Training a new generation of ‘climate doctors’

By Caleb Hellerman, Global Health Reporting Center

College Station, Texas (GHRC) — For Dr. Aaron Hultgren, the wake-up call was Hurricane Sandy in 2012, when the young emergency physician returned from an overseas trip and found his hospital without power, its doors closed to the public.

Dr. Lakshmi Balasubramanian, an oncologist in Austin, Texas, signed up to study climate medicine after 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 motivated by 2023’s summer heat wave, when temperatures cracked 100 degrees Fahrenheit for nearly a week straight in July, setting all-time records.

Hultgren, Charlton and Balasubramanian traded these stories in early November as they gathered in College Station, Texas, midway through a first-of-its-kind diploma program that will mint them as certified experts in “climate medicine.” The course is the brainchild of Dr. Jay Lemery, director of the Climate and Health Program at the University of Colorado School of Medicine.

“This is our first foray into training a climate-savvy health care workforce,” Lemery said. “We need credible, knowledgeable and effective leaders, and we want to send a message to clinicians that these are critically important skills for mitigating climate-driven health effects.”

This past weekend, at the UN climate conference in Dubai, 123 countries signed an acknowledgment that climate change is having a major impact on human health, along with announcements of nearly half a billion dollars in funding commitments to bolster health systems and reduce overall harms to human health.

Lemery, who was at the meeting, says, “We just saw huge pledges and initiatives to double down on resiliency and decarbonisation, and yet no one has been trained to do this.”

Awareness of climate’s harms has been building, especially since 2009, when the journal The Lancet called climate change the “biggest global health threat of the 21st century.” Warming temperatures extend the range of disease-carrying pests like mosquitoes. Heat and drought disrupt crop cycles, leading to food shortages. Between 2030 and 2050, according to a World Health Organization report in October, climate change will cause an extra 250,000 deaths per year just from malnutrition, malaria, diarrheal disease and heat stress.

Warnings like this are a growing part of US medical education. Since 2019, the number of US medical schools requiring coursework on the effects of climate change has more than doubled. Universities and public health graduate programs offer majors and concentrations, but the Colorado diploma program goes a step further and aims to turn working medical professionals into leading experts on climate and health.

“It’s specifically designed for working clinicians who are seeking a ‘heavyweight’ credential,” said Lemery, an emergency physician by training. “We wanted to build a program that has real gravitas.”

Lemery’s program offers five separate certificate programs, each of which satisfies requirements for continuing medical education credits.

To earn a diploma, students complete all five, over a period of more than two years. The most recent module was designed to help participants prepare for and simulate a response to a major weather disaster.

Following readings and class discussions — over Zoom, since participants live in all corners of the country — course directors Dr. Terry O’Connor and Dr. Bhargavi Chekuri booked two days at a unique training facility. “Disaster City” is sprawled across 52 acres near the Texas A&M campus, where visitors will find upside-down train cars, smashed cars and buses and pile after pile of concrete rubble. Physicians are not the usual clientele; firefighters, EMTs and disasters come for the facility’s world-renowned search-and-rescue training.

The November training didn’t include any rubble piles, but the climate medicine students ran through tabletop simulations posing challenges like: What does your hazard vulnerability assessment need to include? How do you convince hospital administrators to pay for expensive, disaster-proofing upgrades that may never be used? If your hospital’s backup generator runs out, do you evacuate all the patients?

Lemery says the simulations cut straight to the essence of medical training. “Practice makes perfect. We can’t possibly be good at something unless we flex those muscles, go through the paces and learn how to make it better. When disasters hit, we want our medical teams and hospitals to say, ‘Don’t worry, we got this.’ We don’t want them pacing around wondering where we keep the emergency action plan.”

The federal government and states have strict requirements for hospitals to avoid catastrophic power failures, but as the simulation exercise made clear, that may not be enough. Generators flood. Evacuation routes may be blocked.

Dr. Karen Glatfelter, a physician from Lawrence, Massachusetts, told the group that supply chain issues are common.

“After Hurricane Maria, hospitals across the country ran into IV saline shortages that took months to work through,” she said.

Arien Hermann, who oversees a regional hospital coordinating center in southern Illinois, noted that not all electrical outlets are connected to a generator. At one hospital in Hermann’s network, this included the entire kitchen.

“So if you lost power, you weren’t going to have a microwave; you weren’t going to have refrigeration; you weren’t going to have electric stoves; you weren’t even going to have lights.”

Feeding patients and staff, the group agreed, would be a problem.

Hurricane Sandy underscored the vulnerability of many major hospitals. The storm killed at least 147 people and caused $82 billion in damage, according to the US National Oceanic and Atmospheric Association. Even Sandy faded into a mere tropical storm, a massive storm surge flooded 51 square miles of New York City, put much of Lower Manhattan underwater, led six hospitals to close and forced the evacuation of 6,500 patients. Hultgren, like many others, was utterly unprepared. “I never in a million years imagined that we would even lose power. It was a complete shock.”

Since Sandy, the number of weather disasters causing $1 billion or more in damage has soared; this year alone has seen 23 such events. But a changing climate is only one reason. A major factor is the higher cost of rebuilding, due to inflation, coupled with increased housing density in flood-, fire- and storm-prone areas. As a 2022 report from NOAA points out, “Much of the growth has taken place in vulnerable areas like coasts, the wildland-urban interface, and river floodplains.”

But recent years have also seen an apparent rise in storms like Hurricane Harvey, which dropped nearly 60 inches of rain on Houston while barely moving for five days, and Hurricane Idalia, which shocked forecasters in September by growing into a Category 4 storm nearly overnight. Such storms put an additional premium on planning and flexibility.

Unpredictable hurricanes aren’t the only threat from climate change, but they are part of what many people describe as climate “weirding,” new weather patterns that upend patterns of sickness and health.

Charlton, the Indian Health Service physician, whose home base of Gallup, New Mexico, sits at 6,500 feet of elevation, says he never imagined he would see the kind of extended heat that baked the town this summer. “Until now, we haven’t had to have cooling centers.”

Dr. Hilary Ong, a pediatric emergency physician from San Francisco, says doctors are taught to expect a cold and flu season that lasts from October to February. “Now, what I see in the pediatric emergency room is that respiratory season is lasting from September up to August. There was no break.”

Ong regularly cares for young patients who are dehydrated from extreme heat or struggling with asthma flare-ups after being exposed to wildfire smoke. She wonders, “Why am I seeing kids with asthma exacerbations all year ‘round?”

Being “climate-informed” helps clinicians do their daily jobs better, Chekuri says. She offers the example of a patient who comes in with a nagging 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 thinking about that change in the environment, then you can’t ask whether someone has had allergies before.”

Most doctors don’t think about climate on a day-to-day basis.“The realization about climate impacts on everyday patients was slow to come to me,” said Dr. Joanne Leovy, a physician from Las Vegas who is pursuing the climate medicine diploma. “People come into the office all the time with climate-related disease that we don’t recognize. And until you learn about the connections, you’re not going to see it.”

Many of the first doctors to focus on climate were emergency physicians or disaster relief workers. Those specialties are well represented in the Colorado program, but the group at Disaster City also includes three 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. Several students are already deeply involved in efforts to reduce waste and reduce the carbon footprint of the hospitals where they work; they point out that the US health care system is responsible for nearly 9% of the country’s greenhouse gas emissions.

Glatfelter pushed her hospital to switch out the standard gases used for anesthesia – replacing desflurane, the use of which in hospitals produces greenhouse gas emissions equivalent to a million cars – with a less-harmful alternative.

Dr. Elizabeth Cerceo, a hospitalist who chairs the “green team” at Cooper University Hospital in southern New Jersey, says there’s a laundry list of improvements that most hospitals can make, from re-examining their supply chains to simply replacing standard light bulbs with LEDs. Often, she says, it’s simply inertia that blocks change.

Dr. Katie Lichter, an oncology resident at the University of California, San Francisco, co-founded the GreenHealth Lab at UCSF, which generates research reports about the environmental impact of health care practice and “how climate change may reduce patient access to essential care.”

Lichter’s big moment of clarity came during the first days of her residency training at UCSF. Just a few months after she moved to San Francisco in 2020, Northern California was struck with a string of severe wildfires that sent a heavy blanket of smoke across the region. Locals still refer to “orange-sky day,” when the thick smoke generated its most surreal views.

Lichter had just admitted a patient into the ICU with Covid-19 as well as worsening cancer and lung disease. “He had missed weeks of crucial chemo and radiation because he couldn’t travel because of the wildfires,” she said. Pulling off her mask and gloves and home that night, she had an epiphany: “Climate change was going to impact my patients directly. This would be part of my career in medicine.”

Indeed, Lichter’s published research shows that cancer patients treated during times of wildfires have worse outcomes. Although cancer isn’t the first thing that springs to mind when it comes to climate change, Lichter says it shows how climate’s effects ripple through everything the health system touches.

“It’s the whole continuum of care,” she said. “Climate change increases exposure to carcinogens through air pollution and increased exposure to viral causes of cancer. And with screening, climate disasters impact access, like a patient’s ability to go get a mammography.”

The ability to access treatment, too.

Balasubramanian, the Austin-based oncologist, can’t say for sure that a winter storm killed her patient, but the woman had been fine a few days earlier. “She was thriving and doing very well,” the doctor recalls. “She was an avid volunteer and an advocate for pets and other women with breast cancer.”

The Colorado team encourages participants in the diploma program to be advocates on climate-related issues. Says Ong, “That’s really my motivation [for taking this course], to learn about this kind of medicine, to be a better physician and in order to lead and advocate and educate my peers and colleagues.”

Lemery points out that even after the height of the Covid pandemic, doctors and nurses typically rank high as trusted sources of information. “It’s important to bring the best science forward with candid-evidence based risk assessments. Our job is to train practitioners to be confident and proficient in doing just that.”

Mike Bethel, a nurse in Fresno, California, says he feels a duty “to speak out, as that trusted source, about things we know are true. We know that climate change is happening, and we know that it’s impacting our health negatively. When we don’t speak out about that as a profession, I think we do a disservice.”

Bethel says air pollution blocks views of the coastal mountain range that were visible almost every day when he was a Boy Scout roaming the mountains not far from where he lives today. He goes on to list other ominous signs. In Fresno, he says, “summers are longer. Summers are hotter. Our wildfire seasons have extended; they’re starting earlier and ending later. I mean, we’re already beyond a point of no return. There’s some damage that is irreparable, and if we continue, we’re going to damage the planet to the point where maybe it’s just not habitable.”

This dark view is shared by many here, but it’s tempered by a strong streak of idealism. Hultgren, who was an elementary school teacher before going to medical school, says he’s excited about forging a new path.

“As an emergency medicine physician, you always want to be at the front line, and I feel like I am at the front line, really trying to do something. We’re trying to change and hopefully impact our future for the better.”

Correction: This story has been updated to reflect that Disaster City is located near the Texas A&M University campus in College Station, Texas.

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