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H A R D E N T H E H E A LT H

C A R E S Y S T E M , A N D M A K E

I T S M A R T E R

On December 28, 2015, the New York Times ran a story that sent shivers down the spine of public health workers around the globe. The story described the appearance of a virus in Brazil that was being spread by mosquitos. Despite its catchy name— Zika— the virus carries devastating consequences for babies in the womb. Though not typically life- threatening, Zika is known to cause mi- crocephaly, an incurable form of brain damage in newborns whose mothers have been infected with the virus during pregnancy. Fetuses had displayed such catastrophic brain damage that some prominent obstetricians in Brazil were advising their patients not to get pregnant.

It was the third paragraph of the article that particularly grabbed the attention of White House officials. It quoted the Centers for Disease Control and Prevention (CDC) warning that the number of Zika cases imported to the United States would “likely increase and may result in local spread of the virus in some areas of the United States.”1 Before the New York Times report appeared, few on the National Security Council staff at the White House had been

Building a Resilient Tomorrow: How to Prepare for the Coming Climate Disruption. Alice C. Hill and Leonardo Martinez-Diaz, Oxford University Press (2020). © Oxford University Press. DOI: 10.1093/oso/9780190909345.003.0008

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tracking the Zika virus. But the CDC announcement changed all that. Zika quickly came to dominate daily life for many at the White House, just as its staff was winding down the administration’s re- sponse to the threatened spread of the deadly Ebola epidemic. In January 2016, the Zika virus likely appeared in the United States for the first time; a baby was born in Hawaii with the virus and micro- cephaly to a mother who had lived in Brazil.

As concern mounted, the authorities swung into action. The White House convened a task force to oversee the response, and the CDC created a Zika Pregnancy Registry to track potential cases and medical outcomes. The following month, the World Health Organization declared the outbreak an international health emer- gency. The White House sent a request to Congress for $1.8 billion in emergency funding to fight the spread of the disease, though the proposal quickly got ensnared in politics. In August, the CDC instructed pregnant women and their partners to stay away from one of Miami’s trendiest neighborhoods, which had emerged as the epi- center of Zika in the country. It was the first time the CDC had ever advised the public not to travel to a community in the continental United States to avoid catching an infectious disease. Within weeks, Florida began aggressively spraying pesticides to stop the outbreak and continued to do so despite public opposition. By the end of the year, the CDC’s Zika registry had received reports from forty- four states of pregnant women who had tested positive for Zika infec- tion. Of the reported births from mothers with confirmed cases of Zika, an alarming 10 percent of the babies had birth defects.2

Zika’s growing reach serves as a cautionary tale. Health experts expect mosquitos to migrate to new areas as temperatures rise, further spreading not only the Zika virus, but also viruses such as Dengue, West Nile, and Chikungunya.3 Other vector- borne diseases spread through the bites of ticks, fleas, and mosquitos,

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may also make inroads in regions these pests have previously found inhospitable.

Climate change will likely introduce new stresses to human health, and not only from the geographical expansion of vector- borne diseases. Because climate change affects basic elements central to human survival— air, food, and water— more people in more places will face public health threats.4 Extreme heat is a killer. Climate change is also expected to affect access to fresh water and increase the likelihood of human and animal exposure to water- borne diseases, including those spread through bacteria and toxins produced by harmful algae. Food security will be affected as a result of both lowered crop yields and reductions in the nutritional value of certain foods. Indeed, climate change may well affect the entire food chain, from production to storage, distribution, and consump- tion. At the same time, the trauma of climate change- related events will stress mental health, especially among the elderly, the young, and those already suffering from mental illness. Extreme climate events can overwhelm health care facilities and dramatically impair the delivery of health care services.

Despite the clear and present danger climate change poses to public health, the efforts of the medical profession and public health authorities to date have not matched the urgency of the problem. Medical facilities are not being designed, built, and retrofitted to withstand climate impacts. Because we lack sufficient capacity to track, monitor, and warn the public about the spread of disease in a warming world, we find ourselves in a reactive mode, struggling to keep up. Nurses, doctors, and public health officials are often un- aware of how climate change upends their understanding of public health threats and what to do about the growing risks.

While the challenge is daunting, there are certain things we can do to prepare. Here we focus on a relatively narrow but important

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element of the response— the reliability and effectiveness of sys- tems delivering medical services. Communities, governments, and global institutions must develop ways to provide health care in a changing climate. This calls for hardening the infrastructure supporting the health care system so that it can withstand climate impacts and continue to deliver services. Health care systems must also be made smarter, which means training health care providers about climate- exacerbated health conditions, putting in place pre- dictive and early- warning systems, and finding more effective ways to protect and attend to the most vulnerable people.

HARDENING THE HEALTH CARE SYSTEM AGAINST CLIMATE CHANGE

A health care system must perform reliably, but climate change- exacerbated events will threaten that reliability. When Superstorm Sandy struck New York City in October 2012, about 6,500 patients had to be evacuated from six hospitals and thirty- one residen- tial care facilities when these buildings lost power.5 Backup diesel generators quickly ran into problems because builders had installed critical elements such as fuel pumps on lower floors that flooded. At Bellevue, the city’s oldest hospital, workers formed a “bucket bri- gade” to move fuel from the flooded basement’s fuel storage to the generator, thirteen flights up.6 At New York University’s Langone Medical Center, the loss of power forced medical personnel to evac- uate newborn babies from the neonatal intensive care unit, some tethered to battery- powered respirators.7

Auxiliary health care providers also struggled to provide serv- ices. In the greater metropolitan area of New Jersey and New York, patients dependent on home nursing care, electric- powered devices,

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and refrigerated medicine suddenly lost access to these critical serv- ices. As professionals later picked apart the medical response to Sandy, they found that seemingly unrelated disruptions unleashed by the storm further compromised health care delivery and access. Entire neighborhoods were cut off from medical facilities when debris- clogged roads and public- transportation systems shut down. Critical medical supplies, such as portable oxygen, ran short as de- livery systems stopped.8 Many health care workers were unable to get to work and faced the added burden of worrying about the safety of their own families. In total, Sandy caused billions of dollars in damages to hospitals and health care organizations in New York City alone, not counting the hard- to- measure costs to patients of delayed or suspended access to health care.

But even without a Sandy- caliber storm, emergency health services can be disrupted by climate- related events. In flood- prone Norfolk, for example, chronic flooding can make streets impassable, delaying the delivery of potentially life- saving care. In 2017, nearly half of residents living in Norfolk and the surrounding communities reported being unable to drive out of their neighborhoods at least once in the past year because of flooding during high tide.9

Ignoring the risks of climate change impacts to health care in- frastructure costs lives. Consider what happened when Hurricane Irma swept across Florida in 2017. The storm knocked out power to over six million residents, including the Rehabilitation Center at Hollywood Hills, a 152- bed nursing home that housed elderly patients. Loss of power caused the air- conditioning system to fail. Temperatures began to rise, climbing to more than 100°F (38°C) on the second floor. Three days passed before the facility was com- pletely evacuated. By then, a dozen people had died. Criminal authorities investigated the deaths as homicides, and the nursing home lost its license. In the wake of the disaster, the governor of

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Florida signed legislation that requires nursing homes to have ad- equate back- up power systems— a “no more” moment for those caring for the elderly. A year after Irma pummeled Florida, the US Congress took the effort nationwide, directing training for local governments and utilities on ways to prepare for loss of power in medical facilities and nursing homes during extreme weather events.

Pockets of climate- resilient health care— facilities designed to provide health care even in dire conditions— have begun to emerge in some parts of the world. Take, for example, Georgetown Hospital in St. Vincent and the Grenadines, a small Caribbean ar- chipelago that is no stranger to hurricanes. Originally constructed in the 1980s, Georgetown Hospital provides care for close to 10,000 people. In 2013, it launched the Georgetown Smart Hospital Project aimed at building and retrofitting the facility to make it re- silient to hurricanes. Retrofits included new water- storage systems, roof upgrades, natural ventilation and lighting, installation of a gen- erator, and energy- efficiency improvements, all at a cost of under $350,000.10

Another example is the Texas Medical Center (TMC), a 2- square- mile (5 km2) medical district in Houston, Texas. It houses over sixty medical institutions, making it the largest medical com- plex in the world. TMC employs over a hundred thousand people and records millions of patient visits each year, generating an an- nual revenue comparable to the gross domestic product of a small country. In 2001, Tropical Storm Allison hit the complex hard, halting almost all of the center’s operations and inflicting millions of dollars in damages. Vowing to be better prepared the next time, TMC invested more than $50 million in resilience measures. It installed watertight flood doors, widened drainage culverts, elevated electrical equipment and water pump systems, installed stormwater tanks to capture run- off, created a flood- alert system, increased

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training, and built a berm around the McGovern Medical School that stands 1 foot (30.5 cm) above the 500- hundred- year flood- plain (the area that has a 0.2 percent chance of flooding in any given year).11 When Hurricane Harvey hit in 2017, TMC closed its flood gates and went about the business of caring for patients. Every hos- pital on TMC’s campus remained open but one. Babies were deliv- ered and emergency brain surgery was performed. Because medical personnel knew the hospital would remain open, they did every- thing they could to be there to help; some even kayaked through the flood waters to get to the TMC.12

It’s not just major infrastructure investments that can save lives. Preventive steps that carry little or no cost can make a signif- icant difference. Take, for example, what medical personnel did in Ahmedabad, the largest city in the Indian state of Gujarat. In 2010, a heatwave struck the city. Admissions to the neonatal intensive care unit at one of the city’s un- air- conditioned hospitals spiked dramat- ically. The maternity ward was housed on the hospital’s top floor under a dark tar roof, and hospital administrators knew they had to find cooler quarters for the newborns. They relocated the mater- nity ward to the cooler ground floor. The next time temperatures hit 108°F (42°C), that simple move could reduce heat- related admissions to the neonatal intensive care unit by as much as 64 per- cent.13 In a country where less than 1 percent of hospitals are fully air conditioned, this type of measure saves lives, especially as the annual number of very hot days increases with climate change.14

Where air- conditioning systems are commonplace, hospitals and clinics can make other adjustments to account for new climate change- related extremes. For example, health care facilities can en- sure they have adequate back- up power and windows that open to allow fresh air inside should those systems fail over extended periods. Other interventions will require the installation of sophisticated

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equipment. Hospitals operating in wildfire- prone regions may need to install ventilation systems that maintain air quality even under heavy smoke conditions, so that they can continue to treat patients, including firefighters and affected residents.15 If hospitals and other health care providers fail to prepare, the impact on the surrounding communities will be felt quickly and painfully.

MAKING THE HEALTH CARE SYSTEM SMARTER

In a warming world, a resilient health care system also requires enhanced predictive capacity and effective early- warning sys- tems. Once an oncoming health threat is identified, public health practitioners should have the capacity to mobilize resources to address it, including providing the public with the information it needs to take precautions. As we saw in chapter 5, on data, infor- mation technology promises to improve our understanding of cli- mate risks dramatically, and this includes threats to human health. Better surveillance and tracking of the development and spread of diseases allows public health authorities to prepare. For instance, in its aptly named Project Premonition, launched in 2015, tech giant Microsoft partnered with cross- disciplinary researchers across the United States to develop a global system that detects and monitors emerging mosquito- borne diseases before they spread. Early detec- tion has the potential to lower the rate of infection, reduce treat- ment costs, and cut mortality rates, even as climate change expands mosquitos’ habitable range.

How does the system work? Autonomous drones first locate where mosquitos are most active. That, in and of itself, already offers “a revolutionary increase in efficiency,” according to one of

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the researchers.16 Information provided by the drones is then used to deploy robotic “smart traps” in high- risk zones. By measuring the beat of a mosquito’s wings, these traps can distinguish potential disease- carrying specimens from the rest of the known 3,600 mos- quito species. The device captures only the disease- carrying variety. Microsoft’s cloud computing capabilities then sequence the bugs’ DNA to detect pathogens, reducing processing time from thirty days to just twelve hours.

If it is successful, the project could potentially identify Aedes aegypti mosquitos that carry the Zika virus and pinpoint where Zika may emerge.17 “If we can detect these new viruses before they spread,” said Ethan Jackson, who is the lead researcher for the in- itiative, “we may someday prevent outbreaks before they begin.”18 The goal is to set traps around the globe, including in poor coun- tries, where mosquito- borne diseases are killers. This technology could prove valuable not only in searching for Zika, but also for other mosquito- borne diseases such as West Nile, Dengue, and Chikungunya.

Early- warning systems that communicate information about an impending disease outbreak can also save lives by giving both government authorities and the public time to take preventive ac- tion. Some researchers even dream about the creation of a global early- warning system for infectious disease.19 As computer mod- eling improves, along with the collection of all types of data, deeper investments in early warning hold great promise. But any such investments must consider how climate change could impact the spread of disease.

In 2014, Japan and South Africa embarked on a partner- ship to create an early- warning system for infectious diseases in South Africa. When implemented, the system will provide the South African government with information based on the

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climate- prediction modeling of anticipated outbreaks. This will give the authorities sufficient time to prepare, say, by stockpiling neces- sary supplies. Focusing on diseases known to be affected by climate change, such as malaria, pneumonia, and diarrheal diseases, the partnership intends to implement the system across South Africa and neighboring countries as well.20

Three years after the partnership was launched, an unprece- dented outbreak of malaria in South Africa demonstrated how val- uable such a system could be. Japanese researchers, in collaboration with a South African think tank, concluded that climate impacts, including higher levels of precipitation and warmer sea- surface temperatures, had altered the geographic spread of malaria.21 If planners could take advantage of the lag time between climate- related events and the incidence of disease, they could better manage its spread.22

Figure 7 Project Premonition’s mosquito “smart trap.” Source: Courtesy of Microsoft.

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Since heat kills more people than any other natural hazard, better heat advisories promise to save lives. Ahmedabad, the Indian city mentioned earlier in this chapter, is expected to suffer from heatwaves of longer duration, greater frequency, and increasing intensity in the coming decades.23 In 2010, during one particu- larly ferocious heatwave, the city’s seven million people experi- enced temperatures of nearly 116°F (47°C). Although the India Meteorological Department had forecasted the heatwave two days before it occurred, municipal agencies failed to communicate the message effectively.24 Over 1,300 people died.

The disaster was Ahmedabad’s “no more” moment. Authorities became determined to find a better way to give people more time to take precautions. The city partnered with academic, health, and environmental groups to create an early- warning system and become the first city in South Asia to de- velop a comprehensive plan to address extreme heat. The city ’s revised plan, released in 2017, called for improved commu- nication through public messages and social media, text mes- saging, email, and mobile apps such as W hatsApp. The plan also required new training for health care professionals and the mapping of high- risk areas to show where cooling spaces, drinking water supplies, and other preventive measures should be deployed. Since Ahmedabad adopted the plan, heat- related mortality has declined by 20 percent to 25 percent, according to the Indian Institute for Public Health.25 The program has spread to multiple cities in India, accompanied by multiday forecasts from the India Meteorological Department.

It’s not just the people of Ahmedabad who urgently need early warning and heat protection. Experts estimate that about 30 per- cent of the world’s population is exposed to deadly heat conditions for at least twenty days of the year.26 Under a business- as- usual

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scenario, in which emissions continue to rise, it is predicted that by 2100 as much as three- quarters of the world’s population will be exposed to the same frequency of deadly heat. In view of this, developing and adopting early- warning systems and action plans for heatwaves is critical. The Global Heat Health Information Network, a group of scientists and policymakers focused on pre- paring for extreme heat events, took stock of heat action plans across the globe. According to the Network, only about a quarter of the world’s countries had heat action plans in place. Over two- thirds of the countries with plans were in Europe, which had its “no more” moment in the deadly heatwave of 2003 that killed more than seventy thousand people.27

TEACHING PEOPLE TO TAKE CARE OF THEMSELVES

Cholera has plagued human settlements since ancient times. In 1854, British epidemiologist John Snow discovered that the di- sease was spread by contaminated water. He traced an outbreak to a single pump near a cesspool in London, where the mother of a baby who had died of cholera had washed the baby’s diaper. Caused by the bacterium Vibrio cholerae in fecal matter, the disease brings on diarrhea so severe that victims can die of organ failure and shock within hours if it goes untreated. Despite humanity’s long experi- ence with the disease, cholera remains a significant public threat and is anticipated to increase due to climate change. Climate- exacerbated flooding spreads the bacteria, while drought can lead the bacteria to accumulate in dangerously high concentrations. The disease affects all age groups, but it is particularly deadly for young

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children. Concerted public- health outreach can reduce the threat greatly.

Bangladesh is no stranger to cholera. As recently as 1988, 27 percent of flooding- related deaths in rural areas in the country resulted from cholera.28 Yet thirty years later, when unprecedented floods destroyed close to 700,000 homes, almost no one died from diarrheal diseases, including cholera.29 What changed in the in- terim? Bangladesh had launched a proactive campaign to better equip medical facilities and increase public awareness of the need for clean water and basic hygiene and of the use of oral saline to treat diarrhea. Most of the country has access to oral rehydration salts, since even the smallest shops now carry them, and people are well aware of the need to use the salts when diarrhea occurs.30 Women have been taught to filter water through folded saris, which can effectively remove as much as 99 percent of the pathogens.31 In the words of Bangladeshi physician Azharul Islam Khan, “Being a country with 160 million people, we are doing fairly well with diar- rhea control, I must say.”32

THE “WICKED PROBLEM” OF CLIMATE CHANGE AND MENTAL HEALTH

The impacts of climate change on mental health are less obvious but no less important. With more people exposed to extreme cli- mate events, psychological challenges multiply. A growing stack of public health studies suggests a strong link between warming temperatures and deteriorating mental health. Evidence now associates heatwaves with increases in population distress, psychi- atric hospital admissions, and suicides.33 For example, researchers

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have found that warming temperatures are linked to higher suicide rates among Indian farmers and among people in the United States and Mexico.34

Climate- related disasters take a toll on peoples’ mental health. Almost half of Americans who weathered Hurricane Katrina de- veloped some sort of anxiety or mood disorder.35 Take, for ex- ample, the experience of Denise Thornton. Trapped for days inside New Orleans’ Superdome stadium in the wake of Katrina, Thornton and thirty thousand others experienced days crowded into a space that descended into violence, filth, and chaos. The traumatic memories of that time would haunt Thornton long after the storm. “[F] or probably two years after [Katrina] every time I was in a crowd, even at buildings in other cities, I’d have a panic attack,” she said. “The sound of a helicopter would throw me into a panic attack . . . And I didn’t know why, because I knew I was safe.”36 Climate- related disasters can further lead to post- traumatic stress disorder and depression.37 Merely contemplating human helplessness before the “wicked problem” of climate change can lead to feelings of despair.38

Health care providers, policymakers, and researchers must pay more attention to the nexus between climate change and mental health, especially in cultures that still stigmatize mental illness, in- cluding the United States. Governments need to invest in programs like one created in India to reduce the economic and mental stress that comes from losing crops and livelihoods. A $1.3 billion climate- based crop insurance program in that country is aimed at cutting suicides among farmers.39 Additionally, rapid disaster response can reduce anxiety and stress by shortening the period of time people must wait for aid.40 For mental health, as for other types of health

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care, continuity of treatment during extreme weather events is critical.

TRAINING FOR HEALTH PROFESSIONALS

As the Zika crisis demonstrated so vividly, public health officials and practitioners need to understand how to detect, diagnose, and treat conditions they may not have previously encountered as the nature of health threats shifts with a changing climate. Health practitioners who previously never had to worry about a specific vector- borne disease, for example, will need to pay much more at- tention because climate change may bring those vectors into their communities rapidly.

Unfortunately, training has lagged behind. Medical and public health schools have not yet developed deep expertise on climate change- related impacts. Like architecture schools (see chapter 1), medical and public health schools have lagged in establishing specialized training programs on climate risks for health care professionals. Only in 2012 did a school of public health in the United States establish a formal program on the subject; in this case, it was the Mailman School of Public Health at Columbia University in New York City.

In December 2015, during the United Nations conference that produced the Paris Agreement, over a hundred deans of medical, nursing, and public health schools announced their commitment to including climate change in the health education curriculum. Not long after, the Global Consortium on Climate and Health Education at Columbia University was launched. In 2016, the

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consortium announced a set of sixteen core competencies that should be incorporated into the training of health professionals, including the ability to recognize and reduce climate- related health effects. The Lancet, a prestigious medical journal, identified training the next generation of health professionals “to recognize, respond, facilitate preparedness, and educate others [as] essen- tial to preparing for climate impact on health.”41 The International Federation of Medical Students Association has similarly called for incorporating health impacts into the curricula of every medical school by 2020.

Progress in the field of climate and health needs to be made much faster. In 2015, Margaret Chan, the Director General of the World Health Organization, called climate change the defining issue for public health in the twenty- first century.42 Yet three years later, the United Nations Environment Programme concluded that efforts to address health impacts fall “well below” what is required to minimize the harm.43 For any efforts to succeed, health care professionals and public health officials must understand the risks and have access to the tools, training, and facilities to continue to deliver vital care in a changing climate.

PRESCRIPTIONS AND PROVOCATIONS

• Governments should invest in enhanced disease surveillance, predictive capabilities, and early- warning systems to facilitate preparedness efforts and preventive action.

• Hospitals and other medical care facilities should conduct climate- vulnerabiltiy assessments and invest in resilience- enhancing retrofits and upgrades so they can continue to provide care during extreme climate- related events.

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• Medical, nursing, and public health schools should promptly incorporate relevant climate change- related material into their core curricula.

• Community leaders, in partnership with academic institu- tions, emergency managers, and other stakeholders, should develop and implement heat action plans to prepare for ex- treme heat events in at- risk areas.