Climate Change at the Doctor’s Office

Doctors and nurses are increasingly finding themselves on the frontlines of the climate crisis as it takes a direct toll on our health. This is particularly true for those who care for low-income communities and communities of color. Their patients include workers in sectors like agriculture and construction and others who do strenuous labor outside in excessive heat, or who work indoors in poorly ventilated spaces like factories and kitchens. They serve firefighters and first responders who have been confronting rising levels of wildfire smoke, which can exacerbate asthma and contribute to other respiratory diseases. And more of their patients are encountering infectious diseases carried by everything from ballooning populations of mosquitoes to contaminated floodwaters. The mental health trauma of climate change, among disaster workers especially, has also grown clearer than ever.

For health care providers, this means a key part of the job has become recognizing climate-related health hazards, as well as advocating for climate resiliency measures that will improve their patients’ daily lives and health outcomes. This may mean anything from supporting better workplace protections (such as those that keep workers safe from extreme heat and smoke) to helping patients access energy efficiency upgrades that cut down on air pollution in their affordable housing units. And with record levels of burnout in health care, treating patients more holistically in these ways can only help relieve this burden that’s been exacerbated by the COVID-19 pandemic.

Dr. Cheryl Holder is working to expand the knowledge of health care providers on climate change impacts, as a founding co-chair of Florida Clinicians for Climate Action, an affiliate of the Medical Society Consortium on Climate and Health. She recently explained her journey to understanding how climate resilience measures are critical to improving health outcomes, as well as how it’s changed her own medical practice.

How have you seen the health effects of climate change play out in your work and community?

I’d been hearing so much about it—not even health, just about the climate. But I always had images of the polar bears out there and what was happening to them. And the sea level rise—there’s a tremendous amount of information on what the water’s going to do and how the buildings are going to go. But I’m here with patients, and more and more have started coming in [with climate-related health effects]. I started seeing kids with asthma because of mold and extreme weather, and mental health issues.

It all started coming together. How can we not recognize that the climate has changed, that global warming is here? The warming is affecting most of us who are vulnerable and living in these communities. It’s not something that is going to happen in 20 years, 30 years—it is happening now.

I see what my patients are going through. They are expressing it through their health, through asthma, through skin rashes, and through their kidneys. Especially my workers. That’s the population I care for. And so it brought it to the forefront for me. I couldn’t ignore the climate and couldn’t ignore what was happening to patients’ health. We have to act.

How do you approach conversations about the health effects of climate change in the clinic, with patients, and with the broader communities you work with?

I work with folks who are marginally employed, so they’re outside and they don’t have transportation all the time. I’m in the middle of Florida. So when you’re going to a bus stop and there’s no bus shelter, you feel the heat. When you’re walking on the pavement, you feel the heat. I work with folks who sell produce and flowers on street corners. They feel the heat.

I see the resistance to taking certain blood pressure medications like diuretics, which is a very cheap blood pressure medication for my patients’ hypertension. It works really well, but they can’t take it, because they are going to get even more dehydrated with the heat. They have to keep the fluids they have and keep going. It just doesn’t work.

So it’s easier for me in many ways to help them see that it’s getting hotter. “Yeah, but it’s always getting hot,” they tell me—but really, is it always hot at 8 o’clock in the morning? Is it always hot in the night as much as it is now? Has your electricity bill gone up?

As much as I can, I connect it for my patient so that they’ll understand it better, and I help them to take precautions and see what they can do to prevent dehydration. Little things, so they feel empowered and can continue on and keep working with some hope that it’s going to get better. Also seeing that they can advocate for change. So it’s a tiny baby step forward with folks who really don’t have the power to change it—immediately—but they do over time.

What are ways in which medical professionals can engage as advocates protecting workers and other individuals from climate-related impacts on health?

As clinicians, we do have to recognize that if our ultimate goal is to improve health outcomes—and that’s what we said we went to medical school for—then advocacy is a natural part of what we do. Because that’s the only way that we can truly improve the health of the patient that we are caring for.

We [clinicians] have to recognize issues in our society. Sexism, racism, and other -isms—they’re all part of what brings you to power. And to use our voices and use what we do to help change and improve our society. So it’s being realistic and saying, “Yes, we know we have a lot more power as physicians” and to use it in a positive way, because we have to do this as a part of treating our patients. We can no longer think we can just give them a prescription and they’ll go home and get well. It just doesn’t work that way. Physicians have a huge responsibility—but I don’t see it as a responsibility as much as it is a part of providing health care.

And if that’s what we said we’re going to do—health care—then how do we get our team to do the work and find better ways of listening to our patients?

I tell the physicians, you were planning on providing care. How do you do it when your office gets flooded or all your patients’ homes get flooded? Or when you have so many heat advisories and so many changes? Clinicians have to wake up. We feel the brunt of climate change as clinicians in addressing these issues, just as we have felt with the coronavirus.

How can physicians better integrate patient stories and social history–related information in order to help their patients adapt to climate change and improve their health outcomes at the same time?

This is all about the social determinants of health. I have a patient with hypertension, she has COPD, and in the previous way of looking at how we teach students, her case would be “70-year-old woman, noncompliant, using her inhalers, needing refills earlier, COPD exacerbation.” Totally physiologic. Totally based on her using her inhalers too much and possibly not adhering to instructions. So they would probably only teach her how to hold her inhaler and teach her how to use it properly. Rather than framing it as “70-year-old woman, in an old building with limited resources, with a warming daytime and nighttime temperature, an increase in allergens and pollution in her home, triggering her asthma and COPD and overutilization of medication.”

If you reframe it in looking at the real issues that are leading to her ill health, then you have to put these factors in. It pushes the clinician to take it a little bit further: “How do I then address some of these social issues which are important?” In my situation, I had to send her to the social worker. I filled out a form so she could get some benefits. I also tried to get extra inhalers and a better situation for her house, and that’s where the social worker came in. Because if we don’t get a better housing situation, and help her with her bills, her health is going to constantly deteriorate, which will lead to lots of hospitalizations and an earlier death.

It makes it better if you can understand that social history is part of how you diagnose a patient. And you have to address those, otherwise your patient won’t improve.

How do you find a way to sustain your enthusiasm and continue building the momentum without succumbing to climate anxiety?

We’ve had hundreds of years of successes in medicine. Look at all the antibiotics, at the mRNA technology, vaccines, and HIV treatment. So there’s a lot of history. That gives me the hope that we will overcome this. So why should the future be any different? What history has shown me is that if we do not frame climate solutions in a way that helps the vulnerable, then we will get there, but with a lot of loss.

So if we want change, we have to look at how we value people and take it back to our role as humans on this planet. Instead of just talking, how do we make a true obligation to work together across cultures and across the world? I’m optimistic that history tells us that we shall overcome. Climate is the final thing that’s going to push us to work together. We just can’t win any other way.

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