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The Bulletin | 1



Vol. 26 | No. 4 | Fourth Quarter 2020

In this issue SCCMA is a professional association representing over 4,500 physicians in all specialties, practice types, and stages of their careers. We support physicians like you through a variety of practice management resources, coding and reimbursement help, training, and up to the minute news that could affect your practice. The Bulletin is our quarterly publication.

Santa Clara County Medical Association President | Cindy Russell, MD President-Elect Ĺ&#x17E; (%Ƣ+. *#Ĺ&#x20AC; Past President | Seema Sidhu, MD VP-Community Health | Lewis Osofsky, MD Ĺ&#x2018;40!.*(Ƣ%./ | Larry Sullivan, MD VP-Member Services | Randal T. Pham, MD VP-Professional Conduct Ĺ&#x17E; (+.%1Ĺ&#x20AC; Secretary | John Brock-Utne, MD Treasurer Ĺ&#x17E; *$Ĺ #15!*Ĺ&#x20AC;

SCCMA NEWS & ANNOUNCEMENTS A Message from the President


SCCMA 2020 Bioethics Committee Recap


Catching Overlooked Eating Disorders in Medical Settings


San Jose Covid Food Relief Program


CMA Trustee - District VII | Thomas M. Dailey, MD CMA Trustee - District VII | Kenneth Blumenfeld, MD

CMA legislative wrap up




$%!"4!10%2!ĆŁ!. | April Becerra, CAE

El Camino Hospital of Los Gatos | Shahram S. Gholami, MD El Camino Hospital | Anlin Xu, MD Good Samaritan Hospital | Krikor Barsoumian, MD Kaiser Foundation Hospital - San Jose | Danielle Pickham, MD Kaiser Permanente Hospital | Joshua Markowitz, MD Oâ&#x20AC;&#x2122;Connor Hospital | David Cahn, MD Regional Medical Center | OPEN Saint Louise Regional Hospital Ĺ&#x17E; +00!**%*#$+2!*Ĺ&#x20AC; Stanford Health Care/Childrenâ&#x20AC;&#x2122;s Health Ĺ&#x17E; )( Ĺ&#x20AC; Santa Clara Valley Medical Center | Harry Morrison, MD Opinions expressed by authors are their own, and not necessarily those of The Bulletin, SCCMA, or MCMS. The Bul(!0%*.!/!.2!/0$!.%#$00+! %0((+*0.%10%+*/"+.(.%05 * (!*#0$Ĺ&#x20AC;/3!((/0+.!&!0*5)0!.%(/1)%00! %* 3$+(!+.%*,.0Ĺ !,0*!+" 2!.0%/%*#%*$!1((!0%* in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and Ĺ&#x161;.!/!.2!0$!.%#$00+.!&!0*5 2!.0%/%*#Ĺ Address all editorial communication, reprint requests, *  2!.0%/%*#0+Ĺ&#x192; %'!)1*#1Ĺ&#x20AC;*#%*# %0+. ?88),!55 San Jose, CA 95128 760/671-2337 4Ĺ&#x192;<8@Ĺ&#x161;:@AĹ&#x2018;98>< )%'!Ĺ&#x2DC;/)Ĺ +.# Č?+,5.%#$0:8:8Ĺ&#x20AC;*0(.+1*05! %(//+%0%+*

: | The Bulletin

The Earth has a Fever: A Maternal-Fetal Medicine Physicianâ&#x20AC;&#x2122;s Perspective on Climate Change


Why Employers Find It So Hard to Test for COVID


People Proving to Be Weakest Link for Apps Tracking COVID Exposure


AMA: Racism is a threat to public health


Community News Public Health Department: How to Stay Safer at Home and at Work During the COVID-19 Surge


**+1*!/2%*!Ĺ&#x2018;/,!%Ć&#x153;+ !/"+. coronavirus immunizations


CA Congressman Ami Bera, M.D., introduces bill to stop 2021 Medicare cuts


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A Message from the President


by Cindy L. Russell, MD

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While money spent on the 2020 election ($14 Billion) was unprecedented, the conversations on the national election podium were also unparalleled,with discussions of Medicare for all, college for all and the wealth gap. 2020 is a critical year for transition. We have a new President of the United States and hope for a new direction that will address the great issues of our time. These include a third wave of the COVID-19 pandemic, climate change, environmental health, affordable health care, equity and diversity, and corporate control over public policy. Politics and political divisions remain and ďŹ nding common ground and common values will be the challenge. Concern for family, community, safety, security, our health and the health of the planet we are reliant on, bridge our humanity. Perhaps focusing on reason rather than rhetoric will bring some healing. The motto â&#x20AC;&#x153;United We Standâ&#x20AC;? could not be a more appropriate goal for this time. Pandemic

A third and larger wave of COVID fever is upon us, both in the Bay Area and in the U.S. at large. Coronavirus numbers have spiked to an all-time high, with the critical numbers being deaths from COVID-19 and the lack of hospital beds and ventilators. At the time of this writing there were almost 13 million COVID cases reported in the U.S. along with 265,271 deaths. One likely explanation

for this spike in cases are the mass gatherings in the summer and fall. These so-called â&#x20AC;&#x153;superspreaderâ&#x20AC;? events were for political rallies as well as for reunions, such as the 80th Sturgis Motorcycle Rally 2020. It was noted that many attended without masks. At this time 37 states now have a mask mandate. Statistics for the virus do not look promising for a December 2020 family reunion. Being in your own â&#x20AC;&#x153;home for the holidaysâ&#x20AC;? is the popular thing to do to prevent an ICU visit for yourself or loved ones. Masking is so in vogue in California now that there is an assortment of homemade, beaded or embroidered masks of every style, color and opinion available in gift stores, antique stores, grocery stores and even hardware stores. The perfect stocking stuffer! Planetary Fever: A 10 Year Treatment Plan

Personal experience can rapidly shift your views. With the Western ďŹ res and extreme weather events of this last year seen in close up, there is little doubt left that our planet is also experiencing a fever. A growing number of Americans recognize global warming as a threat to human and planetary sustainability. Two thirds think the government should play a larger role in addressing climate change. A 17 year-old Swedish teen, Greta Thunberg, is our eloquent unapologetic international climate change timekeeper. She reminds us

Continued on page 10 Š Can Stock Photo / pressmaster

The Bulletin | 3

Santa Clara County Emergency Covid Update Dear Community Partners,

We write to provide our weekly update related to the County of Santa Clara’s COVID-19 response efforts. This week brought more difficult and ominous news as Santa Clara – like many counties across the state – continues to experience a rapid spike in COVID-19 cases. We have now surpassed the case levels we were seeing in July during the local peak of the epidemic. And, it took very little time to get there. Our 7 day rolling average of cases has skyrocketed 133% in the past 14 days. Despite increased testing (which should drive positivity rates down), the positivity rate has doubled in just 2 weeks, indicating rampant spread of the virus. Even more concerning, the number of COVID positive patients in our hospitals has climbed 88% in the past 2 weeks. As a lagging indicator, this upward trend in hospitalizations is only likely to get steeper in the near term. If our trends continue, hospitals in our county could exceed capacity in just a matter of weeks. We are entering the most difficult challenge of the pandemic. This is essentially our third wave of surging cases and hospitalizations in our county (we had one in the Spring and another in July). However, several factors make this surge more alarming and challenging. First, we are starting from a higher baseline than with previous waves. Second, the rate of rising cases has been steeper and faster than anything we’ve experienced thus far. Third, we are facing this challenge as the weather cools (and people are inclined to move indoors), and as the holiday season is upon us (increasing the desire to travel and gather). With previous waves, we could depend on healthcare staffing support from other communities if needed. Now, nearly the entire nation is facing a similar crisis. So, we can’t rely on that support. Finally, the fatigue of this pandemic is taking its toll. We know that summoning the mental energy to be extra vigilant is becoming more difficult. Despite these substantial challenges, the fact remains, we have flattened the curve before and we can do it again. We have the same tools we’ve always had (minimizing contacts, social distancing, mask wearing, maximizing ventilation, etc.). We must carefully adhere to them. As Dr. Cody expressed yesterday, the choices each of us make in the coming days and weeks may mean the difference between having enough hospital capacity to care for our community, and not having enough. < | The Bulletin

What we do today and over Thanksgiving is critically important. We are urging residents to cancel their travel plans. Stay home and celebrate the holiday with your household or virtually if at all possible. If you must gather in person, keep it small, short, outdoors, and socially distanced. Thank you for your patience and resolve during this harsh year. Still, there is more work to do. The faster we can get this pandemic back under control, the more lives we can save and the better for the health of our economy. California Announces Limited Stay at Home Order, Effective Tonight

On Thursday, November 19th, the State Health Officer issued a new Limited Stay at Home Order that will take effect at 10pm tonight, November 21st. The Order applies to counties in the Purple Tier of the State’s Framework, including Santa Clara. The Order requires all gatherings and other non-essential activities involving multiple households to cease between the hours of 10pm and 5am, except for those activities associated with the operation, maintenance, or usage of critical infrastructure or required by law. Health and Human Services Secretary, Dr. Mark Ghaly, indicated in his briefing on Thursday that non-essential businesses should close their operations by 10pm and not resume before 5am. He indicated outdoor dining must stop by 10pm, though take-out & delivery orders can continue later. Nothing in the Order prevents people from the same household from leaving their residence as long as they don’t engage in interaction with individuals from other households. Walking a dog late at night, for example, is allowed. The Limited Stay at Home Order will remain in effect until 5am on December 21st and may be extended or revised. The Order does not apply to persons experiencing homelessness. California Launches New Loan Program for Small Businesses

Yesterday, the State announced the opening of the California Rebuilding Fund, a loan program to help small businesses rebuild from the current economic crisis. The program began accepting applications yesterday. Loans of up to $100,000 are available and early applications are encouraged. Interested small business owners can apply for a loan at www.CALoanFund.org. To qualify, businesses must have 50 or fewer full time employ-

© Can Stock Photo / prometeus

ees, annual revenues of $2.5M or below in 2019, and revenues must have declined since January 2020. The City of San José will be hosting a webinar on December 1st at 3pm for San José businesses to provide more information about this program. State Pulls “Emergency Brake” and Moves Santa Clara County Back to the Purple Tier

Due to spiking COVID-19 cases across the state, on Monday of this week, California announced it was moving Santa Clara County directly into the Purple (most restrictive) Tier of the State’ Framework. This change took effect on Tuesday (11/17). The State pulled what they are calling their “emergency brake” and modified their tier assignment process to utilize more recent data and to move counties backwards more than one tier at a time, if worsening metrics warrant it. This week, 39 California counties moved back at least one tier. No counties moved forward. The State has now placed 41 counties (representing 94% of the California population) into the Purple Tier, revealing how pervasive the increase in COVID transmission has been across the state. Going forward, tier assignments may now occur any day of the week and more than once per week if the State determines immediate action is needed. Moving to Purple means several businesses and activities are now again prohibited from operating indoors in Santa Clara County. This includes dining, gyms and fitness facilities, pools, family entertainment centers (such as bowling alleys), cardrooms, wineries, museums, zoos, aquariums, and all indoor gatherings (e.g. worship services, movie showings, political events, weddings, funerals, etc.). These businesses and activities may operate outdoors only. Moving to Purple also came with one outdoor closure: bars, breweries, and distilleries serving alcohol with a meal are now prohibited from operating at all. In addition to these required closures, moving to the Purple has changed the capacity requirements for indoor retail (including shopping malls) and libraries, all of which have to reduce their capacity to a maximum of 25%. Grocery stores must also now reduce their capacity to a maximum of 50%. For a summary of all capacity limitations under the Purple Tier, see the County’s new Mandatory Directive on Capacity Limitations. Impact on Schools of Moving to the Purple Tier

The move to Purple has a significant impact on K-12 schools.

School campuses that have already opened for in-person instruction (either fully or partially as part of a phased reopening) can stay open. Schools who are in the process of implementing a phased reopening can continue that phased plan while Santa Clara remains in the Purple Tier. However, school sites that have notalready opened for in-person instruction must remain closed until Santa Clara County has been back in the Red Tier for at least 14 days. The one exception (as was true in August) is that schools may apply for a waiver to offer in-person instruction to students in grades K-6. For more information, see the County’s Mandatory Directive for Schools which was updated just yesterday. COVID-19 Cases in Santa Clara County

Over the last seven days, the County of Santa Clara Public Health Department announced 20 new deaths among individuals with COVID-19, bringing the total number of deaths to 464 in Santa Clara County. Total cases have reached 30,411. Our 7 day rolling average of new cases currently stands at 312 cases per day (up from 210 a week ago and 134 the week before that). Based on the most recent 7 days with full testing data, there have been an average of 10,728 tests performed each day with an average positivity rate of 3.30% (up from 2.45% the prior week and 1.68% two weeks prior). As of yesterday, there were 175 COVID positive patients hospitalized in Santa Clara County and an additional 12 patients under investigation. Of these hospitalizations, 50 were in the ICU. More data can be found through the Public Health Department’s Data Dashboards. COVID-19 Times Series Data Added to Dashboard

The Public Health Department has launched a new dashboard that includes time series maps showing rates of COVID-19 cases, tests and test positivity by city and zip code of residence summarized into three-week time periods. The maps provide information about changes in these key metrics in different areas of Santa Clara County over time. It’s important to note that the data do not necessarily indicate that one city or zip code is more or less safe than another (e.g. knowing the city where someone who’s tested positive lives doesn’t tell us where they acquired the virus). The County is also now providing a Blueprint dashboard that tracks, over time, the metrics used to deterThe Bulletin | 5

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mine Santa Clara County’s tier status within the State’s Blueprint for a Safer Economy framework. To view all Public Health Data Dashboards, see here.

November 17th Report to the Board of Supervisors

On Tuesday, Health Officer Dr. Sara Cody and other County leaders provided an update to the Board of Supervisors regarding COVID-19 trends and response efforts. Dr. Cody discussed the alarming recent trends in the local epidemic and provided an update related to K-12 schools including the latest experience related to school transmission (which indicates that schools do not appear to be significant amplifiers of COVID transmission). The Board meeting also included an update on the County’s tier status, testing, case investigation and contact tracing, health system preparedness, and business engagement and compliance efforts. You can view the full Board presentation here. The COVID-19 item begins at 4:39:55. County Testing Locations – Holiday Schedule for the Coming Week

The community testing program operated by Santa Clara Valley Medical Center (SCVMC) continues to offer drop-in and appointment-based COVID-19 testing at several locations across the county. Note: Testing should not be considered a means to clear people for unsafe activities, such as holiday group gatherings or travel. All County sites will be on a holiday schedule this coming week. Appointment based testing at the Santa Clara County Fairgrounds will be closed on Thanksgiving, but will offer special Sunday testing on November 29th. Residents can book an appointment for the Fairgrounds or various rotating city sites in Vietnamese, Chinese, Spanish, or English. Drop-in testing sites at Emmanuel Baptist Church and the South County Annex in Gilroy will be closed on Thanksgiving and Friday after, but will offer special Monday hours earlier in the week. In addition to our usual drop-in locations, this week the County will also be conducting testing at 1775 Story Road in San José on Wednesday. See below for this week’s full schedule or visit www.sccfreetest.org for additional information. Drop-in Testing – Walk-Up: • Emmanuel Baptist Church: 467 N. White Road, San Jose Monday, November 23 through Wednesday, November 25 from 11am to 5:30pm • South County Annex (formerly Del Buono Elementary): 9300 Wren Avenue, Gilroy Monday, November 23 through Wednesday, November 25 from 11am to 5:30pm • Public Health Resource Hub in East San José: 1775 Story Rd., San José, 95122 Wednesday, November 25 from 11am to 5:30pm Appointment-Based Testing – Drive-through/Walk-Up/ Bike Access: • Santa Clara County Fairgrounds – Lot A – 344 Tully Road, San Jose, parking lot across from Gate B and across from the Blue Arch Tuesday (11/24), Wednesday (11/25), Friday (11/27) from 11:30am to 6:15pm Saturday (11/28) and Sunday (11/29) from 9am to 3pm Appointment-Based Testing – Walk-up:

Sunnyvale, Milpitas Sports Center, 1325 E. Calaveras Blvd., Milpitas Monday, November 23, 9:30am – 4pm (Reservations may be fully booked already) Morgan Hill, Morgan Hill Council Chamber Building, 17555 Peak Ave, Morgan Hill Tuesday, November 24, 9:30am – 4pm (Reservations may be fully booked already) Santa Clara, Central Park Library, 2635 Homestead Road, Santa Clara Wednesday, November 25, 9:30am – 3pm (Reservations may be fully booked already)

Holiday Schedule for Community-Based and StateOperated Testing Options

This week, Gardner Health Services will be offering its free, community-based drop-in COVID-19 testing events on Monday (11/23) instead of its usual Wednesday testing. No appointments are necessary and all individuals are served regardless of insurance or immigration status. Roots Community Health Center will not be testing this week at Antioch Baptist Church. The 4 testing sites operated by State contractors (Verily and OptumServe) also have a modified holiday schedule. The Verily sites will be closed for the full Thanksgiving weekend. Both OptumServe sites will be closed on Thanksgiving day, though the James Lick High School site will add Monday hours. All 4 state sites are free, but require appointments. Verily’s “Project Baseline” testing locations are primarily drive through sites; while the OptumServe sites are walk-up. See below for the full schedule: • Gardner Health Services: Mexican Heritage Plaza, 1700 Alum Rock Avenue, San José, 95116. Testing on Monday, November 23rd from 1pm to 7pm. For more information, call 408-457-7100. • Verily’s Project Baseline at Independence High School: 617 N. Jackson Ave., San José. Testing offered Sunday (11/22) from 9am to 1pm and Monday (11/23), Tuesday (11/24), and Wednesday (11/25) from 12pm to 6pm. Click here to schedule an appointment. • Verily’s Project Baseline at Mount Pleasant High School: 1750 S. White Road, San José. Testing offered Monday (11/23), Tuesday (11/24), and Wednesday (11/25) from 12pm to 6pm. Click here to schedule an appointment. • OptumServe at Gavilan College: 5055 Santa Teresa Blvd., Gilroy. Testing offered Monday (11/23), Tuesday (11/24), Wednesday (11/25) and Friday (11/27) from 7am to 7pm. Visit here or call (888) 634-1123 to schedule an appointment. • OptumServe at James Lick High School: 2951 Alum Rock Ave., San José. Testing offered Monday (11/23), Tuesday (11/24), Wednesday (11/25), Friday (11/27), and Saturday (11/28) from 7am to 7pm. Visit here or call (888) 634-1123 to schedule an appointment. Liaison Officer - County of Santa Clara Emergency Operations Center

Website: http://sccphd.org/coronavirus Facebook: https://www.facebook.com/sccpublichealth/ Instagram: @scc_publichealth Twitter: @HealthySCC The Bulletin | 7

2020 SCCMA Bioethics Committee Recap


he SCCMA Bioethics Committee’s stated purpose is “to educate our members regarding bioethical decision making, discuss bioethical issues, establish guidelines, advise government and industry leaders regarding the ethical aspects of health care policy, and to interact with other professional organizations.” The Committee is composed of representatives from the ethics committees of Santa Clara County hospitals. In addition to physicians of various specialties, our members include bioethicists, clergy, social workers, and members of the legal profession. The Covid-19 Pandemic has presented many logistical problems for us including the elimination of in person meetings and the reliance on remote communication for our meetings and contacts with our members. We have, however, continued to meet and address the important ethical issues presented by this healthcare crisis. In early March of this year, one of the members of the SCCMA Bioethics Committee, Dr. Richard Powers, proposed that our area hospitals be prepared to address the issue of Allocation of Scarce Critical Care Resources in a Pandemic. As a result of this suggestion, our committee investigated whether any State or County policies existed. It was determined that, in fact, no policies or guidelines existed. As a result, a model policy, with emphasis on ventilator allocation, was subsequently authored by several of our members from Good Samaritan Hospital. This model was to serve as an example for our committee members to take to their representative hospitals for consideration in the formulation of their own allocation policies. We drew on numerous resources from around the country including the New York Task Force on Life and Law, “Ventilator Allocation Guidelines”, the AMA Code of Medical Ethics, CDC publications, as well as sources from the University of Pittsburgh, Johns Hopkins University, Stanford University, and the University of Wisconsin among others. We also had input from our members, including our bioethicists, Drs. Margaret McLean and Ann Mongoven. We recognized that our member hospitals varied greatly in their patient populations, parent organizations, and governance structures. As a result, we felt that it would not be appropriate to establish an SCCMA allocation policy which might not be applicable to some institutions. The Allocation Policy, authored by the Good Samaritan members, was to be used as a model only, that could be taken by our committee members to their hospitals for consideration as they saw fit.

8 | The Bulletin

In discussing allocation policies, it was evident, of course, that many ethical issues required consideration. We thought it would be educational and relevant, in a separate document, to describe and discuss in detail the ethical principles which we thought necessary to be considered in establishing such an allocation policy. The document, “Ethical Principles to be Considered in Establishing Policies for Allocation of Scarce Medical Resources in a Public Health Emergency (In Response to the Covid-19 Pandemic)”, was the product of our Committee’s efforts. It may be accessed on the SCCMA website. Many hours were spent in creating this document, and we owe a great deal of thanks to the members of our Committee who selflessly and generously devoted their time and efforts. Specifically, we recognize Ann Mongoven, whose input was invaluable, as well as Drs. Richard Powers, Steven Jackson, Margaret McLean, Sulchana Lulla, Ann Segovia, and our Co-Chairs, Drs. Barry Brummer and Sonya Misra. The SCCMA Bioethics Committee is committed to providing our members and their hospitals with guidance in dealing with the very complex and difficult ethical situations which have arisen from the Covid-19 Pandemic. Our Committee will undoubtedly face many ethical issues related to the Covid-19 pandemic in the future. While the initial impetus for our work surrounded ventilator allocation procedures, there will likely be a shift toward allocation of therapeutics, such as vaccines and anti-viral drug therapies which may be subject to high demand and limited supply. The ethical principles outlined in our paper, however, will be just as applicable. We also look forward to presentations by our members regarding difficult cases and the ethical dilemmas they present to patients and their families and to the physicians who care for them. We will also address a re-examination of our Policy regarding unrepresented patients (those with no known surrogates) who have no decision-making capacity. We are grateful to all who have donated their time and effort toward achieving this goal. The Bioethics Committee Report, “Ethical Principles to be Considered in Establishing Policies for Allocation of Scarce Medical Resources in a Public Health Emergency (In Response to the Covid-19 Pandemic)”, can be found in full at: https://www.sccma. org/news-events/covid-19.aspx#81265-sccma-covid-19-resources.

Catching Overlooked Eating Disorders in Medical Settings BY KIMBERLY ROSANIA, PHD Clinical Instructor, Department of Psychiatry and Behavioral Sciences Stanford University Medical School


ating disorders (EDs) are serious psychiatric illnesses that cause significant impairments in quality of life, high rates of morbidity, and the highest mortality rate of any psychiatric illness (anorexia nervosa). Unfortunately, the majority of EDs go undiagnosed and untreated. This is particularly concerning given that EDs cause serious medical, social, and psychiatric disability; poor quality of life; and the highest mortality rates of any psychiatric illness. As such, an increased ability to identify potential EDs in patients and connect patients with specialty ED evaluation treatment is sorely needed. Medical providers have a unique opportunity to identify patients with ED symptoms and refer for specialty care if needed. Many patients with EDs do not present to mental health providers but may present in medical offices for medical complaints (related to unrelated to ED symptoms) or well visits. For instance, many ED patients experience anosagnosia, i.e., poor insight and awareness of their mental condition and the impairments they are experiencing. Other patients may be aware of their symptoms but ambivalent about seeking treatment, or interested in treatment but unable to access it. Among youth, medical sequelae of ED behaviors, rather than the ED behaviors themselves, are often what prompt parents to bring their child to a doctor. Eating Disorders Don’t Always Look Like What You Think

Many people still think of EDs as illnesses of thin, cisgendered, affluent Caucasian females. This is an outdated myth. In fact, people outside of this description may be at even higher risk for EDs than those who fit this stereotype. For instance, lower socioeconomic status is associated with higher, not lower, risk of EDs, and the LGBTQ+ community is at an elevated risk for EDs compared to their heterosexual counterparts. Additionally, it is increasingly being recognized that males suffer from EDs much more than previously understood, but they have largely been left out of research guiding diagnosis and treatment and may experience different symptom presentations than females. Research suggests that people of color may be just as likely to have EDs as Caucasian patients, but they are much less likely to receive treatment. It is critical that providers become aware of unintended bias in whether or not they consider an ED as a possible explanation for patient symptoms, as such bias in

detection may contribute to low treatment rates. Two “New”” Less Recognized Eating Disorders

In addition to mistakenly associating EDs with a narrow demographic, “eating disorder” is often synonymous in people’s minds with certain stereotypical symptoms: severe underweight (as in anorexia nervosa) or self-induced vomiting (as in bulimia). However, the field is increasingly recognizing that EDs present with a wide range of clinical manifestations, many of which do not involve these characteristics and thus may not draw a provider’s attention. In particular, two EDs introduced in the Diagnostic and Statistical Manual Fifth Edition are often unfamiliar to providers and may not raise concerns for an ED. Atypical anorexia nervosa Atypical anorexia nervosa is diagnosed when all criteria for anorexia nervosa (AN) are met (significant dietary restriction relative to body’s requirements, fear of weight gain or persistent behavior that interferes with weight gain despite malnourished state, body image disturbance), but despite significant weight loss, the patient’s weight is within or above a normal range. Studies with adolescents suggest that the physical and psychological morbidity in those with atypical AN is just as severe as in their underweight counterparts, and that severity of weight loss (amount, rate, duration), independent of weight status, predicted medical and nutritional status. For instance, in one study of adolescents with atypical AN, despite not being underweight at presentation, nearly 1 in 4 adolescents had bradycardia, 1 in 3 had amenorrhea, and over 40% required admission to the hospital. As such, providers cannot rely on current weight to guide clinical concern. Moreover, given obesity prevention efforts, providers should be mindful of accidentally overlooking ED behaviors in individuals with high weight. Indeed, people who are overweight tend to be more likely to experience ED symptoms and may unknowingly develop an ED during their attempts to lose weight. It is not unusual for these behaviors and subsequent weight loss to mistakenly be praised and reinforced by providers, as patients and providers both may misperceive them as the patient making progress towards obesity-related health goals. In high weight patients, severe dietary restriction, preoccupation with eating, exercise, and body weight, and fear of weight gain may The Bulletin | 9

be mistaken as appropriate rather than pathological and causing significant distress and functional impairment. Avoidant/restrictive food intake disorder (ARFID) ARFID is an ED also introduced in the DSM5 that describes a wide range of eating difficulties which often onset in childhood (but can last through adulthood). Individuals with ARFID experience eating problems that cause persistent failure to meet appropriate nutritional and/or energy needs. For example, patients may present with serious nutritional deficiencies, a reliance upon liquid supplements or enteral feeding, faltering growth or failure to gain weight as would be expected, or psychosocial impairments. However, these eating problems are not driven by body image concerns. Instead, research suggests there may be three general underlying reasons for restriction among these patients, and patients may experience only one or multiple. First, some patients’ restriction is driven by persistent low appetite; these patients often describe a lifelong lack of interest in food and often had feeding difficulties as early as infancy. Second, restriction may be driven by sensory sensitivity to particular tastes, appearance, or texture of food; these patients are often described as severe “picky eaters” since childhood and restriction can include particular brands or presentations of food. Third, restriction may be driven by fear of aversive consequences of eating (e.g., vomiting, choking); these are patients who often were eating normally until an aversive incident with food (e.g., food poisoning, choking) that prompted them to drastical-

ly alter their diet out of fear of such an incident recurring. ARFID can cause significant distress and functional impairment, and it tends not to remit without intervention. Although no evidence-based treatments yet exist for ARFID, several psychotherapy treatments under investigation have shown promise. Conclusions

Be open to the possibility of an eating disorder as an explanation for patient presenting complaints, regardless of patient demographic or weight status. When a patient presents with eating restriction even without body image concerns, such as severe picky eating that they have not grown out of, that seems to be causing distress or impairment, they may benefit from a referral for an ED assessment. Where to learn more: • The Academy of Eating Disorders publishes a free guide for physicians highlighting critical points for early recognition and medical risk management in the care of individuals with eating disorders: https:// www.aedweb.org/resources/publications/medical-care-standards • Eating Disorders Resource Center is a local non-profit that promotes awareness, recovery, and advocacy of eating disorders, including free training for physician groups. Please contact them if interested! http://edrcsv. org/

A Message from the President, from page 3 we have about 10 years to reverse course. A lot can be done to reduce the carbon going into the atmosphere with a shift to renewables, improvement in fuel efficiency standards, increasing solar energy, taxing carbon and shifting to green jobs. We all can participate by measuring our own carbon footprint, flying less, planting trees, protecting forests, eating a more plant-based diet, practicing restorative agriculture, restoring nature, having one fewer child and considering a shift towards a voluntary simplicity approach rather than mass consumption. It all makes a difference. Think globally but adapt locally. In This Issue

This issue of the Bulletin features articles by Dr. Santosh Pandipati and Dr. Larry Brummer. Dr. Pandipati, a member of our Environmental Health Committee, discusses global climate change. He gives one of the most compelling and inspiring talks I have ever heard on the subject of global warming, focusing on the impacts to women’s reproductive health, his specialty as a Maternal-Fetal Medicine Specialist. Stay tuned for his not-to-be-missed presentation next year through the SCCMA. Dr. Barry Bummer, Chair of our Bioethics Committee, has put together a stellar group of physicians and community leaders to tackle the most personally difficult areas to discuss, ethics in the practice of medicine. The committee has looked at issues ranging from advanced health directives to allocation of scarce resources

in a public health emergency, a timely topic they completed during this COVID pandemic. Their research has been in depth and with the input of national experts on the subject. We appreciate Dr. Brummer’s article as well as his guidance in these complex matters that require communication and compassion, unique and essential skills of a physician. 2021

To address these issues, the SCCMA in 2021 will be focusing on developing programs to look at diversity and equity, environmental health, climate change and physician well-being, as well as continuing our COVID Task force to confront the next wave of COVID -19. The California Medical Association will continue to lead efforts to help all physicians in California in all specialties and modes of practice get through this difficult time. Practice webinars and wellness programs for John Wooden physicians are already offered. The health of our nation rests on the physical and mental health of our courageous physicians along with a sustainable healthcare system. We are grateful for the efforts of the CMA. We invite you to join one of our committees and be part of the solution. Let’s roll up our sleeves together, envision the world we want to see and change the course of the future, however daunting it may seem. We will take it one fast step at time. The next generation is waiting on the track, watching us and ready to grab the baton.

“If we fail to adapt, we fail to move forward.”

98 | The Bulletin

The Bulletin | 11



As 2019 concluded, reasonable assumptions about 2020 began to emerge. The year was expected to be busy and more polarizing due to the presidential election occurring in November. Large-scale issue-based campaigns calling for new state programs supported by the expected state budget surplus were being announced. State legislators ZHUH¿QDOL]LQJWKHLUOHJLVODWLYHSDFNDJHV$QGODVWO\WKH California Medical Association (CMA) was preparing to defeat yet another attempt to eliminate the cap on noneconomic damages incorporated in Californiaâ&#x20AC;&#x2122;s longstanding professional liability reform law, the Medical Injury Compensation Reform Act (MICRA). In March, the world changed, and California politics and the legislative process went through an unprecedented transformation. On March 19 Governor Gavin Newsom issued the nationâ&#x20AC;&#x2122;s ¿UVWVWDWHZLGHVWD\DWKRPHRUGHULQUHVSRQVHWRWKHDUULYDO

of the novel coronavirus (SARS-coV2) in California. All nonessential businesses, such as restaurants, entertainment centers/activities, etc., were immediately shut down until IXUWKHUQRWLFH7KH6WDWH/HJLVODWXUHZDVIRUFHGWRWDNH multiple extended recesses, and all in-person lobbying was prohibited, leading to the cancellation of CMAâ&#x20AC;&#x2122;s annual Legislative Advocacy Day. 7KHOHJLVODWLYHSURFHVVZDVFRPSOHWHO\XSHQGHG&0$VWD൵ ZRUNHGGLOLJHQWO\WRDGMXVWWRHYHUFKDQJLQJG\QDPLFVDV both houses of the Legislature scrambled to implement social distancing guidelines and condense their calendars. In the end, CMA successfully maintained state funding for physician services, defeated proposals to increase or add new administrative burdens onto physicians, and secured a number of Executive Orders to protect medical practices as WKH\IDFHGDSDQGHPLFXQOLNHDQ\VHHQLQWKHSDVWFHQWXU\

cmadocs.org | Page 1 9: | The Bulletin

However, CMA did not escape the legislative session unscathed. The legislature passed, and the governor signed ǸǚǰĹ ŢZKLFKFUHDWHGWZRQHZFODVVLÂżFDWLRQV for nurse practitioners (NP). While this measure was SDVVHGLQWRODZWKLVPDWWHULVIDUIURPVHWWOHGDVWKHÂżJKW to ensure patient safety now moves into the regulatory process. All of CMAâ&#x20AC;&#x2122;s advocacy centers have prioritized this issue, developed an action plan, and are coordinating with the American Medical Association (AMA) as well as various specialty associations to ensure the bill is implemented in a manner that protects patients and physician practices. BUDGET â&#x20AC;&#x201C; ACCESS TO CARE California began this year with a strong economy, historic reserves and a projected surplus of $5.6 billion. Due to WKH&29,'SDQGHPLFWKHVWDWHÂśVHFRQRP\WRRND VLJQLÂżFDQWKLWZKLFKPHDQWWKH*RYHUQRUKDGWRPDNH VHYHUDOGLŕľśFXOWGHFLVLRQVZKHQUHYLVLQJKLVSURSRVHG budget in May. The Governorâ&#x20AC;&#x2122;s May Revision was a complete redrafting of the state budget proposal released on January 10, 2020. In January, the budget proposal increased our stateâ&#x20AC;&#x2122;s investment in health care, which included growing &DOLIRUQLDÂśVSK\VLFLDQZRUNIRUFH7KH0D\%XGJHW Revision, however, sought to reverse course, proposing to cut Proposition 56 funding for increased physician UHLPEXUVHPHQWVUHGXFHSDWLHQWEHQHÂżWVLQ0HGL&DODQG VWULNHDOOLQYHVWPHQWVVHHNLQJWRH[SDQGWKHSK\VLFLDQ ZRUNIRUFH7KURXJKWKHEXGJHWSURFHVVLQWKH/HJLVODWXUH CMA was able to protect: â&#x20AC;˘

ȨǹŠDz   in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, non-emergency medical transportation and value-based payments. This includes the continuation of all future cohorts of the Proposition 56 Physician and Dentist Loan Repayment Program (years 2-5 of the 5-year program).


ȨǹŠǾ   in General Fund monies to maintain the Proposition 56 Graduate Medical Education program at an ongoing total of $40 million.





   for individuals diagnosed with a maternal mental health condition.

Through the budget process in the Legislature, CMA was able to protect $1.2 billion in Proposition 56 (tobacco tax) funding, which provides supplemental payments for physician and dental services, family health services, developmental screenings, nonemergency medical transportation and value-based payments. In addition, the revised budget proposal included a 47% LQFUHDVHWRWKH0HGLFDO%RDUGRI&DOLIRUQLDÂśVSK\VLFLDQ and surgeon licensing fee. Through CMAâ&#x20AC;&#x2122;s advocacy, the Legislature rejected that proposal. Still, the Legislature could revisit the discussion in 2021 when the Medical %RDUGLVVXEMHFWWRDUHYLHZRIDOORILWVRSHUDWLRQV through the Sunset Review process. It is anticipated that WKH0HGLFDO%RDUGZLOOVHHNDOLFHQVHIHHLQFUHDVHLQWKH context of that process. SURPRISE BILLING â&#x20AC;&#x201C; AB 72 FIX 6LQFHWKHLPSOHPHQWDWLRQRI$% %RQWD UHODWHG WRVXUSULVHELOOLQJ&0$KDVEHHQZRUNLQJZLWKWKH Legislature to mitigate the negative impacts on the physician community. This year, DzǹǾǡĹ Ţ was introduced to address the issues surrounding the independent dispute resolution process (IDRP). Along with several specialty societies, CMA was able to secure amendments that allowed physicians to provide more substantial evidence to better defend their claims during an $%SD\PHQWGLVSXWH7KURXJK&0$ÂśVDGYRFDF\LQWKH legislative process and with the Department of Managed Health Care (DMHC) directly, an IDRP determination KDVEHHQLQWKHSK\VLFLDQÂśVIDYRUDÂżUVWVLQFHWKHODZ EHFDPHHŕľľHFWLYH+RZHYHURXUZRUNRQWKLVLVVXHGRHV QRWHQGWKHUH&0$FRQWLQXHVWRZRUNZLWKUHJXODWRUV and legislators to further ensure a process that is fair and accessible to any physician needing to use it. PUBLIC HEALTH Flavored tobacco products are often the entry point for young people who use tobacco. Over the last several \HDUVDVSLNHLQHFLJDUHWWHXVHDPRQJWKHQDWLRQÂśV\RXWK

cmadocs.org | Page 2 The Bulletin | 13

KDVEHHQOLQNHGWRWDUJHWHGDGYHUWLVHPHQWVRIÃ&#x20AC;DYRUHG tobacco. Menthol cigarettes, sweet cigars, candy vapes DQGRWKHUÃ&#x20AC;DYRUHGWREDFFRSURGXFWVVHUYHRQHSXUSRVH WRPDVNWREDFFR¶VKDUVKQHVVDQGJHWXVHUVKRRNHGWRD dangerous life-long addiction. In 2020, CMA combined forces with a large coalition of health care, youth and community organizations to support ǷǹdzŠŢ, which prohibits tobacco retailers, or any tobacco retailersâ&#x20AC;&#x2122; agents RUHPSOR\HHVIURPVHOOLQJR൵HULQJIRUVDOHRUSRVVHVVLQJ ZLWKWKHLQWHQWWRVHOORUR൵HUIRUVDOHDÃ&#x20AC;DYRUHGWREDFFR SURGXFWRUDWREDFFRSURGXFWÃ&#x20AC;DYRUHQKDQFHU7KLVEDQ includes e-cigarettes and vaping products, as well as WUDGLWLRQDOWREDFFRSURGXFWV6%FURVVHGWKHOHJLVODWLYH ¿QLVKOLQHDQGZDVTXLFNO\VLJQHGE\*RYHUQRU1HZVRP RQFHLWUHDFKHGKLVGHVN7KHQHZODZZLOOWDNHH൵HFWRQ January 1, 2021. DECREASING ADMINISTRATIVE BURDENS &0$ZRUNHGZLWK DzDzǵǷ to further address challenges for physician practices resulting from a bill passed ODVW\HDU $% WKDWPDGHVLJQL¿FDQWFKDQJHVWRWKH GH¿QLWLRQVRILQGHSHQGHQWFRQWUDFWRUVDQGHPSOR\HHVLQ an attempt to be consistent with the court decision in the '\QDPH[FDVH/DVW\HDU$%LQFOXGHGDQH[HPSWLRQ for physicians, but there continued to be a need to address business-to-business and referral agency arrangements. CMA successfully secured amendments to address those outstanding concerns, and the bill was signed into law. CMA also helped lead a coalition to defeat ǹǷǷ Å   Å¢, which sought to expand the California Attorney Generalâ&#x20AC;&#x2122;s existing authority related to mergers DQGDFTXLVLWLRQVLQWKHKHDOWKFDUHLQGXVWU\$OWKRXJK CMA policy supports governmental actions designed to HQVXUHKRVSLWDOPDUNHWFRPSHWLWLRQWKLVEURDGO\GUDIWHG OHJLVODWLRQHVWDEOLVKHGDZLGHGH¿QLWLRQRIKHDOWKFDUH transactions, which included leasing and other medical FRQWUDFWLQJDUUDQJHPHQWV6%XOWLPDWHO\IDLOHGWR PRYHR൵WKH$VVHPEO\IORRU

CMA worked with Senator Dr. Richard Pan to exempt independent medical practices from the mandate, and secured physician involvement in future rulemaking and guidance on this issue and supply chain sustainability.

,QDGGLWLRQWRWKHDERYH&0$ZRUNHGZLWKPXOWLSOH OHJLVODWLYHR൶FHVWRVWRSWKHFUHDWLRQRIQHZDGPLQLVWUDWLYH burdens related to the COVID-19 pandemic. ǶǸǵ ŠŢUHTXLUHVHPSOR\HUVWRSURYLGHZULWWHQQRWL¿FDWLRQ within 24 hours to their employees if they were potentially H[SRVHGDWWKHZRUNSODFHWRDSHUVRQZKRKDV&29,' $VWKLVZRXOGKDYHUHTXLUHGSK\VLFLDQSUDFWLFHVWRUHSRUW this information daily, CMA secured amendments that exempted employees who conduct COVID-19 testing or VFUHHQLQJRUWKDWSURYLGHGLUHFWFDUHWRLQGLYLGXDOVNQRZQ to have tested positive for COVID-19. This approach balanced CMAâ&#x20AC;&#x2122;s support for notifying employees of possible exposure and protecting physician practices from being overburdened. 6HQDWRU5LFKDUG3DQ0'LQWURGXFHGOHJLVODWLRQUHTXLULQJ WKHVWDWHDQGKHDOWKFDUHHPSOR\HUVWRSURFXUHDVWRFNSLOH RISHUVRQDOSURWHFWLYHHTXLSPHQW 33( DVDPHDQV RIDGGUHVVLQJIXWXUHHTXLSPHQWVKRUWDJHVOLNHWKHRQH experienced at the outset of the pandemic. As introduced, WKHELOOZRXOGKDYHFUHDWHGDVLJQL¿FDQWEXUGHQRQ LQGHSHQGHQWSK\VLFLDQSUDFWLFHV&0$ZRUNHGZLWK'U3DQ to exempt independent medical practices from the mandate, DQGVHFXUHGSK\VLFLDQLQYROYHPHQWLQIXWXUHUXOHPDNLQJ and guidance on this issue and supply chain sustainability. IMPLEMENTING TELEHEALTH At the onset of the statewide public health emergency, CMA ZRUNHGWREXLOGXSRQÇ·Ç´Ç´Å   Å&#x2019;Å&#x20AC;DzǰDZǹŢ, ZKLFKUHTXLUHGFRPPHUFLDOKHDOWKSODQVWRLPSOHPHQW payment parity for services provided via telehealth. An DVVRFLDWLRQZLGHDGYRFDF\H൵RUWDOORZHG&0$WRVHFXUH widespread payor coverage across the entire health care V\VWHPWKDWUHTXLUHGDOOFRPPHUFLDO0HGL&DODQGZRUNHUV¶ compensation payors to immediately cover telehealth services at the same rate as in-person services. To achieve WKLVRXWFRPH&0$ZRUNHGZLWKHDFKLQGHSHQGHQW agency and department to ensure consistency between the DMHC and the Department of Health Care Services (DHCS) as well as the California Department of Insurance &', DQGHPSOR\HUVXQGHUWKH'HSDUWPHQWRI:RUNHUV¶ Compensation (DWC). Each agency continued to post updated guidance consistent with CMAâ&#x20AC;&#x2122;s input, and often UHIHUHQFHG&0$¶VVSRQVRUHGWHOHKHDOWKOHJLVODWLRQ $% 744) as their models. CMA also advocated for the Governor to waive existing ODZVUHTXLULQJFRQVHQWSULRUWRSURYLGLQJWHOHKHDOWK services. During the COVID-19 state of emergency, these waivers ensure that no enforcement action would be authorized against covered health care providers providing telehealth services via remote communication technologies that may not fully comply with these privacy laws. CMA was successful in receiving these waivers at the state and federal levels.

cmadocs.org | Page 3 9< | The Bulletin

DECREASING LIABILITY FOR MEDICAL PRACTICES &0$ZRUNHGZLWKDFRDOLWLRQRIKHDOWKFDUHDQGRWKHU business organizations to defeat DzǾǡǰĹ Ţ. This bill would have exposed physicians and their practices to IULYRORXVODZVXLWVPDNLQJLWPRUHGLŕľśFXOWIRUSK\VLFLDQV to maintain the viability of their practices. SCOPE OF PRACTICE As discussed earlier,   Ć?Ǹǚǰ creates two new categories of nurse practitioners, who would be allowed to provide services ZLWKRXWVWDQGDUGL]HGSURFHGXUHV'HVSLWHWKHIHUYHQWZRUN of CMA, the AMA and numerous specialty societies, the bill passed the legislature and was enacted in law. The bill does not eliminate physician supervision and leaves room for interpretation regarding the role supervision can still play in the physician-NP relationship. It should also be QRWHGWKDWH[LVWLQJ13VDUHQRWLPSDFWHGE\$%DQG must continue practicing under standardized procedures. In addition, the measure includes a delayed implementation of three years to allow for the completion of the regulatory process. A detailed factsheet on this bill can be found on the CMA website at cmadocs.org. 'HVSLWHWKLVVHWEDFNWKHÂżJKWWRSURWHFWSDWLHQWVDIHW\ZLOO now roll into the regulatory process. CMA will continue to ZRUNLQWDQGHPZLWK$0$DQGRXUJUDVVURRWVQHWZRUNWR NHHSSK\VLFLDQVHQJDJHGRQWKLVLVVXH

CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice.

UNCERTAINTY CONTINUES $OWKRXJKWKHOHJLVODWLYHVHVVLRQKDVÂżQDOO\ concluded, uncertainty continues. In November, a new ÂżVFDORXWORRNZLOOUHYHDOZKHWKHUWKHVWDWHEXGJHWLVVWLOO facing a multi-billion shortfall. December will provide an idea of whether the Legislature will reopen the Capitol and allow for in-person lobbying. The political process will continue to be uncertain. However, there will be a consistent truth among all the unpredictable chaos: CMA will always be in the midst of every critical political and legislative battle, utilizing our resources to advance an agenda that protects physician practices and empowers the physician voice. 2QWKHIROORZLQJSDJHV\RXZLOOÂżQGGHWDLOVRIWKHPDMRU bills that CMA followed this year. In unity,

Janus L. Norman CMA Senior Vice President Centers for Government Relations and Political Operations

For more details on the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2020. Subscribe to CMAâ&#x20AC;&#x2122;s free biweekly Newswire and stay informed on CMAâ&#x20AC;&#x2122;s OHJLVODWLYHHয়RUWVDQGRWKHULVVXHVFULWLFDOWRWKHSUDFWLFHRI medicine at cmadocs.org/subscribe.

In other scope developments, CMA and the American College of Obstetricians and Gynecologists (ACOG) UHVROYHGDORQJVWDQGLQJLVVXHZLWKWKHFHUWL¿HGQXUVH midwives (CNM) through ǹDzdzǡŠŢ. This bill FUHDWHVDIUDPHZRUNIRU&10VWRSHUIRUPFHUWDLQIXQFWLRQV within the scope of midwifery independently while maintaining a collaborative relationship with a physician DQGVXUJHRQ7KHPHDVXUHDOVRLQFOXGHVDUHTXLUHPHQW for informed patient consent as well as patient outcome UHSRUWLQJUHTXLUHPHQWV

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The Earth has a Fever: A MaternalFetal Medicine Physician’s Perspective on Climate Change SANTOSH PANDIPATI, MD Obstetrix Medical Group of San Jose (Mednax)

Recently, I delivered a mother at 24 weeks gestation via classical C-section for preterm labor, ruptured membranes, and beech fetal lie - bread and butter for a practicing maternal-fetal medicine physician. I knew our superb neonatal team would do their very best to reduce morbidity and mortality risk for the neonate, and if lucky, the baby would be discharged from the NICU many months hence, ideally with minimal longterm physical and neurologic sequelae. I thought of the enormous cost and efforts of a whole host of clinical workers, from physicians to nurses to all kinds of therapists to countless others, that would be invested into ensuring that a single human being would be given the best chance to survive with a decent quality of life. As with all such cases, that would of course not be the end of care for that baby, but just the start, and with success, the child would eventually become an independent and VHOIVXIƓFLHQWKXPDQEHLQJ7KLVZKROHIXWXUHYLVLRQUROOHGRXW in my mind as I was delivering her, and I pondered the thousands of times every year a similar story would be repeated in the United States alone. I wondered about the world that child would grow up in, and whether that world would truly be able to sustain her, much less my own children. I was struck by the hypocrisy of all the arduous efforts we make in safeguarding the most premature of human beings while we as a global civilization existentially jeopardize the wellbeing of all future generations from our use of fossil fuels.

© Can Stock Photo / SeredaGanna

9> | The Bulletin

Climate Truths

The key points about the climate crisis are quite simple. The Earth is unequivocally warming due to rising levels of atmospheric greenhouse gases (GHG) from human activities (1,2). The primary culprit is carbon dioxide (CO2), the rise of which is unprecedented during the entire period of Homo sapiens’ evolution over the past several hundred thousand years (3-6). Carbon dioxide concentrations were last at their current levels 15-20 million years ago, when average temperature and

include: sea level rise; ocean acidification; more intense droughts, flooding, and storms; more frequent hot and fewer cold extremes, resulting in increased frequency and intensity of heatwaves; and more wildfires as well as extreme weather events (1,2,11). The magnitude of these effects will ultimately depend on what steady-state level of GHGs are achieved, and thus, what average temperature eventually results. However, it will take thousands of years to achieve equilibrium, and there will be no “new normal” with regards to climate within the life-

Picture of the sky taken September 9, 2020 from the author’s home in Los Gatos, CA during recent wild˾ȸƺɀ٫

sea level were respectively ~3-6°C and 25-40 meters higher than they are today (7). Alarmingly, there has been an acceleration in GHG emissions since the first UN Intergovernmental Panel on Climate Change (IPCC) report published in 1990, with more than half of all historical CO2 emissions having been released in the past 30 years. Matching this trend, the warmest years on record have occurred since 1970, with ten having occurred since 1998, and the five warmest years being 2015-2019 (8-10). With unabated “business-as-usual” human activity, current projections by the IPCC portend that by 2100 CO2 concentrations will reach levels nearly 2.5 times higher than 2019 levels, resulting in average surface temperature increase by more than 3-4°C. The ongoing as well as anticipated impacts of climate change

times of any human beings who are currently alive, nor will there likely be for tens to hundreds of generations. All of these altered environmental conditions pose dire threats to the habitability of the planet, and the survivability of life as we know it. Indeed, the negative impact on Earth’s flora and fauna from climate change is already underway. It is estimated that up to 1 million species of plant and animal species are now facing the risk of extinction this century, and the current rate of extinction is already tens to hundreds of times higher than that seen over the past 10 million years (12). Besides this current mass extinction, there have been five other major mass extinctions in the history of life on Earth. Alarmingly, four of these five mass extinctions have now been linked to the emissions of greenhouse gases from The Bulletin | 17

geophysical processes (13,14). There is nothing in the record of life on Earth to reassure us that humanity has any protected or sacred place in the evolutionary tree; our species will be vulnerable to climate change just as countless millions of other species have been and will be in the future. Impacts on Human Health: We Don’t Live in a Bubble

Impacts on Vulnerable Populations: Women’s Health

The populations who will feel the initial brunt of climate change will be the most societally disadvantaged. These populations are invariably poor and are already living in environmentally marginal circumstances (18). 18 | The Bulletin

© Can Stock Photo / RaStudio

Anticipated adverse impacts due to climate change specific to human health are wide-ranging, and include increased exposures to extreme weather events, including wildfires, droughts, flooding, and extremes of temperature; altered food-, water-, and vector-borne infectious disease; reduced food, water and air quality; decreased food security; and most alarmingly, mass migration of billions of people due to political, economic, and resource instability leading to loss of access to healthcare resources and further exacerbating the collapse of public infrastructure (1,2,11,14-17). Some of the effects on morbidity and mortality include (15,16): • direct effects, including death from heat, heat stress, and heat stroke • direct injuries, loss of life, and depression and anxiety from extreme weather events • poor air quality leading to respiratory complications (such as asthma, allergies) as well as cardiovascular disease • poor water quality and lack of access to clean water leading to increased diarrheal diseases such as cholera • food insecurity from rising levels of CO2 leading to decreased levels of protein, micronutrients, and B vitamins (and hence, nutritional quality) of rice, wheat, and other crops, as well as reduced yields of vegetables and legumes, in turn leading to undernutrition, stunted childhood growth, and vulnerability to non-communicable diseases • geographic spread of mosquitoes and other vectors that can disseminate diseases such as malaria, dengue, yellow fever, Zika virus, etc. • repercussions from climate-induced migration, including adverse mental health outcomes, lack of access to reliable healthcare, food and water, and violence

Among such populations, women have been recognized as a uniquely vulnerable group, which is of particular interest to me as a maternal-fetal medicine physician. Examples of adverse health effects to be felt disproportionately by women include (19-24): • respiratory and cardiovascular disease from greater exposure to poor-quality air, especially due to particulate air pollution from both indoor sources (e.g., cooking and heating sources), as well as from outdoor environmental sources • anemia and malnutrition from food insecurity and increased nutritional needs due to childbearing and menstruation • pregnancy-related complications (e.g., intrauterine growth restriction, preterm birth, congenital anomalies, stillbirth) • lack of access to prenatal care, contraception, and family planning options • physical and sexual violence, as well as anxiety, depression, and other mood disorders related to climate-induced migration and environmental disasters Women mediate the interplay between population growth and climate change through their reproductive behaviors, which is where the role of women’s health providers becomes crucial. If contraception were more readily available and distributed to millions of women who desire reproductive autonomy in both developed and developing regions, CO2 emissions could be reduced by 30% by 2100 while simultaneously eliminating more than 100,000 maternal deaths per year, resulting in significant benefits not only for regions of the world with high fertility rates, but also with high levels of vulnerability to climate change such as Sub-Saharan Africa and South Asia (2,25-29). Meeting unmet contraceptive demand will result in a greater reduction in per capita emissions from developed nations than in developing nations. However, reducing fertility rates in developing nations would prevent the birth of millions of people who would inevitably become victims of the worst ravages of climate change, but also significant contributors to future GHG emissions due to increasing adoption of high GHG-emitting consumption lifestyles akin to those seen in developed nations (2,18,25). Women’s traditional role as family caregivers in many parts of the world places them in unique decision-making roles that can impact climate for better or worse, including in the use of appliances, purchases of household goods, establishment of family dietary habits and patterns, and the education and shaping of their children’s energy consumption habits (20). The modern

food production industry has significantly contributed to environmental degradation, climate change, and health crises due to insufficient food consumption in over 800 million people worldwide while also resulting in an epidemic of obesity, cancer, diabetes, cardiovascular disease, and other ailments in other parts of the world (30). Aligning the food industry and people’s food-eating habits to plant-dominant diets simultaneously promotes health, sustainability, and climate change mitigation. 1.5°C: Our Time is Limited and Yes, Healthcare Providers Have a Crucial Role to Play

© Can Stock Photo / RaStudio

Consideration of the interconnections between climate, population groups, and health is not in our usual mindset as healthcare providers, as we have historically focused on cultivating one-on-one relationships with our patients. However, more fervently advocating for interventions we have always emphasized—women’s empowerment over their own reproductive health, better diets and lifestyles to reduce risk for chronic medical illnesses such as cardiovascular disease, diabetes, and cancer, and reducing pregnancy-related complications to mother and fetus—brilliantly dovetails with the fight against climate change. But we must act quickly since we will have to limit temperature increase to 1.5°C by 2100 to avoid the worst outcomes. We can only emit 340 gigatons (Gt) of CO2 before we exceed our 1.5°C budget, which amounts to only 8–10 years of current emissions (31, 32). Amazingly, meeting the unmet demand for contraception, providing universal access to 12 years of education for all girls and women, and modifying our diets and lifestyles, have been estimated to collectively reduce global CO2 emissions by 212 Gt by 2050 (33) — enough reductions to “flatten the curve” of global warming and to buy us invaluable time to devise more definitive technological solutions. These interventions are well within the purview of healthcare providers. We can no longer ignore climate change as it threatens to undo all of our diligently-acquired gains in reducing women’s morbidity and mortality related to pregnancy, adverse neonatal outcomes, infectious diseases, and chronic medical illnesses. Additionally, the adverse health outcomes previously listed are not fixed in stone — they represent an initial phase of adversity to the human species, but this adversity will quickly become an existential threat as temperatures rise and tipping points are reached. In the past few years it has become apparent that rising heat will lead to increased rates of fetal congenital anomalies such as heart defects (34), and fetuses exposed in utero to natural disasters

such as Hurricane Sandy and Hurricane Katrina have altered neurodevelopmental outcomes and higher central adiposity, while their mothers having higher rates of anxiety, depression, and PTSD (35–37). Thus, it is clear that the climate crisis is already leading to a continuum of adverse health effects that will ripple across future generations of humanity with unpredictable effects (38). If we know all this already, what then will happen to human health as GHG and particulate emissions continue, warming continues, oceans rise, storms intensify, food and water become scarce, and people migrate in large fluxes leading to unprecedented economic and political calamities? Greta Thunberg famously stated that “our house is on fire.” From a physician’s point of view, it is more akin to the Earth having a fever. And what happens to a human body with a 1°C rise? And what happens if our temperature keeps going up? Our civilization, our agriculture, our species never evolved under the climactic conditions we will face in the coming century and beyond. It is far past time to ask if this uncontrolled experiment is one we truly want to conduct. Is there not enough “interim-analysis” data to abort this experiment now? Furthermore, just as other plant and animal species have their human advocates, aren’t healthcare providers the conservation biologists for humanity itself? And for the critics who still willfully choose to disbelieve scientific facts as they have come to be unequivocally known, it is imperative to emphasize that the solutions proposed to combat the climate crisis will actually lead to a better world than before. Fighting climate change is not, and does not have to be, a zero-sum game. As human beings, we alone in the vastness of the universe are aware of our own physical limitations in space and our mortal limitations in time. Despite these constraints we somehow possess an unmatched and remarkable capacity for insight that can allow us to transcend these very spatial and temporal boundaries. If only for this reason the persistence of our individual and collective human consciousness has the utmost meaning and importance. Indeed, this provides a more than sufficient reason to fight for the survival of our species—including that of a 24-week premature infant. Climate change-mediated effects will pose far greater dangers to the well-being of all humans than any traditional ailments or public health threats that we have historically targeted for intervention. Exactly what we do as a species, how we do it, and how quickly we do it will be the key determinants of humanity’s survival in the face of what has become no less than an existential crisis. Our individual time is limited and precious, and The Bulletin | 19

now it seems, perhaps so too that of our species. Healthcare providers have an opportunity, as well as an ethical obligation, to be a part of the solution. References









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USGCRP, 2017: Climate Science Special Report: Fourth National Climate Assessment, Volume I [Wuebbles, D.J., D.W. Fahey, K.A. Hibbard, D.J. Dokken, B.C. Stewart, and T.K. Maycock (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, 470 pp., doi: 10.7930/J0J964J6. IPCC, 2014: Climate Change 2014: Synthesis Report. Contribution of Working Groups I, II and III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Core Writing Team, R.K. Pachauri and L.A. Meyer (eds.)]. IPCC, Geneva, Switzerland, 151 pp. Keeling CD, Piper SC, Bacastow RB, Wahlen M, Whorf TP, Heimann M, Meijer HA. Atmospheric CO2 and 13CO2 exchange with the terrestrial biosphere and oceans from 1978 to 2000: observations and carbon cycle implications. In: Ehleringer JR, Cerling TE, Dearing MD, eds. A History of Atmospheric CO2 and its Effects on Plants, Animals, and Ecosystems. New York, NY: Springer Verlag; 2005:83-113. MacFarling M, Etheridge CD, Trudinger C, et al. The Law Dome CO2, CH4 and N2O Ice Core Records Extended to 2000 years BP. Geophysical Research Letters 2006;33(14):L14810 10.1029/2006GL026152. Lüthi D, Le Floch M, Bereiter B, et al. 2008. High-resolution carbon dioxide concentration record 650,000-800,000 years before present. Nature 2008;453: 379-82. The Timetree of Life. S. Blair Hedges and Sudhir Kumar (Editors). Oxford University Press, New York. 2009. Tripati AK, Roberts CD, Eagle RA. Coupling of CO2 and Ice Sheet Stability Over Major Climate Transitions of the Last 20 Million Years. Science 2009;326(5958):1394-7. GISTEMP Team, 2019: GISS Surface Temperature Analysis (GISTEMP). NASA Goddard Institute for Space Studies. Dataset accessed 2019-05-08 at https://data.giss.nasa.gov/gistemp/. Hansen J, Ruedy R, Sato M, Lo K. Global surface temperature change, Rev. Geophys. 2010;48: RG4004, doi:10.1029/2010RG000345.

10. NOAA National Centers for Environmental Information, State of the Climate: Global Climate Report for Annual 2018, published online January 2019, retrieved on May 8, 2019 from https://www.ncdc. noaa.gov/sotc/global/201813. 11. USGCRP, 2018: Impacts, Risks, and Adaptation in the United States: Fourth National Climate Assessment, Volume II [Reidmiller, D.R., C.W. Avery, D.R. Easterling, K.E. Kunkel, K.L.M. Lewis, T.K. Maycock, and B.C. Stewart (eds.)]. U.S. Global Change Research Program, Washington, DC, USA, 1515 pp. DOI:10.7930/NCA4.2018 12. Diaz S, Settele J, Brondizio E. Global assessment report on biodiversity and ecosystem services of the intergovernmental science-policy platform on biodiversity and ecosystem services. 2019:bit/ly/ IPBESReport. 13. Brand U, Blamey N, Garbelli C et al. Methane Hydrate: Killer Cause of Earth’s Greatest Mass Extinction. Paleoworld 2016;25(4):496–507. 14. Peter Brannen. The ends of the world. New York:Harper Collins, 2017. 15. David Wallace Wells. The uninhabitable Earth: life after warming. New York:Penguin Random House 2019. 16. Haines A, Ebi K. The imperative for climate action to protect health. N Eng J Med 2019;380(3):26373. 17. Watts N, Amann M, Ayeb-Karlsson S, et al. The Lancet countdown on health and climate change: from 25 years of inaction to a global transformation for public health. Lancet 2018;391:581–630. 18. Stephenson J, Newman K, Mayhew S. Population dynamics and climate change: what are the links? J Pub Health Vol 2010;32(2):150-6. 19. Sorensen C, Murray V, Lemery J, Balbus J. Climate change and women’s health: Impacts and policy directions. PLoS Med 2018;15(7):e1002603. 20. Aguilar L, Granat M, Owren C. (2015). Roots for the future: the landscape and way forward on gender and climate change. Washington, DC: IUCN & GGCA. 21. Glemarec Y, Qayum S, Olshanskaya M. Leveraging co-benefits between gender equality and climate action for sustainable development: mainstreaming gender considerations in climate change projects. UN Women, October 2016. 22. Potts M, Henderson C. Global warming and reproductive health. Int J Gyn Obstet 2012;119:564-7. 23. Kuehn L, McCormick S. Heat exposure and ma-














Warming. New York, NY:Penguin Books 2017. Zhang W et al. Projected changes in maternal heat exposure during early pregnancy and the associated congenital heart defect burden in the United States. J Am Heart Assoc. 2019;8:e010995. DOI: 10.1161/JAHA.118.010995. Zhang W et al. Prenatal exposure to disaster-related traumatic stress and developmental trajectories of temperament in early childhood: Superstorm Sandy pregnancy study. J Aff Disorders 234 (2018) 335–345. Dancause et al., Prenatal stress due to a natural disaster predicts adiposity in childhood: the Iowa flood study. J of Obesity. Volume 2015, article ID 570541. Xiong et al. Hurricane Katrina experience and the risk of post-traumatic stress disorder and depression among pregnant women. Am J Disaster Med. 2010; 5(3):181–187. 38. Pacheco SE. Catastrophic effects of climate change on children’s health start before birth. J Clin Invest. 2020. https://jci. me/135005/pdf.

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ternal health in the face of climate change. Int. J. Environ. Res. Pub Health 2017;14:853. Bekkar B, Pacheco S, Basu R. Association of Air Pollution and Heat Exposure with Preterm Birth, Low Birth Weight, and Stillbirth in the US: A Systematic Review. JAMA Network Open. 2020;3(6):e208243. O’Neill B, Liddle B, Jiang L, et al. Demographic change and carbon dioxide emissions. Lancet 2012;380:157–64. John Guillebaud. Voluntary family planning to minimise and mitigate climate change. BMJ 2016;353:i2102. Stephenson J, Crane S, Levy C, Maslin M. Population, development, and climate change: links and effects on human health. Lancet 2013;382:1665–73. Ahmed S, Li Q, Liu L, Tsui AO. Maternal deaths averted by contraceptive use: an analysis of 172 countries. Lancet 2012;380:111–25. Diamond-Smith N., Potts M. A woman cannot die from a pregnancy she does not have. International Perspectives on Sexual and Reprod Health 2011;37(3):155-7. Willett W, Rockstrom J, Loken B, et al. Food in the anthropocene: the EAT-Lancet commission on healthy diets from sustainable food systems. Lancet 2019;393(10170):447-92. IPCC, 2018: Summary for Policymakers. In: Global Warming of 1.5°C. An IPCC Special Report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty [Masson-Delmotte, V., P. Zhai, H.-O. Pörtner, D. Roberts, J. Skea, P.R. Shukla, A. Pirani, W. Moufouma-Okia, C. Péan, R. Pidcock, S. Connors, J.B.R. Matthews, Y. Chen, X. Zhou, M.I. Gomis, E. Lonnoy, T. Maycock, M. Tignor, and T. Waterfield (eds.)]. World Meteorological Organization, Geneva, Switzerland, 32 pp. Hannah Ritchie and Max Roser (2020) - “CO2 and Greenhouse Gas Emissions”. Published online at OurWorldInData.org. Retrieved from: ‘https:// ourworldindata.org/co2-and-other-greenhouse-gasemissions’ [Online Resource]. Hawken P, editor. Drawdown: The Most Comprehensive Plan Ever Proposed to Reverse Global

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randon Hudgins works the main floor at Fleet Feet, a running-shoe store chain, for more than 30 hours a week. He chats with customers, measuring their feet and dashing in and out of the storage area to locate right-sized shoes. Sometimes, clients drag their masks down while speaking. Others refuse to wear masks at all. So he worries about COVID-19. And with good reason. Across the U.S., COVID hospitalizations and deaths are hitting record-shattering new heights. The nation saw 198,633 new cases on Friday alone. In California, COVID case counts are growing at the fastest rate yet. Unlike in the early days of the pandemic, though, many stores nationwide aren’t closing. And regular COVID testing of workers remains patchy at best. “I’ve asked, what if someone on staff gets symptoms? ‘You have to stay home,’” said Hudgins, 33, who works in High Point, North Carolina. But as an hourly employee, staying home means not getting paid. “It’s stressful, especially without regular testing. Our store isn’t very big, and you’re in there all day long.”

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To the store’s credit, Hudgins said the manager has instituted a locked-door policy, where employees determine which customers can enter. They sanitize the seating area between customers and administer regular employee temperature checks. Still, there’s no talk of testing employees for COVID-19. Fleet Feet did not respond to multiple requests to talk about its testing policies. The federal Centers for Disease Control and Prevention issued guidance to employers to include COVID testing, and it advised that people working in close quarters be tested periodically. However, the federal government does not require employers to offer those tests. But the board overseeing the California Division of Occupational Safety and Health, known as Cal/OSHA, on Thursday approved emergency safety rules that are soon likely to require the state’s employers to provide COVID testing to all workers exposed to an outbreak on the job at no cost to the employees. Testing must be repeated a week later, followed by periodic testing.

California would be the first state to mandate this, though the regulation doesn’t apply to routine testing of employees. That is up to individual businesses. Workplaces have been the source of major coronavirus outbreaks: a Foster Farms chicken-processing facility in the Central Valley town of Livingston, grocery stores in Los Angeles, a farmworker housing complex in Ventura County, Amazon warehouses — largely among the so-called essential workers who bear the brunt of COVID infections and deaths. The U.S. Occupational Safety and Health Administration inspects workplaces based on workers’ complaints — over 40,000 of which related to COVID-19 have been filed with the agency at the state and federal levels. In California, Cal/OSHA has cited 54 workplaces for COVID-related violations to date, amounting to more than $1.5 million in proposed penalties. Workers “have every right to be concerned,” said Dr. Peter Chin-Hong, an epidemiologist at the University of California-San Francisco. “They are operating in a fog. There is little economic incentive for corporations to figure out who has COVID at what sites.” Waiting for symptoms to emerge before testing is ill-considered, Chin-Hong noted. People can exhibit no symptoms while spreading the virus. A CDC report found that, among people with active infections, 44% reported no symptoms. Yet testing alone cannot protect employees. While workplaces can vary dramatically, Chin-Hong emphasized the importance of enforcing safety guidelines like social distancing and wearing face masks, as well as being transparent with workers when someone gets sick. Molly White, who works for the Missouri state government, was required to return to the office once a week starting in July. But White, who is on drugs to suppress her immune system, feared her employer’s “cavalier attitude toward COVID and casual risk taking.” Masks are encouraged for employees but are not mandatory, and there’s no testing policy or even guidance on where to get tested, she said. White filed for and received an Americans With Disabilities Act exception, which lasts through the end of the year, to avoid coming into the office. After a cluster of 39 COVID cases emerged in September in the building where she normally works, White was relieved to at least get an email notifying her of the outbreak. A few days later, Gov. Mike Parson visited the building, and he tested positive for COVID-19 soon after. Following pressure from labor groups, Amazon reported in a blog post last month that almost 20,000 employees had tested positive or been presumed positive for COVID-19 since the pandemic began. To help curb future outbreaks, the online retailing giant, which also owns Whole Foods, built its own testing facilities, hired lab technicians and said it planned to conduct 50,000 daily tests across 650 sites by this month. The National Football League tests players and other essential workers daily. An NFL spokesperson said the league conducts 40,000 to 45,000 tests a week through New Jersey-based BioReference Laboratories, though both organizations declined to share a price tag. Reports over the summer estimated the season’s testing program would cost about $75 million. Not all companies, particularly those not in the limelight, have the interest — or the money — to regularly test workers.

“It depends on the company how much they care,” said Gary Glader, president of Horton Safety Consultants in Orland Park, Illinois. Horton works with dozens of companies in the manufacturing, construction and transportation industries to write exposure control plans to limit the risk of COVID-19 outbreaks and avoid OSHA citations. “Some companies could care less about their people, never have.” IGeneX, a diagnostic testing company in Milpitas, California, gets around 15 calls each day from companies across the country inquiring about its employer testing program. The lab works with about 100 employers — from 10-person outfits to two pro sports teams — mainly in the Bay Area. IGeneX tests its own workers every other week. One client is Tarana Wireless, a nearby telecommunications company that needs about 30 employees in the office at a time to operate equipment. In addition to monthly COVID tests, the building also gets cleaned every two hours, and masks are mandatory. “It’s definitely a burden,” said Amy Beck, the company’s director of human resources. “We are venture-backed and have taken pay cuts to make our money extend longer. But we do this to make everyone feel safe. We don’t have unlimited resources.” IGeneX offers three prices, depending on how fast a company wants the results: $135 for a polymerase chain reaction (PCR) test with a 36- to 48-hour turnaround — down to around $100 a test for some higher-volume clients; one-day testing costs $250, and it’s $400 for a six-hour turnaround. In some cases, IGeneX is able to bill the companies’ health insurance plan. “Absolutely, it’s expensive,” said IGeneX spokesperson Joe Sullivan. “I don’t blame anyone for wanting to pay as little as possible. It’s not ‘one and done,’ which companies are factoring in.” Plus, cheaper, rapid options like Abbott’s antigen test, touted by the Trump administration, have come under fire for being inaccurate. For those going into work, Chin-Hong recommends that companies test their employees once a week with PCR tests, or twice a week with the less sensitive antigen tests. Ideally, Chin-Hong said, public health departments would work directly with employers to administer COVID testing and quash potential outbreaks. But, as KHN has reported extensively, these local agencies are chronically underfunded and overworked. Free community testing sites can sometimes take days to weeks to return results, bogged down by extreme demand at commercial labs like Quest Diagnostics and LabCorp and supply chain problems. Hudgins, who receives his health insurance through North Carolina’s state exchange, tries to get a monthly COVID test at CVS on his own time. But occasionally, his insurance — which requires certain criteria to qualify — has declined to pay for it, he said. “Being in the service industry in a state where numbers are ridiculously high,” he said in an email, “I see volumes of people every day, and I think getting tested is the smart and considerate thing to do.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. The Bulletin | :;

© Can Stock Photo / galitskaya

People Proving to Be Weakest Link for Apps Tracking COVID Exposure BY RAE ELLEN BICHELL | CALIFORNIA HEALTHLINE


he app builders had planned for pranksters, ensuring that only people with verified COVID-19 cases could trigger an alert. They’d planned for heavy criticism about privacy, in many cases making the features as bare-bones as possible. But, as more states roll out smartphone contact-tracing technology, other challenges are emerging. Namely, human nature. The problem starts with downloads. Stefano Tessaro calls it the “chicken-and-egg” issue: The system works only if a lot of people buy into it, but people will buy into it only if they know it works. “Accuracy of the system ends up increasing trust, but it is trust that increases adoptions, which in turn increases accuracy,” Tessaro, a computer scientist at the University of Washington who was involved in creating that state’s forthcoming contact-tracing app, said in a lecture last month. In other parts of the world, people are taking that necessary

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leap of faith. Ireland and Switzerland, touting some of the highest uptake rates, report more than 20% of their populations use a contact-tracing app. Americans seem not so hot on the idea. As with much of the U.S. response to the pandemic, this country hasn’t had a national strategy. So it’s up to states. And only about a dozen, including the recent addition of Colorado, have launched the smartphone feature, which sends users a notification if they’ve crossed paths with another app user who later tests positive for COVID-19. Within those few states, enthusiasm appears dim. In Wyoming, Alabama and North Dakota, some of the few states with usage data beyond initial downloads, under 3% of the population is using the app. The service, built by Google and Apple and adapted by individual countries, states or territories, either appears as a downloadable app or as a setting, depending on the state and the

device. It uses Bluetooth to identify other phones using the app within about 6 feet for more than 15 minutes. If a user tests positive for COVID-19, they’re given a verification code to input so that each contact can be notified they were potentially exposed. The person’s identity is shielded, as are those of the people notified. “The more people who add their phone to the fight against COVID, the more protection we all get. Everyone should do it,” Sarah Tuneberg, who leads Colorado’s test and containment effort, told reporters on Oct. 29. “The sky’s the limit. Or the population is the limit, really.” But the population could prove to be quite a limit. Data from early-adopter governments suggests even those who download the app and use it might not follow directions at the most critical juncture. According to the Virginia Health Department, from August to November, about 613 app users tested positive and received a code to alert their contacts that they may have exposed them to the virus. About 60% of them actually activated it. In North Dakota, where the outbreak is so big that human contact tracers can’t keep up, the data is even more dire. In October, about 90 people tested positive and received the codes required to alert their contacts. Only about 30% did so. Researchers in Dublin tracking app usage in 33 regions around the world have encountered echoes of the same issue. In October, they wrote that in parts of Europe fewer people were alerting their contacts than expected, given the scale of the outbreaks and the number of active app users. Italy and Poland ranked lowest. There, they estimated, just 10% of the app users they’d expect were submitting the codes necessary to warn others. “I’m not sure that anybody working in this field had foreseen that that could be a problem,” said Lucie Abeler-Dörner, part of a team at the Big Data Institute at Oxford studying COVID-19 interventions, including digital contact tracing. “Everybody just assumed that if you sign up for a voluntary app … why would you then not push that button?” So far, people in the field only have guesses. Abeler-Dörner wonders how much of it has to do with people going into panic mode when they find out they’re positive. Tessaro, the University of Washington computer scientist, asks if the health officials who provide the code need more training on how to provide clear instructions to users. Elissa Redmiles, a faculty member at the Max Planck Institute for Software Systems who is studying what drives people to install contact-tracing apps, worries that people may have difficulty inputting their test results. But Tim Brookins, a Microsoft engineer who developed North Dakota’s contact-tracing app as a volunteer, has a bleaker outlook. “There’s a general belief that some people want to load the app so that they can be notified if someone else was positive, in a self-serving way,” he said. “But if they’re positive, they don’t want to take the time.” Abeler-Dörner called the voluntary notification a design flaw and said the alerts should instead be automatically triggered. Even with the limitations of the apps, the technology can help identify new COVID cases. In Switzerland, researchers looked at data from two studies of contact-tracing app users. They wrote in a not-yet-peer-reviewed paper that while only 13% of people

with confirmed cases in Switzerland used the app to alert their contacts from July to September, that prompted about 1,700 people who had potentially been exposed to call a dedicated hotline for help. And of those, at least 41 people discovered they were, indeed, positive for COVID-19. In the U.S., another non-peer-reviewed modeling study from Google and Oxford University looking at three Washington state counties found that even if only 15% of the population uses a contact-tracing app, it could lead to a drop in COVID-19 infections and deaths. Abeler-Dörner, a study co-author, said the findings could be applicable elsewhere, in broad strokes. “It will avert infections,” she said. “If it’s 200 or 1,000 and it prevents 10 deaths, it’s probably worth it.” That may be true even at low adoption rates if the app users are clustered in certain communities, as opposed to being scattered evenly across the state. But prioritizing privacy has required health departments to forgo the very data that would let them know if users are near one another. While an app in the United Kingdom asks users for the first few digits of their postal code, very few U.S. states can tell if users are in the same community. Some exceptions include North Dakota, Wyoming and Arizona, which allow app users to select an affiliation with a college or university. At the University of Arizona, enough people are using the app that about 27% of people contacted by campus contact tracers said they’d already been notified of a possible exposure. Brookins of Microsoft, who created Care19 Alert, the app used in Wyoming and North Dakota, said that offering an affiliation option also allows people who’ve been exposed to get campus-specific instructions on where to get tested and what to do next. “In theory, we can add businesses,” he said. “It’s so polarizing, no businesses have wanted to sign up, honestly.” The privacy-focused design also means researchers don’t have what they need to prove the apps’ usefulness and therefore encourage higher adoption. “Here there is actually some irony because the fact that we are designing this solution with privacy in mind somehow prevents us from accurately assessing whether the system works as it should,” Tessaro said. In states including Colorado, Virginia and Nevada, the embedded privacy protections mean no one knows who has enabled the contact-tracing technology. Are they people who barely interact with anyone, or are they essential workers, interacting regularly with many people that human contact tracers would never be able to reach? Are they crossing paths and trading signals with other app users or, if they test positive, will their warning fall silently like a tree in an empty forest? Will they choose to notify people at all? Colorado’s health department said it’s issuing thousands of COVID codes a day. As of Wednesday, 3,400 people have used the codes to notify their contacts, it said. An automated system issues codes for positive COVID-19 tests even if the infected people don’t have the app, making it impossible to know how many users are acting on the codes. “I have hope that the vast majority of Coloradans will take this opportunity to give this gift of exposure notification to other people,” said Tuneberg. “I believe Coloradans will do it.” This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. The Bulletin | :=

AMA: Racism is a Threat to Public Health KEVIN B. O’REILLY News Editor | American Medical Association

Building on its June pledge to confront systemic racism and police brutality, the AMA has taken action to explicitly recognize racism as a public health threat and detailed a plan to mitigate its effects.

© Can Stock Photo / Deagreez

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“The AMA recognizes that racism negatively impacts and exacerbates health inequities among historically marginalized communities. Without systemic and structural-level change, health inequities will continue to exist, and the overall health of the nation will suffer,” said AMA Board Member Willarda V. Edwards, MD, MBA. “As physicians and leaders in medicine, we are committed to optimal health for all, and are working to ensure all people and communities reach their full health potential,” Dr. Edwards said. “Declaring racism as an urgent public health threat is a step in the right direction toward advancing equity in medicine and public health, while creating pathways for truth, healing, and reconciliation.”

To that end, the AMA House of Delegates (HOD) adopted new policy to: • Acknowledge that, although the primary drivers of racial health inequity are systemic and structural racism, racism and unconscious bias within medical research and health care delivery have caused and continue to cause harm to marginalized communities and society as a whole. • Recognize racism, in its systemic, cultural, interpersonal and other forms, as a serious threat to public health, to the advancement of health equity and a barrier to appropriate medical care. • Support the development of policy to combat racism and its effects. • Encourage governmental agencies and nongovernmental organizations to increase funding for research into the epidemiology of risks and damages related to racism and how to prevent or repair them. • Encourage the development, implementation and evaluation of undergraduate, graduate and continuing medical education programs and curricula that engender greater understanding of the causes, influences, and effects of systemic, cultural, institutional and interpersonal racism, as well as how to prevent and ameliorate the health effects of racism. Delegates also directed the AMA to: • Identify a set of current best practices for health care institutions, physician practices and academic medical centers to recognize, address and mitigate the effects of racism on patients, providers, international medical graduates, and populations. • Work to prevent and combat the influences of racism and bias in innovative health technologies. • Recognizing race as social construct In an additional move to promote anti-racist practices, the AMA discussed the use of race as a proxy for ancestry, genetics and biology in medical research and health care delivery. Delegates adopted new policy to: • Recognize that race is a social construct and is distinct from ethnicity, genetic ancestry or biology. • Support ending the practice of using race as a proxy for biology or genetics in medical education, research and clinical practice. The AMA also will encourage undergraduate medical education, graduate medical education and continuing medical education programs to recognize the harmful effects of presenting race as biology in medical education and that they work to mitigate these effects through curriculum change that: • Demonstrates how the category of “race” can influence health outcomes. • Supports race as a social construct and not a biological determinant. • Presents race within a socioecological model of individual, community and society to explain how racism and

systemic oppression result in racial health disparities. Delegates also directed the AMA to “recommend that clinicians and researchers focus on genetics and biology, the experience of racism, and social determinants of health—and not race—when describing risk factors for disease.”

Ending racial essentialism

In addition, the HOD took action to counteract the notion of racial essentialism, which is identified in a resolution presented at the Special Meeting as “the belief in a genetic or biological essence that defines all members of a racial category.” Delegates adopted new policy to: • Recognize that the false conflation of race with inherent biological or genetic traits leads to inadequate examination of true underlying disease risk factors, which exacerbates existing health inequities. • Encourage characterizing race as a social construct, rather than an inherent biological trait. • Recognize that when race is described as a risk factor, it is more likely to be a proxy for influences including structural racism than a proxy for genetics. The HOD also directed the AMA to: • Collaborate with the Association of American Medical Colleges, American Association of Colleges of Osteopathic Medicine, National Board of Medical Examiners, National Board of Osteopathic Medical Examiners, Accreditation Council for Graduate Medical Education, and other appropriate stakeholders— including minority physician organizations and content experts—to identify and address aspects of medical education and board examinations which may perpetuate teachings, assessments and practices that reinforce institutional and structural racism. • Collaborate with appropriate stakeholders and content experts to develop recommendations on how to interpret or improve clinical algorithms that currently include race-based correction factors. • Support research that promotes antiracist strategies to mitigate algorithmic bias in medicine. “The AMA is dedicated to dismantling racist and discriminatory policies and practices across all of health care, and that includes the way we define race in medicine,” said AMA Board Member Michael Suk, MD, JD, MPH, MBA. “We believe it is not sufficient for medicine to be nonracist, which is why the AMA is committed to pushing for a shift in thinking from race as a biological risk factor to a deeper understanding of racism as a determinant of health.” Previous action by delegates led to the creation of the AMA Center for Health Equity, led by AMA Chief Health Equity Officer Aletha Maybank, MD, MPH. Discover how the AMA is reshaping its path toward racial equity. Health care in the United States is beset by wide disparities. Learn more about what the AMA is doing to promote health equity for all Americans.

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How Healthcare Workers Can Stay Safer at Home & at Work during the COVID-19 Surge SARA H. CODY, MD RƺƏǼɎǝ…ǔ˾Ƭƺȸ County of Santa Clara Public Health Department


ur county entered the purple (most restrictive) tier in November, indicating that COVID-19 is again very widespread in our community; in fact, it is more widespread now than at any other time during this pandemic. Both the number of cases and hospitalizations have increased sharply and, at the time of this writing, show no signs of slowing. You probably know people who have had COVID-19, and you may be concerned about getting COVID-19 yourself and bringing it home to your family or friends. This letter shares some ways to stay safer at work and at home. Your health matters. Without you, important facilities like hospitals, long-term care facilities, jails, and shelters cannot safely operate. As we have experienced many times during this pandemic, outbreaks of COVID-19 spread rapidly within congregate settings. Now more than ever, your community is counting on you to stay healthy and practice COVID-19 safety precautions both at work and outside of work. Here are my best recommendations to protect yourself and the people you serve at work. Please share these recommendations with every employee in your organization. They are available in Spanish and Tagalog online at www.sccphd.org/ covidproviders. • I strongly urge you to cancel any travel plans you may have right away. Traveling puts you at higher risk of getting COVID-19. Your travel also puts your family, co-workers, and people you serve at risk, and may put your facility at risk of staffing shortages. Travel is risky because it is difficult to maintain distance from others outside of your household, and you are likely to come into contact with many people. Many people get COVID-19 from traveling. If you absolutely must travel, I strongly recommend that you self-quarantine at home for 14 days after return, especially if you were indoors with people you don’t live with, like visiting a relative in their home. Watch yourself for symptoms for 14 days and get tested around 3–6 days after returning.

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Gather safely and avoid being indoors with people you don’t live with. You may be wondering if it is safe to gather with loved ones you don’t live with. Any activity with people who do not live in your house or apartment increases your risk of catching the virus. (This includes eating with coworkers in a breakroom, which must be avoided.) Eating indoors with anyone you don’t live with is a high-risk activity because you have to remove your protective face covering to eat. Many people get COVID-19 from friends, relatives, and coworkers. The safest way to meet is virtually. If you must meet in person, keep it short (less than 2 hours), meet outside, sit more than 6 feet apart, keep your face covering on, and do not gather with more than two other households. Unsafe gatherings, especially when indoors without good ventilation (e.g. open windows), distancing, and masking, may also put your facility at risk of staffing shortages. • Get tested for COVID-19 regularly, and if you experience any symptoms of COVID-19, get tested right away—don’t wait. People look up to you. Set the right example by getting tested regularly. It protects the people you see at work and at home. If you test positive, there are programs to help you with rent and food while you isolate and recover. Testing is free and painless. Your employer may provide testing. Or, if you have health insurance, your regular doctor is required to test you. For anyone who does not have health insurance, or anyone who finds it more convenient, the County of Santa Clara offers many locations for free testing. Schedule a test at www.sccfreetest.org. If you have questions or need resources, calling 2-1-1 is a great place to start. They can route you to the right support. You can also visit www.sccphd.org/coronavirus. Keeping you healthy is important. Supporting you if you become sick is important too. The County of Santa Clara has resources available to you. Thank you for your service to our community.

Your Membership Offers Additional Savings on Already Low Rates! Preferred Employers Insurance workers’ compensation rates have the potential for savings to physicians. Santa Clara County Medical Association/ CMA members are eligible to save an additional 5%* because of their membership! SCCMA and CMA partner with Mercer Health & Benefits Insurance Services LLC and Preferred Employers Insurance to provide best-in-class Workers’ Compensation insurance that includes safety and risk management advice along with outstanding customer service and an easy to navigate website in the event of a claim. This program is already serving the needs of hundreds of California physicians. Have you considered the Safety, Service, Stability, and Savings, offered by Preferred?

Save today! It’s easy to get a quote. Visit CountyCMAMemberInsurance.com, call 800-842-3761 or email CMACounty.Insurance.service@mercer.com to request a premium indication form.

Sponsored by:

Underwritten by:

Administered by:


| a Berkley Company

* Most practices will qualify for group pricing and receive the 5% discount; however some practices will need to be underwritten separately when they do not qualify for the special program terms and conditions. A minimum premium applies to very small payrolls.

Program Administered by Mercer Health & Benefits Insurance Services LLC

CA Insurance License #0G39709 • Copyright 2020 Mercer LLC. All rights reserved. 633 West 5th Street, Suite 1200, Los Angeles, CA 90071 • 800-842-3761 CMACounty.Insurance.service@mercer.com • www.CountyCMAMemberInsurance.com • 90761 (7/20) The Bulletin | :A

AMA announces vaccine/,!%Ɯ+ !/"+. coronavirus immunizations


he American Medical Association (AMA) today published an update to the Current Procedural Terminology (CPT®) code set that includes new vaccine-specific codes to report immunizations for the novel coronavirus (SARSCoV-2). Working closely with the Centers for Disease Control and Prevention, the CPT Editorial Panel has approved a unique CPT code for each of two coronavirus vaccines as well as administration codes unique to each such vaccine. The new CPT codes clinically distinguish each coronavirus vaccine for better tracking, reporting and analysis that supports data-driven planning and allocation. Importantly, these CPT codes are available prior to the public availability of the vaccines to facilitate updating of health care electronic systems across the U.S. The new Category I CPT codes and long descriptors for the vaccine products are: • 91300: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted, for intramuscular use • 91301: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage, for intramuscular use • In accordance with the new vaccine-specific product CPT codes, the CPT Editorial Panel has worked with the Centers for Medicare and Medicaid Services to create new vaccine administration codes that are both distinct to each coronavirus vaccine and the specific dose in the required schedule. This level of specificity is a first for vaccine CPT codes, but offers the ability to track each vaccine dose, even when the vaccine product is not reported (e.g. when

;8 | The Bulletin

the vaccine may be given to the patient for free). These CPT codes report the actual work of administering the vaccine, in addition to all necessary counseling provided to patients or caregivers and updating the electronic record. The new vaccine administration CPT codes and long descriptors are: • 0001A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; first dose • 0002A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 30 mcg/0.3mL dosage, diluent reconstituted; second dose • 0011A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; first dose • 0012A: Immunization administration by intramuscular injection of Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, preservative free, 100 mcg/0.5mL dosage; second dose All of these new CPT codes will be available for use when these coronavirus vaccine receive Emergency Use Authorization or approval from the Food and Drug Administration. Additional information is available on the AMA website.

CA Congressman Ami Bera, M.D., Introduces Bill to Stop 2021 Medicare cuts


ongressmen Ami Bera, M.D., (D-CA) and Larry Bucshon, M.D., (R-IN) have introduced a bill to stop the looming Medicare payment cuts while protecting the primary care payment increases of the forthcoming Medicare physician payment rule. The bill – H.R. 8702, the “Holding Providers Harmless from Medicare Cuts During COVID-19 Act of 2020” – was drafted in response to the anticipated impact of the 2021 Medicare physician payment rule, scheduled to be released around Dec. 1, which will cause substantial payment cuts to some physicians. The California Medical Association (CMA) is urging physicians to contact their Members of Congress to cosponsor H.R. 8702. While the changes in the proposed rule would provide long overdue and much-needed payment increases for physicians delivering primary care and others who primarily provide evaluation and management (E/M) services, the law requires corresponding payment cuts. The Centers for Medicare and Medicaid Services (CMS) operates under a statutory “budget neutrality” rule that requires any increases in Medicare payments for these office visits to be offset by corresponding decreases. As a result, many physicians now face substantial cuts beginning on January 1, 2021, if Congress does not act before the end of the year. In the proposed rule, CMS estimated the impacts on specialties to range between -11% and +17%, depending on the mix of services provided. CMA, the American Medical Association (AMA), and a coalition of organizations representing physicians and allied health professionals sent a letter to Congressional leadership expressing support for H.R. 8702. CMA, AMA and the rest of organized medicine have been urging Congress to waive the budget neutrality requirement, or to at least postpone it during the COVID-19 pandemic, given the pandemic’s already severe impact on practice revenues.

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However, due to the budget impact and Congress’ concerns about setting a precedent of legislative intervention into statutory budget neutrality requirements, a total waiver is no longer being discussed. H.R. 8702 would effectively freeze payments at 2020 rates for services scheduled to be cut in 2021 for a period of two years, while allowing the planned E/M payment increases to take place as scheduled. It also allows physicians billing office visits without the new GPC1X add-on code for complex cases to avert payment cuts. At the end of the two-year reprieve, the full budget neutrality adjustment would take effect unless Congress enacts a longer-term solution. Importantly, according to the AMA analysis, all specialties will benefit from higher average payments under H.R. 8702. No specialty would experience a negative impact below 0% (as opposed to a cut of 11% under current law) and specialties anticipating total Medicare payment increases in 2021 will see additional increases. The legislation is broadly supported by physician organizations. The pandemic has hit all specialties hard, and there is no question that payment reductions in a program as important as Medicare threaten practice viability and must be stopped. According to a recent CMA survey, physician practice revenue is still down by 40% and COVID-19 related practice costs are up 14%. CMA supports H.R. 8702 because it is the best compromise under current circumstances, stopping very ill-timed Medicare payment cuts while allowing scheduled payment increases to move forward and protecting access to care during the pandemic and beyond. Please contact your Member of Congress and ask them to support and co-sponsor H.R. 8702, the “Holding Providers Harmless from Medicare Cuts During COVID-19 Act,” today!

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