September 28, 2022

Dear 2072 Contra Costa Health Director,

It's impossible to write this letter and not think about what this job, this county and this world will look like from your perspective fifty years from now. Will hospitals still exist? How will health information be dispersed? Will poverty, racism, injustice and other factors impacting health equity have been resolved? Will climate change have been remediated? Given the dramatic social, technological and environmental shifts taking place in 2022, I can only imagine how future changes will reshape the job of Contra Costa's Health Director. I expect, however, that there will be one constant - the same constant that has driven every Contra Costa Health Director since our system emerged from a poor farm in the early 1900s - our commitment to care for the health of all people in Contra Costa County, with special attention to those most vulnerable.

While I was appointed Health Director in 2018, I started my career with the health system 25 years earlier as a front-line nurse at Merrithew Memorial Hospital (which would be replaced with the Contra Costa Regional Medical Center). During my hospital tenure, I viewed health through the most visible lens of our system, the hospital, and didn't understand how far­ reaching and critical Contra Costa Health (CCH) was in our county. A 1993 industrial accident at General Chemical in Richmond led to a huge toxic release that sent more than 20,000 people to seek emergency care. In addition to providing that care, CCH mobilized its hazardous materials division to respond to and address this environmental danger. The rippling effects of that accident continued to reverberate throughout the county, eventually allowing Contra Costa to usher in the nation's first Industrial Safety Ordinance of its kind and to use settlement funding to build a health center in North Richmond. As a nurse, I didn't then understand that I was a part of a much bigger system that drew on the passion, skills and dedication of staff in an array of divisions to create one of the greatest public health care systems in the world.

My understanding of the truly amazing system I was a part of rapidly evolved as I witnessed Contra Costa County build on the pioneering work of my predecessors and lead the nation on a host of different health issues. Our capacity to ensure health access to our community is largely reliant on the foresight of my predecessors, who introduced the nation's first federally qualified, publicly sponsored health plan. In 1976, Contra Costa again led the nation in developing a national model for mass casualty response, when the health department and our hospital partnered with the sheriff's office, first responders and firefighters to respond to a tragic school bus accident that claimed the lives of 28 students and an adult adviser. In the later part of the last century, when AIDS was ravaging our communities, CCH created an HIV program in collaboration with those most impacted. Our Family Practice Residency Program continues to be one of the most sought after in the nation, and we were one of the earliest systems to implement the Affordable Care Act.

All of this is the collective legacy that Contra Costa health directors, past, present and future, leave you. And since it has occupied the bulk of my time for the last three years and is without a doubt the largest test any health system has faced in a century, I'd be remiss if I didn't mention our response to the Coronavirus COVID-19 pandemic. It was both our most challenging time and our proudest moment. We saved lives, provided an anxious public with reliable, consistent and science-based information, and mobilized the largest testing and vaccination program in our county's history. I imagine by the time you read this, you will know what became of this pandemic and may have already faced your own global health emergency. Much of the pandemic organization, details and intricate planning will undoubtedly be lost to time, but what I predict will endure is the heart and love that our health team has for this community.

Early in the pandemic, COVID-19 arrived in Seattle and the San Francisco Bay Area. This was when we weren't yet able to test for the presence of the virus except by sending samples to the CDC National Lab (Contra Costa would soon become one of the earliest public health labs with the capability of testing for the virus). Overnight, tents were erected and plastic and plexiglass shields became omnipresent throughout our operations. Creating as much clinical capacity as possible became a priority as we watched health systems in China, Italy, and New York City collapse. With death counts mounting, health workers at high risk, and schools and businesses shutting down, these early days were terrifying. Partnering with seven other counties and the city of Berkeley, Contra Costa Health officials led the nation in the first of its kind "Stay Home" health order.

In the midst of these disorienting and scary times, I watched proudly as our health system team courageously donned untested protective gear and went to work. They entered skilled nursing facilities, where we were seeing the highest rates of deaths, to provide care. I had always known our team was incredibly dedicated, but it was still deeply inspiring to see the magnificence of their creativity, tenacity and courage . Despite the tragedy of the pandemic, there were bright spots, such as watching, after a 5-week stay in the intensive care unit, much of it on mechanical ventilation, one of the first early victims of the pandemic wheeled out of our hospital to return home. Or the unabashed joy and hope on the faces of exhausted staff as they watched some of the first vaccine in the region arrive at our hospital. And always true to our mission, I was moved as several members of our community and our ethics team helped determine how we would distribute this scarce and life-saving vaccine.

The anxiety and fear brought on by the pandemic was exacerbated by an unprecedented level of social upheaval and crisis. A series of police killings of people of color, including those experiencing a mental health crisis, ignited protests around the country and further polarized the nation. Inequities were in the spotlight, and nowhere was this more evident than those hardest hit communities of essential workers and particularly amongst the elderly who would constitute more than 75 percent of the lives lost to COVID. Social injustice, economic uncertainty and the unabashed display of racism by citizens and politicians alike undermined our democracy, something that came to a head when rioters stormed the U.S. Capitol. Even as the pandemic was tailing off, we faced a new health and social crisis when the U.S. Supreme Court ignored forty years of precedent by overturning Roe v. Wade and curtailing the reproductive rights of women across the country.

Despite these dire times, I draw confidence in the goodness of the people that I work with every day-a dedicated, inspiring staff of professionals and the legions of community volunteers, advocates and partners who lock arms with us to protect the health of our communities. Currently, our state is leading the way in health care for all. It is my hope that when you read this it will be a distant memory that so many went without access to health care or had to make the excruciating choice between food, rent, utilities or needed medicines. Our current Governor aims to expand Medi-Cal and has been consistently doing so incrementally.Our health plan has been instrumental in ensuring those expansions help to place health care coverage within reach for many.

It is also my hope that when your read this, Contra Costa will have solved three critical areas of focus for health: equity, housing and climate. During my administration, we've taken important steps to find a solution to these issues, which I expect my successors will have built upon.

CCH continued to recognize and address the impact of health disparities on our communities and strengthened our commitment to eliminating them in 2020 when we appointed a Chief Equity Officer to further address historic and structural discrimination within our health system and in our communities.

The housing crisis has grown exponentially. In recent years we expanded the boundaries of the definition of health by taking this on - establishing our Health Housing and Homeless Services, increasing our offerings from health clinics for those experiencing homelessness to mobile support teams and housing development specialists. The pandemic offered us the opportunity to purchase a hotel in Pittsburg, Delta Landing. Similarly innovative ideas are making a difference.

Most of all, as I consider you sitting at my desk fifty years from now, I wonder what climate legacy we have left for you and how that will impact your work. Throughout my career, scientists have warned of the threat of climate change. For the most part, those warnings fell on deaf ears, even as we witnessed ever-increasing evidence of this reality. 2022 will be the fifth year in a row that our county has experienced planned power outages and massive smoke events. The past few summers have been unnerving as we raced to locate individuals who were reliant on power for medical care. Today we have many more systems in place but sadly this seems to be a new annual norm with fire and smoke season increasing each year, as well as the threat of mega-storms, flooding and sea level rise. While national politicians and business leaders have been slow to act, CCH recognized the need for action. This last year we created a dedicated leadership position to work on climate and health policy.

It's been both a sobering and emotionally rewarding exercise to write to my future counterpart. Sobering in realizing the many obstacles that still stand in the way of true health equity but rewarding in knowing that we leave you with a well-established foundation of service, excellence and innovation upon which you can continue to serve the people of Contra Costa County. I wish you the best of luck in your important work. May you have the joy of sharing in that work with the caliber of colleagues that have helped me progress our mission forward.

Anna M. Roth, RN, MS, MPH
Contra Costa Health Director