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    Dr. Grant Colfax on His Life, Work, and Applying Lessons Learned from HIV/AIDS to COVID-19

    As the Director of the San Francisco Department of Public Health, Dr. Grant Colfax makes decisions that directly impact over 7,000 individuals, including teams at Zuckerberg San Francisco General Hospital and Laguna Honda Hospital. Along with the San Francisco Health Commission, which is the governing and policy-making body of the Department of Public Health, he also makes decisions that affect the lives of all San Franciscans. It is a role of immense and almost unfathomable responsibility, usually capping off the careers of former such leaders, and yet it feels as if Dr. Colfax has not even reached his prime.

    He has made headlines since he was a teenager, defying public expectations at every turn and influencing such seemingly disparate matters as homeschooling, social justice, public health, and much more.

    Interracial Family Raised on a Ranch

    Back in the 1970s and 1980s, the Colfax family—with parents Micki and David at the helm—became well-known, as well as controversial. Largely this was because of the way in which Micki and David raised their four boys. Grant is the oldest, and John Drew is the second oldest. Micki and David then adopted Reed, who is Black, and Garth, who is of Native American ancestry. All lived at Shining Moon Ranch in Boonville, California.

    Grant raised goats that he proudly brought to the Mendocino County Fair and Apple Show. The animals at first got last in all divisions, but Grant was tenacious and determined. He improved his techniques, such that an Alpine doe raised by him earned the coveted title of Grand Champion for her breed. On the cover of the 1992 book Hard Times in Paradise by Micki and David, chronicling their life on the ranch located in a redwood forest, Grant is shown with one of his goats, who looks like another well-cared-for member of the family. The book shares how the Colfax home had no electricity, running water, or a phone.

    The Mountain School

    Dissatisfied with public education at the time, David and Micki decided to homeschool all of their children. They registered their ranch as a private school, calling it The Mountain School. The number of pupils? Four—the Colfax boys. Believing that everyday work and real-life experiences were essential to education, David and Micki allowed their sons to mostly study on their own and to juggle that with the necessities of life on a working ranch. Well educated themselves and originally from the East Coast, both David and Micki were deeply involved in civic matters and served on local boards, committees, and organizations.

    David notably served on the Mendocino County Board of Supervisors for several terms and was a popular and charismatic leader. He often involved his entire family in discussions with experts of various fields, including healthcare specialists from San Francisco. This too became part of the flexible Mountain School curriculum, which always emphasized being of beneficial service to others.

    Acceptance to Harvard

    Desiring to go to medical school, Grant set his sights on Harvard despite the fact that his unorthodox educational background was in stark contrast to that of all other applicants. His intellect and eagerness to learn, evident in his SAT scores, writing, and interviews, wowed the Harvard admissions officers. He was accepted to the prestigious college in 1983. (Drew eventually went to Harvard’s Medical School. Reed also went to Harvard. All four Colfax boys have achieved success in their educational and professional lives dedicated to serving others.)

    Drew told The Harvard Crimson: “We basically studied on our own from the age of 12 on. We helped each other a lot … Grant was really the guinea pig [in terms of selecting textbooks and other reading materials]. He would tell me which books were good.”

    News of the Colfax boys’ success made national and even international headlines. Other Harvard students therefore knew about aspects of Grant’s life. He later shared with the Crimson: “When I first got here, a lot of people knew who I was, but that didn’t bother me at all. Then I went through a period where I was tired of being perceived as a ‘goat-boy.’ Now I feel like I’ve established my own identity away from typecasting.”

    Out and Proud

    Part of that identity forged by Grant involved coming out as a gay man. He did so proudly, even as the HIV/AIDS crisis led at the time to fear and backlash against the LGBTQ community. Passionate about helping others during the crisis, he completed his residency in Internal Medicine at the University of California, San Francisco, and worked in Ward 5A at San Francisco General Hospital, which with Ward 5B was the world’s first dedicated HIV/AIDS hospital ward.

    In 1997, Dr. Colfax joined the San Francisco Department of Public Health, where his focus was on researching and implementing HIV prevention interventions. As Director of HIV Prevention and Research, he emphasized bringing an evidence-based, community-informed approach to addressing gaps in HIV care and prevention.

    Member of the Obama Administration

    From 2012 to 2014, Dr. Colfax was a member of the Obama Administration, serving as Director of the Office of National AIDS Policy. As President Obama’s primary adviser on domestic HIV policy, Dr. Colfax coordinated federal efforts to implement the national HIV/AIDS strategy.

    2015 marked another shift in Dr. Colfax’s already storied career. That year he was named Director of Marin County’s Health and Human Services, leading the Public Health, Social Services, and Behavioral Health divisions until 2019. His focus, in part, was on increasing health and wellness equity in Marin County.

    Present Position

    In January 2019, San Francisco Mayor London Breed announced that she had chosen Dr. Colfax to serve as the Director of the Department of Public Health. Making the announcement, she said, “Dr. Colfax knows our city and its challenges, and he is ready to get to work. He knows that we need to get to zero HIV infections in San Francisco and that we need to reach our most vulnerable populations, particularly our African-American and Latino communities who are not seeing their HIV infection rates drop as others do. This means getting everyone—and I mean everyone—access to services, treatment, and preventative medication like PrEP. I know Dr. Colfax will get us to that goal.”

    Dr. Colfax then envisioned that his work would “require effectively addressing the health challenges facing the city, as reflected in Mayor Breed’s priorities. This includes improving mental health and substance use treatment services, addressing the medical needs of people experiencing or at risk for homelessness, and reducing health inequities. With the Department’s history of innovative public health initiatives, community-driven programming, and superb clinical care system, I am optimistic about what can be achieved.” 

    A New Pandemic

    Just over a year into the already formidable work underlying these goals, COVID-19 was identified and began to rapidly spread. During the subsequent months, San Francisco rose to deal with the crisis. In June 2021, it was announced that San Francisco was the first major U.S. city where 80% of eligible residents had received at least one COVID-19 vaccine dose. At that time, the city had nearly 70% of eligible residents fully vaccinated and the COVID case rate had dropped 96% since January 2021.

    Then came the Delta and Omicron variants, with the latter first detected in the U.S. in San Francisco during December 2021. This herculean feat was due to the bravery of the patient who fully cooperated with researchers, to UCSF scientists, to the work ethic of Dr. Colfax and his colleagues, and to the testing technologies, including genomic sequencing, available here in the Bay Area. As The New York Times reported about the variant detection, “In less than 24 hours, scientists at the University of California, San Francisco, had determined that it was Omicron.”

    Now, still during the international Omicron surge, we met up with Dr. Colfax to learn more about his remarkable life, work, and goals for the Department in the challenging year ahead. The following represents excerpts from our recent discussion with him.

    San Francisco Bay Times: Your experience in clinical medicine, research, policy, and administration is both unique and exceptional. Going back in time, to your upbringing in Mendocino and homeschooling, who were your role models and mentors then as well as later when you attended Harvard Medical School?

    Dr. Grant Colfax: Many of my mentors then were very much mission driven and focused on social justice work. It would be difficult to provide specific names, as there were so many. A number of those people included healthcare providers who were working in rural communities or underserved urban communities. I developed a deep appreciation for their work and that was solidified in me at a very early age.

    My parents were grounded in social justice work. Being homeschooled, there was flexibility and we had permission to explore and to delve deeper into our own interests.

    San Francisco Bay Times: Given that your family was based in rural Mendocino County, how did you connect with so many other community leaders, particularly in healthcare professions?

    Dr. Grant Colfax: Even though we were 2 1/2 hours north of San Francisco, I did have mentors and people I engaged with directly, including practitioners at San Francisco General Hospital. The legacy of public service and what can be done in that way resonated with me early on. There was not just a connection at the very local level, but there was a thread to San Francisco that continues to this day.

    They were colleagues of my parents actively practicing medicine in San Francisco. I had a very deep appreciation and admiration for them. They gave me a lot of perspective on what it meant to be in medicine at that time. There was a focus among these practitioners, not just about academic medicine but also about community medicine and social organizing. It was the time of barefoot doctors and thinking how people can empower themselves and communities and take charge of their own health.

    I recall staying up late and listening around the table when my parents would meet with them. I would also go to bookstores and pull off books I was interested in. Going to libraries was a huge part of our learning and engagement. My parents would ask, “Are you interested in this? Let’s explore it more.” That approach was formative in helping to develop the perspective that I have today.

    San Francisco Bay Times: What led to your focus on HIV/AIDS clinical medicine during your later education, and then your pivot toward policy and administration work?

    Dr. Grant Colfax: As a gay man, I came out quite early at a time when, particularly in medicine, there were not a lot of people who were out. This time coincided pretty directly with the HIV/AIDS epidemic. I already had a longstanding interest in medicine, but this [HIV/AIDS] really solidified and drove so much of my work going forward. It was impossible being a gay man to ignore the fact that there was this massive health crisis. And it directly intersected with the social justice work and advocacy that was happening at the time.

    I saw what happens when the federal government ignores a pandemic and when the federal government actually engages. So, I had a deep appreciation for what the possibilities are and an appreciation for the connection between science and community and what can be done when those two things come together with government—whether that government is local, state, or national. That really informed my work at the policy level, but I also learned and experienced how to care for people at the very granular level.

    I went to medical school in Boston and then came out and did a rotation at SF General Hospital at the 5A Ward, which was the HIV/AIDS ward. The focus on caring for people with a social justice and holistic lens was really inspiring and remarkable. I was pretty sure that I wanted to come back to San Francisco for my residency, but that experience really crystalized it. It [5A] was an incredible model. That model had not been present where I had trained at the time. I think that legacy has carried into and inspired the work at Zuckerberg San Francisco General Hospital and other components of our healthcare system.

    San Francisco Bay Times: Please share some of your memories of serving as President Obama’s top HIV/AIDS policy adviser from 2012 to 2014. How did that experience help to shape your work thereafter?

    Dr. Grant Colfax: It was incredible to see what policies can do at the macro level to inform work at the local level and at the individual level. In my conversations with patients and other clinicians, I feel the tangible effect of the Affordable Care Act (ACA) that has been transformative. Prior to the ACA, so many people didn’t have coverage and yet many had severe health problems. Because they didn’t have coverage, many went into debt and their lives were destroyed in ways that extended beyond health.

    Being with the Obama Administration as the ACA was literally being implemented—sort of having that connection at the macro level and then seeing how these policies are incredibly important and beneficial to people at the local level—has just been incredibly inspiring. It’s been an honor to see and experience and support that in the small ways that I’ve been able to do so.

    San Francisco Bay Times: You seem to transition with ease from national to local and even international work. When you accepted the position of Marin County Health Chief, however, you said, “Working at the local level has always been my passion.” Please elaborate a bit more on why work at the local level remains so important to you.

    Dr. Grant Colfax: It’s the granularity and the proximity to the issues and being able to effect change in a way that is tangible and, for me, rewarding, and I hope for others as well. To be able to scale up programs. To be able to support community. To be able to take a pilot project, especially with some of the work we’ve done with COVID and HIV and increasingly around health equity. Community tells us what’s needed, which then intersects with what evidence tells us from the science and the medical work and then we attempt to bring those things together to get the best.

    [It’s important for me] to meet people where they are and to ensure systems are responding to the needs of people. To design systems to meet people’s needs in the most effective way. It’s hard and challenging, but it’s incredibly exciting and effective when it actually works.

    San Francisco Bay Times: What is a typical—if there is such a thing—day like for you?

    Dr. Grant Colfax: There is no typical day. Days are extremely fast paced. They are inevitably rewarding. There are days where you feel like the teams and communities that they have been working for are achieving success on the ground and those are incredible. And there are challenges almost every day.

    I think, because of the support of the great team at the Health Department and the work we do with the community, there are a lot of great things happening. I am very optimistic at the end of each day as to where things are headed while acknowledging that there are challenges. It is often complex and challenging work. But we need to embrace that and continue to strive for health equity and social justice and better outcomes for our citizens and communities.

    San Francisco Bay Times: Please share more about the members of your team.

    Dr. Grant Colfax: We have over 7000 people working at the Health Department. We have both hospitals: Zuckerberg SF General and Laguna Honda Hospital. We have 14 clinics and many divisions, so literally thousands of people within the Department are working every day on factors relating to health and wellness.

    I think of those now working on the front lines, whether it’s directly COVID-related or in areas that are COVID-impacted—from the Intensive Care Unit at Zuckerberg SF General to the vaccine teams in the communities that we’re serving, including in the Bayview and the Mission, to primary care in Chinatown and all across the city, and to the HIV care that’s being given in our primary care clinics. It’s just a remarkable group of people who are very mission driven and are now working harder than ever before.

    Dr. Susan Philip, Deputy Director of Health Care Delivery Systems at the California Department of Health Care Services, has done a remarkable job. This health officer role has come into greater focus and I want to acknowledge and thank her and, again, to thank the people on the front lines for going to work every day. These last two years have put the importance of their work at the forefront.

    I also want to emphasize that Mayor Breed has been so supportive of the Department across the city. Having the support of the leaders you are working for is so important to make things go forward.

    San Francisco Bay Times: Your Department recently made news when the Omicron variant was first identified here in San Francisco. Share some insight into how that happened.

    Dr. Grant Colfax: The reason it happened is because we have such a great team of people involved in testing and case detection. Credit first goes to the person who was diagnosed, since that person called and shared a travel history. Our team literally worked overnight with our collaborators at UCSF to do the sequencing. That doesn’t happen on a routine basis. People were driving so hard to move forward because it was such an important piece of information from a public health perspective, not only for our local response but also, of course, nationally. That is emblematic of the work that our people do.

    San Francisco Bay Times: What advice do you have for our readers, in light of the coronavirus variants?

    Dr. Grant Colfax: Getting the initial vaccines and your booster are so key right now. Omicron has pushed us to understand that COVID is going to be here for the long term. Omicron is forcing us to better understand our risk levels and our ability to manage and live with this virus for the foreseeable future. Aside from vaccinations and boosters … layering other layers of protection with testing and masking are so important right now.

    Hopefully this surge will be quick and we will be able to go back to a more normal situation than we are in right now. But I want to emphasize how we’re all going to need to learn how to live with COVID to a degree, and we’re still waiting to see to what that degree is.

    San Francisco Bay Times: From HIV/AIDS to COVID-19 to substance abuse disorders and more, the current health challenges in San Francisco are many. What are some of your specific goals for the months ahead?

    Dr. Grant Colfax: A goal continues to be to get as many people vaccinated and boosted as possible. We continue to focus on the most vulnerable populations due to COVID, particularly elderly populations, those in skilled nursing facilities, and people who are immunocompromised. I think the other part of this is ensuring we keep schools open because we know that is incredibly important.

    There are other key parts of our care system that have been incredibly strained because of the pandemic, but we nonetheless need to continue to focus on them. Our behavioral health system, for one. We recently brought in a new Behavioral Health Director, Dr. Hillary Kunins, who has a new perspective that I am very excited about. This effort includes the all-important issue of the overdose pandemic in San Francisco and working with the community, scientists, and others to ensure we are doing everything we can to prevent overdose deaths by providing treatment, strengthening overdose reversal programs, and providing support for people. We again need to ensure that our system is driven by what the people need and not by what the system needs. We need to make sure we have a low barrier to care so that people are able to get healthcare if and when they need it and ask for it. This must be addressed in a much deeper and broader context than ever before. I’m optimistic that we will be making good progress in this area, but it is a key challenge. It is something that we will need to continue to focus on.

    The other areas of focus include health equity and looking at health outcomes in specific communities, particularly in the Black and African American community where we continue to see poorer health outcomes, whether it is COVID, HIV, preterm birth, or hypertension. We have a number of initiatives that we are working on to improve those outcomes. Part of that effort includes strengthening our work with communities and neighborhoods. COVID really catalyzed that, but we are continuing to ensure that we are having the meaningful, focused discussions to take meaningful actions. Having meaningful intentions is inadequate. We are actually taking meaningful actions and holding ourselves accountable as a healthcare system and as a governmental department affecting the change that so many people have been asking for, for so many years.

    San Francisco Bay Times: Has your experience working on HIV/AIDS helped to inform your response through the Department to the COVID-19 pandemic?

    Dr. Grant Colfax: The COVID-19 pandemic and how it has evolved and the challenges that we have encountered with it do really reflect the history of HIV in some ways. I flashed on this thinking back on my training in the 5A ward. When I was training, there were different HIV meds that were coming out. The way it was recommended that people take the meds shifted and changed and adjusted. It was not that everything overnight changed. It was a process that adjusted according to the science and the feedback from patients and community as to what was working and what was not. I think that is important to remind ourselves of, now two years into COVID.

    People, for example, are wondering whether or not they will need another booster. Remember that we do not have an on-off switch in terms of this is what we know now, so this is what you will do for the foreseeable future. Things can shift and change and that is what happened with HIV/AIDS. The iteration of our response is going to be something that we need to be flexible about and adjust. That is something we learned with HIV and now COVID is teaching it to us all over again.

    San Francisco Bay Times: You are such a powerful role model, and particularly for other LGBTQ individuals. What advice do you have for others who, like you, have sought to make a positive difference in their communities?

    Dr. Grant Colfax: What I advise people, if they ask, is to stay proximal and granular to the issues that you are responsible for or for which you are trying to effect change. Go out and ask questions. If you are responsible for developing programs that reach people, talk to the people you are meant to reach and develop the programs according to what you are hearing from people. Don’t design the program or policy and expect people to come to it. Ask yourself, how do you stay connected to the work so that you are actually listening to and engaging with the people you are trying to reach?

    I learn more from talking to the patients in my clinic every week than I learn from my emails or some of the broader policy documents that I often review. Asking questions and listening to a variety of different people, whether they are leaders in their community or leaders within a specific field, is incredibly important. Be authentic and have integrity. As much as is possible, make sure that you are focusing on what matters: what matters to you and what matters to the people you are serving.

    Published on January 13, 2021