Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. Throughout the long run of this pandemic, we've been running episodes to keep you our listeners informed about the latest changes in the emerging science of COVID, nineteen, treatments appropriate to it, and public health responses available for dealing with it. As the country has gone through a substantial third wave of the virus, and as hospitals, especially in the Southeastern United States, are coming dangerously close to capacity, we thought it was the right time to have another conversation about this topic, and particularly on what looks like it will emerge as the new normal in the wake of the variant. Here to discuss this with me today is doctor Susan Philip. She is the health officer for the City and County of San Francisco. I wanted to talk with her in particular because San Francisco's COVID response is in many ways a model for major American cities. Nearly eighty percent of the eligible population is fully vaccinated there. Just last week, San Francisco made news by becoming the first big city in the us to require proof of vaccination to get into restaurants, gyms, recreation centers, or any event at all with more than a thousand people. Doctor Philip wields the power to write health orders for the city. She's been at the front lines of determining the right policy responses to the challenges of the current moment. Doctor Phillip, thank you so much for being here. I'm really looking forward to delving deeply into the complex po see questions that you're managing every day and your very important job. To start the conversation, I thought we should try to just do some level setting on the state of play of the science, recognizing that this is a moving target and that science is not an exact science when it's constantly getting data at every given moment. But I want to start by asking you about the Israel data that seemed to suggest the need for booster shots at least for people sixty and over and potentially for more people, and how you think about that question of boosters interacting with the broader question of the different variants delta and beyond. Thank you and thank you very much for having me today to speak with you. So you know, the news coming out of Israel, and science just recently that shows that a proportion of their hospitalized patients are are actually fully vaccinated is concerning, and I think that goes along with the data that ADC and other agencies in the US have shared that really is more of the step before that looking at immunologic response and seeing that decline over time in some of these post approval studies of people that have been vaccinated, and I think those together are leading to this conversation about boosters and when we do those in the United States and what that looks like, and that of course raises a whole set of other questions about the timing of doing that as opposed to getting first doses to as many people as possible. But that data seems to be increasingly clear that over time there does seem to be a decrease antibody response immune response that, at least in Israel, such a very highly vaccinated country, we're seeing translate into some cases and certainly hospitalizations and some of their population. And the reason I'm asking about that is that if it were not for this, it would be possible to frame the discussion rightly or wrongly by saying, well, look, as soon as we can get as large a number of people as possible vaccinated. We can take on board that variance aside, we're just going to get back to normal, and then what we're basically debating is how fast, how slowly, what's the appropriate step. But it may be that this data suggests that it is not going to be as simple as that, that we're going to have to have rolling vaccinations even for those who are vaccinated, in order to avoid substantial amounts of breakthrough infection. So seen through that lens, now let's turn to sort of the incredible complexity that is your day to day life with the judgments that you have to make. Where do you currently stand in San Francisco on public places and access to those public places? Well, in San Francisco we do know that as everywhere, that vaccination is going to be the key, if not to getting back to full normalcy, at least to getting to a place where fewer people are getting infected and we're preserving the ability of our health system to take care of people that need care for anything COVID nineteen or otherwise. So in San Francisco, as of Friday, we have a health order that went into effect that requires that in indoor settings where food or drink are served, or in any type of fitness establishment, gyms, other recreation facilities, if they're indoors, people have to show proof of a full vaccination to access those spaces, and we also have that in place for any gatherings that are of a thousand people or more. So these are some of the ways in which we have a very high vaccination rate in San Francisco, but these are ways in which we want to encourage others to get vaccinated in order to access these spaces that we know are higher risk. Throughout the pandemic in the United States and worldwide, we've seen that these indoor spaces are among those that are highest risk or transmission led you to the conclusion, and I'm sure this is a complex conclusion that includes both scientific elements and policy judgments that places that don't primarily serve food and drink, like workplaces for example, would not be logically included in this current round of orders. You know, early on and throughout the pandemic, some of the news that came from the CDC, from the Morbidity and Mortality Weekly Report, which is their journal CDC puts out, really showed in rigorous case control studies where people are interviewed after they become positive, what their activities may have been in the weeks leading up to their testing positive, and then compared to a group of people that tested at the same time but tested negative. Really showed that the areas that I mentioned restaurants, bars, gyms, were among those most associated statistically associated with becoming positive. These sites are places that by definition, people are removing their face coverings, they are in contact with other people outside of their household, and so there are more aerosols, more virus particles in the air in restaurants, in bars, and you add into that in bars and some other restaurants, it's loud, it's crowded, people are leaning in closer to each other, and also with the addition of drinking and alcohol, people are talking louder, maybe more disinhibited talking to other people. So that explains a little bit about why the risk might be there in bars and restaurants. For fitness establishments, those have also been associated in several studies from across the country in outbreaks and increases, and there it's really again recognizing it's a respiratory aerosol transmitted virus that people's respiratory rates are up, they're breathing heavily, they're in an enclosed room with others, and that's why we see that elevated risk. Let's talk about the mechanisms that you might use to check that people have been vaccinated. As I understand it right now, you would accept the physical vaccination card. I'm imagining you would also accept someone's picture on their phone or their vaccination card or something similar to that. Have you, as a city yet flirted with vaccine passports or other mechanisms that might potentially be more reliable than a rather flimsy piece of cardboard or a photograph of said flimsy piece of cardboard. You know, we have not talked about San Francisco having its own version of New York's excelsure pass or anything like that. We do know that there are private companies and others who have been working on these, and so what we're trying to do is evaluate which of those would also be acceptable for businesses to use in San Francisco. For instance, the state also it's not a full vaccine passport, but what they have done is they allow people to access the state Immunization Registry and get on their phone a QR code and so their name and their dates of their vaccinations. One of the topics that is widely discussed but is not so widely discussed in the media, is the possibility of people falsifying vaccination records. Right. I mean, in the world of things that are hard to copy, and there are many in our world, your vaccination proof is not one of them. So somebody who wanted to spend ten minutes falsifying proof of vaccination presumably could do that extremely easily, and there would be absolutely no way for anyone to tell if that were the case, or not to say nothing of the person that a restaurant puts at the door, you know, the greeter whose job is now includes not only being nice to you and telling you how long the weight is going to be, but also checking your proof of vaccination. So, given that how much of what you're doing is sort of a signaling function to try to send to the public the feeling that you and San Francisco really expect people to be vaccinated, how much of it is you just calculate people are so moral that they would never lie about such a thing. How much you calculated people can't be bothered to do that, and it would just be easier for them to go and get vaccination than it would be to mess with a PDF. What's the as it were, actual thinking behind this, if you're willing to share it, sure, yes, I think that the way I have always thought about it, the health orders themselves are not enough to make the full impact. The health orders are important, but they're not sufficient. So the way we have always addressed this in San Francisco from the beginning is to be very visible, to make sure that we put out reasoning, that we share the science. And I think we're fortunate to work in a city where people are responsive to hearing about the science. They don't doubt that the virus is real, they don't doubt that vaccines work. So addressing really the importance of doing it for their own individual health, and then the health orders are important in driving up the understanding and the demand for vaccine, for people to understand that it's expected, that it's required, but this is the most important thing that they can do, and that this is going to have the most impact over time. So it's using this as another opportunity that gets a lot of attention. People are very focused on the vaccination mandates. The truth is we have the highest rate of full vaccination you know, of any city in the US, so the incremental increase in this is important. We want every single additional person to get vaccinated that we can. We have to marry that though with explaining why it's important, and then most importantly, we have to have highly accessible routes for vaccination in the city as well. The health order load is not perfect, as you said, but in my mind, the goal is not for it to be perfect. It's really to add cumulatively to all the work that we've been doing around increasing our resilience and our response to COVID nineteen. I think that you know, this requirement for vaccination in public spaces is the most recent vaccination requirement, but it's not the only one. It's not been. The first one that we actually put out as a health order was related to higher risk settings, settings in which the people that are within those settings are at higher risk for either severe illness or death. So that includes our acute care hospitals, our nursing homes, our jails, and so that was the first place where workers were required to be vaccinated. We do have an indoor masth mandate as well, So we've had that since the beginning of the month, and so we have both. Now we just have this newly implemented vaccination requirement in these certain public businesses as we talked about, but we do have in all indoor spaces a mask requirement as well. I think that the delta variant had introduced enough level of uncertainty to not be sure, even with our highly vaccinated city, what was it going to mean for our hospital system, what was it going to mean for people that had already been vaccinated. That we determined to do the mass mandate first because it could be implemented very quick CLEA and we had done it previously, and then work on this vaccination requirement. So going forward, what we're going to have to see is keep looking at our case numbers. They are coming down slowly, and we'll have to see if that continues and decide how we move forward. We are going to have to learn to live with COVID nineteen in San Francisco and elsewhere, but for now we do have both of those measures in place. Let's talk about the formulation that you just used, which is one that I think is very important that we're going to have to learn to live with COVID nineteen formulation. And I'd love to hear in more fine grain detail what you think that living with is going to look like. Let me make the con question concrete in the following way. You've got great uptake at eighty percent or so of eligible residence getting a vaccine. That's amazing. Let's say you got to ninety five, right, which is as close to perfect as anyone's going to get. And let's say the Delta variant still existed, because it's still going to exist, although perhaps it will have burned itself out in this latest round, but it or other things like it, we'll be back in the future. This doesn't seem like it's some outlying evolutionary development. It's a kind of to be expected and doubtless will be recurrent in various ways. We'll have to learn the names of lots of other Greek characters beyond Delta. So in that environment, does living with it basically mean that we would move towards a world where no mask requirements and we would just understand that there was a certain amount of breakthrough infection that was going to keep on happening in the light of future variants, and we will try to manage that and if it requires building more hospital beds to be prepared for those potential surges, will do that. Is that sort of what you're picturing. Well, I think what we'll picture is again continuing to take in any new information. You know, and as you pointed out earlier, this virus has done nothing if not keep throwing curveballs, and we have to adapt to what we might need to do. We were not talking about masks early on in the pandemic, and that was not in our culture as a country before, as it was in some other Asian countries, but it is something now. Are we going to have to mask completely going forward? I don't think that that's likely, but I do think that people may choose during cold and flu season in coming years to wear a mask. Hopefully people have a sense that if they're sick, they stay home. So there are some lessons I think from COVID nineteen that I hope do continue pass this current time. And I do think that there will be other challenges potentially, as you said, other Greek letters maybe coming at us, and then we will have to adapt over time. So what I'm hopeful is that we will get a high level of vaccination that that will continue. We'll understand if and when we need to continue having boosters of these vaccinations, and then if we need to adjust further, we will have to adjust. But I do think that we will eventually be able to peel away some of these other non pharmaceutical interventions like masking, and we've already peeled distancing away and have the vaccine really really hold the bulk of the work for keeping population safe. And you know, as a health officer, we're working at a population level, so we do know unfortunately that there still will be people that get infections and get sick. But what we're trying to do is really make sure that the bulk of the population is protected and that everyone has as much information as they might need to make decisions. But for right now, as we are working to get all of our populations as vaccinated as we possibly can, and we don't know where we'll end up with that, these are the additional protections that we want to have in place using the power of state law, the health officer authority to be able to do that. For the moment, we'll be right back where does rapid antigen testing, in your view, fit into this series of different measures that you're engaged in. I got my first wedding invitation post COVID today that noted not only that they wanted people to prove vaccination to attend the wedding, but also that they wanted people to get a rapid antigen test that day, not even a PCR test, you know, in the previous thirty six hours. And I, you know, thought maybe this is the new normal. There's an expense question, of course, but when you think about the various components of a preventive plan, testing surely is one of them. Prices have come down, although not as much as one would have hoped thus far. So how does testing fit into the picture? I mean, I think, to put another way, how we been discussing this at the beginning of the pandemic, before vaccines were available. A lot of our conversation would have been and we did these conversations on deep background, you know, the centrality of testing to a successful regime and the mechanisms that can be undertaken to make testing more efficient at scale. And yet now it doesn't seem to be as central to the at least to the Public Health Conversation. I think you're right. You're absolutely right. The testing remains really important when you think about schools which are opening soon in a matter of days. We still don't have authorization for vaccination for under twelve, but for twelve and over. Is San Francisco in its public schools requiring vaccination universally? You know, in San Francisco our schools opened last week. It was very exciting because we had not had all of our schools opened during the last year, and so we're encouraging them for twelve to seventeen. But they're not mandated, and the San Francisco Unified School District has a different governing entity. They don't fall under the mayor and the rest of the city department, so we work very closely with them, but they have a different decision making and policy approach and independent of the rest of the rest of us and independent of health officer or orders as well. They make decisions there, so they are supporting twelve to seventeen year olds and the rest of the city. Our Health Department is working closely with the Unified School District to be able to do that and have there be events where entire families can come where we facilitate vaccine, and we'll have increasing sites numbers of sites on school property to be able to get vaccination, but we're not requiring it yet. That was such a beautifully diplomatic answer that I almost don't want to draw attention to how diplomatic it was. It's a reminder that being public health officer of a city is not dissimilar from being, you know, an abassador with United Nations or something. You have to be careful in what you say. Let me try to parse it. I mean, what I heard you say is that the schools don't answer to you and they have a different policy. Without stating it. The natural implication I want to ask you to confirm this or deny this, but the natural implication when it might have been that you might have reached different decision if they were within your decision making authority. Let me use that to ask a further question. You know, across the country, this is going to be replicated a much greater scale, right, I mean, even within a progressive city like San Francisco, it's clear that there's some nuanced difference between different agencies at the county, at the city level, at the level of the education system, and nationally, we've got a huge range of variation all the way from where you guys are to you know, the governors who prohibited even not just as governors, but there were state laws passed signed by governors that prohibited mandatory masking. So the other very very grave extreme. When you think of this, not just in your role in San Francisco, but you know, your role as a national leader on questions of public health, are you worried about just the range, just the huge disparity of viewpoints that we're getting from governmental elected officials on these matters of life and death. You know, are these are matters, as you said, of life and death, these are public health matters, these are scientific matters. And it really has been troubling since the beginning of this pandemic how there had initially not been a national response. You would think that when there was a pandemic that there would be a coordinated response at CDC, would be at the forefront, and that we as local health department leaders would be responding to the same stimuli and not not really trying to do our own thing and come up with how we were going to get PPE and how are we going to do testing, and what was our approach going to be there. It's been better more recently, but I think that that set the precedent for there being such a diversity of opinion, and then this whole way of thinking that masks were a sham, that the virus itself was a sham, and the splittization of the response of the science of the health officials, many of whom my colleagues in California have received threats, have really been unduly harassed for just trying to do their jobs and save lives. So there is a lot there. It is really concerning last question. We mentioned the terrific rate of a vaccine uptake that the city has. Are there measures that you have of what those numbers look like for people who are not just poor but are actively homeless in the city, and do their numbers look comparable to the general population in terms of vaccine uptick. I don't know if we can pinpoint the exact numbers. We do know that they are generally lower than the general population. But what we've tried to do is make mobile vaccination available, allow people to drop in and get them at the sites where they get their usual services or care and we right now have mobile vaccination teams that are going out to work with persons experiencing homelessness, so they are a priority, and we do recognize that we're going to have to try different strategies to increase those rates among those populations in San Francisco. And have you gotten broadly speaking yet, the criticism from the civil rights community that would be might be worried that given differential vaccination rates when measured by socioeconomic state or by race, that a public vaccine mandate could look like it involves the turning away of a disproportionate number of people of color. Because that's obviously, from a straightforwardly ethical and legal perspective, that's a grave concern. I agree with you that that is a concern from a moral and an ethical standpoint, let alone the legal risk. And we have again worked with community leaders and ask them to help us really reinforce the importance again make the vaccine accessible. We wouldn't have done a mandate without a feeling confident that we have worked with informed community really tried to do that from the beginning. So it's an ongoing it's got to be an ongoing communication effort has got to be an ongoing support effort with community, and relative to other cities, San Francisco's populations of color are more highly vaccinated than other areas. So are black African American population Sixty five percent vaccinated right now, that's not as good as our overall percent of seventy nine percent of eligible, but we are working on getting there. That number is higher than it used to be, and we're going to keep working until it can get higher. Yet it's a fascinating problem. I mean, the law professor in me immediately pictures the scenario of a disparate impact civil rights lawsuit that says, you know that sixty five percent of African Americans are vaccinated in the city relative to seventy nine percent of the general population. Therefore, you know that this band will have a disparate impact on access to restaurants, fitness centers, and so forth on the basis of race and in other contexts. The progressive position in general favors looking at disparate impact independent of discriminatory intent. Right the standard progressive position is, we don't care how good your intent is. If the law has a disparate impact, that's a prima facial reason to treat it as unlawful unless a really good justification can be offered, and you're case may well be that. And the conservative position is typically no, we're only interested in intent when it comes to discrimination. We ought not to look at disparate impact. Presumably in this case the positions would end up being something reversed, right. I mean, it's very clear from everything you've said that your overarching goal is public health, that you have no interest in any disparate impact. In fact, you wish you didn't have a disparate impact on the basis of race. But it's a really tricky situation when conceptualize in those terms. Yes, I agree with you, and I think you. In public health, like in all public policy, there's no absolute right or wrong answer. Most of the time, there's just trade offs. And so again, what we have committed to doing, what I've committed to doing as health officer is really to work with populations and try and communicate the reasoning, communicate what's coming, to make sure that all the stakeholders are aware, and then trying as much as we can to say, look, this is also to protect the communities of color that are working as weight staff, as barbacks as other people who are in them to increase the safety at their place of work as well, because they have to have that income, they have to keep going to work, So there are multiple ways at looking at this. As you said complex, Susan, I really want to thank you for your time in describing and engaging with me about these policies and how you're thinking about them. I really value insights into what the new normal might come to look like. And I also want to thank you for your very intense work over the last couple of years in an extraordinarily important and influential position. So thank you very much. Thank you very much for having me. I've enjoyed talking with you. We'll be right back listening to doctor Susan Phillip. It struck me that we may be closer than we think to ascertaining what a new normal is going to look like, even in the aftermath of the delta variant. That is, requirements for vaccination at least in place is across the country where large numbers of people are vaccinated. Not every place is San Francisco, and many places would lack the political will or the number of people who are vaccinated for vaccination proof requirements to be implemented. Nevertheless, if they work in San Francisco, they have the chance of becoming a gold standard. Simultaneously, masking requirements which San Francisco, like other big cities, has reinstated for unvaccinated people may become an ongoing thing in places where vaccination numbers are lower and where there is a public health will to protect people. San Francisco represents only one possible direction that we might end up going. Across the country. There are lots of locations where we don't have mandatory vaccination rules, where we don't have mask mandates, and indeed, we have plenty of places where state legislatures and governors have outlawed mandatory masking. So it emerges that our new normal may be highly bipolarized, with very different practices in the most progressive places than in more conservative locations. As this new reality continues to emerge, we here on Deep Background will continue to cover the question, returning to COVID as always when there are new developments, new norms, and new practices that deserve your attention until the next time I speak to you. Breathe, deep, think, deep thoughts, and at least if you can provide proof of vaccination, go ahead and have a little fun. Deep Background is brought to you by Pushkin Industries. Our producer is Mola Board, our engineer is Ben Talliday, and our shore runner is Sophie Crane mckibbon. Editorial support from noahm Osband. Theme music by Luis Gara at Pushkin. Thanks to Mia Lobell, Julia Barton, Lydia, Jean Coott, Heather Fain, Carlie Migliori, Maggie Taylor, Eric Sandler, and Jacob Weissberg. You can find me on Twitter at Noah R. Feldman. I also write a column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts and if you like what you heard today, please write a review or tell a friend. This is Deep Background.

Pushkin from Pushkin Industries. This is Deep Background, the show where we explore the stories behind the stories in the news. I'm Noah Feldman. Throughout the long run of this pandemic, we've been running episodes to keep you our listeners informed about the latest changes in the emerging science of COVID, nineteen, treatments appropriate to it, and public health responses available for dealing with it. As the country has gone through a substantial third wave of the virus, and as hospitals, especially in the Southeastern United States, are coming dangerously close to capacity, we thought it was the right time to have another conversation about this topic, and particularly on what looks like it will emerge as the new normal in the wake of the variant. Here to discuss this with me today is doctor Susan Philip. She is the health officer for the City and County of San Francisco. I wanted to talk with her in particular because San Francisco's COVID response is in many ways a model for major American cities. Nearly eighty percent of the eligible population is fully vaccinated there. Just last week, San Francisco made news by becoming the first big city in the us to require proof of vaccination to get into restaurants, gyms, recreation centers, or any event at all with more than a thousand people. Doctor Philip wields the power to write health orders for the city. She's been at the front lines of determining the right policy responses to the challenges of the current moment. Doctor Phillip, thank you so much for being here. I'm really looking forward to delving deeply into the complex po see questions that you're managing every day and your very important job. To start the conversation, I thought we should try to just do some level setting on the state of play of the science, recognizing that this is a moving target and that science is not an exact science when it's constantly getting data at every given moment. But I want to start by asking you about the Israel data that seemed to suggest the need for booster shots at least for people sixty and over and potentially for more people, and how you think about that question of boosters interacting with the broader question of the different variants delta and beyond. Thank you and thank you very much for having me today to speak with you. So you know, the news coming out of Israel, and science just recently that shows that a proportion of their hospitalized patients are are actually fully vaccinated is concerning, and I think that goes along with the data that ADC and other agencies in the US have shared that really is more of the step before that looking at immunologic response and seeing that decline over time in some of these post approval studies of people that have been vaccinated, and I think those together are leading to this conversation about boosters and when we do those in the United States and what that looks like, and that of course raises a whole set of other questions about the timing of doing that as opposed to getting first doses to as many people as possible. But that data seems to be increasingly clear that over time there does seem to be a decrease antibody response immune response that, at least in Israel, such a very highly vaccinated country, we're seeing translate into some cases and certainly hospitalizations and some of their population. And the reason I'm asking about that is that if it were not for this, it would be possible to frame the discussion rightly or wrongly by saying, well, look, as soon as we can get as large a number of people as possible vaccinated. We can take on board that variance aside, we're just going to get back to normal, and then what we're basically debating is how fast, how slowly, what's the appropriate step. But it may be that this data suggests that it is not going to be as simple as that, that we're going to have to have rolling vaccinations even for those who are vaccinated, in order to avoid substantial amounts of breakthrough infection. So seen through that lens, now let's turn to sort of the incredible complexity that is your day to day life with the judgments that you have to make. Where do you currently stand in San Francisco on public places and access to those public places? Well, in San Francisco we do know that as everywhere, that vaccination is going to be the key, if not to getting back to full normalcy, at least to getting to a place where fewer people are getting infected and we're preserving the ability of our health system to take care of people that need care for anything COVID nineteen or otherwise. So in San Francisco, as of Friday, we have a health order that went into effect that requires that in indoor settings where food or drink are served, or in any type of fitness establishment, gyms, other recreation facilities, if they're indoors, people have to show proof of a full vaccination to access those spaces, and we also have that in place for any gatherings that are of a thousand people or more. So these are some of the ways in which we have a very high vaccination rate in San Francisco, but these are ways in which we want to encourage others to get vaccinated in order to access these spaces that we know are higher risk. Throughout the pandemic in the United States and worldwide, we've seen that these indoor spaces are among those that are highest risk or transmission led you to the conclusion, and I'm sure this is a complex conclusion that includes both scientific elements and policy judgments that places that don't primarily serve food and drink, like workplaces for example, would not be logically included in this current round of orders. You know, early on and throughout the pandemic, some of the news that came from the CDC, from the Morbidity and Mortality Weekly Report, which is their journal CDC puts out, really showed in rigorous case control studies where people are interviewed after they become positive, what their activities may have been in the weeks leading up to their testing positive, and then compared to a group of people that tested at the same time but tested negative. Really showed that the areas that I mentioned restaurants, bars, gyms, were among those most associated statistically associated with becoming positive. These sites are places that by definition, people are removing their face coverings, they are in contact with other people outside of their household, and so there are more aerosols, more virus particles in the air in restaurants, in bars, and you add into that in bars and some other restaurants, it's loud, it's crowded, people are leaning in closer to each other, and also with the addition of drinking and alcohol, people are talking louder, maybe more disinhibited talking to other people. So that explains a little bit about why the risk might be there in bars and restaurants. For fitness establishments, those have also been associated in several studies from across the country in outbreaks and increases, and there it's really again recognizing it's a respiratory aerosol transmitted virus that people's respiratory rates are up, they're breathing heavily, they're in an enclosed room with others, and that's why we see that elevated risk. Let's talk about the mechanisms that you might use to check that people have been vaccinated. As I understand it right now, you would accept the physical vaccination card. I'm imagining you would also accept someone's picture on their phone or their vaccination card or something similar to that. Have you, as a city yet flirted with vaccine passports or other mechanisms that might potentially be more reliable than a rather flimsy piece of cardboard or a photograph of said flimsy piece of cardboard. You know, we have not talked about San Francisco having its own version of New York's excelsure pass or anything like that. We do know that there are private companies and others who have been working on these, and so what we're trying to do is evaluate which of those would also be acceptable for businesses to use in San Francisco. For instance, the state also it's not a full vaccine passport, but what they have done is they allow people to access the state Immunization Registry and get on their phone a QR code and so their name and their dates of their vaccinations. One of the topics that is widely discussed but is not so widely discussed in the media, is the possibility of people falsifying vaccination records. Right. I mean, in the world of things that are hard to copy, and there are many in our world, your vaccination proof is not one of them. So somebody who wanted to spend ten minutes falsifying proof of vaccination presumably could do that extremely easily, and there would be absolutely no way for anyone to tell if that were the case, or not to say nothing of the person that a restaurant puts at the door, you know, the greeter whose job is now includes not only being nice to you and telling you how long the weight is going to be, but also checking your proof of vaccination. So, given that how much of what you're doing is sort of a signaling function to try to send to the public the feeling that you and San Francisco really expect people to be vaccinated, how much of it is you just calculate people are so moral that they would never lie about such a thing. How much you calculated people can't be bothered to do that, and it would just be easier for them to go and get vaccination than it would be to mess with a PDF. What's the as it were, actual thinking behind this, if you're willing to share it, sure, yes, I think that the way I have always thought about it, the health orders themselves are not enough to make the full impact. The health orders are important, but they're not sufficient. So the way we have always addressed this in San Francisco from the beginning is to be very visible, to make sure that we put out reasoning, that we share the science. And I think we're fortunate to work in a city where people are responsive to hearing about the science. They don't doubt that the virus is real, they don't doubt that vaccines work. So addressing really the importance of doing it for their own individual health, and then the health orders are important in driving up the understanding and the demand for vaccine, for people to understand that it's expected, that it's required, but this is the most important thing that they can do, and that this is going to have the most impact over time. So it's using this as another opportunity that gets a lot of attention. People are very focused on the vaccination mandates. The truth is we have the highest rate of full vaccination you know, of any city in the US, so the incremental increase in this is important. We want every single additional person to get vaccinated that we can. We have to marry that though with explaining why it's important, and then most importantly, we have to have highly accessible routes for vaccination in the city as well. The health order load is not perfect, as you said, but in my mind, the goal is not for it to be perfect. It's really to add cumulatively to all the work that we've been doing around increasing our resilience and our response to COVID nineteen. I think that you know, this requirement for vaccination in public spaces is the most recent vaccination requirement, but it's not the only one. It's not been. The first one that we actually put out as a health order was related to higher risk settings, settings in which the people that are within those settings are at higher risk for either severe illness or death. So that includes our acute care hospitals, our nursing homes, our jails, and so that was the first place where workers were required to be vaccinated. We do have an indoor masth mandate as well, So we've had that since the beginning of the month, and so we have both. Now we just have this newly implemented vaccination requirement in these certain public businesses as we talked about, but we do have in all indoor spaces a mask requirement as well. I think that the delta variant had introduced enough level of uncertainty to not be sure, even with our highly vaccinated city, what was it going to mean for our hospital system, what was it going to mean for people that had already been vaccinated. That we determined to do the mass mandate first because it could be implemented very quick CLEA and we had done it previously, and then work on this vaccination requirement. So going forward, what we're going to have to see is keep looking at our case numbers. They are coming down slowly, and we'll have to see if that continues and decide how we move forward. We are going to have to learn to live with COVID nineteen in San Francisco and elsewhere, but for now we do have both of those measures in place. Let's talk about the formulation that you just used, which is one that I think is very important that we're going to have to learn to live with COVID nineteen formulation. And I'd love to hear in more fine grain detail what you think that living with is going to look like. Let me make the con question concrete in the following way. You've got great uptake at eighty percent or so of eligible residence getting a vaccine. That's amazing. Let's say you got to ninety five, right, which is as close to perfect as anyone's going to get. And let's say the Delta variant still existed, because it's still going to exist, although perhaps it will have burned itself out in this latest round, but it or other things like it, we'll be back in the future. This doesn't seem like it's some outlying evolutionary development. It's a kind of to be expected and doubtless will be recurrent in various ways. We'll have to learn the names of lots of other Greek characters beyond Delta. So in that environment, does living with it basically mean that we would move towards a world where no mask requirements and we would just understand that there was a certain amount of breakthrough infection that was going to keep on happening in the light of future variants, and we will try to manage that and if it requires building more hospital beds to be prepared for those potential surges, will do that. Is that sort of what you're picturing. Well, I think what we'll picture is again continuing to take in any new information. You know, and as you pointed out earlier, this virus has done nothing if not keep throwing curveballs, and we have to adapt to what we might need to do. We were not talking about masks early on in the pandemic, and that was not in our culture as a country before, as it was in some other Asian countries, but it is something now. Are we going to have to mask completely going forward? I don't think that that's likely, but I do think that people may choose during cold and flu season in coming years to wear a mask. Hopefully people have a sense that if they're sick, they stay home. So there are some lessons I think from COVID nineteen that I hope do continue pass this current time. And I do think that there will be other challenges potentially, as you said, other Greek letters maybe coming at us, and then we will have to adapt over time. So what I'm hopeful is that we will get a high level of vaccination that that will continue. We'll understand if and when we need to continue having boosters of these vaccinations, and then if we need to adjust further, we will have to adjust. But I do think that we will eventually be able to peel away some of these other non pharmaceutical interventions like masking, and we've already peeled distancing away and have the vaccine really really hold the bulk of the work for keeping population safe. And you know, as a health officer, we're working at a population level, so we do know unfortunately that there still will be people that get infections and get sick. But what we're trying to do is really make sure that the bulk of the population is protected and that everyone has as much information as they might need to make decisions. But for right now, as we are working to get all of our populations as vaccinated as we possibly can, and we don't know where we'll end up with that, these are the additional protections that we want to have in place using the power of state law, the health officer authority to be able to do that. For the moment, we'll be right back where does rapid antigen testing, in your view, fit into this series of different measures that you're engaged in. I got my first wedding invitation post COVID today that noted not only that they wanted people to prove vaccination to attend the wedding, but also that they wanted people to get a rapid antigen test that day, not even a PCR test, you know, in the previous thirty six hours. And I, you know, thought maybe this is the new normal. There's an expense question, of course, but when you think about the various components of a preventive plan, testing surely is one of them. Prices have come down, although not as much as one would have hoped thus far. So how does testing fit into the picture? I mean, I think, to put another way, how we been discussing this at the beginning of the pandemic, before vaccines were available. A lot of our conversation would have been and we did these conversations on deep background, you know, the centrality of testing to a successful regime and the mechanisms that can be undertaken to make testing more efficient at scale. And yet now it doesn't seem to be as central to the at least to the Public Health Conversation. I think you're right. You're absolutely right. The testing remains really important when you think about schools which are opening soon in a matter of days. We still don't have authorization for vaccination for under twelve, but for twelve and over. Is San Francisco in its public schools requiring vaccination universally? You know, in San Francisco our schools opened last week. It was very exciting because we had not had all of our schools opened during the last year, and so we're encouraging them for twelve to seventeen. But they're not mandated, and the San Francisco Unified School District has a different governing entity. They don't fall under the mayor and the rest of the city department, so we work very closely with them, but they have a different decision making and policy approach and independent of the rest of the rest of us and independent of health officer or orders as well. They make decisions there, so they are supporting twelve to seventeen year olds and the rest of the city. Our Health Department is working closely with the Unified School District to be able to do that and have there be events where entire families can come where we facilitate vaccine, and we'll have increasing sites numbers of sites on school property to be able to get vaccination, but we're not requiring it yet. That was such a beautifully diplomatic answer that I almost don't want to draw attention to how diplomatic it was. It's a reminder that being public health officer of a city is not dissimilar from being, you know, an abassador with United Nations or something. You have to be careful in what you say. Let me try to parse it. I mean, what I heard you say is that the schools don't answer to you and they have a different policy. Without stating it. The natural implication I want to ask you to confirm this or deny this, but the natural implication when it might have been that you might have reached different decision if they were within your decision making authority. Let me use that to ask a further question. You know, across the country, this is going to be replicated a much greater scale, right, I mean, even within a progressive city like San Francisco, it's clear that there's some nuanced difference between different agencies at the county, at the city level, at the level of the education system, and nationally, we've got a huge range of variation all the way from where you guys are to you know, the governors who prohibited even not just as governors, but there were state laws passed signed by governors that prohibited mandatory masking. So the other very very grave extreme. When you think of this, not just in your role in San Francisco, but you know, your role as a national leader on questions of public health, are you worried about just the range, just the huge disparity of viewpoints that we're getting from governmental elected officials on these matters of life and death. You know, are these are matters, as you said, of life and death, these are public health matters, these are scientific matters. And it really has been troubling since the beginning of this pandemic how there had initially not been a national response. You would think that when there was a pandemic that there would be a coordinated response at CDC, would be at the forefront, and that we as local health department leaders would be responding to the same stimuli and not not really trying to do our own thing and come up with how we were going to get PPE and how are we going to do testing, and what was our approach going to be there. It's been better more recently, but I think that that set the precedent for there being such a diversity of opinion, and then this whole way of thinking that masks were a sham, that the virus itself was a sham, and the splittization of the response of the science of the health officials, many of whom my colleagues in California have received threats, have really been unduly harassed for just trying to do their jobs and save lives. So there is a lot there. It is really concerning last question. We mentioned the terrific rate of a vaccine uptake that the city has. Are there measures that you have of what those numbers look like for people who are not just poor but are actively homeless in the city, and do their numbers look comparable to the general population in terms of vaccine uptick. I don't know if we can pinpoint the exact numbers. We do know that they are generally lower than the general population. But what we've tried to do is make mobile vaccination available, allow people to drop in and get them at the sites where they get their usual services or care and we right now have mobile vaccination teams that are going out to work with persons experiencing homelessness, so they are a priority, and we do recognize that we're going to have to try different strategies to increase those rates among those populations in San Francisco. And have you gotten broadly speaking yet, the criticism from the civil rights community that would be might be worried that given differential vaccination rates when measured by socioeconomic state or by race, that a public vaccine mandate could look like it involves the turning away of a disproportionate number of people of color. Because that's obviously, from a straightforwardly ethical and legal perspective, that's a grave concern. I agree with you that that is a concern from a moral and an ethical standpoint, let alone the legal risk. And we have again worked with community leaders and ask them to help us really reinforce the importance again make the vaccine accessible. We wouldn't have done a mandate without a feeling confident that we have worked with informed community really tried to do that from the beginning. So it's an ongoing it's got to be an ongoing communication effort has got to be an ongoing support effort with community, and relative to other cities, San Francisco's populations of color are more highly vaccinated than other areas. So are black African American population Sixty five percent vaccinated right now, that's not as good as our overall percent of seventy nine percent of eligible, but we are working on getting there. That number is higher than it used to be, and we're going to keep working until it can get higher. Yet it's a fascinating problem. I mean, the law professor in me immediately pictures the scenario of a disparate impact civil rights lawsuit that says, you know that sixty five percent of African Americans are vaccinated in the city relative to seventy nine percent of the general population. Therefore, you know that this band will have a disparate impact on access to restaurants, fitness centers, and so forth on the basis of race and in other contexts. The progressive position in general favors looking at disparate impact independent of discriminatory intent. Right the standard progressive position is, we don't care how good your intent is. If the law has a disparate impact, that's a prima facial reason to treat it as unlawful unless a really good justification can be offered, and you're case may well be that. And the conservative position is typically no, we're only interested in intent when it comes to discrimination. We ought not to look at disparate impact. Presumably in this case the positions would end up being something reversed, right. I mean, it's very clear from everything you've said that your overarching goal is public health, that you have no interest in any disparate impact. In fact, you wish you didn't have a disparate impact on the basis of race. But it's a really tricky situation when conceptualize in those terms. Yes, I agree with you, and I think you. In public health, like in all public policy, there's no absolute right or wrong answer. Most of the time, there's just trade offs. And so again, what we have committed to doing, what I've committed to doing as health officer is really to work with populations and try and communicate the reasoning, communicate what's coming, to make sure that all the stakeholders are aware, and then trying as much as we can to say, look, this is also to protect the communities of color that are working as weight staff, as barbacks as other people who are in them to increase the safety at their place of work as well, because they have to have that income, they have to keep going to work, So there are multiple ways at looking at this. As you said complex, Susan, I really want to thank you for your time in describing and engaging with me about these policies and how you're thinking about them. I really value insights into what the new normal might come to look like. And I also want to thank you for your very intense work over the last couple of years in an extraordinarily important and influential position. So thank you very much. Thank you very much for having me. I've enjoyed talking with you. We'll be right back listening to doctor Susan Phillip. It struck me that we may be closer than we think to ascertaining what a new normal is going to look like, even in the aftermath of the delta variant. That is, requirements for vaccination at least in place is across the country where large numbers of people are vaccinated. Not every place is San Francisco, and many places would lack the political will or the number of people who are vaccinated for vaccination proof requirements to be implemented. Nevertheless, if they work in San Francisco, they have the chance of becoming a gold standard. Simultaneously, masking requirements which San Francisco, like other big cities, has reinstated for unvaccinated people may become an ongoing thing in places where vaccination numbers are lower and where there is a public health will to protect people. San Francisco represents only one possible direction that we might end up going. Across the country. There are lots of locations where we don't have mandatory vaccination rules, where we don't have mask mandates, and indeed, we have plenty of places where state legislatures and governors have outlawed mandatory masking. So it emerges that our new normal may be highly bipolarized, with very different practices in the most progressive places than in more conservative locations. As this new reality continues to emerge, we here on Deep Background will continue to cover the question, returning to COVID as always when there are new developments, new norms, and new practices that deserve your attention until the next time I speak to you. Breathe, deep, think, deep thoughts, and at least if you can provide proof of vaccination, go ahead and have a little fun. Deep Background is brought to you by Pushkin Industries. Our producer is Mola Board, our engineer is Ben Talliday, and our shore runner is Sophie Crane mckibbon. Editorial support from noahm Osband. Theme music by Luis Gara at Pushkin. Thanks to Mia Lobell, Julia Barton, Lydia, Jean Coott, Heather Fain, Carlie Migliori, Maggie Taylor, Eric Sandler, and Jacob Weissberg. You can find me on Twitter at Noah R. Feldman. I also write a column for Bloomberg Opinion, which you can find at Bloomberg dot com slash Feldman. To discover Bloomberg's original slate of podcasts, go to Bloomberg dot com slash podcasts and if you like what you heard today, please write a review or tell a friend. This is Deep Background.