The Healthcare Paradox: Our Quest to Heal Climate-Related Disease

Climate change impacts care access and contributes to worse health among vulnerable populations. While the SGIM Forum’s March 2021 issue was devoted to climate change and health, one issue remains unaddressed—the fact that health care is responsible for more than 8% of our nation’s total carbon emissions.¹  These emissions contribute to exacerbations of the very health issues and disparities we as generalists aim to solve. Thus, it is imperative that within our own profession, we take necessary steps to reduce the carbon footprint of our health systems.

The Health Sector’s Impact on Climate Change

In 2012, U.S. hospitals ranked second in use of fuels, among all commercial U.S. buildings.² The U.S. healthcare sector (including computer usage, use of operating and procedure rooms throughout the night, air conditioning, and transportation to provide supplies) accounts for 25% of global healthcare emissions.¹ This is due not only to direct emissions caused by operations within health systems but also the result of purchases made for heating and cooling these facilities and the fact that the healthcare supply chain relies heavily on goods transported from other regions of the United States. Importantly, the National Wildlife Federation’s National Report Card on Environmental Performance and Sustainability in Higher Education found that transportation is a significant cause of carbon emissions around university campuses and academic health centers, creating a major impetus to “reduce congestion and pollution associated with travel” as a means of “improving community relations and air quality.”³

A Negative Cycle that Could Worsen Health Disparities

The healthcare sector is negatively affected by the very climate changes that result from these emissions, causing a vicious negative feedback cycle. Natural disasters such as hurricanes, tornadoes, and flooding result in power outages, infrastructure damage, medical supply shortages, and evacuations within health systems, thereby limiting access to and provision of healthcare services within the very communities affected by these catastrophes. What’s more, these financial losses are often translated into higher costs for payers and patients.²

The effects of climate change accentuate racial, ethnic, and socioeconomic gaps in access to and quality of treatment. Although poor individuals and minorities are disproportionately vulnerable to the health effects of climate change, they contribute the least to greenhouse gas emissions. When compared to non-Hispanic Whites, African Americans are 52% more likely to live in places at risk for heat-related dangers, non-Hispanic Asians are 32% more likely, and Hispanics 21% more likely.² This approximates disparities noted during the COVID-19 pandemic and highlights how changes to existing infrastructure and policies are necessary to mitigate the health disparities that occur during public health emergencies.

Addressing Air Pollution Caused by Transportation of Supplies (and Patients) through Health Systems

Health inequities are also caused by environmental injustices. For example, highway air pollution is higher in communities of color, due to our nation’s history of erecting highway systems that disrupt and invade communities of color.⁴ Given our heavy use of transportation to provide supplies and transport patients, health systems should consider how their employees, patients, and visitors travel to healthcare sites. Use of electric fleets could be considered; in fact, the University of Georgia has secured grants to electrify much of their bus fleet. Collaboration between fleet managers of health systems may promote sharing of best practices. Additionally, higher education institutions often have endowments for future construction of buildings; those in charge of endowment projects might assist with the implementation of Sustainable Charging Systems on campus.

Changes to Local Health System Infrastructure

Local hospitals could address innovative changes internally, which would foster their own resilience amidst climate-related events affecting patient populations, and return on investment in the form of downstream financial savings. Some medical centers, for example, have installed solar panels on their hospital roofs to serve as an on-site generator during climate-related power outages They also use energy-efficient LEDs, including programmable lights in patient rooms that imitate natural sunshine variation to assist patients in resetting their circadian clocks. Moreover, outdoor walking trails for patients and staff are now manicured with native plants and watered with recycled rainwater in the outdoor spaces.

Sustainable infrastructure changes could also include (1) making the exterior walls of new construction using a high-performance building envelope, with white roofing, in an effort to optimize energy savings; (2) using low-flow plumbing in restrooms, which have been shown to reduce the use of potable water by 34%; (3) ensuring any new or exchanged carpet, tile, and painted walls is constructed of refurbished, salvaged, and/or recyclable/reusable material, to lessen the demand for raw materials; and (4) guaranteeing 15% or more of building materials are manufactured within 500 miles of the location, reducing environmental impacts of excessive transportation (inspired by a billboard seen by the author at SFO, 11-19-2021, touting the airport’s commitment to environmental sustainability).

Academic campuses can reduce the urban heat island effect by having solar on every rooftop, and tree canopy covering 30% or more of the campus. One study suggests that tree planting and preservation in large cities can result in milder days and nights, with benefits of greening initiatives leading to as much as 15°F(-9°C) of cooling in the summer. When paired with reflective roofing and paving strategies, tree planting and preservation lower the number of deaths from hot weather by more than 20%.⁵

Collaborations with National Regulatory Bodies

Implementing renewable energy sources within health systems is a complex problem and not something just one healthcare institution can address on their own; it also depends on city and state plans and federal involvement. Although environmental regulations vary by state, national commissions or organizations that are involved in health care could lend the pressure needed to support positive environmental changes.

Thus, it is incumbent upon regulating bodies of the healthcare industry to collaborate with the National Highway Traffic Safety Administration, Department of Transportation, and Environmental Protection Agency (EPA) to implement stronger corporate average fuel economy standards. Stronger standards would lower many forms of air pollution, including particulate matter (PM).¹ For example, current EPA standard for annual PM2.5 is 12 μg/m3; if the standard were lowered to 10 μg/m3, hospitalizations for dementia in the Southeast, particularly vascular dementia most heavily affecting communities of color, could decrease by ~10%.⁴ The PM created by fossil fuels is estimated to contribute to approximately 13% of U.S. deaths.⁴ Other health effects caused by PM include heart attacks, strokes, lung disease, and cancers.⁴ Among children, it has been associated with preterm birth, low birthweight, damaged lung growth in children and teens, and cognitive problems.

A Call to Action by the Joint Commission

To address these issues, the Joint Commission could work to ensure a commitment by health systems towards sustainability and resilience. This should include the requirement of a role within health systems to assess and monitor efficiency of energy usage within their facilities, and to advocate for funding from local, state, and federal sources to address sustainability needs. This is especially important among disproportionate share hospitals and safety-nets caring for vulnerable patient populations, especially those operating in non-Medicaid expanded states where large numbers of patients remain uninsured and are thus encumbered by chronic conditions.

Our Professional Privilege

As we think about the impact of climate change on the patients we serve and strive to address and improve their health through our educational expertise, I urge all SGIM members and advocates to leverage another useful tool we carry within our white coats—the networking opportunities that result from our professional privileges. As generalists who bridge the chasm between vulnerable communities, public health, and policymaking individuals, we must leverage our knowledge of health care’s impact on climate change and health, and advocate for policies and multi-sector collaborations that solve this paradox.