Wednesday, May 25, 2016

World on FireThis past April 4th, the White House released a report titled, "The Impacts of Climate Change on Human Health in the United States: A Scientific Assessment."  The nine chapter, 400 page document, which includes 150 pages of references, was drafted over three years by the EPA, DHHS, DOD, NASA, NOAA, the USDA and other federal agency and department scientists.  In sum, the report explains in nearly overwhelming detail why, "climate change is a significant threat to the health of the American people," particularly and not surprisingly, pregnant women, children and the elderly, communities of color and those with disabilities and/or pre-existing conditions.1  It is a work on a topic that deserves far more attention by health care policy makers and the provider community than has been witnessed to date.     

Regardless of whether you believe human activities affect global climate, (for example, the increase in atmospheric carbon dioxide levels or greenhouse gas concentrations due to emissions from anthropogenic fossil fuel burning), the fact that the Earth has been warming over the past century, is, as the report states, "unequivocal." Average U.S. temperatures have increased, the report states, by 1.3 to 1.9 degrees Fahrenheit over the past 125 years, with most of the increase occurring since 1970. Last year was the warmest year globally.  Fifteen of the 16 warmest years on record have occurred since 2001.  For the U.S., last year was the second hottest and third wettest on record. Last year also marked the 19th consecutive year the contiguous U.S. had an above-average annual temperature.2  "While health has always been influenced by climate and weather," it is the change "in climate and climate variability, particularly changes in weather extremes" the report states, that present a significant threat "not just in the future but right now."3 Depending largely on future emissions of greenhouse gases, temperatures are expected to increase by an additional 3 to 10 degrees Fahrenheit by the end of this century.

Beyond heat-related deaths, the direct effects of higher temperatures also cause heat exhaustion, heatstroke, hyperthermia and dehydration that can worsen pre-existing conditions such as hypertension; cardiovascular, respiratory, cerebrovascular and kidney and diabetes-related conditions; and mental health. One study cited in the report concluded that future warming, absent any adaptation, will result in an increase of 2,000 to 10,000 deaths annually in each of 209 US cities.  Among other effects, warmer winter and spring temperatures means the earlier annual onset of Lyme disease cases, which already number 35,000 annually in over 14 eastern states. Higher temperatures also affect other vector-borne diseases carried by, for example, mosquitoes, fleas, ticks and rodents. Currently there are 14 vector-borne diseases, including West Nile Virus, that are a national public health concern. The current outbreak of the Zika virus serves as the latest example. Warmer temperatures speed up the reproductive cycle of cold blooded mosquitoes.

High and prolonged heat have also increased drought conditions, particularly in the West. The report notes that the Southwest has "experienced the most persistent droughts since record keeping began in 1895."  These are expected to intensify. Outside the U.S., currently a third of India's population, or 330 million East Indians, are suffering from prolonged drought. When soil dust becomes airborne, asthma, acute bronchitis, and pneumonia frequently result.

Heat, stagnant heat, and drought increase the prevalence, intensity and duration of wild fires.  By 2050 it is anticipated that western U.S. wildfires will result in a 40 percent increase in organic carbon and a 20 percent increase in elemental carbon aerosol concentrations. Simply stated, this means air quality will decline and public health will be compromised. The currently burning wildfire in Alberta, Canada, as of this writing, covers 2,000 square kilometers, or the size of Mexico City, and may double in size due to extremely dry conditions before being extinguished. 

Heat, drought, and wild fires contribute to poorer air quality or worsening ground-level ozone pollution, particle pollution, and increasing levels of aeroallergens such as pollen. Combined, these are responsible for tens of thousands of acute care episodes. The report states, "future ozone-related human health impacts . . . are projected to lead to hundreds of thousands of premature deaths, hospital admissions and causes of acute respiratory illnesses including increases in asthma episodes in children due in part to a longer ragweed pollen season." Approximately 10 percent of Americans have been diagnosed with asthma. 

Warm air holds more water and higher temperatures cause elevated surface evaporation. This in turn increases the number and severity of rain storms, the resulting storm surge, and the intensity, frequency and duration of North Atlantic hurricanes. Forty percent of summer sea ice in the Arctic is gone. Coastal flooding is also the result of rising sea levels.  For example, flooding frequency in South Florida has significantly increased over the past decade due to an increasing number of high-tide flooding events. This means that drinking water is compromised, as are human waste water treatment and storm water disposal, resulting in increased risk of waterborne diseases caused by bacteria, viruses and protozoa. The report notes that between 1948 and 1994 68 percent of waterborne disease outbreaks in the U.S. were preceded by extreme precipitation events. The report emphasizes that the incidence of waterborne diseases may be underestimated by as much as 43 times their actual rates, and, for some species, by as much as 143 times their true infection rates.  Severe storm events also lead to increased food contamination via rises in the transport of pathogens in agriculture such as salmonella and noroviruses. "Climate change," the report notes, "will influence the fate, transport, transmission, viability and multiplication rate of pathogens in the food chain." Cases of Legionnaires' disease, spread by contaminated aerosolized water, have increased, not surprisingly by nearly 200 percent between 2000 and 2009.  

The climate penalty is also associated with a long list of mental and behavioral health conditions ranging from anxiety, depression, and alcohol and substance abuse to post-traumatic stress and suicide. For example, following Hurricane Katrina, the report notes, veterans with preexisting mental illness had nearly a seven times greater risk for developing an additional mental illness. Suicide attempts after Katrina among women living in temporary housing increased  to 15 times to the regional averages, and incidence of violent crime, including homicide and violence against women, rose substantially. 

The report raises numerous additional or cascading climate change-related health consequences.  These, again, disproportionally affect pregnant women, children, the elderly and disabled, minorities and the poor. Vulnerability, as the report explains, is a function of sensitivity to change and adaptive capacity to adjust or cope. The elderly are particularly vulnerable, since they are frequently immuno-compromised, are prescribed certain medications that compromise thermo-regulation or block nerve impulses, and because a significant percent are cognitively impaired and/or socially isolated. It is no surprise to learn, therefore, that half of the deaths resulting from Hurricane Sandy were among those age 65 or older. Ethnic minorities are also disproportionately effected: hurricane-related African American mortality was two to four times higher than for whites.

All this begs the question: What has been the response by Federal health care officials and health care leaders to climate change and the White House's recent report?   In 2009, while under Democratic control, the House passed by one vote the American Clean Energy and Security Act of 2009 (the Waxman-Markey Bill), that would have instituted emissions trading, but the legislation died in the Senate. This was the first and last Congressional effort to address climate change.  

Among relevant federal agencies, the CDC does make available decision support tools related to disease risk and preparedness, however admits the agency's programming does, "not address the causes of climate change."3 SAMHSA's most substantive effort to date appears to be a brief, 2015 supplemental research bulletin titled, "Traumatic Stress and Suicide After Disasters." AHRQ, the federal agency charged with making health care more effective and more equitable, has not conducted any climate change-related research. PCORI, created by the Affordable Care to fund "patient centered care," has awarded $1.4 billion in research grants to date, but has funded no research related to climate change. Neither the AMA nor the AHA have made mention of the White House report, nor does it appear that either association has conducted any climate change programming for its members. Both organizations were silent on the Waxman Markey bill.  The outlier appears to be the APHA, which has conducted 12 webinars to date, that are advertised as sessions "outlin[ing] how and why our health is being affected by climate change."5 

The White House report is welcomed. Nevertheless, it fails to make any recommendations. The report's accompanying fact sheet does note that the administration will be taking additional climate change-related actions. For example, the President's Task Force on Environmental Health Risks and Safety Risks to Children will expand its scope to include climate change. However, the report challenges no one. It asks nothing from anyone.  One could conclude the health care leaders have no obligations, no responsibilities. This is particularly disappointing considering the industry's track record to date. It is also disappointing when survey data show that although a significant majority of Americans know climate change is occurring, another significant majority have given little or no thought to the consequential health effects.6    

Notes

1. The report is at: https://health2016.globalchange.gov/.  The related fact sheet is at: https://www.whitehouse.gov/the-press-office/2016/04/04/fact-sheet-what-c....

2. See, for example, http://www.accuweather.com/en/weather-news/2015-shatters-warmest-year-on... and https://www.ncdc.noaa.gov/sotc/global/201513.

3.  See, http://www.cdc.gov/climateandhealth/factsheet.htm.

4.  See, http://www.samhsa.gov/sites/default/files/dtac/srb_sept2015.pdf.

5.  APHA's climate change webinars are at: https://www.apha.org/events-and-meetings/webinars/climate-webinars.

6.  Howard Koh, "Communicating the Health Effects of Climate Change," The JAMA Forum (December, 9, 2015).  At:

https://newsatjama.jama.com/2015/12/09/jama-forum-communicating-the-heal....


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