Clinicians' Challenge: 'Bring Climate Change to the Bedside'

GIPL Board member, Neha Pathak, MD, shares her perspective on the climate crisis we are facing and how it should affect bedside manners.  This article was originally published in Medscape on February 19, 2020 - pre-declaration of the COVID-19 pandemic. For frontline clinicians throughout the United States and the world, managing the health impacts of climate change has moved from theory into practice, according to health experts at a recent symposium on climate change held in Boston. On February 13, 2020, the New England Journal of Medicine (NEJM), Harvard Medical School, the Harvard Global Health Institute, and the Harvard Center for Climate, Health, and the Global Environment (Harvard C-CHANGE) hosted the first Climate Crisis and Clinical Practice Symposium, cosponsored with every teaching hospital in the Boston area, to start this conversation.The goal, according to Aaron Bernstein, MD, MPH, a pediatrician, interim director of Harvard C-CHANGE, and coorganizer of the symposium, is to "bring climate change to the bedside."The health toll of climate change is vividly embedded in the mind of Arnagretta Hunter, MBBS, MPH, a cardiologist and clinical senior lecturer at Australian National University Medical School."We are emerging from a 'Black Summer' marked by unprecedented bushfires...with about half the population of Australia exposed to hazardous air pollution levels at some stage over the summer period," she told Medscape Medical News by email. "The combination of devastating drought, water shortages, and then extraordinary wildfires and the associated air pollution have really highlighted the inter-relationship between environment and health."Though these types of weather events are not new, the growing intensity and frequency of these incidents is staggering and the number of people suffering health harms from climate change-related stressors continues to increase. Clinicians like Hunter are looking to understand how they can continue to provide effective healthcare and protect health systems in the face of an unpredictable climate future.Applying a "Climate Lens"Over 100 clinicians and healthcare leaders gathered at the Boston symposium, where panelists spoke about the climate impacts on the health of patients in their daily practice, particularly on those most vulnerable including children, older adults, and the socioeconomically disadvantaged.From rising pollen levels and longer allergy seasons, to the harmful effect of extreme heat on health and the decline in effectiveness of certain medications, to natural disasters disrupting supply chains for necessary medications or medical supplies, no geographic location or medical specialty is likely to escape climate disruption to clinical practice.Given this reality, Renee Salas, MD, MPH, MS, an emergency medicine physician, coorganizer of the symposium, and assistant professor of emergency medicine at Harvard Medical School spoke of using a "climate lens" to pursue practical, tangible solutions that can improve health and increase the resilience of healthcare systems.In an NEJM perspective she authored, published to coincide with the inaugural symposium, she further detailed threats to health and to the healthcare system. Salas argues that medical professionals will need to work together as interdisciplinary teams to provide safe and effective care for patients as they make their way through the healthcare system.First responders, physicians in clinics and hospitals, and nursing staff coordinating discharge planning all have a role to counsel patients about how they can protect themselves from increasingly prevalent climate stressors, she said at the symposium.During a panel discussion moderated by Gina McCarthy, MS, former administrator of the Environmental Protection Agency during the Obama administration and current president and CEO of the Natural Resources Defense Council, leaders from several Boston area hospitals spoke about the various steps they have taken to build resilience and sustainability into their systems using the "climate lens."Kate Walsh, CEO of Boston Medical Center, stressed that she looked toward energy solutions primarily as a cost-saving measure for her safety-net hospital system and has found that working on sustainability has been "energizing" for her workforce.McCarthy agreed, telling Medscape Medical News, "climate change isn't a planetary problem, it's a people problem affecting our health…part of the solution is using energy sources that are cleaner, better, and cheaper."The Climate Crisis and Clinical Practice InitiativeThe Boston symposium marks the first time every major teaching hospital in the area has come together to coordinate a response to a health threat.Already, six more locally led meetings are being planned to bring together healthcare institutions throughout different regions of the United States. The goal is to understand and address the specific climate threats that vary by geography. The University of Washington, Emory University, Stanford University, the University of Colorado, and the Cleveland Clinic Foundation will host similar symposia in the coming year and continue to work with the Boston-based group to identify and share best practices.The process of developing best practices will likely vary by location and specialty based on the local climate threats.For example, pediatricians may focus on developing counseling strategies to advise patients to avoid outdoor activities during high heat or poor-air-quality days. Internists may target outdoor workers or those on high-risk medications like SSRIs on strategies to avoid heat exposure. Infectious disease specialists may focus on not only vector borne illness treatment but also emerging climate change-related concerns like increased antibiotic resistance. Procedural specialties may work to develop contingency planning in the event of heat or extreme weather-related power outages.Australian National University is the first global partner that has agreed to plan a "local" symposium that will be nationally accessible around Australia. Hunter, the leader of the Australian flagship site, hopes that this meeting will also offer a chance to help shape the climate change curriculum that all medicals school in Australia are working to develop."Climate change is making our jobs more difficult and we've got to figure out a way [to] address the risks in a way that makes sense for clinicians," symposium coorganizer Bernstein told Medscape Medical News.Core to the objectives of the initiative is not to overburden already overworked clinicians but to assist with developing care pathways that help health professionals continue to provide safe care in a changing climate."We can't expect that all providers can talk about this with their patients and their communities, but we clearly can expect that there will be some who want to do that…these kind[s] of events help people build that momentum," Bernstein explained.

Addressing the Harms We Can Predict

Among the attendees enthusiastically engaged in the proceedings were first-year medical students James Sullivan and Katherine Lowe from the Cleveland Clinic Lerner College of Medicine.Each described how climate and environmental issues had directly affected their lives. Sullivan shared that growing up on the edge of a superfund site in Massachusetts, where the industrial solvent trichloroethylene had contaminated the drinking water, inspired him to take a keen interest in protecting his patients from climate and environmental impacts.Lowe described growing up in Denver where she's seen less and less snow every year. "It's very traumatic to see your climate changing, we've had huge droughts and…we've had a wildfire within a mile of my house and that never happened before," she told Medscape Medical News.Their personal experiences have contributed to a sense of urgency to deal with the scientific consensus around climate change and the burgeoning health impacts. Both want to work toward incorporating climate change and environmental health education into curricula at their respective schools. According to their observations, many students at their institutions are highly motivated to understand the health challenges of the climate crisis as well.Caren Solomon, MD, MPH, an internal medicine physician and an editor at NEJM, closed the symposium by advising members of the medical community to consider making personal choices to lessen individual carbon footprints, discussing the impacts of climate on health with colleagues and patients, and educating lawmakers about the importance of addressing climate change.NEJM is also hosting an online discussion, Health Care and the Climate Crisis: What Can You Do? until February 23rd on NEJM Resident 360 to help medical residents share knowledge and ask questions about how to adapt clinical practice in the changing climate."We must prevent the harms that are foreseeable," Bernstein said. "I don't see how we can achieve health in our patients without dealing with climate change."About the Author: Neha Pathak, MD is a member of the GIPL Board of Directors.  Neha is a physician, currently working for WebMD.  She is Hindu and resides in Atlanta with her family.