with his approach to the management of his people and i really have admired that because i think that he's developed a division there that i am hoping -- i know that will continue the work and honor that work that he has done. i think that nobody needs to reemphasize again that i think that much of what we have today have been successful in the data showing our low death rate. even lower -- and also the low infection rates, it was certainly a lot of work on his part. i think we should all also be

very grateful for that. so thank you for your dedication, for your work to all of the san franciscans. and we wish you well. >> president bernal: thank you, commissioner chow. commissioner green. >> commissioner green: everyone said it so eloquently but how grateful we are for the talents that you have brought to this city and this department. i remember that you gave me a 23-page paper that made my head spin. and you are able to approach any topic, this incredible breadth of information. and the expertise that you developed, you know, to the greatest of detail. and it's one thing to develop detail and understand it, and it's another thing to really operationalize it, tomas. you have done that beautifully. and especially in the context of

this pandemic. i said before that you turned into an action hero. i think you not only exceeded expectation, but your tireless devotion when i know that you have family -- i don't know -- like i said before, i think that probably what you have gone through for us. i hope that you will work that hard for the state. but in your humility, because you're so approachable and i understand why people work for you and enjoy it so much. you're so kind of humble and then i read your c.v. and i was really knocked over for all of the education talents and achievements. so i just wanted to, you know, personally thank you. and really, really miss you. but you have done an amazing job for all of us. so thank you so much. >> president bernal: thank you, commissioner green. commissioner chung. >> commissioner chung: yeah, i just want to join, you know, all of the commissioners and echo

all that have said. and i also want to personally, you know, to let you know that you have been a great teacher. at least for me personally. i have learned so much, you know, like commissioner green says, you know, like the great examples. and the other great example is really about collective impact. and i want you to know that your presentations have made such a great impression on me that i thought that it was all the work that we could do now. thinking about how we can all work and create an impact that we envision. so thank you so much for being such a great teacher and such a great -- we just have public health fun. i don't know how you do it, and listening to you, you make it fun. we'll miss you greatly and knowing that you have going to be leaving the health department

for california -- you'll be still be working for the health department for california, i feel safer. thank you. >> president bernal: thank you, commissioner chung. commissioner christian. >> commissioner christian: thank you, president bernal. dr. araagon, going to miss you going forward, and i just wanted to say thank you for your incredibly gentle generosity that you have shown me as a brand-new commissioner, not a position, but you answered my questions and you took them seriously. and you explained things in a way that was easy to understand. so i enjoyed your presence and i miss it. and i wish you best of luck with the state. and i know that -- i'm glad that at least we'll still benefit from your intelligence and your knowledge and your dedication. so best of luck. and maybe i'll see you on the street when we can go back out again. >> president bernal: thank you, commissioner christian. i would just like to echo my

fellow commissioners and the thoughtfulness with which dr. aragon approached the matters of public health, even during the most uncertain timess with this pandemic. i would like to recognize dr. aragon, if you would like to say anything -- before we take the vote on this resolution. >> yes, everyone, thank you very much. i have been incredibly grateful for everything that you're doing today. i do -- i miss everybody, i miss san francisco. i do drive there and i drive home on friday nights and i am in san francisco on the weekends so i get to enjoy the city. one thing that i want to say is that everything -- everything that happens, it's about teamwork. and i have been surrounded by amazing people. and san francisco really is really proud -- it should be incredibly proud for everything that it's accomplished. i tell some of my san francisco

folks up here in sacramento, you know, that the state is so big and there's so many big issues to work on, in general we don't spend that much time worried about san francisco because san francisco is doing an incredible job. so everyone should feel very proud and thank you, commissioners, for everything. and that's it. yeah, thank you, thank you, thank you. >> president bernal: thank you, dr. aragon. seeing no other comments from commissioners, mark, let's move to a vote. >> clerk: i think that we need motions first. >> president bernal: i'm sorry. a motion to approve? >> so moved. >> so moved. >> president bernal: and a second? >> second. >> president bernal: dr. aragon has a copy of the resolution there, and if not, i know that he'll have one soon. so let's move to a vote. >> clerk: [roll call vote]

great. the item passes. >> president bernal: thank you, and thank you, dr. aragon. all right, our next item for discussion is food security in san francisco during covid-19 and food as medicine update. we have a great team of folks who are going to make this presentation. so i will let them introduce themselves. >> thank you. >> clerk: before we begin, everyone, we're all very excited. i recommend that you all hold questions until the end of the presentation. it's going to be a long presentation. and to get through it so that we're cohesive, you note your questions and ask them all at the end. thank you. >> president bernal: thank you, mark. i believe that dr. paula jones is coming up first. >> good afternoon, commissioners. yes, my name is paula jones and i'm with population health. along with my colleagues we will provide an update on covid-19

and at the end, and we will provide an update on this. next slide, please. and we'll go through first how food insecurity negatively impacts health and how food is also a way to achieve all of our priorities and then the steps on how covid-19 has an impact on food insecurity. and then an update on some of the department of public health's food security initiatives. next slide. and food insecurity means that you must have adequate food and other resources and it affects health in many ways. and it reduces risk of chronic diseases and likely to have larger babies. and an impact on child development. and mental health outcomes. all of this increases the health care costs and increasing human suffers.

first of all, (indiscernible) it's not just one person. and food insecurity is not having money and, three, one food program is not enough to solve food insecurity. prior to covid-19, one in four san franciscans were at risk for food insecurity and now the problem is much more widespread. so i want you to look to achieve our priorities, and to have (indiscernible) and supporting small businesses and economic recovery. and addressing inequities and health disparities. this is a call to action that is part of our health and health programs. one of the best examples of how food was the programs, one of the first to recognize the vital role of interventions of housing, transportation and especially nutritious food as a

key determinant of health. this example must inform how we create food in all of our health interventions. next slide, please. and during covid-19, we had food insecurity locally and nationally. it's more than doubled overall and tripled with households of children under 18 and if you can let that sink in. it has tripled for children under the age of 18. and we have seen an increase in food insecurity in san francisco, and during the pandemic, 44% of our workforce has filed for unemployment and leaving many families without a way to provide food. many food programs closed during the pandemic, including schools, and over half of our food pantries closed, leaving thousands of san franciscans without a source of food. and since covid-19, and the need to shelter in place, many

residents didn't have access to food. a survey was done by the human service anxious in may and june of last year, showing that food was an immediate need, especially (indiscernible) for negative health outcomes from covid-19. latinx and pacific islanders and native american families, for example. these were the families that were more likely to report not having enough food in the past few weeks. food insecurity, again, and local (indiscernible) that households with children had high rates of food insecurity. and also immigration status households. next slide. now data in the slide that is from the pandemic survey, and the survey was sent to over 150,000 households in manitoba, and jug link assistance. and they received a and on the

zip code with the darkest brown color (please stand by) -- the only issue with a priority was employment and 33% said this was the highest need. next slide, please. the department of public health as you have seen, has prioritized the health issues. in 2019, they supported to work to ensure that there's adequate food resources for all food insecure san franciscans. and also representing the critical role of health care on ensuring that san franciscans had food. and the department of public health also provides leadership

to the council since 2005, and on the next slide i'll give an update on the work of that group. and after that the remainder of the presentation is our work across departments on food insecurity. next slide. the food security task force consists of city agencies and organizations, and prior to covid-19, the task force had a strategic plan based on our 2018 food security assessment as well as stakeholder input. through this process, the recommendations were to enforce specific priorities. first, sustainability. that was the resources to enable the task force to deliver on the mandate to achieve a strategic priority. the next priority showed measurements and that was a common set of shared metrics to inspire action, track progress. and the third was adequate and appropriate community resources. this was appropriate for

realizing all of the recommendations that are going forward in our 2018 assessment. and then referrals. this was (indiscernible) and a fully innovative system. we developed (indiscernible) and then covid hit. the past few months the task force has been viewing the strategic plan and which have been advanced and what is needed now. i will just note that also this task force is set to sunset in june and we're working on recommendations to extend the task the work of this task force or another convening body. next slide, please. now some have been announced with the creation of the food coordination group. from the beginning of the crisis, i was activated to work at the emergency operation center and also now embedded at the covid enforcement group.

and at the beginning of the emergency, we heard that covid positive people were not able to quarantine because they didn't have enough food in their house for the entire isolation period. so that's one of the first things that i focused on, to create a food program to support people with covid-19 to stay in isolation while they were infectious. and working at the e.o.c., we have a program to delivers meals and food to those with covid-19 and medical providers and contact tracers and people who can also call 311 to be connected to this program. the program provides food for the entire household for the entire period that they're isolated and quarantined. and it's with partners (indiscernible) and market on market. and i just want to share a story that as a client living alone that received support had a

covid-19 outbreak in her s.o.r. building. she was also ill and she couldn't prepare food. so she called one of the intake worker she talked about the feelings of being isolated and alone and giving up on things. she said that the food support programs for her and the support and the reliability (indiscernible) she talked about how it enabled her to get out and to get back to work. today this program has provided food for over 4,700 households and 16,500 people. the food group has created a public website for food resources. it has tracked data on some of the major food programs. it helped food programs at the community level and it's also helped the community partners to private funders. i want to make a point that this type of focused coordination around food has been immensely

helpful and the enormous response of the city and it's very well appreciated, and we need to have continued coordination around food for many months and possibly years to come. next slide, please. and so the next slide will also be some of the programs that we as a department are managing. the first is our healthy food supplement program. this is one that i oversee and it's grocery vouchers and vouchers for people to be able to buy healthy food. prior to covid-19 we supported fruits and vegetables vouchers for pregnant women, and older adults on fixed incomes. we also provided matching funds for the farmers' market. and in addition to this during covid-19, we have partnered with a vendor for the vouchers and many organizations to provide two types of vouchers. one was a fruit and vegetable vouchers that we normally did. and the second was a covid emergency (indiscernible) that

you needed to purchase any food that you could use your pal fresh card with. these vouchers were worth $10 each and the fruit and vegetable vouchers were $5 each and that's around 30 retail food storers in san francisco that took them. so weeb able to provide 100,000 vouchers to 3,400 families and we focused on latino and latinx families. and we had boxes for families and the next slide we will tell you more about this program and more of the goals (indiscernible) next slide. >> thank you so much, paula. my name is prite rani, the director of nutrition. and since the pandemic hit back in march, the program has been providing benefits remotely and

this includes the nutrition and breastfeeding counseling and as well as providing the benefits of the w.i.c. cards so that families can go grocery shopping. the other unique effort that we took on over the summer was the delivery of produce boxes. and this helps to us meet the need of families that were sheltered in place and also helps to us utilize the farmers' market programming that we receive every summer. for this we partnered with population health and the farmers' market which was the heart of the city farmers' market and the alameda farmers' market. and the care.org and door dash to serve 3,000 families with organic produce over the summer. and with our equity approach, over 60% of the produce boxes

were delivered to families in the tenderloin and the outer mission, excelsior and bayview and hunter's point neighbors. these are areas with the highest food insecurity. and those that are most impacted by covid. i do want to mention though that if a family asked to receive a box, we were so grateful that we were able to provide them with one. and the majority of the families that received a box were really satisfied with the variety of produce. they tried to keep it culturally appropriate so that it appeals to a wide variety of different families, especially families with young children. and so box his berries and, you know, cucumber and lettuces and it would appeal to a variety of families with different cultural backgrounds. and we also have been acting to offer something like this again in the summer. in addition to utilizing the -- in addition to the funds in

march and we'll distribute the -- some additional grocery vouchers that dr. paula had mentioned and we'll be distributing them to families in health programs and latina families enrolled in w.i.c. but dr. paula mentioned before that it's important to keep in mind that vulnerable families with young children have been disproportionately impacted by this pandemic due to lost jobs and wages. food insecurity continues to be one of the biggest needs among this population. and we will pass it on to christina for the next part of the presentation. next slide, please. >> thank you. >> yeah, you can go to the next slide. >> thank you. good afternoon, commissioners.

so my name is christina gata, and we are funding numerous community organizations to address chronic disease issues, prevent chronic diseases and to increase (indiscernible) consumption. as we became aware of the deep needs that resulted from the covid pandemic, we did a number of different things. first, we started by allowing and asking our grand (indiscernible) to pivot to what they were doing to focus more on feeding people. and several of them did want to do that and were able to do that. and we also took a look at

funding that we had not yet expended in the last fiscal year and we were able to allocate $1.6 million to eight different organizations. and with what paula and priti were speaking to, we're very much looking at equity as the center of the work as we do with our grand distribution anyway. -- our grant distribution, anyway. so we wanted to make sure that the funding was going to the populations that were needing it. so we partnered with the wholesale produce market to get fresh produce into the hands of many, many different groups, large and small throughout san francisco. and they were able to set up a very simple straightforward easy process for community groups to access. i am very grateful to them for doing that. jan corederro helped to make

that happen. and we funded seven other groups to increase their food distribution and you will hear from one of them from veronica in a moment. but we were able to reach black african american communities and latinx and pacific islander populations in particular. i think that i'll leave it at that and i will pass it on to i believe veronica next. >> president bernal: thank you. >> clerk: are you with us? >> veronica, unmute yourself. >> can you hear me now? >> clerk: yes, thank you. >> thank you, sorry. my name is veronica shepherd and i'm the director of the office

of anti-racism and equity and i have been doing a lot of work around food security for many years with dr. paula jones, dr. rita noonan and franny and pritie rain, we have been doing this together. but a lot of my focus is on the african american faith-base the coalition. it begun in 2016 as they were not on our radar at the health department prior to 2016. and they came together and they are working to address health and wellness across the city. this network crosses multiple christian denominations and spans across the city in the mission, the excelsior and western addition and the bayview. if you look at the survey that the coalition took in 2019, hunger was their major issue, even pre-covid. as you can see, 50% were worried

that their food will run out and they couldn't afford food and they had to cut of size of their meals and skip meals. next slide, please. excuse me. when covid hit, it was this coalition that had the infrastructure, the manpower, and the people in place to immediately to respond to household food needs across san francisco. that partnership has just taken on a level of mass feeding to peaks unknown. but they have delivered meals and groceries as well as cooked meals within their churches for 3,000 households weekly. they have been directly delivering to about 1,400 households meals and groceries, primarily to our senior population.

again, they came together across their network and they adjusted the demands and the needs that they knew that were impacting their community. in december, through partnership with the faith-based coalition and d.p.h., we were able to keep people safe in their homes and brought community-based faith-based universities, plethora of agencies together to feed 5,000 households during the christmas holiday season. next slide. what we've learned this crisis continues and we know that we have to fund long term and not short term methodologies. what we have learned is to do this work that we have to do it through a health equity lens. because this lens, you will see a different population of people with the highest health needs.

we also have learned that we must as i have heard a previous colleague say -- have a household level response. in our communities we live multi-generational. grandma could live in a house with six to eight other people in the household. so if she gets that one food pantry bag, that bag will be gone by that evening. because all six or eight of those people will eat from that bag. we know that no matter someone's economic status, people want high quality and culturally appropriate food. therefore, as you will hear more from dr. rita and erin, food is medicine. we've learned that we at d.p.h. know this is crucial work to work in collaboration, focusing on a collective impact. we know that each area of our work targets many of the same

vulnerable populations, so we within d.p.h. know that it's imperative that we realign our efforts for the best outcomes for the communities that we serve. we know that d.p.h. is the only city agency that understands the role of food security city-wide and all of its interfaces. and as paula stated earlier, not enough food leads to all types of negative outcomes. so it's critical to look at this really health equity lens. we can't achieve our goals without integrating food security into everything that we do. we learned that we need to continue our departmental coordination, data tracking, information and referral. we must do this. we've learned that the health department needs to have a bigger role on food security. and should guide all of the city

agencies' efforts around food. since this the area that we know and do very well. we've learned that your voice as commissioners is critical to amplifying the values of our department. and we need you to keep food security in the forefront. thank you and i want to pass the next slide to my colleagues, drn frans. >> thank you, veronica. i just want to thank again all of my colleagues whom i miss personally and i miss working on this more closely with you while i have been in the covid hurricane. so i'm going to shift gears a little bit and we're still talking about food insecurity. in answer to one of the commissioners who wanted to hear about the collaborative, and we will focus for 10 minutes on that and to look at their social

determinant of health. by actually caring about the public health issues. and this issue around social determinants of health. so what drives this body of work is the patients that i've had is taking care of chronic diseases such as diabetes and hypertension. and the frustration of being able to write prescription upon prescription of pills for my patients and yet they have come back with elevated blood glucose and all i could do was to write another prescription. as a health care system we weren't doing anything with the other half of the equation which was food security. and so that's really what inspires this work is, like, how can we get help to be a partner in this work. and i have been inspired by the author who says that people are fed by the food industry which pays no attention to health. and actually by the health industry which pays no attention to food. so the food is medicine collaborative is to try to get exactly this -- how do we bridge the health care systems and food systems to address food insecurity and support

behavioral change and advance health equity? it's a collaboration of 20 organizations that have health systems and not profits and is backed by d.p.h. and myself and erin freney, my program manager. we have on-site food programming which is tangible entity that is co-locating food in health care settings so that clinicians and businesses can see the impact of linking food security and health outcomes. by scaling that, we were able to provide culture change, so they see that food insecurity is not just a public health issue but it's truly a health care issue they need to tackle. and finally, being able to then to leverage that culture and change for a wider scale policy change and actually getting the same resources of funding to veronica's point to get ongoing funding to pay for food insecurity.

and with the elements so co-locating food within health care systems. so having the prescription of healthy foods to chronic disease patients and to fill those prescriptions on-site. we know that food access in and of itself is not often adequate to enable people to be able to eat well. so we have paired it with knowledge and skills. so most of our sites have a registered dietician on site doing cooking demos -- this is pre-covid and a lot of patients don't even have kitchens so we give them tools like crockpots and spices and measuring cups and knives and that sort of thing. and then importantly, connecting them back to the community connections and the food-based unit. and it's not to convert clinics into food pantries or to grocery stores, but to leverage the power of health care to marry this message between food and medicine. and then to create the best community clinical linkages, and

the idea with these focused efforts paired with health care that we could have the improved health outcomes. in 2015, the first pilot was underway at zuckerberg's wellness center for pregnant women with diabetes. this expanded to a pilot at maxim hall center for diabetic patients. they received funding to apply human-centered designed empathy to the work. what we see with outcomes is that 92% to 93% of the patients have healthier practices and they feel part of a community, which was by design. we recognized that creating a sense of relationship and community is really important in creating experiences for patients that they want to come back to. as a result, 83% of patients felt they were more likely to seek care after attending these. and importantly we saw statistically significant decline in blood pressure among the participants. so this 5 mm mercury of

decline in the blood pressure is the same effect that you would see if the patient lost 11 pounds of weight or changed their medication from a less effective to a more effective medication. the same year we aligned with the health network to -- the net metrics where we shifted to how to embed this in a culture change. so as many of you know back in 2015 there was an 8% disparity gap with bloom pressure gaps between all americans and black and african american americans. and so, again, culture change around equity. and through that we were then to able to outreach to black african american populations for the interventions that were pursued. so on the health network side, it was health interventions with medications and nurse and chronic care visits. but then how do we address the determinants of health that lead

to hypertension, which is one which is food insecurity. and the food pharmacies came in and to address the need that you have heard from the prior speakers around food security of being a major barrier to health. in 2017, we were funded by the helman foundation and able to hire background support. and so we started three clinics and health networks in that year and it went to six clinics in 2019, and this year we have 16 clinics with food programming and co-relocating across five systems between san francisco and morin. so what we then saw is that when you scale an intervention like this and you create change is that we can actually see the changes in blood pressure for the entire system. so this is the san francisco health network data, and it was surpassed as it relates to food pharmacies, 71% of the attendees were black or african american, and, again, we're not claiming that it was all because of the food farms.

we had amazing partners in the clinical interventions but it's hard to ignore how the outcomes with looking at the determinants of health. so this decline in the blood pressure control is about a 30% decrease of black african americans with uncontrolled hyper tension. so the literature shows that even a 10% decrease in the u.s. population for black african americans leads to about 1,100 strokes and 1,700 heart failure events that could have been avoided. so if we were able to see all of this impact. you can see what happens when race equity is part of a culture and a system, in the same way that food security becomes part of a problem that health field takes care of. and we have been lucky to dissystem neat this work in a -- disseminate this work at a number of systems. they've reached out proactively and asked us how to get health

care and traditionally what is thought of as a public health problem or a problem of a non-profit space. so moving on to what we were able to do with that culture change, that moved on to perceived policy aims. so many of you are probably familiar with the fact that the u.s. spends disproportionate amount of our g.d.p. on health care relative to social care, compared to other developed country. we're about the same when you add up the investment but it's a flip inverse investment. and you are probably familiar with the data that the u.s. falls off the chart for how much money we spend in health care, yet we're appallingly low in terms of life expectancy or mortality and a number of other indicators. so it begs the question -- is this really the right investment with health investment and preventative measures. so for three years, they administered medicaids and it

includes a slew of new covered benefits. and so this time around, they included home delivered meals upon discharge. so it would pay for food but only if you had already been hospitalized. so the ask of the collaborative was to expand the services to cover medically supportive food and nutrition, so asking for health care and health insurance to pay for food in the same way that you pay for prescription pills. and so we drafted a position paper and we had over a hundred sign ons, including a number of health care associations, including the california association of public hospitals and health systems. and the american heart association and a number of community clinic associations across northern and southern california. i'm thrilled to report that as of january 8th of this year, food actually got included in the medi-cal waiver. it's a huge deal. as long as they just leave it in there. when it gets sent to the federal

government and approved, medi-cal now pays for food and so interventions like the food pharmacy or the supplement that dr. janice mentioned can now be paid for by health insurance. in terms of covid-19, i think this speaks to the systems and the investment in health care that a lot of the health clinics said that we want to continue to do this work and so we have been able to serve over 700 patients a week at the clinics. and our partners have been able to leverage $1.7 million this year in terms of food. in terms of future directions and in culture assistance change and policy,... (please stand by)

>> they consider comments from members of the public when discussing an item and making a request to dph. all right, so we've got several requests and i'll take them in the order i see.

each of you have two minutes. caller, i'm going to unmute you. let us know you are there. >> hi, my name is filice and i'm the executive director of it book center in the omi. our seniors were benefactors of several of the programs discussed today and most importantly, food is medicine, working with gianna we were able to access fresh fruits and verge tees and we got to pick greens and collar greens and mustard groans and okara for our african american seniors, which was dear to their heart, especially around the holidays. working with ms. veronica shepherd we got dairy products in additional food bags and the $25 gift cards they were able to use to help compliment their thanksgiving meals like being able to buy aluminum pans and foil and things that you can't

buy with food stamps. we have heard from our seniors time and time again that these culturally competent high-quality fruits and veggies they're receiving have not only changed their health but changed their spirit in this time of covid. in the oemi there's no access to a grocery store. minimal fresh fruits and veggies and there's whole food and mcdonald and you have to take your pick on what your budget is. so we've been on a weekly basis, able to give our seniors competent, high-quality value fruit and veggies, dairy, bread, and things that they would have not normally had access to. this program is vital, vital. it makes a huge difference. not only does it provide us an opportunity to give our seniors fresh fruits and veggies but we used the opportunity as a wellness check.

we were doing wellness calls but what we get to see with our eye, to deep our eye on our seniors sheltering in place was invaluable and i believe it helped stabilize versus neutrally and physically. i thank you for your support and please continue to fund and keep these programs. the staff at department public-health have their fingers and pulse on the heartbeat of marginalized communities. thank you. caller, please let us know that you are there. >> caller: hello, can you hear me? tony kelly at bayview hunters point community. we're one of the smallest recipients of the soda tax money. you may have seen us on the list. this isn't our core mission.

our core mission under this grant is to develop a co-op grocery in bayview. with the lock down in the beginning of the pandemic, we were drafted to provide food support and one reason because we were getting calls in the community at one of the mornings from families needing food that were falling through the gaps. and in that case, support to other circles and not being able to order groceries online. so we started with the six-week pilot funded by the public of public-health. it provided high-quality food at a low cost and we're happy with funding to keep that program going as long as we could. the funded ended then because a lot of private funding that was dedicated to the emergency and the pandemic, ran out at the end of last year between october and december of the year. and a lot of that private funding was dedicated to an emergency in the hopes that public funds and other funders would step up after that. well, here we are for the past three or four months, a lot of food security programs in the

neighborhood and bayview have stopped and aid is not getting to the community. we're beginning to get calls again. from families in those kinds of gaps and right now we have nothing to tell them. i know that there's been a lot of talk about the budget right now, both for the current year and for next year and talk about getting funds from other sources and getting funds into bayview and getting funds for black communities and black and brown communities, and so far it's not getting to the families. i just wanted to thank you for the funding that's been there so far but also a small challenge because we're getting those calls again and we need to know what you at the city can tell these folks who still continue to need food as the pandemic goes on. thank you for your support and please pay attention to it in the future. >> thank you so much for your comments. caller, can you let us know you are there. >> i can hear you and you have

two two minutes. >> i work with the foreign farm and shelter in place were early march foreign was forced to shut down our food distribution services to local families and thankfully in late april we formed a new partnership with the san francisco produce market and we were able to launch our food decision and delivery services for every friday thanks to $1,000 budget provided by the sf produce markets emergency food fund and supported by the soda tax initiative. we were able to work with venders such as new city fruit and co produce and everything was created through sf produce market program manager and we purchased sf markets food recovery with program coordinator carolyn lizard. every friday morning, executive is east ant alicia fung, that's me and a few other volunteers

helped pick up waste recovery food donations from wholesale merchants like what a tomato, washington and great risk gourmet for the waste recovery donations we were able to inspect the quality of the pro before bringing them to the farm. at the farm, they helped divide the food including fresh produce on the farm. they are shared with each family that come to pick up with the farm and we deliver to them if they have mobility problems. our volunteers short out the vegetables and fruits and use them for soil and we check off the volunteers names when they received the box. each week we distribute to low income seniors thanks to the support of the sf market. our volunteers youth and families were happy when they received their food. they distributed $75,000 in 30 pounds of foods and we

served. >> please begin, you have two minutes. >> caller: i'm also from the community farm and i'm one of the founders of the farm and thank you for just saying a couple of words and the food oven tee program in the department of public and tax initiative has been a great as set in feeding people and not just feeding 800 people who really need it in the bayview right now, i think it's vitally important and i also want to

touch on the longer term impact on social determinants of help benefited by this program. and also, we have programs that focus local on black youth growing up they help to bring these people together so that in the community, we can be growing not just strong communities and not just healthy communities but diversity and diverse communities as well and we started with a community garden on one side and we have black organic farming on the other side and everybody works side by

side together when there's a lot of calls to stop the crime, hate and there's a place for that and there's also a place for doing positive good and making a difference with positive good. it's not just feeding people it's growing communities and it's cultivating diversity and this is a great public-health commission as the carried out by the department of public-health. >> thank you, very much. please let us know that you are there. >> you have two minutes, please. >> my name is january see and i work for produce at the san francisco market and we are really grateful with the city for all the efforts that you guys are doing and supporting

the community groups and we were able to groups developing fruits and vegetables to families and i want to point out the city should work with the small and medium in the area and especially those that can stay behind the quality of the produce and being able to customize the needs of every community. not only will help all the the small businesses and in the san francisco but also the employees and the families. and we have seen that one standard box of food will not satisfy the needs of everyone. so priorities should be on providing access of quality, choice and appropriate food to every family and it would give food the families want to eat and we should be really proud of the many community groups and clinics that are stepping out and helping. we should back it up with quality and healthy items from the small and medium businesses

to recover the economy and especially see the families with respect and care. thank you. >> thank you. >> all right. please let us know that you are there. >> i'm here. when the covid-19 pandemic started, i had a program for household necessities and medical supplies and most importantly healthy food in the families and through this program we stop about eight dph affiliated clinics in the hardest hit neighborhoods and as well as the sfg where families go home with those bundles of

joy and with healthy food and we take the nutritionist, healthcare, casework and he is when i started it was just be for a couple months until covid is over and that really shows how ignorant i was but the impact i've seen on the health of our families is far beyond anything i could have done with my medical training and we had a pregnant patient with diabetes who was having a hard time controlling her blood sugar and when a woman goes on insulin her risk of lifelong problems for the baby obesity increases substantially but we were able to deliver her the food she needed to manage her diabetes and it was our food through the sf market and she was able to avoid not only being on insulin and having to come in multiple times during pregnancy but also,

a lifelong of health to come. the other important thing is the quality of the food that we give. we got, we lost our funding and from sf wholesale and we had to throw out 30% of food that we were getting and i'm so grateful for the food bank and and it's critical. thank you. >> thank you. >> caller, please let us know that you are there. >> hello, this is antoni kaleo. >> clerk: you have two minutes. >> caller: i'm grateful to have this opportunity to address this commission and give my gratitude. i'm here representing being a

family and providers here and san francisco but also professionally working with community-based organizations specifically in district 10 and bayview hunters point community advocates addressing not only this food insecurity crisis but this publicity of pandemic and understanding that something that you all have grappled with throughout the months, since that time back around march, you know, friday the 13th, to be exact, coming up on a year of proper and understanding how we've been responding to this pandemic specifically in regions of our city it's been impacted exponentially and thinking about how those have not exacerbated the current conditions of folks living in those areas but

specifically around food security. when we understand that food security is a right and the city's response to ensuring the responsibility to address those matters, we only in the form of delivering food to the store steps of people in need but we understand that this crisis and this pandemic of not only food insecurity, but the environmental justice insecurities that we face on a daily has effected -- >> clerk: please finish your statement. >> caller: has affected us beyond and just understanding

that the investment to continue this must continue. thank you, very much. >> thank you. >> hi, this is jana cordero the program manager at the sf market. can you all hear me? yes, so, i think you've just experienced what my life has been like for the last year. which is working hand and hand with both the beautiful people from the department of public-health who do their work with so much heart and also these incredible folks out in the community working with all kinds of people but in particular those that are most impacted by covid and this all started to working with aren and

rita to buy california grown organic produce from the southeast health center ex then when covid hit, christina called me and asked if we could scale up this program and work with not just clinics but non profits and i worked with over 20 groups and including some food pharmacies that were still allowed to operate because i would like to say that the health department shut down all food services at their clinics when covid hit. and i hope in the future, we don't do that because we see that food is actually very essential to the health of folks. and then, 400 soda tax money. we can have small companies and nancy who called in earlier and encouraged you to support small

businesses and we were able to supply 15,000 grocery bags and 50,000 meals in a short two and a half month period and they were going to give us $1.32 million to continue the program for another six months. we expanded and i was able to work with over 35 community groups, some all volunteer and and dr. misa does it all volunteer. i see my team is up but were distributed 60,000 grocery bags and 160,000 meals. i want you to implore to support money for food in the clinics to supply them with a healthy, good

quality, culturally appropriate bag or box of food. consider that, thank you. >> let us know that you are there. >> caller: yes, i'm so glad to be going after all these amazing speakers. my name is the legislative aid for the district 11 office. food insecurity has definitely impacted it's really been exacerbated so just let me give you a history of me in this work and is that prior to coming over to supervisor safai's office, i was the chief equity officer at our covid command center and jana, paula jones, dr. nguyen, veronica shepherd are all real

champions. the prosecute is deeply invested in this issue and also sustaining it. we continue to have food problems, we can identify over 700 residents that are in secure with our offers is working on comprehensive legislation that will probably be introduced in march and so i just want to be here and to support everyone and that has presented because this is the one of the unintended blessing is now people can get food they eat. people deserve food that's not

bruised. that is not beat up and thrown away. the informed that we give people that the most vulnerable should be the best quality and that is paula jones words, that's not my words in veronica shepherd. i just wanted to speak on this because this is imperative, this work, and -- for us to really make comprehensive legislation. thank you. >> clerk: thank you, ms. morris. >> you have two minutes, thank you. >> caller: thank you. my name is (inaudible) and i am a constituent here in d-11 and i have been a member of a team delivering food to our community here in the omi.

it's so imperative we give our community our families food that is culturally appropriate that can nourish them and build their immune system as we continue in this pandemic. we are spending time at home and it's crucial that we just continue to invest in a sustainability plan. we'll be in this for quite a while. we're about to hear our one-year of shelter in place and it's so important that we just continue to invest in good quality food, continue to our city have our city continue to invest in just sustainability plan. we're coming in a year, we have a few more years so dph, set aside plans and make food access

easy. we have two more callers, commissioners. caller, please let us know that you are there. >> caller: yes. >> clerk: you've got two minutes, thank you. >> caller: ok. yeah, i think the amount quoted earlier it's not a significant amount. it's less than the we will continue to invest in this program. however, i have some concerns that perhaps this program does

not adequately meet the needs of residents at my local food pantry, they often request donations from the community for culturally appropriate foods and foods for specific populations such as seniors and in san francisco we have a diverse community. we have people with various diets and people who might have and the few times i'll volunteered at the pantry, there didn't seem to be segregation of food it was sure things were packed into bags without any special consideration of special

diets and so people might have special needs like say religious diets. they are kind of out of luck. whether they were medical diets and it would be appropriate. seeing into the needs of people on special diets whether they're religious or ethical or medical. thank you. >> clerk: thank you for your comments. >> i'm here. you have two minutes. >> caller: thank you commissioners for hearing my

public comment. my name is suzie and i'm the executive director of vouchers of veggies eat sf. i just want to say thank you to dph for partnering with us to serve emergency grocery vouchers to low income folks across the city. in particular, you've heard it so much from the other callers so i won't go too far into it. cul actually competent quality food and when we were working with the clinics distributing these grocery vouchers, such appreciation we had so many folks say that this is a lifeline and their ability to purchase the foods of their choice in the neighborhoods where they live and when they felt like it was safe for them to go out was just critical. i double down on what all of you have heard and the wonderful program with the food is medicine and the food pharmacies. to just really support food,

especially in clinic environments. thank you for your time. >> clerk: thank you. and our final comment, commissioners, is from -- oh. actually, we do have that person anymore. we're done, commissioners. public comment is complete. >> thank you, mark. let's see, let's go to commissioners questions and comments. commissioner christian. >> thank you, president bernal. to the presenters, i just want to say thank you so much for this brilliant work, this incredible work. when we first got this presentation in our public-health subcommittee and i was intrigued by the idea that the concept of food as medicine -- [please stand by]

are solving some problems that are bubbling up now in these multiple pandemics. so i just wanted to let you know how deeply you're appreciated that i certainly look forward to trying to be a part of helping you to do more what you're doing. so, thank you so much.

>> president bernal: thank you, commissioner christian. commissioner green. >> commissioner green: as the commissioner christian so eloquently said, your work is absolutely exceptional. the last time that you presented, the wonderful book that you gave us, i had so many cases to share with others and got so much positive feedback. as commissioner christian said, not only does your leadership and commitment show, but this is just the perfect example of how community and the department of public health can work together along with the medical profession. it's really astonishing to me in a way, you know, a lot of us know that they said let food to be your medicine and let medicine to be your food. so it's astonishing that here we are, a century or more later and we still have to make such an effort to help there to be a better global understanding of the importance of food to

health. how it absolutely impacts the differential life expectancy between, you know, individuals and poverty and individuals who are better off and the need to really expand. so i hope that i had really two questions. i'm wondering if you can elaborate more on reaching people in need, whether we're doing a good job of that and the w.i.c. programs are well known and have been around for a while. but in 2019, people with supplemental security became qualified for cal fresh and i'm wonder wag your abilities wondering what your assessments are to raise awareness to reach people who can qualify to participate in the program. and the second thing is collaboration and coordination amongst the various organizations. because, clearly, you know, as i saw in your slide, there are organizations at many levels and what i heard today is the incredible work done in san

francisco and with our, you know, our local produce and so forth. and yet there's the food industry. and there are national organizations such as feeding america. there's so many. and i'm wondering whether you have a comment on how you -- whether it's just overwhelming or whether there is a way to really to get the best and the most perspective of funding but also collaboration and best practices. although you're setting the best practices, you know, with the organizations that are national in the state and then non-profit level, how that all works and how we can really do the best possible job to help people. >> i'll take that one. thank you, commissioner green so much for your question and for all of your support. first of all, reaching people in need i would say that through the program we have seen an increase from previous years. so a lot more people are signing up for cal fresh.

we're seeing that there are some programs that there's been flexibility allotted to some of the federal nutrition programs as priti talked about, being able to do remotely and getting people signed up for w.i.c. and the same with cal fresh. so that is an extension to getting more people on. there's a program that has also gotten rolled out across country and it was only piloted at several states before the pandemic and it's for schoolchildren. and ones that are qualified for free and reduced. we do need some help in getting the word out around that, so families are signing up for that. it provides money for parents to buy food that -- like, assuming that the children would have eaten during school lunch, it's giving debit cards to children. and it's been amazing. and what is talked about through the relief efforts, the federal relief efforts, there's going to

be hopefully an increase in the amount of money that people get through the cal fresh cards. so that will help. but in general what we see is what i said from the beginning, one program is not enough, right? there's very few programs that -- some of these during the pandemic have been innovative in terms of providing for households. but that's generally been the innovations and generally privately funded. so i think that we're fixing gaps, especially among households with kids, which is very, very heartbreaking. so we are trying to really push out all of these federal and essential programs and take advantage of all of the waivers that are in place. the school districts have gotten waivers to serve all of the children. we need more -- definitely need more people signing up for some of these things, but, at the same time, being with cal fresh

is wonderful, but it's not enough. so i think that there is those gaps and as a pandemic, you know, continues and the impacts of it, we will have to sustain the hurts that we are seeing and that we'll talk about. and the question and your question around coordination, one thing that i have heard of from city partners as well as the community partners and the food task force is that the food coordination that emerged with covid with the creation of the food group, e.o.c., and later the covid food coordination at the t.c.c., has been to be sustained. this has never happened in this way where there is a coordination among the community groups and the city. i mean, certainly, we can always do more, but that kind of coordination is going to be -- we know that it's filling a gap that will need to be sustained. and i'm so thankful for the call

from supervisor safai's office, and she's definitely leading the charge and with supervisor safai to try to figure out how to sustain some of these innovations and structural change that we have seen through covid-19. >> one last thing. i know that kaiser has done a large program and i'm wondering how they have contributed to your efforts? you mentioned that it benefits people. but just having a huge program that they developed, it's in the last few years. >> that's -- >> i can help with that and erin can assist. so we have worked with kaiser on the food pharmacy concept and we have partners in the east bay doing things in alameda as well. but we as a entire system have not fully engaged with them. but, erin, am i missing

anything? i'll just say that erin has pretty held this torch for me while i've been in covid. so she's been amazing. to your question about accessing different communities, i think that where i want to uplift my colleagues with veronica shepard and christina on the sugary drinks where we're trying to put money into the community to directly to access the community leaders and trusted members. because w.i.c. and the government is one aspect and very important, but, again, what we have learned in d.p.h. is that it's really about getting into community with the community members to access the populations. >> i would like to jump in and to add to what rita and my colleagues have said. there has never been enough food for many of the populations that we serve. even with the programs that have

been existing, amongst us on this panel we have worked outside of some of the boxes just to get people, families, seniors, our most vulnerable populations with high quality food. you have heard janet cordero and felicia, and many people who got on this call that are our community partners. a lot of this happens through word of mouth. people hear about what programs and how they can get help, or i'm a patient at southeast, and i already know who they can contact. it's a huge word of mouth network, but i know that we can do better, particularly for the populations that we are serving. so we just need to do more and provide more food. people, as we are on this call, are hungry. and my phone blows up regularly with people looking for food and they want -- as you have heard from everyone -- high quality

culturally appropriate food. thanks, everyone. >> president bernal: thank you. commissioner chow. >> commissioner chow: thank you, and thank you for this amazing presentation and when we pass the social determinants and food as one of the important aspects of medicine, or i should say health, i think that we weren't aware that this type of work could be done so quickly. and perhaps the pandemic has pushed that in order to bring everybody about. and so i'm looking to see if we can enhance the information that we're getting and particularly through our health equity lens. and, certainly, all of the populations that you're serving, i think that we aren't able to

see exactly what about the other parts of the city and particularly the asian and the -- the asian population that has over 35% also of food inequity. and i'm sure that they are part of this. i think that with the garden, they have helped in a small way to try to answer that. and i think in a presentation of this nature or any other nature, where we are looking at trying to target vulnerable populations, then we should not forget that there are other vulnerable populations. and i'm curious, therefore, that you're talking about culturally appropriate foods and, certainly, this is not only important in the latino population and the black

population, but extremely important in the asian population. so i think that the presentation could have been enhanced with describe wag you're doing within that -- describing what you're doing within that population. and we're looking at health equity and i'm seeing that is one of the inequitable areas. and saying that it would be not just at this presentation, but other presentations being made that are showing the work that the department is doing. and that the work should should also be broken down so we can understand the good work that you're doing within the asian and the chinese communities. >> president bernal: thank you, dr. chow. director colfax, i believe, wanted to say something. >> thank you, president bernal. and i just wanted to express my gratitude for the presentation and the work that the people

presented and that the teams are doing. if anything, the covid-19 pandemic has reinforced the commitment, resilience and the effectiveness of the work. and just to acknowledge and to appreciate that this group and their teams have been on the front lines from the beginning of the covid pandemic and really have the -- in addition to ensuring that healthy food is provided to communities most in need, it really helped us to build the broader infrastructure in our covid-19 response. i think that a key example of that is the intersection of the provision of food with wrap around services, including with testing. so this has been a remarkable response, a remarkable group of people. i want to express my gratitude. this will need to be strengthened and sustained as we go beyond the acute stages of the pandemic. but just as covid-19 has exposed

other fault lines among health inequity in our cities and our community, so has it done with food insecurity. but this team has just been remarkable and i want to thank them for their leadership, their commitment and their fortitude, and being there every day to help people in san francisco. >> president bernal: thank you, director co fax. i would like to associate myself with the comments from my fellow commissioners and thank you for the entire team and we'll look forward to continuing to work with you through the remainder of the pandemic and into the future. so thank you very much. we can go on to our next item, which is an epic update with our chief information officer. >> yes, and i'm giving you permission right now, i apologize for giving you permission to share your screen. >> thank you.

>> got it. just coming up. okay, good evening, president bernal and commissioners, secretary, and i understand that i may be the only thing standing between you and the evening meal so i'll try to move swiftly, but do let me know at the end if i can follow-up with more detail. this is our regular standing ethic update. i would like to acknowledge my co-contributors on the bottom of the screen and i'm not able to pull this together without them. so the take home message for this evening in three parts. the epic my chart tool has been absolutely essential to our pandemic response and we'll talk a little bit about that. i want to revisit our

information exchange, how epic receives and sends information with other health care systems across country and how that's benefitting us. especially as we're now starting to look at vaccine records. that is a picture of a roller coaster on the far right to symbolize that the epic schedule is moving to adjust to all of these twists and turns and ups and downs that we are working within with our pandemic response. this slide is probably getting familiar to you. we remain in our get better phase, which is where we want to stay with epic. i mentioned the last time that we met that we're in wave 2a. and we split 2 into two pieces, a and b, because of our response to covid-19. so we've added covid-19 response as part of our getting better, because we're learning a lot about things and capabilities within epic that we didn't know

before the pandemic. so we're trying to learn as much as we can on our epic journey, even as we are responding very quickly to a lot of demands for the services that this software platform provides to us. and then we've added one more category here, which i will just call it spread. now as it was inspired by the last presentation and immediately, you know, my head began thinking about all of the ways that we can coordinate in ways that i don't think that most people understand that even exist. but i know that they do in epic and i can't wait to follow up with the leaders who just spoke with us about how we might be able to partner and to contribute to continuing getting better. certainly business not just with epic, but with all of the work that we're doing in d.p.h. we're going to spend a little more time talking about my chart today. there were a few questions that the commission had about my chart. so we'll zip right in. as a reminder, this is what my chart, the personal health

record for d.p.h. patients, this is what is on screen, a quick reminder. so one page is statistics. you can see some rapidly growing lines as you look over time from april 2020 on the left side of the screen until the end of this january. and what you're looking at, the yellow bar on top, is the total number of log-ins to the my chart application. whether that's on a mobile device or a regular computer. in january, we had over almost 112,000 log-ons, whereas if we look back to april we were only at 18,800. so there's been a lot of changes in how folks are becoming dependent on my chart. and as you might imagine and we will show in a minute, a lot has to do with messaging securely with providers as well as look

up results, results for things such as covid tests as well as now vaccinations. and those vaccination records. we're offering my chart to patients about 95% of the time at every opportunity, whether it's discharge from the hospital or the conclusion of a clinic session. you can see the enormous growth rate. it's harder to see the scale at the bottom of the chart, but if you look at the total number of users, the top line, the dark blue -- i'm sorry, the second line down, the blue line -- you will see in april 2020, we had about 7,500 my chart users and of january, we have 36,000. so folks, our patients, are have being access to health records in a way that they did not have access before we had epic. quickly about epic and my chart and covid-19, the fastest way

that i can say it is if the san francisco health network is vaccinating someone, those vaccination activities ride in epic. we have worked to respond to a lot of requests to establish unionization clinic options and we have used my chart and extended it even out to the internet where we're -- we are enabling our patients and clients to schedule for their vaccination appointments, opening up the schedule which a lot of folks don't understand in epic and my chart, but that's exactly how we're using my chart to ensure that we can get folks who have access and have successfully crossed the digital divide and have a way to reach our electronic presence on the internet. to be able to do the important work of getting ready and getting scheduled for vaccine appointments. and then another quick reminder, all of the vaccine records are

being kept in epic. and they are all sharable, as we will talk about in another couple of minutes, across to other health systems where our patients and clients can be co-managed. we're vaccinating also the d.p.h. staff. we're not quite fully ready to move all of the occupational health functions. one of the epic implementation two-way projects into production. we're getting close. however, we did move and activate the immunization clinic capability for the d.p.h. staff. so what's important there is that while d.p.h. vaccinates you and maintains the record, thanks to robust information exchange, wherever our staff are receiving their health care, whether that's kaiser or sutter or ucsf or dignity health, it doesn't matter. they're all connected to a large information exchange network. and those vaccination records

are making it to the e.h.r.s where our staff are getting their health care regularly. this is a list in most popular order of the favorite features in my chart as defined by how frequently they're accessed by our my chart users. in the top five, it shouldn't surprise you, these usually pop up and looking for your care team and following up on requesting appointments. and results and secure messaging. and my suggestion at number seven, checking your own immunization record may grow and supersede and pop up into the top three or four as more and more of our patients want to be sure that they can prove that they have that record of their immunizations for covid-19. a quick revisiting on my chart and digital literacy and equity and i think that i would make the comment that i don't think that i made when we talked about

this last time. but my whole team is very aware that no matter how much software and access that we can provide, it doesn't necessarily get us across the finish line if the digital divide has not been crossed successfully. which means both having access to a computer or a phone and having data on that phone or a wifi network that you can be connected to, to access these features. we're really glad that the city has such a strong digital equity team and we're excited because we think that this is one of a handful of services that the city provides. they can provide immediate benefit, because you can actually take care of scheduling and even having an encounter with a provider with the same piece of software. so this is a reminder. my chart is available in english and spanish. we have taken some careful steps

over the course of starting to use epic for coronavirus vaccine, and then we have just about finished translating the workloads that a patient or a client would see when they're working to schedule their vaccination appointments into the city's -- all seven of the city's threshold languages. it's exciting and it's not something that we expected to be able to do, but great minds got together and in accordination with the joint information center at the c.c.c., they made it happen. and all of the materials are multilingual and proxy accessed. so a loved one, or someone else that the patient trusts, for them to be the person who accesses the patient information via my chart is yet another way where we can help to bridge the gap that can be presented if somebody has not been able to get online.

or does not speak english or spanish fluently. i wanted to address one of the commission's questions that i received in advance of this evening about the grade level of text in my chart. that's actually a great question. what i can tell you is that i ran some of these scripts that patients see in my chart through a number of tools this morning. and i can tell that you on average the grade level that comes out is 7th grade. so it's not quite fifth grade, and i think we can continue to work with other partners in the city to see how we can bring that language to that fifth grade standard. i know that san francisco digital services program highlights that all materials on sf.gov are at the fifth grade reading level and we'll take

that away and see if we can update you next time on how we're doing. thank goodness that we don't have time to read the entire 21st century act this evening. it would definitely make you hungrier. the 21st century act has all sorts of provisions for actually working on cures. everything from diagnostics to therapeutics, but there's a portion of the cures act that is very specific to the exchange of information in health care. and it's important right now because it actually has been implemented during covid-19. so officially on november 2, 2020, the cures act was enacted in adherence or in compliance with that act with regard to something that is called information blocking, and it has been withheld to the fifth of april. but in preparation to be compliant with the cures act we have taken a number of steps

that really represent positive changes for our patients and clients. and they're on the left side of your screen. most importantly, that when there are patient results available, we are releasing those into my chart in near real time. so there's no delay in patients getting access to their diagnostic test results as well as other studies. we also have begun the process of making notes available, whether that's a history and a physical or a consult and a whole other host of note types. those are now available to the patient. traditionally you might get an after-visit summary that has a very brief summary about what went on and the fact that you might have a new prescription or something like that, and to follow-up, you know, see me in a year. this is not that information. as the commission knows, this is a full component for that visit that the provider recorded in

epic. and they are now being made available to patients. we also are looking at how we can make even more available -- the information available from the client's record. and that will probably be in about a year, to a year and a half. there was a question from your commission about smart phrases and how they might be linked to information such as this. so the reminder, all patients and proxies can at any time ask that their provider not share this information. and so if a patient or their proxy asks for that, the provider has to take a couple of steps in epic. one of them involves making a number of selections in epic to not share a certain note type with -- outside of our epic

environment. and the use of a smart phrase is part of that process. i know that is a technical thing to talk about, but i wanted to try to answer your question effectively. the smart phrase is do not share note, that is all one big phrase. what it does is that it prompts the provider to choose the reason why the information is not going to be shared with the patient. and in this case it would be at the request for patient privacy by the patient. so i wanted to make sure that i could share this information with you as this is work going on that has a direct impact on what our patients and clients see in their my chart. so i'm not going to read this to you, but they are all about information sharing. the top vignette is about a cantonese-speaking patient who actually was seen for a traumatic injury and didn't even know the extent of the injury

until he came in for a follow-up appointment. when he came in for the follow-up appointment, the provider was able to see all of the records and able to have a meaningful conversation and inform the patient about what actually had happened. so thankfully this information exchange between the hospitals and health systems is in this case really came to the rescue for this gentleman. the success vignette is from a filipino-speaking patient specialist about a concern with lab results. and in this case we were able to use a secure messaging back and forth with the patient's daughter, who was his proxy in the my chart tool to get this patient in for a referral in a timely manner. so ways that we're getting information from outside of the d.p.h. environment has become really essential in our world. this is a big screen with a lot of numbers on it and we're not

going to talk about all of them. but we'll start with the text on the left. as a reminder, information moves both into and out of our epic to other health care systems around the country. and that includes epic systems, but it also includes all sorts of different electronic health record platforms, including our partners here in san francisco, dignity health, and chinese hospital, that both run a platform and we were able to exchange information successfully with them. as you might expect the top trading partners are our partners in the city. and they are listed on the right side of your screen. ucsf, and kaiser and dignity and stanford round out the top end of that list. and the providers do not have to do anything to share this information.

your commission had questions, do you need a password to move the information back and forth and i interpreted the question correctly, my answer is that it is automatic. every health care system that participates in this information-sharing network signs a data-use and reciprocal shares agreement called a dersa for short, that's a really long term. but all parties agree to the same data-sharing rules which have been blessed by many groups of attorneys. and that is how we're able to successfully to move information automatically both information coming in about patients who we have providers, who have had a patient experience with, and also the same going out to where our patients have had experiences in other health care organizations. and i did want to mention briefly that there have been questions about, well, how do we know that names match, names

with hyphenated last names, for example. and basically the way that it works is that this information-sharing network that all of our -- all of these health care systems across the country participate in, they use a matching tool that looks at a number of demographic attributes in our electronic health records. and does a pretty reasonable job of matching up patients. so that we can -- we are able to see most of the time when a patient has had a health care experience in a different organization. your commission also had a question about searching epic for patients with hyphenated last names. and i have spoken with two or three different providers as well with our epic program manager, and some of his team, and i have seen the search for hyphenated names. and i haven't seen a problem with being able to identify

them. but i would be happy to follow-up in more detail with searching for individuals that have hyphenated names. there was also another question about lost records. i want to address that. it doesn't deal with information exchange between the d.p.h. epic environment and any other health system. i think that (please stand by). -- it is possible that they say,

gosh, i just don't see that person in here and a duplicate record can be created. but have no fear. this happens and it's been happening since the dawning of electronic health records and we have a team that works in an organization called health information management. this is one of their core responsibilities is to make sure that any potentially -- any potential duplicate records can be evaluated and we have the ability to actually to merge those records together if they are truly one and the same person. so that we don't lose any information. but it may not be ready right at the instant that a duplicate record is created. and we're hoping that answers that question that your commission had. and, finally, this is the epic schedule. you will notice that the blob in the middle that looks like a sideways letter l, which is where we created buffer in our schedule to handle both covid-19 vaccination programs as well as

the ramp-up of the mental health san francisco program. and we have eaten into that blob a bit with our work with the occupational health program and for the t.b. clinic. so we're glad that we have created the head room and as i said at the beginning that it's been a bit of a roller coaster. and we're still adjusting and we're happy to talk about any of that's programs whenever you would like to get an update on these. and that wraps up my update on epic for this evening. happy to take your questions. >> president bernal: thank you. before we go to commissioner questions or comments, mark, do we have any public comment on this item? >> clerk: folks on the public comment line, if you would like to comment, please press star, 3, to raise your hand. star 3, to raise your hand. there are no comments, commissioners and i hope that we all thank him for staying so

late. this was an unexpected late meeting and he's doing a great job. >> president bernal: yes, thank you. we do have commissioner chow. >> commissioner chow: yes, thank you. a wonderful presentation and you obviously are continuing to move and covid, certainly, is challenging. and i think that your timeline still is amazing for all of the work that you all have to do. my two questions, actually are related to basically to the records. and i really am pleased, by the way, to see the uptake on the part of the clients as you call them, our patients, who actually seem to be using my chart a lot more. so this is more back to the question of searching for records and being sure that we were able to find the record.

one is within our own system, it may be possible that people -- and i just use chinese as an example -- may, in fact, have two ways of having their name. for example,... because it depends on which way that somebody might actually put it down. and the chinese names are often with the first name -- the sirname first and then the first name. but it can sometimes get reversed. so is there a way that the recommended search is able to take that into account? i understand about the hyphenated and that sounds fine. you might have a similar problem, where it's not quite as likely. but definitely, for example, asian names that have this and i

think that the koreans may also have it, if it was translated into the korean language. or could also be three names. but again the sirname is first and this happens a lot with different races, for example. so records are really important. and the access to it is really -- it's not good if it's not timely and particularly in an emergency room where you're trying to search for it. so not sure -- first of all, if our own system can accommodate that and then what happens when you're reaching out to the other hospitals? that's one question. secondly really is related to private practitioners and how would they -- well, you had described systems but not everybody is (indiscernible) on these systems. so the hospitals have a good way to connect with your emergency

rooms and so forth, which is prime importance. but what about private practical sessioners out with their -- practitioners with their own network, how do they get access to the records and that's more important under the government who wants a seamless exchange of records. so those two questions. and i realize that the hour is late. if you want to answer it later, that would be perfectly be fine. >> let me answer the second one because i have an immediate answer. the first one is more challenging for obvious reasons. if names are entered differently in different fields it can be a challenge. for accessing records outside of a hospital like a big enterprise d.h.r., there's two ways. the first way is that there's dozens of companies who run smaller systems that you may

find in a medical practice. and they can actually connect to the very same framework. so that's one way. and the other way is that epic offers a read only view into the record and so this is definitely something that is used today. and it's called carelink, all one word. and they support an external provider's look into the d.p.h. records. before epic was here, we had plenty of providers here on staff who could then look into, say, the ucsf records using the same technology. so that is definitely an option if that particular provider or the provider organization is not connected to this national framework. >> commissioner chow: good. so perhaps you could send us that so we could inform some of the doctors who have been asking

about this. >> yeah. >> commissioner chow: i would really appreciate that. and i appreciate that if you would just take the time and research, but i think that the asian name it is often could be mistaken as you say, and -- i would like to know what we could potentially do. i mean, i would like to know what you're doing. thank you. >> we'll definitely dive into that. thank you for the questions. >> president bernal: thank you, commissioner chow. any other commissioner questions or comments? seeing none, thank you again for staying with us so late and for your excellent presentation as always. it's always a very positive experience to learn about our epic updates and where we are at and how we continue to progress and you always frame them so well. so thank you again for your presentation.

>> thank you. >> president bernal: okay. our next item is other business. do we have other business from anyone on the commission? seeing none -- >> clerk: i will check the public comment line. if you would like to make public comment on other business, please press star 3. no comments. >> president bernal: and the next is the brief update on the laguna honda hospital -- >> clerk: i believe that commissioner green who chairs the meeting can give an update? >> commissioner diamond: i don't have minutes -- >> commissioner green: , i don't have remarks. >> commissioner chow: how about if i read the thing that i emailed you. i will read what i read and you can jump in.

>> commissioner green: great. >> commissioner chow: give me one second, everybody. so at the february la geunda honda committee meeting they looked at the c.e.o. report and the regulatory report. and the c.e.o. report included data showing the effective vaccine rollout at the hospital and the c.e.o. michael phillips announced that dr. hathaway was selected as the new chief medical officer. and incredible work of both of these physicians is well known to the committee members. during the discussion of the regulator to are affairs reports, they heard that six surveyors noted no deficiencies in the conference. and the whole report will come in weeks to come. and in closed session they approved the report and discussed. >> commissioner green: i would just say that it was a really excellent meeting and the success they've had at laguna

honda is quite remarkable, especially with the way they've been able to vaccinate close to 90% of the residents and upwards of 80% of the staff. and, you know, you go there and the collaboration and the spirit and the teamwork are just quite remarkable. so everything about the meeting i think was very positive news, even in the face of the cases of covid-19 that have occurred among the staff and the residents. i think that the team there is very well grounded and doing a superb job in leading, with the fact that there's no deficiencies when they looked at the covid set-up in itself is a testament to how things are working. and it's a seamless transition in leadership so it was a pleasure to be there. >> commissioner and secretary, could i add good news today.

we do not have a resident within laguna honda with covid-19. that's the first time in a month that we've been able to say that so it's very good news. >> president bernal: thank you for that good news, director colfax. that is a continuation of the excellent work at laguna honda in controlling and preventing outbreaking. very good news indeed. do we have any commissioner comments or questions? seeing none we can move to our next item of business which is adjournment. does someone have a motion to adjourn? >> so moved. >> second. >> clerk: i'll do the roll call vote. [roll call vote] have i got everybody? i think that i got everybody.

commissioner giraudo says yes. >> clerk: i apologize. i'm blurry tonight. >> president bernal: all right, and thank you to the staff for the presentations tonight and for the late hour and for the commissioners as well. we will see each other in two weeks. >> good night, everyone. >> president bernal:good night, everyone. bye-bye.

>> san francisco mayor london n. breed. for persons who wish to ask questions, include your name, outlet and up to two clearly stated questions in webex chat. and now we welcome mayor london breed. >> thank you so much. and good morning, everyone. i am excited to be here today because we know that most recently we have a vacancy in the city administrator's office, and i am so proud to announce that i am nominating carmen chu to serve as san francisco's city administrator. many of us know carmen over the years. she has served the city and county of san francisco since 2005. she currently serves as our assessor recorder and in that role she is responsible for managing a team of over 200 people. under her leadership, the aassessor's office has reversed

a decades old backlog of assessment cases and generating $3.6 billion in property tax revenue annually to support public services in san francisco. had it not been for carmen's leader snip that role, we would have a budget that was deficient in the amount of $3.6 billion. that gives you an indication of how amazing and how valuable she is to san francisco. such achievements have earned her office the prestigious 2020 good government award, an honor recognizing excellence in public sector management and stewardship. she currently serves on the san francisco employees retirement system board where she oversees the investments and policies of a $26 billion public pension system in san francisco. assessor chu has really stepped up during covid to lead our economic recovery task force as one of the co-chairs. this was not in her job description, nor was it her

responsibility, but when i called carmen to ask for her help because we needed all hand on deck to address the challenges that none of us thought we would be dealing with with covid, she immediately said yes. and with her leadership the task force developed 41 recommendations and policy ideas to make the city's economy stronger, more resilient, and more attainable. prior to the career as assessor, she was an elected representative of the board of supervisor. when she served as budget chair of the board of supervisors, there was no one who was more fiscally conservative and focused on equity and serving the public's best interest and made sure we understood the value of every single dollar we spent. there was no one more of an advocate in that role than carmen chu when he served as the budget chair of the san

francisco board of supervisors. she also served as the deputy director of public policy and finance for gavin newsom when he was mayor. she's been actively engaged in really changing bureaucracy in san francisco on so many levels. and just to go back to some information about the assessor recorder's office which was experiencing a lot of challenges, a lot of uncertainty, a lot of confusion, the work that she did to put everyone for the most part on an electronic system and to re-organize the files in that system was pretty amazing. now, i know it's very bureaucratic and very technical, but to make san francisco work in a more efficient way that provides information to the public in a way that people can understand so that they can pay their taxes and they can do whatever business they do with the city t work she has done has really been about making sure

that the average, everyday citizen in san francisco who is not connected to city hall, who is not involved in city hall in any way, that they have a voice. and they have some level of understanding and access to the resources we provide. she is the only asian american woman elected as assessor in the state of california, and she is the daughter of immigrants. her family worked hard to make sure she had some amazing opportunities to succeed in life, and boy, has she made them proud. the city administrator's office consist of more than 25 departments and programs that provide a broad range of services to other city departments and the public. and ladies and gentlemen, i am so honored to introduce the next city administrator for the city and county of san francisco, assessor recorder carmen chu. >> good morning, everybody.

first off, i just want to say thank you so much, mayor breed, for your confidence in me. i am humbled and i'm honored by your nomination, so thank you so much for this opportunity. >> thank you. >> if confirmed by the board, of course, i look forward to working not only with you but also with the board to make sure that we continue to move san francisco forward. i want to speak a little bit about my parents as i start off with the this. my parents were immigrants. mayor breed spoke about this a little bit ago, and my parents had a small restaurant and we all grew up, my sisters and i, working in that restaurant. i tell you this and i share this with you because so much of our service and so much of what we do in life is grounded by our life experiences. how we were raised. the people who loved us. those who supported us. those were part of our lives. and what they taught me was the importance of making sure that

we provide honest day of hard work, and making sure you do everything you can in every single role that you play is important. but they also taught me the importance of helping those who are in need. mike like my parents, not everybody starts off with resources. not everybody starts off with money, with support, and not everybody starts off with even the ability to communicate or speak english. and i think it's recognizing that so many people start off from different places that it's a privilege when any of us have the ability to serve in the public capacity. it is this grounding, this belief that government can serve and the belief that government can help to support people, especially in their greatest times of need that gives me the privilege and honor of working as a public servant for the city and county of san francisco. first off, i want to recognize

the people of the city administrator's office. your responsibility is a big one. the span of your responsibilities serve as a backbone for all of the city's operations. and i really want to thank you, a heartfelt thank you, especially during this time this, time when we're asking you to not only carry on with that work that you do, but also to do double duty especially as we continue to respond to an active global pandemic. this is something that is not easy. and i know that san francisco is better off for all the work that you are doing not only in your existing roles but also in the extra work that you are doing to make sure that we respond to with the best way possible to serve is city well. to the people of the assessor's office, and i simply put and i want to tell you that i will miss you. we built a really great team in the assessor's office and we have accomplished so much. and things that seemed

insurmountable to do and reversing a decades backlog and exceeding revenue expectations in half a billion during my time. and making sure we are completely overhauling outdated tools and systems that we have in our office. these may sound boring to many people, but honestly, it is this kind of attention and this kind of work that really drives change and excellent public service. i want to thank each and every person in the assessor's office. i enjoy working with you on the professional growth and challenges that you took on and i hope you will carry on the accomplishments and legacy with you as you go forward. and finally, i want to close by recognizing and thanking the contributions as city administrator naomi kelly. i understand your decision was a difficult one.

and thank you for helping meet the needs of the city during the global pandemic when we needed the support to lift up so many things that we have done. the accomplishments are not to be diminished, and icismly want to say thank you. with, that i am available, of course, for any questions. and i am really honored for this responsibility coming forward. >> thank you, assessor chiu and we are honored that you are willing to take on this responsibility. i want to provide member of the public with information about the city administrator's office. they are responsible for overseeing animal care and control, the office of cannabis, the medical examiner's office, and the real estate division. the technology division. our community challenge grant, our grants for the arts program, the mayor's office on disability, risk management, and all of the things, many of the things that make