Even before COVID-19 put the American health care system to the test, that system was under strain from another invisible enemy: climate change.
Dr. Cheryl Holder remembers her first encounter with that enemy. An elderly patient with chronic obstructive pulmonary disease – let’s call her Annie Mae – came to Holder in desperation because she couldn’t afford to refill her inhaler. Miami was in the grip of a stultifying heat wave, something that’s increasingly common in a warming world. The heat made it hard for Annie Mae to breathe, so she was running her air conditioning unit night and day, and racking up an electric bill she could barely afford to pay. Now her lifesaving inhaler was financially out of reach.
For Holder, who teaches at Florida International University, Annie Mae’s predicament revealed the insidious effects of climate change, especially on the most vulnerable.
“For people living in poverty, heat waves and other climate impacts can set off a cascade of bad outcomes,” Holder says – including illness, eviction and even death. The pandemic and its economic fallout have only increased vulnerability, especially among the poor and people of color.
Holder co-founded Florida Clinicians for Climate Action, which works to educate doctors, patients and policymakers about the links between climate change and health. She is not alone: Today, many in the health care sector are sizing up the threat of climate change and taking action in their practices, in their facilities and in the communities they serve. And some are taking a broader, more holistic view of health care – considering their responsibility to address the malignant mix of factors that leave patients like Annie Mae gasping for breath.
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The Elephant in the Waiting Room
No one can guess the ultimate toll of COVID-19, but climate change has the potential to cause even more sickness and death. Indeed, a 2009 report by a Lancet and University College London Commission called climate change “potentially the biggest global health threat in the 21st century.” Rising temperatures bring ever-more deadly heat waves, wildfires, storms and flooding. As a result, doctors see more heat stroke, heart disease and asthma, as well as diseases – such as Zika and dengue fever – that have jumped to new locations. The toll of climate change on health is so great – and so underappreciated – that Gary Cohen, president of Health Care Without Harm, calls it “the elephant in the waiting room.”
But if the health care sector is part of the problem, it can also be part of the solution. With its massive carbon footprint and mandate to promote wellness (or at least, to do no harm), health care is well-positioned to bend the arc of greenhouse gas emissions.
Leading the charge is the U.S. Health Care Climate Council, convened by Health Care Without Harm in 2014. The council represents 19 health systems in 36 states, with the systems’ annual collective operating revenue totaling more than $215 billion. Council members are reducing their carbon footprints, readying their facilities for extreme weather, and educating and preparing their communities for the impacts of climate change.
And they are making progress. Dignity Health, which is part of CommonSpirit Health, a nonprofit Catholic hospital system, has nearly met its goal to reduce its greenhouse gas emissions by 40% by the end of 2020. Ohio-based Cleveland Clinic, with facilities in multiple states, cut energy use intensity by 19% since 2010. Collectively, council members produce or purchase more than 1 million megawatt hours of renewable energy each year.
Council members also leverage their economic and political power to move markets and policy. For example, Dignity Health advocated successfully for California’s groundbreaking climate legislation, which set ambitious goals for a transition to renewable energy, and a path to achieve them.
Health care systems can open legislators’ doors that may remain closed to, say, environmental groups. That’s been true for Cleveland Clinic, which is the largest employer in Ohio. Jon Utech, senior director of the clinic’s Office for a Healthy Environment, says his team meets with state and federal policymakers to educate them about the health dimensions of climate change and its impact on hospitals: “We go in and say, ‘Hey, climate change is real. It’s happening now and it’s affecting the health of the residents of your district or your state.’”
Climate-Proof Health Care
While working to head off the worst climate scenarios, health care systems are also adapting to the warming that is now inevitable. In the wake of the deadly chaos that engulfed hospitals in New Orleans due to Hurricane Katrina – and more recent hospital closures from hurricanes Sandy and Harvey – they are fortifying their facilities for an era of supercharged storms, fires and floods. Health systems that invest in sustainable, resilient facilities, such as Spaulding Rehabilitation Hospital in Boston, find that savings on operating costs, not to mention lives saved and damages avoided, far outweigh extra construction costs.
“Our climate strategy started with mitigation, but moved to this concept of resilience,” Utech says. For Cleveland Clinic, that means adopting building standards geared to the weather of the future, rather than the past. And it means addressing climate-related risks in the supply chain, so that food and medicine remains available in a crisis.
Most importantly, Utech says, Cleveland Clinic is partnering with local and state officials on emergency management plans that ensure continued operation and patient access during disasters.
Thinking Outside the Hospital Walls
“It’s not just about preparing your facility,” says Rachelle Wenger, system vice president for public policy and advocacy engagement at CommonSpirit Health. “Health care systems are thinking about resilience within our hospitals, as well as in the communities we serve.” For CommonSpirit Health, these actions flow from a recognition that “human health is inextricably connected to the health of our planet and a commitment to the most vulnerable,” Wenger says.
For that reason, CommonSpirit Health is working to ensure that the benefits of clean energy are available to all. Along with other religious health care systems, CommonSpirit Health, through Dignity Health, invests in the Solar Energy and Loan Fund (SELF) in Florida that provides low-interest loans to low- and middle-income households for solar panels and efficiency upgrades. SELF hopes to prevent the problem that faced Annie Mae, by helping vulnerable Florida residents cool their homes without breaking the bank.
Nonprofit hospitals – a category that includes nearly 60% of the nation’s community hospitals– have another reason to help out their neighbors: They receive substantial tax benefits for providing benefits to the community. To that end, the Affordable Care Act requires nonprofit hospitals to conduct regular assessments of local health needs.
The ACA also urges health care systems to look upstream at the complex factors that shape health and well-being. Indeed, it’s estimated that just 20% of health depends on clinical care; the other 80% is derived from health behaviors and social determinants of health such as income and the environment. Armed with that understanding, health providers can adopt a holistic approach to wellness that reduces the need for costly medical intervention.
“Health is dependent on so many things – where you live, where you work, your economic situation,” says Dr. Holder of Florida International University. “Climate change adds an additional burden. We need to help patients connect the dots, so they can protect themselves.”
Hospitals’ efforts to connect climate change to the social determinants of health are still emerging. According to Denise Fairchild, president of the Emerald Cities Collaborative, the potential is enormous: “Community-based organizations have been working on resilience for decades, by fighting for environmental justice, safe and affordable housing, community infrastructure and economic opportunities. But this work is still at a cottage-industry level. By combining the resources of health care institutions with the assets of communities, we can deliver community climate resilience at scale.”
One way to scale up community benefits is by leveraging hospitals’ role as “anchor institutions.” Unlike corporations, which might pull up stakes in search of cheaper labor, anchor institutions such as universities and hospitals remain rooted in their communities. Hospitals are often major employers, and they command large budgets for services such as catering and laundry. But too often, that spending benefits national corporations rather than the hospital’s neighbors.
In the depths of the Great Recession, The Democracy Collaborative co-founder Ted Howard set out to change that. Howard partnered with multiple anchor institutions in Cleveland – including Cleveland Clinic – to launch the Evergreen Cooperatives. Evergreen’s trio of businesses now supply fresh produce, renewable energy and laundry services to the city’s anchor institutions.
Now, through the Healthcare Anchor Network, some 45 health systems across the country are working to create similar synergies in their communities.
The Greatest Global Health Opportunity
The changing climate is indeed the greatest health threat of our time. But, as the 2015 Lancet Commission on Health and Climate Change found, tackling it could also offer the greatest “global opportunity” of the 21st century. That opportunity could be more fully realized if the health care sector deploys its considerable resources to heal the climate and protect communities.
Health systems have the means and a moral imperative to reduce planet-warming carbon emissions. And, increasingly, health care providers are looking upstream to the social and environmental factors that drive sickness and health. The COVID-19 pandemic has revealed disparities in health outcomes that parallel inequities of race and class. Those same inequities make people like Annie Mae much more vulnerable in a warming world.
Addressing climate change and inequity represents a significant shift for a sector that has long focused on clinical care. But many believe it is a necessary one.
“If our healing mission is to have meaning and relevancy today, health care must change course,” says CommonSpirit Health’s Wenger. “Successfully transforming health care depends on not just what we do within the four walls of hospitals, but also on the part we play to further the health and well-being of communities and the planet – how we ultimately show up in the world.”