Q3 2021 Bulletin: Correlative Health Effects of the COVID Pandemic

Official Magazine of the Santa Clara County Medical Association

Vol. 27 | No.3 Third Quarter 2021

This issue:

CORRELATIVE HEALTH EFFECTS OF THE COVID PANDEMIC

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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 12 Summer of Love: Rising Rates of Sexually Transmitted Diseases Post Vaccination Seham El-Diwany, MD

15 The Critical Need for Comprehensive School-Based Mental Health Resources Senator Dave Cortese

16 The Pandemic of Loneliness Avram Goldstein

22 Pandemic Unveils Growing Suicide Crisis for Communities of Color Aneri Pattani

26 Trends in Breast Cancer Screening in a Safety-Net Hospital During the COVID-19 Pandemic 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 Staff Chief Executive Officer | April Becerra, CAE Deputy Director | Erin Henke Physician Engagement Associate | Angelica Cereno Programs and Community Outreach Coordinator | Sameera Manucher Facility Manager | Paul Moore

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 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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Ana I. Velazquez, MD, MSc, et al.

30 Public Perspective on Decisions About Emergency Seeking for Care Unrelated to COVID-19 During the COVID-19 Pandemic Rebecca Gale et al.

26 Air Quality Implications of COVID-19 in California

Shuai Pan et al.

31 One Year On: Unhealthy Weight Gains, Increased Drinking Reported by Americans Coping with Pandemic Stress 33 Guidance for Health Care Leaders During the Recovery Stage of COVID-19 Pandemic

Jaason M. Geerts, PhD et al.

35 Incidents of Violence Increased During COVID-19 Pandemic

Amy Vatne Bintliff, PhD

37 Our Healthcare Heroes Deserve Better

Evan Low, Assemblymember

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

09 Historical Perspective: The Long and Winding Road Michael Shea, MD

Community News 39 Award Nominations 14 SCC Public Health Department Update

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

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Membership Insider JOIN OR RENEW TODAY As a member of the Santa Clara County Medical Association (SCCMA) and California Medical Association (CMA), you join more than 4,500 members in Santa Clara County and 50,000 members throughout Califonria of all specialties and practice settings who are actively protecting the practice of medicine and defending public health. We cannot do this alone.

The COVID-19 pandemic has exacted a heavy toll on our physician community – from extreme mental and physical demands, to emotional stress and financial difficulty. Unfortunately, 2022 brings with it another significant MICRA battle as trial lawyers have once again put forth an initiative that has the potential to be incredibly harmful to all physicians, regardless of where they practice.

Your support through SCCMA/CMA membership is absolutely critical to the success of our efforts on behalf of the profession of medicine.

Please join or renew your membership today so we can put forth a united front and successfully defend MICRA in the coming year.

NEW MEMBERS – Join SCCMA/CMA today and receive 15 months of membership for the price of 12. Starting in October, new members who join and pay in-full for the next year will receive the remaining months of this year for free! Join online at https://www.cmadocs.org/ join.

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MONTHLY PAYMENT OPTION AVAILABLE – New and renewing members have the option of paying dues with a credit card on a monthly basis. Simply select the monthly dues option when joining or renewing online.

CMA Updates COVID-19 Vaccine Reimbursement Toolkit and Guide

New AMA Report on the Uptick in Telehealth Use During the Pandemic

The California Medical Association (CMA) has updated two resources to help physician practices avoid delays and denials of claims for COVID-19 vaccine administration—the COVID-19 Vaccine Toolkit for Medical Practices (https://bit.ly/2YeClE5) and COVID-19 Vaccine Reimbursement Quick Guide (https://bit. ly/2Yb3Le7). These documents contain with the latest information on the important billing requirements specific to COVID-19 vaccine administration that can impact reimbursement. Providers should be aware there are some nuances to successfully submitting claims for COVID-19 vaccine administration services that differ from the normal claim submission process. These two resources are available free to all interested parties.

A new report based on the American Medical Association’s (AMA’s) Physician Practice Benchmark Survey describes the rapid uptick in physicians’ use of telehealth between Sept. 2018 and Sept.

2020. Over that period, the share of physicians in practices that used videoconferencing to provide patient visits increased from 14.3% to 70.3%. The report also shows that telehealth was used to treat a diverse set of patients with a variety of needs. In 2020, 58.0% of physicians said their practices used telehealth to diagnose or treat patients, 59.2% to manage patients with chronic disease and 50.4% to provide care to patients with acute disease. View the report at https://www.ama-assn.org/system/files/2020-prp-telehealth.pdf.

New Resource Provides California’s Physician Workforce Trends

AMA Releases Educational Resources to Advance Equity in Health Care

Physicians for Healthy California’s (PHC) GME Startup Solutions (https://www.phcdocs.org/gme-startup-solutions) has released a new resource to develop presentations on key trends in physician counts, geographic, demographic, and specialty distribution of active patient care physicians, medical students and residents, as well as projected demand and supply for primary care and psychiatry physicians. The free resource also includes information on CalMedForce program outcomes, including funded resident position counts, and geographic and specialty distribution of funded positions.

GME Startup Solutions was launched by PHC in December 2020 and is focused on providing resources, events and programs that help California communities grow medical residency and graduate medical education programs in underserved areas and for the most needed specialties. The initiative is supported by CalMedForce and the University of California.

The AMA recently announced a series of CME and educational activities aimed at addressing the root causes of inequities, including racism and other structural determinants of health. The new content will equip physicians and other learners with core health equity concepts needed to support them as they continue to take action and confront health injustice. Additional new health equity-related modules are scheduled for release throughout the remainder of 2021 and beyond, covering key topic areas such as structural competency, public health, social sciences, critical race theory, and historical basis of disease. An overarching goal of the content is to help learners better understand how systems of power, structures, policies, and practices impact us all. Learn more at https://edhub.ama-assn.org/health-equity-ed-center.

The Bulletin | Third Quarter 2021 | 5

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A Message from the President

Variants and Variables

by Cindy L. Russell, MD

SCCMA President

Entering the Fall of 2021, we have all become tired of surfing the large COVID waves that keep breaking. But we need to keep our feet firmly planted on the longboard for a bit longer ride on these swells.

The latest surge, as we all know, is the highly contagious Delta Variant (B.1.617.2) that made its way from India to Britain to the U.S. to Israel and now dominates the original Alpha (B.1.1.7) strain here.

The total deaths to date just surpassed 4.5 million with highest deaths per country in the U.S. at 666,000.

Delta: A More Virulent Viral Variant A recent Nature article explains that Delta variant enters the cell more easily. Researchers at the Guangdong Provincial Center for Disease Control and Prevention reported in a recent study that the Delta virus also multiplies more readily inside the respiratory tract. On average, people infected with the Delta variant had about 1,000 times more copies of the virus in their respiratory tracts than those infected with the original strain of the coronavirus.

They also found that it took only four days for Delta to reach detectable levels when a person is first infected versus six days for the original strain.

Breakthroughs…for the Virus A Yale report highlights that even vaccinated people can get Delta but the original COVID vaccines do give significant protection against severe illness and hospitalizations. Delta may spread more rapidly among young persons as well. In the U.S. most hospitalizations now are for unvaccinated persons; however, in Israel the statistics are changing. www.sccma.org

Israel is now an important country to study the pandemic as they have a robust health care system, excellent data collection and have fully vaccinated 78% of those 12 years and older (mostly with the Pfizer). Breakthrough infections are now occurring at a high rate in Israel, and over half of the infections now are the Delta variant. Studies indicate that the vaccines are still effective in preventing most cases of serious illnesses or death, but only 59% of those now hospitalized for severe COVID were vaccinated (41% were vaccinated). Israel is now offering booster shots to try and reduce the burden of hospitalizations as staff are once again reaching the point of exhaustion.

Lambda has entered the fray, along with the Mu variant in Columbia that has a constellation of mutations that may allow immune escape. Will vaccines continue to be effective as COVID mutates?

Will this virus and variants eventually fade away?

Variables: Playing it Safe with Community Transmission The WHO and public health officials worldwide are calling for governments to continue basic preventative health measures – wash hands frequently, wear a mask and socially distance – regardless of vaccine status, to reduce the spread of this evolving group of viruses. In a news briefing in Geneva, Dr. Mariangela Simao, WHO assistant director-general for access to medicines and health products, said “People cannot feel safe just because they had the two doses. They still need to protect themselves…Vaccine alone won’t stop community transmission. People need to continue to use masks consistently, be in ventilated spaces, The Bulletin | Third Quarter 2021 | 7

[use] hand hygiene, physical distancing, avoid crowding. This still continues to be extremely important, even if you’re vaccinated when you have a community transmission ongoing.”

Research Continues We are still learning about variants, vaccines and variables that will help the situation. While vaccines remain the best way to prevent serious infection, public health measures never go out of style. We also have many other environmental and public health issues that are important for our patients, communities and our planet to tend to. While COVID dominates the stage, it is still imperative we keep an eye on the horizon for other emerging issues of concern that compete, intersect and influence the pandemic and could overshadow COVID’s effect on

our health and economy, i.e. air pollution, toxic exposures and climate change. Prevention still matters.

Join the SCCMA as we continue to work on these issues. The Wellness, Diversity and Inclusion, External Affairs and the Environmental Health Committees welcome your participation.

Stay positive, test negative.

Cindy Russell, MD SCCMA President

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.

How the coronavirus infects cells — and why Delta is so dangerous

Scientists are unpicking the life cycle of SARS-CoV-2 and how the virus uses tricks to evade detection. Nature. July 28, 2021. https://www.nature.com/articles/d41586-021-02039-y

How the Delta variant achieves its ultrafast spread

Viral load is roughly 1,000 times higher in people infected with the Delta variant than those infected with the original coronavirus strain, according to a study in China. Nature. July 21, 2021. https://www.nature.com/ articles/d41586-021-01986-w

5 Things To Know About the Delta Variant

Yale Medicine. Aug 26, 2021. https://www.yalemedicine.org/news/5-things-to-know-delta-variant-covid

Notes from the Field: Transmission Dynamics of an Outbreak of the COVID-19 Delta Variant B.1.617.2 — Guangdong Province, China, May–June 2021. http://weekly.chinacdc.cn/en/article/doi/10.46234/ccdcw2021.148

A grim warning from Israel: Vaccination blunts, but does not defeat Delta With early vaccination and outstanding data, country is the world’s real-life COVID-19 lab. Aug 16, 2021. Science. https://www.science.org/news/2021/08/grim-warning-israel-vaccination-blunts-does-not-defeat-delta

8 | The Bulletin | Third Quarter 2021

www.sccma.org

by Michael Shea, MD

Historical Perspective:

The Long and Winding Road In ancient times, disease was believed to be a curse of the Gods. If they favored you, you were healthy. If you were sick, you had done something to displease them.

In 460 BC, a man named Hippocrates was born. He had different ideas on the cause and treatment of diseases. He believed that disease might be transported by something in the air or in the water. He suspected that epidemics occurred due to contaminated winds coming in contact with large masses of people.

He proposed dietetics, exercise, cleanliness, and nutrition as the basis for prevention of illness. He also believed in the Four Humor Theory to explain and treat some illnesses. This theory proposes that the body functions on the proper proportion of these humors or liquids. They are blood, phlegm, yellow bile, and black bile. The correct balance between them was necessary to maintain good health. This led to the use of bloodletting and purgatives to treat the majority of illnesses. www.sccma.org

This medical model was also favored by another famous Greek physician, Aelius Galenus, born in 130 AD. The Four Humor Theory lasted well into the nineteenth century.

Benjamin Rush was born on January 4, 1746 in Byberry Township, Pennsylvania. Perhaps no other physician in American history has influenced US medical practice as this man did. He was the surgeon general of his time. Dr. Rush championed the use of bloodletting and purgatives to treat most acute illnesses.

He is most remembered for treating the yellow fever epidemic in 1793 with bloodletting and calomel. There was growing opposition to this approach, and by the mid to late 1800s, bloodletting was on the wane.

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It must be remembered that bacteria were unknown to doctors until 1856, when Louis Pasteur, a French biologist, discovered them while investigating the spoilage of wine. This led to the Germ Theory, and ultimately to the discovery of penicillin.

Pasteur’s discovery caught the attention of Joseph Lister, a Scottish surgeon who, in 1865, used an antiseptic solution (carbolic acid) to prevent infection in wounds and surgical cases.

This, plus the discovery of anesthesia, changed surgery from a “game of chance” to a safer scientific field.

Also noticing Pasteur’s work was a Hungarian born physician, Ignaz Semmelweis. He changed the maternal mortality rate of childbirth from eleven to fifteen percent to near one percent.

He did this by insisting on frequent hand washing with a chlorinated solution. Like Lister, his findings were, at first, rejected by his colleagues, and it was twenty years later (1899) before these antiseptic measures were widely used.

There were many other discoveries along the way that brought more science into the medical world. The compound microscope was invented in Holland circa 1590 by two spectacle makers, Hans Jannsen, and his son, Zacharias. The stethoscope was created by a French physician, Rene Laennec, in 1816. A funnel shaped otoscope was created by Austrian physician, Ignaz Gruber in 1838. The ophthalmoscope was made in 1851 by a German physicist, Hermann von Helmhaltz. This led to the Welch and Allen version in 1915. The first sphygmomanometer was invented by Samuel Von Bosch in 1881. The syringe and needle came into existence in 1853, and discovery of diagnostic x-ray was credited to William Roentgen, a German professor of physics, in 1895.

One of the blockbuster discoveries of the past was penicillin.

It was discovered in 1928 by a Scottish physician, Alexander Fleming. It would save thousands of military lives during WWII, and even more in the civilian population.

feared diseases in the United States. It affected mainly children under the age of five, with one out of two hundred suffering permanent paralysis. In 1952, there were 58,000 cases in the United States with 3,145 dying, and 21,269 left with mild to disabling paralysis. A dedicated scientist, Jonas Salk, MD, developed the polio vaccine in 1952, and it was successfully used nationwide in 1955. An oral vaccine was developed by Albert Sabin in the 1950s. It was also an effective vaccine.

The dark ages were definitely over. Surgical advances were surging. Coronary bypass, arterial stents and heart transplants all brought new life to thousands of patients. New drugs to lower cholesterol, maintain regular rhythm, maintain normal blood pressure, and dissolve clots, all contributed to the breakthroughs in maintaining health in cardiovascular and cerebral vascular disorders. Breakthroughs in radiation techniques and new chemotherapeutic drugs are extending the five-year survival rate in cancer patients.

Medical progress has not always been consistent. It has faltered along the way, and during the Middle Ages, must have seemed hopeless. Scientific breakthroughs came in clusters.

They came from all over the world, but in the nineteenth and twentieth centuries, they were largely from Europe and the United States.

Is the end in sight? The answer is sadly no. Alzheimer’s Disease and cancer are just two examples of mountains still to climb, but they will be climbed. Medical research is relentless and will continue to uncover the secrets to a healthy life.

That long and winding road is getting shorter!

Diabetes was first described by Egyptian physicians about 3,500 years ago. It was a devastating disease, killing children and adults in just a few years after onset. The scene changed dramatically when insulin was discovered in the 1920s by two Canadian researchers, Frederich Banting, MD and Charles Best, MD. The Nobel prize for medicine was awarded to Dr. Banting, who shared it with Dr. Best.

In the early twentieth century, polio was one of the most

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The Bulletin | Third Quarter 2021 | 11

Photo by Anna Shvets from Pexels

Love

Summer of

Rising Rates of Sexually Transmitted Diseases Post Vaccination As COVID vaccinations rise so has the desire to return to dating and intimate connections. Unfortunately, during the pandemic screening for STD's has dropped by 40%, with people feeling more comfortable being tested for COVID rather than for STD's.

In addition, condom use is not popular in youth culture. As expected, the CDC has been reporting increasing rates of some sexually transmitted diseases, especially chlamydia, gonorrhea, and syphilis, with 25 million cases in 2019. Education and proper treatment are key.

New CDC Guidelines for Sexually Transmitted Diseases CDC recently released the Sexually Transmitted Infections Treatment Guidelines 20211. This document provides current evidence-based diagnostic, management, and treatment recommendations, and serves as a source of clinical guidance for managing sexually transmitted infections (STIs).

Main STI Diagnostic, Treatment, and Management Updates for Providers

The new guidelines include notable updates from the previous 2015 guidance, including: • Updated treatment recommendations for chlamydia, trichomoniasis, and pelvic inflammatory disease.

• Updated treatment recommendations for uncomplicated gonorrhea in neonates, children, and other specific clinical situations (e.g., proctitis, epididymitis, sexual assault), which builds on broader treatment changes published in Morbidity and Mortality Weekly Report2.

• Information on FDA-cleared diagnostic tests for Mycoplas12 | The Bulletin | Third Quarter 2021

• • •

•

ma genitalium and rectal and pharyngeal chlamydia and gonorrhea.

Expanded risk factors for syphilis testing among pregnant patients.

Recommended two-step serologic testing for diagnosing genital herpes simplex virus.

Harmonized recommendations for human papillomavirus vaccination with the Advisory Committee on Immunization Practices.

Recommended universal hepatitis C testing in alignment with CDC’s 2020 hepatitis C testing recommendations3.

STD's are Common and Costly

STIs are common and costly4. With 26 million new STIs occurring each year, totaling nearly $16 billion in medical costs, evidence-based prevention, diagnostic, and treatment recommendations are critical to STI control efforts now more than ever.

San Jose and Santa Clara County may not struggle with sexually transmitted diseases quite as much as other areas of California, but their rates of infection are still high and have been rising steadily over the last several years. The most common STDs in the San Jose area and Santa Clara County are chlamydia, gonorrhea, and syphilis.

According to the 2019 STI surveillance rates by state5, California ranks # 15 in chlamydia with 236,719 cases (598.4 rate per 100,000 population); # 18 in gonorrhea with 80,301 cases (203.0 rate per 100,000 population) and # 4 in syphilis with 8,266 cases (20.9 rate per 100,000 population).

During the COVID-19 pandemic, CDC provided guidance for www.sccma.org

the disruption of STD clinical services6, focusing on syndromic management and STI screening approaches to maximize the number of people with STIs identified and treated, while prioritizing those most likely to experience complications. However, most drug and testing kit shortages have since resolved and many health care providers are returning to normal clinical practices, which includes conducting STI evaluation and management in accordance with CDC Sexually Transmitted Infections Treatment Guidelines, 20217.

Provider Resources for STIs

You can stay informed on the latest STI recommendations and clinical guidance with CDC and partner resources which include: • High-quality printable copies of the wall chart, pocket guide, and MMWR, which are available for download now on the STD website8. A limited number of free copies will be available for order through CDC-INFO On Demand9 in the coming weeks.Training and technical assistance, which are available through the National Network of STD Clinical Prevention Training Centers10. STD clinical consultation services, which are available through the STD Clinical Consultation Network11.

• Free continuing education credits (CME and CNE), which are available through the National STD Curriculum12.

• Recommendations for Providing Quality STD Clinical Services (or STD QCS)13, which complement the STI treatment guidelines, focusing on managing clinical operations.

• An updated STI Treatment Guidelines mobile app, which is in development and is expected to launch in the coming months. NOTE: The 2015 STD Treatment Guidelines app will be retired at the end of July 2021. CDC is finalizing an interim, mobile-friendly solution – please visit STI Treatment Guidelines (cdc.gov)14 for information, as it becomes available.

You can also find additional information and resources on CDC website15. For questions about the updated 2021 STI Treatment Guidelines, you can email the Clinical Team in CDC’s Division of STD Prevention at stitxguidelines@cdc.gov as well as our local Santa Clara County public health department16.

Thank you for your commitment to improving the sexual health and wellness of people in Santa Clara County.

by Seham El-Diwany, MD

Pediatrician Kaiser San Jose and Past President SCCMA

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https://www.cdc.gov/std/treatment-guidelines/default.htm https://www.cdc.gov/mmwr/volumes/69/wr/mm6950a6.htm?s_cid=mm6950a6_w https://www.cdc.gov/hepatitis/hcv/guidelinesc.htm https://www.cdc.gov/std/statistics/prevalence-incidence-cost-2020.htm https://www.cdc.gov/std/statistics/2019/tables/2019-STD-Surveillance-State-Ranking-Tables.pdf https://www.cdc.gov/std/prevention/disruptionGuidance.htm https://www.cdc.gov/std/treatment-guidelines/default.htm https://www.cdc.gov/std/treatment-guidelines/provider-resources.htm https://wwwn.cdc.gov/pubs/CDCInfoOnDemand.aspx https://www.nnptc.org/ http://www.stdccn.org/ http://www.std.uw.edu/ http://www.cdc.gov/std/qcs https://www.cdc.gov/std/treatment-guidelines/default.htm https://www.cdc.gov/std/statistics/2019/default.htm https://publichealth.sccgov.org/services/std-and-hiv-testing-services

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PUBLIC HEALTH UPDATE On COVID-19 Vaccine and PREP/PEP Treatments to Prevent HIV The CDC recommends that individuals who are HIV positive receive the COVID-19 vaccine. Those who are negative but taking the drug Truvada as part of a PREP or PEP HIV prevention strategy should also receive the COVID-19 vaccine1.

There is no known negative interaction with any of the three vaccines and HIV medications. This information comes from individuals who were taking Truvada during the vaccines’ trials, as well as those vaccinated since authorization.

The use of the HIV medication Truvada as a form of pre-exposure prophylaxis (PrEP) or post-exposure prophylaxis (PEP) was approved by the federal government almost a decade ago.

A second drug, Descovy was approved in 2019, though it not for people assigned female sex at birth. Both medications are a combination of the drug emtricitabine with either tenofovir disoproxil fumarate (Truvada) or tenofovir alafenamide (Descovy) and have proven enormously successful in greatly reducing the number of new HIV infections among those who have taken them as prescribed.

The Public Health Department has received questions from providers wondering if their patients who are on PrEP or PEP, or any HIV medication regime, can safely receive a COVID-19 vaccine. The CDC has been clear that there is no reason that those taking anti-retrovirals should not receive a COVID-19 vaccine.

There are currently no medications that are considered contraindications for the vaccine, though women under age 50 who are on blood thinners are alerted to the possibility of develop14 | The Bulletin | Third Quarter 2021

ing blood clots if they receive the Janssen COVID-19 Vaccine.

The Infectious Diseases Society of America advises that patients do not need to pause taking of HIV medications (whether on PrEP, PEP, or HIV positive) in order to get vaccinated for COVID-192. Pausing medication increases the risk of contracting HIV for those who are negative and passing along the virus for those who are positive and currently have the virus suppressed.

Those who are positive and unmedicated face even greater risks of serious complications if they contract COVID-19.

Some of your patients may find helpful information about COVID-19 vaccination for LGBTQ populations3, as well as information about COVID-19 vaccine related topics in many languages on the County’s website4.

https://www.cdc.gov/hiv/basics/covid-19.html https://www.hivma.org/globalassets/idsa/public-health/covid-19/covid-19vaccines-hiv-faq.pdf https://drive.google.com/file/d/1DXr66_MqTfD7jb9Dw0GAUKY3wekTlQuN/ view https://covid19.sccgov.org/covid-19-vaccine-information

www.sccma.org

The Critical Need for Comprehensive School-Based Mental Health Resources “The pandemic has changed the future of our schools and will affect the psychological and social well-being of our students for years to come.”

by Senator Dave Cortese

As many students return to their classroom this season, parents, educators, and legislators are rightly focused on efforts to address learning loss experienced during the pandemic. But responding to academic impacts brought on by the pandemic is only part of what is needed in our educational recovery.

There is no question that distance learning has produced significant consequences for adolescent mental health, which for many students have been compounded by a variety of factors. Afterschool and extracurricular programs, including sports, have been impacted, students have faced isolation losing critical connections with their peers, and many are carrying an extra financial burden as families deal with economic challenges and food insecurity.

At a time when our physical health is being discussed every day, we must ensure our mental and behavioral well-being is also getting the attention it deserves. And for students to be able to cope, timely access and new sources of support at their school-site is critical.

As a former school board member, I have seen firsthand how school-based mental health interventions have improved the ability for families to find and navigate resources, helped them advocate for their child, and increased student academic success.

Steven Luo, a senior at Evergreen Valley High School, said it best during this year’s virtual 18th annual “Sacramento Bus Trip for Education”, an event hosted by my office each year to uplift student voices: “As a student, I can give you plenty of anecdotes of friends and classmates who feel stressed, anxious, or even depressed, yet do not access services. Seventy-nine percent of youth and young adults experiencing mental health issues don’t access care. Unfortunately, these resources aren’t always readily available or there are roadblocks to access them.”

As Steven noted, nearly 50% of mental health issues are established by the age of 14 and 75% by the age of 24, meaning that having widely accessible mental health support services is essential for student well-being. And the CDC has found that mental health-related emergency room visits have increased by 24% for those aged 5 to 11 and 31% for those aged 12 to 17. www.sccma.org

My colleagues in the State Legislature are also making student mental health a priority.

The success of school-based mental health programs such as “School-Linked Services” in Santa Clara County, with credentialed professionals available to meet the needs of students, is serving as a model for mental health partnerships between counties and schools across California.

And I’m proud to announce that a budget request I made this year for the augmentation of the Mental Health Student Services Act grant program was approved and will allow for millions of other children and youth to receive mental health and emotional support through the “School-Linked Services” framework as they return to schools and everyday life.

This month, I was appointed to serve on our state’s Mental Health Services Oversight and Accountability Commission (https://mhsoac.ca.gov/) and I look forward to working in this role to continue to identify and provide new ways to meet the mental health needs of our community, especially our student community. The pandemic has only further revealed that we need to invest more in our mental health treatment, diversion and education programs in our state to serve people of all ages.

Before I go, I’d like to ask you to consider taking this small action - share with a loved-one an anecdote or personal story around how COVID-19 has impacted your mental health.

Speaking with others about mental health is an important way to remove any stigma and identify our own needs.

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.

The Bulletin | Third Quarter 2021 | 15

The Pandemic of Loneliness

by Avram Goldstein

“When we are separated from other people, we enter that stress phase as a signal for us to seek out connections. And if not attended to, it can cause damage in the same way that hunger or thirst can if they are not attended to.”

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www.sccma.org

An illustration from Kristen Radtke’s new graphic nonfiction book, Seek You: A Journey Through American Loneliness.

In this extraordinary era of pandemic isolation, social distancing, and masking, it makes perfect sense that loneliness and its impact on mental and physical health would garner literary attention. Vivek Murthy, MD, MBA, the US surgeon general, released a book early in the pandemic saying America is experiencing a loneliness epidemic1. Murthy reported that chronic loneliness works this way: Persistent stress increases inflammation that damages tissues and blood vessels, increasing risk of cardiovascular illness and death. It can interfere with the function of the immune system and make high blood pressure, obesity, and other conditions more likely, Murthy said. www.sccma.org

In her new graphic nonfiction book Seek You: A Journey Through American Loneliness, artist-writer Kristen Radtke takes a qualitative look at the emotional dimensions of this daunting subject2. Her illustrations, musings, and reminiscences explore “the space between the relationships you have and the relationships you want.” She ponders the roots of the peculiarly American form of social isolation.

“Loneliness is often exacerbated by a perception that one is lonely while everyone else is connected,” Radtke wrote. “It’s exaggerated by a sensation of being outside something that others seem to be in on: a family, a couple, a friendship, a joke.

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Perhaps now we can learn how flawed that kind of thinking is, because loneliness is one of the most universal things any person can feel.”

While loneliness is not a medical or psychological diagnosis, it is strongly associated with behavioral health, physical maladies, and increased suicide rates. The data on the connection between loneliness and human health are robust, according to the American Psychological Association3.

When COVID-19 erupted in 2020, quarantines, social distancing, and stay-at-home orders exacerbated the baseline level of loneliness. Through the pandemic in the US, the sense of isolation has fluctuated, rising last summer and again in June 2021 even as the economy improved and restrictions were eased, Reed Abelson reported in the New York Times4.

Newly released data from a recent federal telephone survey of 11,000 Medicare enrollees show 40% reported feeling less socially connected to family and friends (PDF) than they were last November, 28% more stressed or anxious, and 22% more lonely or sad5.

Social Isolation

Chronic loneliness is associated with increased rates of anxiety, depression, and suicide, according to the US Centers for Disease Control and Prevention (CDC). “Loneliness among heart failure patients was associated with a nearly 4 times increased risk of death, 68% increased risk of hospitalization, and 57% increased risk of emergency department visits,” according to the CDC6.

At the same time, about one in four Americans over 65 are socially isolated, a condition that significantly raises a person’s risk of premature death, rivaling smoking, obesity, and physical inactivity, according to Social Isolation and Loneliness in Older Adults, a 2020 report from the National Academies of Sciences, Engineering, and Medicine7. Social isolation is associated with a 50% increased likelihood of a person developing dementia. The absence of meaningful social relationships is associated with a 29% higher risk of heart disease and 32% higher risk of stroke.

For seniors, many of whom live alone or are coping with hearing or vision loss that further isolates them, the challenge may be even more pronounced for those living in rural areas. In 2018, Capitol Public Radio health care reporter Sammy Caiola reported on high suicide rates for seniors in Amador County. She interviewed volunteers who navigate Amador’s twisting highways to find isolated people and keep them company. “There are many little roads in Amador County that have a lonely person at the end of them,” one volunteer told Caiola8.

Lonely older adults are nearly twice as likely as seniors not experiencing loneliness to use painkillers and sedatives, which frequently leads to substance use problems, accidents, medical complications, falls, or death, according to a new UCSF study in JAMA Internal Medicine9. Geriatrician Ashwin Kotwal, MD, who was first author on the study, urges community physicians to connect lonely elders to senior centers, exercise classes, grief groups, or volunteer programs rather than reflexively prescribing opioids and other drugs10.

Loneliness and isolation are on the rise for young people as well. During the COVID-19 era, students have spent long periods in isolation, away from school and friends. In a CHCF-supported survey released in March by Common Sense Media and Hopelab, nearly 38% of teens and young adults reported symp18 | The Bulletin | Third Quarter 2021

toms of moderate to severe depression, up from 25% just two years earlier11. In a 2020 study in the Journal of American Academy of Child and Adolescent Psychiatry, researchers reported that children and teens are more likely to experience depression and anxiety during isolation and after it ends12.

For many Americans who have been socially isolated, life won’t return to normal soon because of the pandemic’s cumulative effects, researchers told Abelson. “Recovery from the pandemic may take a long time and could affect people’s view of their relationships over time,” Abelson wrote.

The Ministers of Loneliness Murthy argues that policymakers must confront the loneliness challenge to avert countless individual disasters. “Even though our circumstances have changed dramatically, our nervous system is still very similar to what it was thousands of years ago,” he told Roge Karma of Vox. “When we are separated from other people, we enter that stress phase as a signal for us to seek out connections. And if not attended to, it can cause damage in the same way that hunger or thirst can if they are not attended to.”

Policymakers in other countries are starting to respond to the loneliness problem. In Japan, where suicide among women has been on the rise during the pandemic, the nation’s prime minister in February created a cabinet post to alleviate social isolation, Shogo Kodama reported in Tokyo-based financial news outlet Nikkei Asia13. “Telework and the lack of social gatherings during Japan’s fight against the coronavirus have left people feeling increasingly stressed and lonely,” Kodama wrote. The new minister, Tetsushi Sakamoto, planned to put together an interagency team and meet with advocacy groups and others to identify top priorities and solutions.

A 2017 report in the UK14 issued by the Jo Cox Commission on Loneliness15 reported that more than nine million people feel lonely much or all of the time. The finding prompted then prime minister Theresa May to create a government position, the minister for loneliness, according to New York Times correspondent Ceylan Yeginsu16. Baroness Diana Barran holds the job and is focusing on using social media to disseminate information about local resources to combat isolation, as well as funding community-based organizations tackling the issue. Young people, people with disabilities and chronic health conditions, caregivers, people who have lost a loved one, and new mothers are especially susceptible, she said17.

Help for Californians

The California Department of Health Care Services operates CalHOPE, a hub for social and emotional resources like a “warm line” that connects callers to people who have lived experience with stress, anxiety, depression, and other impacts of the pandemic and life in general18. These peer counselors provide nonjudgmental support and guide people to community resources that can help them cope with emotional issues and stay connected to others. Although set up as a response to the pandemic, the service is intended to remain after the COVID-19 emergency. Warm Line counselors are able to connect people to many culturally sensitive services provided through CalHOPE. The Warm Line is at 833-317-HOPE (4673) and www.calhope. org.

www.sccma.org

An illustration from Kristen Radtke’ A scene from author-illustrator Kristen Radtkes’s new graphic nonfiction book on social isolation. s new graphic nonfiction book, Seek You: A Journey Through American Loneliness.

About the Author Avram Goldstein is a senior engagement officer at CHCF, where he is the editor of The CHCF Blog. Av came to the foundation after serving for five years as communications and research director for Health Care for America Now, a national grassroots coalition in Washington, DC, that invested $60 million in the successful campaign to enact and implement the Affordable Care Act. His interest in health care and health policy arose during his 30plus years with major news organizations.

He covered physicians, hospitals, insurance companies, government health programs, and public health for the Washington Post, Bloomberg News, the Detroit News, and the Miami Herald. He held editing roles at some of those news outlets. Av also served as top editor at a newspaper for South Florida physicians and later at a daily newspaper for California lawyers. Av received a bachelor’s degree in finance and insurance at the University of Miami.

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https://www.vox.com/2020/5/11/21245087/america-loneliness-epidemic-coronavirus-pandemic-together https://www.newyorker.com/books/page-turner/where-loneliness-comes-from https://www.apa.org/news/press/releases/2017/08/lonely-die https://www.nytimes.com/2021/07/08/health/coronavirus-pandemic-recovery-social-isolation.html https://www.cms.gov/files/document/medicare-current-beneficiary-survey-covid-19-data-snapshot-infographic-winter-2021.pdf https://www.cdc.gov/aging/publications/features/lonely-older-adults.html https://www.nap.edu/read/25663/chapter/2 https://www.capradio.org/articles/2018/09/12/chronic-loneliness-is-a-major-cause-of-suicide-for-seniors-especially-in-rural-california/ https://bit.ly/2XHFOec https://www.ucsf.edu/news/2021/07/421126/over-65-and-lonely-dont-talk-your-doctor-about-another-prescription https://www.chcf.org/publication/coping-covid-19-young-people-digital-media-manage-mental-health/ https://www.nationalgeographic.com/family/article/lonely-kids-concerning-during-the-pandemic-coronavirus https://s.nikkei.com/2XBfDGc https://bit.ly/2XyArgO https://www.ageuk.org.uk/our-impact/campaigning/jo-cox-commission/ https://www.nytimes.com/2018/01/17/world/europe/uk-britain-loneliness.html https://bit.ly/3tZL5cW https://www.calhope.org/pages/current-services.aspx

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The Bulletin | Third Quarter 2021 | 19

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The Bulletin | Third Quarter 2021 | 21

By Aneri Pattani

Pandemic Unveils

Growing Suicide Crisis for Communities of Color Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie’s 19-year-old son, Jamal Clay — who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes — killed himself in their garage.

“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.

Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among white residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

Interviews with a dozen suicide researchers, data collected from states across the country and a review of decades of research revealed that suicide is a growing crisis for communities of color — one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020.

National and local studies attribute the trend to a drop among white Americans, who make up the majority of suicide deaths.

Meanwhile, rates for Black, Hispanic and Asian Americans — though lower than their white peers — continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

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“Covid created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color and an assistant professor at the University of North Carolina-Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”

Losing Generations

Although the suicide rate is highest among middle-aged white men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of white kids and, over time, their suicide rates have grown even as rates have decreased for white children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the seven years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.

“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”

These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations be-

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Photo by Eric W. from Pexels

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The Bulletin | Third Quarter 2021 | 23

cause they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that’s changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, eight years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, North Carolina, and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”

Pandemic Sheds Light on the Triggers

Pinpointing the root causes of rising suicide within communities of color has proven difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, covid may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap and more public attention on police killings of unarmed Black and brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, an assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk.

For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, an assistant professor at UCLA, based on preliminary research findings.

Covid intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their white counterparts.

24 | The Bulletin | Third Quarter 2021

“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, an assistant professor of psychiatry at the University of Pennsylvania’s school of medicine.

Lessons From Texas

In Texas, covid hit Hispanics especially hard. As of July 2021, they accounted for 45% of all covid deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities, but decreased for white Texans.

The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.

“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before covid struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data shows.

None died by suicide.

Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.

“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.

A Good Future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma.

As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies and public policy officials about their responsibilities.

“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.” www.sccma.org

For Jamal Clay in Illinois, the systemic barriers started early.

Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”

But when the pandemic hit, everything got worse, she said.

Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

“He felt uncomfortable being out in the street,” she said.

Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes — including Jamal’s old ones — to those impacted by violence, suicide and trauma.

“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.

But she hopes his shoes will carry someone else to a good future.

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

About the Author Aneri Pattani, Correspondent, reports on a broad range of public health topics, with a focus on mental health and substance use.

Pattani has also worked as a health reporter for The Philadelphia Inquirer, WNYC (New York City's NPR station) and The New York Times. She was a 2019 recipient of the Rosalynn Carter Fellowship for Mental Health Journalism. She graduated from Northeastern University in Boston.

KHN senior correspondent JoNel Aleccia contributed to this report.

Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as white, including those who are multiracial. Hispanics can be of any race or combination of races.

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation. www.sccma.org

The Bulletin | Third Quarter 2021 | 25

Trends in Breast Cancer Screening in a Safety-Net Hospital During the COVID-19 Pandemic

by Ana I. Velazquez, MD, MSc, Jessica H. Hayward, MD, Blake Gregory, MD, et al Introduction

National estimates project COVID-19 negatively influenced cancer screening, leading to an estimated deficit of 3.9 million breast cancer (BC) screenings among US adults.1,2 In San Francisco, California, low-income neighborhoods disproportionately affected by COVID-19 bear the burden of higher BC stage at diagnosis.3,4 We sought to evaluate the association of COVID-19 and BC screening in a safety-net hospital in San Francisco.

Methods

This cross-sectional study evaluated trends in BC screening at an urban integrated health system’s safety-net hospital. We obtained the number of screening mammograms per month during 2019 from electronic health record (EHR) data, and aggregate numbers between September 1, 2019, and January 31, 2021, after the implementation of a new EHR. The number of screening mammograms per month was plotted against the 2019 baseline. Proportions of completed tests by phase of the pandemic (pre–COVID-19, first stay-at-home order, reopening, and second stay-at-home order) were compared by race/ethnicity and age with 2-sided, 2-sample proportion tests. Race/ethnicity was used as a proxy for the disproportionate burden of COVID-19 and experiences of individual and systemic racism experienced by minority communities. Analyses were conducted with Stata, version 16 (StataCorp LLC). P < .05 was used to determine significance. We followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.5 Deidentified data collected for quality improvement activities does not require approval from The University of California, San Francisco institutional review board; this study was therefore exempted from review.

Results

A total of 9291 screening mammograms were performed from January 1, 2019, to January 31, 2021: 5662 during 2019, with a mean of 472 mammograms per month (95% CI, 430514 mammograms), and 3385 in 2020 (60% of the 2019 volume) (Figure 1A). During the first stay-at-home order (February 1, 2020, to May 31, 2020), the number of screening mammograms decreased to 194 in March (41% of baseline [mean of 472 mammograms per month during 2019]) and to 0 in April (Figure 1B).

The number of missed appointments increased during 2020, with 127 of 321 (40%) missed in March, compared with 585 of 2764 (21%) from September 2019 to January 2020 (pre–COVID-19) (Figure 1C). During the reopening phase (June 1, 2020, to November 30, 2020), the number of screening mammograms increased but remained below baseline, except in October, when 496 mammograms were completed. The number of screening mammograms declined during the second stay-at-home order.

The mobile mammography unit volume decreased from 831 during 2019 to 248 in 2020, with 0 mammograms between April and June 2020.

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The proportion of monthly screening mammograms completed was 244 of 392 scheduled (62%) in January 2021 compared with a mean (SD) of 436 (36) of 553 (41) (79%) from September 2019 to January 2020 (pre–COVID-19; test of proportions P < .001). Compared with pre–COVID-19, the volume and proportion of mammograms completed decreased across racial/ ethnic groups (from 311 of 441 [71%] pre–COVID-19 to 96 of 157 [61%] during the second stay-at-home order among White women; from 941 of 1081 [87%] to 220 of 307 [72%] among Asian women; from 716 of 881 [81%] to 230 of 378 [61%] among Latinx women; and from 203 of 344 [59%] to 70 of 184 [38%] among Black/African American women) and age groups (from 241 of 312 [77%] to 63 of 108 [58%] among women 40-49 years; from 774 of 1011 [77%] to 266 of 427 [62%] among women 50-59 years; from 861 of 1043 [83%] to 230 of 371 [62%] among women 60-69 years; and from 290 of 376 [77%] to 64 of 119 [54%] among women ≥70 years) (Figure 2). The proportion of completed mammograms was lowest among Black women at all time points, younger women during the first stay-at-home order, and women aged 70 years or older during the second stay-at-home order.

Discussion

The reduction in the cumulative number of mammograms suggests a substantial deficit of missed BC screening, which may worsen preexisting disparities. Our results are consistent with those of reports that found discontinuation of BC screening in April 2020.2,6 In contrast to reports showing recovery of screening volumes,2,6 our data highlight persistent low BC screening volumes and an absolute decrease in the proportion of completed mammograms among Latinx and Black women.

We hypothesize that these differences by race/ethnicity are multilevel and reflect the effect of worry, competing priorities, limited access, and disproportionate burden and socioeconomic impact of COVID-19 in Latinx and Black communities.4 Resource and staff reallocation from preventive health community-based efforts likely contributes to these disparities, as suggested by the lower patient volumes of our mobile unit.

Limitations of this study include the use of aggregate data from a single institution, use of race/ethnicity as recorded in the EHR, and lack of baseline characteristics before August 2019. Although vaccination efforts are a top priority, health care systems should leverage COVID-19–related community outreach and engagement to develop concerted efforts that promote preventive care and ensure preexisting disparities do not worsen among communities with higher risk.

Article Citation: Velazquez AI, Hayward JH, Gregory B, Dixit N. Trends in Breast Cancer Screening in a Safety-Net Hospital During the COVID-19 Pandemic. JAMA Netw Open.

2021;4(8):e2119929. doi:10.1001/jamanetworkopen.2021.19929 Read the full article at https://bit.ly/3tVM6CA www.sccma.org

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The Bulletin | Third Quarter 2021 | 27

by Rebecca Gale, MPH; Samuel Eberlein, MHDS; Garth Fuller, MS; et al

Public Perspectives on Decisions About Emergency Care Seeking

for Care Unrelated to COVID-19 During the COVID-19 Pandemic Question What do people prioritize when deciding whether to present to the emergency department during the COVID-19 pandemic for care unrelated to COVID-19?

Importance

Delaying critical care for treatable conditions owing to fear of contracting COVID-19 in the emergency department (ED) is associated with avoidable morbidity and mortality.

Objective

To assess and quantify how people decided whether to present to the ED during the COVID-19 pandemic for care unrelated to COVID-19 using conjoint analysis, a form of trade-off analysis that examines how individuals make complex decisions.

Design, Setting, and Participants

This cross-sectional survey study was conducted using a nationwide sample from June 1, 2020, during the initial peak of the COVID-19 pandemic. Included participants were adults aged 18 years or older in the US who self-reported that they had not tested positive for COVID-19. Data were analyzed from July 2020 through May 2021.

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Exposures

Participants completed a self-administered online survey.

Main Outcomes and Measures

Using a choice-based conjoint analysis survey, the relative importance was assessed for the following attributes for individuals in deciding whether to seek ED care for symptoms consistent with myocardial infarction or appendicitis: reduction in chance of dying because of ED treatment, crowdedness of ED with other patients, and chance of contracting COVID-19 in the ED. We also performed latent class analyses using conjoint data to identify distinct segments of the respondent population with similar choice patterns. Logistic regression was then used to explore whether patient sociodemographics and political affiliations were factors associated with decision-making.

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Results

In this survey study of 933 US adults, we found that 16.9% and 25.5% of individuals confronted with scenarios consistent with myocardial infarction or appendicitis, respectively, prioritized avoidance of COVID-19 exposure in the emergency department over seeking appropriate care. Sociodemographics, political affiliations, and personal knowledge, attitudes, and beliefs regarding COVID-19 were not factors associated with decision-making regarding emergency care seeking.

Among 1981 individuals invited to participate, 933 respondents (47.1%) completed the survey; participants’ mean (SD) age was 40.1 (13.0) years, and 491 (52.6%) were women. In latent class analyses, 158 individuals (16.9%) with symptoms of myocardial infarction and 238 individuals (25.5%) with symptoms of appendicitis prioritized avoidance of COVID-19 exposure in the ED (ie, chance of contracting COVID-19 in the ED or crowdedness of ED with other patients) over seeking appropriate care for symptoms. Having a usual source of care was a factor associated with lower odds of prioritizing avoidance of COVID-19 exposure (myocardial infarction scenario: adjusted odds ratio, 0.49 [95% CI, 0.32-0.76]; P = .001; appendicitis scenario: adjusted

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odds ratio, 0.57 [95% CI, 0.40-0.82]; P = .003), but most sociodemographic factors and political affiliations were not factors associated with decision-making.

Conclusions and Relevance

This study found that up to one-quarter of individuals were willing to forgo potentially life-saving ED care to avoid exposure to COVID-19. These findings suggest that health care systems and public health organizations should develop effective communications for patients and the community at large that reassure and encourage timely health care for critical needs during the ongoing COVID-19 pandemic and other scenarios.

Article Citation: Gale R, Eberlein S, Fuller G, Khalil C, Almario CV, Spiegel BM. Public Perspectives on Decisions About Emergency Care Seeking for Care Unrelated to COVID-19 During the COVID-19 Pandemic. JAMA Netw Open. 2021;4(8):e2120940. doi:10.1001/jamanetworkopen.2021.20940 Read the full study at https://bit.ly/3CCSYI2.

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by Shuai Pan, Jia Jung, Zitian Li, et al

Air Quality Implications of COVID-19 in California (PM2.5) of −2.04 ± 1.57 µg m−3 and ozone of −3.07 ± 2.86 ppb. If the air quality improvements persist over a year, it could potentially lead to 3970–8900 prevented premature deaths annually (note: the estimates of prevented premature deaths have large uncertainties).

Public transit demand showed dramatic declines (~80%). The pandemic provides an opportunity to exhibit how substantially human behavior could impact on air quality.

To address both the pandemic and climate change issues, better strategies are needed to affect behavior, such as ensuring safer shared mobility, the higher adoption of telecommuting, automation in the freight sector, and cleaner energy transition.

Article Citation: Pan S, Jung J, Li Z, Hou X, Roy A, Choi Y, Gao HO. Air Quality Implications of COVID-19 in California. Sustainability.

2020; 12(17):7067. https://doi. org/10.3390/su12177067 Read the full study at https://bit.ly/3CAqhMc.

Photo by Darius Krause from Pexels

The COVID-19 pandemic has significantly affected human health and the economy.

The implementation of social distancing practices to combat the virus spread, however, has led to a notable improvement in air quality.

This study compared the surface air quality monitoring data from the United States Environmental Protection Agency (U.S. EPA)’s AirNow network during the period 20 March–5 May in 2020 to those in 2015–2019 from the Air Quality System (AQS) network over the state of California.

The results indicated changes in fine particulate matter

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One Year On: Unhealthy Weight Gains, Increased Drinking Reported by Americans Coping With Pandemic Stress APA’s Stress in America ™ poll reveals secondary pandemic health crisis; parents, essential workers, communities of color more likely to report mental, physical health consequences.

As growing vaccine demand signals a potential turning point in the global COVID-19 pandemic, the nation’s health crisis is far from over. One year after the World Health Organization declared COVID-19 a global pandemic, many adults report undesired changes to their weight, increased drinking and other negative behavior changes that may be related to an inability to cope with prolonged stress, according to the American Psychological Association’s latest Stress in AmericaTM poll.

APA’s survey of U.S. adults, conducted in late February 2021

by The Harris Poll, shows that a majority of adults (61%) experienced undesired weight changes—weight gain or loss—since the pandemic started, with 42% reporting they gained more weight than they intended. Of those, they gained an average of 29 pounds (the median amount gained was 15 pounds) and 10% said they gained more than 50 pounds, the poll found.

Such changes come with significant health risks, including higher vulnerability to serious illness from the coronavirus. For the 18% of Americans who said they lost more weight than they wanted to, the average amount of weight lost was 26 pounds (median amount lost was 12 pounds). Adults also reported unwanted changes in sleep and increased alcohol consumption.

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Two in 3 (67%) said they have been sleeping more or less than desired since the pandemic started. Nearly 1 in 4 adults (23%) reported drinking more alcohol to cope with their stress.

“We’ve been concerned throughout this pandemic about the level of prolonged stress, exacerbated by the grief, trauma and isolation that Americans are experiencing. This survey reveals a secondary crisis that is likely to have persistent, serious mental and physical health consequences for years to come,” said Arthur C. Evans Jr, PhD, APA’s chief executive officer. “Health and policy leaders must come together quickly to provide additional behavioral health supports as part of any national recovery plan.”

The pandemic has taken a particularly heavy toll on parents of children under 18. While slightly more than 3 in 10 adults (31%) reported their mental health has worsened compared with before the pandemic, nearly half of mothers who still have children home for remote learning (47%) reported their mental health has worsened; 30% of fathers who still have children home said the same. Parents were more likely than those without children to have received treatment from a mental health professional (32% vs. 12%) and to have been diagnosed with a mental health disorder since the coronavirus pandemic began (24% vs. 9%).

More than half of fathers (55%) reported gaining weight, and nearly half (48%) said they are drinking more alcohol to cope with stress.

The majority of essential workers (54%), such as health care workers and people who work in law enforcement, said they have relied on a lot of unhealthy habits to get through the pandemic. Nearly 3 in 10 (29%) said their mental health has worsened, while 3 in 4 (75%) said they could have used more emotional support than they received since the pandemic began.

Essential workers were more than twice as likely as adults who are not essential The Bulletin | Third Quarter 2021 | 31

workers to have received treatment from a mental health professional (34% vs. 12%) and to have been diagnosed with a mental health disorder since the coronavirus pandemic started (25% vs. 9%).

Further, people of color reported unintended physical changes during the pandemic. Hispanic adults were most likely to report undesired changes to sleep (78% Hispanic vs. 76% Black, 63% white and 61% Asian), physical activity levels (87% Hispanic vs. 84% Black, 81% Asian and 79% white) and weight (71% Hispanic vs. 64% Black, 58% white and 54% Asian) since the pandemic began. Black Americans were most likely to report feelings of concern about the future.

More than half said they do not feel comfortable going back to living life like they used to before the pandemic (54% Black vs. 48% Hispanic, 45% Asian and 44% white) and that they feel uneasy about adjusting to in-person interaction once the pandemic ends (57% Black vs. 51% Asian, 50% Hispanic and 47% white).

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“It’s clear that the pandemic is continuing to have a disproportionate effect on certain groups,” said APA President Jennifer Kelly, PhD. “We must do more to support communities of color, essential workers and parents as they continue to cope with the demands of the pandemic and start to show the physical consequences of prolonged stress.”

Overall, Americans are hesitant about the future, regardless of vaccination status. Nearly half of respondents (49%) said they feel uneasy about adjusting to in-person interaction once the pandemic ends. Adults who received a COVID-19 vaccine were just as likely as those who had not received a vaccine to say this (48% vs. 49%, respectively).

Article citation: American Psychological Association. (2021, March 11). One year on: Unhealthy weight gains, increased drinking reported by Americans coping with pandemic stress [Press release]. http://www.apa.org/news/press/releases/2021/03/ one-year-pandemic-stress

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Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic

by Jaason M. Geerts, PhD, Donna Kinnair, LLB/MA, Paul Taheri, MD, et al

Question:

What leadership imperatives are most essential for health leaders following the emergency stages of the COVID-19 pandemic?

Importance:

The COVID-19 pandemic is the greatest global test of health leadership of our generation. There is an urgent need to provide guidance for leaders at all levels during the unprecedented preresolution recovery stage.

Objective:

To create an evidence- and expertise-informed framework of leadership imperatives to serve as a resource to guide health and public health leaders during the postemergency stage of the pandemic.

included the terms leadership and variations of emergency, crisis, disaster, pandemic, COVID-19, or public health. Using the Standards for Quality Improvement Reporting Excellence reporting guideline for consensus statement development, this assessment adopted a 6-round modified Delphi approach involving 32 expert coauthors from 17 countries who participated in creating and validating a framework outlining essential leadership imperatives.

Findings:

In this consensus statement,32 coauthors from 17 countries with expertise in various aspects of health leadership, health care, public health, and related fields outline 10 imperatives to guide leaders through recovery from the emergency stages of the pandemic. Key leadership capabilities and reflection questions are presented to guide leaders and to structure performance reviews.

Evidence Review:

A literature search in PubMed, MEDLINE, and Embase revealed 10 910 articles published between 2000 and 2021 that

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The 10 imperatives in the framework are: (1) acknowledge staff and celebrate successes; (2) provide support for staff well-being; (3) develop a clear understanding of the current local and global context, along with informed projections; (4) prepare for future emergencies (personnel, resources, protocols, contingency plans, coalitions, and training); (5) reassess priorities explicitly and regularly and provide purpose, meaning, and direction; (6) maximize team, organizational, and system performance and discuss enhancements; (7) manage the backlog of paused services and consider improvements while avoiding burnout and moral distress; (8) sustain learning, innovations, and collaborations, and imagine future possibilities; (9) provide regular communication and engender trust; and (10) in consultation with public health and fellow leaders, provide safety information and recommendations to government, other organizations, staff, and the community to improve equitable and integrated care and emergency preparedness systemwide.

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Conclusions and Relevance:

Leaders who most effectively implement these imperatives are ideally positioned to address urgent needs and inequalities in health systems and to cocreate with their organizations a future that best serves stakeholders and communities.

Article Citation: Geerts JM, Kinnair D, Taheri P, et al. Guidance for Health Care Leaders During the Recovery Stage of the COVID-19 Pandemic: A Consensus Statement. JAMA Netw Open.

2021;4(7):e2120295. doi:10.1001/jamanetworkopen.2021.20295 Read the full study at https://bit.ly/2W78htc.

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by Amy Vatne Bintliff PhD

Incidences of Violence Increased During the COVID-19 Pandemic New data reports that increases in violence have indeed occurred, as well as increases in incidences of discrimination. The University of California San Diego researchers and NORC at the University of Chicago conducted a survey at the start of the COVID-19 pandemic in March of 2020, and then again in March of 2021. This study design allowed a direct comparison of data from the start of pandemic-related shutdowns and then again one year later.

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The sample of surveyed participants is representative, meaning that statistical sampling was used to make conclusions that are representative of California adults based on key demographics including age, race/ethnicity, income, and disability. The survey of 2,203 adult Californians demonstrated that in addition to difficulties people faced due to rising unemployment or job loss (57 percent reported lost jobs), discrimination, harassment, and violence have risen.

Data Shows Violence on the Rise During COVID-19

Nineteen percent of respondents reported an increase in violence in their communities during the pandemic. Threats with a weapon increased from 4 percent in 2020 to 7 percent in 2021. Past year reports of violence for females doubled from 3 percent in 2020 to 6 percent in 2021. Additionally, 16 percent of respondents reported increased partner violence against women in their community. This especially impacted Black (23 percent) and Latina (18 percent) women disproportionately when compared with White (7 percent) and Asian (11 percent) survey participants.

Additional concerns arise over the safety of children. Eleven percent of study participants reported increased family violence against children in their community. And 20 percent reported increased neighborhood violence in their community. Blacks (20 percent), Latinx people (23 percent), and Asians (23 percent) reported this more than Whites (14 percent).

With many individuals working in online spaces during the pandemic or generally spending more time online, the study also explored incidences of online harassment. Reports of past year cyber-sexual harassment increased from 3 percent in 2020 to 6 percent in 2021. Females were more likely to report this form of abuse. Just a reminder that this study featured adult participants, so emerging data from other studies are needed to determine the impact of online harassment for children or adolescents during this time period.

According to Dr. Anita Raj, the principal investigator of the study, “We found significant increases in physical violence as well as cyber-sexual harassment of women over the past year pandemic period, with abuses most commonly coming in the forms of family and partner violence. Isolation at home may have helped prevent infection, but it also left many vulnerable to those who harm them.”

In addition to increasing reports of violence, more than 1 in 4 (26 percent) Californians surveyed reported that they faced discrimination during a typical week. Blacks were more likely to report discrimination (40 percent), followed by Asians (31 percent), and Latinx people (33 percent). Whites reported facing discrimination in a typical week at 16 percent. Discrimination itself is a form of violence against one’s ability to fully access one’s human rights and it needs to be considered as an important indicator of societal well-being.

funding initiatives that support survivors of violence as part of post-COVID-19 relief packages.

Knowing that violence rose during the pandemic does not mean that the rates of violence will automatically fall post-pandemic. Patterns of violence may persist long after times of crisis.

Thus, in addition to providing prevention-based community education, community and psychology networks need to be able to provide services to all those impacted by the violence. Better networks for reporting discrimination need to be created, funded, and facilitated while survivors of discrimination need access to emotional support.

When discrimination rises within communities of color, more attention needs to be paid to the data so that anti-discrimination policies and legislative action can be strengthened. Serious attention should be paid to this data as any increases in violence directly impact individual and community well-being.

To Learn More: CalVEX 2020 surveyed experiences of violence in the past year in California, conducted in March 2020. The CalVEX 2021 study was conducted in March 2021, allowing for a direct comparison between state-level representative data collected at the start of the pandemic versus one year later. Full results are available at https://geh.ucsd.edu/cal-vex/.

The survey of 2,203 California adults was conducted March 12-24, 2021 by NORC at the University of Chicago. Funding for the study was provided by Blue Shield Foundation of California and Kaiser Permanente. The margin of sampling error is +/- 2.9 percentage points at the 95% confidence level.

View the article at https://bit.ly/3hYPW9k.

About the Author Amy Vatne Bintliff, PhD, is a developmental psychologist and professor at the University of California, San Diego.

Note: Dr. Bintliff is an unpaid member of the CalVEX 2020 and 2021 Advisory Board.

Recommendations

What can be done to reduce or eliminate these rising incidences of violence and discrimination? States should consider

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Our Healthcare Heroes Deserve Better

By Evan Low, Assemblymember

Evan Low, D-Silicon Valley, represents District 28 in the California Assembly.

I don’t know if words can adequately express just how much of a debt this country, the state of California, and my community in Santa Clara County owe to health care and frontline workers.

We hear the stories of healthcare heroes being the last person to hold a COVID-19 patient’s hand as they take their last breath.

We read about frontline staff risking their health and the wellbeing of their families back home to support the mission of saving lives. And we see the pictures of pure fatigue, a level of exhaustion that can be traced by N95 mask-induced scars but all too often runs deeper, resulting in burnout, mental health crises, drug addiction, and other hazardous outcomes.

I was proud to introduce Assembly Bill 562 this legislative session to help alleviate some of the burdens so many of these people have been facing — and continue to face. The bill would establish a temporary mental health resiliency program to provide additional services to frontline COVID-19 providers.

The pandemic placed our physicians, nurses, and other frontline health care workers under enormous stress, and they’ve been carrying this unbelievable weight for more than a year and a half. The trauma these heroes are experiencing didn't evaporate when vaccines became ubiquitous. The hard work is far from over, as the Delta Variant and vaccine hesitancy has tragically ensured. We need urgent action to support these workers by expanding access to mental and behavioral health services.

Last year, a survey of more than 32,000 health care professionals and nurses in California found that more than 10% reported a lack of mental health resources needed to cope during the pandemic. This poll was conducted before the deadliest

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surge in COVID-19 cases began in December 2020.

In January, the California Health Care Foundation conducted a survey that found 59% of respondents said they were “burned out” from their work, while 83% of those surveyed said that not enough was being done to address the problems facing health care workers.

If a society is best judged by how it treats its most vulnerable people, we should be equally concerned with how we support those who have worked nonstop during a generation-defining crisis.

AB 562 aims to provide free mental and behavioral health services to qualifying frontline healthcare workers. This would include in-person and telehealth services to support mental and behavioral health needs stemming from the COVID-19 pandemic. Other services would range from counseling and wellness coaching to providing online psychological distress self-assessments and other mental and behavioral health services and tools.

The pandemic shows no signs of abating in the months to come, but President Biden’s order this month to get 100 million Americans vaccinated is a positive step. I hope we can be equally dogged in making sure we give the proper attention to supporting the very people who kept this tragedy from spiraling further out of control.

If you have any ideas on what the Legislature can do to assist yourself, a colleague, or someone you love, please don’t hesitate to reach out to my office at (408) 446-2810 or evan.low@asm. ca.gov. Thank you for your sacrifice and stay safe.

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Upcoming Events 150th Annual Session of the CMA House of Delegates Saturday, October 23 & Sunday, October 24 | Virtual Event 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.

What is Value-Based Care and What Does it Mean for My Practice?

Wednesday, October 27, 12:15-1:15pm | Webinar Register at https://www.cmadocs.org/event-info/sessionaltcd/ CMA21_1027_VALBASCAR/t There continues to be a big push away from paying physicians under traditional fee-for-service (FFS) models and toward payment based on providing high-value, population-based care. This shift was further supported by COVID, magnifying how important it is that physicians have the support and resources to be financially resilient when patient volume dips, but quality does not. You may have questions about what this shift toward value-based care means for you and your practice. What is a value-based payment contract? Who offers them? How does it differ from capitation?

How do value-based payment contracts differ from each other?

What additional revenue will I be eligible for? What resources do I need for my practice to be successful under these models? CMA is hosting this webinar to discuss three different value-based care programs.

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Medi-Cal Rx Transition Thursday, October 28, 12:15-1:15pm | Webinar Register at https://www.cmadocs.org/event-info/sessionaltcd/ CMA21_1028_MCALRX/t On January 1, 2022, the California Department of Health Care Services (DHCS) will be transitioning all Medi-Cal pharmacy services from managed care to fee for service, referred to as the “Medi-Cal Rx” initiative. Under the Medi-Cal Rx program, most physicians who write prescriptions for Medi-Cal or Medi-Cal managed care patients will use a new secure portal for key prescribing functions. This free webinar will address: • What’s changing • What’s staying the same • How to sign up to use the new portal • Where to go to learn more about Medi-Cal Rx SAVE THE DATE: SCCMA Annual Awards Gala & Membership Meeting Thursday, December 2, 6:30pm | Virtual Event Santa Clara County Medical Association cordially invites you to attend our 2021 Awards Gala and Membership Meeting, bringing together our colleagues, supporters, advocates and allies to celebrate the work of the SCCMA, introduce SCCMA’s incoming President, Clifford Wang, MD, and bid farewell to outgoing President, Cindy Russell, MD. We will also honor those who are making a difference in medicine. Additionally, we will conduct a brief Annual Membership Meeting. Registration coming soon!

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OFFICE SPACE FOR RENT/LEASE MEDICAL OFFICE SPACE FOR LEASE • LOS ALTOS Three exam rooms, digital x-ray available, large lobby. Available 3-5 days. Call Kelly at (650) 575-6889.

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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 31,, 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

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