What happens when a pandemic becomes endemic? S.F.’s top health official weighs in

Dr. Susan Philip envisions a city that will manage this ongoing disease

You don’t want Dr. Susan Philip’s job.

San Francisco’s public health officer has lived at the corner of pandemic and pain for nearly two years now.

But that hasn’t stopped her. Standing alongside Mayor London Breed and The City’s Director of Public Health Dr. Grant Colfax, Philip has authored a winning formula to keep San Francisco relatively safe from the novel coronavirus.

Has it been easy? No. Has it worked, from a public health perspective? Yes. Has The City’s conservative stance on COVID-19 hurt the economy? Without a doubt.

Philip said she is aware of all that. But she’s done her job with aplomb and conviction. She’s taken account of the circumstances. Her own family has felt the coronavirus wrath. And she sees a future we can all embrace.

As San Francisco emerges from this most recent omicron surge, seeking a path to live with this disease, Philip sat down with The Examiner to discuss her experiences and parse the key question before us: What happens when a pandemic morphs into an endemic? Here’s what she had to say.

There’s been discussion, locally and nationally, about shifting COVID strategies, acknowledging the disease may be moving from a pandemic phase to an endemic phase. Do you agree with that assessment? I think all of our work has to fall into how we view where we are and where we’re going with COVID-19. This particular term, “endemic,” I think when people ask me about that, what I’m hearing them ask is, ‘When are we going to be able to live with some normalcy even as COVID-19 is not completely eliminated?’

I think what we have been able to see clearly is that a zero COVID strategy is really not going to be possible with this particular respiratory virus. So we are going to have to figure out how to live in some balance with COVID-19, (along with) all of the other essential activities that we all need to do, (such as) school, work, being able to be social and having that connection with other people.

So, I see it more as being able to think into the future about how we balance COVID-19 risk with all of the other risks that we are continually thinking about, like flu during flu season. I do think that we are headed now into a new phase of the of the pandemic. And we don’t have a completely clear crystal ball with this. I think it’s important for San Francisco to … do this really considering the equity components and being in close, continued relationship and partnership with the communities that are most impacted, as San Francisco has tried to do throughout the pandemic.

Can you define for us the difference between a pandemic and an endemic? Sure! Initially, this was a new communicable disease. None of us had any immunity to it. We did not have any of the tools that we have (now). In 2020, we didn’t have vaccines. We didn’t have very much testing. We didn’t have any treatments out. And we didn’t know exactly what would be the best ways to prevent it. So we were very, very limited. We had to respond in the way that we did, and the rest of the Bay Area did and eventually the rest of the state and the country did, as well. Keep people as safe as possible while we learn more about the disease. Shut everything down and try to have people stay home and not do their usual activities.

That was the right decision with what we knew then. (Now) we understand more about how we can stop transmission of the virus and protect ourselves. In 2022, we have these additional tools, vaccines first and foremost among them. It’s been really dramatic to see the difference that vaccines have made, even with this huge omicron surge in cases, which are now dropping.

We had the highest peak in the whole two-year pandemic … on Jan. 9 (2,164 cases). It’s dropped steadily since then. So we’re on the back end of it. But with that very, very high peak, what we saw with all the work that San Franciscans have done … the high level of vaccinations that we have really uncoupled that huge case rate from hospitalizations.

So, now we’re moving into a phase where we have these tools and San Franciscans have done an amazing job of taking them up. That’s going to allow us to be able to move into a new phase where we are not restricted in the same ways. There’s a lot that we can do to improve our overall health and the health of The City. Using the tools we have, primarily vaccination, but also ventilation and testing. (And) you’re going to have treatments around the corner. Masks remain an important component of people’s personal decision-making around their own level of risk.

There may be something that happens in the future. So I do think that we have to continue to watch and be prepared, as the rest of the world is not as highly vaccinated. But San Francisco? We’ve put ourselves in the best possible place to be able to coexist with the virus.

What might an endemic strategy look like in San Francisco? We will have our sectors open. We will have our schools continuing in person. We will have businesses that are able to operate. We will be able to have gatherings. … I think we’ll see people who, in some situations, will want to continue wearing masks, maybe during cold and flu season. We may also continue to see people who are thinking about ventilation. And we will see what happens after omicron. We likely will not see large city-wide restrictions on sectors or activities. Those will not be needed as much because we are in a different stage of the pandemic where we haven’t seen the severe … hospitalizations and deaths that we had before. We want to make sure people are as healthy as possible.

What do you expect in terms of more readily available drug treatments? Will it change the way you and your colleagues strategize? Absolutely. Having this additional tool is going to change the calculus of our public health (and) clinical decision-making. Even people’s individual decision-making, right? It’s so exciting to see the oral treatment(s). So there’s a drug by Pfizer. Paxlovid is its name. And it shows very high efficacy against keeping people out of the hospital … at a rate of like 85 90% in the clinical trials. Very, very exciting. … If your doctor could prescribe you an oral treatment, like we can do now for the flu in some cases, that will be a game changer. People who might otherwise have an increased risk of having to go to the hospital … would have that additional layer of protection. Now, it’s not highly available yet. The supplies are not where they need to be. But we’re hearing that’s gonna keep ramping up. California is getting an allocation. Just like with vaccines, and masks and everything else, we are going to work to make sure that there’s equity in who’s able to access those (treatment) tools.

Why does it seem San Francisco has been less willing to come back to work in offices compared to other large cities? Along those same lines, do you take into account economic concerns when weighing public health recommendations? I don’t have the exact answer. I wouldn’t be able to speculate as to why why we have less people coming back in person. San Francisco probably does have a large component of its workforce that is able to work remotely. And I’m sure those considerations come into play. San Francisco has always been a relatively cautious city around COVID. Part of that is also thinking about this pivot to being able to live with COVID and assess the risk, our personal risk and our societal risks. So, there’s no perfect answer here. It’s a series of trade-offs. And there is a trade-off in not being able to interact with others or feeling worried about interacting with others. That’s why we want to keep giving that information out about how the landscape is changing in terms of severe disease.

In terms of how do I think about the overall impact of health orders and our health policies? I do think about that. I do think that, holistically, we’re thinking about health broadly. We’re thinking about mental health and physical health. People need to have their employment in order to be healthy, have food, have all the essentials for living. I do think about the economic impact. There were very difficult calls early on to have to shut things down because that’s all that we could do.

Moving on to schools. You’ve been a strong proponent of in-person learning throughout the pandemic. Do you see an end to mask mandates in schools anytime soon?

The mask mandates come from the state. When there is a state order or state guidance, we locally are required to follow it. So we could be more strict than the state, and San Francisco has done that in a lot of instances. But we can’t be any looser. So we couldn’t say, ‘You know what, schools, you don’t need to wear your masks any longer.’ We’ve got to keep it in place, as long as the state does.

I understand that parents feel very, very strongly about masks. We have tried, and have advocated with the state, to remove (the mask mandates) where we can, such as outdoors. We don’t think that children need to wear masks outdoors any longer. But, as vaccination rates go up among kids who are (ages) five to 11, we can rethink masking indoors, as well. There are some parents and students who would feel nervous about being in school with others who were unmasked. We have to acknowledge our overall goal. We want to keep kids in school. And I think we’ll have to balance the tools that we have to keep them there. Right now, masks have a place, especially during the (omicron) surge.

How do you manage COVID exposure personally? Most of us are making decisions on a daily basis weighing risk and reward. What’s your process on that? Do you go out to restaurants? I would go out more, but COVID response has taken up most of my time. I have come in person to work throughout the pandemic. I never stopped doing that, so I take public transit and do all those things. I don’t have underlying medical conditions and I’m not at a generally high risk for COVID. So, I wear my mask. I don’t wear it outside. My children both go to school and they tested positive for COVID. I did not. I think that’s OK. We want children to be able to go to school. I knew that was a risk. For most of us, we’re going to have to put this into balance with all the other things that we do every day. I can sympathize and empathize with people who are experiencing this. Everyone has probably known somebody with COVID because it’s so prevalent right now. There should be no stigma with this. People didn’t do anything wrong to get COVID.

You’ve had one of the toughest jobs imaginable during this pandemic. Can you tell our readers maybe one high point during this period of time? And one low point? Do you have any touchstones that you can look back on? What a good question. I think the high point is just really thinking about how well this city has done for its residents. In so many ways, I think we’re up to the challenge. I think that the the residents in San Francisco are so informed and so willing to understand the science. I’m very proud. … The low point is just that I am human. … It’s tiring to be doing this for two years. And I have not been able to see my family as much as I would like during this time because of work. But I know that other people have have had all these challenges also. So I think that the good and the bright spots, and what we’ve been able to do in San Francisco, so much outweighs any of the concern. I’ve really been proud of how we’ve used our policies, our health orders and our resources as a city to protect some of the most vulnerable. A lot of a lot of great work by a lot of people I’ll never know. But I just feel comfort in thinking about the ways in which people big and small kept themselves and their neighbors safe through this pandemic.

Well said, Dr. Philip. Thank you for your public service, and for your work throughout the pandemic. Thank you for taking time for The Examiner.

Well, thank you so much for your time!

This interview has been edited for length and clarity.

Editor’s note: Welcome to The Arena, a new column from The Examiner’s Al Saracevic. He’ll be exploring San Francisco’s playing field, from politics and technology to sports and culture. Send your tips, quips and quotes to asaracevic@sfexaminer.com

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