Doctors and medical schools are changing treatments and training to respond to the warming climate
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It took nearly a month to contain the wildfires that burned over 40,000 acres around Los Angeles in January, but doctors warn that serious health implications from the blazes are just starting to unfold and will likely persist much longer. While all wildfires produce particulate matter and caustic ash, the toxic elements from burning buildings, cars and infrastructure differentiate the smoke and ash from last month’s Southern California fires. Children are especially vulnerable to the toxins in the smoke and ash.
As climate change drives an ongoing explosion of wildfires and blazes burning into urban areas, doctors agree that preparations, diagnoses and treatments will have to change to address the needs of their patients.
Dr. Anthony Gerber, a pulmonologist at National Jewish Health in Denver, Colorado, said that the recent Los Angeles fires could contain toxins such as formaldehyde, asbestos, cadmium and other heavy metals from old homes and burnt cars. According to Gerber, the abundance of man-made materials makes it more difficult for doctors to know the specific makeup of the toxic particulates from urban wildfires.
“Those elements can take what we know is already toxic and potentially make it even more toxic,” said Gerber.
While a reaction like an asthma flare can occur as an acute result of a single instance of breathing in wildfire smoke, Gerber is concerned that more attention isn’t being given to the long-term effects of chronic exposure. He estimates that the West Coast can expect to see one to two months a year of poor air quality due to wildfire smoke.
“That kind of chronic, every year, getting one to two months of particulate, crosses into the line where you’d be worried about long-term effects on lung function, dementia, cardiovascular health, all of those other things,” said Gerber.
When air quality levels are unhealthy or hazardous due to wildfire smoke, he recommends avoiding outdoor exercise, keeping indoor spaces clean and dust-free, running an air conditioning unit instead of opening windows, cleaning air with a HEPA filter in bedrooms and wearing a N95 mask outside. He also suggests especially sensitive groups such as people with asthma or chronic obstructive pulmonary disease have plans in place to avoid unhealthy air before the smoke arrives.
“It’s, unfortunately, the new reality,” said Gerber.
New Threats in Smoke
The man-made materials and structures burning have made recent wildfires different from those of the past, said Dr. Katy McNamara, an exposure scientist and executive director of the Center for Healthy Climate Solutions at the UCLA Fielding School of Public Health.
She has noticed local concerns regarding the ash and recommends hosing down vegetable gardens while wearing a mask and goggles and only vacuuming with a vacuum bag or HEPA vacuum filter to avoid spreading the ash.
McNamara also worries about the mental health struggles of firefighters and extreme heat exposure for informal labor workers.
Her team of researchers at UCLA has worked to build publicly available tools for use during natural disasters like wildfires. One tool is heat exposure modeling that is used to determine the number of ER visits that are associated with heat.
“There’s a bunch of different kinds of heat maps available,” said McNamara, “but ours is using actual health data because heat stress also manifests in diabetic patients and patients with heart disease, such as cardiovascular events and kidney failure.”
McNamara’s team has also researched the interactions between air pollution and heat, and wildfire smoke and heat. Studying the long-term health impacts of wildfire smoke, McNamara’s team looks at the mortality estimates of areas beyond the evacuation zones, where the plumes of smoke have traveled.
“I think everyone needs to assume that these are going to continue in the future and understand clearly how to read the advisories, interpret the air quality index, and protect themselves from exposure,” McNamara said.
McNamara hopes that public health information can be streamlined for easier access for those navigating climate change-induced disasters like the wildfires.
“Everyone has questions about the ash, and these are legitimate concerns,” she said. “So I think we need a better mechanism to get this information out to practitioners.”
Diagnosing Climate’s Impacts on Health
Dr. Rima Habre, USC’s CLIMA Center’s director, believes medicine is changing in response to new health challenges presented by climate change, though. Medicine has long focused on the genetic causes of disease, she said. “We’ve quickly realized that genetics don’t explain a lot of the disease risk. It’s really a lot about the environment and what people are exposed to.”
USC’s CLIMA Center recently received a $4.1 million grant from the National Institutes of Health Climate and Health Initiative to create a research center dedicated to climate change solutions. Here, a group of professors teach students to research and analyze exposures to the effects of climate change and integrate that data into patients’ records. The Center is partnered with L.A. Children’s Hospital and USC’s Keck School of Medicine.
Habre hopes that the data collected by the CLIMA Center can provide a more comprehensive background of environmental exposures so doctors who are too busy to gather that information themselves have a fuller picture of what their patients are experiencing.
This is no simple task, though. Habre said there are multiple things to consider when studying urban wildfires, such as how the winds redistribute the ash and heavy metals and how sometimes there can be a cascading series of natural disasters, like heat waves, wind storms, wildfires, downpours and mudslides. Habre calls these “compound climate events.”
“Air pollution, we know by now, affects pretty much every organ system,” said Habre. “It used to be that we only understood about the respiratory effects; now we know there’s respiratory, cardiovascular, neurological, brain, metabolic, microbiome and gross pregnancy outcomes. So we will have the data to look at that retrospectively.”
Habre believes that treating patients in the face of climate change needs to be more personalized, requiring clinicians to know and be aware of the environmental context of a condition they are treating.
“That’s the future,” said Habre. “We need to train experts who can handle these situations, who can talk to the environment people, but also talk to the health people, but also talk to the public and policymakers on what to do in these situations.”
Across the U.S., many medical schools note that students are requesting this specific climate change training, which has made more programs available nationwide. Comprehensive and progressive, these programs are building a network of “climate doctors” who seek to look at the bigger picture when treating their patients.
Climate change is a public health issue, according to Dr. Jay Lemery, a professor of emergency medicine and co-director of the Climate & Health Program at the University of Colorado School of Medicine, who has urged doctors to reframe the dialogue so that instead of thinking of polar bears on shrinking glaciers, society sees global warming as an issue affecting every avenue of their health.
Some years ago, when looking for people to work with on shifting this narrative, Lemery realized that there were only a handful of doctors, including himself, focused on global warming as a public health issue, so he sought to grow that number by training others to be “pushing all aspects of society and in policy, toward solutions, toward climate-informed health policy.”
Over the last decade, Lemery and his colleagues developed various programs at the University of Colorado for new and established doctors to lead the medical field in looking at health through the lens of climate change. Interest and enrollment in the programs have been “robust,” Lemery said, with a waiting list for their diploma program and doctors from all aspects of medicine enrolled in their fellowship program. Students who graduate from the programs take on the title of “climate doctor” or “diplomat in climate medicine (DCM).”
“There’s a body of knowledge that is not part of core medical training that physicians need to know if they’re going to be effective in taking care of patients from the effect of climate change,” said Lemery.
It’s doctors’ responsibility to discuss the health effects of climate change with their patients, just as they would urge patients to wear seat belts or quit smoking, he said.
Yale, Columbia, Harvard, Emory and other universities have also developed comprehensive programs in climate medicine training. Despite their different specialties, Lemery sees all of these doctors as colleagues with the same common interest who can assist each other in their programs, working towards a common goal.
“I came from a place of this feels really hard and scary,” said Dr. Gaurab Basu, a primary care physician in the Department of Medicine at the Cambridge Health Alliance and an assistant professor of medicine and global health & social medicine at Harvard Medical School and of environmental health at Harvard’s T.H. Chan School of Public Health. “It feels overwhelming for health professionals in their personal lives and seeing the way it impacts their patients.”
Harvard has initiatives similar to those at the University of Colorado for doctors going through medical school or already practicing medicine. The programs prepare doctors to be leaders in considering climate in medical treatment rather than simply responding to various environmental crises.
Doctors should be explaining the effects of climate change to patients seeking treatment, Basu said. Exposure to climate-related health threats like Lyme disease and air pollution, as well as the monitoring of the dosage of heart medications during heat waves due to their diuretic properties, should be topics of conversation with patients before prescribing drugs and treatments, he said.
Both Lemery and Basu believe that providing mentorship and education for a new generation of doctors is vital to help medical care keep up with the accelerating impacts of climate change. The wildfires in Southern California are the latest proof that climate change is creating complex situations that call for comprehensive understanding and clear communication from medical practitioners. Doctors nationwide are recalibrating to meet their patients’ needs, and every effort to consider climate change in health care helps on both individual and community scales.
“Helping people feel a sense of agency and purpose and community feels really important,” said Basu, “probably a central way I think about what to do for educational programs.”