Source: JAMA Network
In the spring of 2020, Maddy Kline was finishing her first year of medical school at Harvard and things were not going as expected. As the COVID-19 pandemic was surging across the nation, it was highlighting entrenched socioeconomic inequalities in health care and working conditions. George Floyd’s death at the hands of police officers was igniting protests. Suddenly, a national spotlight was being cast on long-standing social problems and Zoom rooms were buzzing with conversations about social justice and health disparities. But Kline noticed one omission: climate change—another looming threat poised to deepen inequities.
“I think for a lot of us, it felt like climate change was already becoming inexorable,” said Kline, who is pursuing a PhD in epidemiology alongside her MD. “It would be unethical to not give it due attention.”
A growing body of evidence is revealing the impact of climate change on human health, as outlined in a 2022 report from the Intergovernmental Panel on Climate Change. Among the effects of warming temperatures and shifting weather patterns are an increase in communicable diseases, a surge in chronic respiratory conditions, and a troubling uptick in heat-related deaths. Moreover, the report highlighted how climate change is exacerbating global food insecurity, leading to widespread malnutrition, and forcing mass displacements that further strain public health systems.
Acknowledging these realities, most US medical schools have added climate change to the curricula. Between the 2019 and 2021 academic years, the percentage of MD-granting schools that required curriculum on climate change and health rose from 27% to 55%, according to a survey by the Association of American Medical Colleges. In the 2022 school year, the percentage increased to 65%.
Back at Harvard Medical School, Kline and a handful of her classmates were among those who felt an urgency to act. With guidance from faculty mentors, they developed a pilot program about the effects of climate on respiratory health. Course directors approved the lessons’ integration into Harvard’s first-year medical curriculum in 2021. The group was careful not to overload an already packed syllabus, by introducing the information in small bites scattered throughout the existing coursework. “Our approach was to come to the course directors with a couple of ideas already prepared and be willing to do the work to create the course integrations ourselves,” she explained.
When the class was learning about childhood asthma, for example, they were asked to consider a hypothetical patient’s social and environmental risk factors, like living in a neighborhood with air polluted by the burning of fossil fuels or wildfires. The team developed an explainer on different types of pollution, its various sources and interactions with the lungs. Particle size determines where pollution is deposited in the lung, a concept already being covered in medical school, but the new lesson discussed how different types of pollution interact with the physiology of the lung to create disease.
Last year, Harvard Medical School’s Educational Policy and Curriculum Committee approved the course additions as part of the MD program’s societal themes curricula, which address social determinants of health. Kline’s group led the effort to add additional coursework for all the body systems in close collaboration with course directors and faculty mentors, including primary care physician Gaurab Basu, MD, MPH, the director of education and policy at the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health. Together, the students and faculty published the implementation details in an article in PLOS Climate this May.
“The students brought passion, vision, and ideas,” said Basu, who now serves as faculty director of the new Harvard Medical School Climate Change, Environment and Health curricular theme. Being knowledgeable about climate change is central to being a good doctor, he says. “We want to make this an inherent part of medical professionalism.”
Lisa Patel, MD, MESc, executive director of the Medical Society Consortium on Climate and Health, echoed this. “The majority of our health outcomes don’t actually take place in the clinic or in the hospital—they happen outside of it,” she said. Patel, who coleads a similar effort to integrate climate change education into medical school curriculum at Stanford School of Medicine, where she is a clinical associate professor of pediatrics, says climate change needs to be a part of the nationwide movement to incorporate social and environmental factors into medical education.
Harvard’s revised curriculum now includes lessons on disaster planning and reducing the health care system’s carbon footprint. For the section on kidney and endocrine health, Kline said they incorporated a module for natural disaster planning. Patients with chronic kidney disease who rely on dialysis will need a disaster plan in place if a weather event interferes with their access to care, she explained.
Stanford meanwhile is adding coursework about medications that make people more susceptible to the risks of heat, how to safely evacuate a hospital, and how air filters and masks can help people reduce the risk of wildfire smoke.
“There are massive implications that we aren’t prepared for,” Patel said of climate change.
Efforts to incorporate climate change–related board questions in medical school and residency training are underway, Basu noted. But although medical education is being reshaped, most practicing physicians didn’t get this formal instruction during their training.
“We are trained with certain disease model paradigms related to molecular mechanisms, genetics, and epigenetics—which are important. But more and more, we are seeing the environmental impacts on the origin of disease,” said Cecilia Sorensen, MD, an associate professor of emergency medicine at Columbia Irving Medical Center. “We need to be able to understand these environmental impacts so that we can actually diagnose patients appropriately and then prescribe treatment plans that are going to make them better.”
In 2017, following her medical residency at Denver Health, Sorensen codeveloped the University of Colorado’s Climate & Health Science Policy Fellowship for health care professionals with Jay Lemery, MD, a professor of emergency medicine specializing in wilderness and environmental medicine. The fellowship has graduated roughly 25 physicians so far, Sorensen said, many of whom have gone on to develop and lead climate health programs.
One of those physicians is Stefan Wheat, MD, who today directs the planetary health climate change curriculum at the University of Washington School of Medicine, where he’s an assistant professor of emergency medicine.
“People need to be exposed to this at different stages of their training,” he said. For practicing physicians, “the idea is to create someone who is not just comfortable dealing with this in the clinical space, but who can take it to the next level and be a regional or national leader around the issue of climate change and health.”
As the program’s first fellow, Sorensen worked under mentors in the environmental health field and attended national and international policy meetings. She traveled to Guatemala where she witnessed how extreme heat affected agricultural workers. Young and otherwise healthy people were falling ill with chronic kidney disease due to exposure to higher-than-normal temperatures. When Hurricane Maria devastated Puerto Rico, she flew there to assess the health effects of the disaster.
After completing her fellowship, Sorensen joined the Global Consortium on Climate and Health Education, which aims to equip health professionals worldwide with necessary knowledge and skills. The organization includes more than 360 medical, nursing, pharmacy, public health, social work, dental, and veterinary schools. Its Climate & Health Core Concepts for Health Professionals, first published in 2018, is now in its third edition. The group also offers free online certificate classes for health professionals and has created an open-access repository of expert-reviewed medical educational resources on climate. The resource bank is organized by organ systems and specialties, ranging from primary prevention to intimate partner violence.
“We wanted to figure out how to change the training of doctors, nurses, and public health professionals so that they are prepared to diagnose, treat, prevent, and respond to climate impacts,” Sorensen said.
Basu acknowledges that it’s easy to get discouraged and feel despair when thinking about all the ways climate change could affect human health. But he said he hopes to energize medical professionals and empower them to take action on the issue. “Showing them ways they can have agency and do something about it is important,” he said. Educating physicians about the health effects of climate change could enable them to invent creative and innovative solutions, for example, or use their unique influence to advocate for policy changes.
Physicians, he says, can humanize the problems for policymakers. “If we say that a certain number of babies will be born premature if we don’t address heat, for example, it makes it more human.”
There are signs of progress. At Stanford, for instance, faculty are teaming up to think about how the medical field contributes to climate change and are working on ways to decarbonize the hospital and reduce medical waste. It’s not hard to imagine what future generations of climate-trained physicians might be able to accomplish.
“I have a vision of a healthy planet that is full of healthy people,” Basu said. “It’s completely intertwined.”
Published Online: August 16, 2024. doi:10.1001/jama.2024.13506
Conflict of Interest Disclosures: Dr Basu reported being an expert advisor to Rewiring America; serving on the advisory councils of the Medical Society Consortium on Climate and Health and the Environmental League of Massachusetts; serving on the advisory board of Pattrn; receiving funding from the Winslow Foundation, CHA Foundation, High Tide Foundation, Heinz Foundation, National Institutes of Health, Boston Foundation, and Climate and Health Foundation; received honoraria from Rush University, Grist, and Southwest Idaho Medical Education; receiving travel support from the Aspen Institute and the Climate and Health Foundation and to speak at the conference for North American Refugee Health Conference. Dr Patel reported serving on the boards of Our Children’s Trust and Undaunted K12; holding a leadership position with the American Academy of Pediatrics on their Council on Environmental Health and Climate Change; receiving grant funding from Commonwealth Foundation, Northlight, Robert Wood Johnson, Energy Foundation, and Kresge Foundation; receiving honoraria from Wellcome Trust, Moms Clean Air Force, the Montreal Planetarium, National Environmental Education Foundation, and Zero to Three; and that the program she leads at George Mason receives sponsorship dollars from Johnson & Johnson for generational operating funds and an annual meeting. No other disclosures were reported.