Q2 2021 Bulletin: Environmental Health Threats Loom Large Post-COVID by SCCMA

Vol. 27 | No. 2 Second Quarter 2021

Official Magazine of the Santa Clara County Medical Association

This issue:

ENVIRONMENTAL HEALTH THREATS LOOM LARGE POST-COVID The Bulletin | 1

2021 Call for Award Nominations It’s that time of year to recognize outstanding members at our Annual Awards Gala. The recipients are selected from among our outstanding members who have distinguished themselves with extraordinary service to medicine in general, to the association, to the community, or to medical education.These awards are significant honors which reflect the respect, recognition, and appreciation of our membership. Selections are made by the Awards Committee, with input from the membership at-large. Your suggestions for recipients for each of the awards, outlined below, would be appreciated. Please visit https://form.jotform.com/211734892925060 to submit your nomination. Nominations must be received by October 1,, 2021.. Thank you for your recommendations. If you previously suggested a candidate who was not given an award, please feel free to resubmit that name.

ROBERT D. BURNETT, MD LEGACY AWARD

For a physician member of the Medical Association who has demonstrated extraordinary visionary leadership, tireless effort, selfless long-term commitment, and success in challenging and advancing the health care community, the well being of patients, and the goals of the medical profession.

BENJAMIN J. CORY, MD AWARD

For a physician member of the Medical Association who has displayed forward- looking, pioneering ideas, enterprise, enthusiasm, and prolonged professional stature and ability.

OUTSTANDING ACHIEVEMENT IN MEDICINE

OUTSTANDING CONTRIBUTION IN MEDICAL EDUCATION

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more medical education activities over and above that expected of the membership at-large.

OUTSTANDING CONTRIBUTION IN COMMUNITY SERVICE

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the community over and above that expected of the membership at-large.

CITIZEN’S AWARD

For a physician member of the Medical Association who, during his/her medical career, has made unique contributions to the betterment of patient care, for which he/she has achieved widespread recognition. Consideration shall be given to research and/or the development of procedures, methods of treatment, pharmaceutical agents, or technological advances in the field of medicine.

For an individual who is not a member of the Medical Association, who has achieved public recognition for a significant contribution in the health field. (This usually will be a non-physician, although physicians are not categorically excluded.)

AWARD FOR OUTSTANDING CONTRIBUTION TO THE MEDICAL ASSOCIATION

This award is named after the beloved long-time executive director of the Santa Clara County Medical Association and recognizes an individual whose leadership, innovation, and dedication have resulted in profound improvement to healthcare in Santa Clara and has left a lasting impact on the physicians and patients of the County. William Parrish is the first recipient of this award (established in 2018).

For a physician member of the Medical Association who has exhibited sustained interest and participation in one or more activities of the Association over and above that expected of the membership at-large.

WILLIAM C. PARRISH, JR. LEADERSHIP IN HEALTHCARE AWARD

For a complete list of ALL award recipients since 1978 please refer to www.sccma.org/news-events/sccma-physician-awards.aspx

2 | The Bulletin | Second Quarter 2021

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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.

Feature Articles 09 Where Do We Go from Here? Santosh Pandipati, MD Santa Clara County Medical Association Officers President | Cindy Russell, MD President-Elect | Clifford Wang, MD Secretary | Danielle Pickham, MD Treasurer | Anh T. Nguyen, MD Immediate 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

SCCMA 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 | OPEN, MD Kaiser Permanente Hospital | Joshua Markowitz, MD O’Connor Hospital | David Cahn, MD Regional Medical Center | OPEN Saint Louise Regional Hospital | Scott Benninghoven, MD Santa Clara Valley Medical Center | Harry Morrison, MD Stanford Health Care/Children’s Health | Sam Wald, MD Managing Editor | Erin Henke Production Editor | Prime42 - Design | Market | Host 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 of products or services advertised. The Bulletin and SCCMA reserve the right to reject any advertising. Address all editorial communication, reprint requests, and advertising to: Erin Henke, Managing Editor 700 Empey Way San Jose, CA 95128 408/998-8850 Fax: 408/289-1064 erin @sccma.org © Copyright 2021, Santa Clara County Medical Association

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12 Children’s Environmental Health Philip J. Landrigan, MD, MSc, FAAP

16 What’s Next for Schools? Matt Miles and Joe Clement

18 Screentime is Making Kids Moody, Crazy, and Lazy Victoria L. Dunckley, MD

20 Healthy Food Sustainable Agriculture Ted Schettler, MD

23 Healthy Food in Health Care 25 California Needs Increased Oversight of Toxic Sites to Safeguard Environmental Health Senator Dave Cortese

26 Silent Calamity: The Health Impacts of Wildfire Smoke

Bob Henson

Monthly Columns 05 Membership Insider 07 President’s Message Cindy L. Russell, MD

Community News 02 Award Nominations 24 SCC Public Health Department Update 29 Returning to the Physical Workplace: Legal Parameters and Considerations for Employers

New and Noteworthy 05 Classified Ads 36 Upcoming Events 38 Advertiser Index The Bulletin | Second Quarter 2021 | 3

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Membership Insider Need Vaccine? Have Too Much Vaccine? Check out the Vaccine Marketplace Now Available in myCAvax In order to accelerate the use of vaccine before it expires, providers are now able to share or post interest in state-allocated doses in the myCAvax Vaccine Marketplace. This new feature is open to all providers in the COVID-19 Vaccination Program who are approved in myCAvax, including newly enrolled providers and all other providers, regardless of TPA network enrollment or if they have never received doses. Requesting or sharing vaccine is easy – all you need to do is log in to myCAvax (https://mycavax.cdph.ca.gov), find “Vaccine Marketplace” in the menu and complete the required information. Read more at https://bit.ly/3jaHaX8. The Nocturnists Launches Part 2 of Stories from a Pandemic Podcast Series At the onset of the COVID-19 pandemic, the California Medical Association’s (CMA) partner podcast The Nocturnists began gathering stories from health care workers on the frontlines. Between March and May of 2020, The Nocturnists collected hundreds of audio diaries from health care workers about the COVID-19 pandemic, which were used to produce the audio documentary storytelling series, Stories from a Pandemic (https://thenocturnists.com/the-nocturnists-stories-from-a-pandemic). One year later, The Nocturnists have launched Stories from a Pandemic: Part 2 (https://thenocturnists.com/stories-froma-pandemic-part-2) which cultivates a selection of stories to prompt a more enduring meditation on fundamental questions that arose during a year of lockdown. What have we been learning from this extraordinary time? What processing do we still

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need to do? What kind of future can we imagine together? Part 2 serves as a potent exploration of medical workers’ psyches during a time when the stress and expectations on both individuals and institutions has been difficult to adequately portray. New episodes are released each Tuesday through July 27, 2021. Listen and follow the Nocturnists on your favorite platform. Are You Ready for California’s Electronic Prescribing Mandate? In 2018, the California Legislature passed a law (AB 2789) that created a state-level mandate that all prescriptions must be transmitted electronically by January 1, 2022. The law applies to all physicians and almost all prescriptions, with very few exceptions. The CMA has compiled a frequently asked questions document for members to help physicians understand their requirements under the new law. Read the FAQ document at https://bit.ly/3vRALmy. New AMA Report on Physician Practice Ownership and Other Practice Attributes A recent report by the AMA describes changes in physician employment status and practice size, type, and ownership between 2012 and 2020. The content of the report is based on the AMA’s Physician Practice Benchmark Survey (https:// www.ama-assn.org/about/research/physician-practice-benchmark-survey). Although the 2020 data are consistent with earlier trends, the size of the changes since 2018 suggest that the shifts toward larger practices and away from physician-owned (private) practices have accelerated. 2020 was the first year in which less than half (49.1%) of patient care physicians worked in a private practice, a drop of almost 5 percentage points from 2018. 17.2% of physicians were in practices with at least 50 physicians in 2020, up from 14.7 % in 2018. Read the report at https://bit. ly/2T2UVwi.

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A Message from the President

The Environment and Covid-19

by Cindy L. Russell, MD

SCCMA President

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Summertime… and like a lazy dog day afternoon the pandemic seems quiet. A little over a year after the onset of COVID we now are able to attend graduations that can be outdoors, and travel to vacation destinations with “precautions”. The pandemic, however, is still not over. COVID-19 is still rumbling around and causing smaller third surges in other states and countries, with an unprecedented and puzzling reemergence in India. This could be due to highly transmissible variants in combination with large crowds in celebration resulting in tragic consequences. As of this date vaccines have now been administered to about 42% of the population of the U.S., with 135 million fully vaccinated. John Hopkins reports that about 33 million people in the U.S. have had confirmed cases of COVID-19 with many others unconfirmed and thus immune from the virus. Herd immunity is now apparent. New interim guidance by the CDC as of May 28, 2021, stated that because hospital and death rates are so low now, fully vaccinated people can “resume activities without wearing masks or physically distancing, except where required by federal, state, local, tribal, or territorial laws, rules and regulations, including local business and workplace guidance; and resume domestic travel and refrain from testing before or after travel or self-quarantine after travel.” Planes and trains and other forms of transportation still require masks as do physician’s offices. Not all agree with shedding our masks and argue the incidence of COVID-19 is still higher in communities of color where vaccination rates are lower. In addition, there are still a small number of people who are getting COVID-19 after being fully vaccinated. A study of 6,710 health care workers in Israel found that eight had symptomatic and 38 had asymptomatic breakthrough COVID infections after being fully vaccinated. The CDC reported a total of 10,262 SARS-CoV-2 vaccine breakthrough infections from 46 U.S. states and territories as of

April 30, 2021, where 27% were asymptomatic, 10 % were hospitalized and 2% died. Small numbers indeed but it still highlights that a level of precaution still seems warranted. Academic data show that about 3-4% of the population has an impaired immune system, due to disease or organ transplants or cancer treatment or immune suppressive medications. Research has shown that a significant number of these patients do not mount an immune response and others may safe harbor the virus which can multiply and evolve, as was found in the New York B.1.256 variant in a patient with advanced AIDS. Research continues to reveal the mysteries of COVID-19, long haul and vaccinations. It will be a while before we know all the answers. In the meantime, appropriate and considerate masking and social distancing seem sensible. The Environment and COVID-19 The COVID pandemic has underscored the environmental impacts of human activities, from air pollution to climate change to chemicals in consumer products that can cause immune suppression (PFAS). Environmental issues still loom large. This issue of the Bulletin highlights the SCCMA Environmental Health Series 2021 with discussions by experts in climate change, children and technology, children’s environmental health, and food and the environment. All of these webinars have been recorded and are available on the SCCMA. org website and You Tube. All are supremely educational, inspirational and worth watching and sharing. Environmental Health Series 2021 Climate Change: Our series began on Earth Day, April 22, 2021, with the topic of climate change, featuring Dr. Santosh Pandipati, a fetal maternal specialist, and Amory Lovins, a leading international advisor to governments on addressing climate change. Dr. Pandipati provided a rivThe Bulletin | Second Quarter 2021 | 7

eting discussion of the effects of climate change on women’s health and reproduction, followed by an equally captivating and hopeful talk on energy efficiencies and new technologies by internationally recognized expert Amory Lovins, of the acclaimed Rocky Mountain Institute. Children and Technology: On May 6 we had compelling and engaging presentations on Children and Technology: Schools, Screens and COVID-19 with psychologist and author of “Glow Kids”, Nicholas Kardaras, PhD, who discussed the pervasive issue of internet addiction; integrative psychiatrist and author of “Reset Your Child’s Brain,” Dr. Victoria Dunckley masterfully explained the dysregulation of children’s emotions with screen time; and two unapologetic honest veteran teachers, and authors of “Screen Schooled,” Joe Clement and Matt Miles, discussed the effects (and failure) of Zoom School on learning during the pandemic. A must see for teachers and parents who are concerned about this issue. Children’s Environmental Health: May 20 gifted us with a special presentation by Dr. Philip Landrigan, one of a handful of global experts on Children’s Environmental Health, who literally wrote the seminal “Textbook on Children’s Environmental Health,” a chapter of which will be posted on our website. The question and answer period proved equally as revealing as the talk. The newest article he co-authored, “Public policy and health in the Trump era” (Woolhandler S et al 2021) is a candid blueprint for a sustainable future for all of us, as well as a good read. Dr. Gina Solomon, Clinical Professor at UCSF and co-author of “Generations at Risk,” provided a glimpse into her long-term work on children’s health and now community en-

gagement, examining the cause of benzene-laden drinking water last year from the taps of fire-ravaged Northern California. We must all know this information. Food and the Environment: The series ended on June 3 with Dr. Ted Schettler discussing “How Our Modern Food System Affects Our Health, Planetary Health and Opportunities for Change.” Dr. Schettler is co-author of “The Ecology of Breast Cancer,” “Generations at Risk,” and “In Harm’s Way,” publications that shake our conventional thinking about the modern convenient “forever” chemicals we so readily embrace to line our coffee cups and protect our shoes from stains. He was joined by Courtney Crenshaw of Health Care Without Harm, who inspired us with physician and community actions to move a new generation into equitable and healthy foods for all of us while preserving the critters we share the earth with. The discussion highlighted the direct and indirect consequences of large-scale factory farming on soil, water, air pollution, greenhouse gases and climate change, and how hospitals across the country have been changing their menu to support sustainable and nutritious meals. We are lucky to have such skilled and caring individuals advocating on our behalf and on behalf of our children who will lead the future. Read more about them in this issue and be sure to visit SCCMA.org to link to the videos which I am sure will be shared and enjoyed by physicians and leaders alike. Think about getting involved. We need you. Be informed, be kind, be hopeful, be safe. Dr. Cindy Russell

About the Author Dr. Cindy Russell is a board-certified plastic surgeon with the Palo Alto Medical Foundation, and the current Santa Clara County Medical Association President. She has also served as the Chair of the SCCMA Environmental Health Committee, and as a Delegate in the CMA’s House of Delegates. Dr. Russell is the Executive Director of Physicians for Safe Technology and is determined to bring environmental health issues and concerns to the attention of both physicians and the public. 8 | The 8 | The Bulletin | Second Quarter 2021

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The 21st century has already seen many momentous orbits of the Earth around the Sun, but that the current year — 2020 — will remain a singular year in human history is no longer of any doubt. As of the date of this publication, for over 1.44 million people around the world, 2020 was also their final year of life. Millions more and their families have suffered quietly, from being ill, or being hospitalized, or dealing with disabling and prolonged recovery, or being laid off work, or losing their life savings. The litany of loss is nearly endless. While for many this year is a low point in suffering, as a maternal-fetal medicine physician I have confronted the joys and sorrows of humanity on a daily basis, on a granular level: one mother and baby at a time, one family at a time. I have been a physician for twenty years now. Twenty orbits of the Earth around the Sun. Time enough to witness a great deal of human joy, courage, strength, and yes, frailty, failure, and suffering. With every patient encounter over these two decades I have been the bearer of news that has carried much import. No conversation has been, or is ever, trivial. On some days I may converse with thirty or more mothers and their families. Some patients have been referred because of a suspected abnormality seen on an ultrasound of their fetus that was performed elsewhere. Some patients have been referred because the patient herself has a serious medical condition, such as lupus or chronic hypertension or diabetes, that poses significant risk to her pregnancy. All need advice. All need guidance. And all need resolution to their anxieties. Often I am able to soothe their worries, but sometimes I am unable to do so. Sometimes, even with the best of my abilities, I am unable to predict an undesired outcome, for we physicians lack technological capabilities to divine all forms of impending despair. Sometimes I actually contribute

to a mother’s worries. When I see a fetal abnormality on an ultrasound screen I am inherently aware of the difficult message I will have to convey to a patient. I anticipate the psychic wound I will inflict on her and her family, and I innately know that a profound realization will settle in: the dashed dreams of a life that could have been lived, but because of my words will now no longer be actualized. Alas, as is valid with moving objects in Newtonian space, so too is true with human words and actions: there is always an opposing reaction within the messenger’s psyche. Doctors are not immune from this reality. It’s a lot to bear on one’s own shoulders, the weight of humanity’s trials and tribulations, one individual at a time, one family at a time. This year has been different for me professionally, of course. From restricting all family members from accompanying patients coming to our office for their fetal ultrasounds and genetic evaluations, to testing all patients for a viral plague at the hospitals where I work, to knowing that I am constantly exposed to the public and could acquire this very same deadly virus — one that randomly slays several percent of the infected — I can recall no other year of medicine in recent history bearing such a bleak semblance. Having fallen victim to COVID-19, some of our patients have required prolonged hospitalizations, some requiring ventilators, some requiring premature cesarean sections, some having been near death. As a middle-aged male diagnosed this very same year with chronic hypertension, and already having asthma, hypercholesterolemia, and a strong family history of cardiovascular disease and diabetes, I have been especially wary of my personal risks. My wife and I have three children, each of whom we love immensely. Each in his or her own way has been a blessing for us. Our eldest, conceived accidentally fourteen years ago, out

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of profound love, and very much desired, is named for “life” in Greek. Our middle child, who had also been conceived accidentally, a month or so before we were actually planning to conceive her, and thus, very much desired in her own right, is named in Greek for “light.” Our third and final child, willfully conceived, is named for “enlightenment” in Sanskrit. Perhaps one notices a poetic progression to these names that harken back to ancient, great, and noble human civilizations — a progression that each of us hopes to mirror for ourselves within the timespan of our own lives: to marvel at the vibrancy of conscious life; to illuminate our minds and hearts with education, love, and passion; and ultimately, hopefully, to gain a glimmer of wisdom, to glean a sliver of the universe’s deep truths before we disintegrate back into the dust from which we were born. We have had some of our own sufferings in parenthood. The first child of “Life” had a mild speech deficit that was unknown to us until several years of age. We had a scare, but therapy with a speech pathologist rectified the situation rather quickly. Our scare flew off, like a spirit that no longer had a reason to haunt our child. The second pregnancy that birthed in “Light” began as a twin gestation, but alas, one fetus demised at the end of the first trimester. We wonder about this occurrence even to this day — dashed dreams of how life might have been. Our third pregnancy of “Enlightenment” has been the biggest challenge of all. He was born with an anomaly that could not have been detected prenatally, but was discovered soon after birth. Our young boy had to undergo surgery at one year of age, which, though relatively minor in a grand sense, was nevertheless palpitation-inducing, especially since it required general anesthesia and since he also suffers from a mildly recessed jaw. A few years ago we also began to notice behavioral difficulties. Though incredibly keen in his interest in nature, science, and history, and reading several grade levels above his own, as well as being quite jovial, being quite loving of those around him, and being fortunate in having numerous friends and being universally liked by his teachers, he was becoming a literal terror at home. Obstinate, defiant, controlling, inappropriately 10 | The Bulletin | Second Quarter 2021

self-centered for his age, and constantly requiring reassurance for all things, we knew he and the rest of us would not survive intact without an urgent restitution of sanity. Raked with our own anxiety about what was happening, we struggled with behavioral therapy for him without much avail. Over the past year we began to notice vocal and motor tics, and my wife astutely suspected what was recently confirmed: Tourette syndrome, likely coupled with obsessive-compulsive disorder (OCD)— and perhaps even exacerbated by aliquots of anxiety and attention deficit hyperactivity disorder (ADHD). It is finally a relief to have a diagnosis, to know that there is very much a possibility of full recovery, to know that treatment is available. But there are no guarantees, and though many with this condition see a resolution to their tics, they then suffer throughout life with OCD and ADHD. So now we will begin our journey of cognitive behavior therapy, and perhaps medication, for our young man of “Enlightenment” in order that he may one day experience his name in full. The irony has not escaped us that we ourselves will need to strive hard to cultivate our own inner patience, inner mindfulness, and inner serenity to be able to properly guide our son on a path of healing. Action and reaction. And so I ask myself, whose enlightenment will it ultimately end up being? Who perhaps were we really appealing to when we named him so many years ago? From our human vantage point we are rapidly coming to an ending, and as with all endings, to a new beginning. The Earth has nearly completed its circumnavigation around the Sun as it has done billions of times before. We have collectively breathed in, and we have collectively breathed out. To some it’s a silly game, marking the passage of a year, taking stock of where we have been and making resolutions for where we want to go. One could argue that there is nothing innately special about January 1. From our all too limited human timescale, and setting aside the particularities of Earth’s complex orbital dynamics, every day is, after all, a one year anniversary of essentially being in the very same position around the Sun as we were one year prior — and where we are to be again one year hence. Inwww.sccma.org

deed, taking that perspective, every moment is an anniversary of sorts, an opportunity for remembrance and reflection. I have brought up our own family struggles not out of any desire to incite sympathy or pity in the reader, but rather to state that even as a physician’s family we ourselves are prone to the vicissitudes of life. We stand no more above nor any more below anyone else. As the Earth has circled about the Sun from time immemorial, so too has human happiness and suffering cycled over time. I and my family are not privileged in avoiding this universal truth. This same year that we have come to know of the particular ailment afflicting the mind of our son is the very same year our species has been ravaged by a novel coronavirus that will ultimately extinguish millions of lives. This is the very same year when millions have lost their livelihoods due to poor pandemic management, when our government and leaders — at least in the United States where I live — should have known and acted better. This is the very same year that there has been an acceleration in the repercussions of our self-inflicted human-caused climate crisis, where my family’s home was surrounded by wildfires and millions like us in Northern California were exposed to the most toxic air on Earth. This is the very same year that millions around the planet were afflicted with food shortages and faced a risk of mass starvation. This is the very same year that American democracy nearly succumbed to a maelstrom of conspiracies that were concocted within the cauldrons of bubble information universes embedded deeply within the world wide web. And yet civilization has seemingly survived to see the emergence of another year, uncertain as to how badly it has been truly bruised — and whether mortally so. For in 476 CE did the Romans who arose from bed the morning after the deposition of Emperor Romulus Augustulus truly realize that their empire had begun its descent into oblivion? There has been so much life that has been lived by the universe already. This we know to be true from just our own planet’s history. It is estimated that there are currently one trillion species of life on Earth. One trillion. And yet we know so painfully little about conscious experiences scattered throughout existence in space and time. What perceptions run through the minds of dolphins and whales? Of elephants and wolves? Of owls and eagles? Of domesticated cows and pigs? Of all the other creatures that roam our world even as I write this? And what ran through the minds of ancient life that has come and gone, now evidenced only by the muck of oil, the smearing stain of coal, and the occasional stone of fossils? What runs through the minds of innumerable alien species undoubtedly peppered throughout our universe, but too remote to ever access? It is estimated that 108 billion modern Homo sapiens have lived on Earth since the dawn of our species. A hundred billion human beings. Each who possessed dreams, desires, feelings, pain, sorrow, grief, joy, love — innumerable experiences of life. Conscious conceptions of our universe, all long-since vaporized, each a part of an organic individual whose matter now circulates through all of us as part of his or her ultimate legacy. Were humanity to burn itself into oblivion we can still take solace in knowing that there is so much of life still left on Earth, and likely in the universe, and that there will continue to be so for aeons of time. And yet, with such awareness, isn’t it an extreme form of tunnel vision for our species to hold its suffering in one miniscule year above all other suffering its members have had to endure www.sccma.org

in all the years that have passed? Or for one human family to do so? Or for one human individual to do so? Alas, there is no escape for each of us from this perspective of the one. This is our fundamental dilemma as human beings: that we are able to conceive of multitudes, and yet somehow we have to reconcile this reality with our innate limitations as individuals, as solo travelers in a vast expanse. We are each in some way an isolated eye of illuminated matter trapped briefly in spacetime, a lens of the universe through which it may gaze upon itself in partiality, struggling to visualize itself in unity. So many windows of consciousness gazing upon existence. So many perspectives, so many feelings, and so many attitudes that are so many times colored by discriminating vision, so many times limited by the conceit of a local vantage point, virtually always a sliver of the whole, never truly an apprehension of totality. And so I come back to myself, the only perspective from which I can write assuredly. So much has been lost this year, and yet there is reason and cause for hope for all of us individually, and for all of us collectively. That language can convey a shared experience of awareness between people is a miracle unto itself. This very language is the crucial engine necessary to help us climb our way out of an existential hole that we have dug for ourselves, one that if we keep digging will lead to civilizational collapse — and perhaps much worse. That I am able to contribute to this language of shared experience, if only for a brief flash of time in a cosmic scale, is a blessing that I choose not to ignore. Rather I choose to fight for life — to persuade, to coax, to enrich my fellow human consciousnesses, if only to set us on a collective path to betterment. And so I will set about to improve my language and my thoughts, and to seek wisdom in the stillness between my thoughts in the coming year. Perhaps that is the best contribution one human being can make towards the improvement of the human condition. And perhaps that is the best resolution one individual — I — can make for a New Year, and for a new circumnavigation of life.

About the Author Dr. Santosh Pandipati is a board-certified physician in maternal-fetal medicine and obstetrics and gynecology. For the past nine years, he has been working with the Mednax/Obstetrix Medical Group. He has been a Medical Director for Maternal-Fetal Medicine at O’Connor Hospital, and is actively on the medical staffs of several other hospitals in our County. He is currently working on ways to leverage technology to improve prenatal care delivery to pregnant mothers. Dr. Pandipati has a passionate interest in climate change, especially as it affects women’s reproductive health. He has written several popular articles on this subject, and he is an active member of the Committee on Climate Change and Toxic Environmental Exposures for the International Federation of Gynecology and Obstetrics.

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Children’s Environmental Health is the branch of pediatric medicine that studies the influence of the environment on children’s health, development and risk of disease (1). Children’s environmental health considers environmental exposures during pregnancy as well as exposures in infancy, childhood and adolescence. It studies parental environmental and occupational exposures that may influence the health of children. It traces the influence of early-life environmental exposures on health and development across the life span - from conception, through infancy, childhood and adolescence, and on into adult life and old age (2). The core concept of children’s environmental health is that children are unique. Because they are passing through the early, formative stages of human development, children are qualitatively and quantitatively different from different from adults in their patterns of exposure and in their vulnerabilities to environmental hazards (3). The health consequences of environmental exposures in infancy and childhood are often very different from the consequences of exposures later in life. Children’s environmental health is highly interdisciplinary and considers the environment broadly. It recognizes that children’s environments are complex, are comprised of many layers and change over the course of a child’s development. It therefore studies the influences on children’s health of chemical exposures in early life (4), the nutritional environment in the womb (2), the built environment (5), stress (6) and the social environment (7). It studies interactions among these multiple environments at different life stages, a broad view of the universe of children’s exposures termed the ‘exposome’ (8). It examines interactions between environmental exposures, poverty and social injustice (9). It examines the influences of the environment on the human genome and epigenome (10). Children’s environmental health is inherently translational. It translates the findings of research into evidence-based blue12 | The Bulletin | Second Quarter 2021

prints for the prevention of disease and the protection of children’s health. The ultimate goals are to safeguard children’s health and to improve the environments where children live, learn and play. Four great challenges confronting children’s environmental health discussed in this chapter are: 1. Rising rates of non-communicable disease among children worldwide. Environmental exposures are now known to be responsible in part for these increases. 2. Children’s exposure to thousands of inadequately tested chemicals of unknown hazard. 3. The global movement of toxic chemicals and hazardous waste from industrially developed countries to developing countries. 4. Inadequate training of physicians and other health professionals in environmental medicine, which results in missed diagnoses of environmental disease in children and lost opportunities for prevention and treatment. Historical Origins of Children’s Environmental Health

Children’s environmental health arose in the second half of the 20th century through a convergence of scientific insights from three fields: pediatric toxicology, nutritional epidemiology, and social science research. The Contributions of Pediatric Toxicology

Pediatric toxicology, the study of the effects of toxic chemicals on children’s health, is the oldest of the disciplines that have contributed to the formation of children’s environmental health. It derives many of its approaches and methodologies from toxicology and occupational medicine. Pediatric toxicology had its origins in clinical and epidemiologic studies of disease outbreaks in children that resulted from the dissemination of toxic chemicals, inadequately tested pharmacologic agents, www.sccma.org

and other hazards into the environment where children were exposed. Typically these early episodes involved high-dose, acute exposures: 1. An epidemic of lead poisoning among children in Queensland, Australia, in 1904. The source was found to be lead-based paint ingested by children playing on painted verandas (11). 2. An epidemic of leukemia among children in Hiroshima and Nagasaki exposed to ionizing radiation in the atomic bombings (12). Cases began to be seen in the first 2 to 3 years after the attacks. Incidence peaked approximately 7 years after the bombings and then declined. Risk was highest in the most heavily exposed children. 3. An increased risk of microcephaly among infants in Hiroshima and Nagasaki exposed to radiation in utero in the first trimester of pregnancy (13). The cause was radiation injury to the developing brain. There was no comparable damage observed in adults. 4. An epidemic of cerebral palsy, mental retardation, and convulsions among children in the remote fishing village of Minamata, Japan (14). This epidemic was traced to maternal ingestion during pregnancy of fish heavily contaminated with methylmercury. The source was a chemical factory that had discharged mercury-containing waste into Minamata Bay. Mothers were physically unaffected. 5. A major epidemic of phocomelia, a previously rare birth defect of the limbs, in Europe in the 1950s and 1960s (15). Clinical and epidemiologic studies found that the affected babies had been exposed in utero to thalidomide, a sedative prescribed to women during the first trimester of pregnancy to alleviate morning sickness. More than 10,000 cases were reported worldwide (8,000 of them in Germany) before thalidomide was removed from the market and the epidemic halted. Thalidomide was most harmful when taken between days 34 and 50 of pregnancy, precisely the time when the limbs form. Depending upon the timing of exposure, thalidomide was found also to be associated with defects of the eyes, ears, and heart as well as the alimentary and urinary tracts; it also was associated with an increased risk of autism. 6. Cases of adenocarcinoma of the vagina among young women who were exposed in utero to the synthetic estrogen diethylstilbestrol (DES), which had been prescribed to their mothers to prevent miscarriage (16). Incidence peaked in the years immediately after puberty. Mothers were physically unaffected. These epidemics of disease of environmental origin in children established three principles that are fundamental to children’s environmental health: 1. They dispelled the myth that the placenta provides an impervious barrier and showed instead that toxic chemicals can cross the placenta to cause injury to the fetus. 2. They established that early-life exposures to toxic chemicals and other environmental hazards, including exposures in utero, can have devastating effects on children and that these effects can last lifelong. 3. They established that infants and young children have windows of developmentally determined vulnerability to www.sccma.org

toxic chemicals in which even extremely small exposures can cause devastating injury. These windows of vulnerability have no counterpart in adult life…. Recent research suggests that epigenetic modification of fetal gene expression based on metabolic cues received from the mother during pregnancy may be a mechanism of fetal programming that accounts at least in part for Barker’s observations and for the developmental origins of adult disease (22). The Contributions of Social Science Research

Epidemiologic research in the social sciences is the third area of scientific inquiry that contributed to the growth of children’s environmental health (7). As a result of this research, exposure in utero to maternal stress and exposure in early childhood to traumatic events such as extreme violence, child abuse, rape, and incest are now understood to be able to increase risk of disease in childhood and across the life span (23). These studies demonstrate that psychosocial stress in early life is linked to a wide range of physical and mental illnesses, including asthma and obesity in childhood (24, 25) and depression, cardiovascular disease, and autoimmune disease in adult life (26)… Growth of Research in Children’s Environmental Health

A further consequence of the 1993 NAS report and of the policy changes it stimulated was a substantial expansion in US federal research investment in children’s environmental health. As a result of this increased investment, the field has grown exponentially over the past two decades. Specific consequences are the following: • A national network of CEH and Disease Prevention Research Centers was established with support from the National Institute of Environmental Health Sciences (NIEHS) and the US EPA. Research in these centers has led to the discovery of numerous environmental risk factors for disease in children, including previously unrecognized developmental neurotoxicants, endocrine disruptors, and respiratory toxicants (33, 34). • A network of clinically oriented Pediatric Environmental Health Specialty Units (PEHSUs) was established across the United States with support from the Centers for Disease Control and Prevention (CDC)/Agency for Toxic Substances and Disease Registry (ATSDR) and now also includes units in Canada, Mexico, Argentina, Uruguay, and Spain (35). • National and international conferences on CEH have been held since 1994 and have established and refined a research agenda for CEH. Sessions on CEH are now a major component of the annual meeting of the International Society for Environmental Epidemiology. • Environmental Health Perspectives, the high-impact, peer-reviewed journal of NIEHS, has established a special section in each issue devoted to children’s environmental health. Since 1995 the number of articles in this section has increased by nearly 25-fold. • The American Academy of Pediatrics has published the Handbook of Pediatric Environmental Health, known as the Green Book, now in its third edition (36). • The first Textbook on Children’s Environmental Health was published in 2013 (1). • Training programs have been launched to educate pediaThe Bulletin | Second Quarter 2021 | 13

tricians and research scientists in children’s environmental health (37). • Major prospective birth cohort epidemiologic studies have been launched in countries around the world to discover new associations between environmental exposures in early life and children’s health. These include the US National Children’s Study (38), the Japan Environment and Children Study (39), the Avon Longitudinal Study of Parents and Children in the UK (40), and the Norwegian Mother and Child Cohort Study (41). To further increase statistical power for discovery of possible environmental causes of rare disease outcomes such as childhood malignancy, data from a number these birth cohorts are being pooled globally by the International Agency for Research on Cancer through their International Childhood Cancer Consortium (42). Children’s Environmental Health Today

The environment of the United States and in other developed countries has changed dramatically in the past two hundred years, and patterns of health and disease in children have changed in parallel…Today, in the aftermath of the epidemiological transition, non-communicable diseases are the major diseases confronting children in the United States, and they are on the rise: Asthma… birth defects… neurodevelopmental disorders… Leukemia…pre-term birth…obesity… Evidence is mounting that harmful exposures in the environment are important causes of non-communicable diseases in children. Today, in consequence of the acceleration of research in children’s environmental health described above many links between disease in children and harmful exposures in the environment been discovered. Prospective birth cohort epidemiological studies have contributed greatly to these discoveries and have been especially effective in linking prenatal exposures to disease in childhood and beyond… Evidence-Based Prevention of Environmental Disease in Children

A very exciting consequence of the discovery of environmental causes of disease in children is the successful translation of these discoveries into science-based blueprints for disease prevention…Removal of lead from gasoline, which resulted in a 90% reduction in blood lead levels of American children (Figure 1) (75);

These successful prevention programs have not only benefitted children’s health, but they have also benefitted the economy. Improvements in air quality in the United States are associated with estimated benefits of nearly $30 for every dollar invested (81). Removal of lead from gasoline has not only reduced lead poisoning by over 90%, but also has returned an estimated $200 billion to the US economy in every birth cohort born since 1980 through the increased economic productivity of more highly intelligent and creative children not impaired by lead (75). Children’s Exposures to Synthetic Chemicals Today

Despite the great advances in knowledge and prevention of environmental disease in children described above, children today are exposed to thousands of manmade chemicals of unknown hazard. More than 85,000 chemicals are currently registered with the US Environmental Protection Agency (EPA) (4). These chemicals are used in millions of consumer products ranging from food packaging to clothing, building materials, motor fuels, cleaning products, cosmetics, medicinal products, toys and baby bottles. Most are new chemicals that did not exist 50 years ago…. A recurrent theme in all of these tragedies is that the new chemicals were brought to market with great enthusiasm, came into wide use and were widely disseminated in the environment with no premarket assessment. Then belatedly they were found to have harmful effects on health. Chemicals have simply been presumed to be safe and no systematic effort has been made to assess their potential toxicity. A second repeated theme is that early warnings of danger have been ignored. As a result, efforts to control exposures and to prevent injury were delayed, sometimes for decades. In some instances, industries with deeply vested commercial interests in protecting markets for hazardous technologies, such as the lead, tobacco and asbestos industries, have actively opposed efforts to understand and control children’s exposures to these materials. These industries have used highly sophisticated disinformation campaigns to confuse the public and to discredit science (84). They have attacked heroic pediatricians and environmental scientists who called attention to the risks of emerging technologies and new chemicals. A major unanswered question in children’s environmental health is whether there are additional chemicals in wide use today that pose unrecognized hazards to children’s health… Approximately twelve chemicals are known from clinical and epidemiologic studies to be developmental neurotoxicants in children, but another 200 chemicals have been shown to cause neurotoxicity in adult workers, and an another 1,000 are known to cause neurotoxic effects in experimental animals (85). It is not known how many of these 1,200 chemicals – some of which are currently in wide use – may pose neurotoxic hazards to infants and children. The Global Export of Toxic Chemicals

Globalization of commerce has encouraged the relocation of polluting industries such as chemical manufacture, pesticide production and waste recycling from high-income countries to low- and middle-income countries (94). These industries are now booming in poor countries where labor costs are low and environmental regulations, worker protections, and public health infrastructure are often scant (95). Workers and communities in these countries are increasingly exposed to multiple 14 | The 14 | The Bulletin | Second Quarter 2021

Figure 1

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forms of pollution, often under highly unpredictable circumstances, and hazardous wastes are accumulating (96). The once very separate patterns of environmental contamination in developed and developing countries are converging.

tal exposures as a cause of illness in children. Inadequate professional education is at the root of this problem. A 1985 survey of American medical schools found that the average US medical student received less than 4 hours of training in environmental and occupational medicine (105)… Conclusion

Figure 3. Children at an E-Waste Recovery Site, South China Training Needs in Children’s Environmental Health

Physicians and other health care providers are critical to the recognition, management, and prevention of disease of environmental origin in children. The alert clinician is in a unique position to identify new associations between environmental exposures and pediatric disease and thus to initiate appropriate treatment and prevention (104)…. Informed suspicion is the principal tool for the correct diagnosis of environmental disease. The alert clinician needs to be open to the possibility that any child may have an illness that is caused or exacerbated by an environmental exposure. Because diseases of environmental origin in children seldom have unique physical signatures, the exposure history, supplemented by laboratory testing, is the principal diagnostic tool. Unfortunately, diseases of environmental origin in children are underdiagnosed, and many are incorrectly ascribed to other causes. Opportunities for prevention and treatment are therefore lost. This reflects the fact that most physicians and other health care providers have not been adequately trained to take a history of environmental exposure or to recognize environmen-

Children’s environmental health is an exciting and expanding area of pediatric medicine. It offers opportunities for the discovery of new associations between environmental exposures and disease in children as well as opportunities for disease prevention. Students, health professionals and others interested in obtaining more information on children’s environmental health or on career opportunities in the field can consult the following resources: • American Academy of Pediatrics, Council on Environmental Health. Available at: https://www.aap.org/en-us/aboutthe-aap/Committees-Councils-Sections/Council-on-Environmental-Health/Pages/default.aspx. • American Academy of Pediatrics. Handbook of Pediatric Environmental Health. 3rd ed. Etzel RA, Balk SJ (editors). Elk Grove Village, Ill: American Academy of Pediatrics; 2012. • Academic Pediatric Association, Special Interest group on Environmental Health. Available at: http://www.ambpeds. org/specialInterestGroups/sig_env_health.cfm • Children’s Environmental Health Network. Avaialble at: http://cehn.org/wordpress/. • Environmental Health Perspectives, the peer-reviewed, open-access journal of the National Institute of Environmental Health Sciences regularly publishes articles on topics in children’s environmental health. Available at: http:// ehp.niehs.nih.gov/. • Textbook on Children’s Environmental Health. Landrigan PJ, Etzel RA (editors). London: Oxford University Press, 2013 (1). • World Health Organization. Network of Collaborating Centres for Children’s Environmental Health. Available at: http://www.niehs.nih.gov/research/programs/geh/partnerships/network/index.cfm.

About the Author Dr. Philip Landrigan is a pediatrician and one of the world’s leading authorities on public health, particularly children’s health. He is Director of the Global Public Health and the Common Good Program at Boston College and Director of the Global Observatory on Pollution and Health at Boston College, and former Chair of the Department of Preventive Medicine at Mount Sinai School of Medicine. Dr. Landrigan spoke at the SCCMA Environmental Health Series on May 20, 2021 on “Children’s Environmental Health”. The recording of this Session 3 with Q and A can be found at http://www.sccma.org/resources/webinars/sccma-on-demand-webinars.aspx. This is an abbreviated article from his classic book “Children’s Environmental Health” (2013) that provides essential background on this topic and with key resources for pediatricians. The full 18-page article, which is quite compelling and inspiring, can be found at http://www.sccma.org/resources/programs/environmental-health.aspx. www.sccma.org

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What’s Next For Schools? By Matt Miles and Joe Clement The cavalry is coming. There is light at the end of the tunnel. This nightmare is coming to an end. Pick your expression of hope that things may soon be returning to “normal.” For schools, we worry about what that might mean. Between us, we have forty years of classroom teaching experience. Most thinking adults and kids who have seen online school up close and personal, as students, teachers and/or parents, will tell you that school on a screen is not really school. Calling it virtual school is right on. We look at our kids staring at a screen all day long, and it’s unnerving. Not quite right. Better than nothing, perhaps – but that’s a pretty low bar for what we should expect from schools. However, all of that is going away once “things return to normal” (whenever that is), right? Kids and teachers will be back in school, eventually without masks, and we can all get back to school as it was before Covid showed up. That’s a nice narrative, but that assumes school decision makers are going to make that happen, and educational technology firms are going to walk away from all of the cash – and the free data they’ve been mopping up for months. Neither is likely to happen, and we must be on guard – because while there is scant evidence that education through screen-based digital technologies is good for kids, there is a growing mountain of evidence that school this way is bad for © Can Stock Photo / Len44ik kids. When we see school going on in this manner, our intuition tells us something’s not right. We need to listen to it. It’s not that nothing good can come from using digital tools in the classroom. But because something can have benefits does not mean that it will. Because digital tools can be helpful in certain situations does not mean that kids need to have them all day in order to learn. Here’s an analogy: Suppose you are considering a home renovation. Your house is fine as it is, but it’s a little crowded and could use some updating. No change you are making is truly necessary, but it might be nice to have more room. It’s fun to think about the possibilities: a bigger kitchen; a guest room; another bathroom; a fireplace. Oooh, a fireplace. However, you likely won’t get everything you want because that is really expensive. You have to think about the costs. That is the only reasonable way to make any decision: to consider the costs as well as the benefits. When it comes to educational technology, though, many decision makers often think only about the cool stuff and the possibilities. We are told about all of the great things kids can do if 16 | The Bulletin | Second Quarter 2021

only they had the tools. Too often, though, these same decision makers ignore costs. We do not do a good enough job looking at what kids actually do when they have these digital tools. The costs of screens in school go far beyond dollars and cents. No discussion of technology’s role in the lives of our children is complete without honestly and fully considering the enormous social, psychological, emotional, physical and intellectual costs alongside any potential benefit. The point of using digital technology in the classroom is the same as using any classroom tool, from chalk to paper to iPads: if a particular tool is the absolute best way to help a student learn content or a skill, then that is the tool that should be used. Sometimes, that tool is some sort of screen-based device. Most times, though, it is not. Well-intentioned technology initiatives (in which, for example, all students gets a device to keep with them at all times) miss the mark on this point. Why give a student a laptop 24 hours a day if that laptop is really only the best tool for three lessons in a week? There is a reason we do not require our Social Studies students to bring a protractor to class: they do not need one. Math teachers don’t require students to have screwdrivers, and physical education teachers don’t require students to carry calculators. The notion that a child needs a computer in order to learn every day is equally absurd. Laptops and tablets have helped create an approximation of school over the last several months. Once some semblance of “normalcy” returns, the temptation will be great to continue our reliance on them. We need to guard against that so we can be sure we are doing what is best for our kids, and not just what we’ve gotten used to.

About the Authors Matt Miles and Joe Clement are award-winning teachers and coaches in Northern Virginia for well over a decade. In 2017 they authored the book “Screen Schooled: Two Veteran Teachers Expose How Technology Overuse Is Making Our Kids Dumber.” Since then, they have spoken out about the problems created in screen-dependent children and issues around educational technology. Matt has authored articles published in Psychology Today, Education Week and the Washington Times. Joe has authored articles published in the Richmond Times Dispatch, Psychology Today, and numerous other publications.

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Children or teens who are “revved up” and prone to rages or—alternatively—who are depressed and apathetic have become disturbingly commonplace. Chronically irritable children are often in a state of abnormally high arousal, and may seem “wired and tired.” That is, they’re agitated but exhausted. Because chronically high arousal levels impact memory and the ability to relate, these kids are also likely to struggle academically and socially. At some point, a child with these symptoms may be given a mental-health diagnosis such as major depression, bipolar disorder, or ADHD, and offered corresponding treatments, including therapy and medication. But often these treatments don’t work very well, and the downward spiral continues. What’s happening? Both parents and clinicians may be “barking up the wrong tree.” That is, they’re trying to treat what looks like a textbook case of mental disorder, but failing to rule out and address the most common environmental cause of such symptoms—everyday use of electronics. Time and again, I’ve realized that regardless of whether there exists any “true” underlying diagnoses, successfully treating a child with mood dysregulation today requires methodically eliminating all electronics use for several weeks—an “electronic fast” —to allow the nervous system to “reset.” If done correctly, this intervention can produce deeper sleep, a brighter and more even mood, better focus and organization, and an increase in physical activity. The ability to tolerate stress improves, so meltdowns diminish in both frequency and severity. The child begins to enjoy the things they used to, is more drawn to nature, and imaginary or creative play returns. In teens and young adults, an increase in self-directed behavior is observed—the exact opposite of apathy and hopelessness. It’s a beautiful thing.

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At the same time, the electronic fast reduces or eliminates the need for medication while rendering other treatments more effective. Improved sleep, more exercise, and more face-to-face contact with others compound the benefits—an upward spiral! After the fast, once the brain is reset, the parent can carefully determine how much if any electronics use the child can tolerate without symptoms returning. Restricting electronics may not solve everything, but it’s often the missing link in treatment when kids are stuck. But why is the electronic fast intervention so effective? Because it reverses much of the physiological dysfunction produced by daily screen time. Children’s brains are much more sensitive to electronics use than most of us realize. In fact, contrary to popular belief, it doesn’t take much electronic stimulation to throw a sensitive and still-developing brain off track. Also, many parents mistakenly believe that interactive screen-time—Internet or social media use, texting, emailing, and gaming—isn’t harmful, especially compared to passive screen time like watching TV. In fact, interactive screen time is more likely to cause sleep, mood, and cognitive issues, because it’s more likely to cause hyperarousal and compulsive use. Here’s a look at six physiological mechanisms that explain electronics’ tendency to produce mood disturbance: 1. Screen time disrupts sleep and desynchronizes the body clock (link is external). Because light from screen devices mimics daytime, it suppresses melatonin, a sleep signal released by darkness. Just minutes of screen stimulation can delay melatonin release by several hours and desynchronize the body clock. Once the body clock is disrupted, all sorts of other unhealthy reactions occur, such as hormone imbalance

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and brain inflammation. Plus, high arousal doesn’t permit deep sleep, and deep sleep is how we heal. Screen time desensitizes the brain’s reward system. Many children are “hooked” on electronics, and in fact gaming releases so much dopamine—the “feel-good” chemical—that on a brain scan it looks the same as cocaine use. But when reward pathways are overused, they become less sensitive, and more and more stimulation is needed to experience pleasure. Meanwhile, dopamine is also critical for focus and motivation, so needless to say, even small changes in dopamine sensitivity can wreak havoc on how well a child feels and functions. Screen time produces “light-at-night.” Light-at-night from electronics has been linked to depression and even suicide risk in numerous studies. In fact, animal studies show that exposure to screen-based light before or during sleep causes depression, even when the animal isn’t looking at the screen. Sometimes parents are reluctant to restrict electronics use in a child’s bedroom because they worry the child will enter a state of despair—but in fact removing light-at-night is protective. Screen time induces stress reactions. Both acute stress (fight-or-flight) and chronic stress produce changes in brain chemistry and hormones that can increase irritability. Indeed, cortisol, the chronic stress hormone, seems to be both a cause and an effect of depression—creating a vicious cycle. Additionally, both hyperarousal and addiction pathways suppress the brain’s frontal lobe, the area where mood regulation actually takes place. Screen time overloads the sensory system, fractures attention, and depletes mental reserves. Experts say that what’s often behind explosive and aggressive behavior is poor focus. When attention suffers, so does the ability to process one’s internal and external environment, so little demands become big ones. By depleting mental energy with high visual and cognitive input, screen time contributes to low reserves. One way to temporarily “boost” depleted reserves is to become angry,

so meltdowns actually become a coping mechanism. 6. Screen-time reduces physical activity levels and exposure to “green time.” Research shows that time outdoors, especially interacting with nature, can restore attention, lower stress, and reduce aggression. Thus, time spent with electronics reduces exposure to natural mood enhancers. In today’s world, it may seem crazy to restrict electronics so drastically. But when kids are struggling, we’re not doing them any favors by leaving electronics in place and hoping they can wind down by using electronics in “moderation.” It just doesn’t work. In contrast, by allowing the nervous system to return to a more natural state with a strict fast, we can take the first step in helping a child become calmer, stronger, and happier.

Source: Chubykin Arkady/Shutterstock

About the Author Dr. Victoria L. Dunckley is a board-certified integrative child psychiatrist in Los Angeles, California with a special focus on the physiological impact of screen-time on the developing nervous system, mood, focus, sleep, and behavior. Dr. Dunckley is the author of “Reset Your Child’s Brain: A Four Week Plan to End Meltdowns, Raise Grades and Boost Social Skills by Reversing the Effects of Electronic Screen-Time.” She was part of a panel discussion on Children and Technology: Schools, Screens and COVID-19 on May 6 as session 2 of the SCCMA Environmental Health Series 2021. The video can be viewed at http://www.sccma.org/resources/webinars/ sccma-on-demand-webinars.aspx.

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Reviews of the Federal 2020-2025 Dietary Guidelines for Americans were mixed. Nutritionists welcomed recommended limits on added sugars, sodium, and saturated fat combined with emphasis on healthy fats and overall eating patterns rich in fruits, vegetables, and whole grains. The guidelines recommended relatively lower consumption of red and processed meats, sugar-sweetened foods and beverages, and refined grains. But once again, any mention of the sustainability of food production, a major part of an earlier advisory committee analysis, was left out. Critics denounced the politics behind the omission.

USDA Dietary Advisory Committee Guidelines: Sustainability is Critical

The 2015-2020 guideline advisory committee said that sustainability plays a critical role in meeting current and future nutrition needs. Promoting healthy dietary patterns that are produced more sustainably will conserve resources for present and future generations and help ensure long-term food security. But Big Agriculture would have none of it, lobbying successfully to reject considerations of sustainability in Federal dietary guidelines. Big Ag Lobbied to Reject Sustainability in Final Guidelines Big Ag’s program of high-input large-scale monocultures and crowded factory-like animal farms that produce abundant cheap calories often of poor nutritional value while putting workers and communities at risk, degrading soil, and fouling air and water with noxious pollutants and greenhouse gases is threatened by a sustainability goal. But a diverse and growing food movement in the US and abroad has different ideas. At its core it embraces the need to address the sustainability and resilience of food systems, as well as just and equitable access to healthy food, as essential to protect public and planetary health using approaches shaped by local circumstances. The dominant agricultural system in the US relies on government support and public acceptance of externalized costs of pollution, loss of biodiversity, and ecosystem degradation. It is 20 | The Bulletin | Second Quarter 2021

based on assumptions of climate stability, reliable water sources, and cheap energy. Structural vulnerabilities of the entire enterprise are increasingly obvious. Big Ag’s Model: Adverse Impacts and Risks In Iowa, the heart of corn production, the Des Moines Water Works brought a lawsuit against three drainage districts to recover costs of removing unsafe levels of agriculture-related nitrates from their drinking water. They lost and local communities are paying for it. Schools and their advocates in CA demand extended pesticide-spraying buffer zones to protect their children from drift. Ranchers in the West are selling off cattle earlier because of feed and water shortages. Weather patterns are changing. Wells are drying up. Conflicts over access to surface- and groundwater are growing. Food systems that do not adapt will be increasingly at risk from conditions that they helped create. Climate Change and Agriculture In the US, the EPA limits its estimate of agriculture-related greenhouse gas (GHG) emissions to non-CO2 sources—about 8.5% of the total. (fig.1). But this is obviously an accounting gimmick since the agency’s GHG inventory assigns production of energy-intensive nitrogen-containing fertilizers to the industrial sector, carbon releases from agriculture-related land use change to a land-use change category, and carbon from on-farm energy use and food transport to the energy sector. www.sccma.org

2014 US Agriculture Greenhouse Gas Emission Sources (MMT CO2 Eq.)1

Agriculture contributes three GHGs—carbon dioxide (CO2), methane (CH4), and nitrous oxide (N2O). Their turnover rates and global warming potentials (GWP) differ. For a 100-year timeframe, equivalent masses of CH4 and N2O have an estimated 23 and 300 times the GWP, respectively, as CO2.ii Animal agriculture in the US accounts for about half of EPA’s inventory of agriculture-related GHG emissions, although globally livestock are responsible for about 14% of all GHG emissions.iii Much of that excess comes from the release of enormous amounts of carbon stored in forests and grassland soils converted to corn and soybean production for animal feed to satisfy the rapidly growing appetite for meat, particularly in developing countries.

beef is responsible for 50-600 kg CO2e/kg protein, varying with feeding and production practices, pork for 20-55, poultry for 1030, and pulses—e.g. lentils, chickpeas, dry beans—for 4-10.viii Water Use in Agriculture is Huge: Meat and Dairy Products Dominate Livestock alone accounts for more than 8% of total global water use, most of which goes to irrigate feed crops.ix Irrigation withdrawals increasingly exceed supply rates, for example, in the Ogallala aquifer underlying the Great Plains.x In CA, long embroiled in conflicts over competing water uses, more than 90% of the state’s “water footprint” is associated with agriculture. (Figure 2) Meat and dairy products have especially large water footprints due to the amount of water-intensive feed re-

Cattle and Sheep Emissions are the Largest Source of Agriculture-related GHG-Methane Enteric fermentation of feed in cattle and sheep is the largest source of agriculture-related CH4 in the US, representing nearly 25% of total emissions from anthropogenic activities. About 80% of all N2O emissions come from fertilized soil, nitrogen runoff, and manure.iv Manure management accounts for about 14% of the total GHG emissions from agriculture. Animal Feed Corn Production and Nitrates Tens of millions of acres of corn production largely in the upper Midwest, more than 35% of which is processed for animal feed, is heavily dependent on use of energy-intensive nitrogen-containing fertilizer. Nitrogen leaching is not only a source of N2O but also unsafe spikes of excessive nitrates in drinking water sources. Elevated levels of nitrate in drinking water can increase the risk of birth defects and thyroid cancer in communities downstream and contribute to eutrophication of freshwater and marine aquatic systems.v vi vii Analyses of the carbon footprint of various protein sources find that beef production is responsible for far higher emissions of GHGs than others. Expressed as CO2 equivalents/kg protein, www.sccma.org

Figure 2. California’s Water Footprint by Sector:xii

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quired to raise the animals. A study of virtual water content of various food products using intensive systems in CA finds that beef requires 100,000 L/kg protein compared to 47,619 for pork, 30,303 for poultry, and 13,158 for beans.xi Healthy food, sustainable agriculture: Achieving food system sustainability is critical in order to meet current and future nutrition needs. Soil and ecosystem degradation, chemical contamination, unsustainable water use, and climate change are driving development of new models of food production. Among current efforts: organic farming, rebuilding soil carbon through reduced tillage, more extensive use of cover crops, restoring grasslands and biodiversity, improved grazing management, and combining crops, trees, and animal husbandry in integrated systems.i ii iii The good news is that truly healthy diets can be produced with sharply reduced environmental and public health impacts. Local, regional and institutional efforts are gaining traction around the country. In the health care sector, the Healthy Food in Health Care program of Health Care Without Harm is deeply engaged in this transformation.iv Health care systems, professionals and communities have forged partnerships with food producers, processors, and distributors in order to align pur-

chasing with sustainable agricultural practices.v Early projects that focused on rejecting the routine use of antibiotics in meat production are expanding to include a less meat-better meat approach and increasing plant-based protein alternatives. Hospitals around the country are hosting farmer’s markets and community supported agriculture distributions featuring healthy local and regional food produced more sustainably. In higher education, Real Food Challenge recently developed a set of sustainable food standards for evaluating the ecologic, sociologic, and economic impact of food products to inform purchasing decisions in universities.vi Perhaps the next iteration of Dietary Guidelines for Americans will reflect the obvious need for sustainable food production over the long-term. If not, it will become irrelevant as drivers of new agricultural models are not waiting for the government to catch up. The world is warming, oceans are acidifying, rainfall and weather patterns are changing, soil is degraded, and water supplies are dwindling. We can respond now to help mitigate these changes and their impacts or force current and future generations to adapt to an uncertain future in which food security becomes more and more tenuous for large and growing numbers of people around the world.

About the Author Ted Schettler MD, MPH, is science director of the Science and Environmental Health Network and the Collaborative on Health and Environment (CHE). Dr. Schettler authored “Generations at Risk: Reproductive Health and the Environment;” “In Harm’s Way: Toxic Threats to Child Development;” and “The Ecology of Breast Cancer.” He presented “Food and the Environment: How Our Modern Food System Affects Our Health, Planetary Health and Opportunities for Change” on June 3rd, as the last session of the four-part SCCMA Environmental Health Series 2021. The presentation was recorded and can be viewed at http://www.sccma.org/resources/webinars/sccma-on-demand-webinars.aspx.

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

15. 16. 17. 18.

US Greenhouse Gas Inventory Report: 1990-2014. Available at https://www.epa.gov/ghgemissions/us-greenhouse-gas-inventory-report-1990-2014 IPCC, 2001 FAO. Tackling climate change through livestock. 2014. http://www.fao.org/ag/againfo/resources/en/publications/tackling_climate_change/ index.htm Park S, Croteau P, Boering K, Etheridge D, et al. Trends and seasonal cycles in the isotopic composition of nitrous oxide since 1940. Nature Geoscience. 2012; 5:261-265. Brender J, Weyer P. Agricultural compounds in water and birth defects. Curr Environ Health Rep. 2016; 3(2):144-152. Ward M, Kilfoy B, Weyer P, Anderson K, et al. Nitrate intake and the risk of thyroid cancer and thyroid disease. Epidemiology. 2010; 21(3):389-395. http://www.gulfhypoxia.net/overview/ Nijdam D, Rood T, Westhoek H. The price of protein: review of land use and carbon footprints from life cycle assessments of animal food products and their substitutes. Food Policy. 2010; 37:760–770. Schlink A, Nguyen M, Viljoen G. Water requirements for livestock production: a global perspective. Rev Sci Tech. 2010; 29(3):603-619. Kirschenmann: Anticipating the future? Available at http://lib.dr.iastate.edu/leopold_letter/60/ Schlink A, Nguyen M, Viljoen G. Water requirements for livestock production: a global perspective. Rev Sci Tech. 2010; 29(3):603-619. Fulton J, Cooley H, Gleick P. California’s water footprint. 2012. Pacific Institute; Oakland CA. Available at: pacinst.org/app/uploads/2013/02/ ca_ftprint_full_report3.pdf Used with permission. Lal R, Follett R, Kimble J. Achieving soil carbon sequestration in the United States: a challenge to the policy makers. Soil Sci. 2003; 168(12):827-845. Olander L, Eagle A, Baker J, et al. Assessing greenhouse gas mitigation opportunities and implementation strategies for agricultural land management in the United States. Nicholas Institute for Environmental Policy Solutions. Report NI R 11-09. November 2011. Available at https://nicholasinstitute.duke.edu/ecosystem/t-agg/assessing-greenhouse-gas-mitigation-opportunities-and-implementation-strategies-for-agricultural-land-management-in-the-united-states Schwartz J. Soil as carbon storehouse: new weapon in climate fight? Environment360. March, 2014. http://e360.yale.edu/feature/soil_as_carbon_storehouse_new_weapon_in_climate_fight/2744/ https://noharm-uscanada.org/healthyfoodinhealthcare https://noharm-uscanada.org/healthyfoodinhealthcare http://calculator.realfoodchallenge.org/help/resources

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www.sccma.org

In the United States, leading causes of hospitalizations, health care costs, and death are directly linked to poor diets. But food quality cannot be judged only by the nutritional value of what someone eats. Driven by food production policies, programs and practices, the dominant industrial food system damages human health and the environment in other ways too. While producing a surfeit of cheap food much of which is of poor nutritional quality, the food system relies on hazardous synthetic pesticides, fossil-fuel-based fertilizers, antibiotics, and hormones, as well as low-wage laborers who face unsafe working conditions. Common food production practices pollute air and water and drive climate change. We know that with dietary changes, reduced food waste and changes in production practices we can feed a growing global population in a sustainable way that better supports human and environmental health. With leadership and expertise from Health Care Without Harm’s Healthy Food in Health Care (HFHC) program, dedicated staff at health care facilities across North America are implementing policies and programs that support sustainable food systems. Using an environmental nutrition framework that includes the entire food value chain, they leverage their respected voices, purchasing power, investments and other assets to develop food systems that conserve and renew natural resources, advance social justice and animal welfare, build community wealth and resilience, and fulfill the food

and nutrition needs of all eaters now and into the future. The health care sector can help ensure that food systems “do no harm.” Partnering with more than 1,000 hospitals across North America, the HFHC program advocates on the local, state, and national level for: • People and planet-friendly food • Healthy food and communities • Food policy action to support sustainable food systems Through regional innovation hubs, we work with hospitals and communities to implement successful strategies for food system improvement, including developing innovative plant-forward menus and local and sustainable food purchasing. Hospitals that want additional tools and resources to prioritize healthy food in health care, develop cost-effective sustainability initiatives throughout hospital operations, and benchmark their success become Practice Greenhealth members. Practice Greenhealth is the leading membership and networking organization for sustainable health care, delivering environmental solutions to hospitals and health systems across the United States. By shifting our dietary patterns toward delicious foods produced in just and sustainable ways, we can improve individual, community, and environmental health while sharply reducing food-related greenhouse gas emissions.

Additional links at Heath Care Without Harm • Healthy Food in Health Care | Health Care Without Harm (noharm-uscanada.org) • People and planet-friendly food | Health Care Without Harm (noharm-uscanada.org) Healthcare Without Harm is an international collaborative organization that “works to transform health care worldwide so that it reduces its environmental footprint, becomes a community anchor for sustainability and a leader in the global movement for environmental health and justice. Programs include Medical Waste, Toxic Materials, Safer Chemicals, Green Building and Energy, Healthy Food, Pharmaceuticals, Sustainable Procurement, Climate and Health, Transportation, Water. www.sccma.org

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From the County of Santa Clara Public Health Department Vaccine Branch, Emergency Operations Center

Santa Clara County leads the way on COVID-19 vaccination, with one of the highest vaccination rates of any large county in any state in the country. Many people take advantage of the availability of COVID-19 vaccine at large community sites here. However, some patients continue to express the desire to wait until their own doctor can provide the vaccine and discuss concerns they have about the vaccine. Surveys have shown that people trust their own doctor to help them to make important decisions about their health, and especially about COVID-19 vaccination. Enroll as a vaccine provider

Physicians can now easily enroll as a COVID-19 vaccine provider. You can further protect your patients, patients’ families, and our community by offering COVID-19 vaccines in your practice. It is easier than you think. Vaccine management requirements have changed a bit in recent months, as manufacturers and the federal government have learned more about what is required to protect the vaccine and what is not. Vaccine supply and support are available. COVID-19 vaccine providers must enroll in some state systems, including CAIR2 and myCAVax: https:// mycavax.cdph.ca.gov/s/. The County can provide free vaccine upon request to providers who have completed all of the enrollment processes. More information is available on the County’s webpage for vaccine providers. Promote vaccination with every patient

National surveys strongly indicate that the public wants to hear from their own doctors about the COVID-19 vaccine. More than sports stars, clergy, politicians, or other influencers - doctors are the most trusted messengers of vaccine information for many people. All physicians – from primary care doctors, to family medicine practitioners, to specialists, and emergency room doctors – have an opportunity and a responsibility to help patients with their questions about COVID-19 vaccines. With high COVID-19 case numbers looming throughout the world, please help your patients understand the value of the vaccine and its role in stopping the pandemic. Pockets of un-

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vaccinated people remain vulnerable in our own local communities. Many may not be at high risk for severe virus symptoms, but of course there is still a risk of acute or long-term health impacts from the virus. Please make a point to recommend COVID-19 vaccination in every visit to all of your patients aged 12 and older who do not have contraindications. During patient visits, make the COVID-19 vaccine a new vital sign. Ask every patient, or their parents or guardians, what their vaccination plan is. For those that are unsure, discuss their concerns and try to answer any questions they might have. Share educational material widely, including posting posters and flyers in waiting rooms, staff break rooms, and common areas. You can also public information on your website, including a way for people to contact you with questions. Consider sending a letter or email to your patients, especially your unvaccinated patients. Provide facts, refer them to additional resources, and offer to answer questions. You are the most influential vaccine communicator. Coadministration

There is other good news. The CDC and the California Department of Public Health no longer require patients to wait two weeks between COVID-19 vaccination and any other type of vaccination. Physicians can now provide COVID-19 vaccination as part of their regular office visits. Pediatricians and family medicine practitioners are encouraged to offer COVID-19 vaccination at Back To School visits and sports physicals, along with other routine childhood immunizations. Adults can also receive indicated vaccine along with a COVID-19 vaccination. Additional information regarding vaccines can be found on the County’s COVID-19 website at sccFreeVax.org. A number of languages are available, including Spanish at sccVacuna.org.

www.sccma.org

California Needs Increased Oversight of Toxic Sites to Safeguard Environmental Health By Senator Dave Cortese

Senator Dave Cortese

About the Author Senator Dave Cortese represents District 15 which encompasses much of Santa Clara County in the heart of Silicon Valley. Along with his accomplished career as an attorney and business owner, the Senator previously served on the Santa Clara County Board of Supervisors, the San Jose City Council, and the East Side Union High School District Board.

www.sccma.org

For decades, the State of California has tracked the location of sites that release hazardous materials into the communities we live in – these toxins pollute the air that we breath, the water that we drink, and the soil our crops depend on. Known as the “Cortese List” and named after my father, Dominic Cortese, the former legislator who authored the original law that led to its conception in the 80’s, this annually updated inventory of hazardous sites has served to inform the public about the alarming contamination that exists around us. Posing unquestionable harm to our public health, the chemicals at Cortese List sites are associated with weakened immunity, can cause certain cancers as well as other serious health issues, and are even linked to certain birth defects. They’re not only a risk to humans, they threaten our animal population and ecological system as a whole. The Cortese List provided information about these sites at a time when nobody knew where they were, leaving planning agencies and developers blind to the potential health risks of families being exposed to contamination. Laying the foundation for future legislation in California to better protect public health, the Cortese List has brought about enhanced safety standards and better public awareness around these hazardous sites. Most significantly, it led to a law that prohibited projects on these sites from being granted exemptions for the environmental review processes required through the California Environmental Quality Act (CEQA). Recently, we have seen local agencies skirt this law by granting exemptions under the guise of “common-sense”, allowing projects to be carried out without adequate environmental review. This loophole in existing law is not only a danger to community members living in the surrounding areas, it jeopardizes the safety of the workers on these sites, and has profound public health and environmental impacts.

One of the more egregious cases of a Cortese List exemption being granted is in San Francisco, where a 100-year-old auto body shop slated for condominium development contained levels of substances that far exceeded what is considered safe for human exposure, including benzene levels 900 times above acceptable residential standards. Our CEQA process is integral to protecting the rights of community members and all impacted parties to understand the environmental and health risk imposed by certain projects right in their backyard. And years of research has demonstrated what we already know - that these hazardous waste sites and polluting industrial facilities are disproportionately located in underserved and underrepresented neighborhoods. This year, I am pushing our state to take a critical step towards protecting public health and promoting public accountability by ending, once and for all, the abuse of the “common sense” exemption for projects impacting Cortese List sites. SB 37, The Hazardous Waste Site Cleanup and Safety Act, is a bill I have introduced to carry forward the work of my father that will close the loophole that currently allows “common-sense” exemptions for environmental review on Cortese List sites, and I’m pleased to announce that SB 37 has cleared the Senate Environmental Quality Committee and is one step closer to becoming law. We cannot continue to allow projects to bypass important CEQA review and put environmental health and worker safety at risk. Pursuing these projects without public accountability and appropriate cleanup creates severe health concerns for laborers working at the site, members of the community that live near the site, as well as our state’s diverse ecosystem. We must establish long-term sustainable solutions to ensure that all Californian’s are provided the environmental health and safety protections they deserve.

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Stanford University. Burke is lead author of a 2021 paper in the Proceedings of the National Academy of Sciences (PNAS) on the evolving, multipronged threat posed by increasing U.S. wildfires. In an October 2020 policy brief, Burke and two Stanford colleagues noted that wildfire smoke likely is responsible for 5,000 to 15,000 U.S. deaths in a typical year, and that especially smoky years like 2018 or 2020 will have a much higher death toll. “Our research suggests that many more people likely perish from smoke exposure during large fire events than perish directly in the fire, and many more people are made sick,” Burke says. (Image Credit: Tiana Huddlestun/USFS)

Articles on U.S. wildfires don’t often show a photo of someone gasping in a hospital bed or felled by a heart attack. Yet an increasing body of evidence suggests that the biggest societal impacts of increasing wildland fire are happening in our own bodies, the result of tiny particulates spewed in vast amounts. Millions of people across the western U.S. coughed and hacked their way through the summer and autumn of 2020, when some of the region’s worst fires on record ripped across the landscape. It’s too soon to know the full range of health consequences from that summer’s blazes, but there’s already evidence now in peer review that more than 100 deaths may be attributable to 2020’s late-summer smoke in Washington state alone. If another early estimate is on target, the smoke may have contributed to between 1,200 and 3,000 premature deaths in California among people 65 and older. Research on wildfire smoke and health is advancing hand in hand with the threat itself. The western fires of 2020 came soon after several disastrously hot, fiery years in California, which spawned a grim bumper crop of case studies. Meanwhile, an expanding array of satellite imagery is helping pinpoint where and when smoke is being emitted and transported. That’s helping scientists determine the number of people hospitalized or killed in a given area as a consequence of smoke.“I think one of the biggest developments of the last three years has been the intense interest on the part of government, health organizations, media, and the public on the whole topic of fire smoke and health,” says Wayne Cascio, who directs EPA’s Center for Public Health and Environmental Assessment. “It’s been raised to such a high level nationally and even globally that it’s motivating a lot of action to support science and to answer key questions.” Among other relevant issues, smoke appears more likely than the fires themselves to affect communities already struggling with socioeconomic and race-based health disparities. “Nearly all the media attention during wildfires focuses on the lives and property directly in harm’s way. These are important and tragic impacts, but are likely only a very small portion of the overall societal impacts of wildfire,” says Marshall Burke, an associate professor of Earth system science at

(Photo credit: Christopher Michel / CC BY 2.0)

By Bob Henson

Firefighters in California September 2020 The interagency firefighting group, Lassen Hotshots, holds the line on September 24, 2020, against California’s largest fire by far in 89 years of modern record keeping: the one-million-acre August Complex.

Fine particulates: minuscule and merciless The most concerning byproducts of wildland fire are the smallest particulates routinely tracked by EPA: PM2.5, those no larger than 2.5 microns in diameter. These have long been linked to increased risk of illness and death, as they’re small enough to enter lungs and also the bloodstream, thus affectwww.sccma.org

ing both cardiovascular and respiratory systems. occur. “Nobody wants to change the Clean Air Act,” says Globally, more than 4 million deaths per year are estimated Wara, but “everybody recognizes we need to change how we to be triggered by outdoor air pollution. The actual toll could manage this.” be twice that, if one recent study is correct. A large share of those fatalities can be chalked up to PM2.5. Smoke, health, and the environmental equity Although PM2.5 from pollution has decreased by more implications than 40% in the U.S. since 2000, wildfire-related PM2.5 is on Wildfires are seldom viewed through the lens of environthe increase. Burke and colleagues found that the fraction mental justice. The reason, in part, is that most immediate of total nationwide PM2.5 that originates from wildfire has impacts of U.S. wildfire, including injuries and deaths as jumped from around 10% in 2010 to around 25% today. In well as structural damage, tend to affect exurban and rural parts of the West, they estimate, fires now produce up to communities in the West that are largely white. For exam50% of all PM2.5 – in other words, as much as all pollution ple, the Camp Fire of November 2018 – California’s deadlisources together. est (85 deaths) and most destructive modern-day fire (18,804 Startlingly, the immense structures lost) – hit hardest in the amounts of smoke thrown into town of Paradise, which was 92% the air by wildland fire aren’t covwhite as of the 2010 census. ered at all under the federal Clean The impacts of smoke, which Air Act: As their very name sugcan extend hundreds of miles gests, wildfires are uncontrollable from a major fire, are another and thus not subject to regulation. matter. Easterly winds pushed At the same time, the periodic smoke from the Camp Fire into controlled burning of fire-prone the Bay Area for two weeks on areas in order to forestall much end, giving San Francisco six of bigger fires – a practice used by its 10 worst PM2.5 days up to that (Image credit: Wikimedia Commons/Test Subject 51.) Indigenous people for centuries, point in data going back to 1999. and more recently taken up by In the East Bay city of Vallejo, as federal, state, local, and private Plume smoke above Paradise, California in 2018 reported by KQED public radio, A massive smoke plume looms above Paradise, Califorland managers – does fall under the levels of PM2.5 soared to 247 nia, on November 8, 2018, the first day of the catastrophic Clean Air Act regulation of both Camp Fire. This photo was taken from atop Butte Hall at micrograms per cubic meter (μg/ PM2.5 and ozone. m3 ) – far above the federal 24California State University, Chico. The paradoxical upshot: cleanhour standard of 35, and closer air law is limiting our ability to quell wildfires that are potento levels observed on a bad day in pollution-choked cities tially riskier than controlled burns to air quality and collecsuch as Beijing or Delhi. Vallejo is one of the state’s most tive health. This conflict is especially pronounced in regions diverse cities: 33% white as of the 2010 census. already struggling to meet national ambient air quality attainEquity comes into play even more when smoke worsens ment levels because of pollution unrelated to fire. health conditions that are already more prevalent in lowIt’s a conundrum that forest managers and air quality er-income locations, including some communities of color. regulators are increasingly pondering, according to StanOne 2016 study in northern California found that people in ford-based research scholar and environmental law expert lower-income zip code areas were disproportionately likely Michael Wara, who coauthored the PNAS paper. on wildfire smoke days to visit emergency rooms for asthma “Doing prescribed fire on a site in a way that prevents a complications. catastrophic wildfire dramatically reduces emissions of PM “Health insurance may be a key factor,” says Colleen Reid per acre. It’s an order of magnitude difference,” says Wara. of the University of Colorado, lead author of that study and “You burn so much less material when you just come in and of a 2016 research review on wildfire smoke and health that burn the forest floor and [not] the large trees.” she expects soon to update. Reid points out that one study Currently, a land manager – whether a private owner, a from Canada, where universal health care access is the norm, government entity, or an Indigenous tribe – can apply for found no differential impact from wildfire smoke based on permission to exceed 24-hour guidelines for PM2.5 and ozone socioeconomic status, whereas several U.S. studies have with a single prescribed burn. However, a season’s worth of found such effects. controlled burning could still run up against annual PM2.5 People in lower-income areas may also be more vulnerable and ozone limits, even if these burns help avoid an eventual to smoke impacts simply because of their housing. Especially wildfire that would be truly catastrophic. when prolonged, wildfire smoke can easily infiltrate homes Wara is part of an embryonic effort to examine how the and compromise indoor air quality. Clean Air Act could be reinterpreted to balance the relative “At least in California, older housing is much less airtight emission harms from controlled burns versus massive wildthan newer housing stock,” says Wara. Moreover, he adds, fires. “We need to bring realistic versions of land manage“Wealthy people tend to have the disposable income to drop ment into the models used to evaluate these processes,” Wara a couple hundred dollars on HEPA filters. I know other peosays. ple who suffer terribly through wildfire season. People I The ultimate air-quality goal, he adds, is to reduce expoknow are taping plastic sheeting over their windows. Even sure to harmful smoke in all the ways such exposures can if you put a box fan together with a filter, if your house isn’t www.sccma.org

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tight, the smoke just gets in.” There’s much yet to learn about wildfire smoke and health disparities. A study published in Science Advances on April 28 found that nearly all U.S. sources of PM2.5 emissions disproportionately affect people of color. However, the study did not cover emissions from wildfires.

(Image credit: EPA.)

Zeroing in on longevity and health impacts Back in 1994, the landmark “Six Cities” study from the Harvard School of Public Health revealed pollution’s terrible toll: long-term exposure to high levels of PM2.5, even in cities that met existing air quality standards, could shorten life expectancy by up to three years. Reducing PM2.5 gives the most

Particulate matter 2.5 The tiny bits of particulate matter known as PM2.5 are smaller than 2.5 microns in diameter – less than 5% of the width of a strand of human hair.

health benefit for each dollar of pollution control. Although PM2.5’s biggest threat is to the cardiovascular system, such effects have been difficult to nail down for wildfire smoke, according to Reid. “A few more recent studies have found more significant relationships,” Reid says. “There’s a lot of statistical methodology differences among different groups, so we need to do some more work.” There are also emerging signs that PM2.5 from wildland fires may be more health-hazardous than other PM2.5, at least in some cases. A recent Nature Communications study led by Rosana Aguilera, a postdoctoral researcher at the Scripps Institution of Oceanography, examined 14 years of Southern California fires. The authors found up to a 10% increase in respiratory hospitalizations for every 10 μg/m3 increase in wildfire-specific PM2.5, compared to a 1.3% increase for non-wildfire PM2.5. Similarly, a 2020 study led by Daniel Kiser of the Desert Research Institute found that asthma-related visits to urgent care centers and emergency rooms in the Reno area were boosted by an additional 6.1% for every 5 μg/m3 increase in PM2.5 for cases when wildfire smoke was present compared to when it was not present. Not all studies have found such differences, however, perhaps because of methodological and regional variations. Health impacts from wildfire smoke may also vary based on exactly what’s being consumed by a wildfire (oak, pine needles, eucalyptus, or peat, to name just a few), and on whether a fire is smoldering versus raging. Such nuances are “pretty 28 | The 28 | The Bulletin | Second Quarter 2021

challenging to investigate,” says the EPA’s Cascio, “but certainly the lab data suggest there may be differences.” Along with its growing body of research on wildfire smoke and health, including new efforts focused on public communication and intervention, EPA launched its Smoke Sense app (available through Android and iOS systems) in 2017. More than 40,000 users have downloaded Smoke Sense, which provides current fire and air-quality data and hourly forecasts of smoke and ozone. People can also gauge their own vulnerability to smoke impacts and anonymously report any symptoms via the app. Bracing for more fire and smoke this summer The accumulating research on wildfires and health could lead to a transformation in how we view the infernos that are becoming more widespread across ever-more-intense fire seasons. Human-produced global heating is not only raising temperatures – it’s also raising the stakes for wildfire risk. In a warming climate, landscapes can dry out more readily even where precipitation trends aren’t changing. “Among the many processes important to California’s diverse fire regimes, warming-driven fuel drying is the clearest link between anthropogenic climate change and increased California wildfire activity to date,” concluded Park Williams of Columbia University in a 2019 paper. Many Westerners are approaching the summer of 2021 with trepidation. As California’s wet season draws to a disappointing close, the state is now virtually certain to lock up its second driest pair of water years in records going more than a century, behind only 1975-77, according to Bay Area expert Jan Null of Golden Gate Weather Services. Not all dry years are particularly fiery, noted Null in a blog post. Less than 34,000 acres burned in California in 1991, even after two relatively dry winters in a row. On the whole, though, Null calls the relationship between drought and California fire “compelling.” By the end of April – weeks ahead of the norm – serious fires had already erupted in California, Arizona, and New Mexico. NOAA’s latest seasonal drought outlook, issued April 15 and extending through July, calls for drought to persist or develop across the entire contiguous U.S. west of the Rockies except for western Washington and far northwest Oregon.

About the Author Bob Henson is a meteorologist and journalist based in Boulder, Colorado. He has written on weather and climate for the National Center for Atmospheric Research, Weather Underground, and many freelance venues. Bob is the author of “The Thinking Person’s Guide to Climate Change” and of “The Rough Guide to Climate Change,” a forerunner to it, and of “Weather on the Air: A History of Broadcast Meteorology”, and coauthor of the introductory textbook “Meteorology Today”. A native of Oklahoma City, he earned a bachelor's degree in meteorology and psychology from Rice University and a master's degree in journalism, with a focus on meteorology, from the University of Oklahoma. www.sccma.org

Returning to the Physical Workplace Legal parameters and considerations for employers

As California businesses begin to transition back the physical workplace, employers understandably have many questions about what is, and is not, allowed as we continue to grapple with the fallout of the COVID-19 public health emergency. Working with employment law counsel Oscar Rivas, the California Medical Association (CMA) prepared this FAQ to help employers understand their rights and obligations. Note: This document is for educational purposes only. Consult with a licensed attorney or other professional if you are facing any legal situation so that all relevant facts can be considered prior to making a decision. Nothing in this presentation should be interpreted as legal advice and no attorney client privilege is established.1

1. Can employer ask about employee's vaccination status? Yes. And you can ask for proof. See: What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws2, §K.3 (updated Dec. 16, 2020) (EEOC Guidance) found at www.eeoc.gov/wysk/what-you-should-know-about-covid-19-and-ada-rehabilitation-act-andother-eeo-laws); DFEH Employment Information on COVID-19, pp. 7 and 10 (March 4, 2021) (DFEH Guidance) found at www.dfeh.ca.gov/wp-content/uploads/sites/32/2020/03/DFEH-Employment-Information-on-COVID-19-FAQ_ENG.pdf.

The danger of this inquiry lies when you ask why someone has not taken a vaccine. Employees can refuse to take the vaccine for medical or religious reasons, and the response may elicit privacy protected information. So, prepare and train the people not to inquire, but if you do, establish a legitimate business reason for asking for the information—we need to reopen and we need to devise a plan to implement how the office will function and knowing who is vaccinated is important to determine job, functions, and limitations. (EEOC Guidance at K.3, K.5-K.7; DFEH Guidance, pp. 8-9)

DISCLAIMER: All content on the cmadocs.org website, including COVID-19 related content, is general in nature, is provided for informational purposes only, does not constitute medical, ethical, financial, legal, coding, or other advice, and should not be used as the sole basis for decision-making or as a substitute for obtaining competent consultation and specific advice from a physician, attorney, insurer, or other knowledgeable professional. In all instances, situation-specific circumstances necessitate consideration of factors which cannot be and are not addressed herein and the information provided is not entirely inclusive, exclusive, or exhaustive of all reasonable methods or approaches to addressing the situation described. CMA makes no warranty, express or implied, and assumes no medical, ethical, financial, or legal liability or responsibility for the content, or for any method, process, strategy, or approach described or referenced herein and CMA shall not be held liable for the content or use thereof. Any use or adaptation of this information must include these disclaimers.

The Equal Employment Opportunity Commission (EEOC) is charged with enforcing most Federal EEO Laws. The Department of Fair Employment and Housing (DFEH) is charged with enforcing state EEO Laws. EEOC and DFEH both have jurisdiction under its own laws, and both sets of laws must be complied with by employers.

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RETURN TO WORK FAQ Also, if you ask, ask everyone to avoid targeting a particular individual. If you target an individual but not others, some objective evidence justifying the question to the particular employee may be required. (Id. at A.9). 2. What are employer risks of knowing employee's vaccination status? Not much risk because it does not trigger any obligations as it is not considered a medical examination. However, asking why someone did not take the test may elicit information that may be protected and be considered an examination, which triggers ADA, Title VII (Religion), FEHA, and others, such as GINA (genetic information based medical reason for not vaccinating). If an employee shows proof of vaccination, ensure to remind employees not to provide any document with additional medical information, and ensure whoever sees the document that they do not inquire or record such information. (EEOC Guidance, A.1, B.1, A.11; DFEH Guidance, p. 2) Any medical information must be stored apart from personnel file with adequate safety protocols requiring locking the information and limiting its access and use. (EEOC Guidance, B.1; DFEH Guidance, p. 1) 3. Can an employer require employees to vaccinate? Yes. Employers may have “qualification standards” for a position. Vaccinations can qualify as qualifications standards. However, if the standard screens out an individual for disability or religion, the employer must show that the employee poses a “significant risk of substantial harm to the health or safety of the individual or others that cannot be eliminated or reduced by reasonable accommodation.” (29 CFR 1630.2(R)) Employers should conduct an individualized assessment of four factors to determine whether a direct threat exists: 1) Duration of risk; 2) nature and severity of the potential harm; 3) likelihood that the potential harm will occur; and 4) imminence of the potential harm. If the employee poses a direct threat and cannot be vaccinated, the employer may only exclude the employee if there is no way to reasonably accommodate him/her absent undue hardship. As this is an affirmative defense, the employer must demonstrate it could not reasonably accommodate the employee. Care must be taken to ensure proper analysis and documentation is followed if the decision gets to this point. (EEOC Guidance, K.5; DFEH Guidance, p.7-9)

No reasonable accommodation is required if an employee does not want to take the vaccine for political or safety concerns. (Id.) The term “reasonable accommodation” is a term of art in employment law. There is a whole body of law under the Title VII, ADA, and FEHA around the meaning of an employer’s obligation to “reasonably accommodate” an employee with a disability, along with what constitutes an “undue

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RETURN TO WORK FAQ burden” that renders an accommodation not reasonable. For purposes of this presentation, an employer is required to accommodate an employee’s disability if that disability interferes with the employees ability to apply or perform the “essential functions of the job” unless that accommodation would cause an undue hardship. The form of the accommodation may include 1) changing job duties, 2) providing leave for medical care and recovery, 3) changing work schedules, 4) relocationg work area, and 5) proving mechanical and electrical aids. However, the actual accommodation is highly dependant on the disability (such as an inability to lift certain amounts, inability to stand for long periods of time, sensitivity to light due to migraines, etc., the job duties, and the burden that accommodating that employee will impose, such as length of the disability, costs of modifying duties, or changing certain duties. Generally, the employee asks for an accommodation by telling the employer that they are unable to show up, perform, or need time off for a protected condition (medical condition, pregnancy, religious observance, etc.). This is the beginning of the “interactive process” required under the law in which the employer, employee and (oftentimes) the employee’s physician engage in a dialog to try and determine an accommodation for the disability. Ultimately, the doctor has the last word on the medical limitations but it is the employer who determines how to accommodate the employee. Failure to enage in the interactive process is itself a violation of the law. The employer generally can ask for a doctor’s note if the condition is medical in nature. The note will indicate what the limitation is that the employee has which needs to be accommodated. If the disability cannot be accommodated because the employee cannot perform the essential functions of the job, the employer may try to place the employee in a similar position (duties, responsibility and pay). If this cannot be done, another position may be considered, even if it is at lower pay, different duties, or different responsibilities. If there are no alternate similar or dissimilar positions, a leave of absence may be granted until the employee may recover. Finally, if no accommodation can be made or if the only accommodations create an undue burden on the employer, the employer may terminate the employee as being unable to perform the essential fucntions of the job with or without a reasonable accommodation. (See, e.g., www.dfeh.ca.gov/accommodation.) It should be noted that employees with disabilities may also be entitled to leaves under other laws, such as the Federal Family and Medical Leave Act (FMLA) or the California Family Rights Act (CFRA). Given that all these laws must be complied with, all accommodation issues should be discussed with an attorney or, at minimum, an HR specialist.

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RETURN TO WORK FAQ 4. Can employer make decisions regarding employee work environment, assignments, workspace, etc., based on whether employee is vaccinated? Yes. The employer may require employees to wear PPE or impose infection prevention protocols (wash hands, etc.) or take other actions designed to protect employees. The only limitations are that such requirements not violate the other provisions of the law, as changes that may create medical risks or infringe on religious or other protected categories. For example, if an employer requires latex gloves, but a person is allergic to latex, the employer may have to modify the requirement for that employee as an accommodation under the ADA. An ER may also modify work areas to ensure distancing and safety, such as requiring handwashing or other sanitary actions.

(EEOC Guidance, G.1 - G.2,

DFEH Guidance, p. 3)

5. What are an employer's legal obligations for employee safety as it relates to COVID-19 (i.e., Cal-OSHA, etc.)? OSHA basically requires that employers provide a safe and healthy work environment. To that end, it has published emergency rules requiring the implementation of a safety plan, and other requirements related to COVID, that mimics their normal duties. (8 CCR §3200)

OSHA Safety Plan Mandate OSHA’s Emergency Rules (codified at 8 CCR §§3205, et seq.) require employers to “establish, implement, and maintain” an effective COVID-19 Prevention Program, which should include: Identification and evaluation of employee exposures to COVID-19 health hazards 1. Implementation of effective policies and procedures to correct unsafe and unhealthy conditions (such as ensure distancing, modifying workplace, and staggering work schedules) 2. Provide and ensure workers wear face coverings to prevent exposure in the workplace. You must ensure requests for accommodation based on legitimate reasons are considered and addressed. (See Cal/OSHA COVID-19 Emergency Temporary Standard Fact Sheet found at www.dir.ca.gov/dosh/coronavirus/ETS.html).

OSHA rules are complicated and very detailed, this FAQ only generally addresses the issues that may arise. Before implementing the plan, any employer is urged to consult an OSHA specialist to ensure full compliance. Model Written Program at: www.dir.ca.gov/dosh/coronavirus/ETS.html

Reporting

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RETURN TO WORK FAQ Employers must report to their county public health department outbreaks (3 or more COVID-19 cases in a 14-day period) or major outbreaks (20 or more COVID-19 cases in a 30-day period). Notification is to be made immediately but no later than 48 hours after “the employer knows, or with diligent inquiry would have known, of three or more COVID-19 cases for guidance on preventing the further spread of COVID-19 within the workplace.” (8 CCR §3205.1(f)(1))

Record-Keeping Employers must keep a record and track all COVID-19 cases while ensuring all medical information is maintained confidential. (See Cal/OSHA COVID-19 Emergency Temporary Standard Fact Sheet, supra.). These records must be made available to employees, authorized employee representatives, or others, as required by law. (Id.) These records, as any record related to an injury and illness prevention (IIP) plan, must be kept at least one year. (8 CCR §3208)

Workers Comp Any infection at work may be covered by workers comp. Employers should refer the employee to an industrial injury clinic and give employee a DWC 1 Form if they suspect the employee was infected at work. While the presumption that an employee who worked in the last 14 days was infected at work under the Governor’s Order N-62-20 is no longer in place, that presumption is now codified in law by the passage and signing of SB 1159 (codified as Labor Code §3212.86). Aside from the requirements imposed by state and federal law, each city and county has additional requirements. Follow the tier system of each county in terms of where they are with their COVID-19 ranking. (See for example www.saccounty.net/COVID-19/Pages/default.aspx.)

New Leave California recently enacted SB 95 (codified as Labor Code §§248.2 and 248.3) as enacted grants employees up to 80 hours of paid sick leave (in addition to any other laws or prior COVID-related leaves) if the employee is subject to a quarantine or isolation order, or has been advised to quarantine by a healthcare provider, to attend an appointment to receive the vaccine, suffering from COVID-related symptoms preventing the employee from working or teleworking, the employee is suffering COVIDrelated symptoms and is seeking medical diagnosis, the employee is caring for a family member who is subject of an order or has been advised to self-quarantine, or if the employee is caring for a child because the school or place of care is unavailable due to reasons related to COVID. (Labor Code §§248.2 and 248.3)

The statute was signed in March 2021 but is retroactive to January 1, 2021, and anyone

who has already taken the leave for a qualifying reason may ask for reimbursement of the time off or for pay, if the time off was unpaid. (Id.)

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RETURN TO WORK FAQ 6. Can employer require COVID-related safety protocols beyond what is required by federal/state/ local law? If employee challenges those protocols, does employer have to accommodate? Yes, within reason. Employers can impose safety protocols under the normal mandate requiring they provide a safe and healthy workplace. If an employer feels that certain actions should be taken that are not specifically covered by official guidance, those actions can be taken. The only limitation is the general discriminatory rules. If an employee asks for an accommodation, the employer would be required to follow the normal good faith interactive process as required by ADA, FEHA, Title VII if a measure being imposed by an employer triggers any of those protections. (EEOC Guidance, D.1 - D.12, G.2; DFEH Guidance, p. 5-6)

7. Are employees required to notify employer of a positive COVID-19 test or exposure to someone who has tested positive? There is nothing that specifically requires employees to disclose this information. Most guidance says that employees “should” let their employers know. However, given that an employer may require the employee to disclose this information, the employer can require it and the employee must comply. (EEOC Guidance, A.1 – A.8) 8. What are an employer's obligations if notified that an employee tested positive for COVID-19 or that an employee was exposed to someone who tested positive? The CDC states that if anyone is suspected or confirmed of having COVID-19, the employer need not close down the facility, but it recommends waiting 24 hours before cleaning the area where the employee worked to protect the cleaner. If waiting 24 hours cannot be accommodated, wait as much as possible, then clean surfaces with soap and water and disinfect other areas. If confirmed that the employee had COVID-19, employers should inform other employees of possible exposure while maintaining confidentiality of employee, and employees who test positive should quarantine and employer should provide information related to COVID-19, if employee not in hospital. The employee can be sent home to quarantine and asked not to return to work until they have consulted a health provider. (See www.cdc.gov/coronavirus/2019-ncov/community/general-businessfaq.html#Suspected-or-Confirmed-Cases-of-COVID-19-in-the-Workplace.)

Employers may need to work with local health agencies when there is an outbreak. Any employee potentially exposed to another employee who has COVID-19 should quarantine for 14 days. If the exposure happened outside of the workplace (i.e., the employee was exposed to COVID-19 elsewhere), the employer should still send the employee home to quarantine to prevent any spread. (Id.) 9. If employer requires all employees to return to work in-office, does the employer have to make exceptions or accommodations for employees that request such an accommodation to

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RETURN TO WORK FAQ continue to work from home? (e.g., child-care issues, school issues, underlying health condition, etc.; note that an employee's county of residence may be under different public health restrictions/guidance than the county where the workplace is located). Generally, an employer does not need to accommodate any employee’s request unless it is protected by law, such as the ADA, Title VII, or the FEHA. An employer is not required to accommodate a request for an accommodation because of child-care. There are laws that allow employees to take time off to address school issues but nothing long term. For example, an employer with 25 or more employees, would be required to allow an employee up to 40 hours a year for “school-related emergencies,” which the pandemic would likely satisfy. (Labor Code §230.8). An employee may also use vacation and other paid leave, and the employee may even be able to use paid sick leave as “preventive care,” according to the DIR. However, nothing that was not protected before is not protected now. Prior to the pandemic, employers did not have to accommodate childcare issues, danger of exposure of family members who fear going out, etc. Also, SB 95 (see above), would require an employer to provide up to 80 hours of paid sick leave if the employee is sick or under orders to quarantine or isolate due to COVID-19 or COVID-19 exposure, is caring for someone who is sick from COVID-19, is taking time to take the vaccine or recoup from being vaccinated, or is caring for a child whose school or child care facilities are unavailable due to COVID-related reasons. (Labor Code §§248.2 & 248.3) If an employee is covered by this leave, the employer should not use PTO, vacation, regular paid sick leave under state statutes as this provision is in addition to any other rights. Also, the employer is not required to accommodate fear of the vaccine or whether the employee lives with a “high risk” person, or not wanting to take the vaccine, if required, due to political reasons. However, any religious or medical reasons or if the policy discriminates on the basis of gender, legal protections may come into play. (EEOC Guidance, K.5 – K.7; DFEH Guidance, pp. 8 – 9.)

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Upcoming Events Wellness Engagement Groups for Physicians Screening/Treating Patients with ACEs or Toxic Stress Saturdays starting July 10, 2021 from 10:00-11:00am | ONLINE Tuesdays starting July 20, 2021 from 7:00-8:00pm | ONLINE Register at https://bit.ly/3gzMfqe Treating patients with multiple ACEs or toxic stress can potentially impact your personal wellness and increase feelings of burnout. CMA Wellness' engagement groups will support providers by offering subject matter experts, best practices and an open forum to share experiences, facilitated by trained, volunteer physicians. Each monthly webinar is organized around a prevailing theme with a stakeholder co-host to provide a variety of perspectives with a general discussion and breakout rooms. Registration is required, and providers can choose between joining the Saturday or Tuesday series for a six-month duration. Virtual Grand Rounds: A Fireside Chat with California’s Top Doc, Dr. Mark Ghaly, Secretary of Health and Human Services Agency Tuesday, July 13, 2021, 12:00-1:30pm | ONLINE Register at https://bit.ly/35wsDx7 Physicians and other health care providers have played many roles in the COVID-19 pandemic beyond their work as front-line providers of care – they have played roles as public health leaders, powerful advocates, communicators and experts, and caregivers for their own family members. Join us for a fireside chat with Secretary of the Health and Human Services Agency, Dr. Mark Ghaly, to hear about his experience as a key decision-maker and leader during these unprecedented times. Dr. Erica Pan, California State Epidemiologist, will provide updates on the state of the COVID-19 pandemic nationally and in California, review the progress of the vaccine rollout, and the evolving story of COVID-19 variants. AMA STEPS ForwardTM Webinar Series: Integrating Organizational Actions Toward Patient Safety and Clinician Well-Being Thursday, July 15, 2021, 9:30-10:30am | ONLINE Register at https://bit.ly/2TV8qhN

33rd Annual Western States Regional Conference on Physicians’ Well-Being Friday, July 16, 2021, 8:00am-12:15pm | ONLINE Register at http://www.rcmadocs.org/pwb The virtual conference, hosted by the Riverside County Medical Association, is open to anyone involved or interested in improving the health and well-being of physicians. Topics to be covered at this year’s conference include aging physicians, safe and legal monitoring of physicians in a treatment program, physician well-being committee roles and responsibilities, and more. This virtual event offers 4 AMA PRA Category 1 CreditsTM. AMA STEPS ForwardTM Webinar Series: Promising Practices To Support Physician Well-Being During COVID-19: A Case Study From Evergreenhealth Tuesday, July 20, 2021, 9:00-10:00am Register at https://bit.ly/35JY2fl In the spring of 2020, EvergreenHealth became the first site in the U.S. with a confirmed case of COVID-19. In this case study, EvergreenHealth will share the proactive strategies they enacted to ensure the well-being of their workforce throughout the pandemic. Highlighting their transition to a virtual environment, cohorting patients to reduce widespread transmission, and their ongoing communications strategy, this case study will leave viewers with several successful strategies to support physicians during times of crisis. 150th Annual Session of the CMA House of Delegates Saturday, October 23, 2021 – Sunday, October 24, 2021 | Marriott L.A. Live, Los Angeles, CA Information at https://www.cmadocs.org/hod CMA’s House of Delegates establishes broad policy on current major issues that have been determined by the Committee of Delegation Chairs, Speakers and the CMA Board of Trustees to be the most important issues affecting members, the Association and the practice of medicine. The two 2021 Major Issues are Racism and Other Barriers to Health Equity and Corporatization of Health Care.

In the dynamic and stressful environment of health care, leadership training hasn’t always incorporated rapid technology advancement and how to lead teams through those changes. Understanding the lag of human cognitive adaptation behind technological advances can be key in mitigating risk associated with medical error, and understanding basic human factors can help leaders and clinical teams connect and advance patient safety together. During this webinar, you will hear about a framework to build on traditional safety models, integrated with consideration for human factors affecting outcomes in patient safety as well as the well-being of those taking care of the patients.

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House of Delegates 149th Annual Session October 24, 2020 AGENDA (v2) Saturday, October 24, 2020: GENERAL SESSION 1 (1:00PM-5:00PM) 1:00 pm

CALL TO ORDER (First Session): Tanya W. Spirtos, MD, Speaker NATIONAL ANTHEM SPEAKER’S REMARKS: Tanya W. Spirtos, MD, Speaker WELCOME FROM THE GOVERNO ADDRESS OF THE AMA PRESIDENT: Susan R. Bailey, MD HOUSE BUSINESS & ANNOUNCEMENTS CONSENT CALENDARS & HOUSE REPORTS REPORT OF THE CHIEF EXECUTIVE OFFICER: Dustin Corcoran CMA’s COVID-19 RESPONSE MAJOR ISSUE A (PANDEMIC) Session • • • •

Report Presentation (Oldham) Advocacy Environment Q&A Survey Questions

RECOGNITION OF THE PAST PRESIDENTS IN MEMORIAM BREAK PPE PROJECT PRESENTATION RATIFICATION OF TRUSTEE ELECTIONS ADDRESS OF THE CMA PRESIDENT: PETER N. BRETAN, MD 2020 CMA DIVERSITY AND INCLUSION EFFORTS (MAJOR ISSUE B (HEALTH CARE IN A POST-COVID-19 WORLD) Session • • • •

Report Presentation (Ajayi) Advocacy Environment Q&A Survey Questions

OFFICER ELECTIONS (Speaker, Vice-Speaker, President-Elect) GOVERNMENT RELATIONS UPDATE: Janus Norman CANDIDACY ANNOUNCEMENTS ANNOUNCEMENTS AND 2021 PREVIEW • • • •

5:00 pm

OMSS YPS CALPAC RAFFLE ANNOUNCEMENT HOD 2021

ADJOURNMENT (time approximate)

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Q2 2021 Bulletin: Environmental Health Threats Loom Large Post-COVID

Articles inside

Returning to the Physical Workplace Legal Parameters and Considerations for Employers

Silent Calamity The Health Impacts of Wildfire Smoke

California Needs Increased Oversight of Toxic Sites to Safeguard Environmental Health

SCC Public Health Department Update

Healthy Food Sustainable Agriculture

Healthy Food in Health Care

Where Do We Go from Here?

President’s Message

Children’s Environmental Health

What’s Next for Schools?

Screentime is Making Kids Moody, Crazy, and Lazy

Award Nominations