Nov/Dec 2019

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

ENVIRONMENTAL HEALTH 2020 As Wildfires Burn, it's Time for CMA to Lead on Climate Reproductive and Developmental Environmental Health Planetary Health: The Future of Environmental Health Medical Education at UCSF The New Generation of Physician Environmental Leaders

PLUS: CMA Annual Meeting Report & CMA's State Legislative Wrap-up

Volume 92, Number 6 | NOVEMBER/DECEMBER 2019

Proposition C Rejected by Landslide!

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IN THIS ISSUE

NOVEMBER/DECEMBER 2019 Volume 92, Number 6

ENVIRONMENTAL HEALTH FEATURE ARTICLES

MONTHLY COLUMNS

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Membership Matters

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President's Message: Transitions, Trials and Triumph Kimberly L. Newell Green, MD

The Environment is Us Robert Gould, MD and Steve Heilig, MPH

10 Reproductive and Developmental Environmental Health

Linda Giudice, MD, PhD and Jeanne Conry, MD, PhD 12 Benzene Contamination of Drinking Water: A Surprise Complication from Wildfires

Gina M. Solomon, MD, MPH and Daniela Morales 16 Cognitive Decline: Sam's Story

Ted Schettler, MD, MPH

17 As Wildfires Burn, it's Time for CMA to Lead on Climate

Karly Hampshire and Michelle Tong

20 Latest Research: OK to Eat Red and Processed Meat Again? NOT!!

Thomas B. Newman, MD, MPH and Michael J. Martin, MD,

MPH, MBA

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2019 House of Delegates Report Michael C. Schrader, MD, PhD, FACP CMA Legislative Wrap-Up Janus L. Norman

A Tribute to Our Departing Executive Director, Mary Lou Licwinko

15 The Vaping Battles: What's Next?

John Maa, MD 36 Upcoming Events

COMMUNITY NEWS

22 The Climate and Mental Health: A Review of Impacts and Implication for Action

Robin Cooper, MD

16 Death Associated with e-Cigarettes in Marin County Jon Friedenberg

26 Planetary Health: The Future of Environmental Health Medical Education at UCSF

Annemarie Charlesworth, MA

36 Kaiser News Maria Ansari, MD, Kaiser Permanente

24 The California Healthy Nail Salon Collaborative: Working to Reduce Toxic Exposures for Immigrant Women Workers

Catherine A. Porter, JD

27 How Much Cannabis do Californians Use?

from California Public Radio

28 The Nuclear Arms Race Comes Home: Contamination at Hunters Point Naval Shipyard Superfund Site

Daniel Hirsch and Taylor Altenbern

32 The UCSF Chemical and Fossil Fuels Industries Documents: Advancing Public Health through Transparency and Sound Science Annemarie Charlesworth, MA

OF INTEREST 3

Welcome New SFMMS/ CMA Members

Back cover Advertiser Index

33 Chemical Exposure Web Tool Defines Risks Faced by Millions of Californians

Elizabeth Fernandez

Friday, January 31, 2020, 5:30-9:30pm Green Room at the SF War Memorial, San Francisco

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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 Congratulates Peter Bretan, Jr. MD, on Being Installed as CMA President The most important goal, not just in this year of my presidency, but always, is to take back our profession by enabling physicians to lead the struggle to protect, expand and make universal access to health care Dr. Bretan (center) with campaign team for all of our patients Drs. Lawrence Cheung (left) and John Maa. in California,” said Dr. Bretan. “If we are successful in this state, it will lead the way for sustainable universal health care for all of America.”

SFMMS's Welcomes 22nd Biennial Japanese Medical Mission Team SFMMS had the recent pleasure of greeting members of the Hiroshima Prefectural Medical Association (HPMA) and the 22nd Biennial Japanese Medical Mission Team during a welcome breakfast at St. Mary’s Medical Center followed by a visit to the SFMMS office. SFMMS leaders thanked them for once again conducting medical examinations in San Francisco for local “hibakusha” – survivors of the atomic bombings of Hiroshima and Nagasaki. Since 1977, HPMA has sponsored official biennial medical missions for the benefit of hibakusha and their children living in the United States who, due to the survivors’ exposure to radiation in the 1945 bombings, might face continuing medical problems. As the sister society to HPMA since 1981, SFMMS has provided the local affiliation necessary for the team of HPMA physicians to conduct these medical examinations during their visits. Read more at http:// bit.ly/2O5yxNG.

SFMMS Proudly Sponsors Assemblymember Chiu

The SFMMS PAC and several SFMMS members were proud sponsors of a recent campaign fundraiser for Assemblymember David Chiu. Chiu has been a strong MICRA advocate for the medical profession. We look forward to our continued relationship with him.

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“I grew up as a child farm laborer, and I know what it is to be without adequate health care. My greatest motivation in service is to give back to society for my good fortune,” said Dr. Bretan.

Dr. Bretan has served as a CMA trustee and delegate, and is a three-time President of the Marin Medical Society. He is the current president of the California Urological Association and serves as an adjunct clinical professor at Touro University, where he has taught classes in health care policy for the past 16 years. He earned his Bachelor of Science degree in physiology from University of California, Berkeley and his medical degree from the University of California, San Francisco, where he completed residencies in general surgery and urology, as well as a fellowship in radiology. He also completed a fellowship at The Cleveland Clinic Foundation in transplantation and renovascular surgery. Read more about Dr. Bretan at http://bit.ly/2qvxEoD.

New Health Laws 2020: Are You Ready?

The California Legislature had an active year, passing many new laws affecting health care—with a strong focus on health care coverage, drug prescribing, public health and mental health issues. The CMA has published a summary of the most significant new health laws of interest to physicians. For more details, access "Significant New California Laws of Interest to Physicians for 2020" at http://bit.ly/2rVfblF..

CMS Releases Final 2020 Medicare Physician Fee Schedule

The Centers for Medicare and Medicaid Services (CMS) recently released its final rule updating the Medicare physician fee schedule, quality payment program and other Medicare payment policies for 2020. The rule covers diverse topics, including major evaluation and management (E/M) payment changes, updates to the quality reporting program and geographic payment adjustments. Read more at http://bit.ly/346eMv4.

CMA Releases 2020-2025 Strategic Plan

The CMA recently released its 2020-2025 strategic plan that will empower physicians to lead and transform the health care system. The plan is based on extensive research conducted from January to August 2019 aimed at looking at the organization, environment, industry, stakeholders and competitors, as well as customer needs and preferences. Moving forward, California physicians are looking to CMA to further reduce administrative burdens in their practices, support them in providing quality care and ensure they thrive amid industry consolidation. To best meet these needs, CMA has refined its value proposition to emphasize physician empowerment to lead the transformation of the health care system. Read the full 2020-2025 CMA Strategic Plan at http://bit.ly/2Xy9ypa.

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Join Us for the 2020 SFMMS Annual Gala The 2020 SFMMS Annual Gala will be held on Friday, January 31, 2020 from 5:30-9:30pm at the Green Room at the SF War Memorial and Performing Arts Center in San Francisco. President-elect Brian Grady, MD, will be installed as the 2020 SFMMS President. Watch for your invitation to arrive in the mail. Tickets are available for purchase at www.sfmms.org/events.aspx. Individual and organizational sponsorship opportunities are available – contact Erin Henke at ehenke@sfmms.org or (415) 561-0850 x268.

SFMMS Advocacy and Policymaking Helps Advance Ban on e-Cigarettes, Vaping Products San Francisco’s upcoming ban on the sale of e-cigarettes will remain in place, as voters soundly rejected a ballot measure that would have overturned the prohibition. Proposition C was soundly defeated by a 4 to 1 margin. On the national front, East Bay Congressman Mark DeSaulnier (CA-11) announced the introduction of the Preventing Vape Use Act, a bill to immediately halt the sale of all e-cigarettes nationwide until they undergo a pre-market review by the U.S. Food and Drug Administration (FDA). Additionally, the American Medical Association has called for an immediate ban on all electronic cigarettes and vaping devices. The AMA will lobby for state and federal laws, regulations or legal action to achieve the ban. “It’s simple, we must keep nicotine products out of the hands of young people,” Dr. Patrice Harris, AMA’s president, said in a statement. The AMA said the recent U.S. outbreak of lung illnesses linked to vaping also prompted its action.

SFMMS has actively contributed our voice to this important public health issue at the local, state and national levels.

WELCOME TO OUR NEW SFMMS/CMA MEMBERS: Regular Active Members: Shannon Chain, MD | Physical Medicine and Rehabilitation Stephanie Chen, MD | Internal Medicine Amitra Kachru, MD | Obstetrics and Gynecology Laura Mainardi Villarino, MD | Neurology

Shila Manandhar, MD | Obstetrics and Gynecology Jennifer Tan, DO | Family Medicine Zhi Xiong, MD | Obstetrics and Gynecology WWW.SFMMS.ORG

November/December 2019 Volume 92, Number 6 Editor Gordon L. Fung, MD, PhD, FACC, FACP Guest Editor Robert Gould, MD Managing Editor Steve Heilig, MPH Production Maureen Erwin EDITORIAL BOARD Editor Gordon L. Fung, MD, PhD, FACC, FACP Michel Accad, MD Stephen Askin, MD Toni Brayer, MD Chunbo Cai, MD Linda Hawes Clever, MD Anne Cummings, MD Irina deFischer, MD 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 Lynne Deepe Manager, Operations & Administration 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

TRANSITIONS, TRIALS, AND TRIUMPH The air is crisp and the pumpkins have arrived, in front

of houses in the form of Jack-O’Lanterns, and on the table where I break bread with family and friends in the form of soup, bread, and my personal favorite: pumpkin ice cream.

It is also nearing the time for me to turn into a pumpkin, or rather to turn over this role in which I have served over the year to our incoming President, Dr Brian Grady. I stepped into this role on the shoulders of giants, with so much to learn. And I step out of it a great deal more experienced, and yet still with so much to learn about the important work of health advocacy.

2019 has been a year of great successes, thanks to the tireless work of our staff and a dedicated army of passionate volunteer physicians.

As usual, there has been a great deal of work in the world of public health advocacy. For the first time ever, the SFMMS Board decided to take on a single issue and do a deep dive. On the issue of how to keep our youth safe in the setting of legalization of adult recreational use of cannabis, we have educated ourselves, produced a fact sheet, published an editorial, created talking points, and successfully advocated for it to be a major issue for the CMA. The report the CMA created and which was voted on at this year’s House of Delegates was robust and thorough, as CMA has a staff that has more resources than we do. We can now use this report and the clear CMA mandate as a foundation and springboard for continued work and advocacy in this area.

We have worked on issues of long-standing interest in this organization, and newer issues that have bubbled to the surface as vital areas of our attention: tobacco control, firearms, public charge, child separation, and sugary drinks among others this year. However, every year there is a Big Issue, and this year that has been e-cigarettes. We started the year working hard advocating for flavored tobacco bans in Marin, and then waged a strong and successful campaign to prevent Big Tobacco and Juul from attempting to regulate themselves in the form of San Francisco’s Prop C —a measure placed on the ballot via signatures paid for by Juul. We are celebrating major wins along the way, although we cannot forget that these wins happened in the context of far too many cases of severe respiratory illness and deaths caused by vaping. This work, I suspect, will continue for some time.

I was finally able to attend my first CMA House of Delegates meeting and it was an inspiring meeting for me: the major issues of cannabis, homelessness and augmented intelligence were addressed in a very comprehensive manner, and there was some robust debate and a great deal of education. It was incredibly exciting to see many of our local leaders in places of WWW.SFMMS.ORG

great influence and particularly exciting to join the party that SFMMS threw to welcome the next President of CMA, our own Peter Bretan.

This year we have continued our work in partnering with our elected officials, both building on established relationships and forging new relationships with amazing health advocates, including San Francisco Mayor London Breed; Supervisors Shamann Walton and Matt Haney; Assemblymembers Mark Levine, David Chiu and Richard Pan; Congresswoman Jackie Speier and Speaker Nancy Pelosi, among many others.

We are holding a Board retreat this month during which we will envision the future of SFMMS. Today we are in an incredibly strong position as an organization, and I can’t wait to spend a day at beautiful Commonweal thinking hard about what might be possible in the future of SFMMS. How might we amplify the work we already do? What parts of our work might be strengthened and pushed to new levels? What new ideas do we have to improve the health of our patients, our communities, and the joy, satisfaction and success of our practices?

Additionally, we are embarking on a CEO transition, looking for the next leader of this august society—not someone to replace the irreplaceable Mary Lou Licwinko—but rather the right person to lead SFMMS into the future that we envision.

(See my tribute to her from the CMA meeting on page nine.)

The year has flown by, and I am so honored to have been in this position. Thank you to our Board, our staff and our members for allowing me to serve you. Thank you for teaching and mentoring me, and thank you for experimenting and dreaming with me.

I quoted the poet Mary Oliver at the beginning of my tenure, and will end with another quote as I move into the role of Past President and continue the work of helping SFMMS envision our future: “Only if there are angels in your head, will you ever, possibly, see one.”

Kimberly L. Newell Green MD is a pediatrician in San Francisco and Assistant Clinical Professor at UCSF. 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.

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EDITORIAL:

THE ENVIRONMENT IS US Robert Gould, MD and Steve Heilig, MPH "Environmental" issues are everywhere, and have been knocking at the doors of Medicine for some time now. This edition of the SFMMS journal is the seventh biannual environmental health theme edition, and once again arrives at a timely moment.

Consider just a few items in the medical literature and public media in the past few weeks as we put this edition together.

First, 11,000 climate scientists from around the world issued a statement that climate change, especially but not only warming, poses a severe human health threat that verges on the existential. An October Lancet study named pollution as key in 16% of deaths worldwide, three times more than AIDS, tuberculosis, and malaria combined. At the November AMA meeting, an entire session was devoted to urging advocacy for action on climate science.

The journal Science felt compelled enough by recent politicized interference with longstanding principles of research and policy to publish a strongly-worded editorial titled "Researchers must unite against environment agency's attack on scientific evidence" - a sad commentary on current affairs indeed. The editors of JAMA noted that "virtually every time JAMA publishes an article on the effects of pollution or climate change on health, the journal immediately receives demands from clinics to retract the article for various reasons." A famous book on the lobbying of chemical, tobacco, and other industries was titled "Doubt is Our Product" - science cast as "fake news." For some of the same reasons, enforcement of environmental regulations is now at a longtime low.

The Oxford Dictionary just named "climate emergency" its 2019 Word of the Year (well, two words, but they know best). In November, the Lancet Countdown: “Tracking Progress on Health and Climate Change” was launched in association with the UCSF Institute for Global Health Sciences Global Health Group. This collaboration represents a revitalized effort to mobilize global health leaders to advocate for climate solutions while supporting health sector efforts to minimize current adverse impacts of global warming, while building climate-resilient health systems to withstand our future daunting challenges. In its own words, the Lancet aims at “ensuring that the health of a child born today is not defined by a changing climate.”

Physicians and other clinicians have undeniably been asked to confront more and more issues, often with less time to do that well. Gun violence, poverty, rotten digital media, and much more are all proposed for our consideration as part of a truly comprehensive picture of what impacts our patients’ health.

Environmental health has risen to the forefront of framing the full determinants of health and how we can best improve it – from dealing with worsening air and water pollution through confronting environmental and social injustice that impact our poorest and most vulnerable communities.

Young and future physicians seem to increasingly arrive well-informed by these broader perspectives on what health is 6

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and how we can improve it. As such, they clearly recognize our common climate emergency, and have embraced our urgent need to respond as health professionals. This makes sense – after all, it's their future, both at the personal level and for the patients and the communities they will serve in coming decades. Many young people report they are suffering from "climate grief" and an absence of hope for the future. We feel it is critically important for our medical institutions to nurture their idealism and actions.

In this issue you can read what some committed young UCSF future physicians are urging our health professions to teach and to practice. It's so inspiring. You can also read about the health threats posed by our “new normal” of disastrous fires; how what we eat impacts our environment; how toxics and related environmental factors impact our mental health; as well as our fundamental ability to reproduce and have healthy children.

You can explore how local communities have worked to counter clearly preventable risks, and more. Some of our authors are world-renowned leaders, and some are future ones. All are committed to evidence-based knowledge and action.

The SFMMS first became involved in these issues over fifteen years ago, with a large conference chaired by our longtime member UCSF chancellor emeritus and former United States Assistant Secretary of Health Philip R. Lee, MD. He became the chair of the large network founded at that meeting, the Collaborative on Health and the Environment (CHE), which continues today as reported herein. Working with that broad group of scientists, clinicians, environmentalists and more has informed much SFMMS and fraternal county medical society policy adopted by the California and American Medical Associations. Phil, now in his nineties, spent a long career nurturing the advancement of many fields, and many professionals, and the UCSF health policy institute is aptly named after him. He is now retired in New York City. We dedicate this edition of this journal to him, with gratitude.

Robert M. Gould, MD, guest editor, is an Associate Adjunct Professor in the Program on Reproductive Health and the Environment at UCSF School of Medicine. He is a Past-President of National Physicians for Social Responsibility (PSR), President of SF-Bay Area PSR, and a longtime delegate to the CMA House of Delegates.

Steve Heilig is managing editor of San Francisco Marin Medicine and co-founder of the Collaborative on Health and the Environment.

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REPORT:

2019 CMA HOUSE OF DELEGATES (HOD) Michael C. Schrader, MD, PhD, FACP The CMA held its House of Delegates (HOD) Meeting in Anaheim at the Disneyland Resort from October 20-22. This annual meeting had many highlights including the inauguration of our own Peter Bretan as CMA President, a vigorous contest for Vice Speaker of the House; debate of four major issues with subsequent adoption of important policy; and exciting news about the growth of the CMA.

For the CMA election, Vice Speaker candidates Jack Chou, Donaldo Hernandez, and our own Lawrence Cheung campaigned at the individual delegation meetings beginning Friday afternoon and continuing through Saturday. These were three excellent candidates each promising to do his best to lead the HOD forward. Lawrence presented a compelling vision for reforming the HOD process to improve the representation of the delegates.

Despite Lawrence’s valiant campaign, well supported by SFMMS Delegation VIII, Jack Chou prevailed in the runoff election. We look forward to supporting Jack in the coming years and Lawrence has already expressed his desire to run again in three years.

Peter Bretan was inaugurated as CMA President. Peter is the first Filipino-American President of the CMA. The invocation of the HOD was given by Assemblyman Rob Bonta, the first FilipinoAmerican representative to the California State Assembly. SFMMS District VIII hosted a reception for Peter Bretan that was well attended. Peter introduced Melanie, his wife of 40 years, and his accomplished family.

CMA CEO Dustin Corcoran addressed the HOD with exciting news about the growth of CMA membership. CMA revenues are at a record level. Dustin anticipates that the CMA will soon be bigger than the Texas Medical Association.

Spirited debate was presented on the four major issues: adverse childhood events, cannabis, homelessness, and augmented intelligence. State Senator Dr. Richard Pan gave an excellent talk about adverse childhood events. Our delegates uniformly agreed that the didactic talks were much improved from last year.

A pleasant surprise for Delegation VIII was an amendment to the cannabis major issue banning vaping products. This was easily adopted by the HOD. We felt this was an affirmation and an extension of our own efforts to regulate vaping in San Francisco. Through our work to defeat San Francisco Proposition C we have become more adept at politics at the CMA and AMA levels and have gained recognition as leaders in opposing Big Tobacco.

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We submitted an emergency resolution to the Board of Trustees about the vaccination of detained migrant children. The Trump Administration has said that detained migrant children will not be vaccinated against influenza despite the deaths of two detained children during the last influenza season. Our resolution was rejected as an emergency resolution and we elected to resubmit it to the year-round resolution process.

During the HOD we met with vaccine advocate and State Senator Dr. Richard Pan who agreed to be a co-author on this important resolution.

Kimberly Newell Green delivered a lovely tribute to the career of our retiring executive director Mary Lou Licwinko and thanked her for her 21 years of service including overseeing the merger of the San Francisco and Marin Medical Societies. We wish Mary Lou a wonderful retirement.

We remembered Jeffrey Stevenson who passed away this past year with a resolution to the HOD. Jeff was a dedicated member of our delegation who believed in the value of organized medicine. We missed him.

This was an exhausting but rewarding weekend for SFMMS at the CMA HOD. I received several gracious, unsolicited compliments for the dedication and activism of District VIII. We should all be very proud of our efforts to protect the health of our patients and the dignity and strength of our profession.

Moving forward, we have submitted three resolutions to the year round resolution process. These are: Revitalizing Residential Mental Health Services, Supporting the Health of Detained Migrant Children, and Mental health screening and access to mental healthcare for civil immigrant detainees of U.S. Homeland Security. More to come regarding these important and sometimes controversial issues.

Michael C. Schrader, MD, PhD, FACP, is vicechair of the SFMMS delegation to the CMA, Treasurer of the SFMMS, and Clinical Professor of Medicine, UCSF.

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WINNING THE FIGHTS THAT MUST BE FOUGHT CALIFORNIA MEDICAL ASSOCIATION’S 2019 LEGISLATIVE WRAP-UP Janus L. Norman, CMA Senior Vice President, Centers for Government Relations and Political Operations In January, California witnessed something completely new.

The swearing in of Governor Gavin Newson marked the first time in state history that a Democratic governor was succeeded by another Democratic governor. Political history is flush with examples of challenges facing the incumbent party attempting to hold on to statewide power. Typically, voters seize the opportunity for change by electing a leader of a different party. But this time, voters chose to move from a moderate Democrat (Jerry Brown) to a progressive Democrat (Gavin Newsom).

The transition from Brown, who retained tight control of the state’s budget and legislative process, to a first-time governor provided the legislature with an opportunity to reshape California’s policy landscape.

Discussion, debate, dialogue and compromise were the overwhelming themes of the 2019 session. Since Governor Newsom did not have a public veto or signing history, his policy perspective was not yet set in stone. Legislators saw this as an opportunity to bring nearly every recycled and newly minted policy idea to the proverbial table.

The tone of the 2019 legislative session was overall one of unbridled optimism. Such political environments pose many risks and opportunities, with many competing interest groups jockeying to raise their priorities.

The California Medical Association (CMA) successfully collaborated with the legislature on proactive efforts to expand public health initiatives, reduce administrative burdens, increase physician reimbursements and strengthen the physician workforce.

However, over the course of the legislative year, additional reactive efforts emerged as various stakeholders launched unmerited attacks against the profession.

RELIEVING ADMINISTRATION BURDENS

In January 2019, CMA was faced with an immediate crisis: flawed implementation of a new state law—intended to improve the security of physician prescription pads as a solution to the opioid crisis—left pharmacies unable to fill prescriptions and patients being refused necessary medications.

CMA quickly worked with the Newsom Administration, the California Department of Justice and the legislature to resolve the matter. The result was the swift approval and enactment of CMA-sponsored AB 149 (COOPER), which allowed patients to immediately start receiving their prescriptions and physicians to utilize their existing prescription pads until July 2021.

CMA also sponsored AB 744 (AGUIAR-CURRY) to revamp the rules regarding the payment of health care services provided via telehealth in order to increase access to care. Under existing law, physicians are incentivized to require patients to physically enter medical offices for services that could otherwise be delivered uti8

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lizing telehealth. Health plans sought to maintain existing law as a means of creating barriers to care. However, CMA worked with legislators from both rural and urban areas, showcasing the benefits of telehealth and the necessity for plans to pay for physician expertise regardless of the modality under which it is delivered.

Despite the opposition of the health insurer lobby, the measure received only one “no” vote throughout the entire process.

During the last weeks of the legislative session, the United Healthcare Workers Union went after the physician community and sought to shame physicians for the compensation they receive. CMA successfully stopped the union’s sponsored bill, AB 1404 (SANTIAGO), which would have required targeted physician groups to disclose the total compensation of their physician partners as a means of creating leverage in union contract negotiations. Such attacks don’t belong in the health care legislative space; they increase the difficulty of recruiting the quantity of physicians needed to serve patients and negatively impact efforts to constrain health care costs.

In addition to the above, CMA took the following actions to either relieve existing administrative burdens or stop the creation of new burdens: • PASSED legislation to alleviate burdens associated with mandatory use of the CURES database • DEFEATED legislation to change prescription labeling requirements • DEFEATED legislation to require referral to alternative medicine practitioners prior to prescribing an opioid

• DEFEATED an attempt to dramatically increase physician licensing fees • DEFEATED multiple attempts to publicly disclose physician reimbursement and contracted rates

This year’s budget contained $120 MILLION to support loan repayment programs for physicians and dentists (administered

by Physicians for a Healthy California)

ACCESS TO CARE

In June, Governor Newsom signed his first state budget.

The process for the 2019-2020 budget was dramatically different than prior years. Consistent with his campaign promises, Newsom prioritized health care. Not only did he expand health care insurance coverage, he was equally committed to funding access to care. This year’s budget contained:

• $2.2 BILLION for provider rate increases funded by the Proposition 56 tobacco tax • $120 MILLION to support loan repayment programs for physicians and dentists (administered by Physicians for a Healthy California) WWW.SFMMS.ORG

• $250 MILLION for the creation of a Value-Based Payment Program within Medi-Cal • $150 MILLION for developmental and trauma screening supplemental payments

• EXPANDED MEDI-CAL ELIGIBILITY, which now includes all young adults aged 19-25, regardless of their immigra tion status • A STATE-LEVEL INDIVIDUAL MANDATE to obtain health coverage

PUBLIC HEALTH AND POLICING THE PROFESSION

The physician members of CMA hold sacred the trust patients and communities have in the medical profession. On countless occasions, the leaders of state, county and specialty societies wrestle with a variety of policy questions. And while there are many perspectives from which a policy can be debated, inevitably the question will be asked: how will this impact our patients and the trust the public places in physicians to look after their best interest and health?

In 2015, CMA sponsored SENATOR RICHARD PAN, M.D.’S SB 277 to eliminate the personal belief exemption from the statutory requirements for childhood vaccinations.

The fight to enact SB 277 was fierce. Thousands of antivaxxers flooded the hallways of the Capitol. New security protocols were required for Senator Pan and CMA headquarters. The bill was heavily protested at the Capitol and in local districts; thousands of rabid anti-vaxxers spewed inflammatory rhetoric and threats of bodily harm. When Governor Jerry Brown signed that measure into law, Sacramento assumed the chapter on vaccines was closed.

The result of SB 277 was positive overall, and statewide vaccination rates improved. However, a number of geographic pockets of unvaccinated children emerged due to vaccine hesitancy and a few physicians willing to inappropriately monetize the moment by providing vaccine exemptions with questionable medical rationales. While some abuse was anticipated, the quantity of exemptions issued by a few physicians was alarming. On social media, parents openly discussed how to purchase exemptions, which physicians were open to such transactions and what medical symptoms to highlight in the visit. As such behavior persisted, Senator Pan and CMA faced a dilemma: how to respond to physicians whose actions threaten to erode public trust in the physician community?

Courage! CMA and Dr. Pan chose to once again brave the turbulence and introduced legislation (SB 276) to increase vaccination rates by cracking down on inappropriate physician behavior.

The reaction of the opposition exceeded our expectations. We knew there would be threats and a high number of anti-vaxxers protesting at the State Capitol and in the districts. We did not expect blood to be thrown onto the Senate floor from the gallery or parents forming chains to block the entrance of the Capitol.

CMA’s obligation to protect the integrity of the profession and the public trust in the physician community outweighed the fear of facing fierce, threatening opposition.

Similar courage was necessary on other fronts, including the legislature’s response to the sexual misconduct of gynecologist WWW.SFMMS.ORG

George Tyndall in student health centers at the University of Southern California. CMA ensured important due process protections for physicians remained, while not protecting the deplorable behavior of a specific physician. Navigating such troubling matters is complex, and CMA successfully preserved fundamental protections, while building our creditability with the legislature that CMA is an association that stands for quality physicians with the ability to self-police the profession.

Courage to fight for patients, courage to fight for the betterment of the profession and courage to fight for the public’s health is why CMA is the most effective advocacy organization in the Golden State!

For more details on the major bills that CMA followed this year, visit cmadocs.org/leg-wrap-2019. Subscribe to CMA’s free biweekly Newswire and stay informed on CMA’s legislative efforts and other issues critical to the practice of medicine at cmadocs. org/subscribe.

A TRIBUTE TO OUR DEPARTING EXECUTIVE DIRECTOR, MARY LOU LICWINKO (Read to the CMA House of Delegates 2019) My name is Kim Newell Green, President of the San Francisco Marin Medical Society, and I am speaking on behalf of our District VIII Delegation. I rise to ask this House to join me in recognizing the substantial contributions of Ms Mary Lou Licwinko, our executive director, who will be retiring at the end of the year.

Mary Lou has served the SFMMS for more than 20 years, and throughout her career, her dedication to advocating for physicians and for the health of our patients and our community has been impressive.

Under Mary Lou’s leadership as our Executive Director, SFMMS has flourished. In fact, we wouldn’t have our second “M” without her. Mary Lou spearheaded and oversaw an incredibly successful merger between the San Francisco and Marin Medical Societies in 2017.

Mary Lou has also been a vital force in our local PAC, and that, along with her facility at building relationships, has helped us to cement strong and lasting partnerships with local and state elected officials that have resulted in significant accomplishments in many health initiatives, from tobacco and e-cigarette control to marijuana policy and end of life care to sugary beverages.

We have sincerely appreciated Mary Lou as our leader, our colleague, our mentor, and our friend these many years, and frankly we cannot imagine the society without her. She will be missed. Please join me and the SFMMS Delegation in recognizing Mary Lou for her 21 years of dedicated service.

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REPRODUCTIVE AND DEVELOPMENTAL ENVIRONMENTAL HEALTH Linda Giudice MD, PhD and Jeanne Conry MD, PhD Improving Maternal Child Health Outcomes

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One thousand days. One thousand days is the amount of time thought most important for investing in the life of a healthy child. Pregnancy, Infancy, Early Childhood. One Thousand days.

But what if we said that 1,000 days is not enough? The number won’t have the catchy ring of 1,000. But what if the argument was made that the health of a woman BEFORE she conceives is important? What if we said that ENTERING pregnancy at an ideal weight, off medications that can cause birth defects, on prenatal vitamins, with medical problems under control, vaccines completed and exposure to toxic substances eliminated made for the healthiest start? Then we are looking at 1,000 days plus. Certainly most women who are aware of the impact of toxic exposures on their pregnancy would want to allow time to change habits to avoid exposure if possible. Plus at least 100 days more to allow for vitamins and vaccinations. Perhaps 200 days more to allow for tobacco cessation, control of blood pressure, and loss of weight. Whatever the amount, 1,000 days is NOT the answer. It has a great ring, but the health of a mother before conception is one of the most important investments we can make.

When we invest in women’s health, we effectively invest in the health of this and future generations. We invest in the health of our children. We invest in the health of our communities.

And, committing to women’s health means that quality care should include universal access, continuity, and prevention as key elements. The World Health Organization defined health as a state of physical, mental and social well-being. But whether we address global or national efforts, achieving women’s health has fallen short of its potential.

We have failed our women, our families, and our communities. We have spent a generation devoted to the concept of preconception health, that planning for pregnancy will improve pregnancy outcomes, improve newborn and maternal health, and improve the health of children. The reality is that fifty percent of pregnancies are unplanned, so merely focusing on women who present for preconception consultations misses the needs of the majority of women and misses an opportunity to begin an early investment in children’s health. The focus instead should shift to optimizing the health and well-being of women across their lifespan so that if or when a woman elects

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to conceive, her health and the health of her offspring are improved. Recognizing these important clinical concerns, in 2016 the American College of Obstetricians and Gynecologists engaged a coalition of health professional organizations and patient advocates to provide guidance and recommendations on implementation of preventive health screening across the lifespan for all women.

Environmental Considerations: Teratogens and Environmental Exposures

Over the past fifteen years, an expanding body of evidence has implicated the role of environmental exposures on health.

Whether scientists are reviewing increased rates of cancer, neurodevelopmental disorders, pregnancy outcomes, chronic medical conditions or birth defects, there is evidence to support the effect of chemical exposures on health. Chemicals in pregnant women can cross the placenta and, as with methyl mercury, can accumulate in the fetus and have long lasting sequelae. We have a long history of understanding the impact of environmental exposures on health, whether it is the early research implicating the effect of diethylstilbestrol on vaginal cancer in the daughters of exposed mothers, the effect of methylmercury in Minamata Japan impacting a generation of children with neurodevelopmental defects, or the thalidomide generation with limb-shortening defects because of maternal exposure in 1950-60s.

In 1991, the Wingspread Consensus Statement was issued by collaborating scientists and defined the term “Precautionary Principle” and codified the term “endocrine disruptors” with cautions regarding environmental exposures to humans and wildlife alike. Since then, there has been a consolidation of scientific opinion, scientific evidence, and statements of a global nature to raise the attention of practicing clinicians regarding the impact of environmental exposures on our population.

As with most aspects of clinical care, information, guidance and incorporation into practice occur many years after clinicians are first cognizant of information. It was in 2013 that the American College of Obstetricians and Gynecologists and the American Society for Reproductive Medicine issued a joint set of guidelines to advance women’s health by preventing exposures to toxic chemicals “Exposure to Toxic Substances” (link). This opinion outlined in detail the scientific basis for clinical findings WWW.SFMMS.ORG

showing adverse health outcomes in reproductive medicine, children’s neurodevelopmental disorders, oncology, and pregnancy, all based on exposures to chemical substances known as Endocrine Disrupters.

In 2015, the International Federation of Gynecology and Obstetrics formally recognized the importance of environmental exposures on reproductive health and issued a white paper and adopted an opinion “Reproductive Health Impacts of Exposure to Toxic Environmental Chemicals.” FIGO pointed out that widespread exposure to toxic chemicals threatens the air we breathe, the water we drink, the food we consume and the products we use on a daily basis. The health impact of exposures is not the same for everyone, and pregnant women and children are the most vulnerable. Pregnancy entails a time of organogenesis, so exposures may have varying impacts depending on timing, on dosage, and on cumulative exposures. The US National Academy of Sciences concluded that in the absence of evidence to the contrary, any level of exposure should be assumed to be potentially harmful; there is no “Safe Dose.” The ACOG Prepregnancy Counseling Guidelines (link) point out the mounting evidence implicating reproductive and pregnancy risks associated with environmental pollutants such as air and water pollution, workplace teratogens, and the widespread contamination from a host of endocrine disruptors. They specifically advise about home and work exposures, including lead, mercury, asbestos, pesticides, BPA, phthalates and the work risks of agriculture (pesticides) and manufacturing (solvents and heavy metals).

Health Impacts

In utero exposures are known to have an effect on future health outcomes. This susceptibility means that there are critical and sensitive periods of development with pregnancy and childhood. Exposure to mercury, lead and chlorpyrifos interfere with neurodevelopment. Research has shown that every pregnant woman in the United States has at least 43 different environmental chemicals in her body, and persistent organic pollutants are found in pregnant women around the globe. Pollution is one of the most under-reported problems in the world. The CDC summarized in 2009 the Fourth National Report on Human Exposure to Environmental Chemicals. This report evaluates 75 chemicals measured for the first time in the USA populations.

What is a Health Care Provider to Do?

Health care providers share knowledge and guide patients in “shared decision-making,” particularly when it comes to family planning. There is no evidence-based published study that looks in depth at preconception health care and supports that at a health system level, integrated health care with preconception health improves maternal health outcomes and children’s health. Certainly, research supports the individual elements of preconception health, from vaccine to management of chronic diseases. It makes sense, but it is one area where broad-based and adequate research is lacking. One review did show that women who received preconception education and counseling had improved knowledge. In spite of these limitations, individual studies show that improved and integrated care improves individual health outcomes. It follows that a systematic approach WWW.SFMMS.ORG

to preconception and prenatal care would improve outcomes!

There are reports from the clinical work group of National Preconception Health and Health Care Initiative for recommended health care system measurements that are indirect reflections of preconception health care. The Workgroup reached unanimous agreement on an aggregate of nine preconception wellness measures to serve as a surrogate but reasonable assessment of quality preconception care with the larger health care community. These indicators include: 1) pregnancy intendedness 2) access to care 3) preconception intake of multivitamin with folic acid) tobacco avoidance 5) absence of uncontrolled depression 6) healthy weight 7) absence of sexually transmitted infections 8) optimal glycemic control in women with pregestational diabetes and 9) avoidance of potentially teratogenic medications. Following these measures offers concrete quality measurements of preconception health.

All clinicians should recommend that patients have or are asked about:

• Their interest in conceiving at this time “pregnancy intendedness” • Adequate intake of folic acid • Vaccinations that are up to date • Underlying medical conditions, such as obesity, hypertension, diabetes, thyroid disease, sexually transmitted infections • Exposures: drugs, alcohol, tobacco, medications • Optimum nutrition status and vitamin intake • Optimum periodontal health • Risk of Interpersonal Violence • Optimum maternal mental health • Reproductive history and prior obstetric outcomes • Familial and genetic history • Environmental risks from occupational and home exposures: instruct on reducing exposures to environmental toxics

Summary:

The facts remain: As long as at least fifty percent of pregnancies are unplanned, our health and wellness focus MUST be on improving the health and well-being of all women, at all times.

Only then are we likely to optimize the health of all pregnancies, if and when a woman elects to conceive. Well-woman health care and reproductive access are the cornerstones to preconception health and planned, healthy pregnancies. They are also the corner stones to a healthy population, regardless of pregnancy intendedness. An important and often unrecognized element is the impact of environmental exposures on the health of women and children. We see 2020-2024 as a time to engage leaders from around the world to bring about local and global changes to improve the health of all women.

Resources for more information:

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Benzene Contamination of Drinking Water: A SURPRISE COMPLICATION FROM WILDFIRES Gina M. Solomon, MD, MPH and Daniela Morales Massive wildfires have torn through California and other Western states in recent years. The magnitude and destruction of these fires is unprecedented, and fueled by a combination of drought, pest invasions, forest management policies, and development along the wildland interface (Vose, 2018). The fires brought loss of life and property, severe air quality impacts, generation of hazardous and municipal waste, and disruption of community and social structures (Cascio, 2018). A new and unanticipated drinking water contamination problem arose after two recent fires, the Tubbs fire in Santa Rosa, California in 2017, and the Camp fire in Butte County in 2018.

The Tubbs and Camp Fire Experiences

After the Tubbs fire, residents returning to unburned homes in the Fountaingrove neighborhood of Santa Rosa reported a strong chemical odor from their tap water. Testing revealed benzene and other volatile organic compounds (VOCs) at levels far above regulatory limits (Wilson, 2018). Concentrations of benzene reached as high as 40,000 parts per billion (ppb), compared to the California limit of 1 ppb (the federal limit is 5 ppb). Other reported VOCs included vinyl chloride, styrene, ethylbenzene, toluene and xylenes.

Ultimately the City of Santa Rosa conducted sampling at 3,625 sites in their system, finding benzene at 3,576 of those locations.

The city repeatedly flushed the system, replaced water service lines to the 352 properties in the area, three water mains, and eight hydrants at a cost of approximately $8 million. Nearly a year after the Tubbs fire, the drinking water advisory was lifted.

Previous to that time, no such contamination had ever been documented after a fire. This incident never reached national attention, in part because only 13 homes survived the fire in the affected neighborhood, and the contamination was addressed before homes were rebuilt.

More than a year later, after the Camp fire, returning residents to the town of Paradise, California complained of chemical odors, and benzene was discovered in numerous samples at levels up to 918 ppb (Bizjak, 2019). Testing shows that the source water is not contaminated, nor is the water at the treatment plants, so the problem is within the distribution system. About 1,700 homes survived the fire in Paradise and nearby towns, and residents are hesitating to return due to the water contamination. This incident has affected many more people than after the Tubbs fire, and it has received national attention (Siegler, 2019).

Benzene Toxicity and Potential Sources

Benzene is a hematotoxin that is known to cause blood cell proliferation and Acute Myelogenous Leukemia, as well as bone marrow suppression, lymphocytopenia, pancytopenia, and aplastic anemia in humans (OEHHA, 2014). Children may 12

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be more sensitive to benzene because their tissues are undergoing rapid cell division and differentiation (Carlos-Wallace, 2016). Benzene is found in petroleum products and it is also a major contaminant in smoke (including wildfire smoke and cigarette smoke).

Regarding water system contamination, there are three hypotheses: (1) release from thermal stress to plastic water pipes; (2) smoke pulled by negative pressure into the system and adsorbed to the pipes or biofilm; or (3) soil contamination from leaking underground storage tanks, ash, or fire debris entered the water system due to loss of pressure. Most experts believe that the contamination comes from smoke pulled in through service lines due to a loss of pressure, in part because contamination has not been found after other recent California fires where the local water systems did not lose pressure during the fire (personal communication, Dan Newton, State Water Resources Control Board). It is unclear how long the contaminants may linger in the system, but the Santa Rosa experience suggests that concentrations could be elevated for a year. A published study on VOCs from crude oil indicates that adsorption and subsequent release of contaminants varies significantly by type of pipe material, with various types of plastic sequestering and gradually releasing contaminants over weeks or months (Huang, 2017).

Climate change causes multiple stresses on the environment, with sometimes unexpected health consequences. Others have previously traced the effects of climate change on rainfall patterns, temperature, and indirectly on pests such as the Western Bark Beetle that has resulted in extensive tree mortality and high wildfire risk (Vose, 2018). Until now, the chain of causation between climate change and human health has not extended to benzene contamination in drinking water. Addressing this new threat will require research into strategies to protect drinking water infrastructure in fire-prone areas, while redoubling efforts to mitigate climate change.

Gina Solomon is a Principal Investigator at the Public Health Institute in Oakland, CA, where she researches science and policy issues related to toxic chemicals and environmental health. She is also a clinical professor of medicine at the University of California San Francisco (UCSF) where she formerly served as the director of the occupational and environmental medicine residency program and the co-director of the Pediatric Environmental Health Specialty Unit. She served as the Deputy Secretary for Science and Health at the California Environmental Protection Agency (CalEPA) from 2012-2017.

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SFMMS Election Results 2020 Officers

References 1. Bizjak T. 2019. Rare ‘toxic cocktail’ from Camp Fire is poisoning Paradise water. It could cost $300 million to fix.

Sacramento Bee, April 18, 2019. https://www.sacbee.com 2. Carlos-Wallace FM, Zhang L, Smith MT, Rader G, Steinmaus C. Parental, In Utero, and Early-Life Exposure to Benzene and the Risk of Childhood Leukemia: A Meta-Analysis. Am J Epidemiol. 2016 Jan 1; 183(1): 1–14. doi: 10.1093/aje/ kwv120.

3. Cascio WE. Wildland fire smoke and human health. Sci Total Environ. 2018 15;624:586-595. doi: 10.1016/j.scitotenv.2017.12.086.

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Linda C. Giudice, MD, PhD is Distinguished Professor of Obstetrics, Gynecology and Reproductive Sciences at UCSF. She is a biochemist and reproductive endocrinologist specializing in endometriosis, infertility, oligo/ anovulation, and pelvic pain. Her research focuses on human endometrium, genetics/epigenetics of endometriosis, placental-uterine interactions, and evaluating the evidence of environmental impacts on reproductive health and human development. Dr. Giudice is Founder of the UCSF Program on Reproductive Health and the Environment and currently is Chair of the FIGO Committee on Reproductive and Developmental Environmental Health. She is an elected member of the National Academy of Medicine and is active in global reproductive environmental health advocacy and education.

Jeanne Conry, MD, PhD, is the President-elect of the International Federation of Gynecology and Obstetrics and will take office in 2021.

She was the 64th President of the American College of Obstetricians and Gynecologists.

She retired from The Permanente Medical Group after serving as an Assistant Physician in Chief in the North Valley region of Sacramento and Roseville, CA, so that she could advance global women's health and the environment.

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(one-year term):

President-Elect: Monique Schaulis, MD, MPH Secretary: Heyman Oo, MD, MPH Treasurer: Michael Schrader, MD, PhD, FACP Editor: Gordon L. Fung, MD, PhD, FACC, FACP

2019 President-Elect: Brian Grady, MD, automatically succeeds to the office of President.

2019 President: Kimberly Newell Green, MD,

automatically succeeds to the office of Immediate Past President.

Board of Directors (Eleven elected for three-year term 2020-2022):

Tomás J. Aragón, MD, DrPH Ayanna Bennett, MD Peter N. Bretan, MD Anne Cummings, MD Beth Griffiths, MD Robert Harvey, MD Jason Nau, MD Dennis Song, MD Kenneth Tai, MD Joseph Woo, MD Andrea Yeung, MD Nominations Committee

(four elected for two-year term 2020-2021):

Edward J. Alfrey MD Opal Gupta, MD Andrew Tomlinson, MD Helen Yu, MD

Delegation to the CMA House of Delegates (two-year term 2020-2021):

Delegates Monique Schaulis, MD, MPH

(automatically serves in capacity as SFMMS President-Elect)

Ameena Ahmed, MD, MPH Roger Eng, MD, MPH, FACR George Fouras, MD Kimberly Newell Green, MD Michael Kwok, MD Man-Kit Leung, MD Michael Schrader, MD, PhD, FACP Alternates Larry Bedard, MD Ellen Chen, MD Tracy Hessel, MD Jessica Mahoney, MD Ben Meisel, MD Melanie Southard, DO Emma Steinberg, MD Matt Willis, MD, MPH

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Environmental Health

THE VAPING BATTLES: WHAT'S NEXT? John Maa, MD San Francisco voters overwhelmingly rejected Prop C, which was an attempt by Juul and Altria to write their own laws and circumvent local enforcement of FDA e-cigarette regulations. In October, after having spent $12.4 million, Juul reversed course and abandoned further financial support to the Yes on Prop C campaign, which then collapsed.

The summer and fall of 2019 were a challenging period for Juul, which witnessed testimony on Capitol Hill where it was revealed that they had spent hundreds of thousands of dollars to access and speak with students in classrooms. Following a wave of acute lung injuries tied to vaping, civil litigation accusing the company of promoting youth addiction to nicotine, and an FDA warning letter for illegally marketing its products, President Trump announced the FDA would take action to restrict the sales of flavored e-cigarettes.

In response, Juul stopped television and print media advertisements, suspended sales of many of its flavored pods in stores and online, and announced that 500 employees will be laid off before year’s end. Altria wrote down $4.5 billion from its investment in Juul, leading the company to lose $13 billion in market valuation in a single day. Amidst the management shake-up, several top Juul executives including CEO Kevin Burns and CAO Ashley Gould resigned, and were replaced by former Big Tobacco leaders. Some wonder whether Juul’s ultimate fate is to be completely taken over by Altria and Big Tobacco.

“I was most baffled by anybody thinking that Juul’s mission to stop the world’s leading cause of preventable death could be achieved by financially partnering with the same industry responsible for many of those deaths.”

Over my career in surgery, I have witnessed the enormous toll of smoking on our healthcare system, and hidden costs to society from wound infections, failed operations, reintubations, prolonged ICU stay, and hospital readmissions. In recent months across America, over 2,000 people have been hospitalized and 40 have died from vaping related illnesses (the strongest association is with the vaping of marijuana, but a majority of cases also include people vaping nicotine), with many more expected.

The first tragic local death was just reported in Marin County.

Juul was recently accused of allowing 1 million contaminated pods onto the market, and the role these may have played in the recent deaths and illnesses, and need for a national recall remain to be determined. What we are now witnessing is hisWWW.SFMMS.ORG

tory repeating itself, with the added healthcare burden and deadly toll from electronic cigarettes.

I attended the 4th World Innovation Summit in Health in Qatar in 2018, along with more than 1,000 delegates from nearly 100 nations.

During the meeting, I spoke with health ministers and government leaders from around the globe, who shared their challenges with youth vaping, and Juul in particular. The greatest threat from e-cigarettes is to children in nations that have not raised the sales age for tobacco products to 21. California is the home to Juul, and as a State we need to be proactive to protect the children of the world. In states like ours where cannabis products can be purchased legally, the potential for illicit substances to be added to e-cigarettes is high. The California Medical Association recently adopted policy to discourage marijuana vaping, and also endorsed legislation by Congressman Mark DeSaulnier to recall e-cigarettes unless the FDA authorizes their sale.

Until then, the enforcement intent of the San Francisco moratorium may be the strongest action policymakers can undertake to protect public health. The city of Livermore passed legislation virtually identical to SF’s moratorium (Juul abandoned a planned referendum there), and the city of Richmond has passed a similar ordinance too. The Governors of Michigan, New York, Massachusetts, Rhode Island and Washington issued executive orders restricting the sales of flavored e-cigarettes, joining Governor Newsom, who took action to crack down on illegal vaping sales and educate the public. In October, China pulled Juul off the market, and India banned e-cigarettes days later.

I was most baffled by anybody thinking that Juul’s mission to stop the world’s leading cause of preventable death could be achieved by financially partnering with the same industry responsible for many of those deaths. An entire generation of youth has now been exposed to the dangers of nicotine addiction by those actions. I call upon the new Juul leadership to no longer stand in the way of communities taking action to contain the youth e-cigarette epidemic, embrace strong FDA regulation, and respect the decisions made by public officials and the FDA to protect the health of the public.

John Maa, MD, a general surgeon, is an SFMMS past-president.

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SAM'S STORY OF HEALTH Ted Schettler MD, MPH Increasing forgetfulness, missed appointments, and repeating himself were disturbing changes in Sam’s behavior that concerned his son, daughterin-law, and two longtime friends. In this newest and fifth chapter of A Story of Health eBook, (https:// tinyurl.com/y4g6ofv9) 72-year-old Sam, his family, friends and health care providers confront Sam’s cognitive decline beginning after his wife’s death and explore how they might be able to slow or reverse it.

Is it normal aging? Something more serious that could progress to full-blown dementia? Related to underlying depression or another treatable disease?

Progressive cognitive decline and dementia are among the most feared disorders that people and their families encounter.

They are also a growing public health challenge since they become more likely with aging and the number of people older than 65 is increasing in many countries throughout the world.

Studies in the US and Northern Europe, however, find a decrease in age-adjusted dementia incidence in recent years not fully explained by improved education, lifestyle, and cardiovascular health. Environmental risk factors are likely to be involved.

This suggests more opportunities for primary prevention.

Sam’s story reviews numerous modifiable risk factors for cognitive decline and dementia, including environmental variables that can be causally related such as air pollution, lead, pesticides, and solvents. The chapter also explores environmental links to Parkinson’s disease that afflicts Sam’s long-time friend George, in whom he confides.

Sam’s story includes his clinical evaluation, discussion of potential interventions, and general recommendations for healthy aging. It is available free online in an easy-to-read PDF format. The eBook uses videos, infographics and articles by experts to illustrate where and how we live, eat, work, and play can influence health across the lifespan. Written for health care providers, health advocates, policy makers and others concerned about environmental influences on healthy aging, the story includes links to additional resources and is fully referenced.

Health professionals can register for free continuing education credits (CE) through the Centers for Disease Control and Prevention (CDC) with ATSDR hosting the CE accreditation pages.

The first four chapters of the eBook featuring asthma, developmental disabilities, childhood leukemia and infertility/reproductive health are also available to download for free. Since their original release, the first three are updated and have additional references.

Ted Schettler is Science Director, Science & Environmental Health Network, and for the Collaborative on Health and the Environment.

DEATH ASSOCIATED WITH E-CIGARETTES IN MARIN COUNTY Public Health Authorities Warn Against Vaping San Rafael, CA - A Marin County resident has died from complications related to the use of e-cigarettes and the Marin County Department of Health of Human Services is warning community members about the potentially dangerous effects of e-cigarettes, or vaping.

“With sadness, we report that there has been a death in our community suspected to be caused by severe lung injury associated with vaping,” said Dr. Matt Willis, Marin County Public Health Officer.

The victim was a previously healthy woman in her forties, who took up vaping six months ago.

This is the fourth vaping-associated death in California since July 2019. Last week the U.S. Centers for Disease Control and Prevention (CDC) reported 39 deaths nationally, and over 2,000 suspected cases so far in the national epidemic of lung damage associated with e-cigarettes.

“The message is simple: it’s not safe to vape,” said Dr. Willis.

“Until we have a better understanding of the cause of this outbreak, it’s best to avoid these products entirely.”

In response to growing concerns about safety and increasing rates of vaping among Marin youth, many Marin County cities and towns banned the local sale of flavored tobacco and vaping products

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in 2019, following the County’s adoption of an ordinance in 2018.

Most of these local ordinances do not go into effect until January 2020.

While the specific products or compounds that cause lung injury after e-cigarette use are not yet known, the CDC has found Vitamin E acetate is likely to be contributor in some cases. Vitamin E is an oil-based vitamin that is sometimes added to vaping liquids, especially those containing the psychoactive cannabis compound THC. However, many confirmed cases of lung injury have not been tied to this compound.

Marin County Public Health is working with the California Department of Public Health and the CDC to obtain and test samples to determine the specific products that may have contributed to this tragic death. Symptoms of e-cigarette and vaping-associated lung injury (EVALI) can include shortness of breath, coughing, or chest pain, often accompanied by nausea, fever, vomiting, or diarrhea. If you previously used e-cigarettes and are experiencing symptoms, you should seek prompt medical attention and let your healthcare provider know that you have vaped.

For more information about tobacco cessation resources in Marin County go to Marinhhs.org.

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AS WILDFIRES BURN, IT’S TIME FOR CMA TO LEAD ON CLIMATE Karly Hampshire and Michelle Tong Mastering the sheer enormity of information presented in medical school has been likened to “drinking out of a fire hose”. Yet, as medical students in California, a state plagued by anthropogenic wildfires, the fire hose analogy rings even more true. For many, climate change may seem like a distant threat affecting someone else, somewhere else. But walking through the Acute Care for the Elderly inpatient unit at UCSF this week and encountering patients and their families frantically trying to secure their living situations after being evacuated from East Bay hospitals without power, it is clear that climate change is already having profound health effects in our own community—not only on health system infrastructure but on just about every organ system in our bodies.

In California today, the most obvious health effect of climate change is secondary to the wildfire smoke that floods the lungs of those fleeing emblazoned areas. Exposure to wildfire smoke is associated with an increase in all-cause mortality, an increase in emergency department visits and hospitalizations, as well as decreased lung function in non-asthmatic children. A less obvious health-related sequela of climate change is chronic kidney disease of unknown origin (CKDu), an enigmatic nephropathy affecting primarily Central Americans that leads to irreversible renal damage and often, death. While we do not fully understand the pathogenesis of this disease, it is theorized to be linked to extreme heat exposure and dehydration, and farmworkers laboring in high temperatures increasing with climate change are the most impacted.

CKDu is but one example of climate change disproportionately affecting the most vulnerable among us. Profoundly unjust is the fact that those least responsible for causing climate change are those who are most harmed by it. Migrants and refugees in particular are profoundly affected, driven from their homes because of food insecurity, natural disasters, and conflict linked to climate change. Although the prominent media narrative of migrants in “el caravan” is about individuals fleeing gang violence, the most frequently cited reason for leaving for those migrating out of Central America’s drought-stricken dry corridor was “no food.”

Collectively, Central America contributes less than 0.2% of global greenhouse gas emissions, yet its people are the most victimized by climate change and suffer the most detriments to their mental and physical health. Even as busy health care professionals, it is not difficult to see the link. In fact, most of the major humanitarian issues facing the world today— conflict, food insecurity, health disparities- are exacerbated by climate change.

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Yet there is hope; the youth of the world are impassioned and taking action, signified by the four million students who protested during the Global Climate Strike in September of this year.

As the “youth” of the medical hierarchy, medical students are also advocating for change and climate action. After all, climate change will be one of the most pressing public health concerns of our medical careers. In late October, hundreds of physicians and medical students attended the California Medical Association (CMA)’s annual House of Delegates (HOD), where resolutions for the upcoming year were proposed and discussed.

For many medical students, garnering support for climate change-related policy was a key priority. Representatives from multiple medical schools spoke at ten out of California’s eleven district meetings, requesting support for four climate-changerelated resolutions.

The first resolution, authored by the Medical Student Section, asked the CMA to “declare climate change a public health crisis,” “prioritize advocacy for climate action to protect health and recognize the disproportionate impacts of climate change on vulnerable populations,” and “support integration of climate change education into the undergraduate and graduate medical education to teach students the basics of climate change pathogenesis, the many ways that climate change affects health, and how to talk to their patients about climate change.” The second resolution, submitted by the Alameda-Contra Costa Medical Association (ACCMA), requested that the CMA join over 120 other American medical organizations in co-signing the US Call to Action on Climate, Health, and Equity. The third, authored by physicians Don Gaede, Cynthia Mahoney, Lee Ballance, and Ashley McClure, asked the CMA to “support a steadily rising nationwide carbon tax.” And the fourth, authored by Drs. Amanda Nummi, David Redlin, and Ashley McClure, calls on CMA to discourage the use of the anesthetic gases desflurane and nitrous oxide because they are super-potent greenhouse gases that have safer alternatives. All four resolutions are anticipated to be posted online for testimony from November 12th through December 4th.

Another goal of the medical students speaking at district meetings was garnering support among the districts to identify climate change as a “major issue” for 2020. Major issues are topics that have been chosen as policy priorities for the CMA and are devoted most of conference time. For example, this year’s four major issues were adverse childhood events, augmented continued on page 18 NOVEMBER/DECEMBER 2019

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Environmental Health intelligence, cannabis and homelessness. As the health effects of climate change become increasingly obvious and the predictions increasingly ominous, it is critical that major health organizations such as the CMA offer top-down policy support. Drilling down on climate change as a CMA major issue would send a message to health professionals of all partisanship that human and climate health are inextricably interconnected.

Medical students are not the only ones who are advocating for change. Over 120 medical societies and organizations, including the American Medical Association (AMA), have signed the aforementioned U.S. Call to Action on Climate, Health, and Equity, a policy agenda that highlights ten concrete policy actions that government, business, and civil society leaders should take to enact change at the pace and magnitude required to avert the worst health effects of climate change. This broad base of American medical organizations realizes that climate policy solutions are essential public health policies.

The Human Health and Climate Change Club, a newly-formed student organization at UCSF, is also pushing for change at the institutional level. Some students have organized expert panels to educate their peers on the implications of climate change on patient health, and others are successfully pushing for departments to offset carbon emissions attributed to travel to academic conferences. A new initiative, “The Planetary Health Justice Report Card” will evaluate and compare medical schools across the country on the basis of discrete metrics related to curriculum, research, community engagement, and student opportuni-

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ties around environmental health, with the intent of motivating institutional progress in this area. UC’s recent decision to divest from fossil fuels was an empowering attestation that these small actions are effective; our culture is changing.

Beyond making individual environmentally-friendly choices, how can you help our efforts to affect change? An easy way to offer your support is to endorse our three resolutions, which will be posted November 12 to December 4th on the CMA website https://www.cmadocs.org/resolutions). In addition, in January, we will be distributing a letter to medical societies asking for delegates to support climate change as a major issue for CMA next year; your support would be tremendously helpful.

Finally, if you want to collaborate or get involved further, please join our newly launched organization, California Climate Health Now, at climatehealthnow.org. While climate change may be the greatest global health threat of the 21st century, it is also the greatest global health opportunity. Your support can help ensure a healthier future for all.

Karly Hampshire and Michelle Tong are secondyear medical students at UCSF.

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LATEST RESEARCH:

OK TO EAT RED AND PROCESSED MEAT AGAIN? NOT! Thomas B. Newman MD, MPH and Michael J. Martin MD, MPH, MBA Readers who thought they should decrease their intake of red meat may have recently begun to question the science behind that recommendation. First, a widely publicized UCSF/Children’s Hospital Oakland Research Institute (CHORI) study reported that red meat was no worse than white meat for cholesterol levels.1 Then, a series of systematic reviews in the Annals of Internal Medicine2-6 claimed that the effects of red and processed meat on cancer, cardiovascular disease and all-cause mortality were trivial at most, and highly uncertain.

A new guideline7 accompanying these systematic reviews recommended people continue their current intake of red meat. What is the quality of the evidence put forth by these recent papers and do they present any new scientific results? Also, how, if at all, should the recent papers change our own dietary habits and the recommendations we give to patients?

Is red meat no worse than white meat?

The UCSF/CHORI study that received wide attention (133 news outlets, according to Altmetric)8 was a randomized crossover trial comparing the effects of both different levels of dietary fat and different types of meat on blood lipid levels. So, the first important point is that the outcome measure was lipid levels and not heart disease; lipid levels are, at best, a surrogate marker for heart disease. Such surrogates generally overestimate the beneficial effects on patient-relevant outcomes.9 In addition, because red meat intake is also associated with increased cancer incidence and mortality, examining meat’s effects on lipid levels is clearly insufficient to project effects on overall health.

The second important point is that the authors kept saturated fat intake constant when comparing meat types. While this allowed the investigators to answer a narrowly focused question about protein sources, the results are of little relevance to most readers, who are likely to increase their intake of saturated fat (and hence their LDL-cholesterol levels) if they switch from white to red meat.

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Given its limited clinical relevance, this paper received far too much attention and many media outlets reported the findings in sensationalized and misleading ways.

What’s new in the latest systematic reviews of red and processed meat?

The authors’ methods of retrieving and assessing the previous studies were admirably rigorous and transparent.

They found that intake of red and processed red meat was associated with a highly statistically significant increased risk of cancer, cardiovascular disease, and all-cause mortality. The results were consistent with those of previous metaanalyses.10,11 What was new is that the authors pronounced the effects to be so small and uncertain that they were negligible.

So, let’s start with the effect size. The authors provided risk ratios for eating less red meat, so risk ratios were less than one.

The risk ratios for all-cause mortality were 0.87 (95% CI: 0.82, 0.92) for a dietary pattern of low red and processed meat intake (compared with high intake)4 and 0.93 (95% CI: 0.91 to 0.96) per 3 fewer servings per week of red or processed meat. 2 These are not small effect sizes, and the P-values are <0.0001. There are few medical interventions that have any discernable effect on all-cause mortality, much less a highly statistically significant 7% -13% reduction.

Furthermore, the risk ratio of 0.93 for 3 fewer servings per week of red meat corresponds to a risk ratio of 0.84 for one less serving per day. If this risk ratio is true and causal, it implies that over 10 years about 1 death in 6 among people eating > 1 serving per day of red meat could be prevented if they cut their red meat intake by 1 serving per day. This is hardly a trivial effect size.

These highly statistically significant effect estimates were assigned “Low” or “Very Low” grades of evidence certainty. This was because they were based on cohort studies, for which the default evidence grade is “Low” when using the GRADE tool they chose.12 The evidence was then further downgraded to “Very Low” in some cases due to risk of potential bias. By far, the most common risk of potential bias was lack of confidence in the assessment of red meat intake because in many studies red WWW.SFMMS.ORG

meat intake was measured only at baseline or using instruments that were insufficiently validated. However, in prospective cohort studies, the direction of this bias would likely be to attenuate observed associations rather than to make them falsely strong.

In the systematic review of randomized trials 6 the only included trial with mortality outcomes was the Women’s Health Initiative (WHI). However, that study was a trial of a low-fat diet rather than a low-red-meat diet. The authors included the WHI because the women on the low-fat diet reported slightly lower (1.4 servings/week) red meat intake, but they then downgraded the quality of evidence to “Low” because of “serious indirectness.”

What has been the reaction to the systematic reviews and recommendations?

Many nutrition researchers have rejected the methods and conclusions of these systematic reviews because they seem to have stacked the deck in favor of concluding the evidence was weak (as a result of the evidence grading tool used and the inclusion of the WHI). But Bradley Johnston, a leader of the group, responded to this criticism in the Washington Post13 as follows: “Regarding the reaction among some in the nutrition research community … we are sympathetic to the discomfort of acknowledging the low-quality evidence in one’s field. It seems to us, however, that pretending that the rules of evidence differ across fields because the feasibility of definitive studies is not possible in one’s particular field is a poor solution to the problem. We believe it is important to apply common standards for assessing the certainty of evidence across health-care fields.”

Dr. Johnston’s dismissal of evidence that is not from randomized trials is the sort of comment that gives evidence-based medicine a bad name. It defies common sense to suggest that we should use the same evidence standards we use for evaluating prescription drugs when evaluating a high meat diet (or parachutes,14 toxic chemicals, assault rifles, nuclear weapons, etc.). Not all health hazards can or need to be evaluated with randomized trials.14 Given the authors’ dim view of the quality of the evidence to inform a dietary guideline, one would expect them to decline to make a recommendation. Instead, they recommended that “adults continue current unprocessed red meat consumption.”7 This leads to the paradoxical situation in which someone who has given up read meat is advised to continue that abstinence, while someone who has disregarded previous recommendations and continued to indulge in 2 servings of red meat per day is advised to stay on that red meat course.

In fact, livestock production is one of the leading causes of global warming.16 This led UCSF medical students and the UCSF Academic Senate Sustainability Committee to recommend that departments stop serving red meat at events for which they are purchasing food, a recommendation that has so far been adopted by six departments in the UCSF School of Medicine, as well as one in the School of Nursing and the UCSF Real Estate department.

(See https://sustainability.ucsf.edu/3.690 for a listing.)

To issue dietary guidelines that ignore these ecological effects reflects an increasingly indefensible level of tunnel vision. As we write this, California wildfires are raging out of control and friends have been evacuated from their homes. Yet too many in leadership positions are conducting business as usual and too many in healthcare are ignoring this existential threat to human survival.

In a 2006 article in Vanity Fair,17 Al Gore quoted Winston Churchill’s warning about Nazi Germany: "the era of procrastination, of half measures, of soothing and baffling expedients, of delays, is coming to a close. In its place, we are entering a period of consequences."

We have entered that period of consequences for global climate change. For our own health, our patients’ health and the health of our planet, we should strongly encourage plant-based diets and should discourage the consumption of red meat.

Dr. Tom Newman is a Professor Emeritus of Epidemiology & Biostatistics and Pediatrics at UCSF. A longtime member of Physicians for Social Responsibility (PSR) and advocate of sustainability at UCSF, he currently chairs the environmental health committee of the Greater SF Bay Area Chapter of PSR.

Dr. Michael Martin is an Associate Clinical Professor in the Department of Epidemiology & Biostatistics at UCSF. He is also a member of the Greater SF Bay Area Chapter of Physicians for Social Responsibility (PSR) and is the chair of PSR’s national Environment & Health (E&H) Committee.

References may be found online at SFMMS.org

So, what should we eat and recommend?

While we disagree with the authors of the Annals papers about the magnitude of the effects of red meat on mortality and the quality of the evidence available and needed, our biggest beef is that they completely disregarded the ecological effects of a diet high in red meat. The greenhouse gas footprint of red meat (especially beef and lamb) is much higher than that of other protein sources.15 WWW.SFMMS.ORG

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THE CLIMATE AND OUR MENTAL HEALTH A Review of Impacts and Implication for Action

Robin Cooper, MD After hearing a radio interview in which I discussed the effects of climate change on mental health, a woman called and left me a message recounting her experience as a survivor of the Paradise fire. She first expressed her gratitude for validating her feelings of anxiety, worry, anger, sadness, and depression. Then, in a quivering voice she related her startled reaction and fear every time she heard fire-engine sirens (a frequent occurrence living on a street with a fire station). She described low-grade depression and a constant state of anxiety.

She said of her distress: “It is very real and it's very very close now; it is not something that is abstract and isn't the other side of the earth.”

This is not uncommon in my own practice of psychiatry. For example, a psychotherapy patient who is a mother of an 8-yearold boy wept as she expressed her overwhelming dread and fear for her son. “I cannot protect him,” she said. She frantically considered where to move to escape climate disasters. Once she realized there are no good choices she wept and expressed gut wrenching regret as “I never should have had him.”

Another patient–a single dad referring to climate change and the air pollution of the Sonoma fires--stated, “ I can’t let myself think about it. If I do, I won’t be able to take care of my daughters or go to work.”

And young adults have told me that they are contemplating not having children, since they fear the future will be uncertain due to global warming.

The psychological experiences associated with climate change are penetrating the lives of people in dramatic and troubling ways.

Acute and Slow Moving Disasters

The psychological toll escalates as more frequent and devastating acute climate related disasters such as floods, superstorms, hurricanes and wildfires wreak havoc on communities.

Post Traumatic Stress Disorder, anger and depression among survivors of acute disasters is common and can last for years.

The emotional toll of losing loved ones, pets, property, livelihood and community cohesion is incalculable. Increasing rates of substance abuse following acute disasters reflect the struggle to cope with extraordinary fears and loss.

Impacts of what are termed “slow moving disasters” can be equally profound. Wetland inundation and coastal flooding are already occurring worldwide with sea level rise creating areas of uninhabitable low-lying regions.

Regional and global conflicts are exacerbated by communities being forced to flee their homelands. Droughts and sea level rise threaten previously cohesive communities; they are contributing factors leading to mass migrations and political instability.

Unwanted migrations from areas that are no longer habitable have created a new group of “climate refugees” losing deep roots

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to community, history, culture and heritage. Stable agrarian communities can be torn apart as drought-ridden land no longer produces crops. Farmers whose livelihoods are threatened and are not able to predictably care for their families can experience enormous emotional consequences.

In the USA, two indigenous communities are already facing unwanted relocations; one in the Bayou of Louisiana and the other in northern Alaska. A new language is developing with phrases like “receding communities” and “planned retreats” entering the discussion of planners and insurance industry. This language can obscure the psychic pain of this new reality of uninhabitable communities.

In addition, there are many other mental health, behavioral, and cognitive impacts of climate change.

Heat Impacts

Extreme heat has very specific impacts on behavior, mood, sleep and cognition. Evidence of links between extreme heat and aggression confirm the general understanding expressed in our colloquial language of “hot headed “or “so angry my blood is boiling.” Studies report increases of interpersonal violence and group violence. This is particularly a concern for domestic violence and abuse of women and children. Suicide, which is a form of violence turned inward, is reported to increase during heat extremes. Studies indicate this a direct impact of extreme heat. There is speculation that serotonergic functioning which is impacted by extreme heat is an underlying biological contributor.

People have difficulty with complex cognitive tasks of working memory and executive functioning during extreme heat. Work productivity and efficiency and student academic performance are reduced during extreme heat. Impacts on thinking are a particular concern for those with pre-existing fragile cognitive capacities such as the elderly, people with mild dementia, or mental illness. They may have adequate executive functioning during normal conditions, but lose these marginal capacities with extreme heat - creating risks to necessary self-care and protective action.

Air Pollution

Although health professionals are very familiar with the cardiopulmonary effects of air pollution, the direct impacts on brain function are less well recognized. Particulate matter (<2.5 micrometers) directly penetrates the blood brain barrier causing inflammation, oxidation stress and neurofibrillary tangle formation with resultant brain cellular damage.

Psychiatric dysfunction secondary to air pollution exposure has been demonstrated across the life span impacting fetal development to old age. Fossil fuel particulate exposure is associated with lower academic, cognitive, and social performance in chilWWW.SFMMS.ORG

dren and with early and more severe dementia in the elderly.

Among the significant neuro- psychiatric disorders that are aggravated or increased by air pollution are autism; ADHD and other school performance problems; disruptive behavior disorders of childhood; stroke; dementia; Parkinson’s disease, and possible mood disorders.

“Eco-Distress” Syndromes

Many in the general public have recently become acutely aware of the looming threats of climate change. The media is regularly covering climate disasters. Weather reporters are less reticent than previously to make the connection of major storms to climate change. Fears of existential annihilation are no longer only the subject of sci-fi films. For many, the psychic defenses of denial and avoidance are breaking down but at costs of penetrating emotional experiences of fear, anxiety, sadness, grief, depression, hopelessness, frustration, anger and guilt. An entire new language is developing describing these states (eco-anxiety, eco-grief, solastalgia) and providing a lexicon to encompass the profound emotional responses evoked by the changing landscape, potential of collapse of social structures and the future of a shrinking habitable planet.

Vulnerable Populations

Climate change will affect us all in some way. But the impacts are not uniform. Poor people, people of color, elderly, the very young, the mentally ill and those with little political or economic resources to impact the worlds they live in are the people who bear the brunt of climate impacts. They are hit first, hardest and have the least capacity to manage and mitigate the effects. There is no doubt that environmental justice is intricately entangled with climate impacts. Issues of equity and justice must be considered as policies for adaption and mitigation are developed.

Enhancing and building resilient communities, a task for all communities, is essential in the communities that have the least resources.

The mental health impacts of climate change are daunting.

Nevertheless, despite the huge threats and challenges, how we respond today will have a huge impact on what our future world looks like. Although we cannot get out of this crisis without very real and deep damage, we can limit the extent by acting now in collective ways to create effective policies and plans for both adaptation and mitigation.

Physicians and health professionals have a unique voice and can make a difference. There is no time to delay. This is a health and mental health emergency. This is a Code Blue for the world.

Resources and Reference: 1. Hayes, et al. Climate Change and Mental Health Risks, Impacts, and Priority Actions. Int. J Mental Health Systems.

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Robin Cooper, MD is a psychiatrist in private practice in San Francisco for over 35 years. She has been involved in climate change activities and the impacts of climate change on health for over a decade. Her concerns for the underrecognized mental health and psychiatric aspects of climate change lead her with several other activist psychiatrists to create the Climate Psychiatry Alliance (CPA). CPA's mission is to bring mental health professionals together to educate the public and our colleagues about the mental health impacts of climate change, address the emotional suffering and use our leverage within the health establishment to advocate for effective adaptation and mitigation policies. Over the few short years of its existence, CPA has become recognized as one of the leading voices addressing this issue. She is also on the voluntary faculty as Assistant Professor of Medicine, in the Department of Psychiatry at UCSF.

SOME WAYS TO ACT: Sign on as an organization or individual to the California Call to Action on Climate Health, Equity and Justice; https://www.phi. org/policy-advocacy/california-the-path-forward-for-publichealth/california-call-to-action-climate-change-health-equity/

Join Health Groups focusing on climate change: Medical Society Consortium on Climate and Health as an individual; if your professional association is not yet a member, advocate for joining. https://medsocietiesforclimatehealth.org/ • Physicians for Social Responsibility, https://sfbaypsr.org/

• California Climate Health Now, https://actionnetwork.org/ groups/california-climate-health-now

• US Climate and Health Alliance, http://usclimateandhealth alliance.org/ • Climate Psychiatry Alliance, www.climatepsychiatry.org

Greening the health system: • Work within your hospital systems to decrease hospital carbon footprint: See Health Care Without Harm https://noharm.org/ • Join “My Green Doctor”: tools for greening your medical practice. https://www.mygreendoctor.org/ Advocate: • For action within your professional organization.

• For California Medical Association to adopt a urgent policy on climate change and health: Currently under consideration

Educate: • Present Grand Rounds at your hospital; inform your colleagues • Write letters to editors of your paper and medical newsletters

Participate and support political organizations addressing climate change. A Few: • Citizens’ Climate Lobby https://citizensclimatelobby.org/ • 350.org https://350bayarea.org/350-san-francisco • Sierra Club https://www.sierraclub.org/

• Sunrise Movement. https://www.sunrisemovement.org/ • Let your elected officials know that this is a major health concern and demand action • Vote for climate supportive candidates at all levels of government.

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THE CALIFORNIA HEALTHY NAIL SALON COLLABORATIVE:

Working to Reduce Toxic Exposures for Immigrant Women Workers Catherine A. Porter, JD In the early 2000s, a local health care clinic, Asian Health Services, became concerned about acute health problems they were seeing among their patients that worked in nail salons. The founding in 2005 of the California Healthy Nail Salon Collaborative (CaHNSC) grew out of that concern, with the aim of better understanding the causes of those problems and then addressing them.

CaHNSC comprises over 60 public health and environmental advocates, nail salon workers and owners, community-based groups, and allies in government agencies. Its mission is to improve the health and safety of the nail and beauty care workforce and help create a more sustainable and just industry; one way it does that is through policy advocacy to prevent toxic exposures in the workplace. Their nail salon community members actively participate in advocacy efforts by sharing with legislators their powerful stories about why they support needed change for their profession and industry.

Manis/pedis are popular beauty services in California.

Salon professionals represent a significant community of workers in California. In 2018, there were approximately 139,000 licensed manicurists, and 314,500 licensed cosmetologists which are licensed to provide nail and hair services. There are 51,000 licensed businesses that provide nail, hair, barber and other beauty services.

Almost seventy percent of licensed manicurists in California are Vietnamese; most are immigrant and refugee women of reproductive age. Language can be a barrier to accessing information about state and federal labor and occupational health laws designed to protect their rights and safety. Nail salon workers may work as many as many 6 days/week, 8-10 hours/day.

The money spent in the U.S. in nail salons increased from $7.47 billion in 2012 to $8.53 billion in 2017.1 In 2017, the value of the U.S. market for the beauty and personal care product industry, an industry woefully under-regulated, reached around $86 billion. Many of those products are used in nail salons.2 Federal and state laws do not require regulators to ensure that cosmet24

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ics and personal care products are safe, and manufacturers do not have to share any safety information with government entities.

Nail services often result in the mostly women workforce experiencing harmful chemical exposures from the products that are used.

Every day, nail salon workers are exposed to an array of harmful chemicals in products that can cause both acute reactions and chronic harm. Acute symptoms include headaches, dizziness, rashes, respiratory problems, watery nose and eyes. However, nail salon professionals are even more concerned about potential chronic harms, including those related to their reproductive system.

Three chemicals in nail products– toluene, dibutyl phthalate, and formaldehyde – linked to developmental and reproductive harm and cancer, among others, have appropriately received much attention from consumers, government, and industry. Studies have shown a positive association between phthalate exposure levels and adverse reproductive outcomes such as preterm birth.3 Many, but by no means all, manufacturers have removed these chemicals from their nail products.

A 2014 study found that manicurists in California are at greater risk of pregnancy complications such as placenta previa as well as diabetes, gestational diabetes, premature rupture of the membranes, low birth weight and small for gestational age compared with the general population for all races combined.4 While studies that quantify toxic exposure in nail salons are wanting, chemicals of concern have been detected by air monitoring in nail salons.5 We do know that harmful chemicals are getting into nail salon workers’ bodies. For example, phthalate levels in the body have been found to be higher in nail salon workers relative to the general population.6 Some nail technicians say that if they could afford it, they would quit their jobs when pregnant to avoid toxic exposures, underscoring the need for policy changes to reduce toxic exposures for this group of immigrant women workers.

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Policy change can lead to healthier salons and healthier places to work.

Due in large part to the advocacy of CaHNSC, then- President of the San Francisco Board of Supervisors David Chiu authored— and the San Francisco Supervisors adopted—policy in 2010 calling for the development of a “Healthy Nail Salon Recognition Program” in the City. Healthy Nail Salon Recognition Programs (HNSRP) are local voluntary programs that require salons to use less toxic nail polishes (no toluene, dibutyl phthalate, or formaldehyde), improve ventilation, and participate in safety and health trainings. Salons that meet the program’s criteria are given recognition with a certificate and are listed as a healthier nail salon on government websites.

HNSRPs have spread to the counties of San Mateo, Santa Clara County, and Alameda, and the city of Santa Monica. Today, approximately 200 nail salons across California are certified by a healthy salon program. Nail salon owners say being a healthy nail salon is better for their health and good for their customers and business too.

In 2016, the CaHNSC with Asian Health Services successfully cosponsored state Assembly Bill 2125 (Chiu) to help spread HNSRPs more broadly in the state. As a result, the California Environmental Protection Agency was charged with developing a model healthy nail salon recognition program that could be implemented by more counties and cities across California. The agency will also outreach to city and county environmental and health departments to encourage adoption and implementation in their jurisdictions. Those efforts are ongoing.

Making product information more accessible leads to healthier choices.

The right-to-know is critical for workers to make informed decisions about the products they use at work. Until 2017, unlike retail cosmetics, the makers of professional cosmetics were not required by law to list ingredients on product labels. Cosponsored by the CaHNSC,7 Assembly Bill 2775 (Kalra) changed this in California by requiring that any professional cosmetic sold here have ingredients listed on the product label.

Safety data sheets (SDS) are important occupational safety and health tools for employers and workers to better understand what’s in a product, how it can impact health, and how to protect oneself from harm. Unfortunately, nail salon owners often have a hard time obtaining these from beauty supply stores where they purchase their products. In response to this information obstacle, the CaHNSC8 cosponsored Assembly Bill 647 (Kalra) which will require that SDSs for cosmetics and disinfectants be posted on manufacturer and importer websites and be translated into Vietnamese, Spanish, Korean, and Chinese.

Improved labeling and better access to safety data sheets means right-to-know is made more real for this community of Vietnamese women workers. Such policy changes enhance nail and other salon workers’ and owners’ ability to avoid the worst chemicals and choose healthier products for themselves and their families.

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Go to California Healthy Nail Salon Collaborative’s website https://cahealthynailsalons.org/ to learn more about their work, and to find a healthy nail salon near you. Support beauty services that are healthier – especially for the workers providing them.

Catherine Porter is trained as an attorney and previously practiced employment law litigation. For the past two decades, she has worked as a policy advocate to improve women’s health, particularly working women, and the health of the environment. She currently serves as the Policy Director for the California Healthy Nail Salons Collaborative and policy consultant for San Francisco Bay Area Physicians for Social Responsibility.

Resources and Reference: 1. https://files.nailsmag.com/Handouts/NABB2017-18statsLR.pdf 2. https://www.statista.com/statistics/491255/beauty-andpersonal-care-united-states-market-value/ 3. Ferguson KK, McElrath TF, Meeker JD (2014) Environmental phthalate exposure and preterm birth. JAMA Pediatr 168(1):61-68.

4. Quach, Thu, et al, Adverse birth outcomes and maternal complications in licensed cosmetologists and manicurists in California, Int Arch Occup Environ Health (December 2014).

5. Quach, Thu, et al, Characterizing Workplace Exposures in Vietnamese Women Working in California Nail Salons (May 5, 2011) American Journal of Pub Health.

6. Hines, CJ, Nilsen Hopf NB, Deddens JA, Calafat AM, Silva MJ, Grote AA et al (2009) Urinary phthalate metabolite concentrations among workers in selected industries; a pilot biomonitoring study. Ann Occup Hyg 53(1):1-17 7. Other cosponsors were Women’s Voices for the Earth, Black Women for Wellness, and Breast Cancer Prevention Partners.

8. AB 647 was also cosponsored by Worksafe.

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PLANETARY HEALTH:

The Future of Environmental Health Medical Education at UCSF Annemarie Charlesworth, MA Like many expectant, first-time moms, I really tuned in to environmental health when I was pregnant with my daughter, 15 years ago. At that time, the public was first starting to learn about the possible health risks of Bisphenol A (BPA), and I anxiously reacted by disposing all of the child-safe, unbreakable food and drink-ware I had bought for my daughter. My husband and mother thought I was crazy and my healthcare provider did not really know how to respond – the science was new, so their advice was inconclusive.

(However, 15 years later, I have been vindicated as the endocrine-disrupting properties of BPA– and its comparable replacements – have been substantiated.) That experience taught me that 1) chemicals could be put on the market without first determining if they were safe; 2) health care providers might not understand the science nor know how to make clinical recommendations regarding prevention; and 3) that there could be long-term health consequences due to this lack of regulation and ignorance.

Fast-forward to present day – when these lessons have inspired the course of my work. In my current role as Associate Director of Clinical Outreach and Education for the UCSF Program on Reproductive Health and the Environment (PRHE), I think we have been making good advances in translating and synthesizing the state of environmental health science for health professionals and policymakers. Over the past several years, our team has successfully developed a method of systematic review that will help clinicians and policy-makers make science-based decision (which has been endorsed and implemented by leading public health authorities, such as the NAS, WHO, and EPA); harnessed the collective voices of obstetricians and gynecologists nationally and world-wide to advocate for policies and practices that protect environmental, reproductive health); and created a series of patient-focused educational brochures that help clinicians talk about preventing environmental chemical exposures. We are also making good strides integrating environmental health in our School of Medicine curriculum. For the past seven years, we have implemented reproductive environmental health lectures and electives – organized by our medical students – and for the last three years have provided environmental health curricula as part of the foundational education of all 2nd year medical students. In many ways, our work in environmen26

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tal health medical education remains unparalleled by many other medical universities. Yet now - more than ever I am aware that this is not enough, and we are running out of time.

Unlike 15 years ago, when an unsafe chemical finally made the news and compelled action, we are now living in a world with increasing calamities due to climate change. It is almost impossible to not pay attention to the stories of human suffering and devastation related to wildfires, hurricanes, and floods that have become part of our daily barrage of news. While overwhelming, these new climate threats do not mitigate the old environmental chemical ones. Climate change is exacerbating the effects of air pollution, which is affecting our most vulnerable - children, pregnant women, the elderly, and those with cardiovascular and respiratory illnesses. Every wildfire releases particulate matter (PM2.5) that can travel into the respiratory tract and penetrate deep into the lungs and potentially the bloodstream, decreasing lung functioning and increasing respiratory and cardiac symptoms. Chemical contaminants once locked in polar ice sheets now threaten our water supply and the emergence of waterborne diseases.

The truth is that climate and environmental health are inextricably linked, although often researched, taught, and funded in silos. At its best, these siloes create artificial distinctions; at its worst, they impede progress and foster competition between disciplines. They are multi-disciplinary problems requiring multidisciplinary solutions. UCSF medical students are understanding how critically important it is that climate and environmental health are holistically understood as planetary health, and they are seizing the momentum of the climate health movement to demand for more education and training to be better equipped to help their future patients.

On August 20, 2019, Zoe Kornberg, a 4th year UCSF medical student wrote an articulate and compelling letter to the Deans asking that the School of Medicine integrate environmental health and science in the UCSF medical curriculum – garnering the signed endorsements of over 50 other medical students: “UCSF’s own goal in creating the Bridges curriculum is to help medical students meet the challenges of the 21st Century and to answer some of the biggest questions in medicine. Climate change. Nuclear disasters.

Microplastic contamination of the food supply. Clean water scarcity.

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Widespread use of endocrine disruptors. Increase in homelessness.

Teenage vaping. These are the medical and public health issues of today and tomorrow that we need to be preparing UCSF medical students to address. While the idea of solving these problems may seem daunting, we believe our medical school curriculum should give us the tools that treat and prevent death and disease from these all too common hazards.”

Less than one month later, about 20 medical students from UCSF and the UC Berkeley - UCSF Joint Medical Program attended the Youth-led Climate Strike in San Francisco joining millions of other students worldwide. Wearing white coats, they handed out prescriptions for reducing carbon emissions, learning that their voices are powerful forces for change.

I am heartened by our medical students’ rallying cry as I am already seeing it having a strong effect. UCSF leadership and faculty from diverse disciplines are coming together to explore how to create truly integrated, planetary health solutions across the School of Medicine curriculum. Inspired by our students, we are taking action to give health professionals the education, resources, and tools they need to counsel patients and play a critical role in advocating for policies that protect our environment and prevent harm. This is arguably the most proactive, upstream approach we could take to promoting positive health outcomes. It also makes me incredibly hopeful about the next 15 years - and the health of future generations and our planet.

Annemarie Charlesworth, MA is the Associate Director of the UCSF Environmental Health Initiative (EHI) and Director of the Clinical Outreach and Translation team of the UCSF Program on Reproductive Health and the Environment.

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HOW MUCH CANNABIS DO CALIFORNIANS USE? Researchers Want To Ask In Order To Set Safe Pesticide Limits Starting this January, California cannabis users can get a $20 gift card by anonymously sharing their consumption habits with a state-funded survey team.

Researchers from the California Department of Pesticide Regulation and California State University, Sacramento are trying to calculate how much cannabis the average California user consumes on a daily basis. The information will help them set more accurate safety levels for pesticide use on cannabis crops.

The state has had concerns about pesticide levels in marijuana since the drug became legally available to nonmedical users in 2016. The federal government sets pesticide levels for fruits and vegetables based on calculated American consumption, but that data doesn’t exist for cannabis. To calculate a safe quantity, scientists need to know how much cannabis people are ingesting, said department spokesperson Charlotte Fadipe. “We had talked to people in other states ... and looked at tobacco levels, but we didn’t actually have any data on cannabis consumption itself,” Fadipe said. “If it turns out that people are eating a lot more cannabis products than we initially thought, we might need to lower the levels.”

So, starting in January 2020, public health researchers will set up tables at dispensaries across the state to ask volunteers questions about their marijuana use. Participants will remain anonymous and will receive a $20 Amazon gift card for completing the 20- to 60-minute survey.

There’s very little research on the health risks of pesticides in marijuana specifically, but other states have issued health warnings about excessive pesticide levels in certain cannabis products.

California started testing legal marijuana in 2018. At first, about 20 percent of products were found to contain unsafe levels of pesticides and taken off the shelves, but that number dropped to 14 percent after a few months, according to the Associated Press.

There’s still concern that pesticide testing labs are not getting enough oversight. In late 2018, Sequoia Analytical Labs in Sacramento surrendered its license after state regulators found it was conducting faulty tests for pesticides.

People can sign up to take the in-person survey here. https://csus.co1.qualtrics.com/jfe/form/SV_bdfrqol5a64XzU1

– From California Public Radio

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Environmental Health

THE NUCLEAR ARMS RACE COMES HOME Contamination at the Hunters Point Naval Shipyard Superfund Site

Daniel Hirsch and Taylor Altenbern The Hunters Point Naval Shipyard (HPNS), located on the southeast tip of San Francisco, has been entrenched in nuclear activity from the very dawn of the atomic era. The day the “Trinity” atomic bomb was detonated on July 16, 1945, the USS Indianapolis departed from HPNS and sailed to Tinian Island, carrying with it half the global supply of highly enriched uranium and other components of the “Little Boy” atomic bomb.

On August 6th, the assembled bomb was loaded onto the Enola Gay and dropped on Hiroshima.

A year after the destruction of Hiroshima and Nagasaki, the first post-war nuclear tests, called Operation Crossroads, were conducted in the Bikini Atoll in the Pacific. 240 target and support ships circled the epicenters of the nuclear tests, both of which went badly awry. Severe and unanticipated contamination of the vessels resulted. Twelve sank immediately, many were mangled and rendered unusable, while those remaining were intensely coated with radioactivity. After multiple efforts to decontaminate the ships at sea failed, HPNS, in a predominantly minority and low-income community, was selected as the location where the contaminated ships would be taken to be “cleaned.” It was then that problems from the nuclear arms race, once seemingly restricted to remote areas of the Pacific, silently were brought to San Francisco.

The Navy’s attempts to “decontaminate” the irradiated ships included sandblasting and steam cleaning, methods which merely moved the contamination from the ships to Hunters Point itself.

This careless process, along with numerous other sloppy operations—including a secret laboratory that conducted countless tests involving radioactive elements—resulted in the release of dozens of radionuclides, often in large quantities, across the site.

It wasn’t until decades later that HPNS was acknowledged by the EPA as one of the most contaminated sites in the nation and designated a Superfund site. Unfortunately, the troubles quietly multiplied as the cleanup process unfolded.

Following Superfund designation, the Navy hired Tetra Tech to conduct soil testing and cleanup. After decades of work and hundreds of millions of dollars spent, the cleanup came under a cloud when whistleblowers disclosed that soil tests and data were routinely falsified. EPA has concluded that measurements at 90 to 97% of the survey units appear to be fabricated. Now, after two criminal convictions, three lawsuits, and a slew of troubling revelations, there are essentially no trustworthy data to support presumptions of safety at HPNS. While the Tetra Tech scandal has brought the shipyard to the attention of the media and has activated community involvement, there are many more fractured elements of the cleanup that have, until recently, been kept under wraps.

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The interest circulating around the HPNS cleanup is largely centered on the Tetra Tech scandal, but the startling falsifications are just the tip of the iceberg. Four years of research, beginning at the University of California Santa Cruz and continued through the Committee to Bridge the Gap, have culminated to date in a series of extensive reports, each of which uncovered faults embedded in the HPNS cleanup.

The first report details the extraordinary radiological history of HPNS, which the Navy largely neglected or diminished when determining the extent of the cleanup required. Indeed, despite all 883 sites at HPNS having the likelihood of contamination, the Navy claimed only 91 as potentially impacted and therefore to be considered for testing. The remaining 90% were arbitrarily declared to be free of contamination, largely based on fragmentary information compiled from incomplete records. Parcel A, the portion of HPNS that currently houses hundreds of residents, was one of the many areas declared clean without any thorough testing. Years later, spurred by the Tetra Tech scandal and the request of residents, a partial gamma scan was performed by the California Department of Health. Despite using instruments with extremely poor detection capability, the scan found a highly radioactive source, where no radioactivity was supposed to be possible, undermining claims by the Navy that the land is clean.

The small portion of the site that did receive testing, albeit of questionable reliability, was also riddled with shortcomings that prevent the site from being adequately cleaned up. The second report examines a myriad of problems that transcend a single contractor’s apparent malpractice. Astonishingly, 90% of the dozens of radionuclides that were used at HPNS were excluded from the cleanup. Therefore, no cleanup standards were established for them, meaning they can exist at unlimited levels of contamination without being remediated.

Another startling practice examined in the second report which began with Tetra Tech but has continued to date is the use of background measurements from within the contaminated Superfund site itself. Background measurements are meant to establish values for radionuclides which represent levels that would be present prior to any polluting activity. However, what has occurred at HPNS is to inflate these values so that what is actually dirty can be called clean, and subsequently left in the soil or on the buildings.

The cleanup levels that are established for each contaminant greatly determine the overall comprehensiveness of the cleanup.

As was examined in depth in the third report, the standards that were used and continue to be used at HPNS are grossly outdated and far less protective than what was initially promised. Radium226, for example, the most ubiquitously recognized radionuclide WWW.SFMMS.ORG

across the site, is given a cleanup standard by the Navy that is 897 times weaker than EPA’s default Preliminary Remediation Goal (PRG). Using EPA’s PRG Calculators, we were able to show that the ancient standards the Navy has been using at HPNS are hundreds or thousands of times weaker than current EPA PRGs, with resultant cancer risks as high, for buildings, as every 37th person predicted to get a cancer if exposed at the allowable levels.

Virtually the entire radioactive cleanup of HPNS has been in violation of the elementary requirement to use up-to-date EPA standards, violating Superfund law and undercutting public safety, but reducing Navy cleanup costs.

The most recent report discloses that the Navy’s remediation plan for HPNS quietly shifted as more contamination was discovered. Rather than intensifying the cleanup, the Navy changed the remedy to leave much of the contamination not cleaned up, but instead merely covered with a thin layer of soil or asphalt. Such covers are ineffective—for example, plants and burrowing animals bring contaminants back up to the surface. Furthermore, intensive excavation will need to be done to construct what is to be the largest redevelopment project in San Francisco history since the 1906 earthquake. That construction activity will tear up the covers and dig deeply into the contaminated soil below, with the potential to disperse it widely.

The host of flaws present in the cleanup at HPNS persist beyond Tetra Tech’s work. Indeed, the recent retesting which has occurred or is planned to occur in various areas across the site adopt similar troubled practices to those by Tetra Tech that

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triggered the need for retesting in the first place. The shortcomings in the remediation process are thus indicative of a larger problem of lackadaisical oversight by the regulating agencies. The troubled nature of the HPNS cleanup process highlights potential dangers to public health and the environment and underscores the need for reform of agency oversight Daniel Hirsch is the retired Director of the Program on Environmental and Nuclear Policy at the University of California, Santa Cruz, and President of the Committee to Bridge the Gap, an NGO that provides technical assistance to communities impacted by nuclear facilities.

Taylor Altenbern in the Associate Director of the Committee to Bridge the Gap.

The reports summarized in this article are available at www.committeetobridgethegap.org

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Environmental Health

THE COLLABORATIVE ON HEALTH AND THE ENVIRONMENT

Karen Wang, PhD and Stephanie Brinker, MPH

Since its founding at the SFMMS in 2002, the Collaborative on Health and the Environment (CHE) has championed environmental health education. Our work has fostered a community that is passionate about sharing the latest evidencebased environmental health science information with the public.

Through our collective knowledge and resources, we aim to improve individual and collective health. CHE’s work has led to numerous interdisciplinary collaborations, including over 60 publications and several scientific consensus statements, as well as organizing conferences and trainings, and educating health care advocates and professionals.

CHE hopes to build a groundswell of demand for preventionfocused behaviors and policies, and to help create economic and legal structures that protect public health. With the shift from a traditional media environment to one that favors digital content, CHE has embraced digital media as a way to disseminate environmental health education.

CHE webinars

A large part of CHE’s work focuses on science education through webinars. Our webinars give audiences the opportunity to learn about the most recent environmental health topics from top scientists, health professionals, policy experts, and advocates in the field. Our webinars focus on a wide variety of environmental health issues, including toxic chemicals and endocrine disruption. We also focus on the environmental risk factors for specific diseases like cancer, heart disease, and infertility. Every year, CHE hosts about 30-40 webinars; all webinars are recorded and available for free on our website. Audience members including health professionals, environmental health advocates, regulators, and academics, have reported that information they have learned through CHE webinars impacts their professional work.

We just concluded a four-part Climate Change and Health webinar series, with research presentations on the many adverse health outcomes associated with climate change. Topics included heatwaves and health, air pollution, extreme weather events, and infectious diseases. Last year, we put together a four-part webinar series on The Effects of Plastics on Health, that explored the links between petrochemicals, climate change, and human health.

Topics included the hazardous effects of plastic production, the harmful chemicals in plastic food packaging, the emerging science on the impacts of microplastics, and the advantages and disadvantages of bio-based plastics. This winter, we will be starting a four part webinar series on Environmental Health Risks and Cancer.

If you would like to get a newsletter announcing webinar topics and schedules, please sign up for CHE’s newsletter at www. healthandenvironment.org.

Because Health

In April 2018, CHE launched Because Health, a new project that aims to educate millennials about environmental health 30

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issues. The content on our website, social media channels, and newsletter are all positive and actionable, so every reader can feel empowered to reduce environmental risks that harm their health. We purposefully made our content easy-to-digest so that people do not become overwhelmed and tune-out. Topics include tips for parents and pregnant women, recommendations for nontoxic personal care products, information on how to clean without toxic chemicals, and how to become a conscious consumer. We also connect our audiences with advocacy groups that are running market-based campaigns, petitions, or pushing for better regulations. We believe that if individuals have the knowledge and tools to make healthy and non-toxic choices based on the latest science, manufacturers and policymakers will know that we want safe options to be the norm.

In the past 18 months, Because Health has experienced rapid growth; our Instagram account now has over 26k followers and continues to grow each day, and our website averages over 40,000 page views a month. Millennials, between the ages of 20 and 40, make up more than 60% of our audience. We know that our message is getting across to our audience as well. A Because Health survey distributed last year showed that almost all respondents said that they made one change due to something they learned from Because Health. Additionally, 93% of respondents also said that they shared a tip they learned with at least one person online or in person.

Because Health is an excellent resource for the general public looking for more information on environmental health issues. It is an engaging and practical source for information on what to do and buy, instead of just what to avoid and what to not do. We know each reader comes from a unique background, which makes our easy-to-read content perfect for both a lay and scientific audience. Check out our website and sign up for the Because Health newsletter at www.becausehealth.org.

Chances for learning more

There are many ways to engage with, and learn more about, CHE’s work. CHE also teaches environmental health education classes throughout the San Francisco Bay Area. For prenatal women and new parents, we teach quarterly classes on creating a healthy, non-toxic home environment held at Natural Resources, a non-profit in the Mission neighborhood in San Francisco. CHE also teaches an annual class for cancer patients and survivors through the UCSF Ida & Joseph Friend Cancer Resource Center.

Please sign up for our newsletter at www.healthandenvironment. org to find out about these in person opportunities.

Karen Wang, PhD, MSc is the Director of CHE. She holds a MSc in Earth Systems and a BA in Economics from Stanford University.

Stephanie Brinker, MPH is a Program Associate for CHE. She graduated from the UC Berkeley School of Public Health with a concentration in environmental health science.

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Environmental Health

THE UCSF CHEMICAL AND FOSSIL FUELS INDUSTRIES DOCUMENTS:

ADVANCING PUBLIC HEALTH THROUGH TRANSPARENCY & SOUND SCIENCE Annemarie Charlesworth, MA Newly acquired Chemical and Fossil Fuels Industry Documents Collections – part of the 15 million internal industry documents of the UCSF Industry Documents Library (IDL) promise to shed light on what these industries knew about the health impacts of their products, when they knew it, and how they covered up and distorted the available scientific evidence to enrich their deadly profits.

Founded in 2002 as the Legacy the Tobacco Documents Library, the IDL has grown to contain internal documents from the pharmaceutical, sugar, chemical, and fossil fuels industries, as well as tobacco. Donated by lawyers, nonprofit organizations, and private individuals, documents comprising the IDL are the result of the discovery process in litigation, public records requests, and whistle-blowers. The have provided scientists, community advocates, journalists, policy makers, and attorneys with public access to otherwise-unavailable corporate records.

Over 1,000 scholarly articles, news items, books, and other publications have used the IDL as source material, including seminal books such as The Cigarette Papers by Stanton Glantz and colleagues; The Golden Holocaust by Robert Proctor and The Cigarette Century by Alan Brandt; Playing with Fire, the Chicago

Tribune’s expose on flame retardants; and the 2014 documentary Merchants of Doubt.

The Fossil Fuels Collection, spanning 1953 to 2017, come from corporate fossil fuel producers and users, their trade associations and front groups, and think tanks with significant funding from those entities. They contain internal reports, memos, correspondence, and scientific studies into anthropogenic climate change and its impacts, as well as news bulletins, mailers, and other information created for public consumption regarding climate change, environmental policy, international climate negotiations, and the economics of mitigation and adaptation in a carbon-constrained future.

The Collection contains documents obtained by the Climate Investigations Center and a group of Shell Oil Company documents published on Climate Files, which explore in detail the people and institutions that have delayed policy action on climate change and denied climate science.

The IDL Collections are searchable within one industry archive, or across all industry archives at once, facilitating evaluation of connections and threads of research.

For more information, access https://www.industrydocuments.ucsf.edu/fossilfuel/

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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.

Internal Medicine Practice For Sale - Fresno, CA. Revenue $1.4 million on 70 MD hours/week. Perfect for two doctors to take over. This practice is part of a five doctor group that includes a lab, Cardiac Ultrasound, Nuclear Cardiology Stress Testing, Gastroenterology Specialty Services, and Bone Densitometry. Offered at $493,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@ medicalpracticesUSA.com www.MedicalPracticesUSA.com

Internal Medicine Practice For Sale - Northern CA Wine Country. 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 $350,000. Contact Medical Practices USA for more information. 925-820-6758. email: gary@medicalpracticesUSA.com www.MedicalPracticesUSA.com Plastic Surgery Practice For Sale - Modesto, CA. Revenue $1.4 million on 4 doctor days. Cosmetic (breast, body, facial, hair transplant, stem cell) and otolaryngology services in accredited surgical suite that is included in the transaction. High referral rate from both patients and other doctors. Third-party appraisal available. Photos available. Offered at only $519,000. Contact Medical Practices USA for more information.

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CHEMICAL EXPOSURE WEB TOOL DEFINES RISKS FACED BY MILLIONS OF CALIFORNIA WOMEN Tool Depicts Workplace Chemical Hazards that May Put Women at Risk for Breast Cancer Elizabeth Fernandez A new web tool spells out for the first time the exposures that more than 6.5 million working women in California face that could increase their risk for breast cancer, including industrial solvents, antimicrobials and phthalates.

The tool, which was developed by researchers at UC San Francisco and the California Department of Public Health’s Occupational Health Branch, is part of an ongoing study focused on understanding potential breast cancer risks related to workplace chemical exposures.

Users can search the database by ethnicity/race, age, and occupation to see risk information on more than a thousand chemicals, sorted into 24 chemical groups, as well as which chemicals are likely to be present in various occupations. The tool can be found at: http://cbcrp.org/worker-exposure/ “This is the first time that data of this magnitude have been made visible in one place,” said Robert Harrison, MD, MPH, coprincipal investigator on the website project and founder of UCSF Occupational Health Services. He has diagnosed and treated more than 10,000 patients with work- and environmentalinduced diseases and injuries. He also directs the worker tracking investigation program for the California Department of Public Health. “With the site, researchers and advocates can see which chemical exposures may be putting working women in particular jobs at risk for breast cancer,” Harrison said.

Site visitors also can see why certain chemical groups may be of concern for breast cancer, and find information on the likelihood that women in certain occupations, such as cashiers, housekeepers and nurses, are facing increased risk from workplace exposures.

While only a fraction of the estimated 80,000 chemicals used in workplaces have been tested to see if they cause cancer, at least 200 have been shown to cause mammary tumors in animals.

The interactive tool also enables viewers to map out what women’s employment looks like in California, and what chemical exposures are likely to occur in the jobs where substantial numbers of women work. The tool shows known and suspected WWW.SFMMS.ORG

mammary gland carcinogens, mammary gland toxicants, and endocrine disrupting chemicals.

Such explorations will provide important preliminary data to guide future research aimed at understanding breast cancer risks associated with occupational chemical exposures.

“There are currently gaps in our understanding about the risks of cancer faced by working women, particularly women of color,” said Peggy Reynolds, PhD, MPH, co-principal investigator and epidemiologist at UCSF. Her research focuses on environmental risk factors for cancer.

The data presented on the web site are meant to present simple snapshots of potential chemical exposures faced by working California women and enumerate the number and characteristics of the workforce who may be potentially exposed. Exposure probabilities are presented as “probable,” “possible,” or “unlikely” based on a job exposure matrix (JEM) created by the research team.

The matrix is a qualitative assessment of the potential for exposure due to job task or location. The creation of such an assessment was necessitated by the lack of existing occupationspecific quantitative chemical exposure data.

The data visualization tool also indicates which occupational groups are likely to contain an informal workforce that does not show up in formal data sources and often operates outside of established labor laws, and shows the exposure probabilities for women working informally.

Elizabeth Fernandez, senior public information representative at UCSF, covers the clinical cancer program, women’s health, tobacco, emergency medicine, radiology, urology, and dermatology. Previously, she was a journalist for more than two decades, covering investigative stories, health, social justice, law enforcement and education at newspapers around California. Elizabeth holds degrees from Santa Clara University (BA, English) and Columbia University Graduate School of Journalism (MS, Science).

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KAISER PERMANENTE SAN FRANCISCO

MARIN MEDICAL SOCIETY

Maria Ansari, MD

UPCOMING EVENTS 2020 SFMMS Annual Gala – Tickets Now Available!

Friday, January 31, 2020, 5:30-9:30pm | Green Room at the SF War Memorial, San Francisco Purchase your tickets for the 2020 SFMMS Annual Gala!

President-elect Brian Grady, MD, will be installed as the 2020 SFMMS President. Watch for your invitation to arrive in the mail. Tickets are now available for purchase at www.sfmms. org/events.aspx. Individual and organizational sponsorship opportunities are available – contact Erin Henke at ehenke@ sfmms.org or (415) 561-0850 x268.

SAN FRANCISCO

MARIN MEDICAL SOCIETY

JOIN OR RENEW TODAY When you join the San Francisco Marin Medical Society, you join more than 2,000 members in San Francisco and Marin who are actively protecting the practice of medicine and defending public health. Working together with you, SFMMS unites physicians to champion health care initiatives and innovation, advocate for patients, and serve our local medical community, including physicians of all specialties and practice modes. We cannot do this alone.

Join SFMMS/CMA Today to Receive 15 Months of Membership for the Price of 12 Starting October 1, 2019, new members who join paying full 2020 dues, will receive the remaining months of 2019 membership for free. Join today to start receiving your benefits.

Visit www.sfmms.org/membership for more information about SFMMS membership and benefits, or to join online.

Renew Your Commitment to Medicine; Renew Your SFMMS Membership Today Make sure you continue to receive the benefits of SFMMS and CMA membership by renewing today. Full dues-paying members enjoy a 5% Early Bird Discount* if your renewal is received by December 15, 2019. Renewing is easy:

Kaiser Permanente’s environmental stewardship efforts help us advance our mission and realize our vision for total health — an approach that emphasizes the social, environmental, behavioral, and clinical aspects that shape one’s well-being.

In 2016, our organization announced ambitious environmental goals to be achieved by the year 2025. The objectives encompass becoming carbon positive, buying only sustainably produced food, and sending zero waste to landfills.

These long-term goals build on Kaiser Permanente’s longstanding commitment to the environment. In 2016, when we opened our newest medical office building in San Francisco, it was awarded the Leadership in Energy and Environmental Design (LEED) platinum certification for its sustainability and environmentally conscious design. Developed by the U.S. Green Building Council, LEED is a rating system that serves as a guide for the design, construction, and operation of green buildings.

The platinum certification is the organization’s highest designation.

Recently Kaiser Permanente received the U.S. Environmental Protection Agency 2019 Green Power Leadership Award for our use of renewable sources of energy to power our 39 hospitals and more than 700 medical offices. The award recognizes a major renewable energy agreement that will enable our organization to become carbon neutral in 2020.

We’re proud to have been the first health care organization in the nation to begin monitoring and publicly reporting our greenhouse gas emissions, beginning in our California regions in 2005.

We now track greenhouse gas emissions across our operations.

These recognitions are confirmation that Kaiser Permanente is moving in the right direction to set policies and pursue projects that improve the health of our members, our communities, and our planet. Climate health is directly tied to human health, and in order to fulfill Kaiser Permanente’s mission, we will continue to work toward a greener future within our walls and beyond.

1. Mail/fax your completed renewal form when you receive it in the mail; or 2. Renew online at www.sfmms.org with a credit card.

5% Early Bird Discount applies to 2019 full dues-paying members only who are renewing at the same level for 2020; renewal form and payment must be received

by December 15, 2019.

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San Francisco Marin Medical Society 2720 Taylor St, Ste 450 San Francisco, CA 94133

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