Joe Waters: Dr. Renee Salas is a Yerby fellow at the Center for Climate Health and the Global Environment at the Harvard T.H. Chan School of Public Health and affiliated faculty and a previous Burke fellow at Harvard Global Health Institute. She is a practicing emergency medicine physician in the Department of Emergency Medicine at Mass General and Harvard Medical School. She has served as the lead author of The Lancet Countdown on Health and Climate Change U.S. Brief since 2018 and founded and leads its working group of dozens of organizations, institutions, and centers working at the nexus of climate change and health. Dr. Salas, thank you so much for your time.
Renee Salas: Thank you for having me.
Joe Waters: Your work drew our attention because it is focused on this intersection of climate change and health, and in particular, on building the resilience of our healthcare systems to climate shocks. Can you speak to us a little bit more about this work, how you got into it, its relevance for the moment, and what you anticipate we need to do to build resilience across healthcare systems in the future?
Renee Salas: Thank you for that generous introduction. I will put in a plug that the 2022 Lancet Countdown Global Report and U.S. Brief actually just came out yesterday. We had a launch event, so I would refer everyone’s attention there to the Global Report in addition to the U.S. Brief and Appendix – we have a suite of resources. I moved to senior author this year and we have two amazing co-lead authors.
I’ll start at one of the points of your great kickoff questions there – how did I get into this? I read the second Lancet Commission Report back in 2013 and I clearly saw that climate change was threatening the very mission of why I went into medicine in the first place. It was going to be making our jobs harder to achieve, our fundamental mission, which is improving health, preventing harm, and accelerating equity. I think the journey from there has shown that the health connections have really been ones that are likely more recognized and more studied. You can have the latest technology and have all of the tools of the trade but if you don’t have the healthcare system infrastructure that you need in order to provide care, then we cannot get our communities that high-quality, low-cost, and easily accessible care that people need.
The healthcare delivery piece has been one that has been, I think, slower to rise to people’s attention but it’s one that is gaining traction. I’m really glad that you’re focusing on that aspect in particular. There’s a survey that we did with the New England Journal of Medicine Catalyst Group, where we surveyed 800 organizations across the globe. About 500 of them were within the U.S. 70 percent said that they already were seeing that climate change was threatening or impairing their ability to deliver healthcare. I think they have been underestimating across that entire questionnaire, so to me, 70 percent was high. I think as people are seeing that these climate-intensified weather events are challenging infrastructure, power, and supply chains – three key aspects that are essential for me as a clinician – and for us as a healthcare system to be able to operate to provide high-quality care.
Joe Waters: That’s really interesting. Do you have an example of how a healthcare system may be one of the respondents in that survey? What has actually happened? What are they saying has happened where it’s already affecting their operations?
Renee Salas: It’s a great question. I think examples always highlight the relevance of how this impacts our day-to-day life. I’ll preface it with another initiative that I’ve had the honor of being a co-director and spearheading and that’s the Climate Crisis and Clinical Practice Initiative with the New England Journal of Medicine Group. I bring that up because it was launched in February of 2020, little did we know, right, before the pandemic struck, it was one of my last in-person events. The idea of that is to make that connection for clinicians and healthcare administrators to see that climate change actually threatens their jobs and is making their jobs harder. It’s not abstract, it’s actually core to what we do. I’d like to think of that as adding a climate lens. I’m a photographer, so that’s probably why I gravitated towards that analogy, but it’s really just trying to look at what we already do within healthcare and understand how climate change is impacting that now and how it will increasingly impact that in the future.
Some examples: First off, think about power outages. Actually a hospital just down from where I live in Cambridge Massachusetts, it was a 90-degree Fahrenheit day in Boston, again, not enormously high by most people’s standards, but data has also shown that when the heat index is around 86 degrees Fahrenheit, patients actually have peak hospital admission. It’s actually happening oftentimes and there’s regional variation, but it’s often happening before we get to these catastrophic heat waves that really make headlines. So at 90 degrees Fahrenheit, this hospital lost power – not for anything that was climate-related, but because it was 90 degrees Fahrenheit, the top floor of the hospital actually became too hot for patients. Firefighters had to carry patients down to the lower levels where it was cooler, because when hospitals lose power their backup generators often do not supply the backup power to the HVAC system, so they’re not cooling those areas. Imaging modalities and machinery became so overheated that they could not come back online for a couple of hours after power was already restored. I bring that up because none of those features, 90 degrees Fahrenheit or any of those, would probably have raised any red flags. So, think about when there’s a climate-intensified event and it’s 110 degrees, there’s a hurricane that just happened, as we often see with these compounding disasters, and then you don’t have power – that obviously creates a lot of hazards.
An example of supply chains is following Hurricane Maria. More than 50 percent of intravenous saline, literally water in a bag, was produced in Puerto Rico. Following Hurricane Maria, which we know, climate change has intensified as climate scientists did follow-up research, there were shortages across the U.S. and other countries. Me practicing at Massachusetts General Hospital, we had shortages that if you didn’t meet certain criteria, I was handing you a can of Gatorade for hydration instead of providing IV fluids. You can imagine what patients thought when I’m handing them a can of Gatorade, but I think it allowed an opportunity for discussion. I think it also really highlights that we can’t look in the rearview mirror anymore to understand what lies ahead of us. We have to have an evidence-based approach to understand where our vulnerabilities are because these things are going to be increasingly happening and so we have to understand them so we can optimally prepare for them.
Joe Waters: I just want to push a little bit on the concrete examples, because the examples that I have tended to hear have been hospital-based examples, but of course, much of our healthcare system is in the ambulatory clinic setting. What are some of the things that, say, the pediatric primary care provider in suburban Boston, might see showing up in their clinical context as a result of climate change?
Renee Salas: It’s a great question. I think it’s one that we have some forthcoming work that really is going to try to create that expert consensus around because it’s important for us to understand where these intersections are and what the climate lens really means. One other quick thing I’ll add, obviously I know the system best because it’s my own system, but Massachusetts General Hospital has done risk assessments to understand where their vulnerabilities are from flooding to winds and storms, looking at different climate scenarios. So, back to that previous point about having the data, there are some systems that are starting to do it, but I think a key piece that we need going forward is to make sure that data is local because that’s how it’s going to be applicable to healthcare systems and offices and the entire system at large. We also need to make sure that systems that may not have the resources with which to do that themselves, still have access to that information, because we know we’re all interconnected; if one health system fails, the others are going to have to bear the brunt, geographically.
To get back to your question, when I think about what that means for a practicing clinician, from the clinical practice standpoint it’s recognizing that there are patients – I’ll use your example of a pediatrician’s practice – that are going to be at increased risk due to certain climate-related hazards. Whether that’s heat or thinking about air quality. Asthma is a good example, thinking about fossil fuel-generated air pollution if they live near a highway… I’ve never thought about a zip code or a patient’s address as a vital sign. Vital signs are where we’re measuring your heart rate and your blood pressure and things that are important for patient care, but increasingly, we are seeing very clearly that when we look at the downstream harms of fossil fuel, whether that’s air pollution or as it drives climate change, that your address does matter. It could have a flag within an EMR (electronic medical record) system that could say this patient’s address puts them at high risk based on what we know about air pollutants in this area and then that could lead to intervention or counseling.
Pollen levels are higher, and ground-level ozone is higher because of heat in pollen because of different climate change factors, so thinking about how to screen and identify those patients, to intervene, and to have conversations with that patient to understand what their unique vulnerabilities with higher temperatures are. Do they have a backup if they lose power? We need to run a nebulizer machine off of power and so, what are they going to do if they lose power? Most people who are blessed financially are able to run air conditioning, but what happens when the power goes out? These are the types of conversations that I think we as healthcare providers have to begin to have with our patients. These situations are happening more frequently and our patient’s health is at risk. How can we work with them to develop those types of plans?
I think the last piece, again, I’m trying to keep this broad with a few examples, is when we think about even an outpatient office. That also requires power to run the electronic medical record system and so losing power there, if they just shut down and can’t see patients, that’s going to divert those who need care to other local facilities that may or may not have power.
Another thing is around medications. Certain medications that we prescribe may place our patients at increased risk for heart-related diseases. Medications are affected by heat, so epinephrine and albuterol are two life-saving medications, but if you leave them in high temperatures, such as a car during a heat wave, they actually can become degraded and not as effective. Then you think about our patients who are getting these multiple threats and multiple hits of not only being exposed to more climate-related hazards and risks that are making their disease worse but then also the medications we’re prescribing may not be as effective or the pharmacy could be closed and they can’t actually get them refilled. I think that paints the challenges we have but also highlights the opportunities to develop an evidence-based and systematic and comprehensive way to assess it.
Joe Waters: What about our mental health system? We know that climate anxiety is very real – the recent Blue Shield of California Survey said that a very significant number of Californians who are Gen Z, those born between 1997 and 2012, have identified climate change as a source of anxiety in their lives already. Is our mental health system up for the task of what’s to come and if not, what do we need to be doing to ensure that it is resilient in the face of climate change?
Renee Salas: The short answer is, no, it’s not ready. I think it can be overwhelming to think about the interconnected challenges. In fact, I see climate change as what I often call a ‘threat multiplier, meaning it is making existing problems worse. We know that the pandemic has created and pulled at the threads of our mental health infrastructure with the increased need. I’ve seen that in my emergency department with more patients presenting with acute psychiatric needs. We know that rural areas, especially, have decreased access to some of these services. Even people in urban environments are struggling to get those resources. The 2022 Lancet Countdown U.S Brief actually does highlight mental health as one of our four key areas to highlight the latest data on. We don’t have an Atlanta countdown indicator yet, because it’s from a global level; it’s a hard thing with which to try to quantify – there are some different proxies that we use to start to get to that answer, but we know that those impacts are there and I think the evidence is clear. We want to try to start taking steps down that path to begin to shine a data light on these hidden corners.
It’s enormously broad, whether it’s thinking about eco-anxiety, climate anxiety just with climate itself, or extreme weather events creating PTSD or increased depression as people suffer through that – drought especially for people who depend on the land for their culture or livelihood, there’s been links shown there. As with all things, there are multifactorial intersections that, to me, lend an enormous opportunity to rise above multiple problems at once. If we can create a mental health infrastructure that is ready to handle these needs and all of the other interconnected crises that are worsening mental health, then we can begin to again get to the root cause and treat multiple problems at once.
I am happy to refer to other experts who can dive into exactly what the mental health system needs with which to become more resilient, but I can say conclusively, that from a climate change standpoint the mental health system is not prepared and it’s an area where I anticipate growing needs. We have to understand this and start to prepare for it optimally.
Joe Waters: Who is responsible within healthcare systems for bringing a climate lens to strategy, systems, and operations within healthcare systems, and frankly, what are the principles that need to be applied in that work, that could actually be instructive to other systems like our child care system?
Renee Salas: The short answer is, I think all of us are. I think we all have a unique role to play within a system. I’m always reminded of the situations where I get the most inspiration. When a patient crashes in the emergency department and the room fills, everybody has a different role, whether it’s a pharmacist, the nurse, or the radiology technician who’s taking the X-ray. We all have our different roles and through all of us working together, we can create what’s needed to save that patient’s life. I think from a healthcare system perspective, we have to work from both grassroots (bottom-up) and top-down to think about these issues, given the urgency.
I think first and foremost, the principle is to think about it. I can provide the link to that survey we sent out to healthcare administrators, but I think it’s clear that while there was 70 percent of people identified that climate change was having an impact, far fewer had actually taken action with which to start to address their climate vulnerabilities. I think there’s only about a quarter who have actually assessed their climate-related risks – back to that idea of making sure we have that data.
I think leadership needs to prioritize and recognize that this is a critical area that they have to set standards for and commit to understanding their respective facility, but also to recognize that they’re not alone in thinking about this. How can we collectively make sure we can develop the expert consensus and data needed to guide all of us quickly just like with the COVID-19 pandemic? We quickly generated data and people were sharing best practices; we can do that same type of information sharing again around climate change. We have to see it first, make the diagnosis, and then begin to implement the treatment.
I also think there’s an enormous opportunity for healthcare providers and professionals to elevate that discussion to leadership, that it is an issue and to begin to implement the
climate lens to their respective practice. Together, as we try to address it from all fronts, just like with a crashing patient where we’re implementing critical treatment along multiple avenues at that moment to make sure we can save that patient’s life, we need to do the same thing from a healthcare system standpoint.
Joe Waters: Great. What is the message you’re bringing to COP (Conference of the Parties)? I know you’re going in just about a week. What are you going to do and say while you’re there in Sharm el-Sheikh?
Renee Salas: I think this is coming right off the cusp of our Lancet Countdown launch, as I mentioned at the beginning. The Global Report’s main message is that health is at the mercy of fossil fuels. We are seeing these downstream health impacts and when I’m treating a patient, if what I’m doing isn’t working to improve their health, we do something different. We want to really sound the alarm that health is being harmed, that healthcare systems are being threatened and disrupted, and that we could undermine the public health gains that we’ve had over the past 50 years if we do not take action quickly.
Our goal is really to try to place what should be our motivation to act on climate change which is our own health and well-being – I love polar bears and icebergs, but I think that that has created an abstract or disconnected perspective of what climate change really means. The fact is that climate change touches everything we care about and threatens everything we care about, including our own health. We want that to be a message that resonates.
We also want to highlight that there are enormous health benefits that can be achieved through action on climate change and an equitable transition away from fossil fuels in a fair and just way. We cannot achieve true health equity without addressing climate change, given that it is worsening so many inequities, not only here in the U.S., driven by economic injustice and structural racism, but globally. We’re carrying the 2022 Report there, so I’ll be doing some different engagements including a presentation at the World Health Organization’s pavilion.
Joe Waters: Thank you so much, Dr. Salas, for your time. This has been great and we look forward to sharing this message and your work with those in our network and certainly the work of the Early Years Climate Action task force.
Watch the video recording of this interview here.