All right, good morning.

Let's call the order of the health committee for April 27th.

Supervisor present.

Supervisor Miley.

Present.

We have a quorum.

Okay, thank you.

Are there any instructions we need to provide this morning?

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If you'd like to speak on an item, fill out a speaker's card in the front of the room and hand it to the clerk for remote participation, follow the teleconferencing guidelines.

Post it at www.ac.org.

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All right.

First items and informational item.

Housing first overview.

Good morning, uh, supervisors.

Jonathan Russell, director for Alameda County Health Housing and Homelessness Services.

Here with a brief overview presentation, I believe a month or so ago.

Supervisor Miley, you'd requested an overview of Housing First, so that's what we have here.

Go to next slide.

Brief agenda, of course, first starting what is Housing First and what isn't it?

What is the evidence for it?

What are state related requirements for Housing First?

And then how do we here locally implement it?

Next slide.

So first, what is Housing First?

Oh, I should also mention this slide is a combination of some slides also taken from local uh researchers.

So from UCSF, you will see you can see icons in the bottom right, whether it's an AC health slide or from UCSF or from the state.

So I will note that.

But this is some summaries from Dr.

Margot Cushell, who runs the Benioff Homelessness and Housing Initiative at UCSF, which is a preeminent researcher on homelessness that does a lot of academic studies.

Um, and also in the last several years completed the largest uh study of homelessness uh ever completed of about uh 30,000 individuals, I believe were uh survey um through a process across eight counties in California.

So they're a highly respected researcher.

So this is a slide taken directly from a presentation in a briefing um that we both participated in several years ago with our state legislature.

So what is housing first?

Housing first is first and foremost an evidence-based, that is to say a research backed approach to housing people experiencing homelessness.

It is fundamentally an individualized approach, which means it is focused on providing a range of models to meet individuals' unique needs, and it is very much not housing only, which is to say there's much more involved in housing first than the housing part of it.

It was initially developed and continues to work uh as a model to meet the needs of people that are experiencing chronic homelessness, by which we mean long and enduring homelessness with disabling conditions as a factor and serving those with severe mental illness and substance use disorders.

It's also a long-standing practice in that it was first adopted as federal policy under the George W.

Bush administration based on research and studies done at the time in Los Angeles that have grown since.

So, why is it important as an evidence-based approach?

First, it really prioritizes where possible getting people into housing as quickly as we can without mandating certain engagements with services in order to access that housing.

Also, it's important to note that housing first models include services.

So services are embedded throughout the housing first approach.

The distinction is they're not mandated or required in a way that compels people.

It also offers a really important setting.

Housing, I like to say it's an environment first approach in order to offer stability that people need in order to meaningfully engage services and wellness.

It's also supported by a robust evidence base that shows its ability to provide stable housing for people, even with significant behavioral health conditions.

And uh it's been very robustly used by the Veteran uh Veterans Affairs Association alongside the Department of Housing and Urban Development that year over year has led to up until this point a 50% reduction in homelessness for veterans across the country.

So significant impact by the VA taking a strong housing first approach, and I'll come back to that later.

Next slide.

So to briefly summarize again.

Housing First was initially, oh, next slide.

Housing First was developed to serve people with behavior health complexities.

There's a strong evidence base that really shows the outcomes, some of which we'll summarize on the next slide.

It's been very successful in reducing veteran homelessness, which will also show some of the details.

It's also helped to create reductions in some of the negative outcomes, that is people's accessing jail or involvement in the criminal justice system, psych ED experiences, so reducing emergency utilization of emergency services in local communities.

It also has shown that it creates a dramatic increase in the engagement and uptake of services.

So when services are offered assertively but not required, people take a lot more agency in accessing and accepting and making the most of those services.

It has also helped the decrease in reliance on shelters, which we know is a big difficulty in our system, is people are often impacted and staying in shelters for years if they've got nowhere to go.

So having housing first programs helps to create movement through our impacted shelter systems.

And they also has shown that as we have seen, there is a small group of people that often require more service than a housing first model can provide.

And that group is actually considerably small that would require, as we say, a higher level of care, higher level of service.

Next slide.

This is a quick visual.

I didn't, I didn't create it.

It's been used widely in other communities that creates a good representation of the difference between what we might call the staircase model, which is a model that was used through the 70s and 80s and 90s and thereabouts pretty widely in our system, and contrasting that with a housing first model.

Essentially, the staircase model is exactly that.

It sets very clear, discrete steps that someone has to go through go through in order to access housing.

It makes housing essentially an earned criteria where people would have to first go into a shelter and then earn their way into some kind of transitional housing that has lots of embedded requirements, ultimately to eventually potentially make it to permanent housing.

And what the evidence showed over decades is that this model had considerably low outcomes.

So the ability for someone, particularly with high needs, to navigate each of these steps and all the potential gaps, the potential rules, the things that could that could get them put out of a program, for example, over time, show that it was a lot of investment to have lots of different steps, and they did not see considerably higher outcomes in the ultimate end that we all want, which is people accessing and retaining housing independently long term.

So the housing first model actually, where possible, focuses on getting people into that permanent housing as quickly as possible, but it doesn't require that, which is also important to say.

We have shelters that are housing first focused that I'll get into later, that don't require those shelters to turn themselves into permanent housing.

What it means is that they have practices that really focus on removing the barriers for those people to get into housing and supporting them along that pathway.

Next slide.

So here's a brief summary of five key principles of a housing first approach.

It's also important to note, not included here, is that there's actually 34 specific fidelity practices that are that are required to be held under these five categories to be in alignment with the housing first model.

So again, housing first is an evidence-based model where there's a very specific high threshold for evidence-based practices to meet the housing first standard.

And that is again, it has 37 fidelity measures.

This is just the real summary areas of focus.

First and foremost, it provides where possible immediate access to permanent housing that doesn't have any requirements or stipulations in order to access it.

It's really focused on inspiring and supporting participant choice and their own self-determination.

It has an approach that acknowledges that there's multiple multiple, excuse me, pathways to recovery.

So people take different pathways into their long-term recovery.

And it also is really focused on the individual and what we call patient participant-driven support.

So, what is your individual needs plan that we can put together to serve you, knowing that everyone has distinct needs and different desires at different times in life.

And it also really centers on this is often less focused on the real importance of social and community inclusion.

People heal in the context of community, in the context of being in a neighborhood, and housing is fundamental to being in a stable ongoing community.

Next slide.

So just briefly wanting to really drive home why when we say housing first, we do not mean housing only.

When we say housing is the solution to homelessness, that's not because everything else is irrelevant, but because housing creates a dignified space where anything else can safely become relevant, which is to say housing is foundational to people addressing and receiving the support they need to move forward in life with stability and safety.

So giving that housing without preconditions promotes safety and choice as opposed to just compliance and control when people are doing things based on requirements, when they are put through multiple hoops, often when they're having complex difficulties in life, it's really hard to imagine stabilizing where your shelter stay might be dependent on following X or Y rule.

It's often hard to address your mental health under those stressful circumstances.

It also serves as a context, again, being in housing, having that ability to take a breath and develop trusting non-coercive relationships with service providers.

So it takes away, in some ways, as I like to say, that power dynamic of holding something over someone's head in order to receive support.

So it has been shown to really help cultivate those meaningful relationships.

And it also removes barriers.

So often the uh high-risk behaviors that we talk about, uh using substances and otherwise, those can be really driven by environmental factors, i.e.

stress, trauma, being outside, being in a tent, being in a congregate shelter.

Sometimes those can exacerbate high-risk behaviors, and we find that housing helps remove those factors to help people more uh effectively address those high-risk behaviors.

Next slide.

So, what is the evidence?

A couple slides here summarizing the evidence.

Thankfully, we have a robust body of evidence, evidence-based research, some of which is noted in the footnote below.

Again, this is taken directly from UCSF's Benny Hoff Homeless and Housing Initiative summaries.

Over time, we've seen that up to between 73 and 88% of housing participants have remained housed at follow-up across multiple studies over the years, some of these going back to uh the early and this one from 2016, summarized on the bottom.

It also, as we said, increases the engagement in services, so the willingness and likelihood for people to take up those services.

It also is really helpful in that matching people's needs to services.

It really focuses on the fact that we need a range of service types and then there's not a one-size-fits-all approach to homelessness.

Housing first is shown to be very effective in that regard.

It also ends homelessness more rapidly and more durably.

Uh, important to say when we say rapidly, we here mean cost effectively.

There's a lot of talk often about how expensive housing is to build, how expensive subsidies are to have people in housing.

The reality is it cost a lot more money to leave someone with complex needs outside or in a shelter than in a housing user.

So the reason that this was adopted under the first Bush administration was primarily because of that clear evidence that it was a money saver to provide folks with chronic homelessness in housing versus having them bounce between shelters and emergency services.

So it's cost effective ultimately.

It also has shown to considerably roost carceral involvement and recidivism back into homelessness and other systems.

Next slide.

I mentioned that the real paradigm case of success, the epitome of the impact that system-wide housing first approaches can provide, has been really shown by a partnership between HUD and the Veterans Affairs.

This is called the HUD VASH program.

They have really scaled this program such that all of their services are focused on a housing first approach for veterans experiencing homelessness.

Again, it pairs a housing voucher with case management.

Those are the two core anchors.

It showed significant positive outcomes in veterans are maintaining their housing housing.

They're comparatively having less days using alcohol or other drugs, and it's increasing their health care use in the positive sense.

So getting connected to preventative care, that is primary care.

And then over time, we've seen veteran homelessness has dramatically decreased using housing first policies.

The graph on the right shows the increase in housing vouchers through the HUD VASH program that are dedicated to homeless veterans.

And the red line shows the dramatic decrease, again, more than 50% veteran homelessness nationwide.

Next slide.

Zero in in here briefly on our local evidence for housing first.

So we, of course, as I'll talk about in alignment with the state requirements and previous federal requirements.

We use a housing first approach across our system.

Our partners in Santa Clara County had a significant peer-reviewed study, a rigorous research project, also completed by the UCSF Benny Hoff Homeless and Housing Initiative that identified and studied the services for people with the highest utilizers across their system.

And they found that using a housing first approach for those with the most complex needs outside, after three years, 93% of those individuals that were served in permanent supportive housing were still housed.

So they picked the most complex needs population to really demonstrate the impacts, and they found that many of them, the vast majority stayed housed.

It also created significant reductions in emergency department visits, psychiatric stays, and criminal justice interactions.

As you know, those are our highest cost investments in our system.

In some contexts, one day of a psychiatric stay can cost as much as a whole month of a permanent supportive housing subsidy.

In Alameda County, housing first practices had led to considerable year over year increases in our permanent housing outcomes.

Most recently, we had more than 4,700 people gain housing in the last fiscal year that we reported to you.

We also have a really robust intention to provide wraparound tenancy sustaining services across our system that have also contributed to year over year reductions in the rate of return.

So this goes back to the earlier point of recidivism, people falling back into homelessness.

Whereas in 2020, that system-wide rate was uh 18%.

It's now down to 13% in 2025.

And I should also mention we've seen uh decreases in the racial disproportionality of returns, such that we've seen a positive increases in the equity metrics around returns to homelessness as well.

And our programs that provide one specific program that we scaled using the housing uh flex pool that you adopted earlier this year.

We have also seen that our evidence has shown 93% of the households served in that subsidy and support services program have retained their housing two years later, a very high outcomes.

And then, of course, also we believe that the application of these principles across the system have helped contribute to the reduction we saw, the first time reduction in 10 years in our point in time count in 2024.

Next slide.

Okay, what are the state's requirements?

This is a couple slides just drawing directly from state resources, that is the business consumer services and housing agency and California Interagency Council on Homelessness.

These are the three statutes where housing first is established in Senate Bill 1380.

It established the California Interagency Council on Homelessness to oversee the adoption of the housing first statute and the guidelines and regulations.

This is in 2016.

It defines housing first, which I'll show later how that's defined in the welfare and institutions code and the 11 core components.

Assembly Bill 1220 applies it to all state programs funding emergency shelters.

So again, it goes to show you can have housing first principles and practices in the context of shelters.

It doesn't require something to be permanent housing.

And then more recently, Senate Bill Nintendo in 2021 provides requirements for state programs that fund recovery housing still to incorporate housing first principles.

Next slide.

That is the welfare and institution section 8255 D1.

Housing First means that evidence-based model that uses housing as a tool rather than a reward for recovery and that centers on providing or connecting people experiencing homelessness to permanent housing as quickly as possible.

Housing first provide providers offer services as needed and requested voluntarily and do not make housing contingent on participation in services.

Next slide.

While not all programs that we have obviously provide permanent housing, HH funded programs support households with housing first aligned practices that prioritize removing barriers to accessing housing.

First and foremost, our coordinated entry system.

This is a federally required centralized assessment system that matches people and prioritizes the most vulnerable populations with the highest needs to our limited supply of permanent housing resources.

So this is aligned insofar as it doesn't require people to have addressed their complex issues.

If anything, it prioritizes housing for folks with the most complex issues because we know that those services are better received in a housing context.

As I said, we've developed a very robust tenancy sustaining services program using Cal Aim.

This is ongoing supportive services to support tenants when they move into housing to retain that housing, leveraging those Cal A Medicaid dollars in partnership with our Alameda Alliance for Health, and that supports more than 2,100 people a year in housing alone, which is not including those we help that are currently experiencing homelessness to navigate to housing.

So a very robust program that has helped people to again sustain those services because housing first is not housing only.

As I mentioned, we have added more resources through our housing flexible housing subsidy pool that is expanding subsidies and supportive services through what we call our rail program.

That is the program that has a 93% success rate in people retaining housing.

And so year over year, we will be adding 150 to 250 new subsidies each year over the life of the housing uh subsidy pool.

And then lastly, uh, and this goes to show how housing first investments also apply in shelter contexts, new shelter standards and enhanced funding.

So we are updating our shelter standards through going through a robust community process, talking to our providers, talking to people experiencing homelessness in shelters, talking to people not in shelters and what they would need to have in those shelters to be successful by increasing and updating those standards to better meet people's needs, and by our adding more funding to our current shelters receiving the bed night rate, that's allowing them to provide more wraparound services to be aligned and to help people navigate out of those shelters into housing as quickly as possible.

And I believe that's it, except for questions or comments.

Thank you.

Well, thank you for this presentation that's been very informative, and I have a number of questions, but I will start with Steve Colleague Supervisor Lena Tan.

Thank you, Chair Miley.

Um I really appreciate this presentation because it's been coming up a lot in conversations lately with uh different uh city council members uh throughout the county, uh, even ones that are not in my district.

Um so I I know the housing forest model um I I guess a couple years ago, even with at the mayor's conference, they uh emphasize the importance of looking at it holistically.

The the slide that you presented on page 17, I think that's a great summary of um our practices in Alameda County.

And so I'm trying to get a better sense of like where the lanes are between like the cities and the county, because um cities may provide, for example, uh the Mandela House, they would move people from encampments into housing, but if they have navigation services at um at these shelters, how how is that um differentiated between what the county does and what they do, what cities do?

That's a great question.

I think that as we've as we've often shown, there's a mixed model of the approach of what cities and counties do.

There's a fair amount of things that cities are primary in in siting and development of sites.

Um there's a lot of overlap in what we do uh insofar as we often will both fund services at sites, sometimes the same site, or sometimes cities will fund those independently, and then of course the county will work at the system-wide level to try to match people to permanent housing.

In the context of a shelter, I think the Mandela Homes site is a good example.

I will say it is unique in that it was opened in a hotel that was uh acquired by the city using a variety of state funding sources and local sources in order to provide a time-limited shelter stay where it was then intended to convert to permanent housing, the site.

So that was a shelter that was opened with an initial 12 to 18 month term that they would be serving people from the three major encampments they focused on, really seeking to navigate everyone in the shelter during that time to permanent housing, at which stage it would convert and become from a hotel that was being used as a shelter to a hotel that was being transitioned to apartments to be permanent supportive housing.

So it's a great example of a housing first approach, insofar as it says, let's create the kind of shelter as quickly as we can that people will want to go into.

We find that consists consistently that people are much more interested in non-congregate shelter, which we mean where they have their own private spaces, and then wrap around the services to help them navigate to housing.

Ultimately, with the end goal saying we want we want permanent housing to be the priority, and therefore this building is ultimately going to become a site where people live permanently.

So at Mandela Homes, for example, there's there's really two ways that services are funded.

The city, using some of that time-limited budget it put together, provided the base core services to help people navigate at that program.

But also where people were eligible for our Cal Aim housing navigation services, people would be enrolled, in this case housing consortium of East Bay, they were the provider on site in the county's housing navigation services, so that that could actually be billed to Cal Aim versus uh the rest of the budget.

So we're currently funding services dually, if that makes sense.

Some projects are funded by uh cities where they fund the services and the site operations.

Other programs will take advantage of and embed county services if people are eligible or open to those services.

And that's part of what we're working out with the expanded investment through the county bednight rate, is we want to be able to fund robust navigation services at all of the sites that the county funds that will also overlap with sites that are some in some ways co-funded by cities as well.

So with uh Mandela House, did um I I think they were uh trying to move residents from the Wood Street and the East 12th Street encampment there.

Did they have to go through the coordinated entry system at the county?

To move into the shelter?

No.

So there was three encampments, East 12th, um MLK, and Mosswood were the three focus uh encampment projects as awarded under the state's encampment resolution funding.

So those were those were specific approaches where people were supported directly from those sites to access that or other shelter.

So there was no coordinated entry involvement in accessing the shelter.

And then we work through coordinated entry to support people once in shelter to match them to available housing resources and or stay on in the in their housing in that same location.

So for the initial um operation of those three encampments, it was not based in coordinated entry.

Was if they were at those encampments, they were offered shelter there as a part of the resolution activities in those encampments by the city.

But the cities need to have the shelter in order to move and and so I I know recently uh you know our office has been working with you with one of the council members that was concerned about what's happening with the Oakland Alameda Access Project and some of the encampments that have kind of grown a little bit around that area, but they they have no way to move people into shelter because Mandela House is full.

Is there a way through like the new flexible housing subsidy pool um to create opportunities to put to put them?

I know they're not permanent housing, but to put them into a highly underutilized hotels and motels in this area.

Yeah, this is a great question.

I think the it gets to the point of what we're really trying to focus on uh well every day in our system, which is create more opportunity in our existing inventory to help people move inside, and to what we're really lifting up through the robust home up refresh to the home together plan right now to really focus on this optimizing our system to increase uh but also increase the utilization currently.

So to that example, it wouldn't the flexible housing subsidy pool does contribute, and I'll give a good example of creating more opportunity in shelters for people to move inside.

But the flexible housing subsidy pool is actually tying um services directly to individuals, not to sites.

So it's actually saying, hey, you're eligible for a subsidy because you have complex needs, and we've identified that whether through BHSA Prop One funding, local funding, Calim Transitional Rent, that we can offer you a subsidy.

Let's wrap around and help you find a unit that you want to move into.

We have it strategically embedded those expanded subsidies through what we call housing fares at shelters across the county, which is to say we identify the 30 or 40 individuals at an existing shelter in Oakland, for example, that are prioritized for the housing flexible, and then we will go and have a literal fair at the site where we will plan to have the the service provider there that day to meet with residents to show them units to get them signed up to do their documents to quickly move into housing from that shelter site.

What that does is it creates a focused experience of creating vacancies, the good kind of vacancies in that shelter because people move into housing.

And when people are moving into housing, then you've got 30 or 40 beds right there in that local jurisdiction to use to move more people inside.

So it's always a balance.

I will say it's important to note we have more than 3,600 shelter beds in our community every year.

Many of those are underutilized in that people are stuck for years, sometimes two, sometimes three years in a single shelter bed because there's nowhere to go.

The county has expanded over the since 2024, we've expanded 600 beds ourselves of new shelter in the system.

So there's no shortage of added investment on our part.

The strategy is always to say how do we best use those beds we have?

And the housing subsidy, uh, the flex pool is a good example of doing that with shelter-based models where you move in and help people that same day pick a unit, move out uh in the next couple weeks, creates more opportunity for people for cases like that to move inside when there's need for those beds based on a calt transaction or otherwise.

Okay.

That's very helpful.

Uh so one of the criticisms that one of the council members in Oakland mentioned was that the Mandela House has become more of like an indoor encampment because I I'm not quite sure how the navigation services were available at at those sites.

And uh so the concept he's been thinking about along with two other council members is would it make sense for the city through obviously braided funding with Measure W, uh state funding and federal funding, uh be responsible for the the capital projects, the the actual shelters and the housing, and the county comes in mainly with the navigation centers, usually through our community-based organizations.

Do you think that kind of a system would work um well throughout the county?

Yeah, I think I would need some more clarity on how that's being distinguished as not working at Mandela Homes or the perception there.

In many ways, I think that is what uh Mandela Homes was designed to be.

I will say that everyone served in that program, the more than four the more than a hundred people there are going into permanent housing from that shelter.

So that is that is certainly not a city alone affair.

That is involving working very closely with our county counterparts within HH to identify housing pathways through the coordinated entry system for all those households.

So broadly speaking, yes, we're certainly supportive of that.

I think invariably cities have uh understandably very targeted needs for their shelters in certain settings, which is to say we've got an encampment, we need to close it tomorrow, we need to get people inside from that to our shelter.

So often cities have wanted to have um uh their own directly funded shelter that funds the services as well, so that they could have that flexibility to move individuals from one day to the next into their shelters when they're doing resolutions.

In terms of the navigation services, yes, I think that's very much what the county wants to see as our increasing strategic role is to make sure that those services to help people navigate those shelters um is embedded across our whole shelter system.

That is what our new interim housing division is focused on, both for the county funded shelters and for the more broader shelter system.

But I don't think there's a possible world where cities would only fund the build and then sort of release any on any um responsibility for ongoing funding and operations, that would not be a sustainable structure because the operations are considerably expensive.

As I said, it's about uh $35 to $40,000 a year per bed to run a shelter well.

It's about it's almost twice about two-thirds of what it is cost to use a subsidy in permanent housing.

So again, shelters are cost a cost um cost effective compared to being on the street, but they are high cost to provide those wraparound services well, and that often requires two funders.

Okay.

Very helpful.

Um in terms of uh next steps, I I'll try to help, but I I think to a degree when whatever we talk to cities, make sure they know what we are able to provide and very clearly what those lanes are.

Absolutely.

Thank you.

Well, thanks, uh Supervisor Tan for all the questions.

So I have a number of questions as well.

Yeah.

Because I'm trying to understand this, and um uh and it's very controversial.

That's why I wanted to have this brought to us.

Housing first is controversial.

Oh, yeah.

Oh, yeah.

Oh yeah.

Oh, yeah.

Among some sure.

Oh, yeah, very controversial.

So how I think in your presentation, you said housing first has been around since President Bush.

That's correct.

The first one.

So if housing first is such a sound evidence-based model, why are we still dealing with homelessness as a crisis?

That's a great question.

I think this is one of the most common, I'll call it what it is, I think fallacies in the way people critique housing first.

And I'll use an analogy.

In the same way that we know based on the evidence that renewable energies like solar and wind, all of these alternative energies are very effective when they're utilized at providing uh alternative sources uh for energy and electricity in our communities.

What we don't have is enough scale to use those across our whole systems, right?

So critiquing alternative energies for saying, hey, climate crisis has got has gotten worse, and so those alternative energies must not work.

That's a problem of scale, not with alternative energies.

The problem is very similar with housing first.

Housing first works in the settings in which we're able to apply it, right?

Where we have housing and we have funding for services, all of the evidence over and over shows that those people served by those programs have a 90 plus percent success rate, right?

Hands down across the board.

The problem is we don't have enough resources to do housing first for everyone that we serve.

But the problem, the failure is that's not a problem with housing first.

That's a problem with limited resources in the same way that alternative energies haven't solved the climate crisis, not because they don't work, but because we have underinvested in alternative energies.

So Jonathan, um, you're the expert.

How long have you been in this field?

Twenty-some years.

Twenty-some years, okay, yeah.

And I'm not gonna try to um you know come compete with your expertise because clearly you're the expert.

I've only been a policymaker for about 35 years, 10 on the city council, 25 here, and living in Oakland for more than 45 years.

So obviously I've seen things happen over time.

Yeah.

So resources.

Yeah.

We're the voters have given us, and the board has approved, 1.4 billion dollars to go into home together.

What's the problem?

And furthermore, I would suspect if I go back in time and calculate the amount of resources that we've put into homelessness since you've been here, prior to you, uh, when we had everyone home, we've probably put multiple billions of dollars into homelessness, and we're still dealing with it.

So if the issue is resources as a taxpayer and someone who's observed this, I I'm baffled.

Yeah.

I mean, it's a it's a great question, and and I certainly am uh I wouldn't call myself an expert.

I would call myself, you know, seasoned in the in the series in the direct services work um and learning the governmental system side.

So I've got more than uh a lot to learn from from policymakers such as yourself.

And I I think the point stands that when we say that underinvestment, we do not mean to say that local communities, including ours have not invested amply in homelessness.

The wicked problem of homelessness, which is to say the nature that it's connected to so many other problems, is there are waves of investment that goes so much beyond we'll call the homelessness system the emergency room that kind of catches people and seeks to resolve it.

There are so many other systemic pressures that push people in, right?

Wages falling far behind housing costs.

So many of those go far beyond what even Alameda County can mitigate in terms of construction costs and lack of investment at the state and federal level.

So I think what we're seeing is this is for the first time we see an a significantly expanded local investment to go together with our state and federal investments.

And I don't want to sound rosy by saying I'm confident that we will continue to see the curve bend and go down.

But we also know that because of decades, four or five decades of significant underinvestment in low-income communities, in wages keeping up with housing costs.

Um the homelessness system can't solve those problems, but we can use our dollars, our significant expanded dollars as effectively as possible to build to invest in three concurrent areas in the right proportion.

Prevention, the most cost-effective way to have people not fall into homelessness, good shelter that helps people move through uh out of their homelessness, and permanent housing to help people navigate and stay housed.

And those three areas are the areas I think we can we continue to see improvements in our system, and for the first time ever having a large-scale investment of local dollars is going to continue to have positive impacts.

But we need to be cognizant that as any community in California, setting goals to reduce homelessness by 30 to 50 percent count as extremely aspirational these days because there's so many pressures and headwinds.

Um but I think we're seeing demonstrable impacts.

Because I know we've got these folks running for governor, and some of them have indicated that um you know they put more resources into prevention.

So if we put more resources into prevention, because I know you've talked about the inflow.

People becoming homelessness.

So we put more money there.

Why don't we put money there and then also say treatment first?

Because what's what's the the demographic, not the the racial graphic or the um the folks who are homeless out there?

And correct me if I'm wrong.

Yeah.

Some of them are suffering from mental and substance abuse.

Uh and it gets worse if they're out there on the streets.

That's one thing.

Some are like the working homeless, they're homeless because they can't keep up with their you know, with their um payments and things of that nature.

Uh and some are homeless by choice, and we've always had people homeless by choice.

Um it just hasn't been a a crisis.

I mean, I've known homeless people since I was a little Co Scout or something, seeing homeless people, you know, on Skid Row and this, that and the other.

So we've always had homeless folks.

So what if we were to say we're gonna put money into treat into prevention, we're gonna stop the inflow, we're gonna turn that spigot off totally and completely.

So prevention first, treatment first, so we get those folks who are on the streets, off the streets, because as you said, people can't get well if they're homeless.

They're just gonna get worse.

So as opposed to housing first, go with treatment and prevention first.

Yeah.

I think the first to the prevention part, uh, yes, we need we need that at scale.

I also have listened to some of uh the gubernatorial candidates talk about some of which are really prioritizing prevention, and it'd be interesting to see, depending on how that goes, whether the state might increase investment directly in prevention, right?

Which is a different kind of investment than investment in shelters.

So we are for the first time planning to invest uh between 15 and 18% of the annual funds in prevention in our system to go together with some city investment.

So I think that's a very critical thing that we do need to drive drive up considerably.

Um the the distinction I'd want to make is to say housing first is not in an opposition to treatment, right?

Treatment should be happening concurrent to services and housing.

But a treatment first approach, I think is to misunderstand how treatment best works and also the evidence for treatment, which is to say treatment, 90-day treatment, short-term residential treatment, long-term inpatient stay is very, very ineffective long term unless someone has somewhere else to go after, right?

Or concurrently.

So outpatient treatment, for example, the most often way that we're providing substance use and mental health services, right?

A team that is connecting with someone in the community.

As you said so well, people's uh mental health struggles get worse often when they're experiencing homelessness.

And they get and they and they get better when people are in housing.

So housing is in many ways a part of treatment.

It should be seen as a component of treatment.

Um so I think this is very consistent.

So do we need more treatment?

Absolutely.

I think the state has made very clear investments significantly through the behavioral health infrastructure expansion program or B chip.

I think I got the analogy wrong, to significantly expand um residential treatment uh facilities across the state.

Alameda County, our behavioral health department to give them big kudos have gone con big in drawing down those infrastructure dollars, and they intend to fund uh those services as is required to get those dollars.

So I think we have more treatment resources coming into our community.

Um, but the connection to housing first is really that treatment works best in housing.

Kind of that's what the evidence shows.

Um so it's not really an either or, it's a both and.

Um, but it's important to say these little dollars we get for homelessness from the state and the federal government should be spent on the homelessness side of the resources, whereas our healthcare system dollars and the dollars, the significant dollars that come into the behavioral health department should fund the treatment components and helping homeless people access those treatment resources and navigate to housing at the same time, I think is the sweet spot that we're trying to hit in partnership with our with our other departments and city partners.

And super my apologies.

Uh just wanted to add another note on the treatment piece, so especially when we're talking about mental health or substance use treatment, there's it's largely voluntary, right?

So it's as uh I as you've heard from our teams over and over again, it requires a lot of outreach, a lot of engagement for people to finally accept services.

Um, and we have multiple examples of when we pair housing as as a a service that we're offering care court, for example, right?

One of that's a voluntary service that people accept, even though the court may be mandating it.

But one of the key critical components of why people accept that is because it's paired with bridge housing that we're able to offer.

Um so we can only you know, treatment is always gonna be voluntary except for people who continue to meet criteria for involuntary treatment.

Yeah, because I'm not saying we should have treatment first and no housing.

Treatment first and housing continues with with the treatment, and hopefully people get stabilized enough and they continue to be housed that they become effective members of our society.

So I'm not saying treat them and then let them go and get homeless again.

No, no, no, no, no, no.

That's what I'm saying.

Treatment first, prevention, and maybe in my limited thinking, if we put the dollars there, we decrease the number of folks on the streets and we turn off the spigot.

As opposed to housing first, we uh we let people come in, they get housed, but um you know, like Supervisor Dan was pointing out, we have people criticizing us because there's still folks out on the streets.

Right.

And there's still more coming on the streets and and uh we're getting beat up beaten up because we're just not resolving the issue.

Yeah, I I think it's important to talk to the community to to get beyond kind of the the way in which a specific evidence-based practice like housing first has been miss uh diagnosed as uh fault for the fact that homelessness still exists, and so some of that goes to what I said earlier is we need to take the pressure off one single practice as if it's um to blame or not.

Uh and I think one healthy amendment to your treatment first approach, I think it's treatment with and treatment throughout.

It's not so much that we need to put one in the order and one next.

We'd have we need to have treatment available for someone who's in housing, they need to go to treatment and come back.

We need to have treatment available for folks that are literally on the street and treatment's the next best step.

The key is really individual needs-based resources.

The problem is when we immediately require something like treatment before, the evidence has shown considerably that that has low outcomes and high cost, unless you really make the treatment amenable to someone's needs.

So treatment with, yes, I would say treatment first um uh misses the mark a little bit.

Yeah, I would agree.

Treatment with housing, treatment throughout, et cetera.

Yeah.

I would support that.

But now don't we have uh I'm not gonna um name any names, but I think across the bay, are they doing housing first or are they doing, you know, you you get housed, you you get off the streets.

Yeah.

And maybe to the south of us, you you get housed or you get off the streets.

But the point is you can't stay on the streets.

We're not gonna allow it.

Yeah, I mean I San Francisco has historically been a strongly housing first-based system.

I think that they have kind of um built more permanent sportive housing, which is the kind of paradigm example of a housing first approach, create the housing and support services within the housing setting.

Um San Francisco has built, you know, a lot of permanent supportive housing over the years, so been very focused on housing first.

I know that their current uh leadership and administration is looking at um uh broadening their approach to include added, I think transitional and other treatment related services.

Again, none of that is in conflict with housing first, but I would say broadly there's still system focuses on uh getting people into those stable housing environments and making sure all the needed treatment is available to go together with that.

Uh the South of a Santa Clara, I think again depends on the city or the county potentially in terms of their primary orientation.

Um, but broadly have been um committed to having both shelters and permanent housing units in Santa Clara, my understanding.

Um that focus on helping people navigate and end their homelessness, which would be broadly aligned with the the housing first approach that again, the state and the feds have historically promulgated as a policy.

The beauty the the beauty of it is it's very flexible.

It's not a restrictive setting.

It doesn't say you shouldn't have transitional housing.

It says you should help people get through transitional housing as quickly as they can.

Okay.

So I I still believe in uh mandatory treatment.

So um I'm not gonna back away from that.

We need to get people uh even if they don't want treatment, we need to get them into treatment.

Because my feeling is uh as a taxpayer, and I'm just talking as a taxpayer, um their right to be on the streets and not get treatment um abridges my right for a good quality of life.

And you've got to try, and if they're treated, then maybe we there's a win-win as opposed to you're on the streets creating more problems for you know the rest of us who are trying to live in a civilized society.

And and I'm not trying to criminalize homelessness by no means.

What I want to do is get people treated, get them into housing, move that along so we so there's a win-win for all of us, as opposed to, well, you can do this and impact the rest of us uh to our detriment as well as to yours.

Yeah.

I I don't disagree.

I would just one one distinction I think to make, particularly around the homelessness population is we find that it's an exceedingly small amount of the population that are categorically resistant to receiving the services they need to end their homelessness.

It is more often the limitations on those services being available, and I will say prior experience of coercive, unhelpful, I left that back to the streets experiences where people are like, I know what that's like, I don't need it.

So these it's about us living down these former experiences and creating services that people say yes to.

So I think there's a very real myth.

I call it the myth of service resistance, which is to say people are just resistant, they don't want a service.

I think it's much more similar to uh use the analogy of a consumer.

If a consumer was telling us for 20 years that they did not like the product we were selling, we wouldn't say that that that consumer has a problem with uh product resistance.

We would say there's some issues that that product needs to be improved so that people want to say yes.

And I'm my experience has been people really want services, but they want services that meet their needs.

And what we have found year over year is that housing first approaches that provide services and shelters and services and housing that really focus on that individual needs are far more effective.

And so the more we scale those, the more we scale voluntary treatment resources that are embedded in alongside housing.

I think we will continue to see success.

And I'm confident that in our relationship with our uh great behavior health partners and with the state and others that we're on the right track with um having more and more of those resources available and making sure the homelessness system is closely tied to that system.

Okay.

Well, two other things, and then I'll let it go for the moment.

But this has been very helpful because like I said, this whole housing first um controversy has just been um around, and I needed to understand it better.

And I'm glad we were able to bring it to the committee and shed more light on it.

Um we have hotels that the county purchased out in East Oakland.

Um then there's another hotel that we that was being used during the pandemic.

It used to be called the Radison.

Are you are you familiar with the location?

Okay.

Now I drive by that location up periodically, and it's just sitting empty, and it's got a whole bunch of hotel rooms.

Why aren't we looking to try to utilize the Madison?

I mean, the city of Oakland is you know, trying to get people out of encampments.

We've got a big hotel sitting there, got rooms.

It just seems to me, once again, I'm just a simple taxpayer, paying a lot of taxes, and I I see this stuff.

What's the response?

I'd be happy to bring an update on that site in particular, but my understanding is that a provider we work with uh and that works in the county is currently uh looking at um that site for use, uh potentially already in uh in the process of of uh of acquiring, I believe.

But I'll provide an update.

There's definitely there's definitely active conversations happening about uh bringing that site online.

Okay, because I know I talked to the council person about it just last week, in fact.

Um I'll get an update.

Don't quote me on it until I get the details, but let me go back to our team and I can circle back with you directly on that.

Because I know in Oakland they're you know, they're trying to get rid of encampments, and I support that, but I also see people getting rid of encampments and just relocating other places.

So if they can get rid of encampments and put people into you know hotel rooms, that's your housing first model, right?

Yep.

As long as we proportion that with their able to leave that hotel room within the year to not uh the cautionary tale I will say uh share of shifting all your resources from housing to shelter, for example, is what we're seeing in San Jose right now, which San Jose the City diverted understandably at the time, I think, and probably still defensible now, a large share of their local measure resources for permanent housing to expand shelter beds in the past few years.

And now the city has a structural budget deficit and they're needing to reduce 30 million dollars of annual operations in their shelters to keep them open.

So you balloon a certain part of your system that's cost effective and it's a fixed cost that only grows over time, i.e., shelter annual operations, and then you have budget fluctuations and you actually need to reduce costs just to keep your shelter open.

Um again, it gets to that, it gets to that movement.

Unless that shelter has flow, it will quickly drain your whole budget to, and I'll put it pointedly, because people experience this and they experience it in very inequitable ways, to effectively warehouse people in some circumstances is a real risk, and I think we need to continue to stand as Alameda County has on this balanced investment approach that doesn't drain budgets on high cost shelter that you then have to cut on.

And so again, I think that's a that's a that's a worry when you have budget fluctuations of draining uh your cost if you if you swing one way or the other, it's got to be balanced.

Okay, well, like say you're the expert and you have a lot of colleagues um both in this county and I guess throughout the Bay Area.

Um I'd be really eager to see us put on like a symposium so that these items could be thoroughly discussed.

Because I know Mayor Mayhan, he might have a different uh opinion about what you just said.

Uh, because I like Matt.

Uh and he really promotes what he's what they've done in San Jose.

Yeah.

And it'd be curious to hear their retort to what you just said.

But yeah, no, I mean that's not a conflict, it's just it's a real budget challenge, right?

So you have to balance in your budget and balancing your investments, I think is uh this was reported by the city, not not not by me.

So all right.

Well, we're gonna keep pushing you hard.

It's no, you know, I like you, I'm not trying to make you look bad or anything.

But you know, we are public servants, you and I.

We all get paid by the taxpayers, and they look they want results.

And at some point, if they don't get results, then you know they get angry.

Yeah, um, and rightfully so.

And now we have a lot of money.

We you know, at the issue, we need to make sure our strategy is the right strategy to utilize the dollars that we've been so blessed with.

Absolutely.

Happy to host that symposium if it ever comes to it.

Thank you.

All right.

So, Tisa, do we have any speakers on this?

Oh, uh, Supervisor Tim, do you have any other thing, anything else on this at the moment before I go to the public?

Okay.

Supervisor.

Oh, there's our agency director.

Sorry, just one thing to add um, because we had a lot of conversation about city roles, et cetera.

Um, so one of the things that you know we've been sharing with our city partners as we roll out Measure W frameworks, is that in those instances where there's county funding available to provide services, etc., one of the key roles for the cities is to help with that neighborhood engagement and the sighting of if it's a hotel, if it's a safe parking, if it's a whatever the um intervention or solution might be for it for that area.

Um, we're not the county is not the one that can do that community engagement and um and and local siting.

So that's a critical ask that we have of the cities.

Okay.

All right.

Let's see if we have any public speakers on this this important item.

Alison Monroe.

If you want, I could wait till later till the um matters not on the agenda.

Can a person speak twice?

They can't, okay.

Um, that was a really great lucid presentation.

Um the people that I try to represent are those with family members who are very, very sick.

And so we go back and forth about housing first or something else first.

For people that are that sick, you need totally appropriate housing and totally appropriate services, or the whole thing will fall apart.

And perhaps we're recognizing this in Jonathan's presentation about housing first, where he says a small group needs a higher level of service.

I think there is such a small group.

Um, for example, my daughter could not stay housed because she had delusions that she had to take math.

And so the count we all tried to pretend for years or so that she was housed, but in fact, she was damaging her health terribly, not coming home, disappearing for weeks on an end, stuff like that.

She had housing, but she didn't have enough service to go with it, and maybe such service wasn't available.

Also, friends of mine have permanent supportive housing.

They have apartments, but people don't come around very often.

They're not diligent in trying to get these people their benefits.

Um, as time goes on, the support seems to kind of fade sometimes for people in permanent supportive housing.

And they are at a risk of losing their housing by acting up or you know, by doing any number of things and losing their apartments.

Um, I think boarding cares seem to be outside, seem to be an example of the higher level of service that some people need.

And I think boarding cares are kind of outside the debate outside the area of housing first.

We house people first or treat people first, and that's okay.

We need to look at how small or how large that population is.

It may be pretty small.

So it might be possible to keep them alive without having to choose between housing first and something else by supporting board and cares.

Thank you.

Caller, you're on the line.

We're on item one.

You have two minutes, Tesla.

Good morning.

Uh uh for the presentation and um for H's uh leadership on this issue of housing first.

Um my name is Tessa McCarrow.

I am executive director of supportive housing community land alliance, uh, a nonprofit community of land trust formed uh to address the closure of licensed boarding cares in Alameda County.

And really um, you know, wanted to address the issue of um what we think is the missing link.

I think as the last speaker, Alison Road just wanted to license boarding cares for adult residential facilities for individuals 18 to 59, um uh residential care facilities for individuals 60 and above, provide missing link.

Um, that the housing continuum does not currently um uh really include in terms of uh boarding cares are not connected to our coordinated entry system.

Um and so we don't see referrals into boarding cares from our uh continuum of care.

Um, and um to better align uh the need with uh the services on site.

So um placements may be made in a uh permanent supportive housing.

An individual may not be able to take their own medication or prepare their own meals and license boarding cares, uh provide an appropriate level of care and support, ensure that individuals are able to recover, and then that that high needs population is able to uh move on to more um independent uh settings.

We currently have a 24, a 20-bed facility in West Oakland that's available right now to house 20 individuals, 10 individuals in a licensed board and care, um, and then 10 individuals in independent settings at the union in West Oakland.

It's available right now.

We're trying to work with county leadership to ensure that this property uh this project comes online and uh appreciate um all the coordination on that effort.

Yeah, no more speakers on this item.

No more speakers.

Okay.

So Jonathan, you uh do you have any response to anything you heard from this the two speakers?

Yeah, appreciate that, and just uh wholehearted agreement.

I think we are excited that um we have the uh housing support program, which is the behavioral health department's funding to support um boarding cares licensed boarding cares in Alameda County.

The HH administers that program for the 300 plus um beds uh that are funded through it.

And so very um appreciative of the perspective.

I think I am uh one of those that thinks the licensed boarding cares should be seen as an integral part of the housing system as opposed to outside.

And I think as you mentioned well, Alison, that's exactly that example of uh a population or a group that um has needs that might currently or in the future exceed what uh what an independent permanent supportive housing unit might provide.

And so having a permeability where people are able to move between these uh is exactly our vision is that H would continue to support uh the integration and the funding that goes toward um through behavioral health toward boarding cares, to have those work as the same ecosystem, I think is a great point.

Okay, great, because I do think board there's a lot of validity to that comment around boarding cares.

Uh, we just want to make sure they're operated and run uh appropriately.

Now, um and you know, I know you've mentioned that we don't want people to stay in shelters beyond, let's say a year or or two.

You know, I just have to say I agree with that, but I'd rather people be in shelters than be on the street.

So if they have to stay at shelters longer, why can't we have that level of flexibility?

I I agree with you.

I think we do.

I think just um the the point I was trying to make is I think uh shelter is always better than the street, and so I don't want to treat our streets like a weighted room.

I think my point is um economically and practically um the best way to increase your shelter beds is to increase the amount of people that are able to stay in them.

So four people a year will save you fourfold versus one person in that year.

So enriching our current shelters while we add new shelters is a is a dual purpose.

Again, that's the important for the county to say loud and proud since 2024.

We've brought on 600 more shelter beds that we may that we aim to hear more about this potentially tomorrow to sustain going forward over the next years.

Um so deepening the enrichment is a way to have more people off the street.

So I couldn't agree with you more.

Yeah.

Okay.

And finally, what I'll say is um, you know, now that the board has the word has selected uh Nika to be the agency director.

I'm gonna be pushing her hard in her executive team around these issues, uh, particularly in light of Prop one, because with Prop one, if we have more people who end up on the streets because of Prop One, that's not gonna help you.

You could give us a report a year or two from now that things have ballooned because of Prop One, and we don't want that to be the case.

So I know we're gonna have a distinct uh report on Prop One and how we're gonna provide some bridge support there, this that and the other, because we can't allow it to happen that Prop one exacerbates our homeless situation, more people in the streets, more people going to the jail, more people going to Alameda Health Systems, et cetera, et cetera.

So I just want to alert you.

You, Anika, her executive team.

Um, you you know you folks have got to make sure we're able to address this comprehensively comprehensively and holistically, because that's what uh I'm gonna be pushing you on.

I can't speak for the rest of the supervisors, but I will be.

Yeah, thank you for that.

Yeah, can assure you that we're laser focused on that on our part of it.

Uh I I want to underscore something you just said.

The the key thing is comprehensive and balance and sustainability, because I'm sensitive to what you just said.

Even with proposition one, we move funding from prevention to treatment with treatment facilities, and that's how we're using the beechip funds to create treatment facilities like St.

Regis.

But the issue is the long-term sustainability.

Like you said, shelter beds cost 35 to 40,000 a year to maintain.

So we want to be able to create more shelter beds by moving people out of the shelters into permanent housing.

But I I'm not going to hold you accountable for one part of the thing and deal with this issue with the pressures on our budget because we we do have to look at this, like you said, in a very balanced way with the three piece, sort of prevention, the protection, and the production piece of it.

So I appreciate that you're grounding us in that reality.

Yeah, and I know you're kind of on the hot seat today, Jonathan, you know, on this matter.

Um but I just need to keep emphasizing the fact that we have measure W monies and we've allocated 1.4 billion to home together and some to essential services.

I mean, uh, we've got to get a better handle on this homeless crisis, and we can't allow it to get um, we can't allow it to increase just because of Prop One.

That's right.

So I'm you know, I'm saying to Anika and her executive team, you've got to figure this out.

Yeah.

Yeah.

Confident that we are internal.

Okay.

Yeah.

All right.

If there are no other speakers on this item, we'll go to an easy item.

Easy informational item that's been with us forever, maternal health from our public health director, Kimmy Watkins Tart, one of my favorite people who I don't get to see enough of.

Good morning, supervisors.

We have two items to present today.

One on maternal, paternal, child, and adolescent health.

We'll share health status of families with uh infants and young children and the services we're providing.

We're also going to be presenting information on a very interesting pilot that we are engaged in right now, our wastewater surveillance pilot and share how that will be added to our surveillance system and the possibilities ahead for disease uh detection and control.

And with that, I'll turn it over to our MPCAH team to start.

Good morning, Chair Miley and Supervisor Tam.

My name is Anna Groover.

I'm the family health services division director.

Next slide.

Thank you for the opportunity today to speak about maternal, paternal, child, and adolescent health.

This work sits at the foundation of lifelong health and community well-being.

The conditions we create for families before birth and through adolescence shape not only individual outcomes, but also long-term health equity, economic stability, and thriving communities.

Today, together with Dr.

Julia Rafman, CAPE Director, and Dana Cruz Santana, the MPCAH coordinator, we share key data trends, highlight current efforts across the county, identify persisting gaps and disparities, and outline opportunities where continued leadership and investment make a measurable difference.

Next slide, please.

This slide speaks to the role of MPCAH as a connector across systems and across the life course.

Rather than focusing on a single point in time, the work spans from preconception through adolescence, recognizing that outcomes are cumulative and deeply connected.

A key emphasis is on early intervention and prevention, ensuring families can access care and support before challenges escalate.

And underlying all of this is a focus on reducing disparities.

In Alameda County, we continue to see differences in outcomes depending on race, income, and where families live.

And this work is aimed at addressing those gaps directly.

Next slide.

We want to ensure healthy pregnancies, thriving births, and strong families for everyone.

And we want to reduce mortality and morbidity for all women and birthing people in Alameda County.

But we also recognize that families have very different experiences and face different barriers.

So our approach is to tailor services in ways that help each group reach those same goals.

In practice, that means providing more intensive and coordinated care for medically fragile babies, culturally responsive and community-informed approaches for black families who experience disproportionate adverse outcomes, and addressing outcomes and addressing access and trust barriers for immigrant populations.

It also means recognizing life stage and family dynamics, such as providing additional support for first-time moms, and more intentionally engaging fathers.

Across all of these groups, the strategies we focus on include increasing social and practical supports, improving the care experience, and making it easier for families to access and stay connected to prenatal and postpartum care.

Good morning, supervisors, and thank you for the opportunity to present on the important topic of data on maternal, paternal, child, and adolescent health.

I'm Julia Rafman.

I'm the CAPE Director, and it has been a privilege to partner with our family health services colleagues on this important work.

Before I present the data, I want to note that many indicators reflect unjust inequities.

While most pregnant people and babies will avoid severe morbidity and mortality across races and ethnicities, there are inequities in health and survival.

We take seriously the importance of using these data to inform continued work to improve health and reduce health inequities.

As we face federal and state policy changes that may exacerbate already stark inequities, we're grateful to live in a county and a state with commitment to supporting those most affected.

The work that we do here can make a difference.

Next slide, please.

The inequities that we see in maternal and infant health data are shaped by historical and modern day policies.

Food and housing security are important for healthy childhoods.

Unfortunately, policies and practices such as slavery and redlining have driven racial inequities and wealth and resources, which shape stark inequities in food and housing insecurity.

The rising cost of food, reduced investment in SNAP and affordable housing, increasing vulnerability to health costs with Medi-Cal cuts and changes, and increases in unemployment are increasing inequities in food and housing security.

Reproductive rights and access to evidence-based health care and contraception are also important drivers of maternal and infant health.

Immigration policies affect comfort, accessing prenatal and infant care, fear of or experience of family separation, and the health of pregnant people and young families.

Health insurance policies and the fiscal sustainability of services for pregnant people and children are also important drivers of health.

Recent patriotal policy changes may exacerbate vulnerability across these domains.

Next slide, please.

Policy inequities shape inequities in income poverty and the resources available to pregnant people and their young families.

This figure depicts the percentage of women of reproductive age living in poverty in Alameda County.

African American black women or people had a poverty rate 2.4 times higher than Asian women who had the lowest poverty rate.

Next slide, please.

In the next section, I'll describe birds and birth rates across Alameda County.

As the population of Alameda County grows older, there's a declining rate of birds per thousand people living in the county.

Since 2010, the rate of birds per thousand people has declined from about 19,300 to 16,000, a 26% decline.

This is similar to the decline in the birth rate across the state of California.

Birth rates are declining across races and ethnicities in the county, though there are differences in the birth rate by race and ethnicity.

Next slide, please.

This figure depicts differences in the birth rate by race and ethnicity.

The Hispanic Latinx population has the highest birth rate in Alameda County, 2.7 times higher than the American Indian Alaska Native population that has the lowest birth rate.

Next slide, please.

Medical health insurance for low-income populations is critical to healthy pregnancies and childhoods in Alameda County, where it supports more than one in five births.

From 2022 to 2024, more than 40% of birds to Hispanic, Latina, Latinx, and African American black people were covered by Medi-Cal.

We're grateful that our colleagues in the public health department are working to support continued enrollment in Medi-Cal amidst immense challenges of the federal HR 1 bill, which introduces work requirements to remain enrolled in Medi-Cal and affects eligibility for new Medi-Cal enrollments for some immigrant populations.

It's important to know that pregnant people remain eligible for Medi-Cal and can remain covered for 12 months after pregnancy, regardless of the pregnancy outcome.

Children through 18 years old also remain eligible for coverage.

Doing what we can to support continued access to Medi-Cal will affect the health of pregnant people and young families.

Next slide, please.

This map depicts the birth rate by zip code.

Newark has the highest birth rate, 2.8 times higher than Berkeley, which has the lowest birth rate.

Other areas with high birth rates include Ashland, Hayward Acres, and the northern portion of Livermore and East Oakland.

Next slide, please.

This figure depicts teen birth rates by race and ethnicity.

With increased access to contraception and reproductive health care, there have been substantial declines in the teen birth rate over time, but there remain racial and ethnic disparities.

Hispanic, Latina, Latinx teens have a birth rate 30 times higher than Asian teens who have the lowest birth rate in Alameda County.

Continuing to support access to reproductive health care and contraception is important for maintaining reductions in teen birth rates and reducing inequities in teen birth rates.

Next slide, please.

The data in the next section are on maternal, infant, and fetal death.

These data reflect outcomes of immense importance to families and communities.

They reflect moms who don't come home from the hospital with their families, infants who don't make it to their first birthday, and loved ones left grieving the rest of their lives.

While these outcomes are rare events, they are not rare enough, and they are characterized by market inequities.

Policies and conditions drive these mortality rates.

The infant mortality rate is often used as an indication of broader social well-being.

Unfortunately, we have higher rates of infant mortality and maternal mortality in the United States relative to other high-income countries and stark inequities in maternal, fetal, and infant mortality across the country and in Alameda County.

African American and black families in Alameda County and across California are most affected by each of these tragic outcomes.

Maternal mortality, fetal mortality, and infant mortality.

A new lawsuit challenges the black infant health program that is designed to reduce these inequities.

What we see in the data is that African American black infant mortality is higher across neighborhood income levels, and that the Black infant health program provides important services to a population that is disproportionately affected by mortality.

Next slide, please.

Deaths during pregnancy, childbirth, and postpartum are tragic and rare events.

Because it is a rare event, we looked to data from the state of California to understand inequities.

This figure depicts maternal mortality in California by race and ethnicity.

Maternal mortality rate was four times higher for African American black people than for Hispanic, Latina, Latinx people who had the lowest rate of maternal mortality in California.

These are the types of inequities that the Black Infant Health Program is intended to reduce.

Next slide, please.

Fortunately, there is good news that the infant and fetal death rates are declining over time in Alameda County as well as across the state.

Infant mortality is defined as death of an infant before their first birthday, and fetal death is the loss of a pregnancy defined as the demise of a fetus and uterus before delivery.

There's been a 12% decline in the fetal death rate and a 15% decline in the infant death rate since 2013-2015.

Next slide, please.

This figure depicts the Alameda County fetal death rate by race and ethnicity and reflects the loss of a pregnancy and fetus.

African American black Pacific Islander and American Indian Alaska Native women and birthing people are affected by higher rates of fetal deaths.

All three groups had rates three times or more higher relative to Asian people who had the lowest fetal death rate in the county.

Next slide, please.

This figure depicts the tragic outcome of infant mortality with an infant dying before their first birthday.

The African American black infant mortality rate in Alameda County is 3.1 times greater than the rate for the Asian population.

Pacific Islander and American Indian Alaska Native people are also disproportionately affected by infant mortality.

The magnitude of inequities by race and ethnicity is larger than the magnitude of inequities by neighborhood poverty.

When we look by neighborhood income, we see that the infant mortality rate in low-income neighborhoods is two times higher than in the highest poverty neighborhoods.

About 6.3 in the highest poverty neighborhoods relative to 3.2 in the lowest poverty neighborhoods.

But when we look at the intersection of race and ethnicity and poverty, we see that even African American and black infants in the lowest poverty neighborhoods have higher mortality rates than the general population in the high in the highest poverty neighborhoods.

So African American black infants in low poverty neighborhoods have higher mortality than the general population in high poverty neighborhoods.

As we aim to make the best use of limited resources, being able to consider stark inequities by race and ethnicity is important to most effectively support populations most impacted by infant mortality and reduce the numbers of families affected by infant mortality.

Next slide, please.

It's also important to us to consider data by disaggregated race and ethnicity.

We worked with the State Department of Public Health to obtain estimates by disaggregated race and ethnicity since we do not have enough infant deaths to do this at the county level.

This depicts the extent to which African American black infants are disproportionately affected by infant mortality across the state of California, at five times the rate of Chinese infants who have the lowest mortality rate.

The data also reveal high rates of infant mortality among Lao Ocean populations in addition to Pacific Islander and American Indian Alaska Native populations across the state.

Next slide, please.

This figure depicts Alameda County trends in infant mortality overall and by race ethnicity for the past 15 years.

While there's been a decline in infant mortality, the racial and ethnic inequities in infant mortality are persistent, underlining the importance of continued work to address these inequities.

Next slide, please.

This figure depicts the leading causes of infant mortality in Alameda County.

The most common causes are congenital malformations followed by short gestation or small size and sudden infant death syndrome or SIDS.

We see that structural inequities such as housing insecurity and access to paid leave shape large racial and ethnic disparities in SIDS deaths.

We've been researching culturally congruent approaches to safer sleep to reduce risk of SIDS, and structural support, such as improving housing security and access to paid parental leave, can also make a difference.

Next slide, please.

Next, I'll discuss the data on low birth weight and gestational age as indicators of infant and child health risks such as developmental disabilities.

Next slide, please.

This figure depicts racial and ethnic inequities in the percentage of birds that are low birth weight, which can affect the health of infants.

In 2022 to 2024, about 7% of babies were low birth weight.

African American black women and birthing people were 2.3 times more likely to have a low birth weight infant relative to white people who had the lowest risk.

We also looked at these inequities by nativity to understand immigrant health and whether pregnant parents born outside or inside the U.S.

had inequities.

There were not substantial differences by nativity, except that African American women born in the U.S.

had even higher rates of low birth weight births when data were disaggregated by mom's place of birth.

Next slide, please.

This figure depicts preterm births, which are births occurring before 37 weeks of gestation.

In 2022 to 2024, about 8% of births were preterm.

American Indian Alaska Native women and pregnant people had a preterm birth rate 1.8 times that of white people who had the lowest rate of preterm birth.

Next slide, please.

Ahead of presenting data on breastfeeding, we want to name that structural drivers such as paid family leave, safe and stable housing, access to prenatal and postpartum care, and the capacity to pump and safely store breast milk at work affect breastfeeding rates.

Structural supports for breastfeeding can make a difference for young families.

Next slide, please.

This figure depicts the rate of breastfeeding initiation in hospitals.

Overall, 78% of infants initiate breastfeeding in hospitals, though the rate of breastfeeding initiation is lower for Pacific Islander and African American black populations.

Next slide, please.

This figure depicts the rate of breastfeeding initiative.

Whoops, sorry.

Um this figure depicts breastfeeding the infant at three months after delivery.

At three months post-partum, we see that 70% or more families have maintained any breastfeed by racial and ethnic group, and about one-third of families of all races continue to exclusively breastfeed at three months, but with lower rates among African American and black populations.

County programs have identified workplace factors like supportive breastfeeding environments, case manager training on breastfeeding practices and policies, advocacy for pumping at work, and the ability to maintain proper storage of pumped milk at work is being essential to continued exclusive breastfeeding practices.

Next slide, please.

We also want to highlight that there have been rising rates of syphilis circulating in the county population and especially among people facing structural drivers of access to care, such as experiencing homelessness, which has helped contribute to rising rates of congenital syphilis, which is syphilis in a newborn that occurs when a pregnant person passes the infection to their fetus during pregnancy or birth.

Babies born with congenital syphilis may have deformed bones, skin rashes, jaundice, and other physical, neurological, and developmental impairments.

Increasing access to syphilis screening and treatment in the community and addressing structural barriers of access to prenatal care, such as homelessness among pregnant people, can make a difference.

And I am grateful to learn from our communicable disease colleagues here that who are here today that we're starting to see some reversal of this trend.

Next slide, please.

We want to name some key priorities for healthy childhoods, which include ensuring children have economic well-being, including food and housing security and maintaining high immunization rates in pregnancy and childhood.

While it's no longer making headlines in the way it was a few years back, the proportion of children who are overweight has continued to increase over time across the country and to pose a risk for chronic disease in midlife, including here in Alameda County.

We are facing substantial national level changes in each of these domains with the rising cost of food and rising unemployment, increases in vaccine skepticism, and challenges with access to care.

This makes it especially important that we do what we can to support healthy pregnancy, childhood, and life trajectories for populations most affected here in Alameda County.

Next slide, please.

We do see stark racial and ethnic disparities in the proportion of children affected by poverty, which often translates into food and housing insecurity that can substantially affect well-being.

Department of Education data show increasing numbers of school-aged children living in temporary shelters and hotels or motels or unsheltered.

There are inequities in who's affected, and the poverty rate for African American black children under six is more than 13 times the rate among white children who have the lowest poverty rate in the county.

These data that reflect the need for supports to ensure economic security for families with young children, especially among people of color in Alameda County.

Next slide, please.

Finally, we want to close with data on pregnancy and delivery indicators as an important component of our work in the county.

Next slide.

This figure shows the percentage of women and birthing persons who receive early prenatal care initiated in the first trimester, which is essential for the detection of issues like hypertension, diabetes, and severe maternal morbidities.

Without care, preventable complications such as preterm birth, pre-eclampsia, and low birth weight may be more likely.

There are racial and ethnic inequities in prenatal care, with less than three quarters of Pacific Islander women and birthing persons receiving early prenatal care relative to 90% more than 90% of Asian women and birthing persons.

Next slide, please.

Finally, it's important to support the mental health and well-being of pregnant people.

This figure depicts the percentage of women with prenatal and postpartum depressive symptoms.

African American and black people had the highest rate of prenatal depressive symptoms, and American Indian Alaska Native people in California had the highest rate of postpartum depressive symptoms.

We're grateful these data help inform the work of our dedicated colleagues and family health services who help support populations affected by mental health inequities as well as structural inequities and inequities in birth outcomes.

Thank you.

Thank you, Julia.

In this section, we're going to talk about our local response to much of this data that was presented.

Next slide, please.

This visual represents our starting out strong system of care, which is our coordinated model of services and supports to families.

At the center are populations we serve across the life course from interconception, which is the time between pregnancies, pregnancy, and through the postpartum period, and importantly, this includes fathers and partners.

On the outer edges, you'll see outreach intake and community engagement.

This reflects our approach to connecting and engaging families through multiple tailored entry points, as well as broader engagements depending on families' needs.

Supporting all of this are core functions like care coordination, case management, mental health support, and family strengthening services, which help ensure families can access and stay connected to care.

Ultimately, the goal is to improve outcomes by building a more connected prevention focused system for pregnant individuals and families with young children.

Next slide, please.

These are the data from calendar year 2024.

You'll see the number of individuals served and the level of engagements we were able to provide, as well as connections to community resources.

Next slide, please.

Here is the starting out strong clients served by race.

And you will see we most of our clients identify as Latina at 48%, African American and Black at 41%, and then smaller populations of clients served in the other areas by other race ethnicity.

Next slide, please.

This slide shows who we are engaging in program services and interventions.

Overall, the data shows strong early reach, especially with parents and families with young children.

Next slide, please.

This slide provides a snapshot of the families we serve and the range of experiences and stressors they may navigate.

We work with families who are committed to their children's well-being.

These services are all voluntary.

And families are also balancing a variety of life circumstances, such as access to stable housing, health care, social supports, and economic stability.

Our role is to partner with families through care coordination, case management, mental health, and practical supports that help reduce barriers and create more stabilities for families.

Next slide, please.

Here we highlight some of the outcomes we're seeing through starting out strong.

One of the most important indicators is that over 90% of clients report being very satisfied and satisfied with services.

For us, that reflects that families feel supported, that services are relevant, and that they stay engaged in their care.

Clients also report meaningful benefits, greater understanding of their health and their child's development, stronger connections to community resources and improvements in their overall well-being.

From a systems perspective, we are also seeing strong success in connecting families to health insurance coverage, which is a critical step in ensuring ongoing access to care, especially now.

And importantly, we are integrating supports that are often under addressed, including perenatal mental health services and intentional engagement of fathers and partners, both of which are key to strengthening outcomes for the entire family.

Good morning, supervisors.

My name is Dana Crusantana.

I'm the MPCH coordinator and healthy start director for the MPCH unit.

And I'd like to share and describe some of our population health strategies that we're doing to address some of the challenges and structural barriers that Ana just described that our families face that we serve.

One of the strategies is a work group.

It's a reproductive and sexual health work group, and it's to address access to care.

This is part of an incident command system that the Alameda County Public Health Department has established to proactively address the fact that folks are may fall out of care or have fell out of care in a coordinated fashion.

And so MPCH's work group is focused on folks who are at risk of falling out of sexual health and reproductive health care, such as early and continuous prenatal care.

Our strategy for this group is actually to inform Alameda residents about their rights as well as give them factual information about how to access care.

Because we're finding that in the current political climate, folks are reluctant or they're fearful to access those resources.

And we're currently collecting data as part of this work group so that we can better tailor those messages to our residents so that they can feel less fearful and more trustful of our healthcare systems.

We're also participating in a campaign called Deliver Birth Justice.

And this is to end racism and improve birth outcomes for black families.

The campaign fights structural racism and bias that cause black babies to be two to four times more likely to be born prematurely or die within their first year, and black mothers to be three to four times more likely to die during childbirth and not coming home.

MPCH is also leaves the county's fetal infant mortality review, which we also refer to as FEMA for short.

And that and that group examined specific cases in fetal and infant deaths, including SIDS deaths, to identify structural barriers and strategies for prevention.

Additional, oh, next slide.

Additional innovations are our current efforts to culturally adapt and create concordant group prenatal care for Medi-Caleligible birthing people.

Since 2019, we have partnered with Alameda Health System and other organizations to adapt the evidence-based centering pregnancy model into a culturally concordant group prenatal care model to address the black maternal and infant health crisis.

And that program is called Beloved Birth Black Centering.

And so far, in about four years' worth of data, we have shown to have eliminated the racial disparities in preterm birth and outcomes among our participants.

And we're proud to actually share this news with you because it's a huge deal to have moved the needle on a national health crisis in our local through our local efforts here in Alameda County.

In 2025, we've also began developing the Spanish language centering pregnancy model transformation project.

And this is again to adapt the centering pregnancy model for Spanish language immigrant Latina population, which are currently we're finding are more difficult to engage in remaining care.

We're trying to get ahead of that trend so that we don't see a dip or more morbidity and mortality in that population.

I'd like to share that in the last year, we know of two cases where immigrant Latina women delayed care when they were experiencing complications late in pregnancy.

And it resulted in the loss of their almost full-term infants.

And that was related to not wanting to seek care for fear of the repercussions of using public health systems.

Furthermore, um BCH implements the Abundant Birth Project, which is a guaranteed income program for pregnant women at risk of adverse birth outcomes.

There's other counties participating in the state, including Alameda, including us, Contra Costa, Los Angeles, and Riverside in partnership with the Expecting Justice Collaborative.

And thus far, the Abundant Birth Project outcomes support that guaranteed income strategies are a practice that provides enough income stability that results in healthy birth outcomes.

Additionally, MPCH provides dual care services to expectant individuals and families at no cost to them during pregnancy and the postpartum period.

And we've also been involved in local partnership with Alameda Alliance for Health, which is the Medi-Cal administrator for our county, in training doulas to build the local capacity so that birth workers can become certified Medi-Cal providers and serve eligible pregnant women who desire a doula in our county.

Next slide.

And currently that program has received funding to offer financial literacy workshops and coaching for young parents ages 16 to 24 years to help them get a supportive start with being able to manage the affairs of their family.

Furthermore, MPCH offers its family support program participants with mental health services from our Blue Skies mental wellness team.

So it's a short circuit to getting access to mental health services because they're already in our system, starting out strong, and they're able to be referred internally to our own mental health supports.

And despite the fact that that program was defunded by the shift in the MEL the Mental Health Services Act, we continue to support Blue Skies program with public health dollars as well as through a partnership with Alameda County Behavioral Health Care Services.

And MPCH is also embarking on revitalizing local adolescent health strategies through community investments and partnerships with other youth serving organizations through Measure C funds, and we'll be working with stakeholders to identify priorities and develop an implementation plan as well.

Just wanted to thank you for allowing me to share those specific details about our programs.

As we conclude, I want to highlight several critical programmatic and funding challenges that directly affect families in Alameda County.

Housing stability remains one of the most urgent issues connected to the conversation we had earlier.

Approximately 22% of families in our program are experiencing housing insecurity.

This is a direct impact on stress, birth outcomes, and a family's ability to stay engaged in care.

We see the stark reality and deeply, we see the reality of this in stark and deeply concerning ways.

One of our program participants is a pregnant woman who rode the bus all night simply to stay safe and sheltered until the morning.

Another mother pregnant with twins is sleeping in her car that doesn't run alongside her two children.

The first pregnant woman was able to get family shelter later on after she gave birth.

These conditions that no one should endure, especially during pregnancy, and unfortunately, they're not rare or isolated situations.

They're the lived experience behind the data.

We continue to see gaps in broader safety net, particularly in access to family shelter, which limits our ability to stabilize families during some of the most critical and vulnerable periods.

We are also navigating ongoing funding challenges for your awareness and continued advocacy programs like the fetal infant mortality review, which was defunded by the state.

So currently there are funding for two local health jurisdictions in the state, but it's not broadly supported.

So we currently support it with public health dollars.

And of course, there's the potential threat to the federal healthy start funding.

These represent critical components of our prevention infrastructure.

On a positive, we are seeing promising efforts such as guaranteed basic income pilots across Alameda County, including our own, which is now concluding.

These initiatives have demonstrated real progress in improving economic stability and reducing stressors that contribute to poor health outcomes.

However, they remain time limited and restricted in scale without sustainable funding to support long-term impact.

Next slide.

While there are important protections in place for pregnant women and individuals and families with children with disabilities, we are also seeing gaps, especially as coverage transitions after the first year postpartum and as work requirements begin to impact continuity of care.

We are also continuing to support immigrant families who may face additional barriers related to access, trust, and misinformation about eligibility and use of services.

But there are also important opportunities ahead that I would like to uplift, particularly the potential establishment of the birthing center at St.

Rose for Medical participants.

These efforts are about ensuring families can enter, navigate, and stay connected to care where it matters most.

Protecting continuity of care is one of the most important levers we have to improve outcomes and reduce disparities.

Thank you for your time and attention.

Okay, thank you.

Thank you for that presentation.

I know a couple years ago, uh, James Jackson had was highlighting, and I think it made the news the beloved birth black centering program uh was successful in turning the tide that we're seeing with respect to disparities, particularly among uh black infant mortality.

Uh, I think the issues that we're dealing with now are, I mean, you guys are highlighting it because we know uh the housing is a social determinant of health.

We know that um the issues around HR1 and the medical uh impacts are going to have significant uh impacts on programming, especially for the immigrant community and uh and the disparities you show with the Hispanic community.

Uh I'm just trying to like wrestle in my mind.

I'm sure you're formulating this.

Um, how can measured W funds, for example, the essential services fund help with some of these um because I consider these essential services help um fill in some of these gaps.

So, as we described earlier, and as our colleague Donathan also mentioned, you know, we're really interested in comprehensive services and the needs of families are really um they're varied and and they're uh there are a lot of them.

Housing is a really critical element of stability for families, and so for me, I'm always really interested in making sure that families never become homeless.

And so really seeing uh families have the housing stability that they need to have a healthy birth, it's a big deal.

In addition to that, making sure that there are appropriate services to keep people engaged in health care as they become more fearful, and as accessing care becomes more difficult because of the strain that is put on our entire health system.

We may not be seeing it right this second, but I do believe that it will become more strained, and so there will need to be more creative ways of keeping people engaged outside of the physical walls sometimes of our health system in health promoting kinds of activities.

Um and so I'm hoping to see some of that come from investments from Measure W in addition again to the housing pieces.

Thank you.

Um I I know that we kind of reliving the whole public charge issue with people being fearful of seeking assistance, uh even though they may be housed for fear of getting deported.

Uh what do you think is the best way in which we can outreach to to make sure that we get the trusted messengers?

I know we try to do that through the our FQs, but if there's ways that you think we can help enhance that.

I think that grassroots community-based organizations are really well suited to help um support people who are fearful.

There is no replacement for needing to go into a hospital.

If you need when you need to go into a clinic or you need to go into a hospital, there really isn't a replacement, a good replacement for that.

But I do believe that organizations, and we have quite a few of them in Alameda County that do a lot of outreach and engagement in the street with people, they have a really good way of allaying fears, often going with people to the medical facility when it's absolutely unavoidable avoidable.

And so, like when you're pregnant, um my colleagues mentioned you know, the the fetal deaths that we had.

Had those families accessed care or accessed a person in the community who could have encouraged them to get the prenatal care, those fetal deaths could have been prevented, but they weren't speaking with anyone in the community, and they were terrified.

And so we would love to see more of those kinds of supports in the community to help with that.

Thank you.

Okay, so where to begin.

First of all, with the uh Alameda County declining birth rate, um it's is the I'm trying to understand if this declining birth rate is a factor based on um the disparities, or is it a factor based on people or just you know, having as many children any any longer, or is it both?

Yeah, thank you.

That's a great question.

So uh so we look at the birth rate, which is where the population and is really affected by an aging population.

So fewer people are of reproductive age.

We also look at the fertility rate, um, which is the rate of births per people who are of reproductive age, and we see that declining as well.

Um, and I think it is likely related to the high cost of living and in inequities and poverty that are partly shaping um how many children people feel they can afford to have.

Um so uh so it's all interrelated, a lot of structural drivers of the birth rates that we see.

So with because you provided a lot of data, are you able to um disaggregate?

You take out the you know, the baby boomers, the older population of folks younger folks are deciding not to have babies out of choice, and then really look at those that are being impacted because of disparities.

Are you able to you know disaggregate that?

Yes, I'm happy to share.

Um we do have slides on uh on fertility rate by race and ethnicity as well.

Um we don't see as much of a difference um when we look by the reproductive age population, like there are larger differences in the um number of births per total population that are partly a feature of how many people are of reproductive age.

So there are still differences, but not as large a magnitude.

Okay.

Um we don't see as much of a difference um when we look by the reproductive age population like there are larger differences in the um number of births per total population that are partly a feature of how many people are of reproductive age so there are still differences but not as large a magnitude okay so just curious about that um okay because you did give us a lot of data on and by the way what is SCD stand for which slide is that after your your name sorry which slide was that no it's not a slide it's on the agenda oh on the agenda oh my oh my degree thank you doctor of science okay the I the public health play attended is now transitioned to a PhD but there's a period where they get doctor of science awarded doctor of science very good okay very good um then I wanted to ask Supervisor Chan asked a few questions about this so I'm finding it very curious that if housing is a big need and uh there are examples of people um being um challenged with housing who are pregnant why are we putting resources into eliminating that I mean that would what I mean to me that should be minimous we um are working to collaborate we're work we're actually collaborating with housing and and homelessness and actually have a meeting tomorrow to discuss this in more depth um we were able to disaggregate some of our data so of the 3,000 that you saw we were able to specifically identify 30 families that we know are actively homeless and so um we are looking to have deeper conversations around how to how to collaborate and what we can do to address this very important because I think that's really really important um I mean the public health department is part of the agency housing is part of the agency and I don't understand why we even have women who are homeless having babies it it can't be I mean 33 or so I think that's what you said maybe thirty 33 are homeless right now yes and then 22 are housing and staples so our couch surfing living with other family members sometimes after the baby is born the the places that they were staying no longer want them to stay so yes we're we're working towards yeah we need to address that yes I agree because once again it's not an issue of resources as far as I'm concerned and maybe I'm just being naive but it just seems like I think if it was a colossal number then maybe but it just seems like it's a manageable number that we should be able to address.

Probably underreported too yes I add one thing to that supervisor so I I think part of the the underreporting is definitely an issue the other issue is is that our homelessness system uh for a long time it's based on once someone is actually homeless and reaches out to us right so that's where those program connections are so important so that those referrals can be made immediately and then some of what you know both Kimmy and Jonathan talked about in terms of the prevention work um the public health team was a critical part of um helping the HH team sort of develop uh countywide prevention framework that they want to use for homelessness um and so it's really trying to get at some of those upstream factors okay and then the did the defunding of FIMR and had to be supported by public health dollars what kind of money are we talking about there so um initially um California Department of Public Health would fund FEMA activities for every local health jurisdiction those funds were reallocated with a focus on two um two local health just jurisdictions I believe it's Fresno and Riverside right now so public health dollars fund our um our staff that facilitate field infant mortality review and have regular convenings on a quarterly basis it's it's about one position I'm guessing and we do some leveraging 1500 okay so guessing so maybe about half a million dollars or so okay and you would and that's an emerging challenge so that's been flagged that's something we've got to get a grip on yes and I think it's an opportunity for us to look at the structural drivers that impact fetal and infant deaths and so I think that's another reason why it is so important for California Department of Public Health to look at how this looks like across the state we can of course look at our local issues um but the local issues are not isolated to just Alameda County these are issues I think that really are are statewide and it's an opportunity for us to look at statewide also responses to to these issues.

These are issues I think that really are statewide, and it's an opportunity for us to look at statewide also responses to these issues.

Okay.

And then the guarantee basic income pilot.

Will we be giving an update, a report on that?

At some point.

Yes.

And um so Alameda County MPCAH had um this collaboration with Expecting Justice, and we implemented the Abundant Birth Project in Alameda County over the last two years.

We were able to provide guaranteed income for 235 pregnant women that had a variety of concerns that they came into the program with.

So we're still in the process of administering those funds.

It's over the course of one year.

Um and will be done probably in about another nine months we conclude the full program.

And what amount are they receiving?

They receive $981 every month for one year, beginning during their pregnancy up until the child that was born six was six months old.

Okay.

And after funding it concludes, then so are the programs.

And then um I know Supervisor Chan uh Supervisor Tam rather asked about uh Measure W.

Um some of these challenges be offset through what we're trying to do through Health Pack.

Yeah, so where you heard about the um access to health, uh so the Health Pack Network is a crucial part of of that.

Um but as you also heard Kimmy mention, you know, not all of the um health access works happens in a clinical setting.

Um so with the Measure W allocation that your board approved in October, um just this last week you all approved our um about 800 and some thousand dollars in contracts for CBOs that are out there doing uh more li, you know, on the ground engagement with people to help them feel more secure about uh staying enrolled in Medi-Cal or seeking care where they need, so that's health promotion.

Um we do plan to incorporate some of that into our uh essential services ask that that will be coming forward.

Um so on the Medicaid side and the health access side, the the health pack program is a big part of that, and our MPCH team is uh really connected to to that work in a lot of different angles, both at Alameda Health System and with the clinics.

Do you have a sense of what kind of the amount of resources dollar amount that needs to be appropriated for this?

I don't want to spoil our alert for tomorrow.

Oh you said we'll wait till tomorrow.

Uh so it's a part of uh what we've submitted for our essential services request and as a part of the measure that lead conversation.

Right.

All right, just want to make sure we're taking that into consideration.

All righty.

So very interesting presentation.

I don't think I have any other questions.

Let's see if we have any public speakers.

I have no speakers on this item.

Okay.

So this was an informational item.

So we have one more informational item.

And before we have that item, we're gonna take a five-minute recess, just five minutes.

So we are recessing for five minutes, TISA.

Recording stopped.

Recording in progress.

All righty.

Supervisor Tam.

Supervisor Miley.

President.

We have a quorum.

All right.

So we'll take our next item, informational item.

Alameda County waste water surveillance surveillance monitoring pilot program.

Good morning, uh Chair Miley and Supervisor Tan colleagues in the public.

A way to understand what's happening in our community.

And my name is Eileen Dunn.

For this presentation, I'll provide a brief background on wastewater monitoring and an overview of what is happening in the county.

I'll also provide a few case use examples and data to action.

And finally, I'll pr provide a summary and next steps.

Oh no problem.

Wastewater monitoring is the collection of a sample from wastewater that comes from households in the community.

Uh in order to detect viruses, yeah, fungus, bacteria, genes, or substances.

And it it has been used around the world.

It had its start as a way to monitor for polio virus in communities.

By looking for polio in the wastewater, it could be used as a sentinel event or a marker that polio virus was circulating in the community.

The detection was com connected to public health action.

During the COVID pandemic, wastewater monitoring was used to detect the SARS-CoV-2 virus in the community.

And as a result, the true burden of illness in the community was unknown.

Those who are frail, underinsured or uninsured or have other barriers to care.

Also, healthcare surveillance or case counting can miss people who are at home self-testing.

Wastewater detection is in essence an equitable view of everyone in the community on the sewer system.

Very importantly, the data can support early measures to detect and prevent disease spread in a community.

Alameda County began developing a wastewater monitoring request for proposal from 2022 to 2024 for a two-year contract that started January 2025.

This was awarded to Virley and funded by the American Rescue Plan Act or ARPA.

The contract initially included testing for five pathogens and then expanded and also included a partner meeting.

And the budget for this two-year contract was 750,000.

The activity includes purposeful sampling representing rural and urban areas across the county, as well as a focus on vulnerable communities based on an equity framework.

We included six community sewer shed settings and one facility, including Oraloma Union Sanitary, Hayward Sanitary, City of Livermore, and sub sewer sheds of the EB MUD East and West Oakland areas, as well as Santa Rita Jail.

The sub sewer sheds and facility requires special permitting and sampling agreements, which are in progress.

The sampling is twice a week, and the results from the testing are really real time.

They arrive in four days, and we're currently looking in the wastewater surveillance.

We're looking at the pathogens specifically, SARS-CoV-2 or COVID, MPOX, flu A, flu B, RSV, measles, influenza H5, and Canada Ouris, which is a yeast.

This slide shows the map of all of the Alameda County sewer sheds.

And you can see here in pink is EB MUD or East Bay Municipal Utility District.

And just a reminder EB MUD is not included in our wastewater county contract, but the state is actually doing wastewater surveillance in that location.

Next slide.

This is an example of the wastewater monitoring website, which has an infographic making the wastewater testing sort of simplified.

Next slide.

Some of the examples of public health actions that are taken with the data include health communications in the form of social media posts, provider outreach, health alerts, and reaching to community groups.

Public health action can also include focused vaccination activities for vaccine preventable diseases.

Communications to providers can support earlier case detection, limiting spread of a disease.

And then focus efforts can also be taken in vulnerable communities depending on the pathogen assessed, such as skilled nursing facilities or LGBTQ clinics or other settings.

I wanted to provide a couple case use examples of how we've been using wastewater data to date.

This is only a snapshot.

There are many other ways that wastewater detection is providing a vital resource to our community.

In Alameda County, we had several contacts, close contacts to a case with measles in Contra Costa.

And as a part of the contact uh investigation, there's monitoring monitoring of that contact, um, health monitoring as well as isolation of that of those contacts, but also there's a view to what's happening in the rest of the community.

So understanding what's happening around measles in our county is very important when these situations arise.

By looking at our wastewater detection data, we found that there was no detection of measles.

Um that was reassuring that there was not additional cases in our county.

Uh another example of how measles um wastewater detection has been useful is in our neighboring county, San Mateo.

In their county, they detected measles uh persistently in the wastewater, but they had no human cases, no measles cases identified.

So I searched through their records of persons with characteristic symptoms, found um several people that were meeting those criteria and they they were tested.

And as a result of that testing, they detected measles in uh one case, and it the early detection of that measles case was able to prevent further spread in the community.

Next slide.

Another example is using MPOX detection in wastewater.

Uh, we had a small increase in MPOX cases in our county and early in the year.

Um we could we consider this could be a larger outbreak of concern.

Um, and we were able to look at wastewater detection for MPOX in our county, and find that there was no MPOX detection there, which reassured us that there were no additional cases in the county.

So both detection, lack of detection, and other levels of virus and bacteria can help us with understanding what's happening in the community.

Um wastewater monitoring can also be very useful in an emergency response.

And I'll give two examples of this.

One is using geospatial data, so location of where detection occurs, can help focus in specific community settings and support communications and prevention.

Also, wastewater can be used for emerging health threats.

So adding detection for novel pathogen can give us an early measure of a disease of concern in the community, where there might not be other views of that disease.

So, in summary, wastewater monitoring is providing essential data on communicable diseases in our community that can lead to public health actions.

Wastewater detection can support readiness for an emerging health threat.

We see this data to be very valuable, and we want to continue to engage the community on this resource.

And we're also considering the continuation of wastewater monitoring with community and public health uh input.

We would also be happy to provide updates to you about the this resource for the county.

Next slide.

And I would like to acknowledge the many partners that work on this data, in particular the sanitary districts that have readily engaged in this activity without resources, and are really important.

So thank you very much for your time.

So interesting report.

Thank you, Chair Miley.

I just recall that uh when I was at East Bay MUD, we did um uh work with the California Department of Public Health and also at that time.

I think it was is it still called scan?

Wastewater scan, yeah.

Yeah, that was specifically um the sewer corn uh coronavirus virus and also the alert network.

What I was just curious about is um uh there seems to be uh different diseases that kind of come up, and uh how did we know to try to look for MPOX, for example, that spike in 2026 and because I I mean uh the scans and the the surveillance that um are done are typically specific to different kinds of diseases that you asked for, right?

Yes, that's correct.

Yeah, so the the diseases that we landed on were determined to be sort of the most important for public health impact.

So being able to use that measure for doing something to make a difference in the community.

So it rose, of course, was SARS-CoV-2 from our experience in during the pandemic, along with other respiratory viruses that impact vulnerable communities in our county.

Um and Mpox and Measles was also added.

It's um the the way wastewater detection is done for measles is MPOX, it's either detected or not detected, and it's a very useful measure both overall in the county, but also in specific locations, neighborhoods, or areas, so that we can um provide communications.

To date, we've actually had no detection of measles or impacts in our county.

Sometimes where you look, all of a sudden there's an impact there.

Um, but there's been no detection to date, but we see it as a very useful measure going forward with continued threats with measles in throughout the nation and nearby in Utah and around California.

Um and then H5 was also added because influenza H5 uh has been an important emerging health threat as well, and so that was added as well to this mix.

C.

Ouris, which is a yeast that particularly impacts vulnerable persons in healthcare settings, was added as well as a measure of health care facility burden and um of that infection, and so that's a relatively new measure that we added to the mix.

Um I hope that answered your question.

Uh it does, and that's helpful to know.

Uh the the other thing is um I know that we uh just awarded the contract recently to participate in this.

Do you and I know that Eastway Mun at that time uh was funded through the state for the California Department of Public Health.

Do you expect that uh there might be threats to funding at the state level with this monitoring program?

That's a really good question.

In fact, prior to this presentation, I reached out to my contact at EBMUD and um and the state, and they um have continued funding until 2027.

I think that is a question going forward.

Um they have um been able to continue their wastewater detection activity through a number of resources, including CDC, so um, which is very promising for the sustained effort of that work.

Thank you.

That's helpful to know.

All right, thanks.

So first of all I'm looking at the agenda.

So you're a medical doctor.

Yes.

Okay, and what is FIDS?

What is that stand for?

And that's a fellow for the infectious diseases society of America.

Okay, nice.

And HIVS TI.

Yeah, HIV sexually transmitted infections.

That's my focus area.

Okay, very nice.

Very nice.

And you work with Kimmy?

I mean, yes.

You're in the public health department?

Yes.

Okay.

So when these items are detected, are they tested out at our public health lab?

No, so the contract awarded a laboratory that has specialty in wastewater detection, it's called virally.

Um they also then the advantage of using virally is there are other settings that also use virally.

So there can be a can comparison of like to like, so other settings that are also using virally for their wastewater detection.

We can compare and contrast with them.

Okay.

So is it so I'm just curious?

It could our lab be used or yeah, local labs can do it.

It requires a fair amount of uh resources for you know capacity development um and a commitment to long-term wastewater detection.

So I think those two things.

There are some examples in the state.

I think one is Sonoma that's doing their own uh wastewater detection in their lab.

Where's the lab located?

It's at, I believe the public health lab in Sonoma or somewhere nearby.

Yeah, okay.

Yeah.

Right.

And then Supervisor TAM has the funding.

So it's it's two years, 375 per year.

So do um when the pilot ends, what happens?

It's a great question.

We're um considering what's ahead, what has had the most importance and value um and where um that detection we see value in continuing this effort.

Um and so I think just uh assessing with community input, public health input of what's ahead will be useful.

I just want to add that um we see this as an important addition to our tools to be able to keep the public safe, and so I and my team are looking at ways to sustain um this effort.

It's working and we like what we see.

We will not stop advocating, of course, to the state for their uh financial contribution and support.

Um, but we are looking to sustain this effort here in Alameda County.

We believe it is of benefit to us.

Uh thank you for that because I definitely think it's a benefit because you know we heard all about this, you know, wastewater detection as a result of COVID.

I mean, that's when it at least became more conscious to me before that.

It's like you know to have a clue, but with COVID, it's kind of like you hear about it on the news, etc.

So the fact that we're doing this, I think it's definitely something I'd like to see us be able to sustain.

That's why I was trying to get a sense of where the testing's taking place, and if we and since it is out of county with another entity, is it something that we could potentially bring in house?

I I I don't know, I'm just asking the questions.

I yes, I I hear what you're saying.

So we would really need to take a look at what infrastructure would be required to expand this capability with our public health lab.

We have added new capabilities over time, but at this time we think it's most cost effective to continue subcontracting, but that doesn't mean that we would never add this to our platform.

But at this time, um we are really looking to maintain a subcontracted relationship, but we can definitely look into what the cost would be to build out that infrastructure.

Great.

That sounds marvelous.

And if we were to the fact that we do the testing, and you said East Bay Mud's not a part of it, um would that be something that would continue to be the case in the future, or would we want to try to see how we could bring East Bay MUD into this?

Yeah, that's a great question.

So East Bay is doing wastewater monitoring, just not through our contract.

So yes, we do see EEB MUD as very valuable, uh very large population, uh including vulnerable communities.

Um so yes, we're really interested in understanding that that continues.

I think this from what I've heard, the state also sees it very valuable as well.

Yeah.

The state funds East Bay Mud and the East Bay Mud serves two counties too.

Yeah, that's right.

So yeah, I'm hoping the state um sees a value in this because yeah, this is really really important.

Um I'm just looking at if we have to rely on our own efforts, it you know, our ability to to sustain this with the sanitary districts, uh Orloma, Hayward, Union City, City of Livermore.

Um then I guess I guess those are the ones we're talking about.

Uh the fact that we do the testing, do they um I know they're co cooperating, but is there a way for them to help uh provide any funding for this through fees or anything?

Well, so one thing just to know is they're participating with we're not paying the sanitary district to collect the samples, so they're participating at no cost to uh and um I am unaware of resources that the sanitary districts might might have.

I am aware that they are very interested in the continuation and they're broadly sharing this activity, both on their websites as well as their community websites.

Um so I can inquire about other resources for this uh activity as well.

Yeah, because I think it would be really great if sanitary districts um would see the and I guess I do see it as a benefit, but if they would maybe see it as something to help sustain it, if there's a small cost associated with it and it's you know it's kind of shared.

And um based on I don't know the size of the district or whatever, but some formula, I think it would be really beneficial.

So just wanted to kind of make sure that stone isn't left unturned.

Yeah, I appreciate that and I appreciate the consideration for sustaining it.

I do think we uh do you need to look at all the available resources that could be used for continuing this activity.

Now I think my last question, because you know this is you know, this is stuff that um I don't know anything about, but um is it possible to test for PFAS?

I know Dr.

Moss left.

You're dumping me on that one.

So I'm working on an update for you on PFAS.

Um that doesn't answer the specific question.

What's that?

Are you familiar with PFAS?

I'm not familiar with it in waste.

Okay.

Yeah.

Okay.

Yeah.

Uh we're not aware of wastewater detection being used per se for all of the chemicals.

We can look into that, but we we know that the forever chemicals are found in the water.

See where you're going though with this.

Um how about we get back to you and see if that has uh with Dr.

Moth to see if that has ever been done is to the technology has ever been used to more routinely see um if the the extent to where uh forever chemicals are in the water.

Yeah, because the thing is we're trying to come up with wastewater, rather.

Yeah, we're trying to come up with the county's role in PFAS, you know, education, awareness, detection, etc.

Um, and so Dr.

Moss, I think it's bringing a follow-up report to the committee.

I believe in May.

June 8th, yeah, June 8th.

Okay.

So I don't want to miss the because the media when I saw this, I was thinking PFAS, PFAS, PFAS.

So just want to ask that if we can look into that as well.

Okay.

All right.

This is this has been good good stuff today.

Yes.

Do we have any public speakers?

I have no speakers on item three.

Okay, very good.

Okay.

So if there's no other um items before us today, we'll see if there are any public speakers on non-agendized items for the committee.

Alison Monroe for public comment.

Hello.

Alison Monroe here talking about something not on the agenda, which is the budget for behavioral health.

They had a process recently with a 300-page document put out for public comment.

It was confusing.

It didn't say what programs are being cut or why or how much.

If a program wasn't funded by BHSA, it wasn't in the document.

It was heck of confusing.

But we found out by asking that asking behavioral health that three programs are being cut that we people in FASME are concerned about.

And those three programs are FERC, Family Education and Resource Center, FERC.org.

Um a lady that works in John George named Bev Bergman, a patient advocate at John George.

That's the second program.

And the third is the supportive community housing land alliance, which we were talking about earlier.

We would like supporting community housing land alliance to get the operating funding they need to continue because they got two pro projects that are almost ready to start up.

And we talked about that earlier.

But the thing about the patient advocates is we actually need those advocates badly because they tell us family members how to go about trying to get treatment for our loved ones and how to stay sane while doing that, which is difficult.

Um Bev Bergman helped me keep my sanity and helped me understand the system, and so did Josephine and Dino and others at FERC.

They're very important people, and I hate to see them go.

So I'm hoping that you will ask behavioral health why they cut those programs, whether BHSA required them to cut those programs, and how much money is still going for prevention programs, because I think it is BHSA money is still going to a lot of these old prevention programs.

Um various ethnic coalitions and black men speak, it's just going through another bucket.

The answer right now is well, we just have to cut stuff.

We have to cut fifty-three million dollars.

Thank you.

I have no additional speakers for public comment.

Okay, we we are journal.

Thank you all.

Thank you.