Health Effects Of Climate Change

Featured topic and speakers

In today's COVID-19 Update, Colin Cave, MD, the medical director of external affairs, government relations, and community health for Northwest Permanente (NWP), the medical group for Kaiser Permanente Northwest in Portland, Oregon, discusses treating climate change as a public health crisis. Todd Unger, AMA's chief experience officer, is the host.

Transcript

Unger: Today, we're discussing the connection between climate change and health and how doctors and healthcare institutions may contribute to the solution. Dr. Colin Cave, the medical group for Kaiser Permanente Northwest in Portland, Oregon, is here with me. He serves as the organization's medical director for external affairs, government relations, and community health. Dr. Cave, who serves as an AMA delegate, has asked me to phone Colin on this particular day.

I'm Todd Unger, the Chicago-based AMA's chief experience officer. It's a real joy to have you here today, Colin.

Doctor Cave I appreciate you having me, Todd. This is a wonderful chance.

Unger: We all understand the worldwide crisis of climate change. You can't possibly look at the news today and not notice it in the headlines, in my opinion. Some people might not be aware of how much the impacts of climate change have gotten worse recently. Let's start by briefly discussing the course we're on and how Oregon, your home state, has been a particularly striking example of it.

Doc Cave: I agree. You know, I believe we all anticipated things would deteriorate. That has been mentioned to us for a long. But I believe we were taken aback by how swiftly they may deteriorate. We experienced a heat dome last year in the Pacific Northwest. It turns out that the technique used to create pressure cookers is the same as that used to create heat domes, which is why Portland, Oregon, reached a temperature of 116 degrees. I've lived in this area since 1994.

Unger: My goodness.

Dr. Cave: I never even came close. Additionally, the rest of the Pacific Northwest experienced problems. Over 1,000 heat-related deaths occurred in Washington and British Columbia, which was a tragedy. Unsurprisingly, Portland and Seattle are two of the three American cities with the fewest air conditioners per household. And we discovered that the majority of fatalities in the Pacific Northwest involved residents of homes without air conditioning.

And two years prior to that, we experienced the worst fire season ever. You know, the forests are burning even more fiercely now because of these heat waves. Additionally, more than a million acres burned in Oregon two years ago. Four small towns were all but demolished, thousands of homes were damaged, and 11 people died. The fires were so close that even our main hospital was on the verge of being forced to evacuate. This is just not natural.

Unger: Anyone who has doubts regarding the link between public health and climate change as a current crisis might want to reconsider after hearing the tales you're sharing here. Furthermore, you acknowledged that we must approach climate change as a public health emergency. Please elaborate a little more on the connection between health and climate change, both currently and in light of our predictions for the future.

Doctor Cave Well, there are many various angles from which to see it. I believe it's critical that we pay attention to how particular groups are disproportionately impacted by climate change. And the majority of those communities are comprised of people of color. Additionally, when working outside, the impacts are worse. You can only picture what it would be like to be a farm worker and to be working outside in the fields when it is 116 degrees outside.

Unfortunately, many residents of these towns reside in hotspots, densely populated urban areas devoid of trees, and places covered in concrete and asphalt. Furthermore, cities' internal temperature variations, known as heat sinks, can often be considerably worse. Additionally, these homes frequently have no air conditioning at all. Then there is the entire community of homeless people, who are ostensibly living outside. And once more, a greater proportion of these people will come from underprivileged areas.

The effects of climate change worsened conditions including myocardial infarction, strokes, and asthma when we consider the overall disease burden. Once more, how does that work? The woodland dries out as a result of increased heat. Forest fires exist. The flames produce particles that are two and a half millimeters in size, known as fine particulate matter, which enter the lungs and circulation and result in inflammation. And as a result of this inflammation, there might be heart attacks, strokes, vascular problems, and pulmonary problems.

Every time we have a fire in the Pacific Northwest, we know that there is a 5% to 25% spike in emergency room visits and hospital admissions. I also recall two years ago, while I was traveling to my clinic in Salem, Oregon, the air quality there had a rating of over 600, which was simply horrendously unhealthy. And the mental health repercussions in our communities require a whole new level of care for the thousands of people who lost their houses if you live in a city that has been completely destroyed by fire. We could discuss the links for a very long time, but we're keen to talk more.

Unger: Once more, the message is that this situation is urgent and not sometime in the future.

Dr. Cave: Without a doubt.

Unger: You also think that medical professionals, particularly doctors, have a duty to address how climate change is affecting people's health. Why is physician leadership in this field so crucial?

Dr. Cave: Well, when it comes to health, the doctor's voice is unmatched. And regrettably, there hasn't been much medical input in physician leadership over the past few decades. With a few exceptions, our hospital-related colleagues have largely provided leadership in the areas of health and the environment. There have been some excellent doctors who have served as spokespersons, and more doctors are getting involved.

Before we can intervene and inform others, we must first educate ourselves so that we can understand what is happening. And once more, this is beginning to occur more frequently right now. Because 80% of a person's health results from occurrences outside the exam room, this is basically what it comes down to. I have control over 20% of their health, on average, in the exam room.

The socioeconomic determinants of health are something we started addressing. Do they possess the means? Exist traumatic situations similar to unfavorable childhood experiences? And in order to help my patients get better, I must consider their overall health as a doctor. That implies that it is my duty to be aware of these factors and to make every effort to address them.

You understand that the first rule of the vow is to do no harm. Climate change is the best example of how it can be. Every dollar spent on healthcare that has to do with ordering tests, admitting patients, prescribing medications, and other activities related to performing our duties falls under the responsibility of physicians to the tune of 80%. Each of these choices results in a certain amount of carbon emissions.

Isn't it wonderful if we could carry out our duties? take good care of our patients while making decisions that lower emissions. Why is it important? 8.5% of all emissions in the US are caused by the health care sector. That is a lot. I'm pleased that my health system, Kaiser Permanente, received the certification for carbon neutrality in 2020. And just last year, we made the commitment to achieve net zero emissions by 2050, starting with a 50% decrease in emissions by 2030.

To answer your question once more, doctors will need to take the lead since we are the ones in charge of the healthcare system and we have the power to actually bring it down.

Unger: When you discuss that leadership duty with your medical colleagues, please let me know what you say. Do you notice yourself reflecting someone with a rather burdened expression, thinking, "Oh my gosh, it's another thing I need to add to the list of my obligations, of which there are many?"

Doctor Cave I've noticed that I receive a variety of replies. First of all, those who are grateful that there are some of us out there fighting for it and trying to engage the newer perspectives or the impassioned positions are the ones that don't give me the weary glances that say, "I just can't deal with this." I now encounter many doctors who are genuinely curious about how they may get involved. And this morning, I spent another hour on a teleconference discussing the possibility of organizing around environmental leadership with a group of Southern Californian doctors.

But it's intimidating. And if you're not accustomed to this, I can assure you that I wasn't taught this in medical school. There is a lot of learning that needs to take place, and one thing I firmly think is that doctors who are in leadership positions in this field must make themselves available to other positions that want to lead. We must educate ourselves and our colleagues before educating lawmakers and patients. This is the full domino effect of education.

Unger: You already indicated that your system sort of leads by example. Furthermore, Northwest Permanente has been actively engaged in this space for some time. In fact, it is the first physician-led medical group to achieve B-corporation certification. What does that moniker entail? Why is it essential?

Doctor Cave First off, we're quite proud of that. You must operate a for-profit business to qualify as a B-corp. For those listening who are unaware, Kaiser Permanente is composed of Kaiser hospitals and health plan, a non-profit organization based in California and serving all of the regions, as well as Permanente Medical Group, a for-profit independent medical group that has an exclusivity agreement with Kaiser to care for our patients.

But if you hire for fit, our doctors are all quite similar people, so that's really what it comes down to. We strive to make a difference not only in our clinics but also in the communities we serve because we care about them and want to be active members of them. As a result, we are very proud. And then when others come and consider whether or not they want to join our medical organization, that in turn is reflected.

Therefore, we frequently select people who share our goals and are mission-driven. They aspire to more than simply a steady job and a respectable retirement account. They desire a successful clinical practice, but they also want to be a part of an organization that cares for the local area, the environment, and our patients. So it's a win-win situation, especially in a country where there is a physician shortage.

The other thing it enables us to do, in my opinion, is to take the lead in the environmental field. We converted to a B-corp in 2016. When we examine our environmental responses, we see that there are areas where we can take the lead. And as a result, it forced us to declare that we would assume environmental leadership both at the time and going forward. As a result, it has given us good medical group positioning in this nation.

Unger: Would you mind sharing any lessons you gained through the procedure with other healthcare groups that are considering doing something similar?

Doctor Cave Being a B-corp is a great exciting experience, but it's also challenging. 85 percent of businesses who initially want to become B-corps fail the initial assessment. Therefore, you must truly want to accomplish it. You want to develop as a person, as a person, and as a corporation. I believe those are the requirements that let you sort of muster that energy.

Top-down leadership is necessary. One cannot just say, "Make it happen," in this situation. Because it does demand resources, your CEO and executive medical director need to be on board. Staff time must be allocated for it. Then you require the assistance of the front line. This is a collective effort. This cannot be a top-down process. This has to be ingrained in the group's DNA.

And it needs some time. To change your articles of incorporation, pass the examination, and then respond to the literally hundreds of questions—many of which are gated questions based on how you answer them—will likely take two to three years at this time Answering them leads to further inquiries. After that, you must include supporting evidence.

We've all completed the certification processes that the quality organizations require us to complete for the medical organizations. This is another one. However, we are rated on five areas of governance, workers, community, environment, and consumers rather than hospital days or infection rates.

Unger: I want to go back to something you mentioned earlier in the discussion because I didn't immediately think about it. This matter of lowering the carbon impact of healthcare. You've also made a significant effort to draw a link between the growth of telehealth and how it affects carbon footprint reduction. And you even published a sizable study that provided proof of this. So tell us a little bit more about that connection and the benefits of increased telehealth utilization that Northwest Permanente has experienced.

Doctor Cave Yes, since 2015, we have been keeping track of and recording our virtual visits in order to see how much we have improved in that area. Although there have been some smaller studies on this topic, we did disclose the results of the first significant research on virtual visits and their effects on the environment. Looking back from 2015 to 2019, we can see that while our membership and population grew, in-person visits to the clinic climbed by roughly 1.5% annually. But the rate of growth for our virtual visitors was roughly 39% every year.

We have so been asymmetrically expanding our virtual visits in comparison to our in-person visits ever since 2015. However, COVID occurred in 2020, as is well known. At that point, we noticed that our in-clinic visits had decreased by 46% in just one year while our virtual visits had climbed by 108%. And when we calculated the round trip that one of our typical patients would take to go to their primary clinic site, we discovered that, merely as a result, 9,000 metric tonnes of CO2 were effectively prevented from being released into the air in the Pacific Northwest.

We found it interesting that, historically, the square footage of the building you're in has always been used as the denominator for evaluating emissions efficiency or overall performance. As for emissions per square foot, a few of the authors of the paper who recently returned from Boston informed us of the annual reports on efficiency that Boston hospitals are required to submit. And if a hospital decides to construct additional facilities, even though it will require additional cement, CO2 emissions from the concrete, and electricity to operate, if there are fewer patients treated in each square foot, it will save money.

Your efficiency is given that denominator square foot doesn't look so good if you're a different hospital that has decided that instead of building more hospitals, you're going to use the space you already have to the fullest extent, go maybe six days a week, and have extended hours. This is because you have more emissions per square foot. However, I believe that most of us comprehend that the hospital that chooses not to expand is actually more effective. But that wasn't evident from the measurement.

Thus, in our work, we developed what we refer to as the ambulatory visit carbon intensity measurement, which simply states that you should assign a carbon intensity to each outpatient visit. Additionally, we were emitting around 8 kg of CO2 per visit before the year 2020. The carbon intensity per visit decreased to 4 kg after 2020, or when there was a large fall in in-person visits and an increase in virtual visits. Therefore, this offers an alternative perspective to asking whether someone needs to be seen in person and instead examines how many emissions are produced for each visit.

Unger: That's a completely different perspective on the importance of telehealth, and once more, I doubt that anyone else has drawn that connection. Speaking of connections, promoting health equity and reducing climate change are only two other connections that one would not immediately draw. What's the significance of that?

Doctor Cave You certainly nailed the nail on the head. When we begin discussing what you are discussing, we are considering climate justice. People that are socioeconomically disadvantaged are disproportionately affected by climate change, as we previously discussed. Due to health problems or bad living conditions in the past, you are more sensitive to the elements if you are exposed to them more. You'll experience more negative results than those who have resources if you're less able to adjust and more susceptible to negative health impacts. And that is merely a well-accepted fact.

Health effects may essentially be mapped by zip code. People with limited resources frequently reside in areas that act as heat sinks, such as those devoid of many trees, or adjacent to industrial facilities that generate large amounts of pollution. And if you reside in those areas, your health will unquestionably be worse than it would be if you did.

What it all comes down to is that we repeatedly observe that the people that are disproportionately impacted by global warming are also those that suffer from social justice challenges and are more vulnerable to pandemic morbidity and mortality. The overlap between all of these justice-related concerns is really staggering.

Unger: Colin, you really did a great job of outlining a variety of very concrete actions Northwest Permanente has previously taken in the area of climate change. What direction would you like to see it take?

Doctor Cave It's crucial for us to understand that, despite our optimism and desire for global warming to slow down and not exceed that 1.5 Celsius increase, we must also be realistic. This is something we did when we developed our climate action plan in 2019. And we've come to the conclusion that in the future, we'll be practicing medicine in a world with significant climatic change.

As a result, we are working harder than ever to address the problems of how to continue carrying out our mission in the event that our hospital burns down, we lose doctors or nurses as a result of a pandemic, or any number of other things that we are dealing with.

Unger: Colin, I sincerely appreciate your presence today. We've talked a lot in recent years about the relationship between climate change and health, but this is really the first time I've heard anyone go beyond the obvious in terms of immediate health issues and consider potential system-level changes in medicine that could have a significant impact in the future.