March 19, 2021 Dear Governor Gavin Newsom and Dr. Mark Ghaly, As physicians, nurses, and public health professionals, we write with deep concern on the state of school reopening in California. While we have been grateful for this state’s use of science- based decision-making in the early stages of the pandemic, we have not seen the same centering of science in our school reopening process. We write today to urge the California Department of Public Health to update its guidelines on reopening based on the latest science and data and do so no later than April 1. Urgent action is the only hope to reopen schools this year and prevent severe disruption of the academic year ahead. Six million public school children in California have now been out of school for 12 months and counting with no opportunity for in-person education. While we recognize that some counties are proceeding with reopening plans in the coming weeks, these plans are extremely limited, fail to include the majority of students in California, and offer no dates for students who are not yet included. As a result, California ranks last among all 50 states for the proportion of K-12 students who attend school full-time in person. While the governors of Oregon and Washington have both issued mandates that all K-12 schools must reopen by April 19, our state has been left in limbo without a clear mandate. California is now the only West Coast state where schools are not guaranteed to re-open. In our hospitals and clinics, we are bearing witness to devastating health impacts from prolonged school closures in children. Our centers have seen an increase in mental health visits that aligns with trends noted by the CDC. These include increases in anxiety, depression, and suicidality. In our clinics, we are seeing higher rates of obesity, hypertension, and fatty liver disease which will have long-term impacts on children’s health. Children who used to love school are now completely disengaged while children with special needs are regressing in their development. While nearly all children are losing ground academically, the biggest negative impacts are on English language learners and children living in poverty, erasing years of effort towards reducing inequalities. School reopening should be based on science and data. As such, we recommend the following: • Decouple reopening from the rate of community spread: the decision to tie reopening to the color tier process was made before we had evidence to guide our decision- making. A year later, studies from Wisconsin and North Carolina provide clear data that schools can be reopened even in areas of high community spread. Continuing with the tier system widens inequities further by making it more difficult for schools with fewer resources to open while allowing well-resourced schools to continue in-person learning. • Change physical distancing guidelines from a 6 feet requirement to a 3 feet recommendation: The CDC updated their guidelines to allow for 3 feet of distancing in most cases. California school reopening guidelines also specify a preference for six feet of distancing between students, allowing four feet only after all alternate approaches have been considered, including hybrid learning. The 6 foot distancing requirement is not evidence based and is now inconsistent with recommendations from the CDC, WHO and the American Academy of Pediatrics. Recent data from Massachusetts schools indicate that 3 feet of distancing is sufficient to maintain safety, a finding supported by the data from the Wisconsin study. Sincerely1, Dr. Monica Gandhi Dr. Alice Kuo Dr. Bonnie Maldonado Professor of Medicine and Professor of Internal Professor of Global Health Associate Division Chief of Medicine and Pediatrics and Infectious Disease, the Division of HIV, Infectious UCLA and Chief of Medicine, Stanford University Diseases and Global UCLA Medicine, UCSF Dr. Amy Beck Dr. Kim Newell Green Dr. Jeanne Noble Associate Professor of Associate Clinical Professor Associate Professor of Pediatrics, of Pediatrics, UCSF, Past Emergency Medicine, UCSF President San Francisco Director of COVID Response, Marin Medical Society UCSF Dr. Lisa Patel Clinical Assistant Professor of Pediatrics, Stanford University Brian P. Snook San Ysidro Health D.O., Physician, Clinic Medical Director Nazzi Mojibi Chestnut Pediatrics Pediatrician Waldrop MD Aaron Zaheer, MD San Diego Family Care Pediatrician Adam Boxer UCSF Professor University of California, San Adam Leonard Pediatric Nurse Practitioner Francisco Adithya San Francisco General Hospital Professor of Medicine and Epidemiology Cattamanchi 1 All signatories are representing their individual views rather than necessarily representing the views of their institutions Adrienne Ritter- PAMF Pediatrician Ling Palo Alto Medical Foundation, San Aimee Harris, MD MD Carlos Alan Schroeder Stanford Clinical Professor of Pediatrics UCSF Benioff Children's Hospital Alda Lam Pediatric Resident Oakland UCLA David Geffen School of Alejandra Casillas Assistant Professor of Medicine Medicine Alex Zusman MD Alexander Hartman UCSF pediatrics Pediatrics pgy-1 Stanford University - School of Alexander Schmidt Clinical Assistant Professor Medicine Alexandra Cole UCSF Pediatric Hospitalist Benioff Children's Hospital Alexis Fogel MD, MPH Oakland Alice Abrahamian Central Pediatrics Pediatrician MD, FAAP Alice Kuo UCLA Professor and Chief Alice Liu PAMF MD Alicea Wu, MD Board-Certified Family Physician Alisha Keating Sharp Rees-Stealy Medical Group Pediatric Nurse Practitioner UCLA National Clinician Scholars Alisha Ranadive Pediatrician, Post-Doc Fellow Program Alison Borgsmiller Bravo Pediatrics Nurse Practitioner UCSF Associate Professor, Alissa Peterson MD Psychiatry Allen Arieff, M.D. UCSF Dept. of Geriatrics Professor Emeritus Allison Farfel UCLA Pediatrics MD Althea Daniel, MD Loma Linda Children’s Hospital Assistant Professor Amanda Gonzalez FHCSD MD Amanda Millstein UBCP Hilltop Pediatrics Medical Doctor Amanda Schnell Zuckerberg San Francisco RN Heringer General Hospital Amandeep UCSF/ SFVAHCS Professor of Clinical Medicine Shergill, MD MS Amlu Natesan UCLA Dr. Amy Atwal UC Davis MD UCSF and Zuckerberg San Amy Beck Associate Professor of Pediatrics Francisco General Hospital Amy Dennis Kaiser Permanente Emergency Physician Amy Weimer UCLA Health Associate Professor, Medicine-Pediatrics Amy Whittle UCSF Associate Clinical Professor of Pediatrics Amye Farag UCSF MD Andrew McDaniel Kaiser Permanente MD UC San Francsisco, School of Andrew Penn, NP Associate Clinical Professor Nursing Stanford University, Division of Andrew Sweatt, Pulmonary and Critical Care Clinical Assistant Professor MD Medicine Angela Odell Vista del Lago High School Mother Stanford University School of Anita Honkanen Medicine, Lucile Packard Doctor and Clinical Professor of Anesthesiology Children's Hospital Stanford Anjali Rao MD UCSF Benioff Children's Hospital Ann Petru, MD Professor of Pediatrics & Global Health Oakland Anna Mendenhall MD, FAAP Anna Rios Marin Community Clinic RDN Anna-Barbara Chief, Division of Adolescent and young adult UCLA Moscicki medicine Anne Matich, MD Kaiser Permanente Physician Anne Rosenthal UCSF, ZSFG Medical Director Anneka Hooft Ucsf MD, MPH Annelys Roque UCSF MD Gardner UCSF Benioff Children’s Hospital Annie Kaplan Pediatric resident Oakland Ansley Splinter Nationwide Children’s Hospital Doctor Vituity Emergency Physician, Anusha Chari DO SFMH- San Francisco Ariana Thompson- Assistant Professor, Family and Community UCSF Lastad Medicine Arisa Resquer Children's Hospital LA RN Aron Bruhn Kaiser MD Arthur Reingold UC Berkeley SPH Professor University of California, San Associate Professor, Dept. of Laboratory Arun Wiita Francisco Medicine Ashkon Kaiser Permanente Roseville Pediatrician Banihashemi Audrey Combs Marin Community Clinics FNP Augie Phillips Toolbox President Ayodeji Ayeni, MD Pediatrician Barbara R. Adler N/A (retired) M.D., FAAP Baum, Marti Physician Stanford University Hospital and Becky Wong MD, Clinical Assistant Professor Clinics San Ysidro Health, Scripps Health, Ben Dillon MD UCSD San Francisco Department of Ben Meisel CCS Medical Director Public Health Benedicto Cortez Kaiser Santa Clara Medical Center MD Beth Goldberg MD Beth Mulcahy, MD Kaiser SFO Emergency Dept Emergency Physician Bethany Johnson- UCSF Child Neurologist Kerner Bianca Argueza UCSF Physician Brenda Bloodgood UC San Diego Associate Professor Brent Rathbun Sharp Rees-Stealy Medical Group MD UCSF Dept. of Emergency Brian Berger Physician Medicine Brianna Campbell San Ysidro Health Center MD Loma Linda University Children’s Bronwyn Carlson Pediatric Hospitalist Hospital Brooke Cotter MD Bruce Miller UCSF Professor Neurology Bryan Greenhouse UCSF Associate Professor Caitlin Bailey Highland Hospital MD Caleb Siemens Dignity Health Registered Nurse Camille Rogine UCSF School of Medicine UCLA West Los Angeles Candice Ho Physician Pediatrics Caren Schmidt Marin Community Clinics Clinical Child Psychologist University of California, San Carina Marquez Assistant Professor of Medicine Francisco Carly Zapata UCSF Physician Carmine Woodland Clinic Medical Group Carmine A. Cammarosano, MD Cammarosano Carol Elizabeth retired Physician Nicholson, MD Caroline Hill UCSF Benioff Children's Hospital Clinical Social Worker III Caroline Rassbach Stanford University Clinical Associate Professor, Pediatrics Carolyn Jasik UCSF Associate Professor Carrie Senior Scientist, Infectious Diseases, COVID- Genentech, Inc. Rosenberger 19 Translational Research Lead