The Patient by the Bay

By Bruce Morgan
Tufts Medicine, Spring 2008

Deep in the heart of the city's financial district, where towers of glass and steel frame the early spring sky, the meeting on Bush Street is getting under way. The nine people seated around the table are a funky mix of Asian, black and white participants, all types and ages, from trim young women with sparkly earrings to sedate, older men graying at the temples. Laughter erupts frequently, zinging around the small, packed, sunny room. When people speak, they are focused and sharp as razors. Not a syllable is wasted.

At first glance you may not notice the Hispanic woman at the end of the table, with hands folded prayer-like at her lips, listening intently, now and then jotting a note on the yellow pad in front of her, always steering the talk to its implicit resolution.Her voice is unexpectedly low and warm, mellow as cabernet, but firm. She's a minimalist with a bit of an edge.

"So," she says at one point, "what's our deadline for getting this out the door?" The answer comes from the staffer. "And are we good with that?" she persists. "Yes? Then let's do it."

Sandra Hernàndez, '84, has been ceo of the san francisco Foundation (SFF) or the past 10 years and the driving force behind a thorough reinvigoration of the city's and the region's chief philanthropic enterprise. The SFF is a community foundation—meaning its funds come from multiple donors, unlike, say, the Ford Foundation— that distributes some $80 to 90 million annually to nearly 800 nonprofits throughout five counties in the Bay Area, in broad categories including community health and development, arts and culture, social justice, education and environment. Of the 650 community foundations in this country, the SFF ranks in the top 10 by size, with more than $1 billion in assets.

Hernàndez arrived in her current post, a job normally reserved for white men bearing MBAs, by an unusual route. She is, first and last, a primary-care physician. She came west after medical school to pursue a residency at San Francisco General Hospital and stepped into the middle of the AIDS crisis. That immersion led her to assume a series of larger and larger roles in the city's Public Health Department, culminating in a three-year stint as public health director in the late 1990s.

"I kept pushing on the walls of what constitutes public health," she says now, moving her hands slowly apart. That ever-widening definition led her, almost by default, to her present role as CEO, a step back from the front lines of medicine, working the levers of influence to determine the well-being of entire communities.

The San Francisco Foundation was floundering when Hernàndez took the reins in 1997, according to Warren Hellman, former chair of the board of trustees and the man who hired her. "The place was in considerable disarray," he says bluntly.

Rapid turnover of staff, endemic sloppy accounting procedures and the loss of a major lawsuit that stripped away two-thirds of the foundation's assets had left the SFF teetering.Hernàndez began the process of handpicking a staff with deep roots in community activism, ultimately assembling a crackerjack 50-member team that she knew she could count on. She also balanced the books and launched aggressive fund-raising efforts.

"Community foundations can be either community leaders or pass-through organizations," Hellman observes. "Sandra made the decision early on that we would take on a leadership role."

Among the projects that Hernàndez tackled at the start were a complete reorganization of the public park system in San Francisco and a systemic overhaul of the city's schools. The process was anything but snag-free, given the fractious tone of local politics.

"It's been said that we have 670,000 political parties here," laughs Hellman. "In the last presidential election, Nader got more votes than Bush." But his new CEO fared well in her first challenges, he says, navigating the rapids with aplomb.

Almost in spite of herself ("I operate in very political arenas, but I don't consider myself political," is her Zen-like synopsis), Hernàndez quickly enhanced her reputation as a player in local politics. Two years ago, when Mayor Gavin Newsom floated the idea of creating a health-care plan that would cover 82,000 uninsured residents in San Francisco at an estimated cost of $200 million, he first created a 40- member Universal Health Care Council comprising labor delegates, hospital administrators, public health advocates and business owners to hash out the details over a 125-day period.

Can you imagine the tension in the air during these proceedings? As one man who survived the process notes, "Everyone in the room had at least a veneer of good will, but really they were there to protect their own interests."

Barbara Garcia, director of community programs for the San Francisco Department of Public Health and someone who has been close to Hernàndez for 20 years, says, speaking slowly, as though to a young child, "It is impossible to reach a consensus in San Francisco. Let me repeat: It is impossible to reach a consensus in San Francisco." Garcia pauses before adding, "Sandra is one of the few who could do it. She has a knack for bringing people together."

Mayor Newsom apparently agreed, choosing her to co-chair the group. A newspaper story announcing the launch of the San Francisco Health Access Plan in June 2006 shows the mayor and his aides—and Hernàndez, too—looking triumphant, almost giddy at the press conference, everybody half-dancing with glee.

Newsom later called Hernàndez's stewardship of the process "masterful." The plan, unique in the nation, had enrolled some 15,000 residents by late March, and was continuing to enroll them at a rate of 780 per week.

"It's going exceedingly well," says a city staffer. Most doctors see patients one at a time, and that's fine. For most doctors, the approach of improving the world's health person by person and case by case makes perfect sense. But for some others, like Sandra Hernàndez, the problem of public health broadly construed feels too big, sprawling and urgent to be handled this way. Their instincts prompt them onto a larger stage.

THE POLICY SLANT

Hernàndez began humbly. She grew up in Tucson, Ariz., the granddaughter of Mexican immigrants who had settled in the Southwest to work for the Southern Pacific Railroad. Both her parents were strong role models.Her mother worked at a women's clothing store and was seen by neighbors as an independent woman. Sandra's father, a largely self-taught man and ardent Democrat who did New York Times crossword puzzles for entertainment, worked as a machinist for the railroad. He frequently took Sandra with him to meetings at the union hall.

"That's where I learned Robert's Rules of Order," she notes.

Yale may not have been the logical next step, but a high school counselor snatched Hernàndez out of the school's working-class ranks, told her that was where she was going and saw that she followed through.

Once in New Haven, she threw herself into the spirit of the place, rowing crew (which she had never heard of before) her freshman year and playing catcher on the varsity softball team."She's very competitive," says her friend Barbara French, laughing as she tells the story of a casual game of hacky sack that she and Sandra played on vacation once that turned unexpectedly physical. "She practically tackled me."

Even now, at age 50, Hernàndez moves with a cat-like poise, the remnants of an athletic past. She graduated from Yale with a degree in psychology. In medical school, Hernàndez deepened a nascent interest in public health, infectious diseases in particular. She went to see a sympathetic Sherwood Gorbach, '62, professor of infectious diseases, who helped her arrange an exchange with a Mexican student for a sixweek stint in Mexico City. Off she went, a young medical student with open eyes, returning to the land of her ancestors.

The experience was in many ways a shock. As she notes, "You can read all you want in books about infectious disease, but in Mexico people actually have these diseases." The disparities in care between urban and semi-rural populations were especially keen. Hernàndez would routinely travel from the lush, teeming metropolis to the outskirts of the capital, where people were living in cardboard boxes, then back to the city again to complete rounds at the hospital. Even there, the high cost of treatment was never far from her thoughts. She would often probe the doctors after a diagnosis, saying, "What if the family member can't afford to buy the meds?" In Mexico, the worrisome mesh of money, illness and deprivation was laid bare. "It was like Public Health 101," she says.

Nothing could have prepared Hernàndez adequately for the horror show of San Francisco in the mid-1980s. She was a resident there for three years when the AIDS epidemic was at its peak. Dr. Eric Goosby, her attending physician at San Francisco General Hospital (SFGH), remembers this period before the arrival of protease inhibitor cocktails in 1994 as one "when you met the patient for the first time and knew you would be seeing their death. The best we could do was extend life for one or two years."

Hernàndez watched as many as three, four, five of her patients die in a single night. "I went to a lot of memorial services," she says quietly, "at temples, churches, parks, beaches. These were my contemporaries, people in their 20s." Even closer to home, an older brother, Oscar, contracted the HIV virus and died after a 14-month hospitalization, making the affliction personal.

According to Goosby, who was in a position to know, Hernàndez brought a rare measure of comfort to her patients through her personal touch. "Her parents did a good job with her," he comments. "She arrived with an extraordinarily mature style. Her bedside manner was intimate but professional—she conveyed strength—and that's something you can't really teach. She came, Day One, with the ability to get there."

Nor was this an isolated case. Dr. George Rutherford, who met Hernàndez during his tenure as director of the city's AIDS Office during the 1980s, tells the story of being with her in 1989 when a devastating earthquake hit the region. Hernàndez said immediately, "Let's go see patients." The pair traveled south of San Francisco to Watsonville, an agricultural town, where many homes had been knocked off their foundations and aftershocks were still in progress. Hernàndez began moving among the residents, talking to them in Spanish.

"She was so good with those people," Rutherford marvels almost 20 years later. "She had such insight, and she left them feeling much more in control than she found them."

By taking on public roles,Hernàndez was able to extend the scope of her compassion. She began as coordinator of community outreach for the AIDS Activities Division of SFGH, before stepping outside the hospital to become a branch chief in the AIDS Office of the San Francisco Department of Public Health, and later director of the AIDS Office from 1990-92. By entering the public realm, she was wrestling directly with the gnarly issues that had struck her back in Mexico—namely, the social and economic complications of medical care and outcomes.

"Sandra always had a policy slant, even when she was a resident," Goosby says. "She was always looking at the big picture. As one example, I remember her speaking in frustration with me about the medical system not being positioned to handle large groups of our AIDS patients who were going in and out of treatment five or six times in a year without any provision for their housing. These patients generally couldn't hold a job, and so they would lose their homes. Well, where were they supposed to be living? This typified Sandra's thinking. She saw the role of the physician as extending into these other aspects of the patients' lives."

UNPOPULAR MOVES

Hernàndez was on vacation, horseback riding in Mexico, when a friend asked if she had applied for the public health director's job back in San Francisco, saying, "I think today is the last day to apply."

Hmm, no she hadn't. "For the first time in my life, I was panicked," Hernàndez admits.

Taking responsibility for two major hospitals was part of it, but Public Health was also the city's largest single agency, with something like 5,000 employees. It would be a big step up from her current position of county health officer. She applied for and got the job in 1994, becoming not only the first woman but the first Latina in that role. Despite her initial bout of hesitation, as public health director Hernàndez proved bold and fearless.

She made a habit of declaring a state of emergency every Friday in recognition of the large number of people still dying of AIDS. One of her first moves was highly controversial. In defiance of state and federal law, she began distributing free hypodermic needles throughout the city to stem hepatitis B and C infection rates among HIV-infected drug users and their children.

"It was absolutely the right call," says Goosby, currently CEO of the Pangaea Global AIDS Foundation and clinical professor of medicine at the University of California, San Francisco. "Sandra was willing to stick her neck out and undergo tremendous criticism for that. She convinced people who were repulsed by the idea that this was good policy."

The needle exchange program wasn't an easy sell. Many local African-American leaders, in particular, stoutly resisted the approach. But Hernàndez began making the rounds of town meetings in the Bay Area and visiting black churches to make her pitch.

"I went to influential pastors," Hernàndez recounts. "That person would call another person and say, 'This is the right thing to do.'" Gradually the tide turned, and she won the minds of the people. She did it through intellectual honesty, through directness ("There are no end runs with her,"Goosby notes), through her message of common purpose—through the abiding notion that, no matter what, you and I are going through this together.

Is this the same way another public health officer would have handled things? Probably not. For most people, the temptation would be great to issue an edict-setting policy, far removed from the general hue and cry; but Hernàndez was not most people. "She always emphasized community planning as opposed to executive policy—the idea being that decisions are best made when you include community partners," says Dr. Mitch Katz, the current public health director for San Francisco, who counts this among the main lessons he learned as a member of her staff.

Looking back, Hernàndez sees her needle-exchange campaign as having been the only sensible choice to make in terms of public health. "The data were really compelling," she says. "Everything we did had a research component. If you look at major cities where needle exchange was not done, you find a pediatric AIDS epidemic."Hernàndez estimates her intervention saved hundreds, perhaps thousands, of lives.

Another tough-minded move on her part concerned how to address the growth of private sex parties that occurred after San Francisco moved to close down the city's sex clubs. In typical fashion,Hernàndez went straight to the mayor and told him, "We need to inundate these private parties with condoms." As she explains in retrospect, "We weren't in favor of trying to stop people from congregating.We were trying to stop the transmission of HIV." The city took her advice.Hernàndez served three different mayors and treated them all the same, with candor and alacrity. "I didn't play politics," she says.

A DEEPER VIEW

Today's second meeting on Bush Street is bigger than the first. This one involves 17 staffers and is devoted to nominating worthy individuals and organizations to receive special prizes of $10,000 or $20,000 from among the hundreds of those funded by the San Francisco Foundation over the past year. Hernàndez is there, but just as before, she mostly lets her staff members have their say, interrupting only rarely to correct the drift of conversation, address a troubling undercurrent or reinforce a point.Whenever she and a staffer happen to speak at once, like two swords momentarily clicking their metal over the long table, she always yields and lets the staffer follow through. This is conversation as discovery.

A random sampling of areas funded by the SFF is astonishing in its range, and includes economic development in blighted neighborhoods, mime troupes, literacy programs in libraries, environmental activism—exemplified by a local group that recently provided quick clean-up after a nasty oil spill along the coast—and dentistry for lowincome residents. Each member of the staff speaks knowledgeably about his or her favorite nominees as the meeting proceeds. Today, the goal is to arrive at 30 finalists whose merits will be summarized in a single page and further deliberated by a panel of community members, eventually winnowing the number to four most-deserving recipients.

The review is both probing and thorough. A man with a specialty in the arts raises a concern about one of the nominees, a dancer, whose name has come up several times, saying, "There's a question of authenticity with this artist."He points out that she is known for performing a style of dance from a culture that is not her own. In effect, she has borrowed its traditions. The group bats the concept around for several minutes before deciding to let the nomination survive. "The point that John raised—the controversial nature of her work—is a large part of why we're here," Hernàndez notes at the end of the discussion. "So thank you for that."

At this moment, Hernàndez is the mother hen presiding over her flock. The loyalty these staffers harbor toward their boss is obvious to any visitor; you can see it in their eyes. Her ability to listen, her enveloping warmth, her straightforward nature, her steely devotion to the greater good, all combine to make this woman just about irresistible. "She was in the delivery room when my partner gave birth," says her friend Barbara French. "She was there when my mom died. One never gets the sense she's fitting you in. I'll call her with a problem, and she will say, 'Where are you? I'll be there as soon as I can.' "

Hernàndez's shift from the head of the Public Health Department to philanthropy was a change that left some San Franciscans scratching their heads. But for the woman herself it was a natural move.When another brother died of a heart attack at age 59 back in Tucson, she realized that she was not far from that fate, chewing Mylantas non-stop and working around the clock ("I remember getting home and sitting out in the garage still talking on my cell phone at 8:30 at night before I went inside," she says). Plus, she was almost 40 years old, eager to have a child, and if she were going to provide a sane environment for child-rearing, something had to give. These days she and her partner, Viviana, an artist, have a seven-year-old, Maya, and Hernàndez is able to show up reliably for all her daughter's school events.

The day has a start and a finish now. Her commute from home to the foundation offices is precisely 12 minutes by BART, the city's public transportation system. She still manages things, but instead of 5,000 staff members, she has 50. Instead of facing a ward's worth of AIDS victims, she sees a half-dozen long-term patients on Friday afternoons over at San Francisco General. The immediacy of her work has shifted, too. "You look at a long-time horizon in this job," says Hernàndez, before contrasting it with the crisis atmosphere that pervaded her public health director's role, where a call might come in announcing a garbage strike and she would be expected to be in the mayor's office 10 minutes later. "Here, we have an opportunity to be catalytic."

It's a deeper, slower, longer view she's found, and it didn't come without a struggle. "At the time I was considering taking this job," she says, "I was telling myself, I don't know, I'm a doctor, they're a foundation, I don't know. But even then I was beginning to get interested in whether you could improve en masse qualities of life in what is arguably one of the most beautiful cities in the world." Day by day, she is doing just that.