INTERVIEW WITH DR NICK IVERSON, DIVISION OF HOSPITAL MEDICINE AT SAN FRANCISCO GENERAL HOSPITAL + ASSISTANT CLINICAL PROFESSOR AT UCSF DEPARTMENT OF MEDICINE
Q. What are the core ways our healthcare system might need to change to accommodate the present and future health-related impacts of worsening climate change?
I approach thinking about this from two angles: climate change’s effects on health, and health care systems’ contributions to climate change. Similar to managing other health issues, we can approach thinking about climate change’s effects on health from the perspectives of both the prevention of the development or worsening of disease and the management of acute exacerbations of illness.
From a preventive standpoint, health care workers and public health officials should receive education on the health effects of climate change and its disparate effects on vulnerable populations in order to enact change individually or systemically. We know that climate change is already affecting our health in many ways, so part of our change must be to educate our patients on how to protect themselves from environmental changes, and as individual health practitioners recognize when our patients’ environments are contributing to the detriment of their health and consider ways to mitigate modifiable risk factors. We know that climate change disproportionately affects people of color, people with disabilities, and others—part of the prevention piece must also be to consider how our public policies and funding streams as well as health care attention and resources must be redirected to mitigate these ongoing environmental injustices and ensure health equity.
From the standpoint of managing acute health issues related to climate change, we must be prepared for climate disasters that are and will be occurring more frequently. This includes public health contingency management planning, funding and resource reserve storage, and individual health system planning in the event of health care systems overwhelm. For individual patient care, we will also see changes in frequency of lung and heart diseases, mental illness, spread of infectious diseases, and much more, and as individual clinicians we should be aware of how climate change as a health determinant contributes to these issues and how we can educate our patients to mitigate these factors to protect themselves after acute exacerbations of illness.
With regard to health care systems’ contributions to climate change, which are enormous, I view this from the perspectives of education, systems-based improvement, and advocacy/policy efforts. Worldwide, the health care industry contributes to ~4% of global emissions, and in the U.S. that number jumps up to a shocking 9-10%. It is striking that our industry contributes so immensely to this issue that is one of the greatest threats to human health at a systemic level, while trying to mitigate its effects at an individual level.
Regarding education, we should educate health care workers (the future of health system improvement work) on individual sustainable practice and on sustainable health system improvement. Regarding systems-based improvements, we must build into routine practice the reduction of hospital and pharmaceutical waste and move toward reusable devices, build green buildings, and pursue carbon offsetting. It means divestment from the fossil fuel industry. Sustainability has not been built into the improvement practices of many health systems partially due to a perception that the individuals working to improve hospital operations do not have access to experts in sustainability. However, in many ways health systems do have this expertise under different names: value improvement and Lean methodology. The principles of value improvement work and Lean regarding waste reduction can be applied directly and immediately by anyone with experience in those areas to improving health care system sustainability in hospital operations. Regarding advocacy and policy, this must happen at multiple levels. We as individual and collaborative health care workers should feel empowered to advocate to our health system leadership for improved sustainability, even if from the angle of value improvement. We should feel empowered that our voices matter for policy change at a local, state and even national level—and there are many forums where we can advocate for change at each of these levels. As a health care system and health system leadership, we must change our policies and True North priorities to generate funding streams for health care improvement initiatives to promote and invest in sustainable practices independent of the dollar value to the system, given the contributions of our emissions to our own and our patients’ current and future health.
Q. Which of these overlap with the U.S. medical system’s ill-preparedness for the current COVID-19 pandemic?
Three main areas of overlap are in disaster preparedness and response, health care rationing, and data-driven policy.
Regarding disaster preparedness and response, we need not only a knowledge of the hazards and plans for how to initially act on them, but a unified vision with strong leadership for a direction forward, and in acquiring and maintaining adequate supply stores in preparation for and during response to disasters. With climate change as with COVID-19, we must agree upon the fact that it is occurring and move forward with a response in a unified manner for quick recovery. Division on beliefs of the existence or strength of the effect of either issue is harmful to everyone in the recovery process, and ultimately directly affects health care system preparedness because of how resources are allocated to our health care systems to prepare for such events.
Regarding the rationing of health care resources, during a climate disaster, similar to the COVID-19 pandemic, we must be prepared to face conditions where despite our best efforts to plan, we may not have enough resources to serve everyone who is affected. Rationing is extremely challenging yet unavoidable when the health care system is overwhelmed, as we have seen in some areas overwhelmed by COVID-19. By planning for how we will approach this issue systematically and in advance we can relieve our front-line providers of individually deciding who should receive certain care and who should not while providing the best patient care possible under the rationed conditions. Given the approach should be systematic, it is essential that we plan for these challenges in the most equitable way possible and consider how our advanced planning may disadvantage people of color, people with disabilities, and other populations and ensure health equity. Under these conditions, there are many schools of thought for how health care may be rationed, which are well-outlined in the article “The Ethics and Reality of Rationing in Medicine” in the journal Chest, 2011.
Regarding data-driven policy, it is essential that scientists’ voices be considered during policy change discussions, and that policy be driven in part by advancing data and in consultation with experts in that scientific area. Furthermore, already existing policies have reduced our ability to respond to and increased the disparities related to the health effects from both COVID-19 and climate change. Given recent data showing increased rates of death from COVID-19 correlating with exposure to air pollution as well as research demonstrating the immense disparities in COVID-19 spread and deaths, there may be an additive effect of how environmental policies and other public policies lead to disproportionate effects for COVID-19 on communities of color—systemic racism contributing to conditions that put the health of our people at risk independently, and environmental racism from policies leading to increased air pollution in communities of color. For us to be prepared to respond to the health impacts of climate change and COVID-19, we must take a critical look at our policies that create conditions that worsen these health effects.
Q. Health care providers are tasked with communicating complex and emotionally difficult information (such as unwanted diagnoses and demanding treatment plans) in a way that informs, empowers, and helps a patient make prudent long-term decisions. In what ways, if any, do you see this skill as transferable to the task of communicating with people about climate change?
Communication is a key part of our work every day. Part of our job is to provide patient care, but equally as important is health education. Research has shown that health care providers may be a key source of access to learning about climate change through discussion of environmental health effects. In that light, we as health care providers should be prepared to discuss how the environment may be affecting our patients’ health. This may have a number of implications. At the most basic, patients may then be more prepared to mitigate environmental effects on their own health and those around them. Moreover, nutrition is a key part of preventive medicine, and discussing with patients how sustainable food sourcing and living affects their own health, the health of their community, and the planetary health more broadly may motivate patients to make additional changes. An additional layer is that it may give patients tools to discuss environmental health effects with others and disseminate this new knowledge. Last, some patients may feel empowered to then make larger scale changes and begin their own journey to learn about climate change and sustainability and enact change within their community.
Q. What do you see as the most effective ways that healthcare providers might serve as climate advocates?
There are many routes. The first step is to educate ourselves about the health effects of climate change and sustainability (since medical education has not traditionally provided this) so that we may have informed discussions. Advocacy can then come as many forms: in the traditional sense at climate rallies, setting up meetings with policymakers to advocate for change at any level, developing groups within your workplace to advocate to health system leadership to improve health system sustainability, and more.
Q. What existing interventions (such as reducing pollution in frontline communities) do you think should be the immediate focus of climate-related physician advocacy?
Some of the lowest hanging fruit that is still extremely impactful is to reduce waste and the carbon footprint within your own medical system. There are a number of toolkits available for how to do this when operationalizing or advocating for change with health system leadership, but even working to procure reusable devices, decrease the number of unused items thrown away at the end of a procedure, and advocating for more locally sourced, plant-based food options within the health system can have enormous impacts when scaled and may directly improve the individual’s work and life as well.
At a state or local level this will depend on the needs of the community. In the San Francisco bay area, for example, two very different but important ongoing environmental changes are the wildfires causing poor air quality and ecosystem change, and the injustice of the Hunters Point Naval Shipyard environmental attack on the Bayview-Hunters Point community. The poor air quality here affects everyone in the bay area, but it is clear that it disproportionately affects our most vulnerable populations such as people experiencing homelessness. Many people experiencing homelessness do not have options for sheltering during COVID-19, and are unable to escape the severe air degradation from wildfire smoke. Given the severity of the fires and thus increased likelihood of policymakers and the public to respond, advocacy could include sweeping and restrictive changes regarding emissions and waste, or could include advocating for protections for our population of people experiencing homelessness. Similarly, the health of our communities is affected by the radioactive contamination at the Hunters Point Naval Shipyard with knowingly falsified data—not coincidentally occurring in a historically black neighbourhood and still predominantly occupied by people of color.
Physicians will see the health effects of people disproportionately affected by these types of environmental conditions specific to their community, and thus can play a key role in advocating for change locally and within their health system using both public health and health equity lenses.
Q. As someone who educates physicians about the connections between climate change and health, what are some of the topics you focus on, and what learning outcomes do you see as particularly important?
Our curriculum team is taking a novel systematic and comprehensive approach to the climate health and sustainability knowledge and skills we are integrating into the UCSF School of Medicine—however, the particular outcome and an essential component of what we are interested in is student motivation. Each medical student will learn about climate change’s effect on health with a different lens, influenced by their past experiences with climate disasters, the knowledge they have gained from media or more traditional educational resources, and their own beliefs about the physician’s role as an advocate and in climate change.
We view the role of climate change educators and curriculum developers as going beyond helping students gain specific knowledge or skills. We want students to feel motivated to make change in whatever capacity fits their future life and practice, and there are endless possibilities for what this might look like. We hope to educate students in a way that supports and fosters their motivation, and provides them with a set of tools to be able to integrate climate health and sustainable practice in their future careers in whatever capacity they are interested in and is most applicable to their work. By approaching it from this lens, we are hoping to allow students freedom of choice for how they approach engaging with climate change in their work, and hopefully make this type of work more accessible.
Q.Outside of your work as a climate educator for physicians, what forms does your climate advocacy take?
Within my institution I have advocated for more sustainable food sourcing and for refocusing our lens on the health inequities from environmental changes I mentioned above. I have participated in climate rallies and advocate to policymakers as well.
Q. Have your experiences as a physician during this pandemic changed how you think about what prepares an individual healthcare provider for the mental and emotional toll of working on the frontlines during a national health crisis?
Preparedness is both systemic and individual. Systemically, the conditions in which we work play an important role in our wellbeing. Without going into the many ways that may factor in, I will say that health care leaders should consider how health system policies and working conditions affect health care worker wellbeing as a key component of quality patient care and worker retention.
As an individual, we as frontline health care workers face many types of stressors in our daily work which have been increasingly exacerbated in the setting of SARS-CoV-2. I have personally cared for many hospitalized patients with COVID-19, and I can tell you that in a single day emotions may range from nervousness about your own health, frustration with a shortage of resources, sadness about your patient who you are not sure will survive, joy as a patient who has been hospitalized for two months leaves the unit to go home and see their family again, fatigue from almost exclusively caring for people with COVID-19 every day you go to work, uncertainty about when you may next get to have meaningful closeness with your family and friends even when things reopen given your increased risk to them, pride about the work that you do, and despair about the public discourse regarding SARS-CoV-2 and fear about how it may affect your work. Health worker wellness has been an extreme challenge during this time, and historically our training in medical school and residency has done a poor job of providing us the skills we need to handle such circumstances—though fortunately this landscape is changing for those currently in training with a renewed national focus on improving trainee wellbeing.
Traditionally, medical training has focused on “Grit” as its main source of getting through challenging times, the idea that we will get through this if we just band together and push through—or, per leading experts on Grit, as passion and perseverance toward long-term goals as the key to success. While this quality has been studied and is an important success characteristic, its role in resilience during extremely challenging times such as this pandemic may be limited or at times even harmful. For an individual health care provider who is looking to this approach to get through the pandemic but finding they are still feeling unwell, their self-narrative may become “Why is my passion for my work and perseverance not good enough to make me feel okay through all of this?”, or more simply “Why am I not good enough or strong enough to get through this?”
The grit framework may be helpful at times, but more and more I look to reach a state of resilience through the lens of forgiveness. More specifically, self-forgiveness. This is the idea that while you may be gritty at times, the way to get through other challenging times is to realize that it is okay to not be okay. To acknowledge the moments you feel sad, anxious, or fearful and try to forgive yourself for feeling that way, rather than frustrated with yourself or feeling isolated. It is essential that in times like these we maintain communities that are going through these same emotions (even if remotely) and reach out to colleagues, loved ones, or mental health professionals if we are struggling to help us remember that we should forgive ourselves and help us feel connected. In that forgiveness may come resilience, improved wellbeing, and an even stronger sense of community than before.
Q. In the realm of climate change, we have certain myths that constrain our ability to communicate effectively about climate change and get the level of action we need to mitigate the worst effects of it. One such myth, that climate change is a problem to be remedied via individual action and sacrifice, distracts from the larger political change that is needed. What myths do you think impede the kind of preparation the medical system needs for future climate change and pandemic preparedness? How have these myths come up in your own experiences as a doctor?
First, I think many health systems are still coming to terms with their being any role for them in sustainability and carbon neutrality. Though we know there are relationships between climate change and health, until very recently there had been little talk nationally or within individual health systems about how to reduce the carbon foot print of hospitals, clinics, or other large health care systems or buildings. We need to ensure that narrative changes with buy in from leaders in each health system to ensure we are doing all that we can to not contribute to the problem.
Second, though health care rationing is not a new topic in medical ethics, I think many institutions are realizing that this is an issue they may face very soon and must get past the myth that this is something they will see in other cities or settings but not in their own. The hospital I work at fortunately has not had to ration care to date with COVID-19, however there is a committee that worked to establish guidelines for us to follow in case of overwhelm to the hospital from COVID-19—a key step for all health systems to take.
Last is the myth that we have time to prepare and can deal with what seem like other more pressing concerns first and deal with this issue later. Despite expert predictions that a pandemic could come and we needed to be more prepared, we were severely under-prepared for SARS-CoV-2 and not enough effort or funds were put into planning and preparedness when we were financially stable in the U.S. The same can and likely will be said for the effects of climate change and climate disasters on health and the preparedness of our health systems. While climate change’s effects on health will continue to worsen, they are happening right now—this is not a future problem, and we need to start planning and saving immediately. Beyond disaster planning, we must start training our health care workers and reserving financial and medical resources to prepare for the worsening health effects of climate in all of its forms. Moreover, it is in the interest of health system leadership to advocate themselves and change this narrative.