Awareness needed in environmental health

Key takeaways:

• Ozone and particulate matter impact asthma and COPD.
• Physicians can consider environmental factors in differential diagnoses.
• Patients should know about air quality and how they can mitigate its effects.

CHICAGO — Patient outcomes will improve as awareness of environmental impacts on health grows, Sheetal Khedkar Rao, MD, assistant professor of clinical medicine, University of Illinois Chicago Department of Medicine, told Healio.

“It really is a movement within medicine,” said Rao, who completed fellowships in climate change and health with the University of Colorado and Harvard University.

Rao discussed the importance of this awareness as part of the “Climate Change and Us: Why and How to Act Now” panel at the Power of Women in Medicine Summit.

Changing perceptions

The goal is to change how people see climate change, Rao said, from a polar bear floating on a melting icecap to a child who needs more inhaler puffs, a grandparent with heat exhaustion or a pregnant woman infected with the Zika virus.

“All of these conditions are exacerbated by climate change,” she said. “That’s the reason many medical schools are starting to include climate change in their curriculum.”

Physicians should consider environmental determinants of health, which significantly affect modifiable health outcomes, when evaluating and treating patients, Rao said.

“When clinicians understand that maybe a person is more exposed to air pollution or heat because of their job or because the community that they live in is affected by historical injustices like industrial pollution and fewer trees, they are more likely to account for that in their differential diagnosis,” she said.

Greenhouse gases caused by human beings are the biggest contributor to warming temperatures globally, Rao continued, and heat is the No. 1 weather-related cause of fatalities as well.

“Rising sea levels and poor air quality are interconnected with climate warming,” Rao continued, “along with biodiversity loss and its impact on pollinators, vector-borne disease and even pandemic risk.”

Historically, she added, the U.S. Department of Defense has called climate change a threat multiplier because it can lead to scarcity of resources like food and water, leading to poverty, polarization and political instability.

“People that are already vulnerable — the extremes of age, people living in poverty, pregnant people, unhoused people, people working outdoors,” Rao said. “Climate change will make life even more difficult for them.”

People affected by institutionalized racism will be impacted as well, she said.

“They are more likely to live in communities with more polluting industry, landfills, highways and less greenspace, all of which contribute to higher temperatures through the heat island effect,” she said.

Further, Rao noted that 99% of the world’s population breathes air that does not meet WHO standards.

“Ozone and particulate matter, which are two forms of air pollution aggravated by climate change, exacerbate asthma and COPD,” she said, adding that fine particulate matter, diesel fumes and several other types of air pollution have also been linked to lung and other types of cancers.

Rao also noted reports that firefighters battling wildfires are developing lung disease and rare, lethal forms of cancer at young ages from inflammatory toxins and carcinogens in the smoke.

Increases in asthma and allergy exacerbations due to longer and more intense pollen seasons are another result of climate change-fueled illness, she said.

In the clinic

“Every time a clinician learns something new, it can improve the lives of hundreds to thousands of patients,” she said. “Medicine is changing, and we have to keep learning.”

Clinicians who are aware of climate threats can then consider heat, pollution or many other environmental factors in their diagnosis and treatment, she said.

“They can also offer guidance to vulnerable patients,” Rao said.

For example, physicians could advise patients with heart or lung disease to avoid physical or outdoor activity when temperatures or poor air quality are expected to spike.

“For patients with conditions that increase risk of heat-related illness, for example, I would advise against taking a long hike or going to the beach on a hot day,” Rao said.

“I’d also caution them to hydrate early and often and make sure they have a plan to get into air conditioning if they don’t have it at home or the power goes out,” she said. “Sometimes, this means writing letters to the power company or their landlord to support their energy security.”

Rao said she would counsel patients with underlying illnesses to check the local air quality index before engaging in outdoor activities and to wear a KN95 mask when needed as well.

“This type of actionable guidance helps our patients feel better and can even keep them out of emergency rooms and hospitals,” she said. “That’s one huge practice measure that physicians who are aware of this information can take.”

Rao acknowledged the vast number of continuing education topics competing for physicians’ time and attention.

“This is why it’s so important to include climate in health professional curricula,” she added.

Climate and health resources that require varying levels of commitment are available even for professionals who are years out of training, she said.

“Investing a little bit of time into learning climate and health basics leads to a broader differential diagnosis, and a deeper understanding of the risks and challenges patients face,” Rao said.

“Ultimately, the investment is worth it because the WHO, the United Nations and 200 medical journals worldwide including The New England Journal of Medicine have all declared climate change the greatest threat to global public health,” she said.

Rao also acknowledged that time constraints make education about environmental impacts on health challenging during visits with patients, which already have many demands.

“I’m a primary care doc. I get 20 minutes, usually 15 by the time they’re checked in, to talk about what I need to talk to them about, which is disease prevention and management,” she said. “Of course, we also have to cover what they want to talk about, which is often a whole different topic.”

If patients want more information outside of the problem-focused advice that clinicians offer, Rao suggested that clinicians wear a ClimateRx badge, which features a QR code that patients can scan to learn more about climate change via peer-reviewed and vetted educational materials.

“They can read about a variety of different topics on how climate change affects health,” she said. “That can be done outside the visit.”

At the policy level

Clinicians also can be advocates for policy such as the 2009 Endangerment Finding, which declared greenhouse gases harmful to human health and enabled the U.S. Environmental Protection Agency (EPA) to regulate them under the Clean Air Act. The EPA is now considering rescinding this finding.

“Essentially, reversal of the Endangerment Finding would give vehicles and polluting industries free reign to emit greenhouse gases, likely accelerating climate change, pollution, extreme weather events and resulting health harms,” Rao said.

Also at the federal level, Rao said clinicians can support worker protections pertaining to heat, which the Occupational Safety and Health Administration is considering. At the local level, Rao encouraged clinicians to advocate for electric school buses, mass transit and tree-planting efforts.

“We can use our knowledge and our patient care experience to advocate for programs and policies that protect our patients, their communities and our own,” she said. “We can also use it to foster a more sustainable healthcare system.”

If health care were a country, Rao said, it would be the fifth largest emitter of greenhouse gases. Also, she said, health care produces 10% of the greenhouse gas emissions in the United States.

“Everything from hospital food and routine testing to traveling to the doctors’ office adds to health care’s carbon footprint, and not all of it is necessary,” she said. “There are ways to actually practice more sustainable medicine without compromising patient care.”

Health Care Without Harm is one of many organizations that provides resources and educational materials that clinicians and health care systems can use to reduce their environmental impact, Rao said.

Climate change also affects our ability to deliver care, Rao said, citing flooded hospitals after Hurricane Harvey, the shutdown of an intravenous fluid production plant in the wake of Hurricane Helene and a tornado striking a Pfizer plant in North Carolina.

Employees in health care and in the supply chain cannot work during natural disasters as well, she said. Lessons learned during the COVID-19 pandemic can inform better preparation and response in the future.

“The whole point of health care is to heal people and not cause harm, yet our health care system is actively doing harm by contributing largely to climate change,” she said.

Physicians and other health care providers can guide change in the right direction when they are aware of these impacts, Rao said.

“A lot of the talk around climate change is very heavy and depressing, and I really want to make the point that this is an opportunity,” she said.

“Preparing for climate change is an opportunity to work towards a more resilient and more equitable health care system,” she added. “We know we can do better. Why not use this as the impetus to start?”

For more information:

Sheetal Khedkar Rao, MD, can be reached at [email protected].