The coronavirus 2019 (COVID-19) showed us that pandemics harm vulnerable populations disproportionately. Such groups suffer a higher burden of illness and experience greater barriers to work, education, and other daily activities. In the public health literature, parallel conclusions have been drawn about the disproportionate effects of climate change on vulnerable populations. Like COVID-19, climate change has the potential to affect health but also impact other aspects of daily life. Lessons from our response to the pandemic can inform our response to climate change.
Many public health advocates and policymakers have called for rapidly reducing greenhouse gas emissions. Such initiatives often are grouped under the heading of sustainability, but climate scientists classify them as mitigation strategies. Efforts ranging from sourcing renewable electricity to increasing energy efficiency are crucial to our response to climate change at all levels. In fact, a small but growing group of surgeons have highlighted our responsibility to mitigate the emissions associated with surgical practice.
But even under the most ambitious emissions reduction plans, humans will remain dependent on fossil fuels (to some extent) for decades to come. And even if we cut all emissions to zero tomorrow, the excess carbon we have already introduced into the atmosphere commits us to more than a century of rising sea levels, more frequent severe weather events, and extreme temperatures. Therefore, a complete climate change strategy also requires emphasis on adaptation—preparation of our infrastructure and processes for the expected range of impacts from climate change.
The resource-intensive nature of surgery makes our practice vulnerable to the coming effects of climate change.
The resource-intensive nature of surgery makes our practice vulnerable to the coming effects of climate change. Here, we examine a few illustrative experiences from the past couple of years.
We know extreme heat is associated with increased emergency department visits and hospital admissions for respiratory, renal, and (in some regions) cardiovascular disease.1 In the U.S., we see 3 percent excess mortality during heat waves.2 After two decades of increasing heat, early record-breaking heat waves this summer emphasize that the impact of extreme heat on surgical patients is an uninvestigated and crucial area of research.3
In 2020 and now in 2021, we witnessed a terrifying complication of rising global temperatures: the California wildfires. The hotter, drier atmosphere compounded existing risk factors, including risky forest management choices, a lack of fireproofed infrastructure, and poor forest building and zoning regulations. All told, in 2020, more than 10,000 structures were severely damaged or destroyed and 33 lives were lost directly to the fires.4 One hospital was forced to shut down and evacuate its patients twice in five weeks.5 We know the lingering toxic smog drove increased rates of asthma exacerbations, but potential health implications extend beyond acute respiratory disease.6 Does recurrent exposure to severe wildfire smoke increase the risk of lung cancer? And do patients displaced or bankrupted by house fires delay surgical care? Given the increasing breadth of wildfires, such questions will only become more relevant.
The major driver of sea-level rise is the physical expansion of water mass as our oceans warm, though ice melt also contributes to rising sea levels. With this trend, flood zones continue to extend inland, placing more and more hospitals at risk. Over the past year, work has started on the Fifth National Climate Assessment, which will update the inventory of at-risk hospitals. Earlier iterations of the report highlighted that more than 60 percent of hospitals in coastal counties like Charleston, SC, and Miami-Dade, FL, are at risk of major flooding.7
Beyond sea-level rise, higher precipitation rates also are increasing flood risk. In June 2020, a community hospital in the Boston, MA, suburbs suffered a flash flood requiring rapid evacuation. Previously a provider of specialty surgical services, the hospital anticipates it will take more than a year to rebuild its infrastructure.8 In the same year, a New Hampshire hospital—the only trauma center for more than 20 surrounding rural counties—suffered a flash flood, requiring a temporary shutdown and cancellation of operations in the subsequent days.9 Lack of preparation for these increasingly frequent events potentially cuts off access to surgical care.
The federal government collects data on storm events that result in $1 billion of physical damage. Again, 2020 was a record year; 22 billion-dollar storm events totaled $95 billion in infrastructure damage and directly resulted in 262 deaths. Over the past decade, the U.S. saw an average of 12 events per year, costing $82 billion annually. Comparatively, in the 1980s, only three such storms occurred annually.10 These data do not address the accompanying toll of displacement and housing instability. Little is known about the impact on access to surgical care among populations affected by these storms.
In February 2021, winter storm Uri hit Texas mid-February 2021 and called attention to major storm events. The freezing winds of the Arctic polar vortex are typically encircled by a “jet stream” barrier approximately five to nine miles above the earth’s surface, situated over the Arctic Circle. The Arctic atmosphere is warming faster than other areas of the globe in a process known as “Arctic amplification.” Although still freezing, the winds of the polar vortex warmed up in January 2021. Because warm air rises, the polar vortex winds were able to rise above the rim of the jet stream and seep southward, causing freezing temperatures across the U.S. during the following month. Some climate scientists hypothesize that Arctic amplification increases the risk of major cold events in the near future, though debate is ongoing. At the very least, the process introduces further potential for variability in climate.11
Many factors contributed to the crisis in Texas, ranging from nonweatherized infrastructure to a deregulated and isolated electrical grid. To prevent total collapse, the electrical regulatory board implemented blackouts across the state, which were far from random. In fact, residents on microgrids that included a hospital were more likely to maintain power. But even with maintained electricity, hospitals suffered from water shortages and ineffective supply chains.12 From a surgical perspective, we should wonder, how is trauma burden affected by these types of events? And what is the impact of delayed surgical care? COVID-19 may offer some insight into these very questions.
COVID and climate change
COVID-19 resulted in the forced closure of thousands of operating rooms across the U.S. in order to preserve limited resources. Best estimates suggest more than $20 billion in lost revenue, highlighting how little financial wiggle room many hospitals operate within. Especially for rural and safety-net hospitals, federal aid was indispensable in keeping the doors open when profits from elective procedures evaporated.13,14 With the accelerating effects of climate change, hospitals may more frequently face weather-related shutdowns and rebuilding costs while unable to accrue profits through elective procedures. Well-resourced tertiary centers could likely recover, as they did with COVID-19. But rural and safety-net hospitals with smaller operating margins may never rebound. We were unprepared for COVID-19, and vulnerable populations suffered the most. Unaddressed, climate change could continue the trend.
Surgeons across the country already have started to make inroads in mitigating our carbon footprint.
Surgeons across the country already have started to make inroads in mitigating our carbon footprint. The U.S. health care industry represents 8 to 10 percent of national greenhouse emissions and 18 percent of the gross domestic product.15 Improving surgical sustainability not only directly mitigates emissions but also can send a strong market signal in support of mitigation efforts. Such efforts often face a “tragedy of the commons” challenge, wherein the resource of our atmospheric stability is shared by all and owned by no one. Individual stakeholders, for example, such as regional hospital systems, are not incentivized to invest in mitigation behaviors where the benefits are diluted across the globe. Importantly, surgeons have started to advocate for sustainable initiatives that offer cost savings without compromising patient care. The authors are engaged in this work at our own hospital and applaud the growing number of surgeons working on mitigation across the country.
But with the hard-fought lessons of 2020 under our wings, the need to incorporate adaptation strategies is increasingly apparent. Vulnerabilities of each surgical system will vary based on local climate risks. A potential first step toward preparedness is to perform climate change readiness assessments of both the surgical infrastructure and crucial supply chains. Back-up suppliers for drugs and equipment produced in climate-unstable regions can then be identified. A political window may be available now to fund hospital climate assessments and data-driven adaptation strategies. In rural and underserved communities, hospitals also could consider partnering with environmental justice organizations to fund such efforts.
Further opportunities may arise for surgeons who are involved in disaster preparedness planning. Incorporating major climate disasters into training scenarios can improve care delivery during major floods, heat waves, and storms. Such plans could include pursuing data-sharing partnerships and cross-institutional operating privileges to facilitate transfer of care for time-critical surgical patients after a climate event.
Certainly, climate change is only one of many challenges our patients face. Clinical research increasingly reflects the complex physiologic, technical, and socioeconomic factors that affect surgical care delivery. Such work improves decisions and policies for our patients. Incorporating relevant climate variables (heat, humidity, storm events, and so on) could identify high-impact opportunities for both climate change adaptation and mitigation. Such work needs to be undertaken with special attention to patient anonymity because correlating clinical and climate data often requires information on date and geographic location of surgical encounters.
With 2020 in the rearview, lessons continue to emerge. Perhaps climate change is not immediately obvious as a risk to health care. While our resource-intensive surgical practices contribute to climate change, our patients are especially susceptible to climate stressors. Tackling this issue on behalf of our most vulnerable patients will require adding adaptation to our mitigation strategies.
- Bobb JF, Obermeyer Z, Wang Y, Dominici F. Cause-specific risk of hospital admission related to extreme heat in older adults. JAMA. 2014;312(24):2659-2667.
- Anderson GB, Bell ML. Heat waves in the United States: Mortality risk during heat waves and effect modification by heat wave characteristics in 43 U.S. communities. Environ Health Perspect. 2011;119(2):210-218.
- Assessing the global climate in 2020. National Centers for Environmental Information (NCEI). January 12, 2021. Available at: www.ncei.noaa.gov/news/global-climate-202012. Accessed March 3, 2021.
- State of California. 2020 fire season. California Department of Forestry and Fire Protection. Available at: www.fire.ca.gov/incidents/2020/. Accessed March 3, 2021.
- He C. The St. Helena hospital evacuated twice in five weeks due to California wildfires. San Francisco Chronicle. September 29, 2020. Available at: www.sfchronicle.com/california-wildfires/article/The-St-Helena-hospital-that-evacuated-twice-in-15607257.php. Accessed March 3, 2021.
- Reid CE, Maestas MM. Wildfire smoke exposure under climate change: Impact on respiratory health of affected communities. Curr Opin Pulm Med. 2019;25(2):179-187.
- U.S. Global Change Research Program. Fourth National Climate Assessment. 2018. Available at: https://nca2018.globalchange.gov. Accessed September 2, 2020.
- Flooded Norwood hospital to remain closed at least a year more. NBC Boston. October 21, 2020. Available at: www.nbcboston.com/news/local/norwood-hospital-flooded-in-june-to-remain-closed-at-least-another-year/2215861/. Accessed March 3, 2021.
- Coveno A. Grafton County flooding forces hospital to cancel surgeries. WMUR. July 15, 2020. Available at: www.wmur.com/article/line-of-storms-featuring-heavy-downpours-trigger-flash-flood-warnings-in-new-hampshire/33308677. Accessed March 3, 2021.
- Smith AB. U.S. billion-dollar weather and climate disasters, 1980–present (NCEI Accession 0209268). 2020. Available at: https://data.globalchange.gov/dataset/gov_noaa_nodc_0209268. Accessed March 3, 2021.
- Cohen J, Zhang X, Francis J, et al. Divergent consensuses on Arctic amplification influence on midlatitude severe winter weather. Nat Clim Change. 2020;10(1):20-29.
- Lacey S, Shah J, Hamilton K. Texas grid failure. Available at: https://art19.com/networks/greentech-media. Accessed February 24, 2021.
- Levins H. Already in fiscal crisis, rural hospitals face COVID-19. University of Pennsylvania, Leonard Davis Institute of Health Economics. June 2020. Available at: https://ldi.upenn.edu/news/already-fiscal-crisis-rural-hospitals-face-covid-19. Accessed December 9, 2020.
- Bartlett J. Safety-net hospital CEOs say they may not survive the crisis. Boston Business Journal. March 19, 2020. Available at: www.bizjournals.com/boston/news/2020/03/19/safety-net-hospitals-face-existential-crisis-under.html. Accessed December 13, 2020.
- Eckelman MJ, Sherman J. Environmental impacts of the U.S. health care system and effects on public health. PloS One. 2016;11(6):e0157014.