medicine worcester Volume 90
• Number 2
Published by Worcester District Medical Society
March / April 2021
Climate Change The Science of Climate Change Climate Change & Human Health Climate Change, Health & the Marine Environment Inflammation of the Climate: The Impact on Gastrointestinal Infections
WDMS.ORG
a great practice begins with
INN VATION When you join Reliant, you join a large, physician-led medical group where primary care providers and specialists work together to improve the quality, cost and experience of health care. Through innovation and superior care management, we are at the forefront of value-based care.
Learn more at
practiceatreliant.org
Career opportunities in Primary Care, Urgent Care and Medical & Surgical Specialties 19-029 WDMS full page Innovation.indd 1
2/14/2019 3:59:35 PM
Contents MARCH / APRIL 2021
Climate Change Editorial 4
The Impact of Medication Disposal on the Environment 19
Anthony Esposito, M.D.
Anna Morin, Pharm.D.
President’s Message 5
Our Patients and the Planet: Studying Medicine in a Changing Climate 20
Spiro Spanakis, D.O.
The Science of Climate Change: An Introductory Overview 6
Sustainability in Support of Public Health 21
David Spanagel, Ph.D.
Suzanne Wood
Climate Change and Human Health 7
There is Still Hope for Climate Action 23
Nitin Damle, M.D., M.S., M.A.C.P.
Climate Change, Health and the Marine Environment 9 Inflammation of the Climate: The Impact on Gastrointestinal Infections 11
Peter Martin, Esq.
Parul Sarwal, MD & George Abraham, M.D.
Filipino Fish Farmers Amidst Climate Disturbance 13 Climate Change and the Trusted Messenger 14 Matthew Masiello, M.D., M.P.H.
Nurse’s Participation in Reducing the Health Impact of Climate Change 16 Janna Trombley, M.S., R.N.
Congressman James McGovern (D-MA)
Legal Consult Certifiable – A Medical Records Story 24
Sam Truesdell, Ph.D. & Caleb Dresser, M.D.
Phillip Ong
Emily Gentile, B.S.
In Memoriam Monica M. Przelomski-Pacifico, MD 25 Luigi Pacifico, M.D., F.A.C.C.
Society Snippets Dependence on China for Medicines: Implications for Drug Shortages, Recalls, and Health Security 25 Rosemary Gibson
Health Matters 26
published by
wdms editorial board
worcester medicine
Worcester District Medical Society
Lisa Beittel, MBA Anthony Esposito, MD, Guest Editor Heather Finlay-Morreale, MD Michael Hirsh, MD Anna Morin, PharmD Nancy S. Morris, PhD, ANP Thoru Pederson, PhD Joel Popkin, MD Alwyn Rapose, MD Robert Sorrenti, MD Paul Steen, MD Ram Upadhyay, MD Peter Zacharia, MD Alex Newbury, MD Resident Representative Parul Sarwal, MD Resident Representative Aly Rabin, Student Representative
Martha Wright, Managing Editor Studio DiBella, Designer
321 Main Street, Worcester, MA 01608 wdms.org | MWright@wdms.org | 508-753-1579 wdms officers
President Spiro Spanakis, DO Vice President Giles Whalen, MD Secretary Marianne Felice, MD Treasurer Dale Magee, MD wdms administration
Martha Wright, MBA, Executive Director Melissa Boucher, Administrative Assistant
thank you to
The Reliant Medical Group UMass Memorial Health Care Music Worcester Physicians Insurance ReMax Vision advertising
Inquiries to Martha Wright MWright@wdms.org 508-753-1579
Worcester Medicine does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in Worcester Medicine reflect the views of the author(s) and not the official policy of the Worcester District Medical Society unless so stated. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by Worcester Medicine unless stated. Material printed in Worcester Medicine is covered by copyright. No copyright is claimed to any work of the U.S. government. No part of this publication may be reproduced or transmitted in any form without written permission. For information on subscriptions, permissions, reprints and other services contact the Worcester District Medical Society.
WORCESTER MEDICINE
Editorial Anthony L. Esposito, M.D., F.A.C.P
Unseating the Horsemen of the Environmental Apocalypse: The Time Is Now
T
he editorial board recognized that devoting a single issue
of Worcester Medicine to climate change would be a daunting task given the magnitude and complexity of the subject. However, as is often the case, the greater the challenge, the more steadfast the effort. In particular, I am confident readers will discover that the distinguished contributors to this issue have done an outstanding job in addressing the subject from a range of perspectives, and I am certain that readers will find the individual articles engaging and the entire issue, informative. Setting the stage for the articles that follow, Dr. David Spanagel offers a lucid and succinct overview of the scientific basis for linking human activity to climate change. He highlights the fact that conclusions about trends in climate change are based on considerable longitudinal data and a progressively more sophisticated analysis and modeling of that data. Finally, Dr. Spanagel nicely outlines how small perturbations in salient “subsystems,” which include the energy output by the sun and the chemical composition of the Earth’s atmosphere, can precipitate substantial changes in the global climate. In a focused and scholarly overview, Dr. Nitin Damle first notes the recent surge in global warming and then describes five distinct consequences of climate change: heat waves, particulate matter and respiratory diseases, vector borne and waterborne diseases, food (in)security, and mass migration. (Given the bleak outlook for ongoing human misery, could these dire consequences be designated as the Five Horsemen of the Environmental Apocalypse?) After acknowledging he had “painted a sobering outlook,” Dr. Damle calls healthcare providers to action, and he highlights the stunning benefits of reducing greenhouse gas emissions on the health of people living in the United States. In their well-referenced submission, Dr. Caleb Dresser and Dr. Samuel Truesdell outline the destabilizing effects of climate change on marine ecosystems, and the net impact of not only reducing fish and shellfish yields but also on facilitating the emergence of harmful plankton and bacteria. Eye-opening is their referenced comment that microbial toxins produced by coastal algae blooms can cause disease in humans living more than a mile from the ocean. Dr. Parul Sarwal and Dr. George Abraham summarize evidence that warming temperatures have led to increases in the incidence of infections of the liver by viral agents, such as hepatitis E, and gastrointestinal tract by bacterial pathogens, including Campylobacter and Salmonella. They also note the association between rising seawater temperatures and the appearance of non-cholera vibrios in the coastal regions of the northeast. In short, climate change threatens the water we drink and the oceans we fish and swim.
4
MARCH / APRIL 2021
Insight into the impact of climate change on a pivotal industry in one developing country is provided by Mr. Phillip Ong, an advocate for sustainable aquaculture. Mr. Ong outlines the importance of fishing to the Philippines’ economy and food supply. His comments regarding the coastal devastation wrought by increasing numbers of ferocious typhoons is stunning; his observations on the impact of weather extremes on fish breeding are less dramatic but equally unsettling, given his country’s dependence on fish as a major source of protein. Mr. Ong’s report highlights the threats to so many other island nations and coastal communities. Because patients have confidence in their doctors, Dr. Matthew Masiello discusses how physicians could play a useful role in educating patients and their families about the medical risks associated with progressive changes in our climates. The medical risks include infectious diseases due to the geographic expansion of vectors, such as mosquitos, capable of transmitting microbial pathogens, including dengue. Dr. Masiello also rightly notes that in order for physicians and other medical providers to be effective messengers, they must be well-informed about the factors and consequences of climate change. As Ms. Janna Trombley aptly reminds us, because they are universally trusted professionals, nurses are in a unique position to advocate for practices to mitigate the impact of climate change and to improve the lives of vulnerable populations. To illustrate how nurses are already engaged, Ms. Trombley provides examples of programs launched, energized, and sustained by nurses; these include the establishment of “green teams” in hospitals and the founding of advocacy groups, such as the Alliance of Nurses for Healthy Environments. Barriers crumble when nurses unite and advocate, therefore their engagement is most appreciated. One way in which physicians, nurses, and other healthcare professionals can impact the environment is to educate patients and families regarding
...we must act, individually and collectively, with the urgency and scale the climate crisis demands.”
WORCESTER MEDICINE
President’s Message
Editorial Continued
the safe disposal of unused medications. As Dr. Anna Morin reports, numerous studies have documented the presence of medications or their metabolites in not only wastewater but also in streams, rivers, lakes, and public water supplies in the United States. Although present in small concentrations, the chemicals have been shown to have a deleterious impact on exposed flora and fauna. Ms. Emily Gentile, a third-year medical student at the University of Massachusetts Medical School (UMMS), describes her awakening to the disproportionate impact of climate change on the inhabitants of third world countries. She writes, “…the populations who are most vulnerable to the effects of climate change (have) made the least contributions to the drivers of climate change.” Thus, she reasonably argues that both a medical and a social justice imperative exists to address climate change with urgency. Heartening indeed are the initiatives which she and other medical students have launched at UMMS and beyond. Don’t think that individual organizations can have a hefty impact on climate change? Well, prepare to be awestruck by Ms. Suzanne Wood, who reports that the University of Massachusetts Medical School has had a sustainability program since 2004 and who details the school’s innovative programs which have yielded dazzling reductions in energy and resource utilization. For example, Ms. Wood writes, “…even though the UMMS campus has grown by several million square feet of built space in the past 15 years, energy use per-square-foot of building space has dropped almost thirty percent.” Not surprisingly, UMMS has garnered national recognition for its sustainability programs. Congressman Jim McGovern outlines the political challenges to moving forward with sufficient action to mitigate impact of climate change, so thoughtfully presented by other contributors to this issue of Worcester Medicine. Equally important, Congressman McGovern offers a sense of “optimism and possibility” regarding the challenges ahead, and he reminds us that “we must act, individually and collectively, with the urgency and scale the climate crisis demands” in order to “reclaim our climate future.” Given the magnitude of the threat to our planet and the well-being of future generations, how can we do otherwise? + Anthony L. Esposito, M.D., F. A.C.P. Hospital Epidemiologist, Saint Vincent Hospital Professor of Medicine, University of Massachusetts Medical School
Spiro Spanakis, D.O. President, WDMS
G
reetings from the wdms office at
Mechanics Hall. As you read the second issue of 2021 of Worcester Medicine, I wanted to thank Dr. Hugh Silk for serving as the first guest editor of the previous issue. Moving forward, we will be inviting guest editors for each issue. If you have interest in serving as a guest editor for a subsequent issue, please contact the office. As I thumbed through the last issue of our magazine on oral health, I recalled how many patients I cared for who required dental extractions under anesthesia prior to major surgeries. Not only did poor oral health serve as a post-operative risk to the patient but it had also potentially contributed to the need for surgical intervention. These cases serve as a reminder of how important it is to consider the patient as a whole when providing care. I want to thank Dr. Anthony L. Esposito for serving as a guest editor of this issue on the effects of climate change on our patients. As the COVID-19 pandemic rages on, I am encouraged by the progress of public vaccination campaigns. The district Society’s officers, staff, and membership have been busy continuing the work of the Society. We are planning virtual events for the foreseeable future. Please stay tuned for updates. +
upcoming events
March 24, 2021 6:30 pm Virtual Meeting
Local Physician Panel on Vaccination Roll-Out
March 30, 2021 6:30 pm Virtual Meeting
WDMS Talent Show In Honor of Doctor’s Day
April 28, 2021 6:30 pm Virtual Meeting
Annual Business Meeting Awards Ceremony & 25/50 Year Anniversary Members
speaker Madeline Ryan, PhD Librarian/Archivist, Worcester Historical Museum title Medicine for Madness: The Rise and Fall of Moral Treatment at the Worcester State Hospital
May 27, 2021 6:30 pm Virtual Meeting
Women In Medicine Leadership Forum
speaker Dr. Heather Lipkind title From Burnout to Thriving: One Physicians Bundle for Personal Resilience
MARCH / APRIL 2021
5
WORCESTER MEDICINE
Climate Change The Science of Climate Change: An Introductory Overview David I. Spanagel, Ph.D.
M
o d e r n c l i m at e s c i e n c e h a s e n ta i l e d
decades of data collection, modeling, and analysis to understand what factors and conditions trigger significant shifts in Earth’s prevailing climate regime. Earth’s climate can best be understood as the aggregate result of a complex system of interactive factors. Like any dynamic system, a changing (rather than fixed) state is to be expected. Since World War II, scientists have sought to attribute the features and tendencies to be found in the aggregate result (our climate) to specific measurable changes observed in any of the components that contribute to the system. In the International Geophysical Year projects of the late 1950s, scientists began to gather data which led to intriguing insights about global climate. Some proceeded to model the Earth’s climate system by identifying key variables that might “drive” particular kinds of system change. Atmospheric concentrations of carbon dioxide, methane, and nitrous oxides all appeared to be varying over time. Based on initially simplistic linear models of atmospheric chemistry, therefore, some scientists called attention to the importance of these “greenhouse” gases since they tend to trap heat within the Earth’s atmosphere., Further research pursued in the 1970s and 1980s identified even more pronounced greenhouse effect-enhancing halocarbon gases whose presence in the atmosphere could only be explained by their manufacture and dissemination in refrigerants and spray-propellant products. Similarly, studies of natural variations in the total amount of solar radiation received by the Earth (due to both orbital eccentricities and to rates of solar activity) and due to the aerosol cloud albedo effect (basically, the reflectivity that sends solar radiation back away from the planet) called attention to seasonal changes in cloud types, snow cover, and vegetation patterns. Studies also pointed to the significance of where aerosolized particulates may reside at various altitudes in the atmosphere; such particulates are released both 6
through natural volcanic activity as well as through agricultural, industrial, and military activities. With longitudinal observational data accumulating, modelers took advantage of improved computing technologies. They developed more sophisticated models that revealed complex relationships among these variables. As in any system, certain kinds of changes may not disturb the aggregate state (especially if variation is kept within a certain range of values). Some researchers looked at the planet’s geological history of cyclic glaciation and concluded that the planet’s climate system might resemble a living body in homeostasis, wherein changes among interacting variables balance or compensate each other to reinforce an overall stability and resilience. Others noted that an excessive shift in some key variable, or a specific combination of changes among a constellation of variables, have on several occasions so radically destabilized a prevailing state of climate stability that episodes of mass extinctions resulted. Nonlinear feedback mechanisms may trigger such extreme events. With this in mind, studies of oceanic circulation have explored how feedback effects may accelerate the planet towards either global warming or global cooling, based on how a sudden large-scale change in water movement patterns either initiate or terminate widespread redistribution of heat across various latitude zones. There was never much doubt about whether climate can change; it always has. Research has instead illuminated how differences in any of these subsystems could trigger a dramatic global climate transformation: 1) the sun’s overall energy output; 2) the chemical composition of Earth’s atmosphere; 3) the respective proportions of the planet’s surface taken up by dry land, various vegetation types, open water, and ice sheets; and 4) the dynamics of heat transfer via ocean currents. A series of United Nations Intergovernmental Panel on Climate Change assessment reports successively indicated with increasing specificity and confidence how modern industrial society’s planet-wide activities of deforestation and rapid combustion of hundreds of millions of years’ worth of accumulated fossil fuel hydrocarbons have triggered a now ongoing dramatic transformation of the Earth’s climate. A modest global increase of 1 degree Celsius has already wrought noticeably more frequent violent storms, deglaciation, desertification, ocean acidification, and sea level rise. More will come. + David I. Spanagel, Ph.D. is associate professor of history in Worcester Polytechnic Institute’s Department of Humanities and Arts. Email: spanagel@wpi.edu. references
1. Callendar GS. On the amount of carbon dioxide in the atmosphere. Tellus 1958;10(2): 243-248. 2. Keeling C, Whorf T, Wahlen M, and van der Plichtt J. Interannual extremes in the rate of rise of atmospheric carbon dioxide since 1980. Nature 1995;375:666–670. 3.Rasool SI and Schneider SH. Atmospheric carbon dioxide and aerosols: effects of large increases on global climate. Science 1971;173:138–141. 4. Madden RA and Ramanathan V. Detecting climate change due to increasing carbon dioxide. Science 1980;209:763–768.
MARCH / APRIL 2021
WORCESTER MEDICINE
Climate Change
The Science of Climate Change Continued
5. Wang W-C, Yung YL, Lacis AA, Mo T, and Hansen JE. Greenhouse effects due to man-made perturbation of trace gases. Science 1976;194:685– 690. 6. Liousse C, Penner JE, Chuang C, Walton JJ, Eddleman H, and Cachier H. A global three-dimensional model study of carbonaceous aerosols. J. Geophys. Res. Atmos. 1996;101:19411–19432. 7. Hartmann DL, Ockert-Bell ME, and Michelsen ML. The effect of cloud type on Earth’s energy balance: global analysis. J of Climate 1992;5(11):1281–1304. 8. Minnis P, Harrison EF, Stowe LL, Gibson, GG, Denn FM, Doelling DR, and Smith Jr. WL. Radiative climate forcing by the Mount Pinatubo eruption. Science 1993;259(5100):1411–1415. 9. Mitchell Jr, M. A preliminary evaluation of atmospheric pollution as a cause of the global temperature fluctuation of the past century. Singer SF, ed. Global Effects of Environmental Pollution. New York: Springer-Verlag 1970: 139–155. 10. Shaw HR. The periodic structure of the natural record, and nonlinear dynamics. Eos (American Geophysical Union Transactions) 1987;68(50):1651– 1665. 11. Kolbert E. The Sixth Extinction: An Unnatural History. New York: Henry Holt 2014. 12. Barnett TP, Pierce DW, and Schnur R. Detection of anthropogenic climate change in the world’s oceans. Science 2001;292:270–274. 13. Böning C, Dispert A, Visbeck M, Rintoul SR, and Schwarzkopf FU. The response of the Antarctic Circumpolar Current to recent climate change. Nature Geosci 2008;1:864–869. 14.IPCC. First, Second, Third, Fourth, and Fifth Assessment Reports (1990, 1995, 2001, 2007, and 2014, respectively). https://www.ipcc.ch/reports/. Accessed January 13, 2021. 15. NASA Earth Observatory. World of Change: Global Temperatures. https://earthobservatory.nasa. gov/world-of-change/global-temperatures #:~:text=According%20to%20an%20ongoing%20 temperature,2%C2%B0%20Fahrenheit)%20 since%201880. Accessed January 13, 2021.
Climate Change and Human Health Nitin S. Damle, M.D., M.S., M.A.C.P.
I
2015, 186 countries signed the paris climate agreement to limit global warming to “well below 2 degrees Celsius” and avoid the harmful impacts on human health. Integral to this goal was to reduce carbon emissions to near zero over the next several decades. Unfortunately, carbon emissions have continued to rise, and the global average temperature has risen by 1.2 degrees Celsius resulting in the five hottest years on record, all since 2015. The environmental impact is well documented and includes sea level rise, ocean acidification, ice melt, and loss of glacier mass. These changes have resulted in a 46% increase (since 1980) in extreme heat waves, flooding, droughts, forest fires, and intense weather events (hurricanes and cyclones). The above weather events and air pollution lead to downstream consequences on human health. This article will focus on five health effects. n
heat waves
The number and intensity of heat waves has increased significantly in the past 20 years. This burden is borne mostly by the elderly, children, and those with cardiovascular and respiratory diseases, outside laborers, homeless, and the poor. There has been a 53.7 % increase in heat-related mortality for people over age 65. Heat waves and temperature rise increase the risk of myocardial infarction, stroke, and acute and chronic renal injury. Studies indicate for each day that the heat index is 95 degrees Fahrenheit (compared to 75 degrees F), emergency department visits increase by 6.6% over the following seven days, heat-related emergency department visits increase by 89% for seven days and death rates increase by 5.8% for each day. Mitigation is essential and includes early warning systems and response plans, increased access to air conditioning, communication by clinical teams to reach vulnerable populations, and education about the risk of heat illness. particulate matter and respiratory diseases
The primary drivers of respiratory diseases are automobile, power plant emissions, and forest fires. Measured particulate matter includes sulfates, nitrates, black carbon, and nitrous oxide. Forty-three million people in the United States and 92% of the world live in areas in excess of the World Health Organization (WHO) particulate limit, and in 2019 there were eight million deaths worldwide attributable to air pollution. Increased CO2 production leads to increased growth of allergen producing weeds, grasses, and trees with rain and floods leading to increased mold and fungal growth. The aeroallergen season has increased from 177 days in the 1970s to 190 days today and is projected
MARCH / APRIL 2021
7
WORCESTER MEDICINE
Climate Change
“
Climate Change and Human Health Continued to reach 214 days by mid-century. Allergy exacerbations lead to 11 million office visits per year at a cost of 11.2 billion dollars per year and asthma and COPD exacerbations result in two million emergency department visits, 500,000 hospitalizations, and 3,600 deaths at a cost of 56 billion dollars per year. Clinicians will need to educate patients about weather trends, knowledge about air pollution, symptoms, and prevention.
A 30% cut in healthcare greenhouse gas emissions by 2030 would prevent an estimated 4,130 premature deaths... mass migration
vector borne and waterborne diseases
The primary vectors in the United States are mosquitoes, sand flies, and ticks. There has been an increase in cases of dengue, Chikungunya, West Nile fever, Zika, and even malaria. The number of cases of Lyme disease has risen from 50,000 in the 1990s to over 400,000 in 2018 and is reported in most regions of the country. Heavy rains and flooding lead to contamination of water systems, reservoirs, and surface water that increase risk for E. coli, Campylobacter, Leptospira, and Salmonella infection. Vibrio parahaemolyticus infection is a significant seafood-related public health concern. In addition, rates of parasitic infection have increased, in particular Cryptosporidium, Cyclospora, and Giardia Lamblia in contaminated drinking water and fresh produce. Globally, there are over one billion people that lack access to safe drinking water and 2.5 billion lack access to adequate sanitation with an estimated 5 million deaths annually in children. food security
The food system involves a network of interactions with our physical and biological environments as food moves from production to consumption, or from “farm to table.” There has been an increase in crop losses from fungi, bacteria, and viruses. There has been a decrease in food production by 2% per year in the face of a 14% per year increase in global demand with a projected further decline of 6% in global wheat and 10% in global rice production for each one degree rise in temperature. The nutrient content (protein, iron, and zinc) has dropped from 20% to 17% with an increase in carbon dioxide concentration. Carbon dioxide production is ten times greater for the consumption of beef, lamb, and pork versus more plant, fish, turkey, and chicken-based diets.
8
Extreme weather, sea-level rise, floods, food insecurity and drought have forced two hundred million people in the world to migrate from their homes between 2008 and 2018. Modeling predicts that one billion people will need to migrate by the end of the century for these same reasons. Without climate change mitigation, this rate will significantly outpace other causes for migration such as interstate conflict, failure of national governance, unemployment or underemployment. conclusion
The effects of climate change have been predicted since the 1970s. There were non-binding agreements in 1979, 1989, and 1997 that did not succeed in slowing carbon dioxide emissions. It is time for the United States to rejoin and strengthen the Paris Agreement of 2015 and actively engage in setting standards at the upcoming United Nations COP26 climate summit in 2021. If the United States health sector were a country, it would be the fifth largest emitter on the planet with 9 billion dollars annually in energy costs. A 30% cut in healthcare greenhouse gas emissions by 2030 would prevent an estimated 4,130 premature deaths, 85,000 asthma attacks, 4 million respiratory symptom events, and 3,750 hospital visit incidents and save about $1.2 billion in medical costs. As a physician you have the gravitas to make a significant impact on your community by raising awareness through talks in town halls and community gatherings in addition to educating your colleagues and patients. You can lobby your local, state, and national representatives to make climate change and health a high priority issue and you can engage in climate healthy habits including plant-based diets, electric cars, energy efficient homes, and work environments. I have painted a sobering outlook with one last opportunity to mitigate the effects of climate change. It is the existential threat of our time and a moment for all of us to educate and amplify our voices to protect future generations and the planet. + Nitin S. Damle, M.D., M.S., M.A.C.P. Past President American College of Physicians Clinical Associate Professor of Medicine Alpert Medical School of Brown University Senior Partner South County Internal Medicine nsdamle@scim.necoxmail.com
MARCH / APRIL 2021
WORCESTER MEDICINE
Climate Change Climate Change, Health, and the Marine Environment Caleb Dresser, M.D. Samuel Truesdell, Ph.D.
introduction
C
limate change is altering the chemistry, temperature, weather, and ecology of the world’s oceans. Seas are rising at an accelerating rate, causing saltwater intrusion, shore erosion, flooding, and disappearance of low-lying land, all of which are expected to intensify during the 21st century. Changes in the marine environment alter weather patterns and create new opportunities for marine pathogens and biological toxins that can cause health problems. Destabilization of ecosystems can also indirectly harm human health via economic hardship caused by disruption of coastal economies. Despite the specter of uncertainty that climate change presents to human health, we are fortunate to have many tools at our disposal. The more we understand about how climate change is impacting various dimensions of human health, the better equipped we are to mitigate negative consequences. To do so, it is critical that we understand the mechanisms by which evolving ocean conditions impact human health so that anticipated future conditions, rather than historical norms, become the basis for policy decisions.
health effects
Climate change is leading to a range of marine dynamics that can cause health problems for humans. The most important common pathway linking these is rising ocean temperatures. Warmer waters are more hospitable to the growth of a variety of microorganisms, some of which are infectious or toxic to humans. Rising temperatures in brackish coastal environments such as the Chesapeake Bay and salt marshes in New England are making these habitats increasingly hospitable to Vibrio bacteria (1,2). These bacteria cause severe necrotizing soft tissue infections and sepsis and can be contracted from either minor skin injuries exposed to contaminated water or consumption of contaminated shellfish (3). Infections carry a high mortality rate (4) and the number of cases reported to the CDC has increased dramatically over the past 20 years (5).
Warming oceans also increase the occurrence of toxic algal blooms (red tide). In addition to leading to hazardous conditions for swimmers and shellfishing closures, the toxins produced during these events can affect respiratory function. Emergency Department utilization rates increase significantly among people living near the coastline, even if they avoid beaches and contaminated water (6). Warming water in the tropics can also lead to increased growth of the plankton that produce ciguatoxin, which bio-accumulates in pelagic fish and causes ciguatera poisoning in humans when the fish is eaten (7). There is concern that such poisonings may increase among people who consume tropical pelagic fish in coming decades (8). hurricanes
Climate change is making hurricanes more dangerous, increasing the risk to human health both through direct impacts such as bodily injury and the resulting losses to infrastructure and economies. Warmer oceans provide additional potential energy, and warmer air holds more moisture that can later fall as rain (9). While it is challenging to study this system because of its complexity and interactions with other climatological features such as El Niño and the North Atlantic Oscillation, hurricane scientists have found evidence of several concerning trends. Hurricane rainfall and intensity are both expected to increase (9,10). Storm centers may be moving more slowly, meaning longer impact duration in affected locations (11). There is some evidence that the latitude of average peak intensity is moving poleward, increasing risk in temperate zones (9,12). Finally, rapid intensification - a sudden and dramatic increase in power within 24 hours - appears to be on the rise (13,14). Together, these changes are profoundly concerning, particularly for temperate zone coastal areas that are at risk from sea level rise, such as the coastlines of New England. impacts on fisheries
Climate impacts are already occurring regionally over perceptible time frames. In recent years, the Gulf of Maine has warmed at a faster rate than most of the world’s oceans and experienced marine heat waves (15,16). Such environmental change has downstream effects on marine ecosystems, impacting fisheries on which communities depend; climate variability has been linked to decreases in regional fisheries revenue and employment (17). Diminished economies have negative repercussions for human health. Scientists expect distributional changes and productivity impacts on numerous important regional marine populations as a result of climate change (18). For example, both American lobster and Atlantic sea scallops are expected to experience shifts in optimal habitat (19). Further, lobsters have seen settlement declines with increasing temperatures in nursery grounds (20) and increased incidence of shell disease linked to warming waters (21,22). There is also concern that ocean acidification may reduce productivity of sea scallops in the future (23). Fishing will continue to contribute to coastal economies as the impacts of climate change are realized, but to effectively utilize these resources and avoid negative socioeconomic impacts, and by association negative health effects, it is important to integrate our understanding of environmental
MARCH / APRIL 2021
9
WORCESTER MEDICINE
Climate Change Climate Change, Health, and the Marine Environment Continued change into fishery policy. Policy that understates the risks of overfishing remains the greatest threat to fishery performance regardless of climate change (24), but in order to fully support coastal economies it will be critical to incorporate the implications of environmental change into fisheries management. conclusion
5. Vibrio Species Causing Vibriosis. U.S. Centers Dis. Control. https:// www.cdc. gov/vibrio/index.html (accessed Oct 21, 2020). 6. Kirkpatrick, B., Fleming, L.E., Backer, L.C., Bean, J.A., Tamer, R., Kirkpatrick, G., Kane, T., Wanner, A., Dalpra, D., Reich, A. and Baden, D.G. 2006. Environmental exposures to Florida red tides: effects on emergency room respiratory diagnoses admissions. Harmful Algae. 5(5): 526-533.
Climate change is transforming the world’s oceans, destabilizing ecosystems and fisheries, and contributing to the growth of harmful plankton and bacteria that can affect human health. Policies based on historical precedent rather than an understanding of the trajectory of these processes will inevitably fail to meet their goals. In addition to dramatically reducing greenhouse gas emissions, we must understand both the changes our oceans are undergoing and the mechanisms by which they affect human health, and begin taking steps to address these impacts as - or before - they occur. +
7. Tester, P. A.,Feldman, R. L., Nau, A. W., Kibler, S. R. and R. W. Litakera. 2010. Ciguatera Fish Poisoning and Sea Surface Temperatures in the Caribbean Sea and the West Indies. Toxicon 56(5): 698–710.
Caleb Dresser, M.D. is a Fellow in Climate and Human Health in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center. He is affiliated with Harvard C-Change and the FXB Center for Health and Human Rights at Harvard, and supported by the Climate and Health Foundation. Email: cdresser@bidmc.harvard.edu.
10. Ting M., Kossin J.P., Camargo S.J. and Li, C. 2019. Past and Future Hurricane Intensity Change along the U.S. East Coast. Sci. Rep. 2019. 9(1):7795.
Samuel Truesdell, Ph.D. is a Stock Assessment Specialist at the Massachusetts Division of Marine Fisheries. E-mail: samuel.truesdell@mass.gov. references
8. Gingold, D. B., Strickland, M. J., and Hess, J. J.. 2014. Ciguatera Fish Poisoning and Climate Change: Analysis of National Poison Center Data in the United States, 2001–2011. Environ. Health Persp. 122(6): 580–6. 9. Knutson, T., Camargo, S.J., Chan, J.C., Emanuel, K., Ho, C.H., Kossin, J., Mohapatra, M., Satoh, M., Sugi, M., Walsh, K. and Wu, L. 2020. Tropical cyclones and climate change assessment: Part II: Projected response to anthropogenic warming. Bulletin of the American Meteorological Society. 101(3): E303-E322.
11. Kossin, J.P. 2018. A global slowdown of tropical-cyclone translation speed. Nature. 558(7708): 104-107. 12. Kossin J.P., Emanue,l K.A. and Vecchi, G.A. 2014. The poleward migration of the location of tropical cyclone maximum intensity. Nature. 2014: 509(7500): 349-352. 13. Balguru K., Foltz, G.R. and Leung, L. 2018. Increasing Magnitude of Hurricane Rapid Intensification in the Central and Eastern Tropical Atlantic. Geophys. Res. Lett. 45(9): 4238-4247.
1. Watts N, et al. 2021. The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. Lancet 397: 129-170.
14. Bhatia, K.T., Vecchi, G.A., Knutson, T.R., Murakami, H., Kossin, J., Dixon, K.W. and Whitlock, C.E., 2019. Recent increases in tropical cyclone intensification rates. Nat. commun. 10(1): 1-9.
2. Deeb, R., Tufford, D., Scott, G.I., Moore, J.G. and Dow, K. 2018. Impact of Climate Change on Vibrio vulnificus Abundance and Exposure Risk. Estuar. Coast. 41: 2289–303.
15. Mills, K.E., A.J. Pershing, C.J. Brown, Y. Chen, F.-S. Chiang, D.S. Holland, S. Lehuta, J.A. Nye, J.C. Sun, A.C. Thomas, and R.A. Wahle. 2013. Fisheries management in a changing climate: Lessons from the 2012 ocean heat wave in the Northwest Atlantic. Oceanography 26:191–195.
3. Strom, M.S. and Paranjpye, R.N. 2000. Epidemiology and pathogenesis of Vibrio vulnificus. Microbes Infect. 2: 177–88. 4. Heng, S.P., Letchumanan, V., Deng, C.Y., Ab Mutalib, N.S., Khan, T.M., Chuah, L.H., Chan, K.G., Goh, B.H., Pusparajah, P. and Lee, L.H., 2017. Vibrio vulnificus: an environmental and clinical burden. Frontiers in microbiology 8: 997.
10
16. Pershing, A.J., Alexander, M.A., Hernandez, C.M., Kerr, L.A., Le Bris, A., Mills, K.E., Nye, J.A., Record, N.R., Scannel, H.A., Scott, J.D., Sherwood, G.D., Thomas, A.C. 2015. Slow adaptation in the face of rapid warming leads to collapse of the Gulf of Maine cod fishery. Science 350, 809–812. 17. Oremus, K.L., 2019. Climate variability reduces employment in New England fisheries. Proceedings of the National Academy of Sciences 116: 26444–26449.
MARCH / APRIL 2021
WORCESTER MEDICINE
Climate Change
Climate Change, Health, and the Marine Environment Continued 18. Hare, J.A., Morrison, W.E., Nelson, M.W., Stachura, M.M., Teeters, E.J., Griffis, R.B., Alexander, M.A., Scott, J.D., Alade, L., Bell, R.J., Chute, A.S., Curti, K.L., Curtis, T.H., Kircheis, D., Kocik, J.F., Lucey, S.M., McCandless, C.T., Milke, L.M., Richardson, D.E., Robillard, E., Walsh, H.J., McManus, M.C., Marancik, K.E., Griswold, C.A. 2016. A vulnerability assessment of fish and invertebrates to climate change on the northeast US continental shelf. PLoS ONE 11: 1–30. 19. Tanaka, K.R., Torre, M.P., Saba, V.S., Stock, C.A., Chen, Y., 2020. An ensemble high-resolution projection of changes in the future habitat of American lobster and sea scallop in the Northeast US continental shelf. Diversity and Distributions 26: 987–1001. 20. Wahle, R.A., Dellinger, L., Olszewski, S., Jekielek, P. 2015. American lobster nurseries of southern New England receding in the face of climate change. ICES Journal of Marine Science (2015), 72(Suppl. 1). i69–i78. 21. Glenn, R.P., Pugh, T.L. 2006. Epizootic shell disease in American lobster (Homarus americanus) in Massachusetts coastal waters: interactions of temperature, maturity, and intermolt duration. Journal of Crustacean Biology 26: 639–645. 22. Groner, M.L., Shields, J.D., Jr, D.F.L., Swenarton, J., Hoenig, J.M. 2018. Rising Temperatures, Molting Phenology, and Epizootic Shell Disease in the American Lobster 192: E163-E177. 23. Cooley, S.R., Rheuban, J.E., Hart, D.R., Luu, V., 2015. An Integrated Assessment Model for Helping the United States Sea Scallop (Placopecten magellanicus) Fishery Plan Ahead for Ocean Acidification and Warming. PLoS ONE 10: e0124145. 24. Cisneros-Mata, M.A., Mangin, T., Bone, J., Rodriguez, L., Smith, S.L., Gaines, S.D. 2019. Fisheries governance in the face of climate change: Assessment of policy reform implications for Mexican fisheries. PloS one 14: e0222317.
Inflammation of the Climate: The Impact on Gastrointestinal Infections Parul Sarwal, M.D. George M. Abraham, M.D., M.P.H., F.A.C.P., F.I.D.S.A.
T
he united states ventured to return to the paris climate
Agreement this January, a month that saw warmer-thanaverage temperatures in most parts of the country. The average global temperature today is 1 degree Celsius higher than before the industrial revolution of the last century. While this statistic beguiles the gravity of the climate crisis, extreme weather events certainly do not - as demonstrated by the increasing frequency of heat waves and floods, among other natural disasters. The 2020 Atlantic hurricane season witnessed the greatest number of storms in recorded history in the shortest duration of time; so much so, that the National Hurricane Center ran out of human names for the storms, needing to turn to the Greek alphabet for Tropical Storm Beta, the cyclone that affected the southeastern US this past September. One of the myriad corollaries of harsh weather is an upsurge in infectious diseases, primarily gastrointestinal (GI) and hepatic. Studies have consistently demonstrated an association between temperature variations and GI infections. A recent review by Australian researchers confirmed that temperatures warmer than the usual baseline are associated with more frequent bacterial GI infections, which is compounded by an increase in humidity and precipitation. Campylobacter and Salmonella infections peaked in Scotland in July according to one study. This brings to mind the “gastroenteritis season” in July and August every year during my medical school training in India — rows of extra hospital beds in the hallways festooned with bags of IV fluids. A heat wave is defined by the World Meteorological Organization as five or more consecutive days of prolonged heat wherein the daily maximum temperature is at least 9 degrees Fahrenheit (5 degrees Celsius) higher than the average maximum temperature. Scientists in Switzerland reported a nearly 5% increase in GI infections and resultant hospitalizations for every additional hot day during heat waves – an effect not observed during spells of cold weather. The year 2018 saw one of the longest heat waves in the United Kingdom. This prompted water treatment agencies to offer Legionella risk assessments to prevent potential outbreaks. While not primarily a GI infection, Legionnaires’ disease can often cause diarrhea, and its outbreaks have been partly ascribed to climate variations by the scientific community. This is perhaps due to its propensity for spread via internal climate control systems. Thus, it is important to note that external climate change can cause increased disease spread via internal climate change machinery. In the same vein, we are presented with uncharted challenges with respect to sanitation and clean water. There has been a resurgence of hepatitis E virus in endemic areas due to increasing population densities as well as the increased frequency of flooding and drought, impacting access to safe drinking water. Further, variations in temperature and carbon dioxide
MARCH / APRIL 2021
11
WORCESTER MEDICINE
Climate Change
Inflammation of the Climate: The Impact on Gastrointestinal Infections Continued
levels are postulated to have effects on mutation patterns in Rotavirus and hepatitis A virus, both of which have fecal-oral transmission. The 2019 Lancet Countdown report describes how environmental suitability for the transmission of Vibrio species has increased because of climate change. Vibrio species are implicated in a range of infections, including cholera, and are found in brackish waters. Variables such as sea surface temperature and salinity have been reported to affect Vibrio infections. There has been nearly a 30% increase in the coastline area suitable for species of non-cholera Vibrio in northeast US in the 2010s, compared to the 1980s. Increasingly favorable conditions for coastal V. cholerae sensu lato in various regions around the world have allowed it to thrive globally. As the human footprint on the planet grows, wild habitats shrink and we encroach upon their borders, enabling interspecies transmission of pathogens that then amalgamate into new and terrifying disasters – the COVID-19 pandemic being one of the latest in a long line of these infectious harbingers. There is thus a growing need for physicians, as community leaders, to join the current debate on climate change, because it is directly impacting our patients and our planet. If we fail to speak up, we would be guilty of our silence, as Martin Niemöller’s quote goes: First they came for the Communists and I did not speak out because I was not a Communist Then they came for the Socialists and I did not speak out because I was not a Socialist Then they came for the trade unionists and I did not speak out because I was not a trade unionist Then they came for the Jews and I did not speak out because I was not a Jew Then they came for me and there was no one left to speak out for me + Dr. Parul Sarwal is a PGY-III internal medicine resident at Saint Vincent Hospital. Dr. George Abraham is Chief of Medicine at Saint Vincent Hospital, President-Elect of the American College of Physicians and Chair of the Massachusetts Board of Registration in Medicine.
12
“
If we fail to speak up, we would be guilty of our silence... references
1. Watts N, Amann M, Arnell N, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. Lancet. 2019;394(10211):1836-1878. 2. Ghazani M, FitzGerald G, Hu W, Toloo GS, and Xu Z. Temperature Variability and Gastrointestinal Infections: A Review of Impacts and Future Perspectives. Int J Environ Res Public Health. 2018;15(4):766 3. Leddin D and Macrae F. Climate Change: Implications for Gastrointestinal Health and Disease. J Clin Gastroenterol. 2020;54(5):393-397. 4. MacIntyre CR, Dyda A, Bui CM, and Chughtai AA. Rolling epidemic of Legionnaires’ disease outbreaks in small geographic areas. Emerg Microbes Infect. 2018;7(1):36. 5. Climate change is the greatest threat to global health in the 21st century. World Health Organization, Nov 2015. who.int/globalchange/ global-campaign/cop21/en/ 6. Tarek F, Hassou N, Benchekroun MN, Boughribil S, Hafid J, and Ennaji MM. Impact of rotavirus and hepatitis A virus by worldwide climatic changes during the period between 2000 and 2013. Bioinformation. 2019;15(3):194-200. 7. Carratalà A and Joost S. Population density and water balance influence the global occurrence of hepatitis E epidemics. Sci Rep. 2019;9(1):10042. 8. Smith KR, Woodward A, Campbell-Lendrum D, Chadee DD, et al. Chapter 11: Human Health: Impacts, Adaptation, and Co-Benefits. IPCC AR5 WG2 A 2014. pp. 709–754.
MARCH / APRIL 2021
WORCESTER MEDICINE
Climate Change Filipino Fish Farmers Amidst Climate Disturbance Phillip L. Ong
E
arlier this year, the world was transfixed
as forest fires raged across the redwood forests in California, razing beautiful homes and vineyards while people fled for their lives and thousands of weary firefighters battled the blazes. The fires were horrifying to Filipinos who had relatives in California. Filipinos also wondered how global temperature changes would affect their fish farmers and their food security on the other side of our planet. For the last several years, fish hatcheries in Pampanga Province, 70 km north of the capital, Manila, had been experiencing difficulty in breeding during the dry season. The unusually high temperatures of the summer months had caused the breeders to stop spawning. Many of these hatcheries have either ceased operations or have relocated to the cooler areas of the lake province. The inverse of the hot summer for Filipinos is the rainy season. Rains come in July and with them, hurricanes – known to us as typhoons. As children, we enjoyed the surprise holidays when school was called off when a visiting typhoon had wind speeds exceeding 120 km/hr. It was not safe to be out at winds of these speeds, but there were not many of these typhoons with such strength. That was decades ago. This year, with the country in the midst of suffering from COVID-19 and its related lockdown and unemployment, three consecutive typhoons hit the Philippines in October and November: Typhoon Quinta (Molave) with maximum winds of 195 km/hr, Typhoon Rolly (Goni) with maximum winds of 315 km/hr, and Typhoon Ulysees (Vamco) with winds of 215 km/hr. These successive typhoons devastated large parts of the country. Along with the typhoons, continuous rains caused far-reaching floods in Luzon, the largest island of the Philippines. Farmers in Pampanga, who had gotten their fish seeds late in the season, had not yet harvested their crop. They lost much of their hard wrought production to the waters flowing from aging dams that could not hold the volume of the downpour. I am not an expert on climate change. Nor do I have access to the data accumulated by scientists who explore the Arctic for methane emissions, measure seawater rise, and track hurricanes and forest fires. Yet I strongly suspect that these recent typhoons as
well as the earlier dry hot season are manifestations of a globally linked web of factors caused by a warming planet. In the last decade, the Philippines has suffered some of the most ferocious typhoons in history. The largest of these super typhoons was Yolanda (Haiyan) in 2013, which caused the death of more than 6,000 persons and left a million homeless. The next was 2016 typhoon Ferdie (Meranti), which also packed winds of over 310 km/hr. Climate cycles are hard to attribute to any one factor because our views are limited, while the global weather system is a fabric of interlinked butterfly flutters. Some non-believers see extreme climate occurrences, such as three strong typhoons in two weeks as a result of chance. They reason that this clustered mishap was bound to happen to a Pacific archipelago which has been in the way of twenty typhoons a year. The Philippines continues to survive under these risky climate conditions. Fishing is still a main livelihood for many in coastal communities. These municipal fishermen produce 45% of the country’s marine catch. Coastal communities are also the most vulnerable to typhoons. Even when boats are docked onshore, large waves caused by these typhoons easily destroy flimsy wooden vessels. Fish supply in the Philippines is roughly 3 million tons – two thirds from marine catch and a third from farming. Weather events and overfishing have caused the marine catch to level off over the last few decades, and the future source of our fish supply is now centered on farming. Unlike China, with their centuries old tradition in inland aquaculture, the Philippines aqua farming industry is still in its infancy. Fish farming largely depends on stable weather conditions to survive. With progressively unstable weather conditions, the Philippine fish farming industry has nevertheless grown by farming in the sea with the practice of mariculture. With investments in stronger high-density polyethylene (HDPE) fish cages, the commercial fish farming sector is attempting to cope with the uncertainties of nature. Strong typhoons are but one of the effects attributed to climate change. Rising sea levels are also threatening to inundate many coastal municipalities around the world. For the Philippines, this risk is a stark reality. The Philippine National Mapping and Resource Information Authority has reported consistent sea level increases all over the country for the last decade. The cumulative increase in sea level over the last 10 years has been about 6 inches. The Earth has never had so many people breathing, consuming, and discharging waste. Seven billion people on this planet must have some effect on the air, the water, the balance of gases, and the temperature. The majority of these 7 billion have not yet gained access to the lifestyle enjoyed by the privileged. Environmentally harmful conveniences are “dreams” seen daily by these “developing” consumers in commercials and social media. They want to be a part of it, but these goals will further accelerate rising world temperatures and climate disturbances. I would like to believe that given our new awareness of climate effects on people’s lives, we will be doing something to avert a catastrophe. In the meantime, our Filipino fishermen go about their livelihood under clouds of ever-increasing risks of rising summer temperatures and the next ferocious typhoon.
+
Phillip L. Ong, Chairman, Philippine Chamber of Agriculture and Food Inc., Aquaculture Entrepreneur, Advocate of Sustainable Aquaculture
MARCH / APRIL 2021
13
WORCESTER MEDICINE
Climate Change Climate Change and the Trusted Messenger Matthew Masiello, M.D., M.P.H
H
ow we deliver a message, and by whom,
are critically important tenets of public health practice. As that reliable messenger, studies continue to comment on the role physicians have as trusted sources of information. For the segment of our population that dismisses or doubts that climate change is happening, physicians were identified as their most trusted informants. They ranked higher than the CDC, WHO, politicians, and religious leaders. Studies have also demonstrated that the majority of physicians believe climate change is a reality that is affecting, and will further affect, the health and well-being of their patients. To effectively propagate climate change mitigation and adaptation education, physicians must become knowledgeable of how climate change presently and will, more dramatically, affect their patients in this upcoming decade and beyond (1). Regardless of whether we believe global warming is an anthropogenic (human) phenomenon, there should be no doubt our planet is getting warmer. After decades of research and observation, science presented its first warnings of increased CO2 in the Earth’s atmosphere in the 1960s (2). We have made progress. In 1970, President Nixon passed the monumentally important Clean Air Act (3). Unfortunately, as we were approaching 2020 and the fiftieth anniversary of this landmark legislation and the amendments made since, we saw the removal of key regulations. More recently, the 2015 Paris Agreement announced to the world that we need to limit our global average temperature to well below 1.2 degrees Celsius by the end of this decade. Unfortunately, since 2015, our summers have been the hottest on record. Despite some notable successes, unhealthy greenhouse emissions continue to rise, associated with a rising number of climate-related deaths due to extreme heat exposure, extreme weather, and disease. Global warming is increasing the geographical distribution of vector, food, and waterborne diseases. Terms, such as “climate suitability,” now describe the enhanced transmission of dengue, malaria, and pathogenic Vibrio bacteria. It is projected, with climate change as a key factor, by mid to late century an additional 3 to 5 billion people will be at risk for dengue infection, above the present 1.5 billion. Other catastrophic natural disasters have also taken their toll on the human population. The global increase in respiratory, cardiovascular disease, and the related
14
mortality secondary to wildfires has been significant. Many countries are experiencing a significant increase in daily exposures to these catastrophic natural events. Compared to 2001-2004, the US has experienced close to a half million additional daily wildfire exposures (4,5). Global warming will also exacerbate existing negative human conditions. Prior to the pandemic, approximately 10% of US households, 35 million Americans, experienced some level of food insecurity. Over 1/3 experienced a serious disruption in their ability to be adequately nourished. In this pandemic, 20% of Americans are now challenged with food insecurities. Rising temperatures, more severe weather, air pollution, and sea level rise will only exacerbate the nutritional insecurities we are now experiencing globally (6). Between 1981 and 2019, there has been a worldwide reduction, 1.8 to 5.6%, in the production of our terrestrial crops - maize, winter and spring wheat, soybean, and rice production. This crop reduction will not be taking place in all countries and that may not necessarily be a good thing (4). By 2080, the permafrost in northern Russia will be reduced by 50% making it more habitable for human activity, allowing for the farming of previously inhabitable land. Associated with a more temperate climate and an expanded crop production will be an increase in per capita gross domestic product. Yet, the reverse will occur in China, India, and the United States (7). What can physicians and our health systems do to decisively enter this national and global effort to stabilize and improve the health of our ailing planet? First and foremost, we will need climate knowledgeable and public health progressive healthcare leadership. Globally, the healthcare sector contributes approximately 5% to greenhouse gas emissions. In the US, our healthcare systems are responsible for 10% of these emissions. On an optimistic note, we are now seeing our medical students and residents stepping up to hold their medical schools, universities and hospitals accountable to the growing need for immediate and well-defined changes on how we educate these young professionals and in how green of an institution that education takes place. Several US health systems are already moving in this direction (8). The UK serves as that example of what the health sector can do to address climate change. They are committed to becoming the first net zero health system and have placed a timeline on that goal (4). Individual physicians and our professional organizations must become more civically active on the climate change issue. We need more readily accessible climate change education to inform our families, patients, and communities of the concerning consequences of global warming (9,10). New and more politically accepted messaging strategies need to encourage the voting for politicians and policies that bring us all to better and sustainable health. Physicians need to identify the right to vote as preventive medicine (11). Healthcare providers must begin a climate change educational process that is deliberate and deep. The pandemic forced healthcare systems to look at hospital operations beyond that of the four walls of the hospital and into the larger community and how that larger community could dramatically affect the daily operations of the system (12). As we emerge from this pandemic, we cannot settle back to life as we once knew it. The workforce realignment and technological advancements healthcare systems developed for the pandemic must now be carried over to addressing the health-related consequences of climate change. We have a challenging decade before us. These next several years will be critically important as we
MARCH / APRIL 2021
WORCESTER MEDICINE
Climate Change
Climate Change and the Trusted Messenger Continued
recover from the devastation of COVID-19 and move deliberately towards meaningful climate change education and policy development. With the same courage and fortitude we saw with the pandemic, we must now make every attempt to develop, implement, and evaluate our individual and institutional climate mitigation and adaptation initiatives. + Matthew Masiello, M.D., M.P.H is a Clinical Professor of Pediatrics, University of Massachusetts Memorial Children’s Medical Center, and Climate Change Adaptation Practitioner. His blog (https://pp4sr.com) Pediatric Providers for Social Responsibility is available for review and participation. Email: drmatt@mattmasiellomd.com references
1. Roser-Renouf, C., et al. Global Warming’s Six Americas, October 2014: Perception of the Health Consequences of Global Warming and Update in Key Beliefs. Yale University and Mason University/New Haven, CT: Yale Project on Climate Change Communication. P 36. 2. Figueres, C., Rivett-Carnac, T. The Future We Choose. Alfred A. Knopf. 2010, p1. 3. EPA.gov. Evolution of the Clean Air Act. https://www.epa.gov/ clean-air-act-overview/evolution-clean-air-act 4. Watts, N., et al. The 2020 Report of The Lancet Countdown on Health and Climate Change: Responding to converging crises. https://doi.org/10.1016/50140-6736(20)32290-x 5. Hales, S., et al. Potential effect of population and climate change
on global distribution of dengue fever: an empirical model. Lancet. Vol 360, Issue 9336, 14 September 2002, pp 830-834. 6. Owens, M., et al. Prevalence and Social Determinants of Food Insecurity among College Students during the COVID-19 Pandemic. Nutrients 2020. 12,2515: doi:10.3390/nu12092515 7. Lustgarten, A. Catastrophe’s Harvest. The New York Times Magazine. December 20, 2020. 8. Planetary Health Report Card.phreportcard.org 9. The Center for Climate, Health and Global Environment at Harvard T.H. Chan School of Public Health. https:// www.hsph.harvard.edu/c-change/issues/climate-md/ 10. The Medical Society Consortium on Climate and Health. https://medsocietiesforclimatehealth.org 11. American Medical Association. VoteHealth2020 and the vital role of physicians in voting advocacy. https://www.ama.assn.org/delivering-care/ patient-support-advocacy/votehealth2020-and-vital-role-physicians-voting-advocacy 12. American Hospitals Association. Managing Population Health: The Role of the Hospital. Chicago. Health Research & Educational Trust. 2012.
It’s the nature of medicine; complications occur. IS IT TIME TO CHECK THESE ITEMS OFF YOUR LIST? ☐ REVIEW MALPRACTICE COVERAGE TERMS
CONTACT US TODAY TO AUDIT YOUR POLICIES
www.piam.com 781.434.7525
☐ ENSURE ADEQUATE COVERAGE ON BUSINESS POLICY
Make sure you and your practice are properly covered before allegations arise. The team at Physicians Insurance welcomes the opportunity to assist you in your preparedness. We are confident that our experience and industry acumen will generate a customized, competitively priced insurance program designed to address your unique needs in the most cost-conscious manner possible.
MARCH / APRIL 2021
15
WORCESTER MEDICINE
Climate Change Nursing’s Participation in Reducing the Health Impact of Climate Change
and scholarship on climate change and health. The committee is led by eight nurse scholars who are passionate about climate change mitigation, adaptation, and resilience, and identifying climate change as a public health issue (11).
Janna Trombley M.S., R.N. advocacy
C
limate change is one of the largest threats to human
health worldwide with a projected increase in 250,000 more deaths annually between the years of 2030 and 2050 (1). Health effects related to climate change include heat-related illness, respiratory effects, water scarcity and insecurity, nutrition insecurity, increased vector-borne diseases, mental health impacts, and injuries or illness resulting from extreme weather events such as hurricanes, floods, and wildfires (1). The most vulnerable populations including children, older adults, indigenous groups, pregnant women, those with disabilities or chronic medical conditions, minority groups, and those living in poverty will be affected the most (2). Nursing’s awareness of the impact of the environment on health began with Florence Nightingale in the late 1800s. As the largest group of trusted health care professionals, nurses are in an ideal position to help address the consequences of climate change and act to protect themselves, their families, their patients, and their communities (3). Health-related problems associated with climate change are beginning to be addressed by nurses through leadership, education, policy and advocacy, and research (4,5). leadership
Healthcare facilities contribute to three to eight percent of fossil fuel emissions in the United States (3). Nurses advocate for sustainable practice by developing interdisciplinary green teams in hospitals to develop sustainable policies regarding energy efficiency, water conservation, proper waste disposal, environmentally friendly food services, use of reusable products, and using environmentally preferred purchasing (6,7). Patricia Stockwell, R.N. at Dartmouth Hitchcock Medical Center (DHMC) in New Hampshire was concerned with the amount of food waste she was seeing in the hospital. By introducing composting bins along with providing educational materials on composting in common areas of the hospital, she was able to educate both patients and hospital staff on the importance of composting. She became the Chairperson of the OR Green Team at DHMC and her efforts have been recognized in an Environmental Sustainability & Stewardship training module developed by the Johnson & Johnson Institute (8). education
It is essential that the health effects of climate change be integrated into the nursing curriculum at all levels (7,9,10). This can be seen at the Massachusetts General Hospital (MGH) Institute of Health Professions where the nursing faculty developed a Center for Climate Change, Climate Justice, and Health in 2018. This initiative is designed to host symposiums and offer educational opportunities with the goal of promoting research
16
MARCH / APRIL 2021
Nurses are in an excellent position to influence policy and advocate for change (4) and many are members of associations or coalitions in addition to lobbying at the local, state, and federal level (7). For example, the Alliance of Nurses for Healthy Environments (ANHE), launched the Nurses Climate Challenge campaign in 2018 with the goal of educating 50,000 health professionals by 2022 on the impact of climate change on health outcomes (12). The Nurses Climate Challenge also provides excellent resources in their expertly developed toolkit to deliver effective climate change education in the workplace (13). With a goal of decreasing the health consequences of climate change, nursing is advocating for policies that address upstream opportunities (i.e., reducing pollution and building resilient communities) and downstream needs such as disaster response and health consequences of climate change (14). research
Nurses have become more active in the research of climate change and health in recent years (15). Current research by nursing scholars involves exploring nurses’ perceptions and baseline knowledge of climate change and its impacts on human health (13). Elizabeth Schenk, a nurse researcher from Washington State University, co-developed the Climate, Health, and Nursing Tool (CHANT) with the ANHE to examine health professionals’ awareness, motivations, and behaviors to address the gap between climate action and nursing practice (16). Check out: https://labs.wsu.edu/chant/invitation-to-participate/ to complete a survey on your awareness, motivations, and behaviors related to climate change and health. summary
As Nicholas and colleagues (2) suggest, nursing has a responsibility to support climate change mitigation, adaptation, and resilience efforts to protect the health of our patients and our communities and ensure that natural resources will be present for future generations. These efforts are beginning to be addressed by nurses through leadership, education, policy, and research. +
WORCESTER MEDICINE
Nursing’s Participation in Reducing the Health Impact of Climate Change Continued
Climate Change
references
1. World Health Organization. (2018). Climate change and health. https://www.who.int/newsroom/fact-sheets/detail/climate-change-and-health 2. Nicholas, P.K., Breakey, S., Tagliareni, E., Simmonds, K., & Sabo, K.K. (2021). Climate change and population health: Incorporating stages of nursing’s political development. Nursing Outlook, 69, 65-73. https://dx.doi.org/10.1016/j. outlook.2020.08.001 3. International Council of Nurses. (2018). Nurses, climate change and health. https://www.icn.ch/ sites/default/files/inline-files/ICN%20PS%20 Nurses%252c%20climate%20change%20and%20 health%20FINAL%20.pdf 4. Adlong, W. & Dietsch, E. (2015). Nursing and climate change: An emerging connection. Collegian, 22, 19-24. http://dx.doi.org/10.1016/j. colegn.2013.10.003 5. Castner, J. & Polivka, B.J. (2018). Nursing practice and particulate matter exposure. American Journal of Nursing, 118(8), 52-56. https://dx.doi. org/ 10.1097/01.NAJ.0000544166.59939.5f
10. Leffers, J., Levy, R.M., Nicholas, P.K., & Sweeney, C.F. (2017). Mandate for the nursing profession to address climate change through nursing education. Journal of Nursing Scholarship, 49(6), 679-687. https://dx.doi.org/10.1111/jnu.12331 11. MGH Institute of Health Professions. (2021). Center for climate change, climate justice, and health. https://www.mghihp.edu/climate 12. Health Care Without Harm. (2021). Nurses climate challenge. https://nursesclimatechallenge.org/ 13. Cook, C., Demorest, S.L., & Schenk, E. (2019). Nurses and climate action: Opportunities to lead national efforts. American Journal of Nursing, 199(4), 54-59. https://dx.doi.org/10.1097/01. NAJ.0000554551.46769.49 14. Leffers, J. & Butterfield, P. (2018). Nurses play essential roles in reducing health problems due to climate change. Nursing Outlook, 66, 210213. https://doi.org/10.1016/j.outlook.2018.02.008 15. Kalogirou, M.R., Olson, J., & Davidson, S. (2020). Nursing’s metaparadigm, climate change and planetary health. Nursing Inquiry, 27, e12356. https://dx.doi.org/10.1111/nin.12356 16. Washington State University. (n.d.). Climate, Health and Nursing Tool-CHANT. https://labs.wsu.edu/chant/
6. Anderko, L., Schenk, E., Huffling, K., & Chalupka, S. (2017). Climate change, health, and nursing: A call to action. https://envirn.org/climate-changehealth-and-nursing/ 7. Butterfield, P., Schenk, E., Eide, P., Hahn, L., Postma, J., Fitzgerald, C., & O’Neal, G. (2014). Implementing AACN’s recommendations for environmental sustainability in colleges of nursing: From concept to impact. Journal of Professional Nursing, 30(3), 196-202. https://dx.doi. org/10.1016/j.profnurs.2013.10.002 8. Johnson & Johnson. (2019). New module helps nurses lead in environmental sustainability. https:// nursing.jnj.com/nursing-news-events/nurses-leading-innovation/new-module-helps-nurses-lead-in-environmental-sustainability 9. American Association of Colleges of Nursing. (2011). Toward an environmentally sustainable academic enterprise: An AACN guide for nursing education. http:// www.aacnnursing.org/ Portals/42/News/White-Papers/Sustainable-Academic-Enterprise.pdf?ver=2017-08-07-095916-993
Looking to reach medical professionals?
Advertise with a quarter page placement in our next issue. advertising inquiries to Martha Wright
MWright@wdms.org | 508-753-1579
MARCH / APRIL 2021
17
WORCESTER MEDICINE
Climate Change The Impact of Medication Disposal on the Environment Anna K. Morin, Pharm.D.
W
hile the therapeutic and adverse effects of medications
on human health are extensively studied, the potential environmental impacts of the manufacturing, use, and disposal of medications are not well understood. Medications can enter the environment by various routes. Residues released during the manufacturing process can enter the air and surface waters. After administration, human medicines are absorbed, metabolized, and then excreted. Other routes of entry include the disposal of unused medicines and medical waste. When medications and other substances are disposed of in the trash or into wastewater disposal systems, they can find their way into the environment. Many wastewater treatment facilities are not designed to remove medications or metabolites from the water supply and federal regulations regarding medication disposal on the environment are absent. Various studies have highlighted the ecological and human health concerns of medication disposal. Of particular concern is that active ingredients from prescription drugs have been found in streams, lakes, rivers, and the public water supply in the United States (US) (1,2). A 2008 study found a number of medications in US drinking water, including antibiotics (i.e., amoxicillin, azithromycin, sulfamethoxazole, and tetracycline), anticonvulsants (i.e., carbamazepine and phenytoin), pain medications (i.e., acetaminophen, ibuprofen, naproxen, and codeine), and sex hormones (estrone, estradiol, and prednisone) (1). In 2014, a study found hydrochlorothiazide in every sample taken from 50 large wastewater treatment plants. Other medications such as metoprolol, atenolol, and carbamazepine were found in more than 90% of the samples (2). While the majority of these medications were found in very small concentrations, the public health impact can be significant. Unwanted effects range from infertility in fish and surrounding wildlife to the decreased growth or elimination of plant species. The current overall effects in humans are unknown, but concern exists that prolonged exposure to trace quantities of medications could lead to detrimental health outcomes such as antibiotic resistance and abnormal hormonal effects (1,2). In addition to expiration of medications, there are many reasons why consumers may need to dispose of medications. Problems with medication adherence and compliance, inappropriate prescribing and dispensing, adverse drug reactions or dosage changes that result in less than anticipated overall usage, and unused medications following a patient’s death can all lead to the accumulation of unused or unwanted medications. Improper storage and disposal of medications have the potential for negative consequences, including harm to the environment, accidental poisonings, and drug diversion. The safe and responsible use and disposal of medications requires the cooperation of both consumers and healthcare providers. Flushing medications down the toilet or sink or disposing of medications in the household trash allows these pharmaceuticals to pass through wastewater facilities and leach into the soil and water supplies. In addition to consumer medication disposal, healthcare facilities, such as medical offices, nursing homes, and hospitals, also generate a significant amount of medical waste that can cause environmental damage (3). MARCH / APRIL 2021
Pharmacists can play an important role in educating consumers regarding safe and responsible methods to dispose of medications. In addition, the US Food and Drug Administration (FDA), the United States Environmental Protection Agency (EPA), and the Drug Enforcement Administration (DEA) provide resources and guidance regarding the appropriate disposal of unwanted or expired medications on their websites (4-7). The current preferred method to dispose of medications are drug take-back programs that facilitate the collection and destruction of medications. Consumers can contact their healthcare providers, pharmacy, local law enforcement, or the DEA to learn what take-back options are available in their community. + references
1. Donn J, Mendoza M, and Pritchard J. Associated Press. Drugs found in drinking water. USA Today. September 12, 2008. http://www.h2oengineeringllc.com/doc_library/Drugs%20found%20 in%20drinking%20water%20-%20USATODAY.pdf (Accessed 01/25/21). 2. Kostich, MS, Batt, AL, and Lazorchak, JM. Concentrations of prioritized pharmaceuticals in effluents from 50 large wastewater treatment plants in the US and implications for risk estimation. Environmental Pollutution 2014; 184: 354–359. 3. Manzoor J and Sharma M. Impact of biomedical waste on environment and human health. Environmental Claims Journal 2019;31(4):311-324. 4. US Food and Drug Administration (FDA): Disposal of Unused Medicines: What You Should Know. https://www.fda.gov/drugs/safe-disposal-medicines/disposal-unused-medicines-what-youshould-know (accessed 01/25/21). 5. FDA Consumer Health Information: Where and How to Dispose of Unused Medicines. https:// www.fda.gov/consumers/consumer-updates/whereand-how-dispose-unused-medicines (accessed 01/25/21). 6. US Environmental Protection Agency: Collecting and Disposing of Unwanted Medicines: What to do with Unwanted or Expired Medicines. https://www. epa.gov/hwgenerators/collecting-and-disposing-unwanted-medicines (accessed 01/25/21). 7. US Department of Justice Drug Enforcement Administration: Drug Disposal Information. https://www.deadiversion.usdoj.gov/drug_disposal/ index.html (accessed 01/25/21). 19
WORCESTER MEDICINE
Climate Change Our Patients and The Planet: Studying Medicine in a Changing Climate Emily Gentile, B.S.
D
uring the summer after my first year in medical school, I traveled to India for a research project as a member of the global health pathway. The first thing that I noticed when I landed in India was the heat; it was oppressive and overwhelming, reaching 115 degrees Fahrenheit most days. Walking outside felt like a challenge, and both my body and brain seemed unable to work at their usual pace. On my first day shadowing in a pediatric clinic in rural Gujarat, local physicians explained that the summer was not a good time to visit because many patients stayed home due to the heat. They also told me that, during the summer months, a majority of the children seeking care presented with heat-related illnesses. The realization was striking; the health outcomes of the children, as well as their barriers to seeking care, were directly and undeniably linked to the climate in which they were living. Additionally, this conversation was a poignant reminder of the inequities that climate change creates; many of the populations who are most vulnerable to the effects of climate change made the least contributions to the drivers of climate change (1). I later learned that if the world continues with business as usual, India could see the frequency of severe heat waves increase by up to 92 times the current level (2). Rural populations in India are also particularly vulnerable to the effects of climate change due to reliance on agriculture for livelihood (3). Climate change was not a distant thought for a future time but was instead unfolding right in front of me. After returning from India, I attended a talk that framed climate change as a social justice issue. During this session, I was finally able to process what I had seen and felt in Gujarat a few months before. We discussed the health, social, and economic inequities that climate change is already beginning to form and deepen. Medical students spoke openly about their fear and anxiety knowing all that is at risk, and the honesty and vulnerability present in that room were powerful to witness. My discomfort with the wide-ranging impacts of climate change on health outcomes and equity inspired me to act. I co-founded UMMS Coalition for Climate Action, a student organization that seeks to fight climate change, promote sustainability, and prioritize environmental justice through education, research, and advocacy. Enthusiasm for climate action continues to grow in the UMass Medical School community, and the impact of the climate on health is now being incorporated into the medical school curriculum as a direct result of student advocacy. I also recently turned to my community and found courageous climate champions who have been dedicated to serving Worcester for years including a hub of Sunrise Movement, a youth-led organization committed to halting
MARCH / APRIL 2021
climate change and creating good-paying jobs (4). Finally, I found both support and strength in Medical Students for a Sustainable Future, an organization of creative, intelligent, and bold medical students who recognize climate change as a threat to health and social justice and are committed to creating a more sustainable and livable future (5). There was hope all around me, and I drew energy from others who shared both my fears and commitment to change. I was recently confronted with the intersection between climate and health on my family medicine rotation and was reminded of the importance of approaching clinical encounters through a climate justice lens. My team treated many patients who presented with worsening asthma symptoms, and it was difficult to send these patients home with a medication knowing that I was also sending them back to the same polluted air that may have triggered their asthma exacerbation in the first place. There were small wins, however, and I learned that physicians could address the impacts of climate on individual patient’s health from the clinic. For example, one resident that I worked with wrote a letter requesting an air conditioner for a patient who was confined to her home due to a degenerative musculoskeletal disorder. Heat is already putting patients at risk, and research suggests that the northeast US is warming at the fastest rate out of all regions of the contiguous United States (6). The letter successfully secured my patient a free air conditioner, simultaneously increasing her comfort and decreasing her risk of heat-related illnesses in the summer months. This solution was not perfect as the air conditioner inevitably increases energy use, but it was the most effective and safe intervention for our patient at that time. Tackling the root causes of the worsening heat that is putting our communities at risk is another important yet daunting task, one that we must not forget or delay. It has become clear to me that climate work can be complex and emotionally overwhelming, but it is these small but meaningful moments that I have also found to be both empowering and rejuvenating. A change in our approach to climate change is not only possible, but essential. I encourage you to use your voice to advocate for more sustainable and resilient health systems at your place of work, use your vote to support leaders who trust science and prioritize clean energy solutions, and use your actions to fight for climate justice both in and outside of the clinic. Moving forward, we must
20
WORCESTER MEDICINE
Climate Change
Our Patients and The Planet: Studying Medicine in a Changing Climate Continued recognize the people of color and indigenous leaders who have been caring for the Earth for centuries and learn from their wisdom. We must cultivate the creativity necessary for developing climate solutions and expand our understanding of what is possible when we work together toward a common goal. Finally, we must tackle climate change with the strength and urgency required to ensure a better life for our patients, families, communities, and the generations to come, all of whom will be affected by climate change and all of whom deserve the chance for a healthier, safer, more just future. +
Sustainability in Support of Public Health Suzanne Wood
T
he health of our environment is one of
the foundations of public health. This is the central idea that drives the facilities team at the University of Massachusetts Medical School (UMMS) to create a more sustainable campus and enable the vital missions of our students and faculty. UMMS has had a formal sustainability program since 2004. Our initiatives focus on three areas: buildings, processes, and people. We can influence the built environment and operating processes directly, and we promote awareness to encourage people in our community to make more sustainable choices in their daily lives, such as recycling and greener commuting options. Our first Leadership in Energy and Environmental Design (LEED) certified building opened in 2010. The Ambulatory Care Center (ACC) earned a Silver designation for numerous sustainable features, including a white roof to diminish the “heat island effect” by reflecting rather than absorbing heat; a tight exterior building envelope with tinted, reflective, and insulated glass; and an east-west building orientation to minimize the number of south-facing windows. Water use in the ACC is approximately 30 percent less than a conventional building because of automatic low-flow/ low-flush plumbing fixtures. Electricity consumption is reduced by sophisticated controls for heating, cooling, and lighting. In 2013, a larger and more ambitious building, the Albert Sherman Center (ASC) opened and achieved LEED Gold certification. The combination of efficient design, sustainable building practices, and advanced technologies integrated at the ASC enables the building to operate 25 percent more efficiently, consuming 4.1 million fewer kilowatt hours of electricity, using 30 percent less water, and cutting carbon dioxide emissions by 4.5 million pounds annually, as compared to similar buildings of standard design. Among the key technologies used in the ASC are occupancy sensors for lighting, heating, and cooling of offices and conference rooms; heat recovery wheels which allow the building to exhaust stale air and draw in fresh air while retaining most of the heat in the building; variable speed fans, with sash sensors, on
Emily Gentile, B.S., is a third-year medical student at the University of Massachusetts Medical School. Email: emily.gentile@umassmed.edu references
1. Samson, J., Berteaux, D., McGill, B.J. and Humphries, M.M. (2011), Geographic disparities and moral hazards in the predicted impacts of climate change on human populations. Global Ecology and Biogeography, 20: 532-544. https:// doi.org/10.1111/j.1466-8238.2010.00632.x 2. Vimal Mishra et al. (2017), Heat wave exposure in India in current, 1.5 °C, and 2.0 °C worlds. Environ. Res. Lett. 12 124012. https://iopscience.iop.org/ article/10.1088/1748-9326/aa9388 3. World Bank 2013, Turn Down the Heat: Climate Extremes, Regional Impacts, and the Case for Resilience. A report for the World Bank by the Potsdam Institute for Climate Impact Research and Climate Analytics. Washington, DC:World Bank. License: Creative Commons Attribution—NonCommercial–NoDerivatives3.0 Unported license (CC BY-NC-ND 3.0). 4. Sunrise Movement, https://www.sunrisemovement.org/about/?ms=AboutTheSunriseMovement 5. Medical Students for a Sustainable Future, https://ms4sf.org/aboutms4sf/ 6. Karmalkar AV and Bradley RS (2017), Consequences of Global Warming of 1.5 °C and 2 °C for Regional Temperature and Precipitation Changes in the Contiguous United States. PLoS ONE 12(1): e0168697. https://doi.org/10.1371/journal. pone.0168697
MARCH / APRIL 2021
21
WORCESTER MEDICINE
Climate Change
Sustainability in Support of Public Health Continued
the fume hoods in the laboratories; daylight harvesting sensors that adjust interior lights based on the available sunlight; and an automation system that monitors building operations every 15 minutes and adjusts systems for maximal efficiency. Today, there are two buildings under construction on campus that are also designed to LEED standards. A four-story medical building is being built on the site of the former Massachusetts Highway Department District 3 headquarters to house the new VA Central Western Massachusetts Healthcare System’s community-based outpatient clinic for veterans. On the campus quad, site work is underway for a nine-story building that will significantly expand our research and academic programs. We have set the green bar high for that project, seeking not only LEED certification but with aspirations for net-zero energy use. Our sustainability efforts also extend to the rest of the campus. Plumbing retrofitting projects completed in the past 10 years have helped reduce the annual usage of potable water by 23 million gallons. Electrical consumption has been reduced by several LED lighting upgrade projects, replacing thousands of bulbs and fixtures across the campus. LED fixtures consume 40 to 60 percent less energy than legacy fluorescent or incandescent lighting. Recently, we redesigned the air-handling system used to heat and cool a clinical pharmacy unit, which needs to operate 24/7. The new system is segregated from other areas of the building which are not in continuous use. This will save 316,000 kilowatt hours and 107,000 therms (of natural gas) annually. Because of projects like these, even though the UMMS campus has grown by several million square feet of built space in the past 15 years, energy use per-square-foot of building space has dropped almost 30 percent. The way we power our campus has also grown much more efficient. In 2012, we installed a high-efficiency gas-fired combustion turbine and an associated heat recovery system that improves our capacity to generate electricity and steam. Since natural gas burns more cleanly than oil, and the new jet turbine is highly efficient, the expanded power plant has lower greenhouse gas emissions, despite its added energy capacity: producing electricity on-site is approximately 30 percent more efficient than using electricity from the regional distribution network, due to the losses that occur when electricity travels long distances on distribution lines. These improvements were recognized by the U.S. Environmental Protection Agency, which recently chose UMMS as one of four institutions in the country to earn the Energy Star Combined Heat and Power Award for the superior performance of its combined heat and power systems. On the process improvement side, UMMS went paperless in 2016 for procurement and contracting. In a typical year, UMMS processes about 500 contracts for products and services used by the campus community. An average contract has 15 pages and is executed in triplicate: one copy each for the vendor, the contracting school department, and the UMMS Financial Services files. In addition to the contracts, the school must handle bid documents, summaries, invoices, and other reports for the various contracts. Previously, that meant moving a mountain of paper from place to place for reviews, edits, and signatures then managing seemingly endless rows of filing cabinets. The new electronic cloud-based contract management
22
MARCH / APRIL 2021
“
...even though the UMMS campus has grown by several million square feet of built space in the past 15 years, energy use per-square-foot of building space has dropped almost 30 percent. system has reduced annual paper consumption by some 60,000 sheets. The glass washing and sterilization process for laboratory equipment is an essential aspect of our research program and can be resource-intensive. Last summer, our facilities team completed a five-month project to upgrade all of the glass washing and sterilization systems in the LRB. The new equipment uses less electricity and will save an estimated 3.3 million gallons of water a year. With more than 10,000 people using our academic medical center campus on an average day (pre-pandemic) the decisions each person makes will have a large collective impact on our carbon footprint. So, we have an active communications program to promote green choices. For example, we promote the reuse of supplies and equipment through a “Swap Shop” on campus. We are increasing our electric vehicle charging capacity on campus, and we have held several information sessions and a test-drive event to promote use of electric vehicles. Recycling remains a priority, as well as encouraging people to power down their computers and office devices when not in use. UMMS is a large institution. We have mission-critical programs that run 24/7 and, by their nature, require more energy than a typical commercial complex. Nevertheless, by working together, we are reducing our impact on the environment, through more sustainable practices. + Suzanne Wood LEED AP, is an associate director of the facilities management department at UMass Medical School and leads the campus’s sustainability programs. Email: Suzanne.Wood@ umassmed.edu
WORCESTER MEDICINE
Climate Change There Is Still Hope for Climate Action Congressman Jim McGovern (D-MA)
T
2020 was a difficult one for our planet. a global pandemic raged, social and political upheaval bubbled to the surface in frightening new ways, and economic collapse put many millions of people out of work and countless more in danger of hunger and homelessness. Climate disruptions became more severe than ever before. Catastrophic brush fires in Australia, flooding in Indonesia, super cyclones in Asia, followed by flooding in Kenya, locust swarms across Africa, and fires across Central and South America decimated land and consumed lives. The United States saw our own share of natural disasters, as well. Massive wildfires in California burned as much land in a year as had ever burned in the modern history of the state — five of the six largest fires recorded. Colorado faced similar battles. In the Midwest, farmers endured yet another year of unprecedented, unpredictable weather. To the south, thousands of birds fell from the sky, starved by climate disruption. Yet for all the turmoil and pain 2020 brought, it also brought us hope. That’s because, for a short time while communities across the globe took measures to slow the spread of the virus, we were offered a glimpse of the world as it could be. Greenhouse gas emissions dramatically fell. The smog that enveloped many cities dissipated for the first time in decades. Wildlife abounded in urban areas, and dirty rivers ran clean again. The pause was fleeting – not enough to alter our troubling trajectory. But it demonstrated that it is still possible for us to re-examine and change our impact on the planet, and it offered us a glimmer of hope, if only we could break our addiction to fossil fuels. I believe climate change is an urgent threat to our planet, and it is easy to focus on all of the destruction in the world around us. But to spur the kind of action needed to address climate change, we need to foster not just a sense of panic, but also one of optimism and possibility. Since I was first elected to serve as a Member of the U.S. House of Representatives, climate has been at the forefront of my priorities. I am proud of the work that many Massachusetts companies are doing to mitigate their carbon footprint and grow green energy technology and production. Clean, sustainable energy will be the key to energy independence and turning away from nonrenewable energy sources. I know these efforts will only continue to grow and I look forward to supporting them. When looking at our country’s future, I am hopeful for the Biden Administration’s commitment to addressing climate. On day one, President Biden signed a number of executive orders to halt the construction of Trump’s U.S.-Mexico border wall, end the ban on travel from some Muslim-majority countries, declare his intent to rejoin the Paris Climate Accord and the World Health Organization, and revoke the approval of the Keystone XL oil pipeline. To me, this is the beginning of a new era of climate realism where the fight for our future is shaped by the choices we make and the principles we uphold. Plans from our new president face challenges throughout the legislative process: a filibuster in the Senate, a conservative Supreme Court, and a wide range of opinions from my colleagues in the House. This may mean that climate action in America to tackle things like fossil fuel money in politics, public disinformation, and the appropriate funding may come gradually rather than through sweeping legislation. That doesn’t mean progress he year
MARCH / APRIL 2021
isn’t being made. I hold myself and my colleagues accountable to holding out hope while tackling one of the greatest challenges our planet has ever faced. Not only is addressing climate change a moral imperative, but tackling it also offers a chance for economic growth and opportunity. “When I think about climate change,” President Biden has said, “the word I think of is jobs.” And as companies make commitments to decarbonization, even policymakers blinded to the humanitarian case for reform have come to see solving the climate crisis as an investment. Unfortunately, in 2010, the Supreme Court’s dreadful Citizens United decision opened the floodgates for a handful of rich and powerful individuals and corporations to pour unlimited amounts of money into influencing our politics – poisoning our democracy and drowning out the voices of everyday Americans. These dark unchecked corporate campaign contributions allow fossil fuel money to strangle any real climate policy. This is why addressing the climate crisis will require major action to get dark money out of politics. The support of these corporate entities also causes Members of Congress to deny the realities of climate change out of fear of not being re-elected. Their disinformation is a tactic that delays progress – but years of extreme weather, scientific consensus, and public activism have begun to end the age of climate denial. Moving forward, it is our responsibility to better communicate that while these changes are good for the environment, they are also good for American workers and families. Climate promises are not new, but the history of climate action is littered with uncashed checks and unfulfilled commitments. We have learned that awareness of the climate crisis is nothing without action. This is made more challenging because the climate crisis doesn’t respect borders or boundaries —its solution lies in collective action and requires governmental responses like treaties, taxes, and further investment in climate action. Solving climate change is a challenge unlike any we have ever faced, and although our global timeline towards the point of no return continues to shrink, I am hopeful because it is not too late to radically change our trajectory. In 2021 and beyond, we must act, individually and collectively, with the urgency and scale the climate crisis demands. If we act now and continue to share the hopeful message that there is still time to change course, I believe we can reclaim our climate future. + Congressman James P. McGovern represents the Second Congressional District of Massachusetts in the United States House of Representatives. He is the Chairman of the House Rules Committee, Co-Chair of the Congressional-Executive Commission on China, and Co-Chair of the Tom Lantos Human Rights Commission. 23
WORCESTER MEDICINE
Legal Consult Certifiable – A Medical Records Story Peter Martin, Esq.
H
ow would you feel if you were charged $45.00 for copies of two pages of medical records? How would you feel if, having charged that amount, you were subjected to a class action suit with the potential for treble damages and the award of the plaintiff ’s attorney’s fees? That was the situation facing the litigants in Beauchesne v. New England Neurological Associates, P.C., and the subject of an Appeals Court decision rendered in October of 2020. In this decision, the Appeals Court did two things. First, it discussed whether statutes limiting fees that may be charged for providing copies of medical records pertain to certified medical records. Second, it considered the proper remedies available for violations of such statutes. In doing so it followed an earlier Supreme Court decision, Darviris v. Petros, 442 Mass. 274 (2004), that drew a distinction between a medical practice’s negligent provision of medical care (to which medical malpractice law applies) and the “entrepreneurial and business aspects of providing medical services.” As to those latter aspects, legal remedies are not limited to professional malpractice statutes, but may include consumer protection statutes, such as Massachusetts General Laws chapter 93A (the Consumer Protection Statute). Under that law, successful plaintiffs may receive money damages that may be tripled in the case of unfair or deceptive acts or practices that are willful or knowing statutory violations, as well as their attorneys’ fees. This case began with a simple request by Mr. Beauchesne’s lawyer for certified copies of his medical records and bills related to an automobile accident. New England Neurological Associates responded with a letter specifying that the records would be delivered after receipt of $45.00, the fee for retrieval and copying of medical records. The records were delivered along with a certification that they were complete and accurate, pursuant to MGL chapter 233, section 79G. That statute governs the circumstances in which medical records may be introduced as evidence in litigation; it does not address either access rights to, or costs of copying, medical records. When Beauchesne brought the class action lawsuit on behalf of himself and other similarly situated NENA patients, he claimed that the proper fee for copies of medical records is governed by MGL chapter 111, section 70, and chapter 112, section 12CC (the Medical Records Statutes). Those statutes together impose a fee scheme involving a base fee, a per-page fee, and an additional fee covering postage and any requested explanation or summary of the records; all of these fees are subject to adjustment based on changes in a medical care services consumer price index. Under that regulatory scheme, Beauchesne claimed the proper fee for the records he sought would have been $26.81. The trial court agreed with NENA’s argument that, because certified medical records were provided, the charge for those records was not governed by the Medical Records Statutes, but rather chapter 233. The Appeals Court was thus faced with the legal question of whether certified medical records are covered by the Medical Records Statutes. The court answered this question in the affirmative, ruling that nothing in the
24
MARCH / APRIL 2021
Medical Records Statutes limited their applicability to uncertified medical records. The court also noted that the Medical Records Statutes govern situations in which a certification is required, as when medical records are supplied in response to a subpoena. The practical effect of this ruling, if upheld on appeal, is that adding a certification to medical records produced under the Medical Records Statutes does not by itself remove those Statutes’ limitations on the fees that may be charged for such certified records. However, the Appeals Court decision also states that the Medical Records Statutes do permit charging an additional fee for a requested “explanation or a summary of a patient’s records.” The court found that providing a certification “falls squarely into that category.” Thus, had NENA specified in its letter to Beauchesne that the $45.00 included the cost of the requested certification in addition to the cost of retrieval and copying, pursuant to the Medical Records Statutes, it might have avoided the Appeals Court concluding the Medical Records Statutes applied to this matter – an alleged overcharge of $18.19. The court then turned to Beauchesne’s claim he was entitled to a remedy under the Consumer Protection Statute. That statute declares unlawful unfair or deceptive acts or practices in the conduct of any trade or commerce. NENA claimed that the Medical Records Statutes provide a complete regulatory scheme including enforcement by the Department of Public Health and the Board of Registration in Medicine, and that prior case law under the Consumer Protection Statute holds that where such a separate regulatory scheme exists, enforcement under the Consumer Protection Statute is unavailable. The Appeals Court however noted that under other cases, violation of laws and regulations may form the basis for a Consumer Protection Statute claim if the “underlying conduct is unfair or deceptive” and remedies under those laws or regulations are not inconsistent with Consumer Protection Statute remedies. Is overcharging for medical records unfair or deceptive and does that conduct occur in trade or commerce? The Appeals Court answered “yes.” It noted that overcharging is commonly considered an unfair or deceptive act or practice. And, in light of the Darviris decision, it ruled that activities involving the provision of medical records are part of the “entrepreneurial and business aspects” of medical practice. In other words, providing and charging for medical records is part of the trade or commerce of medicine, and not the professional practice of medicine. Thus, Beauchesne adequately asserted a claim for violation of the Consumer Protection Statute. (Because the case was heard
WORCESTER MEDICINE
Legal Consult
Certifiable – A Medical Records Story Continued
by the Appeals Court on a motion to dismiss, the Appeals Court had to assume that Beauchesne’s claims were true, so the court did not conclude that Beauchesne was in fact overcharged.) This decision reminds practitioners that engaging in the learned profession of medicine poses risks of both a professional and a business character. It does suggest a way to get paid for providing certified medical records in accordance with the Medical Records Statutes. But it
also reminds us that in making strictly business decisions, such as charging for medical record copies, providers will be treated by the law like everyone else engaged in trade or commerce. + Peter Martin, Esq. is a partner at Bowditch and Dewey.
In Memoriam
Luigi Pacifico, D.O., F.A.C.C.
Monica M. Przelomski-Pacifico, M.D. October 10, 1953 - March 27, 2020
She enjoyed painting both with watercolors and China for Medicines: DependenceDependence on China foronMedicines: oils for which Implications she wonImplications for Drug Shortages, for Drug Shortages, and Health Security several awards along with Recalls, andRecalls, Health Security By Rosemary Gibson By Rosemary Gibson flower gardening. Of all her achievements, Dependence on China for Medicines: her most precious were November 18, 2020 Dependence on Ch Implications for Drug Shortages, November 18, 2020 her family including: her Recalls, and Health Security Implications for Over 310 Boston Medical Library District and Worcester District daughter, Antoinette, who Over 310 Boston Medical Library and Worcester Medical SocietyMedical Members Recalls, and So H By Rosemary Gibson met virtually to learn from area leaders. met virtually to learn from area leaders. By Rosema will soon complete medical school and pursue training in OB/GYN, her son, Vincent, an architecSpeaker Speaker November 18, 2020 tural designer in Rhode Island, and her husband, Novembe Luigi Pacifico, a practicing cardiologist at Reliant Over 310 Boston Medical Library and Worcester District Medical So Medical Group. + Over 310 Boston Medical Library and W met virtually to learn from area leaders.
M
onica Przelomski, M.D. passed away on March 27, 2020 at St. Vincent Hospital after a long courageous battle with scleroderma. Monica was born in Wester, raised in Dudley. She received a degree in nursing from Quinsigamond Community College before attending Clark University from where she received a B.A. with magnum cum laude in Biology. She graduated from UMass Medical School where she then completed a neurology residency. She then trained in Electromyography (EMG) at Massachusetts General Hospital. She was board certified in neurology and EMG. Dependence on China for Medicines: She published several articles including in the Journal of Neurology: Implications for Drug Shortages, Eastern Equine Encephalopathy (EEE).Recalls, and Health Security
Society Snippets
met virtually to lea
By Rosemary Gibson
Speaker Dependence on China for Medicines: Implications for Drug Shortages, November 18, 2020 Recalls, and Health Security Rosemary Gibson Rosemary Gibson Advisor at the Hastings Center By Rosemary Gibson Senior Advisor Senior at the Hastings Center Over 310 Boston Medical Library and Worcester District Medical Society Members
Spe
Dependence on China for Medicines: ImplicationsAuthor of “ChinaAuthor of “Chinathe Rx:Risks Exposing the RisksDependence of America’s on Ch Rx: Exposing of America’s onDependence China for Medicin met virtually to learn from area leaders. for Drug Shortages, Recalls, and Health Security
By Rosemary Gibson
Panel of Local Experts
November 18, 2020 Panel of Local Experts
Speaker
O
n November 18, 2020, over 310 Boston Medical Library andBoston Worcester District Society Members Gibson Rosema Over 310 Medical LibraryMedical and Worcester District Medical Rosemary Society Members Senior Advisor at the Hastings Center Senior Advisor at met virtually to learn from area leaders. The lecture focused on the increasing U.S. dependence on China met virtually to learn from area leaders.for Author of “China Rx: Exposing the Risks of America’s Dependence Author of “China Rx: Exposing the RisksonofCh A generic drugs and the raw materials, chemical intermediates, and active pharmaceutical ingredients to make antibiotics, heparin, and thousands of other medicines. To hear the reasons for the dramatic shiftSpeaker and the impact on drug Panel of Local ExpertsPanel of shortages, and other challenges to the provision of medical care in the United States visit https://www.wdms.org/past-events/ + RossM.S, W. Thompson, M.S, Sowmya R.Ph A. Gilchrist, MBA, BCPS, DPLA Ross W. Thompson, R.Ph Viswa Neil A. Gilchrist,Neil PharmD, MBA,PharmD, BCPS, DPLA and Chief Pharmacy officer, Chief Pharmacy Officer, Vice President andVice ChiefPresident Pharmacy officer, CMO, Massa Chief Pharmacy Officer, Rosemary Gibson Tufts Medical Center/Floating Hospital for UMass Memorial Medcial Center, Worcester Tufts Medical Center/Floating Hospital for Over 310 B Memorial Medcial Center, Worcester Children in Boston, MA. Senior Advisor at the HastingsUMass Center clockwise Speaker Rosemary Gibson, Senior Advisor at the Hastings Center & Author Author of “China Rx: Exposing the Risks of America’s Dependence on China for Medicines.” of “China Rx: Exposing the Risks of America’s Dependence on China for Medicines.”
Children in Boston, MA.
Moderators Moderators Panel of Local Experts Neil A. Gilchrist, PharmD, Panel MBA, BCPS, DPLA, Chief Pharmacy of Local Experts Officer, UMass Memorial Medcial Center, Worcester; Ross W. Thompson, M.S, R.Ph, Vice Ross W. Th Neil A. Gilchrist, DPLA M.S, R.Ph Ross BCPS, W. Thompson, Neil A. Gilchrist, PharmD, MBA, BCPS, DPLA PharmD, MBA, Vice President a Chief Pharmacy Officer, Vice President and Chief Pharmacy officer, Rosemary Officer, Gibson President and Chief Pharmacy officer, Tufts Medical Center/Floating Hospital for Chil- Chief Pharmacy Tufts Medical C UMass Memorial Medcial Center, Worcester Center/Floating Hospital for UMassSenior Memorial Medcial Center, Childr Advisor at theWorcester Hastings Center Tufts Medical dren in Boston, MA.; Sowmya Viswanathan, MD, MBA, MHCM, CMO, Massachusetts Children in Boston, MA. Author of “China Rx: Exposing the Risks of America’s Dependence on China for Medicines.” Group, Tenet Health Moderators Dr. Dale Magee, BML Chair of the Garland Committee; Dr. Mary O’Brien, WDMS Chair of the Medical Education Committee Neil A. Gilchrist, PharmD, MBA, BCPS, DPLA Chief Pharmacy Officer, UMass Memorial Medcial Center, Worcester
Ross W. Thompson, M.S, R.Ph
Vice President and Chief Pharmacy officer, Tufts Medical Center/Floating Hospital for Children in Boston, MA. MARCH / APRIL
Moderators
Panel of Local Experts
Dr. Dale Magee Sowmya Viswanathan, Dr. MD, Dale MBA, Magee MHCM
2021
Mode
Moderators
Dr. Mary O’Brien Dr. Mary O’Brien
BML Chair of the Garland Committee CMO, Massachusetts Group, Tenet Health WDMS Chair of theWDMS Chair of the BML Chair of the Garland Committee Education Comm Medical EducationMedical Committee
25
The lecture focused onU.S. the increasing U.S. on China forand generic drugs and the che raw The lecture focused on the increasing dependence on dependence China for generic drugs the raw materials, active pharmaceutical ingredients to make antibiotics, heparin, of and thousands of other medici active pharmaceutical ingredients to make antibiotics, heparin, and thousands other medicines. To hear the Author of “Chin shift and the impact on drug shortages, and other challenges provision shift and the impact on drug shortages, and other challenges to the provisiontoofthe medical careof inmed the
WORCESTER MEDICINE
Society Snippets
Health Matters
Health Matters
H
Health Matters isisaa television produced in collaboration withwith The Worcester District MedicalMedical Society Sociand WCCA TV in ealth Matters televisionprogram program produced in collaboration The Worcester District Worcester. Offering information on disease prevention, treatment options, current public healthoptions, issues and more, ety and WCCA TV valuable in Worcester. Offering valuable information on disease prevention, treatment Health Matters is produced in a ½ hour interview format and the program airs on WCCA TV Cable Channel 194: Wednesdaycurrent public health issues and more, Health Matters is produced in a ½ hour interview format and the program Noon and 7:30 pm, Thursday– 7:00 pm and Friday – 9:30 am.
airs on WCCA TV Cable Channel 194: Wednesday- Noon and 7:30 pm, Thursday– 7:00 pm and Friday – 9:30 am. To view episodes of Health visit:www.wdms.org www.wdms.org + To view episodes of HealthMatters Matters please please visit: Show 203
Saving Lives In Massachusetts Is All In Our Hands
Guest: Dr. Joseph Sabato
Host: Dr. Michael Hirsh
Show 204
Health Care Proxy: You Must Choose, But Choose Wisely
Host: Dr. Bruce Karlin
Guest: Dr. Gary Blanchard
Show 205
School Reopening, DPH and DESE Protocols and Resources
Guest: Dr. Michele Parker
Host: Dr. Lynda Young
Guest: Dr. Lloyd Fisher
If you have an idea for a topic or guest, or wish to be a guest,
If you have an idea for a topic or guest, or wish to be a guest, please contact wordmsa@massmed.org or call 508-753-1579. please contact wordmsa@massmed.org or call 508-753-1579.
26
MARCH / APRIL 2021
50 |
The Right Agent knows Luxury
Our Medical Program for Buyers and Sellers ¡ Home warranties ¡ Flexible mortgages ¡ Professional discounts ¡ Relocation services
♦ RE/MAX Vision ♦ Professional Realty Team with In-depth Local Expertise
C
A New Approach to Selling Your Home ¡ Staging ¡ Professional photos ¡ Floor plans ¡ Virtual and 360 tours
Call our Worcester or Shrewsbury office to discuss how we can help you buy or sell a home during today’s new normal business conditions. Worcester Shrewsbury
508-595-9900 508-842-3000
www.visionyourmove.com © 2021 by RE/MAX Vision, Worcester, MA. Each office independently owned and operated.
EXPERTISE. INNOVATION. COMPASSION.
When it comes to heart and vascular care, your patients deserve the best. ADVANCED HEART FAILURE PATIENTS BENEFIT FROM VENTRICULAR ASSIST DEVICE (VAD) PROGRAM
• Improves survival and quality of life for advanced heart failure patients as destination therapy or as a bridge to cardiac transplantation • Certified by the Joint Commission SYMPTOM RELIEF AND FEWER HOSPITAL VISITS FOR MITRAL REGURGITATION PATIENTS
• Transcatheter mitral valve repair using the FDA-approved MitraClip device • Minimally invasive for patients with symptomatic mitral regurgitation due to degenerative mitral valve disease MINIMALLY INVASIVE PERCUTANEOUS TRANSFEMORAL AND TRANSAXILLARY TAVR BETTER FOR PATIENTS
• Transcatheter aortic valve replacement (TAVR) – An alternative to open heart surgery for patients with severe, symptomatic aortic stenosis who are at intermediate- or high-risk for surgery • Only team in New England performing TAVR via completely percutaneous transfemoral or transaxillary access • Majority of patients have moderate sedation
COMPLEX AORTIC ANEURYSM PATIENTS REPAIRED PERCUTANEOUSLY OR WITH SMALL GROIN INCISIONS
• Center for Complex Aortic Disease – Only center in the Northeast to offer two forms of fenestrated and branched endovascular repair of abdominal and thoracoabdominal aneurysms through an FDA-approved clinical trial • More than 350 repairs completed • No treated patients have needed to be converted from minimally invasive repair to open, surgical repair ATRIAL FIBRILLATION PATIENTS NOW HAVE AN ALTERNATIVE TO WARFARIN THERAPY
• A nondrug alternative to blood thinners • The left atrial appendage closure (using the Watchman device) procedure prevents migration of blood clots and reduces stroke risk KEEP YOUR HEART FAILURE PATIENTS OUT OF THE HOSPITAL
• CardioMEMS HF System – First and only FDA-approved device proven to significantly reduce heart failure-related hospital admissions • Uses an implanted wireless sensor and remote monitoring
Referrals: 800-431-5151 UMass Memorial Medical Center 55 Lake Avenue North, Worcester, MA 01655 www.umassmemorial.org/heart
