March/April 2019 by San Francisco Marin Medical Society

SAN FRANCISCO MARIN MEDICINE J O U R NA L O F T H E S A N F R A N C I S C O M A R I N M E D I CA L S O C I E T Y

PUBLIC HEALTH FRONTIERS LOCAL LEADERSHIP FOR THE LONG HAUL The Vaping Wars Wildfire Smoke and Human Health Sugary Beverages Battles Hunger and Food Insecurity Help for Homeless Mortality African American Health Reproductive Health Restrictions Vaccination as a Medical and Public Health Imperative

Interview with New SF Director of Public Health Dr. Grant Colfax Volume 92, Number 2 | March / April 2019

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IN THIS ISSUE

March/April 2019 Volume 92, Number 2

LOCAL LEADERSHIP FOR THE LONG HAUL FEATURE ARTICLES

MONTHLY COLUMNS

Membership Matters

President’s Message: A Season of Renewed Public Health Leadership Kimberly L. Newell Green, MD

Where There's Smoke, There's Vaping! A Case Study in Forward Public Health Policy Tomás J. Aragón, MD, DrPH, Grant Colfax, MD and Steve Heilig, MPH San Francisco's Sugary Drink Distributor Tax: The Potential of Healthcare-Public Health Partnerships Rit Nguyen, MD, Christina Goette, MPH, and Kristine Madsen, MD, MPH

10 Big Tobacco is Marketing Vapes to Our Kids, so Our City Took Them on and Won Kitty Thornton, Derek Smith, and Tomás Aragón, MD, DrPH

36 Community News: Kaiser Permanente Maria Ansari, MD 36 Upcoming Events

OF INTEREST

12 Making Sense of Wildfire Smoke Ted Schettler, MD, MPH

20 Introducing Grant Colfax, MD San Francisco's New Director of Public Health Steve Heilig, MPH with Grant Colfax, MD

16 Investing in Healthy Communities Matt Willis, MD, MPH and Juliet Sims, MPH

23 AMA Statement: Title X Gag Rule and Funding Restrictions Barbara L. McAneny, MD, President, AMA

22 Vaccination as a Medical and Public Health Imperative Richard Pan, MD, MPH

36 Advertiser Index

15 Facing the Race in Racial Disparities Ayanna Bennett, MD

18 Homeless Mortality in San Francisco: Opportunities for Prevention Barry Zevin, MD

23 National Health Decisions Day - April 16

29 CalHealthCares: $220 Million Available for Student Loan Repayments!

26 The Epidemic of Hunger and Food Insecurity in San Francisco Paula Jones, PhD and Tómas Aragón, MD, DrPH

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MARIN MEDICAL SOCIETY

Editorial and Advertising Offices: San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133 Phone: (415) 561-0850 Web: www.sfmms.org

MEMBERSHIP MATTERS SFMMS Featured Member – Heyman Oo, MD, MPH Dr. Heyman Oo is a primary care pediatrician in Marin County and an Associate Physician and Clinical Instructor for the General Pediatrics Department at Zuckerberg San Francisco General and UCSF Benioff Children’s Hospital. She earned her BA in Psychology and Neuroscience from Yale University, Doctorate in Medicine from University of California San Diego and Masters in Public Health from Harvard University’s T.H. Chan School of Public Health in Healthcare Policy and Administration. She completed her residency in the PLUS (Pediatric Leadership Advancing Health Equity) Residency Program at UCSF which is designed to “develop a foundation in leadership, communication, scholarship and advocacy skills” while simultaneously learning clinical medicine. She was inducted into the Gold Humanism Honors Society as a medical student and has continued to earn local and national awards for her leadership and advocacy. She is currently the Pediatric Champion at Marin Community Clinics for a pilot project with the Center for Youth Wellness screening for Adverse Childhood Experiences (ACEs) in a pediatric primary care setting and leading a trauma-informed care initiative through the Resilient Beginnings Collaborative from the Center for Care Innovations. SFMMS is pleased to welcome Dr. Oo as our Featured Member! Read more about Dr. Oo at http://www. sfmms.org/about/featured-member.aspx

AAP and AHA Endorse Suite of Policies to Reduce Kids' Consumption of Sugary Drinks In a joint policy statement, the American Academy of Pediatrics (AAP) and the American Heart Association (AHA) endorsed a suite of public health measures—including excise taxes, limits on marketing to children, and financial incentives for purchasing healthier beverages—designed to reduce kids' consumption of sugary drinks. Children and teens consume gallons of sugary drinks every year, including sports drinks, fruit-flavored drinks and sodas. The 2015-2020 Dietary Guidelines for Americans recommend that children and teens consume fewer than 10 percent of calories from added sugars. But data show that children and teens now consume 17 percent of their calories from added sugars—nearly half of which comes from drinks alone. http://bit.ly/2UY96i4.

New Survey Reveals Physician Priorities for Health Care in California

Nearly 900 California physicians participated in statewide survey conducted by the California Medical Association (CMA). Participating physicians said the most important challenges facing California’s health care system included increasing costs and affordability (32 percent), access to quality care (24 percent) and lack of universal coverage (18 percent). CMA members cited legislative advocacy (48 percent) and communication with its members (11 percent) as the top two reasons 2

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to join the 163-year-old association. And a majority believed CMA was doing a good job keeping them updated about policy issues affecting them (59 percent) and educating elected officials about how proposed legislation impact physicians and their practices (53 percent). Indeed, CMA’s biggest strengths were identified as acting as the voice of physicians (21 percent) and overall advocacy efforts (12 percent). Read more at http:// bit.ly/2WkMFDX.

$220 Million Available or Loan Repayment

CalHealthCares is a new loan repayment program that incentivizes physicians to provide care to Medi-Cal beneficiaries by repaying educational debt up to $300,000 in exchange for a five-year service obligation. All awardees will be required to maintain a patient caseload of 30 percent or more Medi-Cal beneficiaries. The program—which aims to increase access to care for California’s 13 million Medi-Cal patients—was made possible by Proposition 56, which provided a one-time allocation of $220 million for state loan repayment programs. The California Department of Health Care Services has contracted with Physicians for a Healthy California to administer the loan repayment program. Applications will be accepted from April 1-April 26, 2019. Visit https://www.phcdocs.org/Programs/ CalHealthCares for more information or to apply.

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March/April 2019 Volume 92, Number 2 Editor Gordon L. Fung, MD, PhD, FACC, FACP Managing Editor Steve Heilig, MPH Guest Co-Editor Tomas Aragon, MD, Dr.PH Production Maureen Erwin

Senator Scott Wiener spoke to the CMA’s Council on Legislation about his Prep/Pep bill, and later met briefly with SFMMS leaders. From left, George Fouras, MD, Shannon Udovic-Constant, MD, Senator Scott Wiener, Peter Bretan, MD, SFMMS CEO Mary Lou Licwinko, and John Maa, MD.

J. Elliott Royer Award in Neurology Call for Nominations The J. Elliot Royer Award was established in 1957 by the late J. Elliot Royer, MD, as a bequest in his will. The award recognizes two psychiatrists or neurologists, one academic and one community, active in the medical field in San Francisco, Alameda or Contra Costa counties who during the year have made the most significant contribution to the advancement of psychiatry or neurology. The award alternates each year between the specialties of Neurology and Psychiatry. This year, two recipients will be selected for this cash award, one to an academic neurologist and the other to a community-based practitioner. Nominations will be received until 5:00pm on Wednesday, May 1, 2019. For more information, visit http://bit.ly/2FyH4Eu.

Security Prescription Fix Signed By Governor Newsom; Delays Implementation Until 2021

Governor Gavin Newsom signed a bill that will end the confusion caused by flawed implementation of the state’s new prescription pad law. AB 149 will delay implementation of the new law until January 1, 2021, ensuring that patients will continue to have access to the medicine they need while the state creates a system to better track prescriptions across the state. Physicians will be required to order a new set of prescription pads by that date, and the Department of Justice (DOJ) will determine the specs of those new pads sometime next year. In the meantime, physicians will be able to use pads obtained before or after January 1, 2018. Both sets of pads will be accepted until DOJ can come up with guidelines are requirements for the new pads. Read more at http:// bit.ly/2JFht0Z.

Marin Flavored Tobacco Bans Moving Forward in Several Cities

Larkspur and Corte Madera recently took the first step toward banning flavored tobacco sales, joining a growing list of Marin cities and towns that have enacted laws aimed at reducing youth use. Experts say flavored tobacco products target children and mask the harsh effects of smoking, leading to the potential for increased nicotine addiction rates. Read more at https://bayareane.ws/2uqnvYG.

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EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Obituarist Erica Goode, MD, MPH Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD Erica Goode, MD, MPH Shieva Khayam-Bashi, MD Arthur Lyons, MD John Maa, MD David Pating, MD SFMMS OFFICERS President Kimberly L. Newell Green, MD President-Elect Brian Grady, MD Secretary Monique Schaulis, MD, MPH Treasurer Michael Schrader, MD, MPH, PhD, FACP Immediate Past President John Maa, MD Editor Gordon L. Fung, MD, PhD, FACC, FACP SFMMS STAFF Executive Director and CEO Mary Lou Licwinko, JD, MHSA Associate Executive Director, Public Health and Education Steve Heilig, MPH Associate Executive Director, Membership and Marketing Erin Henke Membership Coordinator Ruben Pambid Executive Assistant/Office Manager Ian Knox 2019 SFMMS BOARD OF DIRECTORS Peter N. Bretan, Jr., MD Alice Hm Chen, MD Anne Cummings, MD Nida F. Degesys, MD Robert A. Harvey, MD Naveen N. Kumar, MD Michael K. Kwok, MD Jason R. Nau, MD Dawn D. Ogawa, MD Stephanie Oltmann, MD Heyman Oo, MD Rayshad Oshtory, MD William T. Prey, MD Justin P. Quock, M Sarita Satpathy, MD Dennis Song, MD, DDS Kristen Swann, MD Winnie Tong, MD Eric C. Wang, MD Matthew D. Willis, MD Joseph W. Woo, MD

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PRESIDENT’S MESSAGE Kimberly L. Newell Green, MD

A SEASON OF RENEWED PUBLIC HEALTH LEADERSHIP To address the health challenges of our times....we are going to need a strong vision and multidisciplinary thinkers that include our physicians, our public health leaders, our civic and political and community leaders, and our patients. Spring has sprung! As the birds frolic and sing, and the dense

fields of yellow oxalis (sourgrass) transform my neighborhood in the Presidio after all of the winter’s rains, I am feeling full of the hope and excitement that this season ushers in every year. And it is an exciting time in San Francisco, Marin and in our state as we have new leadership in the public health world. As San Franciscans, we are excited to have Dr. Grant Colfax move across the bridge to lead our Department of Public Health. His move is also an opportunity for new leadership in Marin, and that new leader will have a strong team of amazing public health advocates welcoming them to the “healthiest county in California” (a distinction that Marin has held for 9 of the past 10 years). Though Marin may be the healthiest county in our state we know that there are still public health issues to tackle, chief among them issues of equity and disparities, as well as substance abuse and mental health concerns. These are also bugaboos in San Francisco and broadly throughout our state. I am also thrilled with the team that Gavin Newson, a governor who has committed to putting issues of health access and equity central to his agenda, has assembled. The recent announcement that Dr. Mark Ghaly, a UCSF-trained pediatrician, will be the new Secretary of the Department of Health and Human Services, is a boon for our state. Mark was a year behind me in our continuity clinic pod at San Francisco General Hospital, and I’m quite certain he taught me more than I taught him. While always looking out for the small and vulnerable, Mark has not been limited by his training with children. He is a true warrior for the health of all, especially those not well served but current systems, and is one of the most visionary, hard-working, and dedicated physicians that I know. He comes to Sacramento from Los Angeles where he was a special advisor at the LADPH and worked on projects ranging from homelessness to jail health to foster care. Another San Francisco pediatrician, Dr. Nadine Burke Harris, has been appointed as the state’s first Surgeon General. As the former CEO for the Center for Youth Wellness in the Bayview Hunter’s Point neighborhood of San Francisco, she has been a tireless spokesperson for the link between adverse childhood experiences and toxic stress and harmful effects later in life. I can’t wait to see what she will accomplish in her new role to work to end health disparities and develop systems that are capable of true prevention of psychological and physical disease by starting in the first 100 days of life. WWW.SFMMS.ORG

The work of the San Francisco Marin Medical Society has long had a strong public health interest and emphasis. And our organization benefits hugely from our collaboration and partnership with both the Marin and San Francisco Departments of Public Health, and we are grateful to have leaders like Drs. Alice Chen, Tomas Aragon, and Matt Willis regularly attend our board meetings and participate in our leadership. I am particularly grateful for Dr Aragon for co-editing this exciting issue of our journal which features an interview with Dr. Grant Colfax, the new director of SFDPH, as well as many articles on current public health issues including vaping and Juul, continued efforts to reduce the dangerous consumption of sugary beverages, focuses on homelessness and on black/African-American health, and a look at one of the health consequences of climate change that has been very present in the lives of Bay Area residents in the past year: Massive smoky wildfires. To address the health challenges of our times, challenges that are often as much about mental health as they are about physical health, challenges that impacted as much or more by social context and environmental conditions than they are by areas more traditionally considered the purview of medicine, we are going to need a strong vision and multidisciplinary thinkers that include our physicians, our public health leaders, our civic and political and community leaders, and our patients. I am hopeful that with the dedication and vision of the leaders in our counties, state and nation, we will work towards a goal of health for all.

Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at University of California School of Medicine. She is the former Chief of Healthcare Innovation and Chief of Physician Health and Wellness at Kaiser Permanente in San Francisco where she practiced as a general pediatrician for over a decade and was a member of the senior leadership team. A graduate of Princeton University, she completed a Fulbright Fellowship in India and produced a documentary film about cross-cultural healthcare at the Harvard School of Public Health. She attended medical school at the University of Pennsylvania and completed her pediatric residency at UCSF, and completed the Kaiser Permanente Emerging Leaders fellowship program in 2015.

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EDITORIAL

WHERE THERE’S SMOKE THERE’S … VAPING! A Case Study in Forward Public Health Policy Tomás J. Aragón, MD, DrPH, Grant Colfax, MD and Steve Heilig, MPH A decade ago, “e-cigs” were barely on the public health radar, but were rapidly spreading as a new practice and industry. Advertising was everywhere, touting e-cigs as a “revolutionary” new tool endorsed by doctors for quitting tobacco smoking. Use among all ages, but especially young people, was rising fast. Researchers and health authorities were largely caught off-guard. Wholly unregulated, e-cigarettes were in the “Wild West” of health policy, with a great need to catch up. Much of this scenario was disturbing to longtime local antitobacco advocates, as we did not know the real risks of e-cigarettes. But hoping to catch up and head off disaster, we pushed for preventive policies to regulate vaping products like tobacco with restrictions on sales, marketing, and public use, for example. In 2011, the SFMMS and SFDPH and San Francisco Health Commission adopted such policies, and CMA joined soon after at our urging. More recently, San Francisco adopted a historic ban on all flavored tobacco products, which are a primary attraction to youth, and this policy is being promulgated in Marin now. All of this is vehemently fought by the vaping and tobacco industries, but efforts continue. In March, San Francisco City Attorney Dennis Herrera and Supervisor Shamann Walton announced “joint steps to curb the epidemic of youth e-cigarette use, which has erased more than a decade’s worth of progress in reducing youth tobacco consumption.” Walton introduced ground-breaking legislation at the Board of Supervisors "that would prohibit the sale in San Francisco of any e-cigarette that has not undergone FDA review. Under this legislation, any e-cigarette that is required to have, but has not received, FDA premarket review could not be sold at a store in San Francisco or bought online and shipped to a San Francisco address until the FDA completes its review and allows the products to be sold.” Understanding the public health rationale for banning electronic nicotine delivery systems can be confusing. According to the National Academies of Sciences, Engineering, and Medicine, there is “conclusive evidence that completely substituting e-cigarettes for combustible tobacco cigarettes reduces users’ exposure to numerous toxicants and carcinogens present in combustible tobacco cigarettes.” The tobacco industry argues that e-cigarettes are good because they provide adult smokers with a “safer alternative” to combustible cigarettes, and for some a path to smoking cessation. However, this is only part of the story. The nicotine industry takes a market growth view: e-cigarettes support their strategy to increase the total number of persons addicted to nicotine products regardless of delivery system. Youth are targeted because early exposure greatly increases the risk of addiction. 6

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Here is what we know from research. First, because of its perceived “safety” e-cigarettes entice new users to experiment and become addicted to nicotine. From 2011 to 2018, e-cigarette use among middle and high school students exploded 13-fold from 280,000 to 3.6 million. Second, once addicted, e-cigarette users are likely to move to combustible cigarettes. Third, e-cigarette use among conventional smokers keeps them addicted to nicotine, and they end up using both. Fourth, for most users, e-cigarettes are not effective for smoking cessation compared with other more established interventions. Fifth, vaping has multiple negative impacts on users' health. And sixth, secondhand vapors from vaping also have adverse health impacts. Before the introduction of e-cigarettes, we made tremendous strides in reducing tobacco product consumption. In California the prevalence of smoking was approaching 10%, and some experts believed that eliminating tobacco smoking was attainable. Instead, e-cigarettes may reverse this trend. In public health we focus on optimizing the protection and promotion of health of populations and communities. Sometimes this means making trade-offs with individual rights. Long experience on many fronts have shown that strong majorities of Americans support such restrictions in the name of health. The case of vaping is one where admittedly the health sector was caught by surprise, but we are catching, up, and San Francisco and Marin are helping to lead the way. In this edition of the SFMMS journal are many examples of evidence-based, forward-thinking efforts to improve our communities' health. Public health is “what we, as a society, do collectively to assure the conditions in which people can be healthy.” In this issue we cover youth vaping in more detail, Black/African American health inequities, update on the new soda tax, mortality among persons who are homeless, and more. We thank all the authors for their contributions and hope you can enjoy and learn from their expertise.

Tomás J. Aragón, MD, Dr.PH is Health Officer, City & County of San Francisco; Grant Colfax, MD, is Director of Health, San Francisco Department of Public Health, and Steve Heilig, MPH is director of public health and education for the SFMMS and a past co-chair of the San Francisco Tobacco-Free Coalition. WWW.SFMMS.ORG

Public Health Frontiers

SAN FRANCISCO’S SUGARY DRINKS DISTRIBUTOR TAX: The potential of healthcare-public health partnerships Rita Nguyen MD, Christina Goette MPH, Kristine Madsen MD MPH The decades long trend of increasing obesity and diabetes prevalence has fueled a public health crisis that continues to manifest in clinic exam rooms, hospitals, and mortuaries. Not surprisingly, then, cardiovascular disease continues to be the leading cause of morbidity and mortality nationwide and in San Francisco—with low income communities and communities of color bearing a disproportionate burden of these dietrelated diseases. At the frontline of medical care, physicians are viewed as the stewards of health for individuals and communities. However, it would be unreasonable to expect practitioners in clinical settings to bear the weight of reversing a public health crisis on their own. As was seen when clinicians and public health professionals partnered together to tackle the alarming ubiquity of smoking, the power of unified efforts between healthcare and public health can reverse alarming public health crises driven by industries pushing unhealthy products. Today, a similar battle is underway with the beverage industry marketing tactics that drive the consumption of added sugar into American diets, fueling our obesity and diabetes epidemics. In this arena, San Francisco is in the national spotlight since passing our sugar-sweetened beverage (SSB) tax in 2016, and started in January, 2018. The San Francisco Marin Medical Society was a key advocate in efforts to pass the Sugary Drinks Distributor Tax (SDDT) in San Francisco. As was the case with tobacco and smoking prevalence, a robust partnership between the medical community and public health will be key to bending the curves on the obesity and diabetes epidemics of our day.

The case for sugar-sweetened beverage (SSB) taxes

The recent advent of SSB taxes is a direct response to an American diet that is the unhealthiest it has ever been. Sugarsweetened beverages, associated with the development of obesity, heart disease, diabetes, and dental caries,1234 are the single dietary item proven to cause obesity.5 Sugar-sweetened beverages are the leading source of sugar in the American diet, contributing 36% of the added sugar Americans consume.6 To improve health, numerous organizations and agencies, including the American Heart Association, American Diabetes Association, WWW.SFMMS.ORG

American Academy of Pediatrics, Institute of Medicine of the National Academies, American Medical Association, and the Centers for Disease Control, recommend limiting intake of added sugar and sugar sweetened beverages (SSBs). Of note, every additional SSB consumed daily can increase a child’s risk for obesity by 60%7 and the risk of developing Type II diabetes by 26%.8 Diseases connected to SSBs are also found to disproportionately impact ethnic minority and low-income communities—the very communities that are found to consume higher amounts of SSB. The World Health Organization, Centers for Disease and Control, and Harvard Childhood Obesity Intervention Cost-Effectiveness Study (CHOICES) recommend the passage of SSB taxes as an effective means to address obesity and diabetes. Mexico, where an average of 163 liters of sugar-sweetened beverages are consumed per person each year, enacted an excise tax on SSBs in 2014. By December of that year, the purchase of taxed SSBs had declined by 12% generally and by 17% among low-income Mexicans. In 2014, Berkeley became the first city in the United States to pass a SSB tax and there was a 50% decline in SSB consumption among diverse adults over the first 3 years of the tax.9 Modeling suggests that a national SSB tax that reduced consumption by just 20% would avert 101,000 disability-adjusted life-years; gain 871,000 quality-adjusted life-years; and result in $23.6 billion in healthcare cost savings over just 5 years. The tax is further estimate to generate $12.5 billion in annual revenue.10 The beverage industry spends billions annually on marketing and advertising; in 2013, Coca-Cola and PepsiCo alone spent $7.2 billion on marketing and advertising.11 There is evidence to suggest low income communities of color are particularly targeted for unhealthy beverage advertising. Their investment and focused efforts within these communities are highly effective; sugar-sweetened beverage consumption is highest among low-income communities and communities of color which are also hardest hit by the obesity and diabetes epidemics. Current subsidies to the beverage industry make producing SSBs more profitable; bottled water is often as, or more expensive, than SSBs. Beverage industries target their SSB product advertising continued on page 8 MARCH/APRIL 2019

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Public Health Frontiers to youth. SSB taxes are our best evidence-based intervention to level the playing field and provide counter messaging against advertising that promotes soda consumption.

Implementation in San Francisco

In November 2016, San Francisco voters passed Proposition V, the Sugary Drinks Distributor Tax (SDDT), making San Francisco the third city in the nation to pass a sugar-sweetened beverage tax. The tax established a 1 cent per ounce fee on distributors of bottled sugar-sweetened beverages, syrups, or powders within the San Francisco and collection began January 1, 2018. The measure established a 16-member Sugary Drinks Distributor Tax Advisory Committee (SDDTAC) to evaluate the impact of the tax and to recommend how to invest the approximate $10.4 million a year tax revenue to reduce SSB consumption and to mitigate the health impacts of their consumption.

In December 2017, the Committee was convened and issued its first recommendations in March 2018 (https://www.sfdph. org/sddtac/). The Advisory Committee recommendations were adopted to fund activities that support decreasing SSB consumption and increasing water consumption, oral health, healthy food access and physical activity—with a focus on the most impacted populations. While it is too soon to assess the full impact of the tax, the funds have helped thousands of people get more nutritious food and be more physically active. The Committee’s focus on prevention and early intervention creates a unique opportunity for clinical providers to partner with public health and community-based organizations through programs and policy changes that promote health.

Lawmakers unveil bills targeting Coke and Pepsi in California Efforts aim to reduce incidence of obesity, diabetes, tooth decay and heart disease SACRAMENTO, Calif. A broad coalition of physicians, dentists and public health advocates announced their support for a package of bills aimed at reducing consumption of sugar-sweetened beverages and ensuring that corporations like The Coca-Cola Co. (NYSE: KO) and PepsiCo Inc. (NASDAQ: PEP) stop targeting low-income communities and pay their fair share of public health costs. The California Medical Association and California Dental Association are backing five measures, including a broad array of policy proposals that would reduce the consumption of sugary beverages such as soda, energy drinks, sweet teas and sports drinks that contribute to obesity, diabetes, tooth decay and heart disease. “Like the tobacco industry, companies like Coke and Pepsi are peddling harmful products to children at a significant cost to public health and our health care system,” said CMA President David. H. Aizuss, M.D. “These measures will help lower consumption and help Californians make healthier choices that prioritize public health.” Sugar-sweetened beverages are a major factor in preventable diseases such as Type 2 diabetes, which affects approximately 4 million California adults, costing the state billions of dollars in health care costs. The high levels of sugar and frequency of consumption of these beverages, which are consumed by over 50 percent of 8-year-olds daily, are especially problematic. “The combination of high sugar content and acid makes soda especially damaging to teeth, and dentists see the devastating effects of this in our practices every day,” said CDA President Del Brunner, D.D.S. “Tooth decay is the No. 1 chronic childhood disease and it affects children’s ability to chew, speak properly and learn in school; we must do more to reverse soda’s lifelong negative effects on dental health.” The measures introduced this week include: • AB 766 by Assemblymember David Chiu (D-San Francisco) bans the sale of unsealed beverages larger than 16 ounces at food service establishments, including restaurants with self-service soda fountains. 8

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• AB 764 by Assemblymember Rob Bonta (D-Oakland) prohibits a soda company from offering a manufacturer’s coupon to their partnering manufacturer, distributor or retailer. • AB 765 by Assemblymember Buffy Wicks (D-Oakland) prohibits placement of sugar-sweetened beverages near the check-out counter at supermarkets, larger grocery stores, supercenters and warehouse clubs. • SB 347 by Sen. Bill Monning (D-Carmel) requires a warning label on sugar-sweetened beverages so consumers can make decisions that work best for them. • AB 138 by Assemblymember Richard Bloom (D-Santa Monica) creates a fee on sodas and other sugary beverages and uses the new revenue to offset health and economic costs associated with overconsumption of sugar. Effectively curbing the obesity epidemic will require a comprehensive approach to limit availability, place restrictions on advertising tactics and educate consumers about the harmful effects of sugar-sweetened beverages. The California Dental Association is the nonprofit organization representing organized dentistry in California. Founded in 1870, CDA is committed to the success of our members in service to their patients and the public. CDA also contributes to the oral health of Californians through various comprehensive programs and advocacy. CDA’s membership consists of more than 27,000 dentists, making it the largest constituent of the American Dental Association. For more information, visit cda.org.

The California Medical Association represents the state’s physicians with more than 44,000 members in all modes of practice and specialties, and CMA is dedicated to the health of all patients in California. For more information, please visit CMAdocs.org and follow CMA on Facebook, Twitter, LinkedIn, YouTube and Instagram.

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Future threats and opportunity Similar to the tobacco industry, the soda industry is fighting back. In June of 2018, the beverage industry successfully lobbied the California legislature to prohibit passage of new, local SSB taxes for the next 12 years. This is known as pre-emption and ties the hands of local communities to implement proven, evidence-based interventions that protect and promote health. Clinicians are champions for the health of their patients and communities as well as trusted stewards. We have the power and obligation to objectively relay the health harms of SSBs to our patients. Public health advocates will continue to relay this message outside the exam room, but public health needs the partnership of providers and clinicians on the front line to reinforce messaging. Repetition is the first principle of all learning. How powerful is it to have your trusted physician talk about the health harms of sugar-sweetened beverages, see a billboard about industry tactics to drive demand as you head to the bus stop, and then work out at a public gym made possible from SSB tax revenue? The cultural shift that happened with tobacco absolutely needed the partnership of clinicians and so, too, does the fight against the beverage industry. Clinicians can: • Counsel patients, particularly youth, about the health harms of sugar-sweetened beverages

• Support messaging, through clinical encounters and by posting fliers and materials in your office that encourages healthy beverage consumption (http://choosehealthydrinks. org/#resource)

• Advocate for health-promoting environments in your own clinic or hospital by prohibiting the sale of sugar-sweetened beverages in clinical settings

• Educate and advocate for policies that will improve public health In this era of growing momentum for SSB taxes, a proven intervention that reduces consumption on a population-wide scale, San Francisco and its medical community has a tremendous opportunity to show the nation what a partnership between clinicians and public health practitioners can accomplish. Rita Nguyen MD, a hospitalist at Zuckerberg San Francisco General Hospital, is the Chronic Disease Physician Specialist with the San Francisco Department of Public Health and is a member of the San Francisco Sugary Drinks Distributor Tax Advisory Committee.

Christina Goette MPH is the Chronic Disease Prevention Programs Manager at the San Francisco Department of Public Health and staffs the San Francisco Sugary Drinks Distributor Tax Advisory Committee.

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Kristine Madsen, MD MPH, a pediatrician, is the Faculty Director of the Berkeley Food Institute and an Associate Professor at UC Berkeley's School of Public Health

References 1. Malik, V.S. (2012, January 31). Sweeteners and Risk of Obesity and Type 2 Diabetes: The Role of Sugar-Sweetened Beverages. Curr Diab Rep , 12, 195-203. doi:10.1007/ s11892-012-0259-6. Retrieved from http://link.springer. com/article/10.1007/s11892-012-0259-6 2. Wang, J. (2014, April). Consumption of added sugars and development of metabolic syndrome components among a sample of youth at risk of obesity. Applied Physiology, Nutrition, and Metabolism , 39(4), 512. doi:10.1111/ jhn.12223. Retrieved from http://www.ncbi.nlm.nih.gov/ pubmed/24669994 3. Johnson, R.K., Appel, L., Brands, M., Howard, B., Lefevre, M., Lustig, R., Sacks, F., Steffen, L., & Wyllie-Rosett, J. (2009, September 15). Dietary sugars intake and cardiovascular health: a scientific statement from the American Heart Association. Circulation , 120(11), 1011-20. doi:10.1161/ CIRCULATIONAHA.109.192627. Retrieved from http://circ. ahajournals.org/content/120/11/1011.full.pdf 4. Sohn W, Burt BA, Sowers MR. Carbonated Soft Drinks and Dental Caries in the Primary Dentition. J Dent Res. 2006; 85(3): 262–266. 5. Te Morenga LA, Howatson AJ, Jones RM, Mann J. Dietary sugars and cardiometabolic risk: systematic review and metaanalyses of randomized controlled trials of the effects on blood pressure and lipids. The American journal of clinical nutrition 2014;100:65-79. 6. U.S. Department of Agriculture, U.S. Department of Health and Human Services. (2010). Dietary Guidelines for Americans, 2010. Retrieved from [LINK] 7. Trust for America’s Health and Robert Wood Johnson Foundation. F as in Fat: How Obesity Threatens America’s Future – Fast Facts: Obesity and Health. 2013. Accessed January 15, 2014 at http://fasinfat.org/facts-on-obesity-and-health/ 8. Malik, V.S. (2012, January 31). Sweeteners and Risk of Obesity and Type 2 Diabetes: The Role of Sugar-Sweetened Beverages. Curr Diab Rep , 12, 195-203. doi:10.1007/ s11892-012-0259-6. Retrieved from 9. Lee M, Falbe J, Schillinger D, Basu S, McCulloch C, Madsen KA. Sugar-Sweetened Beverage Consumption 3 Years After the Berkeley, California, Sugar-Sweetened Beverage Tax. Am J Pub Health, epub ahead of print February 21, 2019: e1–e3. doi:10.2105/AJPH. 2019.304971 10. Long MW, GORTMAKER SL, Ward ZJ, et al. Cost Effectiveness of a Sugar-Sweetened Beverage Excise Tax in the U.S. American Journal of Preventive Medicine. 2015;49(1):112-123. doi:10.1016/j.amepre.2015.03.004. 11. Cassady DL, Liaw K, Miller LM. Disparities in ObesityRelated Outdoor Advertising by Neighborhood Income and Race. J Urban Health 2015;92:835-42. MARCH/APRIL 2019

SAN FRANCISCO MARIN MEDICINE

Public Health Frontiers

Big Tobacco is marketing vapes to our kids, so our city took them on and won —

NOW WE MUST WORK TO PROTECT THE NEXT GENERATION Kitty Thornton, Derek Smith, and Tomás Aragón, MD, DrPH

In September of 2018, the Food and Drug Administration’s (FDA) Commissioner announced that the new surge in teen e-cigarette use had reached epidemic levels. In December, the U.S. Surgeon General issued an advisory on e-cigarette use among youth. According to the Centers for Disease Control and Prevention (CDC) and the FDA’s National Youth Tobacco Survey (NYTS) the percentage of high schoolaged youth reporting past 30-day use of electronic cigarettes (e-cigarettes) increased by over 75% between 2017 and 2018. Within the same timeframe, use among middle school-aged children increased by almost 50%. There are now approximately 4.9 million middle and high school students who were current users (past 30 days) of some type of tobacco product in 2018. These shocking numbers can be largely attributed to the availability of sleek and discreet e-cigarette, or vaping, devices and the thousands of youth-friendly flavors they come in such as Mermaid Tears and Razzleberry Ring Pop. Both the devices and flavors mask the harsh taste of tobacco and feeling of smoking a cigarette, making it easier for young people to get addicted. "Big tobacco sees vaping as their future," these are the words of Patrick Reynolds, an anti-tobacco activist and executive director of the Foundation for Smokefree America. He is the grandson of R.J. Reynolds, the man behind the namesake tobacco company largely responsible for millions of Americans being hooked on cigarettes. Reynolds, like many local health departments, sees that a new generation is consuming new and different tobacco products at alarming rates. E-cigarettes are especially dangerous to youth, who are more susceptible to addiction and whose brains are still developing until age 25. Often young people trying e-cigarettes think they are merely inhaling flavored water vapor, not realizing what it’s really made of. ‘Vaping’ is a mode of nicotine delivery that includes e-cigarettes, e-pens, e-pipes, e-hookah, and e-cigars. ‘Vape’ is a misnomer; instead of water vapor it is an aerosol much like smog, and contains propylene glycol, the chemical base used in theater 10

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fog machines. The aerosol has ultra-fine particles that contain heavy metals and other substances that are inhaled deep into the lungs. While originally thought to be a harm reduction mechanism, i.e. better for people than smoking traditional cigarettes, little is known about their long term effects, and many studies show increased harm for dual use with cigarettes and reduced likelihood of quitting. Further, vaping may be an entry point to other drug and tobacco use. Young adults who use e-cigarettes are more than four times as likely as their non-vaping peers to start using traditional cigarettes within 18 months. Local jurisdictions such as the City of San Francisco and County of Marin, as well as others in the Bay Area and across the country, are taking action because federal authorities have failed to do so, leaving children and teenagers vulnerable to the effects of these deadly products. In June 2018, San Francisco passed a ban on the sale of menthol cigarettes and all flavors in e-cigarettes and other tobacco products. Initially, the local public health community worked with elected officials who unanimously approved the ban in 2017. Big Tobacco quickly challenged the local law with a signature-collecting campaign and referendum, however, voters approved the ban by a 2-to-1 margin the following year. San Franciscans effectively finished work that the FDA and U.S. Congress left undone when flavors in traditional cigarettes were banned a decade ago. The tobacco industry did not go down without a fight - R.J Reynolds spent almost $12 million to attempt to defeat the city’s measure. These corporations are fighting so hard to protect these products because their marketing is working, with devastating effects. San Francisco’s sales ban was the most comprehensive to date. Other jurisdictions in California with comprehensive policies include El Cerrito, Oakland, Palo Alto, and Yolo County. Policies with exemptions for certain retailers, or for certain tobacco products, include Los Gatos, Santa Clara, Berkeley, Hayward, and several others. WWW.SFMMS.ORG

Data from the 2017 Youth Risk Behavior Survey (YRBS), based on responses from San Francisco Unified School District high school students, found that students were significantly more likely to consume tobacco through vaping devices than to smoke cigarettes. • Among high school students, 25% have ever used an electronic vapor product • Currently, 7.1% of high school students use an electronic vapor product These rates are compared to that of cigarettes where 16.7% of high school students have ever tried smoking, and 4.7% have ever smoked cigarettes within the past 30 days. These rates of tobacco use are simply not acceptable, and right now, the tobacco industry is winning, continuing to grow their youth customer base almost unchecked. Juul, an extremely youth-popular San Francisco-based nicotine delivery device, in particular, is rising in popularity because it is arguably the most discreet e-cigarette and comes in enticing flavors such as crème and mango. Juul and other e-cigarette manufacturers have been under investigation by the FDA to determine if they were intentionally marketing to youth. The FDA has announced plans to ban most flavored e-cigarettes in retail stores and gas stations. Stricter e-cigarette regulations could also include age-verification for online sales in an attempt to curtail underage purchasing. However, menthol and mint flavored products, which are popular among youth, would be exempt from these potential regulations. Juul has reacted to government pressure and media attention by drastically altering their marketing to only include adults and focusing messaging on making the switch from cigarettes to Juul. They removed all flavors other than mint and tobacco from brick and mortar locations and strengthened their online age verification system. However, since these changes were made, their partnership with Altria, America’s biggest cigarette company, was announced. The battle against vapes is like déjà vu for many of us in the public health community, who successfully fought to eliminate youth-attracting marketing tricks like colorful packaging and candy flavors in cigarettes decades ago. Much of the danger is fueled by the product’s seemingly innocuous presentation. Despite their sleek packaging, e-cigarettes still contain cancercausing chemicals and highly addictive nicotine. There is limited research on effective ways to quit e-cigarettes, especially for youth. We’ve gotten to the point where some teens who vape can’t sit through class without consuming nicotine and don’t know how to go about quitting. Pharmaceutical methods for quitting tobacco, such as nicotine patches and chewing gum, are only approved by the FDA for adult use, which leaves counseling as the only method for reaching youth struggling with nicotine addiction. With the limited resources available, the role of doctors will prove to be ever-important in the fight against tobacco and in protecting the health of the next generation. Doctors’ voices have been vital in tobacco control and prevention in the past, and they are uniquely positioned to provide a tremendous amount of support for youth struggling as well as for continued progress in tobacco policy. Dr. John Maa, of the San Francisco Marin Medical Society, along with WWW.SFMMS.ORG

Derek Smith of the San Francisco Tobacco Free Project, went toe to toe with vaping industry proponents on an episode of KQED’s ‘Forum’ leading up to the vote on Prop E, the flavored tobacco sales ban in San Francisco. Dr. John Butler and Dr. Pamela Ling of UCSF have also been instrumental is supporting restrictions on tobacco sales and use locally. Because the FDA and Congress have not acted to ban the tobacco products that have helped lure a new generation of tobacco users, cities are left to fight Big Tobacco on their own. The work of local jurisdictions has made a profound impact, influencing six California state legislators, led by Jerry Hill D-San Mateo, to propose a statewide law to ban sales of flavored tobacco products in stores. The bill was proposed in late November of 2018 with co-authors from Orinda, San Francisco, Chino, La Canada Flintridge, and Sacramento. The local momentum needs to stay strong in order to continue influencing state legislators.

Despite their sleek packaging, e-cigarettes still contain cancercausing chemicals and highly addictive nicotine. There is limited research on effective ways to quit e-cigarettes, especially for youth.

Getting involved in local coalitions, and working with community-based organizations who are actively fighting for policies to restrict youth access to tobacco, are two ways that have proven to be successful in San Francisco. The San Francisco Tobacco Free Project provides support to the San Francisco Tobacco Free Coalition (TFC) which meets quarterly and is comprised of representatives from a range of organizations that serve populations most affected by tobacco use as well as researchers and doctors from UCSF, SF Unified School District Staff, and many others. Local cities and counties can’t wait for the state or federal government to protect our youth and communities most targeted by big tobacco – we must all work together!

Kitty Thornton is Public Service Aide, Tobacco Free Project, SFDPH, Derek Smith is Director of the Tobacco Free Project, SFDPH, Tomás Aragón, MD, is Health Officer, San Francisco

MARCH/APRIL 2019

SAN FRANCISCO MARIN MEDICINE

Public Health Frontiers

MAKING SENSE OF WILDFIRE SMOKE Ted Schettler, MD, MPH Wildfires are indelible features of the West but their increasing intensity in prolonged fire seasons with more people living in the wildlandurban interface has deepened and widened their impacts. Deaths and injuries to residents and firefighters, catastrophic property loss, socio-economic upheaval and forced displacement of people from their homes are the most wrenching and long-lasting consequences in the immediate fire zone. But health impacts can extend far beyond, primarily due to wildfire smoke that spreads over vast regions, sometimes for many days or weeks.

Wildfire smoke characteristics:

Wildfire smoke is physically and chemically complex. Its composition, formation, behavior, aging, and dispersion are influenced by the fuel mix, kind of fire, rate of fuel consumption, meteorological conditions, and landscape features. The primary emissions from wildfires are coarse and fine particulate matter (PM), including aerosols; gases such as carbon monoxide, methane, nitrous oxide, nitrogen oxides, volatile organic carbon compounds, including formaldehyde and acrolein; trace metals; polycyclic aromatic hydrocarbons (PAHs) and other toxicants. Some of the gases can form secondary pollutants including organic aerosols and ozone when they photo-react in the atmosphere. Particulate matter is typically divided into sub-types by size. Particles less than 10 microns in diameter (PM10) are inhalable but those between 2.5-10 microns are largely confined to the upper airways. Smaller particles (< PM 2.5) can penetrate more deeply into lungs and ultrafine particles can pass into the general circulation. Wildfire-related PM 2.5 is often used as a metric of exposure but it is only a surrogate for the complex mix of particles, gases, and hazardous air pollutants unique to each fire.

Health effects of wildfire smoke

Well-established health effects of exposure to wildfire smoke range from eye and respiratory tract irritation to reduced lung function, bronchitis, pneumonia, exacerbation of asthma and COPD, and premature deathâ&#x20AC;&#x201D;similar to impacts of urban PM. Even children without asthma show a decline in lung function. A causal association between general particulate air pollution and cardiovascular morbidity and mortality is well established. However, data linking wildfire smoke exposure to cardiovascular mortality and morbidity are mixed. Some studies find significantly increased emergency department visits for cardiovascular or cerebrovascular events on dense wildfire smoke days while others find no association. The inconsistencies may be due to

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differences in exposure and outcome assessment methods, considerations of lag times, and variability in smoke composition. Very close to the fire, carbon monoxide concentrations can be high enough to be an acute health threat causing headache, weakness, dizziness, confusion, visual impairment, coma, and death. In addition to impaired lung function, firefighters are at increased risk of several kinds of cancer, plausibly because of repetitive exposures to a variety of carcinogens associated with products of combustion. Cancer risk associated with exposure to wildfire smoke in the general population, however, is uncertain. There is growing interest in learning more about what happens when smoke blankets communities sometimes for weeks at a time, since wildfire smoke waves, events lasting more than two days, are expected to increase sharply in coming years. Birth outcomes, mental health, cognitive impacts, and cancer have not been sufficiently studied but preliminary evidence shows an increased risk of having a low birth weight infant with wildfire smoke exposure during pregnancy. Children, pregnant women, people with pre-existing respiratory disease and the elderly are especially vulnerable to smoke exposure and should take particular care to limit exposures to wildfire smoke.

Personal and Public Health Protection:

Officials from the U.S. Environmental Protection Agency, U.S. Forest Service, Centers for Disease Control and Prevention, and California Air Resources Board have prepared Wildfire Smoke: A Guide for Public Health Officials, which contains a wealth of information useful to all stakeholders, including clinicians who will periodically be advising patients on best practices for minimizing smoke exposure and health risks. Another guide from the CDC summarizes recommendations succinctly for the general public. Health care professionals, health care systems, public health officials, city planners, schools and businesses should all be involved in implementing solutions to mitigate adverse impacts of wildfire smoke.

Strategies for personal protection:

Stay indoors as much as possible: Reduce smoke exposure by staying indoors with doors and windows closed. Effectiveness in reducing exposure will depend on whether or not air conditioning that recirculates indoor air is available as well as the tightness of building construction. With windows and doors closed, particulate air pollution can be significantly reduced, WWW.SFMMS.ORG

although not by much in buildings that allow outdoor air to infiltrate easily. In warm weather, however, without air conditioning it may be too warm to stay in a closed-up house, requiring temporarily moving to a cooler location. High-efficiency particulate air (HEPA) filter air cleaners that do not emit ozone can help reduce indoor particle levels dramatically. They should be matched to the size of the space in which they are placed, which may require creating a “clean room” within a home closed off from the rest of the house where the air cleaner can work most efficiently. Most particulate air cleaners do not remove gases but some models are designed to accomplish that as well by adding an activated charcoal layer. If necessary, a cheaper alternative to commercial HEPA air cleaning devices can be made by attaching a one-inch thick high efficiency furnace filter, available in hardware stores, to the back of a box fan so that air entering the fan is drawn through the filter. In a “clean room” these can significantly reduce particulate levels. Reduce other sources of indoor air pollution during a smoke event such as tobacco smoking, using gas, propane and woodburning stoves and furnaces, spraying aerosol products, frying

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or broiling meat, burning candles and incense, and vacuuming, which can all increase particle levels. In vehicles, people can reduce smoke levels by keeping the windows and vents closed, and, if available, operating air conditioning in “re-circulate” mode. However, in hot weather a car’s interior can heat up very quickly to dangerous levels with windows closed. Reduce activity: Since exercise can dramatically increase respiratory minute volume, reducing physical activity will lower exposure to inhaled air pollutants and reduce health risks during a smoke event. Respiratory protection with facial masks (respirators): Facial masks (respirators) should only be used after first implementing other more effective methods of smoke exposure reduction as described. Appropriately-designed, properly-fitting facial masks can help to further reduce exposures, particularly when outdoor activity cannot be avoided. But masks should not be used as a reason to justify spending more time outdoors during smoke events by creating a false sense of security. continued on page 14

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Public Health Frontiers One-strap paper masks, surgical masks, or covering the mouth and nose with a bandana or handkerchief are not adequate protection from wildfire smoke. The N95, N100 (or P100) particulate filtering masks, sometimes called face piece respirators, are most appropriate for the general public. (N indicates not resistant to oil, P indicates oil proof; either is effective for particulate filtration) N95 masks are rated to capture at least 95 percent of small particles and N or P100 to capture at least 99.97 percent. However, their performance depends on a snug fit to facial contours. Facial hair reduces their effectiveness. They are also very difficult to fit properly to children and do not provide adequate protection. Facial masks may also make breathing more difficult and resistance increases with respirator efficiency, which can make them uncomfortable and potentially hazardous to people with respiratory or cardiac disease. Tightly-fitting respirators with purple HEPA filters offer a high degree of protection from particulates but may be less comfortable and more expensive than flexible masks. Most readily available masks generally do not filter gases but some models are constructed with an additional carbon layer that absorbs some gases. Tightly-fitting respirators with particulate and cartridge filters can also be effective for protection from particulates and certain gases. All respirators can become clogged as filtered particulates build up and should be regularly replaced, particularly as breathing becomes more difficult with prolonged use.

events. They include public service announcements; sharing of recommendations for people of all ages, health status, and social circumstances; and providing â&#x20AC;&#x153;clean airâ&#x20AC;? shelters. These interventions depend on anticipation, preparation, and building partnerships so that they can be implemented on short notice. Despite winter rains and snow, the next fire season seems likely to begin earlier and last longer than ever before.

Additional Resources:

1. Wildfire Smoke: A Guide for Public Health Officials. EPA. Available at: https://www3.epa.gov/airnow/wildfire_ may2016.pdf 2. Protecting Children from Wildfire Smoke and Ash. Fact sheets available at: https://www.pehsu.net/cgi/page.cgi/ resources.html 3. Cascio W. Wildland fire smoke and human health. Sci Total Environ. 2018; 624:586-595. 4. Reid C, Brauer M, Johnston F, Jerrett M, et al. Critical review of health impacts of wildfire smoke exposure. Environ Health Perspect. 2016; 124(9):1334-1343.

Ted Schettler MD, MPH is Science Director of the Science and Environmental Health Network.

Strategies for public health protection:

Strategic public health interventions that complement and inform protective measures undertaken by individuals and families are critical components of the response to wildfire smoke

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FACING THE RACE IN RACIAL DISPARITIES Ayanna Bennett, MD The health and health sciences fields have long been aware that people of different races and ethnicities have different levels of health in this country. For much of American history those differences were viewed as an unfortunate feature of the racial groups themselves and treated as facts rather than solvable problems. In medicine specifically we focused, for example, on genetic diseases like sickle cell or metabolic disorders that track closely to racial or ethnic groups as the main focus for those interested in these differences. This approach among physicians and scientist existed alongside a deep and longstanding principle in public health that the health of groups was determined by their social, economic and environmental conditions. The fact that these conditions were apportioned by race in this country was clear and for many also considered an unfortunate fact, rather than a solvable problem. However, the paradigm is shifting around us and those two lines of thought – the differential health and the differential life conditions of racial groups – have both become less immutable and “unfortunate” to be better seen as within our duty to change. In 2002, the Institute of Medicine published a seminal study “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” showing that racial disparities existed in the provision of care, stemming at least in part from the interpersonal racism of providers. Those conclusions have been strengthened by research into the link between bias, provider-patient interactions and treatment decision-making since then. At the same time, in public health our understanding has grown of the outsized impact of the social determinates of health – moving beyond health behaviors to the environments that shape behaviors, and the policies and practices that shape those environments. We now accept that conditions are proportioned not by fate but by human decisions – the social toxicity of disadvantaged neighborhoods are created through negative attention and underinvestment, rather than the mere presence of poor people. In turn those decisions about how we resource communities are strongly driven by structural racism. The clearest example of the impact of these two forces, interpersonal racism and structural racism - this causal progression from culture to social structures to social deprivations to health disparities - is in the poor health and early deaths of Black/African Americans. The San Francisco Department of Public Health has been grappling with the poor health of our Black/African American residents for many years. We have had good reason. Life expectancy for Black/African Americans is the lowest of all race/ethnicities in San Francisco. Based on the most recent data from 2012-2016, a B/AA resident could expect to live 72 years (a bit less for men vs. women), at least 10 years less than White, Asian, and Latino residents who can expect to live into their 80s. On the other end of the life-course, B/AA infants are five times more likely than White infants to die before their first birthday. These efforts to reduce this myriad of disparities have been primarily WWW.SFMMS.ORG

disease and project based and relatively ineffective. For more data see the Black African American Health Report here https:// www.sfdph.org/dph/files/reports/StudiesData/BAAHI-2018Black-Health-Report.pdf. Since 2014, we have been developing a different approach. The Black/African American Health Initiative began with a focus on a limited number of health conditions with significant racial disparities – breast cancer, heart disease, sexually transmitted infection and alcohol-related deaths. However, through the advocacy of Black/African American staff, it also included components that had previously not been explicitly or strongly linked to health disparities in our system – workforce disparities and cultural humility, or more clearly, the role of racism in the interactions within our staff and with the community. In this initiative, this acknowledgment of the role of racism was included equally with our efforts on specific patient care and has expanded our work in key ways. Intensive training to increase the awareness of management staff to the role of racism in their relationships – over 600 so far - has normalized the conversation about race and racism. More specific training for staff about the role of racism in policy and practice is under development. New workforce development policies – again through the advocacy of staff – have elevated the need for stronger diversity, equity and inclusion practices as an explicit part of improving the health of the community. These efforts are nascent and developing; they demonstrate an evolution past simple solutions. Health disparities will not be eliminated solely through new medical treatments, or through better behavior by black and brown people (the old trope that these disparities exist because of the character or choices of the communities they impact has been implicit our standard approaches). We haven’t solved our problems, but at least now we see our role in them. As James Baldwin said, “Not everything that is faced can be changed, but nothing can be changed until it is faced.”

Ayanna Bennett is a Pediatrician by training and currently the Director of Interdivisional Initiatives at the San Francisco Department of Public Health. Dr. Bennett did her pediatric training at UCSF and medical school in the UCB-UCSF Joint Medical Program, from which she received her Master’s degree in Public Health. Dr. Bennett was both a private practice pediatrician in the East Bay for 12 years, while also founding and leading a non-profit in the San Francisco Bayview Hunters Point neighborhood, called the 3rd Street Youth Center and Clinic. Dr. Bennett transitioned to the Health Department in 2015, first as the interim director of Community Health Programs for Youth before moving into her current position in 2016.

MARCH/APRIL 2019

SAN FRANCISCO MARIN MEDICINE

Public Health Frontiers

INVESTING IN HEALTHY COMMUNITIES Matt Willis, MD, MPH, and Juliet Sims, MPH

As Gavin Newsom takes the reigns of California’s government, recent polls say that universal healthcare is a top priority for the state’s residents. Transformative health proposals took center stage during the election season, and now voters are eager to see how those proposals translate into real-life benefits to their health. The problem is that even the most ambitious proposal to overhaul our healthcare system won’t go far enough if we keep equating healthcare and health. To truly transform health and achieve health equity in our state, we need to address the community conditions that determine whether we’re healthy and safe in the first place, long before the medical system gets involved. California is a global hub of innovation, with the fifth largest economy in the world. But at the same time, when cost of living expenses like housing are taken into account, our state has the highest poverty rate in the United States. Is it reasonable to expect families to be healthy if they can’t afford healthy food, transportation, and quality housing? California has the strongest regulations in place to reduce carbon dioxide emissions and fight climate change, but we’re home to eight of the ten most polluted urban areas in the country. Can parents be expected to keep their children’s asthma controlled if the air in their neighborhood isn’t safe to breathe? Meanwhile, as state leaders express pride in the diversity of our state’s residents and support for immigrant rights, California has yet to fully address the reality that many illnesses and injuries occur in higher frequency and with greater severity in communities of color. This is due in large part to decades of underinvestment and discriminatory policy decisions that have resulted in community conditions that consistently undermine health and wellbeing. It’s time to address these inequities and create a healthy future for all Californians—and that means not just healthcare for all, but healthy communities for all. The federal Prevention and Public Health Fund—created in 2010 as part of the Affordable Care Act—has directed resources

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across the country to support active living, healthy and sustainable food systems, smoke-free spaces, and other community-level public health initiatives. But we can’t count on those funds being available over the long haul, because they’re threatened every time policymakers try to repeal the ACA. That’s why we have a responsibility to do what we can at the state level. One way to achieve healthy communities is through investments like the ones Governor Newsom proposes in his new budget. Investments in paid family leave, early childhood education, water safety, and housing will help our state achieve better health outcomes. An additional way would be to create a state Wellness Trust— a sustained source of funding for community-level initiatives that address health inequities and prevent the onset of some of the leading causes of illness, injury, and premature death. Raising taxes on products that drive chronic disease and injury—like sugary drinks—can go a long way to fund prevention. In California, a Wellness Trust could be seeded by the soda tax currently being proposed by the California Medical and Dental Associations. Wellness trusts in Massachusetts, Minnesota, and Oklahoma have raised millions of dollars to support health and shown significant results. Oklahoma has seen a 45% drop in youth tobacco use since 2000 with programs funded by the Wellness trust saving the state an estimated $1.2 billion in direct medical costs. In Minnesota, a trust funded increased access to healthy foods and physical activity in schools statewide. In our advocacy as organized medicine, it’s important to realize that the benefits of a successful soda tax can include protections for communitybased disease prevention initiatives. To ensure optimal benefit for public health, we recommend some funds be distributed to community-based organizations, nonprofits, and health departments to address the specific factors that shape health at the community level. Including support set aside explicitly for communities facing the greatest inequities. From decades of experience working with California communities to address their health priorities, we’ve learned that WWW.SFMMS.ORG

to achieve transformative and sustainable results, there are two critical elements that should be included in any initiatives that are funded: • Community members need to be involved in the process—from helping determine which health and safety concerns need to be prioritized to designing the right solutions and interven tions. Evidence-based public health programs need to be tailored to match local realities. • Community members and health departments can’t be the only partners at the table. We need to involve other industries and government agencies —housing, transportation, health care, parks, education, businesses, local elected officials and others—whose activities impact community health, safety, and wellbeing. The good news is that many community improvements pack multiple benefits for health and wellbeing. When we invest in parks and green infrastructure, for example, we improve air quality, cut greenhouse gas emissions and create opportunities for people to be physically active and socially connected.

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Similarly, initiatives that support non-motorized transportation have proven environmental benefits while increasing individual health through regular physical activity, with measurable impact in disease prevention. The governor’s first budget proposal, and the widespread support within organized medicine to support soda tax is a promising start for California. As we move the fight forward, we need keep health—not just healthcare—front and center. That means protecting and expanding public health initiatives that build healthy, safe, and equitable communities. Matt Willis, MD, MPH, is Marin County Public Health Officer and Juliet Sims, MPH, is Director at Prevention Institute.

A shorter version of this article appeared in the California Health Report.

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Public Health Frontiers

Homeless Mortality in San Francisco:

OPPORTUNITIES FOR PREVENTION Barry Zevin, MD “Doctor, I am terrified that I’m going to die out here.” As a street medicine physician, I hear that or a close variation as a chief complaint almost daily. Previous research shows that individuals experiencing homelessness are at high risk of premature death. SFDPH Street Medicine and Shelter Health teams work with high risk / high vulnerability people experiencing homelessness. Our mission is to improve the health and prevent deaths in this target population. We also work to mitigate the adverse effects of homelessness on the health of the community as a whole. It is critical for us to understand causes and contributing factors to homeless deaths with a goal of adapting and improving our services with an aim to prevention. Starting in 2015, SFDPH Street Medicine, SFDPH Office of Whole Person Care, the Office of the Chief Medical Examiner (OCME), and the UCSF Whole Person Care Evaluation Team began a project to study and respond to homeless deaths reported by the OCME. On a weekly (or more frequent) basis the OCME sends a list of deaths to Street Medicine. We use an algorithm to determine who was homeless. We are then able to outreach, check on dangerous conditions and provide support and services to partners, friends, and others in the area where the death occurred or the individual usually stayed. At times the death of a partner or friend may be a moment of opportunity in which a survivor is motivated to make healthy changes to their life. We review the history and medical record for each case and reach out for more information to any providers the individual was seeing. We review the OCME final reports and toxicology findings when these are available. Using the SFDPH CCMS data base we are able to gather comprehensive information about service utilization and previous diagnosis in multiple San Francisco systems. The methodology does not allow us to attribute homelessness itself as a cause or contributing factor in these deaths. In January 2019 we analyzed the available data with the aim of developing strategies to prevent future deaths. Our key findings included a steady number of deaths over the past 3 years: 128 in 2016; 128 in 2017; 135 in 2018. The location of death was scattered through many San Francisco neighborhoods but concentrated in downtown areas (Tenderloin, Civic Center, South of Market, Mission district). Most deaths involved alcohol or drug use as a cause or contributing factor. Methamphetamine use was especially prevalent. Violence and the progression of chronic disease were also very common. Most cases were in white men (82% male and 52% white) but African Americans (26%) were far over-represented compared to San Francisco overall demographics. Most of the individuals had been homeless in San Francisco for a long time (42% more than 10 years, 20% 5-10 years). Most were unsheltered at the time of death and very few used shelters on a regular basis. Most were not regular users of any healthcare systems. Since large scale homelessness is likely to be a fact of life

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for the foreseeable future, we are using this data to guide us in prevention efforts. SFDPH is using this data in an integrated way with important findings from studying the “High Utilizers of Multiple Systems (HUMS) and tracking other challenges in providing healthcare for those experiencing homelessness. The high rates of severe alcohol use disorder as a factor in these deaths and alcoholism being the main driving force for HUMS is the impetus for an initiative to improve and align services for this population. The high prevalence of methamphetamine use among those who died, and the impact of methamphetamine on street behaviors and spread of infectious diseases and on physical and mental health have led to Mayor London Breed appointing a Methamphetamine Task Force. Unintentional opioid overdose is a very important cause of death among homeless San Franciscans. The rate of these deaths has remained steady (in contrast to steep rises in much of the rest of the US) which reflects ongoing aggressive efforts in San Francisco to promote recognition of overdose and train the community in overdose reversal. The Street Medicine low barrier medicationassisted treatment (LB MAT) project is expanding the availability of buprenorphine for those experiencing homelessness. The high rates of homelessness among pedestrians killed by vehicles has led to joint planning between Street Medicine and SFDPH Vision Zero—SFDPH’s effort to eliminate pedestrian deaths. The data also suggest a protective effect of shelter and challenge us to create more access to shelter and shelter that is acceptable and inviting for people experiencing homelessness. We have begun the process of studying homeless deaths that are not medical examiner cases. This will give us a broader understanding of the effects of homelessness on the course of chronic and acute disease. We will also begin looking at deaths among formerly homeless individuals who are now housed in SRO settings. When patients express their fear of dying on the street, I feel more confident that I can offer them care that is directed by knowledge and experience gained from study and efforts to prevent homeless mortality. In February, 2019, we presented “Homeless Mortality in San Francisco: Opportunities for prevention” to the San Francisco Health Commission. Our slide presentation is available here: http://bit.ly/sf-homeless-mortality-2019feb .

Barry Zevin MD is medical director of Street Medicine and Shelter Health, San Francisco Department of Public Health. He has 25 years of experience as a healthcare for the homeless physician in San Francisco. Dr. Zevin has provided leadership for many innovative SFDPH projects including the current low barrier buprenorphine project to improve access to treatment for addiction disorders for individuals experiencing homelessness. WWW.SFMMS.ORG

Introducing

Grant Colfax, MD San Francisco’s New Director of Public Health Interviewed by Steve Heilig, MPH Dr. Grant Colfax was recently appointed San Francisco’s Director of Public Health by Mayor London Breed. He is no stranger to our area and its most important health issues. In fact, he has much professional history with the health department, San Francisco General Hospital, UCSF, and Marin County. Here is an introductory talk with him.

First, congratulations on the new job – it’s a big one. But this is really a return to San Francisco for you, right? Yes, and I’m very happy to be re-joining the San Francisco Department of Public Health.

You hail from Mendocino County’s Alexander Valley, correct?

Yes, my family moved there when I was very young, in 1972. It was very rural, and my parents still live “off the grid” there.

I heard you raised goats there?

Yes, and in fact I still do - I’ve maintained a goat herd of varying size since I was twelve years old.

I also heard that you were largely home-schooled as a youth?

Yes I was home-schooled, and went directly from that to college at Harvard.

Was that a culture shock for you?

Well, I think it was about as much of that as anybody going away to college, there are always adjustments. But yes, Boston was indeed a bit different from where I grew up!

And your undergraduate focus o major?

Biology. I think that came particularly from my involvement with the livestock aspects of my youth, so that was a natural fit for me.

And for your residency? I was lucky enough to accepted into what was then San Francisco General Hospital’s primary care program, and that was really a formative experience, working with amazing people and engaging in a community that was exactly what and who I wanted to work with.

You were there during peak years of the HIV epidemic….

Yes I did a rotation at Ward 5A at The General, and that really sealed the deal for me to continue my education and work in San Francisco.

What was your first job out of training?

I spent a year doing an epi fellowship between the General and the VA, and one of my mentors, Dr. Susan Buchbinder, asked me if I would be interested in working with her at the SFDPH AIDS office at 25 Van Ness, working on an HIV vaccine project. Then I stayed with SFDPH for almost 15 years, clinically at Ward 86, with various positions at the SFDPH focusing on HIV work, increasingly on the health inequities linked with the epidemic, and HIV prevention research, trying to bring evidence-based findings to implement them with various partners across various communities.

And that led you to be tapped for a federal position?

Actually that came fairly early too, as I went to college intending to go on into medicine.

I’m still not positive exactly what it was, but we did develop an HIV prevention plan that incorporated treatment as prophylaxis, rapid HIV testing, and more new approaches as we developed the 2010 San Francisco plan, which I think was widely seen as a good one and aligned with President Obama’s national AIDS strategy. So that might have been at least part of why I was asked to be the director of the office of national AIDS policy in the White House.

I was always attracted to working somewhat holistically with people as patients, looking at their broader life and community, and although I enjoyed learning about many specialties, I was drawn to primary care.

I was there for almost two years, and what was striking was how much real commitment there was to addressing AIDS and the iniquities involved, and the commitment to evidence-based

And when did you know you wanted to go into medicine?

And how did you choose a specialty?

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What was most striking about issues you confronted there?

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approaches informed by the science, with a focus on metrics and outcomes. The implementation of the ACA pushed a look at various best practices in addressing the epidemic. There were a lot of great things in implementing the President’s AIDS strategy and the ACA, looking at gender issues and violence against women, and the executive order requiring federal agencies to focus on the HIV care continuum, from testing to care and viral load suppression and other interventions we had recommended.

You then came to be Director of Marin’s Department of Health and Human Services in 2013. What three or so biggest issues did you confront there?

Health inequities in the county are particularly salient, in regards to different life expectancies, childhood outcomes, and more, and we tried to bring more focus to those. The issue of homelessness was another, and the third was behavioral health, trying to develop better programs related to that and substance abuse while addressing the stigmas and discrimination involved as well. We’ll certainly still be dealing with those in San Francisco as well; it’s really a matter of scale but the problems are similar.

Marin has done well regarding vaccination rates as well, right?

Yes, I’m proud of the fact that Marin has been able to make significant progress there, under the leadership of health officer Dr. Matt Willis.

Let’s play a form of “20 Questions” on some key issues and your take on them, starting with the broader efforts to improve access to care.

I think we need to continue to try to improve access to care for all San Franciscans, and we need to be vigilant given changes in ACA policies and rules. We have a new Governor who is really committed to access to care, so it’s an opportune time at the local and state levels, and a very challenging dynamic on the federal side.

Tobacco and vaping?

This is still a huge public health concern, and we just had a report that teen tobacco use is going up for the first time in many years. My concern is that the vaping industry is creating a whole new generation of nicotine addicts, where data shows many of them will turn to tobacco. So it’s an ongoing challenge and focus, and the bans on products specifically targeted to children and/ or communities of color is particularly important.

Other kinds of drug abuse?

These are big issues, and we do have a lot more tools in our toolbox than we used to for addressing and treating substance abuse disorders, so how do we scale up our systems to make treatment on demand available, and how do we increase our work force for this. I’m cautiously optimistic here.

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Related to that, how about safe injection centers? If we are committed to following evidence-based practices, SIS fit in there, with much data from peer reviewed journals such as the NEJM showing these are effective and don’t increase substance abuse. It’s one of our Mayor’s priorities so I am very interested in working with her to bring San Francisco’s leadership forward on this, as we did with HIV and other issues.

Gun violence?

Guns are certainly a health issue, right? Gun violence in San Francisco does exist and we are committed to addressing it as a public health issue, including keeping bringing the health equity perspective to the gun violence issue.

Environmental Health?

One big issue we are certainly going to have to face is climate change, working with all involved to bring the health department to partner with other key players to bring the health and wellness to all the change we are going to be seeing — air quality, rising sea levels, vector-borne diseases. And in general, we’re going to be seeing some radical shifts in our environment that will likely most and first effect communities that already have degrees of health inequities.

Nutrition and obesity?

I think soda warnings and taxes are the sorts of policies we need to continue, as we know that those sorts of policies lead to healthier outcomes. There have been some recent setbacks but we should keep on pushing to make the change we know are needed.

Disaster planning?

The disaster preparedness infrastructure needs to be kept and made robust, and it requires many departments to be working together to be as ready as possible.

HIV/AIDS?

I’m very exited about the Getting to Zero initiative, a key next step, and we are looking at communities where HIV rates are highest. It continues to be communities of color so we need to do everything we can to support those communities in addressing that, as well as addressing chronic homelessness as a health issue as well, offering treatment and other resources across all relevant departments.

Any other comments?

Obviously we have a big and broad agenda. I look forward to working with SFMMS and to maintaining what I already know is a strong partnership, with lots of shared priorities.

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Public Health Frontiers

VACCINATION AS A MEDICAL AND PUBLIC HEALTH IMPERATIVE Richard Pan, MD, MPH As a physician, I have witnessed first-hand how vaccines protect our children and communities from dangerous diseases. In medical school I learned microbiology from Julius Younger, Sc.D, who worked with Jonas Salk, MD to develop the first successful polio vaccine. I never expected to see measles, but in 1991, in a Philadelphia clinic, I witnessed an outbreak that infected over 900 people and killed nine children. In the meantime, widespread use of the Hib (Haemophilus influenzae type b) vaccine began while I attended medical school, and during my residency, I only saw one case of invasive Hib, a disease that previously filled pediatric ICUs. Vaccines are so effective that parents, and even many younger physicians, have never seen many vaccine preventable diseases. This lack of personal experience with these diseases has created opportunities for anti-vax charlatans to spread misinformation and create anxiety and doubt about vaccines for their own personal gain. Years of vaccine hesitancy, fueled by a fraudulent study linking vaccines with autism, have taken a toll on the community immunity needed to keep diseases at bay. In 2000, only 0.77 percent of California kindergartners had personal belief exemptions on file. By 2013, that percentage more than quadrupled to 3.15 percent statewide. In some places in the state, vaccination rates dipped below 70 or 80 percent. As community immunity eroded, preventable diseases returned—with dangerous consequences. In 2010, there were 9,120 cases of pertussis reported in California—more than any year since 1947, and 10 babies died in that outbreak. Measles infections nationally rose from 37 infections in 2004 to 644 in 2014. Then, in 2015, a measles outbreak began at Disneyland, infecting 147 people and hospitalizing at least 20 people. Parents demanded action to keep their children safe, and thanks to the advocacy of Vaccinate California, Senator Ben Allen and I authored and passed SB 277, which eliminated non-medical exemptions to school vaccination requirements. In the first year of implementation, vaccination rates among kindergarteners rose to levels not seen in a decade and a half. Kindergarten students receiving required vaccines rose from 93 percent in the 2015-16 school year to 96 percent in 2016-17. However, many older children who previously received exemptions remain unvaccinated, and an entire generation of young people— referred to as the “Wakefield generation,” after the discredited anti-vax researcher—remain vulnerable and can accelerate the spread of future outbreaks. While laws like SB 277 have a tremendous impact on vaccination rates, continued success requires physicians to educate our patients about the benefits of vaccines and the dangers of the diseases they prevent. Vaccine misinformation continues to be spread by social media, videos and books. Even the President has 22

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Senator Pan presenting Senate Bill 277 in Senate Health Committee.

given credibility to vaccine myths and welcomed anti-vax quacks. Fake news sites such as Natural News, InfoWars and Mercola. com spread anti-science conspiracy theories and attack science advocates like Paul Offit, M.D. As a pediatrician, I learned the science of vaccines; but while passing vaccine legislation, I also learned the myths of anti-vaxxers. Anti-vax charlatans promote parental anxiety about vaccines so parents are more susceptible to the marketing of alternative products they’re selling. These frauds sow distrust of physicians and science and downplay the dangers of diseases. Fortunately, a large majority of parents listen to our advice and support vaccination. However, even if only a few percent of parents don't vaccinate their children, community immunity is compromised for the entire community. Thus, physicians and our public health and education partners must reach out to parents and counsel them about the truth of vaccine-preventable diseases. Physicians should not wait until a baby’s first visit to discuss vaccines, but should begin the discussion while parents are planning a pregnancy or during pregnancy. We need to reach parents early to answer their questions and allay their anxieties. Thanks to a strong partnership between parents and physicians, SB 277 passed in California and our children are safer for it. Many of our most vulnerable children, including very young infants and children who have cancer, transplants, or immune conditions, cannot be vaccinated, and they depend on community immunity from vaccinated people. As physicians, we need to maintain the political will to sustain California’s vaccination laws through our vigorous efforts to teach all parents about the efficacy and safety of vaccines and the dangers of the diseases they prevent. Richard Pan, M.D., MPH, FAAP, is a pediatrician and State Senator representing Senate District 6 (D-Sacramento). He has been a member of the California Medical Association and the Sierra Sacramento Valley Medical Society since 1999. WWW.SFMMS.ORG

CLASSIFIED ADS Medical Office for lease in S.F. Chinatown. 2 Exam Rooms, waiting room, reception area, private bathroom, small kitchenette, and one large office/exam room. 788ft $2300 Call (415)921-2097

Office Space wanted in Greenbrae or Corte Madera for phlebotomist drawing 10 to 20 patients per day. Preferably room with shared reception and sink. Please contact Ray at (650) 433-8930 x 3003

Internal Medicine Practice For Sale - Napa County. Concierge medical practice with revenues averaging $600,000 seeing 8 - 10 patients per day. Seller's net income is near the 90-percentile for IM. Long established in the area, moved to newly renovated 1440 sq. ft. location in 2015; great proximity to hospital. EMR in place. Photos and third party appraisal available. Offered at only $497,000. Contact Medical Practices USA for more information. 925-820 6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com Ophthalmology Practice For Sale - Marin County. Revenue $700,000 with one owner-doctor and well-trained staff. 1350 square feet in medical building with good parking. Strong potential for both revenue growth and efficiency improvements with more surgical time, development of a website, and addition of optometry and optical services and products. Third-party appraisal available. Offered at only $285,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com

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A decade ago, “e-cigs” were barely on the public health radar, but were rapidly spreading as a new practice and industry. Advertising was everywhere, touting e-cigs as a “revolutionary” new tool endorsed by doctors for quitting tobacco smoking. Use among all ages, but especially young people, was rising fast. Researchers and health authorities were largely caught off-guard. Wholly unregulated, e-cigarettes were in the “Wild West” of health policy, with a great need to catch up. Much of this scenario was disturbing to longtime local antitobacco advocates, as we did not know the real risks of e-cigarettes. But hoping to catch up and head off disaster, we pushed for preventive policies to regulate vaping products like tobacco -

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with restrictions on sales, marketing, and public use, for example. In 2011, the SFMMS and SFDPH and San Francisco Health Commission adopted such policies, and CMA joined soon after at our urging. More recently, SF adopted a historic ban on all flavored tobacco products, which are a primary attraction to youth, and this policy is being promulgated in Marin now. All of this is vehemently fought by the vaping and tobacco industries, but efforts continue. In March, San Francisco City Attorney Dennis Herrera and Supervisor Shamann Walton announced “joint steps to curb the epidemic of youth e-cigarette use, which has erased more than a decade’s worth of progress in reducing youth tobacco consumption.” Walton introduced ground-breaking legislation at the Board of Supervisors "that would prohibit the sale in San Francisco of any e-cigarette that has not undergone FDA review. Under this legislation, any e-cigarette that is required to have, but has not received, FDA premarket review could not be sold at a store in San Francisco or

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Public Health Frontiers

THE EPIDEMIC OF HUNGER AND FOOD INSECURITY IN SAN FRANCISCO Paula Jones, PhD and Tomás Aragón, MD, DrPH The increased cost of living and lack of affordable housing leads to more homelessness—and more food insecurity. A greater proportion of earnings go to housing and less to food. Access to food is a basic human right, and essential to health, yet lack of access to food is reality for too many people throughout the United States, California and the Bay Area. A key strategy to prevent and manage diseases is to eliminate the social and economic barriers to the resources essential to live with dignity and full health potential. Food security is a major social determinant of health and a leading health issue. Food security is having “access by all people at all times to enough nutritious, culturally acceptable foods for an active, healthy life.” Food insecurity is a “household level economic and social condition of limited or uncertain access to adequate food.”

Food Security Impacts Health and Development, and Increases Health Care Costs

Food insecurity contributes to poor health and health disparities across the life course, through multiple pathways: stress, trauma, poor diet quality and malnutrition. Food insecurity increases the risk of multiple chronic conditions including diabetes, heart disease, hypertension, and HIV management. It exacerbates existing physical and mental health conditions and impairs child development. Food insecurity is also associated with greater acute care utilization and higher health care costs. Food insecurity results in an estimated $77.5 billion in additional health care expenditures annually in the United States.1

A Validated Screen for Food Insecurity

Because of the growing awareness of the significant negative health impacts of food insecurity, many health systems are beginning to integrate food security screening into routine care. Addressing food insecurity in the healthcare setting involves screening for food security as part of standard protocol within

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outpatient and inpatient settings. Patients screening positive for food insecurity are then referred to resources. The Hunger Vital Sign™2 is already in use by health systems all over the country and programmed into many electronic health records. It is a simple standardized two-question protocol that identifies patients at high–risk of food insecurity if they answer that either or both of the following two statements is ‘often true’ or ‘sometimes true’ (vs. ‘never true’):

“Within the past 12 months we worried whether our food would run out before we got money to buy more.” “Within the past 12 months the food we bought just didn’t last and we didn’t have money to get more.”

Status of Food Security in San Francisco To address basic social needs, in 2005, San Francisco established a Food Security Task Force which continues to lead efforts to improve food security and to mobilize the stakeholders to close this gap. The task force is charged with creating citywide plan for addressing food insecurity, and the task force sees the health care sector as an essential partner and leader to ensuring that all San Franciscans have access to healthy food. In late 2018, the task force released the 2018 Assessment of Food Security in San Francisco. In spite of significant public investments to expand nutrition safety net programs and to create innovative new programs, food insecurity is growing. Conditions that contribute to food insecurity have intensified with increases in the cost of living and more people needing support for basic needs. Infrastructure for many food programs is at capacity and some programs have wait lists. There are declines in food programs serving children and families, and there is a growing concern that some communities may not be accessing food programs due to immigration status. The report outlines a series of systemic, programmatic, and policy recommendations to improve food security.3

Leadership from the Health Sector in San Francisco

In January 2019, the San Francisco Health Commission passed a resolution supporting food security in San Francisco and endorsing the recommendations from the task force. The resolution supports expanded work on food security by the Department of Public Health. It also recognizes the critical role of the healthcare sector in ensuring that San Francisco residents are food secure, and it encourages all health systems, health insurance companies, and health plans, particularly Medi-Cal health plans, to collaborate with their networks to address food insecurity through prioritization of screening, connection to community food resources, and implementation of additional programs and policies to support food security. WWW.SFMMS.ORG

San Francisco Health Improvement Partnership (SFHIP) is a cross sector collaboration of the health sector in San Francisco comprised of nonprofit hospitals, UCSF, ethnic based health equity coalitions, community clinics, SFUSD, philanthropy, faith and community based organizations, and the Department of Public Health. SFHIP oversees the Community Health Needs Assessment and the Community Health Improvement Plan. Food insecurity has been prioritized as a major health need by SFHIP and as the group develops the Community Health Improvement Plan, improving food security is emerging as a strategic area for focus and expanded collaboration. Paula Jones, PhD is the Director of Food Security for the San Francisco Department of Public Health (Population Health Division), and the vice chair of the San Francisco Food Security Task Force.

Tomas Aragon MD is the public health officer and director of the Population Health Division at the San Francisco Department of Public Health at San Francisco Department of Public Health.

References 1.

Berkowitz, Basu, and Seligman. Health Services Research, 2017 2. Hager et al. Pediatrics. 2010 3. The 2018 Assessment of Food Security in San Francisco is available at: www.sfdph.org/foodsecurity

National Health Decisions Day - April 16 Jeff Newman, MD, MPH Since our previous article on Advance Care Planning (1), the San Francisco Palliative Care Work Group has supported a number of initiatives to improve goals of care, end of life, and shared decision-making conversations – especially among low income and diverse communities. We also aim to increase timely utilization of advance directives, POLST, palliative care, and hospice. We applaud health systems that have incorporated ACP data into their information systems, so they are available when needed. Establishment of a population-based registry remains a goal. While there are a variety of forms for advance directives, we are especially enthusiastic about the Prepare for Your Care Program https://prepareforyourcare.org/welcome Besides the forms developed with state of the art design methods, there are friendly videos that model family conversations – in multiple languages. The PREPARE program is evidence-based. This year we are actively supporting local observance of National Health Decisions Day on April 16. Educational sessions are planned in collaboration with SF Public Libraries and other community organizations. We urge you to discuss ACP issues with your patients energized by our campaign, as well as the many others who would benefit. WWW.SFMMS.ORG

AMA Statement on Title X Gag Rule and Funding Restrictions Barbara L. McAneny, MD President, American Medical Association “This rule interferes with and imposes restrictions on the patient-physician relationship. For all intents and purposes, it imposes a gag rule on what information physicians can provide to their patients. The patient-physician relationship relies on trust, open conversation and informed decision making and the government should not be telling physicians what they can and cannot say to their patients. “Protecting the sanctity of the patient-physician relationship and defending the freedom of communication between patients and their physicians is a fundamental priority for the AMA. With this action, the administration wants to block physicians from counseling patients about all of their healthcare options and from providing appropriate referrals for care. This is a clear violation of patients’ rights in the Code of Medical Ethics. “The AMA also strongly objects to the administration’s plan to withhold federal family planning funding from entities that provide critical medical services to vulnerable populations. Millions of women depend on the Title X program for access to much-needed healthcare including cancer screenings, birth control, STI testing and treatment, and other exams. This is the wrong prescription and threatens to compound a health equity deficit in this nation. Women should have access to these medical services regardless of where they live, how much money they make, their background, or whether they have health insurance. “Title X is popular, successful, and has had bipartisan support for decades. Our country is at a 30-year low for unintended pregnancy and an historic low for pregnancy among teenagers — largely because of expanded access to birth control. We should not be walking back from that progress.”

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About the AMA The American Medical Association is the powerful ally and unifying voice for America’s physicians, the patients they serve, and the promise of a healthier nation. The AMA attacks the dysfunction in health care by removing obstacles and burdens that interfere with patient care. It reimagines medical education, training, and lifelong learning for the digital age to help physicians grow at every stage of their careers, and it improves the health of the nation by confronting the increasing chronic disease burden. For more information, visit ama-assn.org. MARCH/APRIL 2019

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UPCOMING EVENTS CMA Legislative Advocacy Day â&#x20AC;&#x201C; Governor Newsom to be Keynote Speaker Wednesday, April 24, 2019 | Sacramento, CA Join more than 400 physicians, medical students who will be coming to Sacramento to lobby their legislative leaders as champions for medicine and their patients during CMAâ&#x20AC;&#x2122;s 45th Annual Legislative Advocacy Day. Attendees will have the opportunity to meet with legislators on health care issues. Meetings with Marin and San Francisco legislators will be scheduled and coordinated by SFMMS. This is a unique event for California physicians and is free of charge to all members. For more information, please contact Erin Henke at ehenke@ sfmms.org or (415) 561-0850 x268, or visit https://www. cmadocs.org/event-info/sessionaltcd/LEGDAY19.

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COMMUNITY NEWS KAISER PERMANENTE

Maria Ansari, MD Homelessness is a widespread public health issue affecting more than 550,000 people nation-wide every day. At Kaiser Permanente, we view stable housing as an integral component to keeping people healthy, both physically and mentally. Without a safe, stable place to live, it is difficult to access medical care and nearly impossible to maintain any health improvements achieved in a medical setting. In an effort to address this issue, Kaiser Permanente recently unveiled several major initiatives designed to improve health outcomes by creating stable housing for vulnerable populations. The initiatives include seeding a real estate investment in Oakland, anchoring an $100 million national loan fund for affordable housing, and kicking off a plan to end homelessness for more than 500 Oakland-area residents. These are a few components of an ambitious $200-million multi-year plan, announced in May, to address housing stability and mitigate homelessness across the country. The joint-equity Housing for Health loan fund is designed to preserve affordable and work-force housing by purchasing, stabilizing, and preserving apartment communities in the Bay Area and Sacramento. The first project, a $5.2-million acquisition of a 42-unit housing complex in East Oakland, is already underway in partnership with the East Bay Asian Local Development Corporation. Last year, Kaiser Permanente San Francisco provided substantial funding support to local organizations engaged in finding creative and effective solutions to homelessness, with an emphasis on behavioral health. These grants enabled the Downtown Streets Team to increase outreach efforts, Swords to Plowshares to provide individualized case management for homeless and at-risk veterans, Project Homeless Connect to bring services and support to the homeless via a mobile van, and more. By investing in community needs such as housing, we are advancing our mission to provide high-quality, affordable health care services and to improve the health of our 12.2 million members and 68 million residents living in the communities we serve.

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