Preparing the Next Wave of Climate Experts: A New Generation of Environmental Physicians
Empowering medical professionals to address the urgent intersection of climate change and health A Colorado program transforms practitioners into climate experts, complementing the growing trend of US medical schools integrating climate change coursework
Dr. Aaron Hultgren's wake-up call came during Hurricane Sandy in 2012. Returning from an overseas trip, the young emergency physician found his hospital without power and closed to the public. In a similar vein, Dr. Lakshmi Balasubramanian, an oncologist in Austin, Texas, enrolled in the study of climate medicine following the death of a patient who was trapped in her home during a freak winter storm two years ago.
Dr. Paul Charlton, a physician with the Indian Health Service in northwest New Mexico, was inspired by the unprecedented summer heat wave in 2023, where temperatures soared to over 100 degrees Fahrenheit for nearly a week in July, breaking all-time records.
Hultgren, Charlton, and Balasubramanian shared these experiences in early November as they convened in College Station, Texas, during a unique diploma program that will certify them as experts in "climate medicine." The program was created by Dr. Jay Lemery, the director of the Climate and Health Program at the University of Colorado School of Medicine.
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"This marks our initial effort to train a healthcare workforce equipped to handle climate-related challenges," stated Lemery. "We seek competent, well-informed, and impactful leaders, and aim to communicate to clinicians the vital importance of mitigating the health effects of climate change."
At the recent UN climate conference in Dubai, 123 countries recognized the significant impact of climate change on human health. Additionally, they pledged nearly half a billion dollars to strengthen health systems and minimize the overall impact on human health.
Lemery, who attended the meeting, expressed frustration, stating, "Despite the significant commitments and efforts to enhance resilience and reduce carbon emissions, there has been a lack of training to support these initiatives."
Awareness of the impact of climate change has been growing, particularly since 2009, when The Lancet journal referred to it as the "most significant global health threat of the 21st century." Rising temperatures have resulted in an increased range of disease-carrying insects such as mosquitoes. Additionally, heat and drought have disrupted crop cycles, leading to food shortages. According to an October report from the World Health Organization, climate change is projected to result in an additional 250,000 deaths annually between 2030 and 2050 due to malnutrition, malaria, diarrheal diseases, and heat-related illnesses.
The prevalence of warnings like this in US medical education is on the rise. Since 2019, the number of US medical schools mandating coursework on the impacts of climate change has more than doubled. While universities and public health graduate programs offer majors and concentrations, the Colorado diploma program takes it a step further by aiming to transform active medical professionals into climate and health experts.
"This program is tailored for practicing clinicians who are looking to obtain a prestigious credential," explained Lemery, who is trained as an emergency physician. "Our goal was to create a program that carries substantial weight and expertise."
Lemerys program provides five distinct certificate programs, all of which fulfill continuing medical education credit requirements.
Students are required to complete all five programs over a period of more than two years in order to earn a diploma. The latest module is specifically designed to assist participants in preparing for and simulating a response to a significant weather disaster.
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Dr. Terry O'Connor and Dr. Bhargavi Chekuri, course directors, organized a two-day training session at "Disaster City" in Texas for participants from all over the country. This unique facility, located near the Texas A&M campus, is known for its world-renowned search-and-rescue training for firefighters, EMTs, and disaster responders. The facility sprawls across 52 acres and features upside-down train cars, smashed cars and buses, and piles of concrete rubble. This experience is a departure from the usual readings and class discussions held over Zoom.
The November training session did not include any rubble piles, but the climate medicine students engaged in tabletop simulations that posed challenges such as: What should be included in your hazard vulnerability assessment? How can you persuade hospital administrators to fund costly disaster-proofing upgrades that may not be used? If the hospital's backup generator runs out, should all patients be evacuated?
Lemery emphasized that the simulations focused on the core of medical training. "Practice makes perfect. We cannot excel at something unless we practice, go through the motions, and learn how to improve. When disasters strike, we want our medical teams and hospitals to be able to say, 'Don't worry, we have this under control.' We do not want them to be scrambling to find the emergency action plan."
The federal government and states have stringent regulations for hospitals to prevent catastrophic power outages, but the simulation exercise revealed that this may not be sufficient. Generators may fail, and evacuation routes could become obstructed. Dr. Karen Glatfelter, a physician from Lawrence, Massachusetts, informed the group that supply chain problems are widespread.
She mentioned that hospitals nationwide faced prolonged shortages of IV saline following Hurricane Maria. Arien Hermann, responsible for managing a regional hospital coordinating center in southern Illinois, pointed out that some electrical outlets are not linked to a generator. In one hospital within Hermann's network, this encompassed the entire kitchen.
If power was lost, there would be no access to a microwave, refrigeration, electric stoves, or even lights, making it difficult to feed patients and staff, the group concluded.
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Hurricane Sandy revealed the susceptibility of numerous major hospitals. The storm resulted in a minimum of 147 fatalities and incurred $82 billion in destruction, as reported by the US National Oceanic and Atmospheric Association. Even though Sandy weakened to a tropical storm, an extensive storm surge inundated 51 square miles of New York City, submerged much of Lower Manhattan, forced six hospitals to shut down, and necessitated the evacuation of 6,500 patients. Like many others, Hultgren was completely caught off guard. "I never imagined that we would lose power. It was a complete shock."
Following Sandy, the number of weather-related disasters causing $1 billion or more in devastation has surged; this year alone has experienced 23 such events. However, a shifting climate is only one factor. A significant contributor is the escalating cost of reconstruction, influenced by inflation, in addition to increased housing density in flood, fire, and storm-prone regions. As per a 2022 NOAA report, "Much of the growth has occurred in vulnerable areas like coasts, the wildland-urban interface, and river floodplains."
In recent years, there has been an increase in extreme storms such as Hurricane Harvey, which brought nearly 60 inches of rain to Houston over five days, and Hurricane Idalia, which rapidly grew into a Category 4 storm in September. These unpredictable events highlight the importance of planning and adaptability.
Climate change not only brings unpredictable hurricanes, but also contributes to what some refer to as climate "weirding" - new weather patterns that disrupt traditional patterns of health and illness.
Charlton, the Indian Health Service physician based in Gallup, New Mexico at an elevation of 6,500 feet, expressed astonishment at the prolonged heat that plagued the town this summer. "We never had to set up cooling centers until now."
Dr. Hilary Ong, a pediatric emergency physician from San Francisco, noted that doctors are trained to anticipate a cold and flu season from October to February. "Now, I observe that the respiratory season lasts from September all the way to August without a break."
Ong regularly attends to young patients who have become dehydrated due to extreme heat or are struggling with asthma flare-ups after being exposed to wildfire smoke. She ponders, "Why am I seeing kids with asthma exacerbations all year round?"
Being "climate-informed" helps clinicians to perform their daily duties better, Chekuri explains. She gives the example of a patient who comes in with a persistent cough. "A climate-informed physician might be aware of the fact that our pollen seasons are longer, sometimes more intense," and unpredictable. "If you're not considering that change in the environment, then you can't inquire whether someone has had allergies before."
Most doctors do not consider climate on a day-to-day basis. Dr. Joanne Leovy, a physician from Las Vegas pursuing a climate medicine diploma, admitted that it took her a while to realize the impact of climate on everyday patients. She stated that people often come to the office with climate-related diseases that go unrecognized until the connections are understood.
The first doctors to focus on climate were often emergency physicians or disaster relief workers, with these specialties well represented in the Colorado program. In addition to these specialties, the group at Disaster City includes oncologists, a psychiatrist, an infectious disease specialist, a pediatrician, a family practitioner, two nurses, and Hermann, a paramedic, Marine Corps veteran, and hospital system administrator. Many of the students are actively working on reducing waste and the carbon footprint of the hospitals where they work, highlighting that the US healthcare system is responsible for nearly 9% of the country's greenhouse gas emissions.
Glatfelter urged her hospital to replace the standard anesthesia gases with a more eco-friendly alternative, as the use of desflurane in hospitals generates greenhouse gas emissions equivalent to that of a million cars.
The Bidwell Bar Bridge in Lake Oroville is engulfed in flames as a boat passes by during the Bear fire in Oroville, California on September 9, 2020. Dry winds fueled California's unprecedented wildfires, leading to new fires and causing hundreds to be evacuated by helicopter and tens of thousands to experience power outages across the western United States. (Photo by JOSH EDELSON/AFP via Getty Images)
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Dr. Elizabeth Cerceo, a hospitalist who leads the "green team" at Cooper University Hospital in southern New Jersey, states that there are numerous improvements that most hospitals can implement. This includes re-evaluating their supply chains and replacing standard light bulbs with LEDs. She notes that often, inertia is the main obstacle to change.
Dr. Katie Lichter, an oncology resident at the University of California, San Francisco, is the co-founder of the GreenHealth Lab at UCSF. The lab focuses on researching the environmental impact of health care practices and the potential effects of climate change on patient access to essential care.
Lichter's realization came during the early days of her residency training at UCSF. Shortly after she relocated to San Francisco in 2020, the region experienced severe wildfires that enveloped Northern California in a heavy blanket of smoke. The locals still remember the surreal "orange-sky day" when the thick smoke created a unique and eerie atmosphere.
Lichter had recently admitted a patient to the ICU with Covid-19, along with worsening cancer and lung disease. Reflecting on the situation, she realized that climate change would directly impact her patients and become a part of her medical career. Her research indicates that cancer patients treated during wildfires have poorer outcomes, demonstrating the far-reaching impact of climate change on the healthcare system.
"It's the entire spectrum of healthcare," she explained. "Climate change leads to greater exposure to cancer-causing agents through air pollution and increased susceptibility to viral cancer causes. Additionally, climate-related disasters can affect access to screenings, such as a patient's ability to obtain a mammogram." The ability to obtain treatment is also impacted.
Balasubramanian, the oncologist based in Austin, cannot definitively attribute her patient's death to a winter storm, but just a few days earlier, the woman had been in good health. "She was thriving and doing very well," the doctor remembers. "She was a dedicated volunteer and an advocate for pets and other women with breast cancer."
The Colorado team urges participants in the diploma program to advocate for climate-related issues. Ong explains, "That's really my motivation for taking this course - to learn about this aspect of medicine, to become a better physician, and to be able to lead, advocate, and educate my peers and colleagues."
Lemery highlights that even after the peak of the Covid pandemic, doctors and nurses continue to be widely trusted sources of information. "It's crucial to present the most accurate scientific evidence alongside honest, evidence-based risk evaluations. Our responsibility is to ensure that healthcare professionals are well-trained and skilled in doing so confidently." Subscribe to CNN Health's weekly newsletter for more.
Register here to receive The Results Are In with Dr. Sanjay Gupta every Tuesday from the CNN Health team. Mike Bethel, a nurse in Fresno, California, believes it is his responsibility to speak out as a trusted source about the negative impact of climate change on our health. He emphasizes the importance of healthcare professionals speaking out on this issue.
Bethel laments that air pollution has obscured the once clear views of the coastal mountain range where he used to explore as a Boy Scout. He also points to other concerning signs, such as longer and hotter summers in Fresno, and an extended wildfire season. He expresses the belief that irreversible damage has already been done to the planet, and expresses concern about the habitability of the Earth in the future.
Despite this grim outlook, there is a strong sense of idealism among many in the community. Hultgren, a former elementary school teacher turned medical student, is enthusiastic about paving a new way forward.
"As an emergency medicine physician, I always strive to be at the forefront, actively working to make a difference. We are dedicated to making positive changes and hopefully influencing our future for the better."
