Mitigating climate health isn’t just the physician’s job – It’s a job for everyone

Weather-related catastrophes make national news with alarming regularity these days, whether it’s wildfires, tornadoes, excessive heat and drought, blizzards, or torrential flooding. London’s heat wave in July may have killed an estimated 1,000 people, the majority over three days. Congress and President Joe R. Biden recently passed legislation that will allocate approximately $369 billion to fighting climate change. However, people are suffering the effects of climate now and need immediate attention to prevent mortality and morbidity. And physicians on the front lines need support.

How does climate affect health?

Extreme weather conditions affect persons with chronic ailments like respiratory and cardiovascular conditions and can lead to new illnesses like chronic kidney disease. Power outages due to storms have been linked to increased hospitalizations for chronic obstructive pulmonary disease (COPD). Smoke from wildfires and dust from drought-affected areas can increase PM (particulate matter) pollution, exacerbating asthma and COPD.Heat can increase mortality. A 2022 meta-analysis in The Lancet showed that heatwaves could increase cardiovascular mortality by 11.7%. Occupational heat exposure has been linked to chronic kidney disease of nontraditional origin (CKDnt) in Central America and Sri Lanka. While populations in the United States have been identified as at risk for CKDnt, these populations have not been adequately studied, sounding the alarm for needed research. Of concern, scientists at First Street Foundation have modeled the development of an “extreme heat belt” in the United States in the coming decades. These findings suggest that chronic disease rates will climb in the future.

How do we manage environmental risk?

Patients with chronic conditions and vulnerable populations are more at risk for climate-related health effects, whether major disasters or seasonal events, like heat waves and poor air quality.Physicians see these health effects of climate in the office, none more evident than in the COVID-19 pandemic. As a result, the academic community has amplified the need for physician-public health leaders to manage collaborations, design initiatives, evaluate programs and effectively communicate health information. At the same time, physicians have few systemic resources to support their patients, and we are now seeing record rates of burnout.

While many organizations have disaster plans in place, a patient-focused strategy may be lacking. Hospital systems may activate the Center for Disease Control’s Incident Management System to respond to natural disasters, like hurricanes, on-site. A payer may have alternate locations to conduct operations if the primary area is subject to a major disaster.However, we need an outreach plan for members to prepare for events, like a storm-related power outage, that can be implemented rapidly and impact large numbers of members. For example, patients need readily deployed reminders to evacuate based on state emergency declarations, instructions to transfer prescriptions to another pharmacy, and telemedicine resources.Members could receive phone push notifications to connect them with resources and case management to increase information dissemination capacity beyond the ability of direct phone calls. Let’s not preserve preparation for weather-related events that lead to large national disasters; we must also plan for heat-related and air quality changes. Cigna recently offered rides to cooling spaces for its Medicare Advantage patients. Communities can support cooling spaces in collaboration with the payer as one mitigation strategy.

Health equity and climate are inextricably linked. Communities of color who live in areas with higher air pollutants and low-income families that live in frequently flooded areas may not have the resources to move. Social ties, financial resources, and employment prevent migration to other locations. Solutions to address housing insecurity may require policy change in collaboration with state and federal government agencies.

What is the solution?

Health systems, payers, communities, and pharmaceutical companies must coalesce to measure and mitigate the effects of climate change. However, these solutions must align with incentives. Examples include:

1. Health systems can manage climate effects through robust telehealth and population-wide education to prevent hospital overflow. They can modify electronic health records to identify at-risk patients and provide medication alerts. For example, patients on a diuretic may need to be more aware of hydration status during a heat wave.
2. Payers can implement digital solutions like apps that allow patients to track symptoms while providing geolocated data for air quality, heat index, and power outages. Push notifications can alert patients to weather changes and provide resources, like access to cooling centers in a heat wave.
3. The FDA and payers are compelling pharmaceutical companies to generate real-world evidence. Collecting real-world data makes controlling for confounders more difficult. Decentralized clinical trials are also becoming popular, enrolling patients dispersed geographically. As a result, regional climate differences and events may affect outcomes. For example, patients with heart disease exposed to a heat wave have more adverse events on commonly prescribed medications. If researchers do not match patients by region, results may have confounders. Pharmaceutical companies can play a role in developing measurement tools around environmental exposures, which they can mitigate to improve trial outcomes.

Changes in climate and extreme weather affect every stakeholder in the healthcare system. It’s time to create alliances to brainstorm and pilot interventions. Identifying solutions that align with each stakeholder’s incentives will ensure that we address the issues of today and prepare for the future.

Cynthia Miller, MD, MPH, FACP, is Vice President, Medical Director, Access Experience Team at PRECISIONvalue.