Tag Archives: San Francisco Bay Area

Open Letter to Benicia City Council: Dr. Richard Fleming on mask mandate

Professional perspective and corrections: vaccine, hospitalizations, role of government, Bay Area comparisons

Email, by Richard Fleming, M.D., November 17, 2021, with permission

Hi Benicia City Council members,

Richard Fleming, M.D.

Thank you for taking the time to discuss and consider the safest way forward for our city during the pandemic. I hope you can take a few minutes to consider the following points:

  1. Vaccination rate.  According to publicly available data from the California Department of Public Health, the fully-vaccinated rate for the city of Benicia is 67.7%.  We have never been above 70% and certainly never been above 80%, numbers which have been mentioned in past city council meetings. (If we include those who got only one shot, the percentage is 76.7%, but the more important number is those who are fully vaccinated.) I strongly urge you to use the CDPH-reported fully-vaccinated rate for Benicia in future city council meetings. Also keep in mind that many fully-vaccinated people have not yet gotten boosters, and are beginning to lose some degree of immunity. Thus, the proportion of our city which has good immunity against covid-19 is actually less that 67.7%.
    You can see the state-provided numbers here:
  2. Vaccine availability is not a good measure of our city’s immunity to covid-19.  It is not a good metric to use in making public health safety decisions. Vaccines are equally available throughout the Bay Area, yet our city’s vaccination rate is below the average vaccination rate for the other 8 Bay Area counties. It is clear that availability of the vaccine does not equate to uptake of the vaccine. It is better to make public health decisions based on the actual level of immunity, rather than the potential level of immunity.
  3. Are cases or hospitalizations a better metric to follow? As Councilmember Largaespada noted at last night’s meeting, covid cases can vary depending on how much testing is being done. He correctly pointed out that the hospitalization rate is a better gauge of the virus’ impact on our city. I am unaware of Benicia-specific hospitalization data, so Solano County’s data is a fair proxy. The August City Council decision used cases as the metric to follow. I strongly urge you to change this metric to hospitalizations, since this measure more accurately captures how the pandemic is affecting our residents. Also, it is important to not view ICU capacity as equivalent to hospitalization rates. Councilmember Largaespada interchangeably referred to ICU capacity and hospitalization rates, but those are two very distinct and different measures. Since treatment options for covid-19 have improved dramatically, many covid-19 patients who are quite sick are now being safely managed on standard medical units or step-down units. The only ones needing ICU beds these days are the sickest of the sick. If ICU capacity in our county is going to be used as a metric, we could have stopped all public health precautions several months ago.
  4. Should covid public health policies let those who choose not to be vaccinated live with the consequences of their decision? At your meeting last night, it was said we at some point need to just move on, and accept the fact the virus will be with us for a long time. Since vaccines are now widely available, it is up to individuals to decide whether to get them or not. I have two responses:
    (a) Yes, covid-19 will likely become endemic at some point, like influenza. But we are not there yet. In fact, we are far from that point. In very bad influenza years, the country loses an average of 142 people per day. Covid-19 is still killing over 1,000 people per day. Covid-19 is surging in many areas of the country and the world, and the coming winter months, along with holiday parties, will very likely increase the risk of viral spread. Most public health experts do anticipate covid-19 will become endemic and something we need to manage in our lives. But we are not there yet.
    (b) Government has always had a role and responsibility to help protect people from themselves. That is why, for example, we have seat belt laws. The availability of seat belts does not necessarily mean they will be used, so we have laws which force people to use them. Even more importantly, government has a role to insure people not make individual decision which harm others. That is why why have drunk driving laws. A person may feel they can hold their liquor and drive safely, but the government has decided to not leave that judgment up to each individual. With covid, those who opt to not be vaccinated are both putting themselves at risk and putting others at risk. It is fully appropriate for government to adopt policies to protect both the individual and the community from those who are putting themselves and others at risk.
  5. What other Bay Area counties are doing. At last night’s meeting, I said that the other eight Bay Area counties are all retaining mask mandates. As was correctly pointed out, Marin has lifted their mask mandate, but it is only lifted for fully-vaccinated people. Partially vaccinated and unvaccinated people are still under a mask mandate. Marin has the highest vaccination rate, the lowest hospitalization rate, and the lowest death rate in the Bay Area. Contra Costa has not yet made a decision to lift their mask mandate. They along with several other counties are lifting mask mandates for selected businesses, but only when 100% of employees and customers are fully vaccinated. The other Bay Area counties have fared better during the pandemic than Solano County, and are approaching easing up on precautions very cautiously. I strongly encourage you to follow a similar approach.

Thank you for your work helping safeguard our community.

Richard Fleming, MD


For details on Council’s discussion and outcome, see: “Benicia City Council debates changing mask mandate, decides to keep in place, will review again on Dec. 7

Entire Bay Area is back in CDC’s orange and red tiers for COVID spread, Solano & Sonoma only counties in red

Entire Bay Area is back in CDC’s orange and red tiers for COVID spread

San Francisco Chronicle, by Kellie Hwang, Nov. 2, 2021
Piper Lind wears a mask and decorated costume while welcoming masked customers to Cliff’s Variety on Castro Street in San Francisco on Wednesday, Oct. 6. Jessica Christian/The Chronicle

The entire Bay Area has returned to the Centers for Disease Control and Prevention’s orange “substantial” and red “high” categories of coronavirus transmission — a step backward for some counties, like Marin and San Francisco, where transmission was previously classified as yellow, or “moderate.”

This comes after Marin County lifted its indoor mask mandate on Monday after reaching key COVID-19 benchmarks agreed upon by eight Bay Area counties. However, the mandate is unlikely to be immediately reinstated; the county’s health officer Matt Willis said last week that an increase in cases alone will not determine whether masks come back; rather he will watch hospitalization numbers, which as of Friday were at a four-month low.

San Francisco had reached the “moderate” level last week, but reverted to “substantial” on Tuesday.

The entire Bay Area has returned to the CDC's orange 'substantial' and red 'high' categories of transmission.
The entire Bay Area has returned to the CDC’s orange ‘substantial’ and red ‘high’ categories of transmission. Centers for Disease Control and Prevention

Under a framework agreed to by eight Bay Area counties, a county may lift its indoor mask mandate for fully vaccinated people when: 1) its vaccination rate reaches at least 80% or enough time has passed that children 5-11 years old can be fully vaccinated; 2) the county has been in the CDC’s yellow “moderate” level of community transmission for at least three weeks — with tiers defined by case rates and positive test rates; and 3) hospitalization rates remain low.

Four counties — Alameda, Contra Costa, San Francisco and Sonoma — have already eased some rules, allowing fully vaccinated people to go without masks in certain indoor settings including gyms, offices and college classrooms. But masks remain mandatory in shops, restaurants and bars in those counties.

Masks remain optional for vaccinated people in Solano County, the only part of the Bay Area not to reinstate a mask mandate.

In recent weeks, the rate of new coronavirus cases per day has been under 10 per 100,000 people in most Bay Area counties — a rate not seen since mid- to late July, after the delta variant became the dominant strain in California and drove a new surge in cases.

Santa Clara and Marin counties were the first to consistently drop below 10 cases per 100,000, on Sept. 24, and Solano County was the latest, on Oct. 16. Only Sonoma’s case rate is over 10, having trended upward since the beginning of last week. The overall Bay Area case rate is 8.2 cases per 100,000, compared to the statewide case rate that is nearly double that, at 14.34.

At the same time, case rates have largely plateaued in the Bay Area’s counties, much as they have across California, which raises questions about what might happen as we approach the busy holiday season that will increase travel and send people indoors.

Peter Chin-Hong, an infectious disease expert with UCSF, said he doesn’t suspect Halloween will result in a significant uptick in cases because it is “generally a local event, and with high vaccination rates not just in adults, but in adolescents in the Bay Area,” which creates a wall of immunity around younger children.

He said there could be a small uptick in cases during the holidays due to travel to areas with higher transmission rates; waning vaccine immunity; and a more substantial flu season that could increase people’s susceptibility to COVID-19.

“I don’t think this plateau will lead to a surge remotely close to what we saw last winter,” Chin-Hong wrote in an email. “With the approval of vaccines in children 5-11, this will further boost community immunity to keep cases down.”

Here is where each Bay Area county stands on COVID metrics and the mask mandate criteria as of Nov. 2.

Note: The 7-day average case rates are from Nov. 1 and come from state data. The weekly new cases per 100,000 over the past seven days and positive test rates are from the CDC.

Benicia physician Richard Fleming: Comparing Solano County’s COVID numbers to other Bay Area counties

Solano County covid-19 numbers

Benicia Nextdoor, by Dr. Richard Fleming, September 8, 2021
Dr. Richard Fleming, Benicia

There are 9 counties in the Bay Area. In 7 counties, covid-19 cases per 100K are declining. In Contra Costa, the case rate has increased by 4%. In Solano, the case rate has increased by 41%. Our case rate is 59 per 100K. The next highest in the Bay Area is 35.

As far as covid-19 hospitalizations, 4 counties are flat or declining. Solano is among the 5 counties seeing hospitalizations increasing. We now have 30 people hospitalized per 100K. The next highest county is 27. Most Bay Area counties are much lower.

The mortality rate in Solano County is 32% higher than the next highest county.

As far as vaccinations, 53% of our population is fully vaccinated. The other 8 counties range between 65% and 76%.


It has been said by some that we are not like the other 8 Bay Area counties. I have to say I don’t understand that statement. As far as our covid-19 metrics, it is clearly true. But I feel Solano County should be able to counter this virus as well as our neighbors in the bay. There is no reason for us to concede that we are, for some reason, incapable of protecting ourselves as well as our peers to the south and the west.

BenIndy editor: for Solano County data, go to nytimes.com/interactive/2021/us/solano-california-covid-cases.html

Benicia physician cites data on mask mandates

Solano Public Health Director opposes mask mandates

By Richard Fleming, MD, September 2, 2021

[BenIndy Editor:  Dr. Fleming slightly modified his analysis here from the piece that appeared in today’s Vallejo Times-Herald.  This updated version is published here with permission.  – R.S.]

Richard Fleming, M.D., Benicia CA

The Vallejo Times-Herald carried an interview with County Public Health Director Bela Matyas on August 29. In it, he explained why he opposes a county mask mandate for indoor public settings and why he feels the recent decision by the Benicia City Council to establish a mask mandate was “unnecessary.”

Dr. Matyas indicated he was looking at three factors – politics, community consensus, and science. He stated there is no consensus on masking in the county so, “My decision is purely based on science.” Yet in that interview, Dr. Matyas offered no scientific data.

These comments echo comments he made before the Benicia City Council on August 24. At that meeting, Matyas said there is no evidence mask mandates work. According to him, if they did, then the disease curve in Solano County would look different than in the eight other Bay Area counties, all of which have recently re-established mask mandates. He  said the curves are the same in all the Bay Area counties.

However, the curves are not the same. On every measure of the covid-19 pandemic, case rates, hospitalization rates, and mortality rates, Solano County is far higher than our peer Bay Area counties. Not only that, the rate of increase for Solano is significantly higher than for the rest of the Bay Area.

When Mayor Steve Young pointed these facts out to Matyas, the health director pivoted and said that  Solano County is not like the rest of the Bay Area, that we are in between the Bay Area and the Central Valley. Yet if one looks at the pandemic numbers in the Central Valley counties, there are quite a few doing better than we are.

There are also studies from various parts of the country showing the effectiveness of masks. A very informative one from Kansas was published in June 2021 in JAMA Network Open. It compared 15 counties which imposed mask mandates to 68 counties that did not. After ten months, the counties with mandates were doing far better on every measure. There are also excellent studies looking at school districts where teachers were mandated to wear masks, and the spread of the virus in those districts was much less than in districts without such mandates.

At the Benicia City Council meeting, Matyas said that in Solano County, “Our data clearly shows that indoor public spaces are not where the disease spreads.” He said spread results from private gatherings, so a mask mandate would not help. When I heard him say this, what came to mind is, “Where’s the beef?” He did not present any evidence publicly to support his statement.

There is no doubt that private gatherings are a big problem. But the odds are high that the virus behaves similarly in our county as elsewhere. There is no infectious disease expert in the country who says that indoor public gatherings are insignificant and can be ignored as a source of viral spread.

Solano County is a great place to live, but that does not mean covid-19 spreads differently here than in the rest of the U.S. During my 30 years practicing internal medicine in Solano County, I was never advised to treat infectious diseases here differently than the way doctors treat them in Kansas, Florida, or New York.

Matyas said he is relying on science to decide against mask mandates. Yet science confirms that mask mandates work. Of course other factors help as well, especially vaccinations. Sadly, our county has the lowest vaccination rate in the Bay Area. And lower than some Central Valley counties.

Matyas says mask mandates can backfire, because people will wonder why they got vaccinated if masks are still needed. He suggests that people in the northern parts of our county are not disposed towards masking. These are valid concerns. And there are two ways our county’s top health officer can address them.

He can say, “I understand why you feel that way, so I won’t rock your boats.”

Or he can say, “I understand why you feel that way, but I want you to understand some things. Vaccinated people are very protected against serious illness, but can still spread the virus. That’s why you still need to wear a mask. And there is very good evidence that wearing masks in indoor public settings will protect our community’s health and help our economy.”

Bela Matyas has chosen the first option. He appears to feel we are somehow incapable of performing as well as our peers in the rest of the Bay Area.

In times of crisis, leaders need to step up and lead. Every other Bay Area county public health director has followed the second option, and the data shows clearly we are falling behind. Thankfully, the city leadership of both Benicia and Vallejo decided we should rise to this challenge, follow the science, and try to protect our communities. They are not willing to say we have to settle for less than our neighbors in Contra Costa, or Napa, or Marin.

But we still have a lot to do to improve our vaccination rate.

See also: