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Vol. 27  |  No. 1   First Quarter 2021

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Official Magazine of the Santa Clara Medical Association

This issue:

COVID-19 VACCINES The Bulletin  |  1


CONTENTS  |  Vol. 27 | No. 1 | First Quarter 2021

© Can Stock Photo / panoramaimages

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  |  Clifford Wang, MD Past President  |  Seema Sidhu, MD VP-Community Health  |  Lewis Osofsky, MD VP-External Affairs  |  Larry Sullivan, MD VP-Member Services  |  Randal T. Pham, MD VP-Professional Conduct  |  Gloria Wu, MD Secretary  |  John Brock-Utne, MD Treasurer  |  Anh T. Nguyen, MD Chief Executive Officer  |  April Becerra, CAE CMA Trustee - District VII  |  Thomas M. Dailey, MD CMA Trustee - District VII  |  Kenneth Blumenfeld, MD

Councilors 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 O’Connor Hospital  |  David Cahn, MD Regional Medical Center | OPEN Saint Louise Regional Hospital  |  Scott Benninghoven, MD Stanford Health Care/Children’s Health  |  Sam Wald, MD Santa Clara Valley Medical Center  |  Harry Morrison, MD Opinions expressed by authors are their own, and not necessarily those of The Bulletin or SCCMA. The Bulletin reserves the right to edit all contributions for clarity and length, as well as to reject any material submitted in whole or in part. Acceptance of advertising in The Bulletin in no way constitutes approval or endorsement by SCCMA/ MCMS of products or services advertised. The Bulletin and SCCMA/MCMS reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Sameera Manucher, Managing Editor 700 Empey Way San Jose, CA 95128 760/671-2337 Fax: 408/289-1064 sameera@sccma.org © Copyright 2021, Santa Clara County Medical Association

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SCCMA NEWS & ANNOUNCEMENTS A Message from New SCCMA President, Dr. Cindy Russell

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SCCMA Environmental Health Spring Series 2021

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SCCMA Call for Environmental Articles

24

Features The Person Reluctant to Vaccination: Some Approaches

12

Black Americans Are Getting Vaccinated at Lower Rates Than White Americans

19

COVID 19 Meets Forever Chemicals: PFAS Vaccines Become Non-Stick?

24

Community News PHD Q1 Bulletin Article- COVID-19 Vaccine update from the County of Santa Clara Public Health Department 8 How to Talk to Patients about the Covid-19 Vaccine

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Classified Ads

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A Message from the President

SCCMA 2020 Awards: Incoming President’s Remarks Dr. Cindy Russell

by Cindy L. Russell, MD

SCCMA President

It is truly an honor and a privilege to be elected as the President of the Santa Clara County Medical Association, of which I have been a member for over 30 years. I would like to take a moment to first acknowledge that 2020 has been a challenging time, with COVID 19, shelter-in -place orders, wildfires and a contentious election. There has been a great deal of sacrifice, suffering and uncertainty.  We hope to find 2021 to be a better year. I follow a long line of distinguished Presidents, some of whom later became president of the California Medical Association such as Dr. Robert Burnett and Dr. Jim Hinsdale (who also became AMA President).  Dr. Tanya Spirtos is now Speaker of the House for the CMA. I thank them as well as all the past presidents before me for being ethical role models for all of us. I want to thank our CEO April Becerra for her hard work and efforts in this tumultuous time, running the Association, developing programs and collaborating with the CMA to help the physicians of this County, and improve the health and well-being of the community at large. This is the mission of the SCCMA. I also want to thank all the staff of the SCCMA for their diligence and long hours of work keeping everything organized and professional.  I thank our Executive Committee and Council for their wisdom and hours sitting through many Zoom meetings that can often go into overtime.  We have a strong diverse Council with different strengths, perspectives and contributions which makes for better decision making.  

One person I cannot fail to mention who has made this transition easier is our past president. Dr. Seema Sidhu. She is organized, thoughtful and has an incredible memory. Her continued presence and guidance has been critical. You learn quite a bit in this job in a short amount of time and passing the gavel is a longer-term proposition than a nod and a handshake, the latter which we do not do these days. I appreciate Dr. Sidhu’s continued involvement and look forward to working with her and our president-elect Dr. Clifford Wang in the coming year. The California Medical Association is Our Critical Ally I wish to thank the CMA for their continued efforts on our behalf in so many areas.  Next year there are several critical issues that will affect the practice of medicine, including the implementation of AB 890 Nurse Practitioner Scope of Practice, Medical reimbursement rates and MICRA. So stay tuned for updates and get involved. Most of all I want to thank my family for their love, support and patience. Without them I could not do any of this. I am fortunate to have a wonderful husband David, who is my rock on this journey, and my daughter Kayla who is a senior in high school working on college applications now. I am proud of her resilience, wisdom and humor. My family is my relaxation and inspiration.

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Some SCCMA History

The SCCMA was founded in 1876 by Dr. Benjamin Cory, San Jose’s first physician who rode on horseback to see his patients. Dr. Cory also founded the Santa Clara Valley Medical Center. Today the Santa Clara County medical Association is a 501(c)6 professional association affiliated with the California Medical Association representing over 4,500 physicians in all specialties, practice types, and stages of their careers with “the goal of improving the physician’s ability to deliver the best care possible.” Modern Medicine

Time traveling forward we see the increasing use of technology in medicine to diagnose as well as treat patients. We now take for granted the widespread use of robotic surgery. COVID-19 has moved us solidly into virtual visits. More change is to come but in the era of the electronic medical records and online physician visits we have to be vigilant to protect meaningful patient physician interaction which it turns out is our soul food as well as theirs.  A Sense of Place

The SCCMA is very fortunate to have a home and offices on Empey Way in San Jose, with the Valley Medical Center as our neighbor. The SCCMA has hosted high school and medical student seminars, suture labs and advanced cardiac life support classes in our building. We hope to resume these as the pandemic eases.   Environmental Health

I became involved with the SCCMA as a member of the SCCMA Environmental Health Committee over 30 years ago. As a breast reconstruction surgeon, I have witnessed the epidemic of breast cancer in younger women over these decades. After learning at one of our Environmental Health Committee meetings many years ago that there are dozens of bio-accumulative toxins in the environment that are stored in fat and found in breast milk I began to connect the dots between environmental health and public health. I learned that we are exposed to 100 common chemicals daily in consumer products that are associated with breast cancer.  They not only promote cancer but also contribute to neurologic decline, reproductive failure, immunologic dysfunction and can affect wildlife and the balance of nature. This prompted me to work on CMA policy recommendations along with our Environmental Health Committee to reduce pesticides, toxic antimicrobials such as triclosan, flame retardants, nanoparticles, endocrine disruptors such as Bisphenol A, fracking chemicals as well as addressing climate change. More recently I have examined the risks of wireless technology. A Multitude of Toxins Meet Our Fragile Biology

I have learned much over the years about toxins. Most of all that the interaction of chemicals and other toxins on our fragile biology is much more complex than we imagined. With so many exposures it has become difficult to sort out the contributions of each toxin to a chronic health disease but it still remains important to reduce toxic exposures. We are exposed to multiple chemicals at once and this mixture creates toxicity in complicated ways. Age, genetics, nutrition and our immune system all play a role in the unique vulnerability of patients to these exposures.

Indirect Costs To Pollution: A Rise in Chronic Disease and Environmental Decline

The indirect costs are often hidden but the burden on healthcare is becoming more apparent. We are now experiencing a crisis of chronic disease. Currently 42% of adults have one or more chronic diseases. Think about how many of your patients are not on medications? JAMA reports the most common chronic condition experienced by adults is multi-morbidity or the coexistence of multiple chronic diseases. This leads to more complex medical care, increased costs not to mention the suffering of patients and their families. Children and Chronic Disease

Children are not faring any better. Fifty-four percent of children have at least one chronic health condition if you include obesity, and developmental delays. Scientific studies show the trend is worsening. Our youth used to be considered the healthiest in our population but that is changing. Generations are now at risk. We now need to examine the root causes of disease and early childhood exposures to toxins.   Root Causes of Disease: Poverty and Social Stressors

The Diversity and Inclusion series highlighted socioeconomic factors as an underlying contributor to chronic disease. Poverty and racial injustice intersect with environmental injustice and pollution, which intersects with climate change and each factor accelerating the pace of the other. Environmental racism worsens air pollution, which worsens susceptibility to respiratory viruses including COVID. More resources are used in healthcare which exacerbates climate change. Cradle to Grave Lifecycle Analysis

Ideally we need to look at lifecycle of products and examine their environmental and health impacts– cradle to grave or we will continue to create more problems than we solve. The solutions cannot just lie with more education. A collaborative effort between communities, physicians and our government agencies is needed to create policies and actions that are precautionary and preventative. We are seeing this already in legislation that calls for diversity on company boards as well as laws that are beginning to reduce chemicals in consumer products. This will reduce toxins we are directly in contact with but also reduce toxins in the waste stream, our water, our air and our soil and which will be served to us again in a different format and affect wildlife along the way.   Physicians in all specialties are becoming much more aware of these issues and want to focus on prevention of disease. It is cheaper and better for everyone. War on Nature

The UN Secretary Antonio Guterres agrees, stating that humanity is “waging a War on Nature” and that by doing this we are committing collective suicide. He advised shifting our fiscal base from “taxing incomes to taxing pollution”. He stated “this is a moral test and immediate action is needed.”

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Climate Change

As we know there has been rather painful but rapid shift in human activity brought on by COVID 19. One silver lining of COVID 19 has been to demonstrate how quickly reducing human activities, especially air travel and transportation in general can have a profound effect on reducing carbon emissions, air pollution, noise pollution, water pollution and unexpectedly improving bird songs. People were breathing easier and we saw blue skies that were not visible for many years. This was short lived however as most cities have gone back to pre-COVID levels of pollution. Business as usual. And unfortunately some agencies in the U.S. have used the COVID pandemic to relax enforcement. We simply cannot put climate change on the back burner. The house is getting hotter and the effects more apparent. Climate change is a global catastrophe far worse than the pandemic but it is a concept that is difficult for us to comprehend.  Like corona-virus we do not see immediate harm when we do not wear a mask. We may not get ill for a few days or a week or not at all, and we may not see that we have indirectly harmed others. When we consume fossil fuels we don’t see any daily change in the weather from adding that extra bit of carbon to the atmosphere that lasts 100 years. But the carbon still accumulates and then reminds us when we have a wildfire or hurricane or a drought. Greta Thunberg tells us we have about 10 years to turn the titanic tide of greenhouse gas emissions around. Economic con-

“There is no vaccine for climate change”

In closing I want let you know that in 2021 we will be developing programs focused on these issues throughout the year so look out for email updates or check the events calendar on the front of the SCCMA website to participate and be part of the solution. If you are not a member of one of our committees please consider joining us. We need you. Heroes

It is a privilege to be a physician. Our profession comprises some of the smartest, most caring and hardest working individuals in society. That is YOU! True heroes. Thank you for everything you do every day to both take care of your families and your patients, especially in these times. Don’t forget to take care of yourselves and practice self-compassion and kindness. Planet of the Year

We are all in this together and will help each other through this, advocating for our patients, our practices, the health of all Americans, not to mention the health of our beautiful, swirling, one and only Planet of the Year. We have the power to change the course of our planet’s future. Let’s continue to think globally but act locally. As President John F Kennedy said,

“As we express our gratitude, we must never forget that the highest appreciation is not to utter words, but to live by them.”

-UN Secretary General Guterres

version to jobs that restore and preserve the environment is an idea that is gaining more traction. If former San Jose State Professor of Environmental Studies, Frank Schiavo were with us, he would tell us that we need to have an economic shift from our 70% consumer oriented society to a 70% agricultural society and use regenerative farming techniques to build soil that sequesters carbon. We may not get to 70% but there is a lot we can do that will make a positive difference to create a stable climate, assure food security and preserve human rights for the next generation. Incentivizing a Sustainable Economy Will Work

All these things can be done if we have fairness, transparency, accountability, public input and center reality into the process of decision making. Corporations have benefited us a great deal but when their profit supersedes our health it has to be called out and checked. Economic improvement cannot be an excuse to ignore environmental health, human rights or the health of future generations. We are now realizing that the environment has to take top priority.    

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COVID-19 Vaccine Update

from the County of Santa Clara Public Health Department

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March 16, 2021 marked the one-year anniversary of the Order by the Health Officer of the County of Santa Clara directing all County residents to shelter at their place of residence as a precaution against the COVID-19 virus. This early and decisive action set the tone for the proactive efforts by the County over the past year to stay ahead of the spread of the virus. Today, we are in a much better place with multiple effective vaccines at our disposal and significant progress vaccinating our most vulnerable population, starting with seniors. Through the end of February, over half a million doses of vaccine had been administered, more than a quarter of those second doses. As part of the County’s commitment to transparency, we make a great deal of data about local vaccine administration available on our website. Please do take a look. New vaccination sites are being launched weekly, with special focus being given to areas with the highest infection rates and communities that have been underrepresented in vaccine distribution to date. The County has prepared materials in a variety of languages to help providers reach out to their patients. Many can be found here: https://drive.google.com/drive/u/1/ folders/1ZKRrvhrZutg9CQLPJ-PrY3WLo65XkLEt.

Included are flyers, social media posts, and posters in English, Spanish, Vietnamese, Tagalog and Chinese that can be downloaded to print for your office, emailed in your patient newsletters, or shared online. New items are added frequently on topics including what to bring to a vaccine appointment, common questions about COVID-19, and information about vaccine safety. There is also a Vaccine 101 presentation, a suggested instructional resource for presentations to lay audiences. One of the most closely followed issues around COVID-19 vaccines has been eligibility. From the initial focus on healthcare workers, staff and residents of long-term care facilities, and seniors age 65 and older, up through the March 15 expansion to several qualifying health conditions, there has been great interest, understandably, among County residents as to when they will be able to receive the vaccine. Our website (sccfreevax.org) has the latest information about vaccine eligibility, as well as responses to Frequently Asked Questions about the process. We also offer versions in Spanish (sccvacuna.org) and three other languages.

Within the general eligibility categories there has been a need to clarify who specifically is included. The State has responsibility for determining eligibility groups and with that the definitions of each sector. Their website is an important source of information on this topic: covid19.ca.gov/vaccines. The County’s website shares this and other guidance from the state, as well as any local prioritization of eligible groups according to current availability of vaccine. Guidance shifts over time, so it is important to stay up to date. For example, many patients incorrectly believe that it is unsafe to be vaccinated if they have had COVID-19 within the past 90 days. The truth is that patients can receive a vaccine after they have completed their isolation period. The exception is treatment with intravenous monoclonal antibodies or convalescent plasma, which requires a 90-day wait before getting a COVID vaccine. When it comes to patient interactions, one of the biggest challenges is addressing vaccine misinformation. From fear about catching COVID-19 from vaccines to concerns about microchips, wild theories shared online have made it harder to persuade all eligible people to get vaccinated. Whether or not you usually counsel patients about vaccines in your practice, these days we are all vaccine ambassadors. Our COVID-vaccine webpage for providers suggests some resources to help you educate your staff to address patient questions about vaccination. That page is sccgov. org/ProviderVaccineInfo. Your interaction with a particular patient may be that person’s only opportunity to ask a doctor about COVID-19 vaccine. As patients’ most-trusted source of information on vaccines, all healthcare providers play a critical role in helping their patients understand the importance of COVID-19 vaccination. What we have found is that the best way to speak to the public at large, or one on one, is to speak in plain language honestly and directly. The best way to stop the spread of the virus and the emerging threat posed by its variants is to The Bulletin  |  9


© Can Stock Photo / the_guitar_mann

get everyone vaccinated as quickly as possible. That means making an appointment for vaccine as soon as you are able and accepting whichever brand you are offered, because all of them provide strong protection against severe cases of COVID-19. That has to be our primary concern, as we know that in addition to death and hospitalization, severe cases can cause long-lasting, if not permanent, impacts to one’s health. We know that there is significant apprehension among some individuals about receiving the vaccine. The fact that tens of millions of Americans have now received the vaccine with few cases of major side effects should give comfort for those who have been hesitating. Many of their peers are likely to have had the vaccine and can tell them firsthand what it is like. Similar to other vaccines, sore arms and minor headaches can occur, but they tend to go away within a day or two. We remain concerned about the need to increase vaccination rates among those who are not computer savvy, face language barriers, work in jobs with more public contact, and those in the African-American or African ancestry or Latin(x) communities, which have lower vaccination rates for a variety of reasons, including greater numbers of comorbidities, challenges with transportation, distrust of our healthcare system, and work category.

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We ask you to help us make an extra effort to reach out to these groups and encourage them to utilize the many resources available to them, including the County’s 2-1-1 phone number, which has operators standing by 7 days a week with the ability to speak to individuals in the language of their choice. They can provide information about transit options for those who do not drive, including the VTA’s free ride offer for those who are trying to reach a vaccine site. With vaccine sites now located across the County, including several drop-in locations that do not require a prior appointment, there is an option for everyone. Times are available on weekday evenings and weekends. Santa Clara County’s No Wrong Door policy means that everyone eligible to be vaccinated can go through any local health agency to make an appointment, as they are all working together to best serve the public. Those with disabilities or who cannot stand for long periods of time can take advantage of the County’s expedited process, which includes special parking sections and staff assistance. We thank you for your partnership in tackling what has been one of the greatest challenges we have faced as a community in the 21st Century. With your help, we believe that we are turning the corner.


SCCMA Environmental Health SCCMA Environmental Health Spring Series 2021 Spring Series 2021 Join the SCCMA and fellow physicians for a 4-part CME webinar series on environmental health to be Join Join the the SCCMA SCCMA and and fellow fellow physicians physicians for for aa 4-part 4-part CME CME webinar webinar series series on on environmental environmental health health to to be be presented on Thursday evenings in the spring 2021. A variety of topics will be covered that are presented on Thursday evenings in the spring 2021. A variety of topics will be covered that are related to presented on Thursday evenings in the spring 2021. A variety of topics will be covered that are related to related to understanding the human impacts of environmental health issues. Experts will discuss understanding human impacts of health discuss not only understanding the the human impacts of environmental environmental health issues. issues. Experts Experts will will discuss not only the thenot only the problems we face, but also innovative solutions to promote health and well-being for our patients, problems we face, but also innovative solutions to promote health and well-being for our problems we face, but also innovative solutions to promote health and well-being for our patients, patients, and our planet. be Climate Change on Day, 22, with Dr. ourselves ourselves and our The �rsttopic topicwill will Climate Change on Earth Day, with Dr. Santosh ourselves and ourplanet. planet. The The first first topic will be be Climate Change on Earth Earth Day, April April 22,April with 22, Dr. Santosh Santosh Pandipati, a Maternal-Fetal Medicine Specialist, who will discuss how climate change affects reproductive Pandipati, a Maternal-Fetal MedicineSpecialist, Specialist, discuss how climate affects Pandipati, a Maternal-Fetal Medicine whowho will will discuss how climate change change affects reproductive health with internationally renowned expert Lovins, founder of Rocky health along alonghealth with the the internationally renowned energy energyrenowned expert Amory Amory Lovins, founder of the theLovins, Rocky Mountain Mountain reproductive along with the internationally energy expert Amory founder of the Join thediscussing SCCMA and fellow physicians for a 4-partenergy CME webinar series on environmental health to be in May and Institute, large scale solutions including efficiency. This will be followed including energy efficiency. This will be followed in May and Institute, discussing large scale solutions Rocky Mountain Institute,evenings discussing large scale solutions e�ciency. This willtobe presented on Thursday in the spring 2021.Children’s A varietyEnvironmental ofincluding topics willenergy be covered that are related June with discussions on Technology and Children, Health and and the June with discussions on Technology andfor Children, Children’s Environmental Health and Food Food andto thebe Join the SCCMA and fellow physicians a 4-part CME webinar series on environmental health followed in May and June with discussions on Technology and Children, Children’s Environmental understanding the human impacts of environmental health issues. Experts will discuss not only the Environment. Environment. presented on face, Thursday evenings in thesolutions spring 2021. A varietyhealth of topics be covered thatpatients, are related to Health and Food and but thealso Environment. andwill well-being for our problems we innovative to promote understanding the human impacts of environmental health issues. Experts will discuss not onlySantosh the ourselves and ourand planet. The first topic willwebsite be Climate Change Events” on Earthon Day, 22, withto Save Dates visit the SCCMA.org  “Upcoming the front page register.  Save the thewe Dates and visit the SCCMA.org  website “Upcoming Events” on theApril front page toDr. register.  health and well-being for our patients, problems face, but also innovative solutions to promote Pandipati, a Maternal-Fetal Medicine Specialist, who will discuss how climateon change affects reproductive Save the Dates and visit the SCCMA.org  website “Upcoming Events” the front page to register.  ourselves ourthe planet. The first topic will Medicine beenergy Climate Change on Earth Day, April 22, with Dr. Santosh April 22, -- and The Earth Has aa Fever: Physician’s Perspective on health along with internationally renowned expert Amory Lovins, founder ofCrisis the Rocky Mountain   April 22, 6pm 6pm The Earth Has Fever: A A Maternal-Fetal Maternal-Fetal Medicine Physician’s Perspective on the the Climate Climate Crisis Pandipati,discussing a Maternal-Fetal Medicine Specialist, whoenergy will discuss how This climate affects reproductive    Institute, including efficiency. willchange be followed in May and large scale solutions April 22, 6pm - Climate Change health along with the internationally renowned energy expert Amory Lovins, founder of the Rocky Mountain

SCCMA Environmental Health Spring Series 2021 SCCMA Environmental Health Spring Series 2021

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© Can Stock Photo / Sandralise

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William Buchholz, MD

The Person Reluctant to Vaccination: © Can Stock Photo / benzoix

Some Approaches Updated 2/15/21

The strategy of changing minds There are many reasons given for declining vaccination: misinformation, lack of knowledge of facts; negative cultural experiences with medicine; deeply held ideas and convictions; fear and underlying suspicion. To address a person’s reluctance start with two principles: be curious why the person is reluctant and allow the person to feel heard and their beliefs understood. Different reasons require different approaches. Misinformation and lack of knowledge may be addressed by providing TRUSTWORTHY true information. Explaining the foundation for misinformation which may have some distorted truth can replace the doubts about vaccination. Providing the scientific source of facts, possibly with a reference website or source of the information (like the CDC or county public health department) makes shifting ideas easier. Acknowledging outright that certain events do occur and adding the frequency—often far lower than the person believes—can create a tolerable sense of risk and benefit. Some persons may recognize only some sources of information as trustworthy. If science is not one of them then the words

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and experience of friends or other individuals like clergy—for example a parish priest--or even celebrities, may allow them to accept information. Negative cultural experiences like the Tuskegee experiment to deny Blacks effective treatment for syphilis to understand the natural history of the disease can create deep suspicion of the medical system in general. Persons of color or underserved populations likewise may have unpleasant and disappointing experiences with the medical system and not understand that it can work well for them. This type of hesitancy may not be refusal but a wait and see attitude. If they can gathering more real time positive information on vaccination that may allow them to accept the shots. Deeply held beliefs, often arising from mistrust and fear, require a different approach. Until you discover what that person believes or fears you can’t have a logical conversation with them. Mark Twain once remarked You can’t reason someone out of something they weren’t reasoned into. The best thing to do is listen without judgement


children? Finding out what is more important to them than their current belief changes the calculus for deciding on vaccination. If they seem open to that then ask what would get in the way of being vaccinated and helping them problem solve. Finally, the most critical element of a successful strategy is timing. Maintaining connection with that person, listening to them without judgment, having conversations that don’t focus on vaccination but shared experiences—grandchildren, golf, go-carting—does establish a relationship that is removed from conflictual positions. That can create the trust needed to feel safe to change minds.

© Can Stock Photo / Maridav

to what beliefs that person holds. Expressing their fears and having someone actually listen to them can be healing. Even if the person sticks to their position after being heard and given accurate information about the risks of vaccination or not being vaccination there is still an opportunity to change the context of the subject. Most people hold ethical values for treating friends and loved ones. These include the wish to help them or at least not harm them. Determine what the person’s values are is a place to start. Posing What if…? questions like What would happen if you did get Covid and infected your parents, grandparents, partner,

Reasons for reluctance and possible responses Many reasons may be given for their reluctance. Common ones include: 1 2.

3. 4.

We don’t know the long-term side effects. What about the side effects now; I heard there some people have anaphylactic shock or even die after getting vaccinated. I might spread Covid from the vaccine. How do I know I won’t give someone Covid even if I get the vaccine?

5. I don’t trust anything/any medicine that was produced in that short a time. 6. They put nanoparticles in the vaccine that will track your body or change your DNA 7. Vaccination is a conspiracy for … 8. What if…?

The Bulletin  |  13


Possible responses could include:

1. It’s true that we don’t know the long-term side effects yet. We do know the short-term side effects of NOT being vaccinated, however. Infecting someone else, maybe someone you love; Getting severely sick and being in the ICU for a month; Having a long recovery with many complications like chronic fatigue, impaired cognition and memory, chronic pain, shortness of breath; and others. 2. Statistics show only 0.2% of people have adverse effects. Of 11,000,000 injections 21 persons had very severe reactions (0.002%). 17 of this group of 21 persons had previous severe allergic reactions to medicines, foods, insect stings. No one died from their reaction. IF YOU HAVE HAD A SEVERE ALLERGIC REACTION BEFORE TELL THE PERSON ADMINISTERING THE VACCINE. THEY WILL OBSERVE YOU FOR AT LEAST 30 MIN. AND BE PREPARED WITH APPROPRIATE MEDICINES IF NEEDED. 3. The current vaccines (Moderna and Pfizer) do not have any virus in them and cannot give anyone Covid. 4. It’s true that at this time we don’t have robust data that proves you can’t infect someone after you’ve been vaccinated. There are some reports that persons who have been vaccinated can later be found to have a positive Covid 19 throat swab. It is not clear whether they can transmit this to anyone else since there may not be enough viral particles—though they can be detected with very sensitive PCR tests—to infect someone else. The sporadic reports, however, show that the number of persons to have a positive test either after vaccinated or recovered from active infection are only a fraction of a percent. 5. Generally fear is the basis for not trusting any medicine that has been produced quickly and verified by impartial doctors. Yet some people with the threat of a seriou disease that could kill them like cancer seek out new medicines that have not even been approved. Since there is a risk of dying from Covid, you need to look at the alternatives. 6. There are tracking numbers on the boxes of vaccine to make sure there is proper distribution. There isn’t any tracking device in the actual vaccine. The vaccine has bits of RNA, not DNA which is different. It cannot affect huma genetics which is based on DNA. 7. Conspiracy theories are unfortunately common these days. It’s impossible to track down the basic information that ha been misunderstood or simply perpetuates fear. Changin the mindset of individuals unwilling to change their mind will take a lot of time; be patient. 8. It is true that the future is unknown, yet we keep on living as best we can with what we have. Overcoming fear and mistrust is the job now. Information Behind The Information

Recent articles highlight healthcare workers who decline vaccination or take a wait-and-see position. This may lead to the conclusion that since they work in health care they must know something that makes them hesitant. The information behind this belief is that many health care workers are African-American or Latinex. They may have 14 | The Bulletin

legitimate reasons to be suspicious of medicine because of racial discrimination or generally poor healthcare. Think of the Tuskegee experiment withholding treatment for syphilis in Blacks or the way that people of color may not have access to medical care at all. Anti-vaxxers, groups who purposely promote misinformation, have 59.2m followers on social media according to an article in a British publication, The Economist. The majority of them (80%) have financial interests like selling alternative therapies or creating advertising revenue for their commercial sites. Their strategies include sowing doubt about the seriousness of the threat, spread concern about the safety of the vaccines; and stress the untrustworthiness of experts. (http://econ.st/3savYM0)

Interesting Statistics and Data

Mark Twain once said There are lies, there are damn lies, and then there are statistics. In this time of lies, misinformation and the global pandemic of fear and mistrust, we still have to deal with reality and data. Most of the following information I’ve gathered from articles published in the New England Journal of Medicine, from Santa Clara County Public Health department and the Centers for Disease Control (CDC). Some comes from citations from reputable journals (like Nature) and reports from other sources I trust. Incidence and Mortality from SARS-CoV-2 Virus and COVID 19 disease

Both Moderna and Pfizer vaccines are used in this area and have similar benefits (95% protection) and side effect profiles. The data does not specify which vaccine was used. The risk of death in Santa Clara County from a new case of Covid has varied from 1% to 3% from Oct. 1 thru Jan. 15. Infections and deaths vary with age. Infections are highest in ages 20-29, 7000/100,000 or 7% though mortality rate is low, 2.5/100,000. For Seniors age 70-79 infection rate is 3300/100,000 (3.3%) and for 80+ the infection rate is 5100/100,000 (5.1%). This is generally lower than for younger groups. The mortality rate is greater, 207/100,000 (0.2%) for 70-79 and 5100/100000 (0.5%) for those 80+. Seniors have more chronic illnesses and co-morbidities that make them less able to survive an additional illness, especially if they have moderate or severe Covid. Risk of Side Effects from Vaccine

About 80% of persons getting vaccinated have one or more side effects, mainly pain or soreness at the injection site after the second shot. In general, older (>55) persons had fewer side effects. Local side effects include pain (50-60%), swelling (20%), achy joints or muscles (20% first shot, 60% second shot). Some people experience a fever or chills, fatigue and headache. All these symptoms were rated mild or moderate and lasted for less than 7 days. There have been some allergic reactions including serious ones. Statistics show only 0.2% of people have adverse effects. Of 11,000,000 injections 21 persons had very severe reactions (0.002%). 17 of this group of 21 persons had previous severe allergic reactions to medicines, foods, insect stings. No one died from their reaction.


Data from the Astra-Zeneca vaccine shows 50% have injection site pain, headache or fatigue though the second shot side effects are milder than the first. There have been no deaths linked to any of the vaccines. Vaccination Beneficial Effects

Immune response is nearly equal in younger (18-55yo) and older (65-85) persons and is measurable 14 days after the first shot. The second shot is given on day 21 (Pfizer vaccine) and improves dramatically one week later, by day 28. People who have had Covid 19 have antibody levels slightly lower than those vaccinated. The current recommendation is to be vaccinated even if you have had Covid 19 infection. The graph below shows the incidence of symptomatic Covid 19 with vaccination vs. placebo. Open circles are cases of Covid 19 and dark circles are severe cases. The two lines are superimposed up to d 12-15, before any immune response occurred in the vaccinated population. The rising line (Placebo) shows continuous rise in cases; the horizontal like shows far fewer cases (94.8% fewer) and only one serious case. This dramatically illustrates that the vaccine prevents total cases as well as serious ones and protection continues for at least 98 days.

other strains is believed to be that they last longer in the person. B117 lasts 13.3 days in the body while other variants last 8.2 days. (S. M. Kissler et al. Preprint at http://bit.ly/3lF3rLT; 2021, not yet peer reviewed data). The increase in death rate is small and not yet understood. For men from 55 to 69 years old, that raised the overall risk of death from 0.6 percent to 0.9 percent. For women in that age group, it raised the overall risk of death from 0.2 percent to 0.3 percent. On Feb. 2, 2021 there was a webinar by the New York Academy of Science that reported a Covid 19 producing virus that had combined RNA from both the British (B117) and California (B.1249) variants. The implications of the finding aren’t yet clear because very little is known about the recombinant’s biology. The concern is that the mutation from B117 making it more transmissible and from B1.429 which could confer resistance to antibodies. http://bit.ly/3c9H9yQ

and

http://bit.ly/3eYSXG2

QUESTIONS ON VACCINES Update 2/28/21

Update 2/28/21 Mutations in SARS-CoV-2

All viruses mutate as they multiply and several new strains have been detected. In Great Britain the mutation B.117 is now predominant and is also widespread in the US. The mutant virus predominant in California is different from B.117 and known as CAL.20C, or B.1429. Mutations continue to evolve and each new virus that is shown to be widespread in a country raises concern about its behavior and whether they will be sensitive to the existing vaccinations. There are new vaccines being released by different companies that are known to be effective on new variants. Existing Moderna and Pfizer vaccines remain effective at neutralizing the variants though at a lower titer than for the original virus. Johnson and Johnson vaccine is now available. It is different from Moderna and Pfizer vaccines in several aspects. It works like other vaccines that rely on the immune system responding to the viral spike protein, not the RNA. It only requires a single jab and doesn’t need special refrigeration. It is effective against some of the variants; 80-85% protection against severe illness and overall including less severe illness, 66% protective. It was 100% effective in preventing hospitalization and deaths in the US as well as South Africa (B.1351) and Brazil (B.11248). There is a pattern in the reports of new variants. Initially they raise concern about the variants in the first two paragraphs and further down in the article it notes that there is insufficient data to know what it will actually do. I update information from reliable resources as it is available. Earlier reports on B.117 suggested it was transmitted 35-45% more easily than the original virus and more likely to cause death. The answer why some variants (like B.117) are more infective than

Does vaccination prevent getting infected from SARSCoV-2 or from spreading SARS-CoV-2 to others?

The current hypothesis is that the immunity from vaccination prevents the virus from getting concentrated enough to cause symptoms. Vaccinated persons can have a positive Covid test and remain asymptomatic even when they have antibodies. The viral load (amount of virus present in the person is too low for them to be infectious and spread the virus. Marks, M. et al. Lancet Infect. Dis. https://doi.org/10.1016/ S1473-3099(20)30985-3 (2021). Levine-Tiefenbrun, M. et al. Preprint at medRxiv  https://bit.ly/3sgqxLq

Update 2/25/21 Nature is a well-respected international journal of the sciences. The following information comes from this website: https://go.nature.com/3vKKWKV are currently licensed vaccines (Moderna, Pfizer, Astra-Zeneca, Johnson and Johnson) protective against emerging variants? When serum from persons vaccinated with Pfizer was tested against the South African variant B.1351 was effective but at 1/3 the titer as against the original virus. (Y. Liu et al. N. Engl. J. Med. https://doi.org/fwsc; 2021) The efficacy of the Astra-Zeneca/Oxford vaccine was even higher if there was a longer interval between the first and second shots. It was 55% effective in those who received their second dose less than 6 weeks after their first, and 81% effective in those whose second dose was more than 12 weeks after their first. A single dose was 76% effective (compared to placebo) for at least 90 days.

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2020 YEAR IN REVIEW 2020 was unlike any other year in CMA’s 164-year history. As an association largely founded during a cholera outbreak, we quickly rose to the challenge and shifted all gears to help physician members, elected officials and policymakers navigate the COVID-19 crisis. This year’s achievements include:

Advised the state’s development of executive orders and laws to ensure physicians could respond to the pandemic, including on telehealth policy, regulatory waivers and public health officer safety.

Distributed more than 60 million pieces of personal protective equipment (PPE) to more than 8,000 physician practices statewide.

Secured more than $100 billion in financial assistance to physician practices in Coronavirus Aid, Relief, and Economic Security (CARES) Act and an additional $75 billion to the HHS Provider Relief Fund in the COVID-19 “Interim Economic Relief” bill.

Convened virtual grand rounds on COVID-19 topics, including transmission, schools re-opening, testing and vaccines.

Protected Proposition 56 funding (tobacco tax revenues) in the state budget, including $57 million for physician loan repayment and $38 million for graduate medical education programs.

Sponsored a new ban on flavored tobacco products that will save lives, as well as limit Big Tobacco’s ability to target children and communities of color.

Continued our court fight to protect the Affordable Care Act.

Created a new COVID-19 website with daily updates, toolkits, webinars and other resources for physicians.

Amended CMA’s mission statement to include health equity.

Helped shape a federal surprise billing ban that includes baseball-style arbitration to resolve disputes between physicians and payors.

Visit cmadocs.org for more information. 16 | The Bulletin


© Can Stock Photo / Feverpitched

CMA Launches Free PPE Direct Shipment for California Physicians and Medical Groups https://www.cmadocs.org/newsroom/news/view/ArticleId/49253/CMA-launches-free-PPE-direct-shipmentsfor-California-physicians-and-medical-groups

The California Medical Association (CMA) is extending its distribution of free personal protective equipment (PPE) with direct shipment of supplies to California physicians. The new online portal offers California physicians the ability to register for specific types of PPE including coveralls, face shields, goggles, hand sanitizer, sanitizing wipes, isolation gowns, N95 masks, surgical masks  and vinyl gloves. The PPE is free, and the medical practice pays a nominal cost for shipping and handling. CMA distributed over 100 million pieces of PPE to physicians and medical groups from August 1 to December 31, 2020. The donations supported approximately 100,000 California physicians and their staff, which represented a total value of more than $200 million.  “Lack of PPE throughout the COVID-19 pandemic has compounded hardships for medical practices and hindered physicians’ ability to serve patients,” said CMA President Peter

N. Bretan, Jr., M.D. “We knew we had to act – and fast – to help physicians keep their practices open. What resulted was an unprecedented effort in the organization’s 165-year history. CMA is grateful to our partners for their collaboration and support, which ultimately helped so many Californians continue to receive health care.”  Last summer, CMA partnered with local county medical societies to develop an entirely new statewide distribution system for essential medical equipment, which included PPE donations from the Office of Emergency Services (OES).  Within weeks, PPE was being moved from state warehouses, repackaged into individual kits and loaded on trucks to be handed out at drive-through events across the state. Physicians and medical practices also accessed PPE through their local county medical society or CMA’s online request portal.

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As of December 31, 2020, the effort had distributed a combination of 35 million masks, 35 million sets of gloves, 2.3 million isolation gowns, 2.5 million face shields, 400,000 hooded coveralls, 21 million N95 respirators, 3 million sanitizing wipes and 700,000 sanitizer bottles. “I’m really impressed with the distribution operations to small- and medium-sized practices,” said Richard Siedman, M.D., Chief Medical Officer of the LA Care Health Plan. “These medical practices are critical to the overall health care delivery system in our state and enables physicians and their staff to more safely provide the care that their patients need.” “These free PPE kits were a lifeline during a very challenging year,” said Elk Grove cardiologist Rajan Hundal, M.D. “Without the donations, we would have had to limit hours or close our practice completely. The PPE helped our patient care team stay healthy and enabled us to continue serving our patients – our community is healthier because of this program.” 

The lessons learned during the PPE distribution effort will be applied to helping the state build its vaccination network. “The administration of COVID-19 vaccines brings hope into focus, but the global pandemic remains challenging,” said Dr. Bretan. “Equity and speed remain vital components of any successful vaccination strategy, and we cannot compromise one for the other. The lessons learned distributing PPE will guide CMA as we help the state build out their robust vaccination network connected to community physicians that millions of Californians already rely on for flu shots and routine vaccinations.”  

Download: Program infographic

https://www.cmadocs.org/ Portals/CMA/files/public/ PPE%2520Relief%2520Infographic%2520(2020).

Watch:

CMA PPE Relief Documentary (October 2020)

See also:

CMA distributes two-month supply of free PPE to more than 40k California physicians (September 2020)

https://www.cmadocs.org/newsroom/news/ view/ArticleID/49021/t/CMA-distributes-twomonth-supply-of-free-PPE-to-more-than-40kCalifornia-physicians

18 | The Bulletin

© Can Stock Photo / Feverpitched

https://www.youtube.com/ watch?v=Mgs7108h5f8


Black Americans Are Getting Vaccinated at Lower Rates Than White Americans By Hannah Recht, KHN Data Reporter and Lauren Weber, Midwest Correspondent, January 17, 2021 Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis. About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher. In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians. The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made

up of physicians, hospital cafeteria workers, nurses and janitorial staffers. If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far. Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.

The Bulletin  |  19


Black, Hispanic and Native Americans are dying from covid at nearly three times the rate of white Americans, according to a Centers for Disease Control and Prevention analysis. And non-Hispanic Black and Asian health care workers are more likely to contract covid and to die from it than white workers. (Hispanics can represent any race or combination of races.) “My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.” Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.

20 | The Bulletin

But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them. “That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.” UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far. A Failure of Federal Response

As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity. That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience. A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories. Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast. Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year. “We were late to start the planning process,” Benjamin said. “We should have started this in April and May.” And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots. “We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.


Speed vs. Equity

Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.” Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.

It might be faster to administer 100 vaccinations in a drivethru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said. “Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.

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In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance. “If we’re going to solve the issues of inequity, we need to think differently,” Boyd said. Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, said the limited supply of vaccine must also be considered. “We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.” While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap. And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when. Historical Hesitation

One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible. Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media. Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans.

That hesitation can even be found in the health care workforce. “We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said. In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap. “To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.” That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens. Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.) In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same. So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them. “I take two employees, encourage them and ask them to encourage another two each,” he said. So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.

Source: https://khn.org/news/article/black-americans-are-getting-vaccinated-at-lower-rates-than-white-americans/ 22 | The Bulletin


SCCMA/CMA Sponsored Insurance Programs

Your Membership Offers Additional Savings of 5%* 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 for information or call 855-770-5257 to speak to a Client Advisor.

Underwritten by:

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* 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 2021 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 • 93998 (3/21)


COVID 19 Meets Forever Chemicals PFAS Vaccines Become Non-Stick? How is a group of persistent industrial chemicals called PFAS, found ubiquitously in our food, soil and water, related to COVID 19? Theses fluorochemicals affect immune function, and may increase our risk of severe COVID symptoms, as well as reduce our immune response to vaccinations. Harvard researcher Dr. Phillippe Grandjean and others have looked at the health impacts of a broad class of synthetic “forever chemicals” called polyfluoroalkyl substances (PFAS), used to manufacture everything from water and stain repellents in carpeting and clothing, non-stick coatings on pans, paper and book coatings, fire-fighting foams to cosmetics, pesticides and food packaging. Monitoring has shown these widely used substances, developed for commercial use 60 years ago, to be in humans worldwide, but also throughout our environment in eggs, fish, birds, polar bears, whales and dolphins. Studies have shown a link to cancer, liver disease, endocrine disruption, bone health and immune toxicity.

Inert or Toxic? Although initially considered inert, perfluorinated alkyl substances were shown to have immunotoxic and carcinogenic effects which were reported in early studies more than 30 years ago. Dr. Grandjean pointed out in a 2015 publication that allowable limits in water were likely too high and needed to be reassessed with more complete research. In 2018 Grandjean published a prospective study on young children showing a 20 to 30% lower vaccine antibody response to tetanus at age 5 in those with higher blood levels at age 18 months and 5 years of age. A similar research paper found lower levels of diphtheria antibodies in 7 year old’s who had higher PFAS levels. Dr. Grandjean and colleagues more recently examined COVID 19 severity and human levels of PFAS. They found that in those with higher levels of PFAS had an increased risk of having a more severe course of COVID-19.

Precautionary or Reactionary? The CDC and the Agency for Toxic Substances and Disease Registry (ASTDR) area aware of the toxic nature of these

Cindy Russell, MD, President SCCMA

substances and are now doing more studies to look at SARSCoV-2 infection and PFAS levels in healthcare workers, as well as overall health disparities related to PFAS levels. While PFAS in takeout food boxes will be phased out in 3 years, PFAS will still be around with companies regrettably substituting longer chain, longer lived chemicals with shorter chained compounds like Gen X, which has been shown to have similar toxicity to its more persistent elders, especially to the placenta. Perhaps we should reconsider having our chemical policies be precautionary rather than reactionary, saving us decades of struggle to remove these chemicals, not to mention the silent unidentifiable health harms that are straining our health care system and failing our families. SCCMA Environmental Health Spring Series 2021

Join the SCCMA and fellow physicians for a 4-part CME webinar series on environmental health to be presented on Thursday evenings in the spring 2021. A variety of topics will be covered that are related to understanding the human impacts of environmental health issues. Experts will discuss not only the problems we face, but also innovative solutions to promote health and well-being for our patients, ourselves and our planet. The first topic will be Climate Change on Earth Day, April 22, with Dr. Santosh Pandipati, a Maternal-Fetal Medicine Specialist, who will discuss how climate change affects reproductive health along with the internationally renowned energy expert Amory Lovins, founder of the Rocky Mountain Institute, discussing large scale solutions including energy efficiency. This will be followed in May and June with discussions on Technology and Children, Children’s Environmental Health and Food and the Environment. Save the Dates and visit the SCCMA.org website “Upcoming Events” on the front page to register. April 22, 6pm - The Earth Has A Fever: A Maternal-Fetal Medicine Physician’s Perspective on the Climate Crisis May 6, 6pm - Technology and Kids: May 20, 5:30 pm - Children's Environmental Health June 3, 6:00 pm - Food and the Environment

SCCMA Environmental Series 2021 Part 1-The Earth Has A Fever: A Maternal-Fetal Medicine Physician’s Perspective on the Climate Crisis Date: Thursday, April 22, 2021 Time: 6pm Location: Virtual Zoom Webinar CME: 1 unit Audience: Members of the SCCMA and the California Medical Association Part 2- Technology and Children Date: Thursday, May 6, 2021 Time: 6pm Location: Virtual Zoom Webinar CME: 1 unit Audience: Members of the SCCMA and the California Medical Association

Part 3- Children’s Environmental Health Date: Thursday, May 20, 2021 Time: 5:30 pm Location: Virtual Zoom Webinar CME: 1 unit Audience: Members of the SCCMA and the California Medical Association Part 4- Food, Water and the Environment Date: Thursday, June 3, 2021 Time: 6pm Location: Virtual Zoom Webinar CME: 1 unit Audience: Members of the SCCMA and the California Medical Association

- Severity of COVID-19 at elevated exposure to perfluorinated alkylates. Oct 26, 2020. Grandjean P et al. . PLOS ONE. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0244815 - Estimated Exposures to Perfluorinated Compounds in Infancy Predict Attenuated Vaccine Antibody Concentrations at Age 5-Years. Grandjean P et al. J Immunotoxicol 2017 Dec; 14(1): 188-195. https://www. ncbi.nlm.nih.gov/pmc/articles/PMC6190594/ - Serum Vaccine Antibody Concentrations in Adolescents Exposed to Perfluorinated Compounds. Grandjean P et al. Environ Health Perspect. 2017 Jul 26;125(7):077018. https://pubmed.ncbi.nlm.nih. gov/28749778/ - Perfluorinated Alkyl Substances: Emerging Insights Into Health Risks. Philippe Grandjean and Richard Clapp. New Solut. 2015 Aug;25(2):147-63. https://pubmed.ncbi.nlm.nih.gov/26084549/

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HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

26 | The Bulletin


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

Your patients consider you their most trusted source of information when it comes to vaccines. This document outlines some common questions patients may ask about the COVID-19 vaccine, along with information for your response. We also provide tips for having vaccine conversations with your patients. Whether you have these discussions with your patients during an in-person office visit or telemedicine appointment, or through messages on your patient portal, your strong recommendation is the most important part of the conversation.

FAQs From Patients to Be Prepared to Address How do we know if COVID-19 vaccines are really safe, especially since they were developed so fast? It is a new vaccine, however, none of the normal steps in the vaccine vetting process were skipped in order to develop these vaccines. Large clinical trials were conducted with more than 70,000 individuals of different ages, races, and ethnicities, as well as those with different medical conditions, to make sure the vaccines meet safety standards. Rapid development was possible because of increased collaboration, new technology, more

funding and the FDA and CDC prioritizing the review process for COVID-19 vaccines. What about long-term data? The CDC will continue to monitor vaccine data. At least eight weeks of safety data were collected during clinical trials. It is unlikely for side effects to appear more than eight weeks after vaccination.

How does the COVID-19 vaccine work? Is it different from the flu vaccine? The COVID-19 vaccines are messenger RNA vaccines – also called mRNA vaccines – which teach your immune system to recognize and fight the virus that causes COVID-19, and this protects you from getting sick with COVID-19. Unlike other vaccines, including the flu vaccine, mRNA vaccines do not use any part of a live or inactive virus to elicit an immune response. A flu vaccine is a diluted version of the virus that might provide a defense if the actual virus is introduced into the human body. After getting the COVID-19 vaccine, wait at least 14 days before getting any other immunizations, including the flu or shingles vaccine.

The Bulletin  |  27


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

Is it better to get natural immunity rather than immunity from vaccines? Because the disease and vaccine are so new, it is not known whether getting COVID-19 will protect someone from getting it again, or if it does, how long that protection might last. If you get COVID, you risk giving it to loved ones who may get very sick. Getting the vaccine is a safer choice.

I’ve already had COVID so do I still need to be vaccinated? Yes. Due to the severe health risks associated with COVID-19 and the fact that reinfection is possible, you should be vaccinated regardless of whether you already had COVID-19. It is unknown how long natural immunity lasts. There is some indication that immunity from antibodies lasts up to three months, with long-term immunity beyond that with T cells. However, reports are preliminary and recommendations may change. There are multiple strains of COVID and the vaccines appear to be effective against multiple known strains.

Who is eligible for the vaccine? The State of California has established phases and tiers for when different populations are eligible to receive the vaccination. Up-to-date information is available on the State of California’s vaccination website, or on the Santa Clara County Public Health website.

How will I know when it’s my turn? The Santa Clara County website, sccfreevax.org, will include the latest information on vaccine eligibility. Sign up for COVID-19 vaccine notifications at myturn.ca.gov to be notified when it’s your turn to get the COVID-19 vaccine. Talk with your health care provider to find out how they plan to notify you when you become eligible.

Where will eligible people go to get vaccinated? Like other vaccines, many people will receive the COVID-19 vaccination from their primary care provider. Large health systems including Kaiser, Palo Alto Medical Foundation, the County’s hospitals and clinics, Stanford Healthcare, and some smaller community clinics may be allocated vaccine to vaccinate their eligible patients. People who don’t have a physician or health insurance can be vaccinated through the County’s Health and Hospital System, El Camino Health, and other providers offering vaccination to the broader community. Some large pharmacy chains may also offer the vaccine. 28 | The Bulletin


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

What will it cost to get the COVID-19 vaccine? COVID-19 vaccines are available at no cost, but they are only available to eligible individuals.

Will the shot hurt? Your arm where you received the injection may be sore, red or warm to the touch for a few days.

Will the vaccine give me COVID? No – none of the current vaccines available contain the live virus that causes COVID-19.

Will it make me feel sick? Serious side effects are very rare. Many vaccine recipients experience mild or moderate side effects, especially after the 2nd dose. Those are normal signs that your body is building protection. Common side effects include mild to moderate pain, swelling, or redness at the injection site and/or mild to moderate flu-like symptoms such as fever, fatigue, headache, and chills. All side effects should resolve in a few days.

How many shots will I need? If you are receiving either the Pfizer-BioNTech or Moderna vaccine, you will need two vaccine injections, either 21 or 28 days apart depending on which vaccine you receive. You should receive the second dose from the same manufacturer as the first dose.

Is the vaccine effective? Very effective. After two doses, the Pfizer-BioNTech vaccine demonstrated 95% effectiveness at preventing symptomatic COVID-19 while the Moderna vaccine showed 94.1% effectiveness.

Will I still need to wear a mask and socially distance after I am vaccinated? Yes – the vaccine protects you against COVID-19, but less is known about the vaccine’s effectiveness at preventing transmission to others. You can still be a carrier and transmit the virus, so continuing to wear a mask is critical.

How long does it take for the vaccine to take effect? One to two weeks after receiving the second dose.

The Bulletin  |  29


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

I have allergies. Can I get the vaccine? Seasonal allergies and food allergies do not exclude you from getting the vaccine. Individuals who have had a severe or immediate allergic reaction to the COVID-19 vaccine or its components (polyethylene glycol or polysorbate) or those with a known allergy to any of the COVID-19 vaccine components, should not get the COVID-19 vaccine at this time. Individuals receiving the vaccine should be monitored for 15-30 minutes after injection to ensure there are no severe allergic reactions.

What if I have had an allergic reaction to another vaccine. Should I get the COVID vaccine? If you have a history of any immediate allergic reaction to any other vaccine or injectable therapy not related to a component of mRNA COVID-19 vaccines or polysorbate, we do not know at this time what the risk is of having a severe reaction to the COVID vaccine. You may wish to defer vaccination and/or talk to an allergist or immunologist as a precaution.

Is the vaccine safe if I’m pregnant or breastfeeding? Clinical trials did not include pregnant or breastfeeding women so there is limited direct data on COVID-19 vaccine safety for this population. Discuss the risks and benefits of vaccination with your health care provider. Based on current knowledge, experts believe that the COVID-19 vaccines are unlikely to pose a risk to a person trying to become pregnant in the short or long term.

Can children be vaccinated? Not at this time but clinical trials are underway for children.

Will I have a choice between the various vaccines available? Current vaccine supplies generally do not permit a choice of the type of vaccine that individuals receive.

30 | The Bulletin


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

Vaccination Conversations Check your pulse: Address your own basic physiological needs Assess your perceptions and knowledge about COVID-19 vaccines Be prepared to answer patients’ questions

Know your audience – for those who are: Ready – encourage their positive health behavior choices, answer questions and give instructions about how to get vaccinated Hesitant – use motivational interviewing to explore the patient’s concerns and discuss potential benefits and drawbacks of each course of action; more than one conversation may be necessary Refusal – respect their perspective, inform them of your vaccine recommendation and offer to be available to speak further if desired

Find the words: Avoid medical jargon and controversial topics such as politics and religion; provide scientifically-based, plain language answers Normalize feelings, allow them to talk about concerns – behavior change is motivated by feelings rather than facts Using strategic self-disclosure (sharing your own or your family’s experiences with vaccinations) can humanize the experience Focus on universal values such as family safety, and protecting one‘s self, loved ones and those in the community Use language and visual representations that are culturally sensitive Verbalize respect for each patient’s right to choose and leave door open to future conversations

Consider the range of literacy in: Health – the capacity to understand health information Digital – the capacity to discern the credibility of online sources Science – understanding the evolving nature of science

The Bulletin  |  31


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

Start from a place of empathy and by asking open-ended questions: How are you doing? How are you feeling about the pandemic? Acknowledge the stress and disruption COVID-19 has caused What have you heard about the vaccine? Acknowledge rather than challenge their hesitancy Validate and speak to their individual concerns

Address the unknown by relating to the known: Explain that like the flu shot, some people have reactions and side effects – most often feeling lousy for the day Ask about their allergy history and any reactions they’ve experienced previously to medications or other vaccines Use foreshadowing to build trust – acknowledge that the situation and recommendations will continue to evolve and that is to be expected It is not yet known if the vaccine helps prevent illness AND spread due to the speed of development, but it IS safe

Share your personal concerns and experience: This pandemic touches everyone – share your perspective as a fellow human Reference things people miss most, especially human connection and visiting with family and friends; acknowledging missed moments serves as a powerful reminder of the ultimate end goal with vaccination being a pathway to regaining these moments Consider sharing your own concerns and why you are still choosing to get vaccinated Assure them that you have already received the vaccine (or will get the vaccine), and share your experience with getting the vaccine Don’t downplay the immune response; share the range of possible responses and typical duration

Do not assume a position of authority: Do not order your patients to get the vaccine or insist it’s the right course of action; be inviting and respectful rather than demanding Engage them in a discussion about their concerns to help lower their fears Ask, affirm and answer – let them come up with the solution and arrive at their own conclusion about vaccination (“the choice is yours to make“)

Acknowledge their realities: Acknowledge that the pandemic has disproportionately impacted people of color Do not try to fight, defend or shutdown causes of distrust in the health care system 32 | The Bulletin


HOW TO TALK TO PATIENTS ABOUT THE COVID-19 VACCINE

Connect more frequently, especially with telehealth patients: Talk about the vaccine at every appointment Give a strong recommendation “I strongly recommend you get the COVID-19 vaccine when it is available to you.” “This shot is especially important for you because of your [ job/underlying health condition].” “I believe in this vaccine so strongly that I have already been vaccinated myself,” or “I plan to be vaccinated as soon as it is available to me.” Begin and end each appointment with a conversation about the vaccine

Messaging to avoid: Negativity - being reminded what a difficult year it‘s been tends to put people in a pessimistic, hopeless or frustrated frame of mind Fear - fear tactics do little to generate trust or address questions about vaccines Guilt - references to social responsibility or others already stepping up can come off as pushy or accusatory; those who are hesitant may be worried about being 'guinea pigs‘ for new vaccines Overpromising - avoid claims that are unproven and be clear about facts without sugarcoating; mass vaccination is a long-term process and the pandemic won‘t be resolved immediately Getting back to normal - for many, post-pandemic life will never be the way it was; focusing on economic recovery does not resonate with some Resources for Patients County of Santa Clara COVID-19 Vaccine Information for the Public: https://www.sccgov.org/sites/covid19/Pages/COVID19-vaccine-information-for-public.aspx What to Expect Handout from CDC: https://www.cdc.gov/coronavirus/2019-ncov/downloads/vaccines/facts-covid-vaccines-english-508.pdf FAQs about COVID-19 Vaccination from CDC: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html Facts about COVID-19 Vaccines from CDC: https://www.cdc.gov/coronavirus/2019-ncov/vaccines/facts.html COVID-19 Pfizer BioNTech Vaccine Fact Sheet: https://www.fda.gov/media/144414/download COVID-19 Moderna Vaccine Fact Sheet: https://www.fda.gov/media/144638/download What to Expect after Vaccination from Vaccinate ALL 58: https://covid19.ca.gov/vaccines/#What-to-expect-after-vaccination Fact Sheet from Vaccinate ALL 58: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/COVID-19/COVID_VACCINE_FACT_SHEET-ENG-08.pdf COVID-19 Vaccine FAQ from American Academy of Family Physicians: https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID19-Vaccine-FAQs.pdf COVID-19 Vaccine Myths from American Academy of Family Physicians: https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID19-Vaccine-Myths.pdf

Resources for Physicians Interim Clinical Considerations for Use of mRNA COVID-19 Vaccines Currently Authorized in the United States from CDC: https://www.cdc.gov/vaccines/covid-19/info-by-product/ clinical-considerations.html Immediate hypersensitivity to polyethylene glycols in unrelated products: when standardization in the nomenclature of the components of drugs, cosmetics, and food becomes necessary Allergy Asthma and Clinical Immunology; published February 19, 2019.: https://aacijournal.biomedcentral.com/articles/10.1186/s13223-019-0327-4 Hypersensitivity to Polyethylene Glycols & Polysorbates: Physician‘s Weekly; published December 30, 2019. https://www.physiciansweekly.com/hypersensitivity-to-polyethyleneglycols-polysorbates/

Information adapted from the following sources: Santa Clara County Public Health vaccine information for the public: https://www.sccgov.org/sites/covid19/Pages/COVID19-vaccine-information-for-public.aspx and for health care providers: https://www.sccgov.org/sites/phd-p/Diseases/novel-coronavirus/Pages/COVID19-vaccine-information-for-healthcare-providers.aspx Vaccination Conversations: Influencing Critical Health Behaviors in COVID-19; Joshua C. Morganstein, MD; Psychiatric News, Psychiatry Online, American Psychiatric Association; December 23, 2020: https://psychnews.psychiatryonline.org/doi/full/10.1176/appi.pn.2021.1.32 How to Talk With Patients About the COVID-19 Vaccine; David C. Henderson, MD; HealthCity Newsletter, Boston Medical Center Health System; December 23, 2020: https://www. bmc.org/healthcity/policy-and-industry/how-talk-patients-about-covid-19-vaccine COVID-19 Vaccine FAQs from the American Academy of Family Physicians: https://www.aafp.org/dam/AAFP/documents/patient_care/public_health/COVID19-Vaccine-FAQs.pdf Recipient Education information from CDC: https://www.cdc.gov/vaccines/covid-19/hcp/index.html Ad Council COVID Collaborative 2020 Interim Clinical Consideration for Use of mRNA COVID-19 Vaccines: https://www.cdc.gov/vaccines/covid-19/info-by-product/clinical-considerations.html

The Bulletin  |  33


Classifieds OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE FOR LEASE • SANTA CLARA Medical space available in medical building. Most rooms have water and waste. Reception, exam rooms, office, and lab. X-ray available in building. Billing available. 2,500–4,000 sq. ft. Call Rick at 408/228-0454.

1100 SQ. FT. • MTN VIEW-CUESTA PARK Recently remodeled modern - 3 Exams 4 Work Stations - Parking - Partnership, LLC - Cat 5 Wiring - Kitchenette Workroom/Lab. Light - High Ceilings - Storage. Contact greatoffice2017@ gmail.com.

PART TIME OFFICE SUBLEASE AVAILABLE Text: Los Gatos office up to 2 days per week. Offers exam room, waiting room, office with handicap bathroom. Call for details (408) 921-8255

OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

EMPLOYMENT OPPORTUNITY OCCUPATIONAL MEDICINE PHYSICIANS • PRIMARY CARE, ORTHOPEDICS, & PHYSIATRY Our occupational medical facilities offer a challenging environment with minimal stress, without weekend, evening, or “on call” coverage. We are currently looking for several knowledgeable and progressive primary care and 34 | The Bulletin

specialty physicians (orthopedist and physiatrist) interested in joining our team of professionals in providing high quality occupational medical services to Silicon Valley firms and their injured employees. We can provide either an employment relationship including full benefits or an independent contractor relationship. Please contact Rick Flovin, CEO at 408/228-0454 or e-mail riflovin@ allianceoccmed.com for additional information.

WANTED FAMILY PHYSICIAN

GREAT BUSINESS OPPORTUNITY • PART-TIME OR ADD-ON TO YOUR EXISTING PRACTICE Medically-supervised weight loss program with 30-year track record. Cash, no insurance. Practice obesity medicine and help patients overcome their weight problems and improve their health. Seeking an associate to train with eventual sale. Contact me at southbayweightloss@gmail.com.

MT. VIEW MEDICAL OFFICE FOR SALE OR LEASE

Family medicine physician needed to share a growing outpatient practice. Start at 16 hours/week and share patient load. Practice caters to 75% PPO, rest Medicare and HMO. Contact ntnbhat@ yahoo.com / 408/839-6564.

2,275 SF medical office available. Adjacent to El Camino Hospital. Office is well-lit and window-lined with reception/waiting area, 4 exam rooms, 4 consult/private offices, lab and private restroom. Christina Yang (408) 457-8805

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MedSkills is a local Bay Area medical scribe matchmaking service. MedSkills offers physicians medical scribe candidates and specialized scribe training. Sign up for MedSkills monthly subscription by downloading the MedSkills Mobile Application or contact info@medskills.com for more information.

OFFICE SPACE FOR LEASE AND OR SALE Medical office space 1,969 sq. ft. on Jackson Avenue opposite to Regional Medical Center for sale or lease, with option to buy. Very well maintained office building. Please call 408/926-2182 or 408/315-4680.

PRIVATE PRACTICE AND BUILDING FOR SALE Family Practice for sale, including inventory, equipment and Real Estate (can also be leased). Great downtown San Jose location. Financing may be available. Minor Laser Surgery performed as well. Call 415/308-3064.

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