Sandra R. Hernandez, M.D., speaks softly, but she's no shrinking violet.
When San Francisco's militant public labor unions took issue with her plans to reorganize the health department and the public hospital, she didn't budge. Even though the unions were big supporters of her boss, Mayor Willie Brown.
When California Gov. Pete Wilson announced the state would no longer pay for prenatal care for undocumented immigrants, she vowed that policy wouldn't apply in San Francisco. She then sued the state and won.
When AIDS activists contended Kaiser Permanente was dragging its feet on performing viral load testing, she gave the HMO the city hospital's data showing its usefulness. Kaiser changed its policy within a week. "There are many different ways to move quality of care," she says simply.
Members of President Clinton's healthcare quality task force should take note: Hernandez has been appointed to the panel. She'll be in their midst, asking tough questions, taking no prisoners and advancing the debate.
For the past 31/2 years Hernandez, 39, has fashioned a bully pulpit out of the position of public health director, which in many cities might be a bureaucrat's sinecure. Not in San Francisco.
Hernandez believes the public sector has the ability and the obligation "to promote the highest quality of care you can in whatever venue you can."
Now she's trying something new. Having spent her entire medical career in public health, she has a keen appreciation of what government can-and cannot-do.
"We can prevent so much of what we spend our time trying to treat," she says. "Government doesn't tend to focus as much of its resources on the preventive side; there's so much pent-up demand for access."
On Aug. 18, she started as the San Francisco Foundation's director and chief executive officer. The foundation controls $463 million in charitable assets it uses to improve the quality of life in the San Francisco region. It made grants of $40.3 million in 1996.
The foundation hired her away from the city to strengthen its ties to the diverse San Francisco Bay Area communities.
It's important to think about public health "in the macro," she believes. "There are many issues that go beyond immunizations and disease control that affect quality of life in communities."
Philanthropy tends to avoid getting involved with government "because it's bureaucratic and political and rigid." Hernandez wants to leverage the foundation's assets to do "the risky things" government can't do. She emphasizes the intimate relationship of health status to income and education.
Her legerdemain at working the bureaucracy is widely admired. Richard Cordova, CEO of San Francisco General Hospital, which is run by the Department of Public Health, says Hernandez is "really good at the politics" of keeping the hospital going, even through a period of budget retrenchment.
"It's been a very exciting 31/2 years working for her," Cordova says. "She gave the department a whole new direction. We repositioned the hospital as part of an integrated delivery system. We're thinking totally differently in terms of how we provide care in the community system."
Mayor Brown agrees: "Dr. Hernandez was the most visionary and effective director of public health this city has ever seen. Her departure is a significant loss." He praised her work in setting up treatment-on-demand for substance abusers and creating a cutting-edge AIDS-care program.
AIDS treatment, in fact, is Hernandez's medical specialty. She says it was a natural for anyone who graduated from medical school in 1984, as she did from Tufts University School of Medicine in Boston.
The best part of her new job at the foundation, Hernandez says, is she's able "to do direct patient care a full day a week."