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. 

I do believe we face a great challenge. A great challenge during a time of year whose hallmark is gathering with family and friends. A great challenge because gathering at this time is exactly the wrong thing to do. I share the intent of the State and my Bay Area colleagues, which is, during this surge, you should be staying at home as much as possible. I also deeply understand how people can look at the same issue, and seemingly the same set of facts and come to completely different conclusions. I’m sure some of what is going on is confusing to many of you, so I wanted to take this opportunity to try to explain some reasons why I haven’t signed onto the concept of a Bay Area Stay at Home (SAH) order (an order that accelerates the timing of the State’s new framework) for San Mateo County, at this time. I certainly understand reasonable people trying different approaches to the unimaginable dilemmas that face us. And I have no intent to fault the State on their impossible task. They have an even more complex task than do the locals. But I’m not managing the State. I’m trying to make the best public health decisions for all of you.

What are some reasons that San Mateo County hasn’t decided, so far, to advance the implementation of the State’s SAH order like some other Bay Area counties have?

1. I may have a different view of the power and authority I have, as a function of my position, than some of my colleagues. During the first Shelter in Place order, which I wholeheartedly endorsed, the virus was brand new and had the capability of spreading exponentially due to zero immunity and people’s complete lack of awareness. It was very much consistent with my long-held views about the judicious use of power. I felt that this was the time for our great power to be maximally applied. And that our power and authority was designed to be broad for situations just like this. However, I very quickly rescinded my initial orders shuttering society and focused my new orders on the personal behaviors that are driving the pandemic, mainly limiting gatherings, using masks, social distancing, and adopting the State’s framework on business capacity restrictions. Just because one has the legal authority to do something, doesn’t mean one has to use it, or that using it is the best course of action. What I believed back in May, and what I believe now, is the power and authority to control this pandemic lies primarily in your hands, not mine. 
2. I’m not sure we know what we’re doing. (Please don’t misinterpret this sentence. The science and public health principles around disease transmission interruption – no gathering, mask wearing, social distancing, etc. – are clear. I’m referring to how to get you, the community, to change your behavior). I look at surrounding counties who have been much more restrictive than I have been, and wonder what it’s bought them. Now, some of them, are in a worse spot than we are. Does an unbalanced approach on restrictions make things worse? Maybe, maybe not. But I think there is a more likely explanation. When I look at the trend data, the Bay Area seems to mostly move as a region, and it seems to me to be pretty independent of individual Health Officers’ actions. 
3. Surely a hard, enforced, SAH order will certainly drive down transmission rates. But what we have before us is a symbolic gesture, it appears to be style over substance, without any hint of enforcement, and I simply don’t believe it will do much good. I think people should stay at home, avoid all non-essential activities, wear masks, and not gather with anyone outside their households. I’ve been saying this for about 10 months now. If you didn’t listen to my (and many others) entreaties before, I don’t think you’ll likely change your behavior based on a new order. I appreciate that some of you think I (or the government) have magical abilities to change everyone’s behavior, but I assure you, I (we) do not.
4. Being in the purple tier, the State has already put significant restrictions on businesses and the public space in San Mateo County. I am aware of no data that some of the business activities on which even greater restrictions are being put into place with this new order are the major drivers of transmission. In fact, I think these greater restrictions are likely to drive more activity indoors, a much riskier endeavor. While I don’t have scientific evidence to support this, I also believe these greater restrictions will result in more job loss, more hunger, more despair and desperation (the structure of our economy is, for the most part, if you don’t work, you don’t eat or have a roof over your head), and more death from causes other than COVID. And I wonder, are these premature deaths any less worrisome than COVID deaths?
5. I don’t see us (governmental public health) looking at data other than case rates and positivity rates and hospital rates in order to make balanced decisions. When you only look at one thing, you only see one thing.
6. I look closely and frequently at our data to try to divine what they mean. Remember, our data are just a proxy of reality, not reality in and of itself. Our cases are certainly going up. But it appears to be a linear increase, with higher increases in 20-40 year olds, but the increases are across all demographics. Our hospitalizations are going up, linearly, and our hospitals feel equipped to deal with a surge, as of today.
7. There is not a good or standard method for understanding ICU capacity on a county level, much less on a regional level. Basing such extreme decisions on non-standardized and poorly understood metrics seems fraught to me.
8. Many hospitals have not yet made the basic internal policy decision of canceling elective procedures. And granted, personnel who provide services for elective procedures may not directly increase ICU capacity when they are freed up, repurposing the services these personnel provide will be required in a surge.
9. Efforts to creatively maximize regional hospital capacity have not yet begun.
10. Regulatory constraints that limit hospital capacity have yet to be addressed.
11. I have grave concerns about the unintended consequences of reducing our grocery store capacity to 20%. 
12. The SAH order will make it more difficult for schools to open or to stay open. It is a very hard needle to thread to message that everyone must stay at home by strict order, but it’s ok for kids to go to school. I continue to strongly believe our schools need to be open. The adverse effects for some of our kids will likely last for generations. Schools have procedures to open safely even during a surge as evidenced by data. My earlier stated positions from June remain the same.
13. That the State considers pro sports a critical infrastructure (essential) activity undermines this whole rubric in my mind. Pro sports is very nice to have and is probably a pleasant distraction. It is not essential. (Granted, I could be very wrong on this point. Maybe keeping millions of people home watching sports on TV without mixing households is exactly what we should do more of. Of course, if folks stay home watching TV and gather with other households, it could be much worse.)
14. The new State framework is rife with inexplicable inconsistencies of logic.
15. Beyond the basic human needs for air, water, food, shelter, and safety, it has, to date, been impossible for me to define what is “essential” to the 800,000 people who live here.

There are additional reasons, but these were enough to give me pause. 

It is possible, under the State’s new regional rubric, that they will apply a SAH order on us as a region in short order. If and when the governor issues the regional stay-at-home order for the Bay Area, San Mateo County will support it. It may be that new data convinces me to take this action prior to the State’s action. Either of these situations occurring is really quite moot, because neither absolves you of your personal, social, and moral responsibility to stop the spread and protect your fellow humans, many of whom can’t stay at home because they are protecting you, or are keeping society running, or are at high risk of death.

Some additional pieces of information for your consideration as you make your decisions:

1. There is a nascent science developing about mobility. This data comes from tracking your cell phone movement (anonymously, I believe, but I don’t know that for sure). What it shows is a strong direct correlation with mobility and spread of the virus. Less overall mobility, means less spread. The take home message here is: STOP MOVING!
2. Right now, based on modeling data, there are an estimated 8-15,000 active cases in San Mateo County capable of transmitting the infection to others. These active infections are EV-ER-Y-where. Literally, they are in every corner of the County. The chance of you encountering this virus anywhere is much, much higher than it was just a few weeks ago. Many people are asymptomatic and can transmit the virus unknowingly. And these asymptomatic people may very well be the ones you are most likely to let your guard down with, your family and friends.
3. Based on modeling data, the overwhelming majority (80-90%) of people in this county are still susceptible and at risk of contracting the virus.

This is a horrible, nasty, and lethal virus that is highly transmissible and one you do not want to get. To get out of this situation depends on all of us. Our collective best course of action: No gatherings outside of immediate households, use facial coverings extensively, and social distancing. And during this surge these are the additional things you should be doing: Stop moving around, stay at home except for essential (please observe the most restrictive definition of what you deem to be essential) activities, avoid all travel that is not essential, never enter an indoor environment without a mask if that environment has people outside your household, get tested if you have symptoms or are concerned, and isolate yourself IMMEDIATELY from your family and others if you have symptoms.

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