Health and Social Justice in a Changing Climate

By Hanna Linstadt MD, Rachel Dahl MS, and Caitlin Rublee MD, MPH, on behalf of the SAEM Climate Change and Health Interest Group

Our knowledge and understanding of history inform our actions in the present. The teachings and foundation “Effects of climate change exacerbate of medical education build critical thinking skills that apply to clinical practice. In emergency medicine, existing social and environmental atypical disease presentations influence future management plans and an conditions, thereby increasing exposure ever-expanding differential diagnosis. The most up-to-date literature informs of at-risk populations to conditions that evidence-based practices that define high quality, timely emergency care year contribute to adverse health outcomes.” after year. One of the challenges of COVID-19 has been the on-the-go learning and development of evidence; yet, even in a global pandemic, we can look to history to inspire and lend key lessons on public health and social justice. The Pandemic of 1918, or the Spanish Flu, transformed public health in the United States (U.S.). It claimed the lives of approximately 675,000 Americans and decreased the average life expectancy in the U.S. by 12 years. The similarities to COVID-19 include strain on health care systems, ill practitioners, rapid spread, altered medical education, specific populations at increased risk, limited gatherings, misinformation, masks and restrictions. Following the Pandemic of 1918, public health, evidence-based medicine, and health care systems developed with a new-found purpose. There was a renewed interest in science and data to inform prevention and treatment, and groundbreaking achievements in modern medicine were accomplished. Population-level surveys were created and implemented, governments created health plans, vaccines were created, and laboratories formed networks to test for diseases. Out of a devastating pandemic came an era of modern medicine which set the foundation for scientific, evidence-based medical discovery and practice. As medical education and research matured, so did recognition of the social and environmental determinants of health. Specifically, a new threat to health was identified: environmental injustice. Environmental justice is “the fair treatment and meaningful

“We can work towards social justice by choosing climate action, thereby advancing health equity.”

involvement of all people regardless of race, color, national origin, or income, with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.” The environmental justice movement had its roots in the 1960s and 1970s civil rights and environmental movements and gained significant momentum following the dumping of polychlorinated biphenyl-contaminated soil in a North Carolina county with a high proportion of Black residents. Shortly after, in 1983, a study was released that found that three out of four hazardous waste landfills were located in predominantly Black communities and impoverished communities. Four years later, another study noted that “although the socioeconomic status of residents appeared to play an important role in the location of hazardous waste sites, the residents’ race was the most significant factor among the variables analyzed.” Despite this knowledge of injustice, resources to prevent further injustice, and even the establishment of the U.S. Environmental Protection Agency (EPA) Office of Environmental Justice, we have not cured the environmental factors that harm health.

Effects of climate change exacerbate existing social and environmental conditions, thereby increasing exposure of at-risk populations to conditions that contribute to adverse health outcomes. There is a vicious cycle in which “initial inequality causes the disadvantaged groups to suffer disproportionately from the adverse effects of climate change, resulting in greater subsequent inequality.” There are numerous examples of the unequal effects of climate change on the health of the Black population, including, but not limited to, the following: increased mortality associated with elevated temperatures, worse health disparities during and following extreme weather events, increased pediatric emergency department visits for asthma exacerbations, and an increase in preterm births associated with air pollution.

These adverse health impacts offer an opportunity for change. As history has demonstrated, laws have resulted in drastic improvements in health for adults and children: • Environmental Laws and

Executive Orders • Clean Air Act 1970

Clean Water Act 1972 • The Comprehensive Environmental

Response, Compensation, and

Liability Act (CERCLA or Superfund) 1980 • Marine Protection, Research, and

Sanctuaries Act 1988 • Pollution Prevention Act 1990 • Federal Actions to Address

Environmental Justice in Minority

Populations and Low-Income

Populations 1994 • Energy Policy Act 1995 Source: Environmental Protection Agency (EPA)

Now in 2020, we see two seemingly different historical events — a pandemic and a movement toward social justice (which is inextricably tied to environmental justice) — combine to present an opportunity for change. It is a time to establish a new standard of operation and equity in our health care systems and emergency departments as we promote institutional research, evidence-based practices, and education. We can work towards social justice by choosing climate action, thereby advancing health equity. Here is how we can start: • Reduce greenhouse gas emissions on an individual, community, and national scale. We can start in our own hospitals, as the U.S. health care system alone contributes an astounding 10 percent of greenhouse gas emissions. • Better recognize and treat climatesensitive conditions while helping patients recognize the effects of pollution on their disease. Improve climate-sensitive disease surveillance and treatment and develop early warning systems from the emergency department. • Build resilience in hospitals against supply chain disruptions and infrastructure failures from extreme weather events so our facilities can remain open during times of greatest need.

By mitigating and adapting to a warming world, we can help protect global populations whose health and well-being have been disproportionately affected by climate change over the past century. Just as the pandemic of 1918 changed the face and practice of medicine, we can emerge from this pandemic with a new goal of health care: to pursue public health through social and environmental justice. By learning from the past, we can choose a healthier and more just future.

Even doctors can be historians. It will allow us to create key opportunities to improve practices, people, and our planet. According to Sir Geoffrey Vickers (1958), public health is “successive re-definings of the unacceptable.” We in academic emergency medicine can keep redefining.

ABOUT THE AUTHORS

Dr. Linstadt is an instructor/ fellow in emergency medicine and the Living Closer Foundation Fellow in Climate Change and Health Science Policy at the University of Colorado department of emergency medicine.

Ms. Dahl is a third-year medical student at the University of Iowa Carver College of Medicine and concurrently pursuing an MPH through the online/n campus public health program at the University of California Berkeley.

Dr. Rublee is an assistant professor of emergency medicine at the Medical College of Wisconsin and the current chair of the SAEM Climate Change and Health Interest Group. @CaitlinRublee