Cultivating a new generation of “climate doctors”

Transforming a new generation of climate-conscious healthcare providers

Dr. Lakshmi Balasubramanian, an oncologist from Austin, Texas, decided to pursue climate-focused research after a tragic event during a winter storm left a patient trapped in her home, leading to her untimely death.

Dr. Paul Charlton, working for the Indian Health Service in the northwest of New Mexico, gained motivation after enduring a heatwave in the summer of 2023, when temperatures broke records and hit almost 110 degrees for a week.

In early November, Dr. Hultgren, Charlton, and Balasubramanian shared their experiences during the inaugural diploma program in College Station, Texas. The course, set up by Dr. Jay Lemery, director of the Climate and Health Program at the University of Colorado School of Medicine, aims to certify its participants as experts in the field of climate medicine.

Lemery commented, "This is our first attempt to train climate-aware personnel in healthcare. We need reliable, knowledgeable, and effective leaders, and we want to convey to physicians that these skills are crucial in combating climate-related health problems."

At the United Nations Climate Conference in Dubai, 123 countries signed an agreement acknowledging that climate change has significant health implications and pledged financial support worth nearly 500 million USD to strengthen healthcare systems and reduce health impacts from climate change.

Lemery, who attended the conference, noted that while there's been significant investment in improving resilience and de-carbonizing efforts, no one has been trained to address the challenges.

Awareness of climate risk has grown since The Lancet characterized climate change as the "greatest global health threat of the 21st century" in 2009. Rising temperatures have expanded the spectrum of vector-borne diseases, such as mosquito-borne infections. Heat and drought disrupt agricultural cycles, leading to food shortages. According to the WHO October Report, climate change will cause an additional 250,000 deaths annually due to malnutrition, malaria, diarrheal diseases, and heat stress between 2030 and 2050.

Similar warnings are increasingly integrated into American medical education. The number of US medical schools requiring courses on climate change impacts has more than doubled since 2019. Graduate programs at universities and public health institutions offer primary disciplines and specializations, but the College diploma program goes a step further, aiming to transform practicing physicians into leading experts in climate and health.

Lemery, an emergency medicine physician, explained, "This program was specifically developed for practicing physicians who aspire to earn their expertise in this field.""We wanted to build a truly serious program."

The Lemery program offers five separate certificate programs, each meeting the requirements for continuing medical education points. To earn a diploma, students must complete each five-year program within a two-year span, including the latest module designed to help participants prepare for major weather disasters and simulate responses.

The training concludes with in-person sessions at Disaster City, a 52-hectare facility in Texas, complete with wrecked trains, crushed cars, and mounds of concrete debris. Usually reserved for fire departments, emergency responders, and disaster relief teams, Disaster City is a renowned training ground for world-class disaster and rescue simulations.

During the November training, there were no debris piles, but the climate medicine students conducted tabletop exercises to address critical challenges. What items should be included in disaster risk evaluations? How can hospital administrators be convinced to invest in costly emergency preparedness upgrades? What if a hospital's backup generator fails, forcing evacuation of all patients?

Lemery stated, "These simulations hit the heart of medical training. Practice makes perfect. We build these muscles, take steps, and learn to improve. When a disaster strikes, we want our medical teams and hospitals to say, 'We've got this.'" We don't want them wandering around wondering where we store our disaster plans."

While the federal and state governments impose stringent requirements to prevent catastrophic power outages, simulations show that these measures may not be sufficient. Generators may flood. Evacuation routes can become blocked.

Dr. Karen Glatfelter, a doctor from Lawrence, Massachusetts, explained that supply chain disruptions are a frequent issue.

"After Hurricane Maria, many hospitals across the country encountered shortages of intravenous saline solutions, and resolving the issue took months," she said. Arien Hermann, who oversees the Southern Illinois Regional Hospital Coordination Center, pointed out that not all generators have electrical outlets connected to them. In her network, this includes the entire kitchen.

"If you lose power, you won't have a microwave; you won't have a refrigerator; you won't even have light." "

The group agreed that food provision for patients and staff would be a challenge.

Hurricane Sandy revealed the vulnerability of many large hospitals. According to the National Oceanic and Atmospheric Association, the storm claimed at least 147 lives and caused damage totaling 82 billion USD. Sandy developed into a tropical storm with devastating storm surges that flooded 51 square miles of New York City, causing widespread flooding in lower Manhattan, forcing the closure of six hospitals, and requiring the evacuation of 6,500 patients. Hultgren, like many others, was unprepared. "I would never in a million years have thought we would lose power." It was a total shock."

The number of billion-dollar weather disasters has skyrocketed since Sandy; there were 23 such events in 2023 alone. However, the climate change is only one factor. Increased rebuilding costs due to inflation and a higher population density in disaster-prone areas, such as coastlines, urban intersections, and floodplains, also contribute.

In a 2022 report from the NOAA, it was stated that "Most of this growth is taking place in vulnerable areas such as coastlines, urban intersections, and floodplains."

In recent years, there has been a significant increase in slow-moving storms like Hurricane Harvey, which dropped 59 inches of rain on Houston in just five days, and Hurricane Idalia, which quickly transitioned into a Category 4 hurricane, shocking meteorologists. Such storms pose additional challenges for preparedness and flexibility.

Schocking hurricanes are not the only threat from climate change, but they are part of what many describe as "climate regression" – new weather patterns that disrupt traditional disease and health patterns.

Charlton, an Indian Health Service doctor with a rural clinic in Gallup, New Mexico, said he could never have imagined the extreme heat the city would endure in the summer. "Until then, we didn't need air conditioners."

Dr. Hilary Ong, a pediatric emergency medicine physician from San Francisco, cited a growing concern for respiratory illness, which now stretches throughout the year instead of being confined to the traditional cold and flu season.

"I see in the pediatric emergency department that the respiratory season now runs from September to August. There's no break." Ong frequently treats young patients who suffer from dehydration or asthma attacks following exposure to wildfire smoke. She asked herself, "Why am I seeing more and more children with asthma throughout the year?"

"Knowledge of climate" helps physicians better manage their daily work, said Chekuri. She said an example of this would be a patient with chronic cough introduced to doctors with expertise in climate change. "Doctors with a deeper understanding of climate might recognize possible contributing factors, like an elongated pollen season that's sometimes intense and unpredictable. They might not be able to ask if the patient has ever had allergies if they don't consider these altered circumstances."

Most physicians barely consider climate change issues in their daily practice. Dr. Joanne Leovy is an oncologist from Las Vegas looking to earn a certificate in climate medicine. "It wasn't until I started considering climate medicine that I realized how much climate impacts daily patients who we don't even recognize. Until we understand the connection, we can't see it."

Numbers of early adopters in climate-focused medicine were often emergency physicians or disaster responders. This specialty is well-represented in the Colorado project, but the Disaster City team includes three oncologists, a psychiatrist, an infectious disease specialist, a pediatrician, a family practitioner, two nurses, and a paramedic. Some students are already actively involved in reducing waste and CO2 emissions at their hospitals; they found that US healthcare systems contribute to about 9% of national CO2 emissions.

Gratfeldt advocated changing the standard gas used in anesthesia to a less harmful alternative, replacing desflurane, which produces greenhouse gas emissions equivalent to one million cars.

Dr. Elizabeth Cerceo, chief attending physician at Cooper University Hospital in Southern New Jersey, said many hospitals could make improvements, from scrutinizing their supply chains to simply switching standard lights with LEDs. "It's often just inertia that holds us back," she said. Dr. Katie Lichter, an assistant oncologist at UCSF, founded the Green Health Lab at UCSF, conducts research on the environmental impact of healthcare practices and is currently studying "Climate: How Changing Conditions Reduce Patient Access to Basic Care."

Lichter's most memorable moment came during her first day of residency at UCSF in 2020, when Northern California was hit by a series of severe wildfires. After a few months, the region was shrouded in dense smoke.

"I had recently admitted a Covid-19 patient and lung cancer patient who missed weeks of chemotherapy and radiation treatments due to the wildfires," she said. In that night, I took off my mask and gloves and returned home with a realization: 'Climate change will directly impact my patients.' This will be part of my medical career."

Lichter later published research showing that cancer patients treated during wildfires had poorer outcomes. She explained that while cancer may not be the first thing people think of when considering climate change, it demonstrates how various climate factors impact all aspects of the healthcare system. "It's a continuum of care." Climate change increases exposure to carcinogens through air pollution and increases exposure to viruses known to cause cancer. Climate disasters can hinder routine preventive care, such as mammograms.

There are opportunities for treatment as well.

Dr. Balasubramanian from Austin couldn't definitively say her patient died directly due to the winter storm, but she remembers the woman being in excellent health before the storm. "She was an enthusiastic volunteer and animal advocate, and she had an active interest in helping other women with breast cancer."

Lemery encourages attendees of the Colorado Diploma program to take on climate-related initiatives. "That was my motivation (to take this course) to learn climate medicine, become a better doctor, lead my colleagues, and educate them."

Lemery points out the critical role physicians and nurses played as trusted sources of information during the COVID-19 pandemic. "It's essential to promote the best science through risk assessment based on data. It's our duty to educate practitioners to do this confidently and competently."

Mike Bethel, a nurse in Fresno, California, said he felt responsible to be a trustworthy source of information and speak the truth about climate change. "We know that climate change exists and it has negative health impacts. If we, as professionals, don't speak up, we're really not doing our job."

Bethel also pointed out that air pollution impedes the view of the mountain ranges he frequently hiked near his home before moving. He enumerated further ominous signs. In Fresno, he notes: "The summers are longer. The summers are hotter. Our wildfire season has been extended; it starts earlier and ends later. I feel like we've reached a point where there's no going back." "Some of the damage is irreparable, and if we continue, we will destroy the planet to the point where it becomes uninhabitable."

This pessimistic view is shared by many, but it is tempered by strong idealism. Hultgren, who worked as a teacher before medical school, said: "As an emergency medicine physician, I want to be on the front lines, and I feel like I am, and I'm really trying to make a difference and try to change things and hopefully improve our future."

Footnotes

World Health Organization. (2023). "Health and Climate Change: Key Messages."

Gan, Y., Frey, E. G., Uccio, G., & Norris, S. (2023). "Climate and Health Curriculum Integration: Guidelines for Medical Education."

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                    **Enrichment Data:**
                    Medical education can incorporate climate change impacts by means of strategies such as:

Interprofessional Education (IPE):
Collaborative Learning: Integrate IPE in medical curricula, where students from different professions, including veterinary medicine, learn together to understand the connection between human, animal, and environmental health. This helps develop team-based competencies to address complex global challenges like climate change.
Planetary Health Education (PHE):
Holistic Understanding: Incorporate PHE into medical curricula, which includes education for sustainable healthcare (ESH). Emphasizes interdisciplinarity, a deep connection with nature, and takes into account restorative, Indigenous, and intergenerational perspectives. Aligns tightly with the concept of One Health, promoting health in humans, animals, and ecosystems.
Climate Change and Health Topics:
Curriculum Integration: Incorporate specific topics related to climate change and health into medical education, such as modules on air pollution, allergens, flooding, wildfires, and their health effects.
Neurological Health Impacts:
Research and Education: Include research and educational information on the neurological impacts of climate change, such as disrupted sleep patterns, increased seizure risks, and cognitive decline. This helps medical students better understand the intricate interplay between climate and neurological health.
Student-driven Initiatives:
Planetary Health Report Card: Encourage student-led initiatives like the Planetary Health Report Card (PHRC), which evaluates PH activities in health professions’ education. This helps assessment of PHE implementation and identify areas for improvement.
Sustainable Practices:
Awareness and Advocacy: Educate students about various contributors to climate change, such as fossil fuel use and agricultural practices, and their impact on human health. This awareness can empower healthcare providers to advocate for policy changes and develop sustainable practices.
Targeted Interventions:
Regional Vulnerabilities: Advocate for targeted interventions tailored to specific regional vulnerabilities. This includes enhancing healthcare infrastructure and developing adaptive policies to address the unique challenges posed by climate change in different regions.

Integrating these strategies can help medical education better prepare future healthcare professionals for the complex impacts of climate change on human health.