Pandemic, Science Politicization, and Risk Assessment

The COVID-19 pandemic has demonstrably exposed the shortcomings in our public health infrastructure and exacerbated the underlying disparities in our communities.¹

For those of us studying climate change and human health, the parallels are all too easy to make: a public health disaster hampered by a lack of preparation and coordination, health effects spilling over to have dire economic consequences, and a disproportionate burden falling upon vulnerable populations.^2, 3 The frightening reality is that too many American policy makers do not see value in public health investment, have an indifference to science education, and allow the most vulnerable to suffer from an indiscriminate disease all for short-term gains and political expediency. The pandemic has served as a palpable admonishment of our custodianship of the commons and the limitations of current governance to implement policy. Effective risk assessment has been obfuscated by conflicting governmental messages, and a lack of policy discipline with any underlying consistency. In this void, we have seen a rise in clarion voices of clinicians in the emergency departments, COVID-19 hospital wards, and increasingly on the podium, accurately reporting conditions, conveying the health risks and earning the public’s trust. Health care providers understand better than most the effects of cruel, societal dynamics and careless policies that disenfranchise our most vulnerable citizens. They are expert science communicators: educators on disease and respected interlocutors on human health risks. They are society’s go-betweens, routinely translating abstract medical science into digestible treatment plans. As evidenced during the pandemic, the doctor-patient relationship is still one people trust, and turn toward to seek understanding amidst conflicting health reports.

In crisis comes opportunity. Looking to a world suffering from COVID-19, we believe there are historic opportunities to reinvigorate and enhance the resilience of our communities and institutions. We have a once-in-a-generation mandate to reconsider our public health and economic operating systems, and in turn, change the trajectory of our next public health crisis—that of a rapidly changing climate.

The insidious encroachment of climate change has been a slow-motion crisis, with little to no effective responses in the United States. It is our sober assessment that when it comes to protecting our health from climate change, we are not keeping pace. It’s easy to look at data and actions to date and feel pessimistic. Yet before we embrace a full-fledged fatalism that we’ll just have to live with it, consider the historic mobilization that we have just witnessed. A call-to-arms of resources and public policy measures, having significant impacts upon business-as-usual and behavioral norms. Massive economic stimulus packages were passed rapidly, with widespread consent from a historically gridlocked, partisan legislature. Prodigious sums of public funds accelerated the development of diagnostics, treatments and vaccines for a previously unknown pathogen. Despite the criticisms that more could and will need to be done, there is no doubt that our society mobilized rapidly to address the crisis, individually and collectively.

As we consider how we may upgrade our operating systems in public health resilience, energy policy, and global governance, climate change has to be on the top of the list, and health care providers should be there too, offering unambiguous, educated, and clear assessments on what’s at risk for human health. In essence, we’ll need doctors who have a clinical expertise in climate medicine.

Creating Experts

Lancet has called climate change the “biggest global health threat of the 21^st Century.”⁴ Consider that wildfires are more intense and longer lasting than ever before.⁵ We have suffered from months of persistent air degradation across huge swaths of our country resulting in untold illness. We have experienced flooding, structural damage, and displacement from hurricanes, each year increasingly energized from warmer average temperatures.⁶ The data tell us that chaotic changes to our ecosystems are undermining healthy living, exacerbating illness, and stressing social determinants of health. The list of climate-related health effects is no different than a busy emergency department triage list: fainting (from extreme heat), shortness of breath (from degraded air quality and increased aeroallergens), fever (from vector-borne diseases), vomiting and diarrhea (from diminished water quality), and trauma (from extreme weather events).  

Such a list is ripe for the physician community to engage in explaining these risks to the public, but to date it hasn’t been the case. Why? A simple explanation is because there is not one clinical specialty that owns the topic, and there is a paucity of formal education on climate and health topics for doctors. Few clinicians have been educated and even fewer are prepared or equipped for handling climate health threats. Meanwhile, our patients become sicker and more numerous and our allotted time to help is more and more brief.

We believe that this is the time for a dedicated, multidisciplinary training program in climate medicine. The goal: to create physicians proficient and credible in climate and health science to assume leadership, disseminate knowledge, and influence policy. Such a program would include formal education in the machinations of policy creation, government, healthcare organization, education, curriculum development, and skillsets in science communication. Clinicians would become proficient in understanding climate change as a disease of vulnerability, disproportionately impacting communities of color, and highlighting socioeconomic health discrepancies experienced from extreme heat events, degraded air quality, and forced migrations from climate disasters. Simply put, the rationale for such a program would be to affect collective risk assessment from climate change. It would empower effective and respected translators of science, giving physicians the knowledge to expound not only on the quality of information that reaches the general public but also on its process (i.e., the pathways of scientific consensus). By changing risk perception, doctors can in turn energize the impetus to affect smart policy—energy use, mitigation, and adaptation.

Adequately trained physicians can also translate these health risks into dollar figures, as a way to better convey opportunity costs to a wider range of policymakers. For example, one recent study provided an excellent conceptual framework for broader estimation of climate‐sensitive health‐related costs. By examining ten climate‐sensitive case study events spanning eleven US states in 2012 (e.g., wildfires in western states, ozone air pollution in Nevada, extreme heat in Wisconsin), the authors estimated the total health‐related costs from 917 deaths, 20,568 hospitalizations, and 17,857 emergency department visits to be $10.0 billion.⁷ For health care policy makers, awareness of the magnitude and specifics of climate-driven health events could lead to better care and reduced costs. Physicians trained in blending climate science, policy, and research have the ability to advocate for patient health while simultaneously increasing efficiency in the healthcare sector and better contribute to the conversation on the systemwide financial risks of climate change on healthcare expenditure. Physicians knowledgeable in these areas also have an opportunity to shape multidisciplinary (i.e., engineering, operations, development) decisions on healthcare systems’ investment in climate-resilient hospital infrastructure, designed to ensure continuity of services during extreme weather events and prevent the downstream negative health outcomes due to lack of access to care following disasters.

Professional Fellowship

When considering just what a training program should look like, there are a few emerging competencies to draw upon. The Global Consortium on Climate and Health Education, an education resource collaboration administered by Columbia University’s Mailman School of Public Health, has published a set of core competencies for health professionals. The competencies are divided into five areas of practice: (1) climate and health knowledge and analytic skills; (2) climate change and public health practice; (3) climate change and clinical practice; (4) policy aspects of climate change and health; and (5) climate and health communication.⁸ These competencies were broadly envisioned to serve an international cohort of health care professionals from a variety of training backgrounds (i.e., public health, nursing, physician), and to serve as a guide for this novel curricula.

We propose a more tailored curriculum for physicians, based on the authors’ experience administering the University of Colorado’s graduate medical education physician fellowship, which began in 2017. Underwritten by a Denver-based foundation, this one-year program was established as an intensive training program for physicians to address the emerging complexities of climate and health issues which necessitate the development and dissemination of new knowledge sets. The four major competencies that trainees develop include:

1. Fluency with climate and health impacts: understanding how perturbations in earth science impact human well-being—both pathophysiologic and societal.
2. Facility with concepts of mitigation and adaptation as actions within public and private entities and the ability to evaluate quality and effectiveness of such actions related to health impacts.
3. Capacity to lead effective climate and health programmatic development within the academic, public, and private sectors.
4. Outstanding science communication skills to effectively articulate the impacts of climate change upon human health—both in academia and through lay communication.⁹

The early success of the fellowship has only been possible through close partnerships with like-minded governmental, non-profit, and academic institutions sharing their knowledge and expertise. In turn, the fellows have provided a valuable clinical health perspective to partners working on climate change policy, including the Centers for Disease Control and Prevention, the Global Consortium on Climate and Health Education at Columbia, the Medical Society Consortium for Climate and Health, the Nature Conservancy, the National Institute for Environmental Health Sciences, the National Renewable Energy Lab, and the Payne Institute at the Colorado School of Mines.

Over the last few years, these partner collaborations have grown significantly, as have the number of physicians expressing interest in participating in the fellowship. Yet the restrictions of a traditional graduate medical education fellowships have curtailed scalability and growth. Given physicians’ expressed interest to know and do more, the steady progression of climate change, and the new complexities brought upon by the pandemic with a lack of a coordinated public health response, we feel that the time is right to scale up this training program to motivated physicians seeking to improve public policy.

Scaling Up

Here’s how we do it:

First, given the experiences of COVID-19, the competencies outlined above almost seem quaint in their scope. COVID-19 hammered home the fact that when public health policy is undervalued and under resourced, disease and suffering will have a disproportionate impact on the most vulnerable and on communities of color. In that regard, we now understand that any comprehensive list of climate and health competencies has to include issues of global health equity, social justice, and diversity and inclusion. We likewise have seen natural disasters increasingly impact our communities, and therefore advocate for greater training on healthcare system disaster impact assessments and management planning for healthcare systems and their communities. 

Second, we foresee a tremendous opportunity in the “greening” of healthcare systems, which currently represents 17.7 percent of GDP and responsible for 12 percent of all employment in the country.^10, 11 Familiarity with climate-smart healthcare initiatives offers significant opportunities for leadership and impact within heathcare systems, particularly as many healthcare systems aspire to meet the goals of the Paris Climate accord and to achieve net zero greenhouse gas emissions by 2050.¹² These include waste minimization and sustainable waste management; low-carbon procurement and product “cradle to grave” life cycle analyses; energy and water efficiencies; sustainable transportation; and relevant hospital metrics (e.g., percent of generated or purchased renewable energy, green building design, and accounting of cost savings from these initiatives).

Third, we must accommodate physicians from diverse backgrounds, specialties, and geographic locations, and accommodate differing clinical schedules. There has never been a time where remote learning has been more acceptable, but we strongly believe an investment of this scope and the ideal pedagogical environment to teach this novel curriculum would benefit from in-person interaction and networking. We likewise believe that faculty-student interaction would optimally benefit from person-to-person teaching for a significant percentage of a curriculum.

Finally, we believe a great deal of success of the fellowship to date has been the steadfast commitment of our partners in exposing our fellows to the unique aspects of climate and health policy in action. To date, they have worked with one to two fellows per year, and we now must reimagine experiences that can be scalable for more fellows. One possible solution is to differentiate a “preceptorship” at the advent of a fellow’s experience, where they are assigned to a particular partner. 

Another opportunity is to liaise with organizations with likeminded missions that can absorb more than one fellow at a time. The AAAS, for example, has a Science & Technology Policy Fellowship professional development program, which provides a two-week orientation, regular workshops and trainings, group events, and summits to support a fellows’ development as a science policy leader.¹³

Such creative solutions and cross-sector partnerships will be integral to develop this climate and health physician fellowship to meaningful scale.

Climate Doctors: Creating Health Diplomats

Otto von Bismark said, "politics is the art of the possible." This past year has viscerally demonstrated the inherent injustices of our society. When trying to comprehend how the lessons of the pandemic foreshadow the health impacts of climate change, there are few who can effectively articulate the dizzy interplay between public health, energy policy, geopolitics, earth science, government, and medicine. We believe physicians can help to fill that gap and to help craft the narratives to build our post-COVID-19 world to value all human life as well as the life of the planet. 

With science policy training and knowledge in climate and health, physicians can practice both medicine and the art of science diplomacy, serving as a trusted resource in advocating for climate-resilient policies that protect the health of generations to come. They can also credibly address deeply rooted environmental justice issues in our communities and convincingly explain how healthcare and public health systems can allow all citizens to enjoy a healthy life. It is through deft and concerted diplomacy, as history has shown us, that we may confront complex problems. By applying such an approach, we can address the climate crisis with smart policy and advance human dignity in the same effort.

Endnotes

1. Merlin Chowkwanyun and Adolph L. Reed Jr., “Racial Health Disparities and Covid-19—Caution and Context,” New England Journal of Medicine 383 (2020): 201-203.
2. USGCRP, Climate Science Special Report: Fourth National Climate Assessment, Volume I (Washington, DC: U.D. Climate Change Research Program, 2017), https://science2017.globalchange.gov/
3. Jay Lemery, John Balbus, Cecelia Sorensen, Caitlin Rublee, Caleb Dresser, Satchit Balsari, and Emile Calvello Hynes, “Training Clinical and Public Health Leaders in Climate and Health: Commentary Explores Training Clinical and Public Health Leaders in Climate and Health,” Health Affairs 39, no. 12 (2020): 2189-2196.
4. Nick Watts, W. Neil Adger, Sonya Ayeb-Karlsson, Yuqi Bai, Peter Byass, Diarmid Campbell-Lendrum, et al. “The Lancet Countdown: Tracking Progress on Health and Climate Change,” The Lancet 389, no. 10074 (2017): 1151-1164.
5. John T. Abatzoglou and A. Park Williams, “Impact of Anthropogenic Climate Change on Wildfire Across Western U.S. Forests,” Proceedings of the National Academy of Sciences 113, no. 42 (2016): 11770-11775.
6. Thomas R. Knutson, Joseph J. Sirutis, Ming Zhao, Robert E. Tuleya, Morris Bender, Gabriel Vecchi, Gabriele Villarini, and Daniel Chavas, “Global Projections of Intense Tropical Cyclone Activity for the Late Twenty-first Century from Dynamical Downscaling of CMIP5/RCP4.5 Scenarios,” Journal of Climate 28, no. 18 (2015): 7203-7224.
7. Vijay S. Limaye, Wendy Max, Juanita Constible, and Kim Knowlton, “Estimating the Health‐related Costs of 10 Climate‐sensitive U.S. Events During 2012,” GeoHealth 3, no. 9 (2019): 245-265.
8. Columbia University School of Public Health, Global Consortium on Climate and Health Education, https://www.publichealth.columbia.edu/research/global-consortium-climate-and-health-education
9. Jay Lemery, Cecelia Sorensen, John Balbus, Lee Newman, Christopher Davis, et al., “Science Policy Training for a New Physician Leader: Description and Framework of a Novel Climate and Health Science Policy Fellowship,” AEM Education and Training 3, no. 3 (2019): 233-242.
10. Centers for Medicare and Medicaid Services, “National Health Expenditure Data. Historical,” December 16, 2020, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
11. Kaiser Family Foundation, “Health Care Employment as a Percent of Total Employment,” May 2018, https://www.kff.org/other/state-indicator/health-care-employment-as-total/
12. Josh Karliner, Scott Slotterback, Richard Boyd, Ben Ashby, Kristian Steele, and Jennifer Wang, “Health Care’s Climate Footprint: The Health Sector Contribution and Opportunities for Action,” European Journal of Public Health 30, Supplement 5.
13. American Association for the Advancement of Science, “Become A Fellow,” https://www.aaas.org/programs/science-technology-policy-fellowships/become-fellow-stipend-and-support#PD