Please read or reread my previous statements below to get a better understanding of where we find ourselves today and actions you can take to protect yourselves and your family.  

What I learned about how to simply quantify droplets and aerosols for you to use in reducing your risk.  The virus appears to be mainly transmitted by droplets.  The degree that the virus is transmitted by aerosols in unknown, but it is likely some non-insignificant proportion is transmitted that way.  Droplets are small particles that are emitted when we sneeze, talk, or sing.  Droplets tend to fall to ground fairly quickly due to their size.  Aerosols are smaller in size, linger in the air longer, travel further distances, and if you inhale them get deposited much deeper in your respiratory tract.  You can think of the spread of aerosols in a similar fashion to the smells of baking, say cookies.  The aroma of the baked goods spread around your house like an aerosol could.  Most folks are familiar with the effects of sneezing, especially if someone sneezes on you.  You feel this wetness on you.  The feeling of wetness is produced mainly by tens of thousands of expelled droplets.  I hope most folks have the basic understanding that avoiding having someone sneeze on you is a good idea.  Surprisingly, talking for one minute produces the same amount of droplets as one sneeze.  Think about that.  Being close to someone talking for one minute is like having them sneeze on you.  Shouting produces 10 times the amount of droplets as talking.  Shouting near others for 6 seconds is equivalent to sneezing on them.  This is the main reason why the extensive use of facial coverings is so important.  Facial coverings remarkably reduce the amount of droplets you put forth into the environment, thereby protecting your fellow humans.   Singing actually creates aerosols.  I would avoid all indoor settings where singing is occurring.  I would also keep a very long distance from people singing outdoors. Facial coverings don’t effectively reduce the amount of aerosols that singing produces.

Schools

I endorse the 4 pillars presented in the school’s pandemic recovery plan as there is scientific support behind them and we are using them more broadly in society to slow the spread of the virus.  But I do so with caveats when talking about them in relation to how schools operate.  Since my intent and words have been misconstrued by many, let me clearly state, I want to see kids back in school.  I also feel that it is very important that kids be allowed to be kids. If you’ve read my statements over the last few months, you’ve noticed I’ve repeatedly used the word “balance”.  Balance means that slowing the spread of the virus is but one of many things to consider when going about the business of living.  As we go through time with this pandemic, the balance needs to shift.  In considering the educational, emotional, and developmental needs of children, I believe the balance shifts in that direction.  Many, if not most, of these needs are met in a school setting.  So to the degree that the pillars interfere with these needs, they need to be modified.  The pillars are not inviolable constructs.  They represent a continuum of risk, such that smaller class sizes are better than larger, outdoor settings are better than indoor ones, 10 feet of distancing is better than 6 feet is better than 3 feet.  Facial coverings are better than no facial coverings, especially if distance can’t be maintained.  But to the degree class size, physical distancing, and facial coverings interfere with the ability to deliver a somewhat normal school experience, they need to be modified.  It is my belief that there are too many variables within school settings to adopt a one size fits all approach.

Why should we consider different standards for schools?  Early childhood experiences and early education sets the trajectory of your life.  A lower educational experience sets one on a lower trajectory, in relation to one’s optimum capacity, that is almost impossible to recover from.  As one example, third grade literacy, an early measure of the quality of education one receives, is directly correlated with income, wealth and ultimately life expectancy.  These educational milestones occur at every age.  While the entire community is affected, the most vulnerable among us are the most likely to be damaged by continuing to not offer a more typical school experience and they are also the most vulnerable to disease spreading out of control.  These are the types of difficult issues that need to be balanced.

Some parents will tolerate zero risk, either through a belief/value system, in light of a high risk setting at home, or other factors.  In that case they shouldn’t be leaving their houses and they should be taking every precaution.  But that level of risk tolerance should not drive the entire decision making process or the structure in which schools operate any more than parents who believe this pandemic is a hoax and no precautions should be put into place.

Ultimately, these decisions of what schools and all their various components will look like will need to be made, but these decisions will not be made by me.  Preferably they will be made with substantial input from the young people who are directly affected by them.  There are many guidelines to review to assist in these decisions.

The Variance

The State has a Shelter in Place order that is used to restrict the type of businesses, organizations, and functions that can be open.  San Mateo County also has a Shelter in Place order.  The State order is the floor.  County orders can be more restrictive than the State, but cannot be less restrictive.  The State set up a process, called a variance, that allowed the relationship between the State order and County orders to change over time.  This process originally set up two speeds for reopening.  Variance counties could move faster through the reopening phases and non-variance counties could move at the rate of the State or slower.  Metrics were designed so that counties could qualify for this variance.  As you may know San Mateo County has just applied for a variance in regards to reopening.  It was not my original intention to apply for one so I wanted to let you know the reasoning behind the decision.  

Initially, when the State first put forth the variance construct, it was so that rural and less impacted counties could open up faster than the rest of the State.  Since we were/are a significantly impacted County and we previously didn’t qualify based on our case rate and hospitalizations, I never thought it was reasonable to go faster than the State.  Somewhere between then and now, the State’s plans seems to have changed.  They began loosening opening restrictions for variance counties, but the cadence allowing opening in non-variance counties mostly stopped.  At each step where the State loosened restrictions on non-variance counties, San Mateo County followed within about a week.  Note that the our orders allowed religious gatherings on 6/1/20 even though I thought such gatherings were high risk.  I sent a letter to all faith leaders (Faith Based Letter, Faith Based Letter (Spanish) ) highlighting my concerns and suggesting further risk mitigation strategies and I held a town hall with faith leaders that you can listen to if you want to hear what was said. (Listen here)

When the State cadence on loosening of restrictions in non-variance counties stopped, a number of us in the Bay Area decided that lower risk activities that we felt were not specifically prohibited in the State order (in our case it was outdoor dining) could be allowed to proceed.  When we did that, the State decided to use their levers to encourage us to apply for a variance.  We spent last weekend talking with leaders at the State trying to convince them that there was more of a middle ground that would work for both them and us.  We were ultimately unsuccessful.   My options at that point were to rescind the orders allowing outdoor dining or apply for a variance.  Our case rate remains high and hospitalizations, until recently, were worsening, our Re is around 1.3, most models (models are forecasts, similar to weather forecasts but less accurate due to the newness of the virus) predict a second wave in August.  But I felt applying for the variance was our best course of action given the change in how the State was now viewing this.  County leadership agreed.  As I have stated before, my intent was to be in alignment with the state regarding reopening.  If we are granted a variance, we will continue with that intent.  

You all are now the most important variable in how our future will develop.  Follow the key behaviors well, including extensive use of facial coverings, and that will bode well for all of us.  Don’t, and our future will be dim. As to a second wave in August, the existence of such a wave and its severity is entirely up to you.  I believe we can completely avoid a second wave if everyone does their part.

Scott Morrow, MD, MPH, MBA
San Mateo County Health Officer