Clinical Conversations

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Four weeks ago — in early March — I interviewed Dr. Renee Salas about climate change and clinical medicine.

Back in those halcyon days, COVID-19 was very much a gathering storm, but it had not yet slammed into the United States.

Here we are, over 10,000 U.S. deaths later in early April, not having heard of much else but the disease.

I thought to use this interview now, both to give listeners a small break from “The Virus” — as President Donald Trump refers to it — and to remind us how quickly things can change on the planet.

We make mention during the course of the interview of the need to take the lessons from unanticipated disasters. We can only hope that the lessons the present crisis affords us won’t be lost.

Links:

Dr. Salas’ Perspective article in NEJM

Dr. Salas’ earlier NEJM editorial, written with Drs. Malina and Solomon, on “Prioritizing Health in a Changing Climate”

Harvard’s Global Health Institute

Running time: 18 minutes

TRANSCRIPT OF THE INTERVIEW WITH DR. SALAS

Joe Elia: This is Joe Elia. We’ve just turned the clocks forward here in the US and so summer is looming after a warm winter for Boston. If the past serves as a guide, we’ll have a warm summer, warmer than usual. Sleeping will get tougher, ticks will show up on our ankles, water will beckon us. Clinicians will work in comfortably air-conditioned suites, but their patients will often not be as lucky. Rene Salas reminds you all in a recent NEJM Perspective that hyperthermia is just around the seasonal corner. Our friends in the Southern Hemisphere have just had a horrible summer. Australia’s was unprecedented with an average temperature exceeding 30 Celsius or 86 Fahrenheit. We’ll talk about such things with Dr. Salas, who is a fellow at the Center for Climate Health and the Global Environment at the Harvard School of Public Health. She’s also in the Department of Emergency Medicine at Mass General Hospital and Harvard Medical School.

Welcome to Clinical Conversations, Dr. Salas.

Dr. Salas: Thank you so much for having me. I’m excited to be here.

Joe Elia: It used to be that summer was the time for bug spray and sunscreen. Everything’s changed, hasn’t it?

Dr. Salas: Yes. I think that there has been this growing recognition that climate change is not only happening in the world around us but it’s also impacting us as humans and it’s impacting our health. As this recognition has grown, there has been a goal to increasingly connect it to what we do every day to our clinical practice.

Joe Elia: Your recent perspective article in the New England Journal of Medicine gives a useful table for various healthcare demands, starting with EMTs who are bringing overheated patients to the ER, all the way out to the management types who need to prepare for what they can’t predict yet. Can you talk a bit about that?

Dr. Salas: So we know that there are associations across a broad range of climate exposure. So that ranges from heat to rising pollen levels, wildfire smoke, infectious diseases as you noted in the introduction, changes in water quality, and the intensification of extreme weather, but I think that the recognition is that all of these have very practical implications no matter what your role is in the healthcare system. So there’s a case that I outline about a man who was brought into the hospital because he was confused, but we were in the middle of a record-breaking heatwave, and his wife had called 911 and the EMT said that when they opened the door that it was like they were being hit by the Sahara Desert heat.

They lived on the top floor of lower-income housing and they had no air conditioner. They only had one window that was partially cracked, and so I think that that shows that EMTs are on the front lines, and I think as medicine is increasingly embracing and trying to expand community paramedicine, recognizing that they are my extensions from the emergency department out in the community and so how can we use them to educate patients about the risk of heat, counsel patients on what to do if they lose power, even if they normally have air conditioning.

The National Climate Assessment put out by the federal government has shown that they anticipate that the intensification of extreme weather and extreme heat are going to amplify and intensify the power outages. We actually had one right down the street, in fact, a power outage at Mount Auburn Hospital. That actually caused them to have to bring patients down from the top floor of the hospital because it was getting so warm because the backup generators don’t actually supply cooling to all areas. Even when the power was restored actually a lot of the equipment was so hot that it couldn’t function so they had delayed ability to be able to resume their normal functions because they had to wait for technology to cool down and this was in Greater Boston in 2019.

Joe Elia: Pretty interesting. So, as we were saying before, there were things that administrators must prepare for that they can’t imagine yet. I guess the only way to imagine it is to experience it and say, “Oh, damn, we should have done it this other way!” I mean of course we could be jocular about it now but when it happens — boy, oh, boy. For instance (and I guess you can’t talk about anything including candy bars without mentioning coronavirus these days). What do you think? Do you see any connection at all between global warming, climate change, and this kind of spread of infection? Is that at all on your radar, or is it a strong signal?

Dr. Salas: Yeah. It’s a great question. I mean we know that vector-borne diseases, so diseases transmitted by mosquitoes and ticks, that those have been on the rise. So not only longer seasons but moving to new geographic regions, which makes it hard for clinicians because now suddenly they’re facing patients who come in potentially with infectious diseases that they haven’t been used to seeing. Lyme disease can present in a multitude of areas and one that has really been expanding, here in the Northeast. So every rash to me in the emergency department has to potentially be Lyme, but I think that that shows that we really need to have a dynamic education curriculum and work closely with our public health colleagues in order to ensure that we can stay up to date on emerging infections and also make sure that we can educate our clinicians on those signs and symptoms of diseases that they aren’t used to seeing.

There’s always this issue, right, that we face these situations and research, because of the sound scientific practice it has to go through is delayed. I have to admit, I feel that climate change is truly that meta-problem and that threat-multiplier. So I believe it connects to everything in some way, whether directly, indirectly or even if it’s minimal effects. So my concern is that climate crisis may be fueling coronavirus in some way, but we don’t know yet. It’s too early. I think that it just shows that there’s so much research that needs to be done because we can’t prepare for what we don’t understand.

Joe Elia: Yeah. So back to those poor administrators who are going to be held to account when things go wrong: Is it really possible, do you think, to have drills about power failure? I’ve noted before that the [Boston] Marathon bombings were made a bit less chaotic because Boston hospitals had practiced, and many cities do practice now for mass casualty events. How does an institution practice for a calamity like power failure?

Dr. Salas: Yeah. So this is interesting and I think I really want to promote that that table [in the NEJM Perspective] was more of a thought exercise, where I was hoping to take the reader with me in thinking through different things that we can potentially implement to help prepare us as clinicians for what the climate crisis has brought and will bring. I think we always are better served if we are as prepared as we can be for situations. I think recognizing that power outages create a limited-resource environment in a normally well-resourced hospital. Again, everything from cooling not being in every area and maybe perhaps limited imaging and all of these unintended and unforeseen consequences that if a hospital has already gone through that and knows exactly what to do when a power outage occurs then inevitably I’d like to believe that we would then be better prepared when we actually face that.

You always have to weigh kind of the number of drills versus the benefits and so kind of rely on my disaster preparedness expert colleagues to end up making that decision but it is something to think about.

Joe Elia: Speaking of that, if that happened at Mount Auburn — and it did — how efficiently are the lessons of that disseminated to the other hospitals in the region? Are you aware of any formal way that a hospital having undergone such a calamity is able to share that?

Dr. Salas: Yeah. It’s a great question, and I think one that I know myself and my colleagues and others are thinking about is how can we share these best practices? Even when you think about heat, for example, and the fact that certain areas of the country and even the world have been facing extreme temperatures that are extreme for areas like here in the Northeast but have been facing hotter temperatures and know how to operate in that environment so we can learn from them. But you bring up a good point that when something like this happens like the power failure at Mount Auburn that that isn’t currently disseminated. In fact, when I talk about it even to people in Boston, many people didn’t know that it happened.

Leadership, again, may be aware but again just creating this sense of dissemination of experience is enormously powerful so we can learn from one another. I always come back to my emergency medicine roots and think about when a patient is crashing in front of us and we save them that it’s not saved by one person — it’s a collective team that saves that patient. Everything from environmental services that cleaned the room to the pharmacist to the nurse to the doctor to everyone. I think I recognize that this climate crisis needs to collectively bring the medical community together, across all sectors and disciplines to learn from one another. I think we’re stronger together and that’s part of why we are building this climate crisis in clinical practice initiative where we’re actually going to have symposiums similar to the one that we actually held in Boston on February 13 in different regions around the US at flagship sites and even internationally.

We currently are going to hold one in Australia. The goal of that is to come up with a group of us that have different geographic experiences, are exposed to different climate change exposure pathways, and to build an initiative where we can get some expert consensus and ways to share best practices.

Joe Elia: Here’s a question, what do you say to people who are skeptical about the role of climate change in clinical medicine?

Dr. Salas: It is enormously hard to scroll through your newsfeed, since most of us nowadays digest our news through a phone or some tablet of sorts without seeing that there are new things that people are experiencing in the environment around us. I think personally the science is very clear that the climate change is happening, that it’s human caused, and we have solutions. Nothing is harder for me than having a patient in front of me where I don’t have a treatment. Thankfully, here we have the ultimate treatment and the ultimate prevention, which is a decrease in our production of greenhouse gases. But I think recognizing that if we want to try to minimize the human suffering that is already happening, especially for vulnerable populations, but recognizing that we also have to simultaneously adapt not only our public health infrastructure but our clinical practice. While some of the implications of the climate crisis are clearer than others now, I think there are these insidious changes that we have to recognize. If we want to put the health of patients first in order to deliver the best patient care that we can, we have to add a climate lens to it because historically we’ve always been able to look backwards and try to predict the future based off the past, but that’s no longer possible.

The climate crisis is creating this uncharted future, and we have to prepare and prepare now and work together to do that.

Joe Elia: I wanted to ask you how you got interested in this whole question of the clinical implications of climate change and global warming.

Dr. Salas: I learned about climate change and its impact on health about six-and-a-half years ago, and it was fascinating because I had not heard about it at all during medical school or residency. For me, it was really an epiphany moment where I recognized that I could not imagine focusing my career on anything else because I couldn’t imagine anything else impacting my ability as a doctor to protect the health of my patients and to do my job than climate change. So it really started me on a path that has put me on the course that I’m currently on. For me, you can call it a job hazard of spending all of my time outside of the emergency department focusing on climate change, but I increasingly began to see that it was harming my patients, again sometimes in small ways, sometimes in larger ways, but I quickly saw that there was a need to add a climate lens to what I did in my practice, and I think increasingly as I had more conversations with others recognized that we needed to have a larger conversation to really adapt our clinical practice in the era of climate change, which has led to the initiative that I spoke about.

Joe Elia: As a result of your efforts, Dr. Salas, what do you hope will happen?

Dr. Salas: I think first and foremost we need to recognize that the health sector and the voices of health professionals is the most trusted messenger to connect climate change and health. I think one thing that at least I personally believe is why we haven’t had as much action on climate change and engagement up to this point is that it hasn’t been personal. We have had visions of icebergs and polar bears. Trust me, I love polar bears but it’s really about our children. It’s about our aging parents, who are enormously vulnerable, our less fortunate neighbors, and if that’s not enough to motivate you then it’s about yourself because climate change is harming your health in some way, again, however small, however large.

So the recognition of making these connections and talking about climate change as a public health threat — and I would argue as something that is changing our clinical practice — is first and foremost what we need to do as a medical community. So the ultimate end goal of that, as we engage in this conversation is that we need to talk about the fact that climate action is actually action to improve health. I would say that the Paris Agreement is the world’s greatest public health pact. So recognizing and connecting these things:

That not only are there short-term benefits of reducing particulate matter from the combustion of fossil fuels (which we know will improve health, but also the driver of climate change and thus will decrease, again, the human suffering that we will experience both now and in the future) is really important and encouraging our transfer to renewable energy sources.

Then I think the second half of that is adapting. So ensuring that we can adapt our public health practice and our clinical practice to continue to provide the best care to our patients and our communities when they need it most.

Joe Elia: All right. Well, I want to thank you very much for talking with me today, Dr. Salas.

Dr. Salas: Oh, it was a pleasure. Thank you so much for having me and for lighting this topic.

Joe Elia: That as our 257^th episode. The whole collection is searchable and available free at Podcasts.JWatch.org. Clinical Conversations is a production of the NEJM Group and we come to you from NEJM Journal Watch. The executive producer is Kristin Kelly. I’m Joe Elia. Thanks for listening.