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Facing the challenges of climate change at the bedside

About three years ago, Dr. Aaron Bernstein, a pediatric hospitalist at Boston Children’s Hospital, ordered intravenous fluids for an infant who had become dehydrated. He was shocked to receive an alert that IV fluids — a common, life-saving treatment — were being rationed. The reason: Hurricane Maria had shut down the Puerto Rican plant that makes them.

Last summer, the wife of an elderly man living near the top of a low-income high-rise called 911 because he seemed confused. When EMTs opened the door to the dwelling, they were met by a heat blast they likened to the Sahara Desert. Taken to the Massachusetts General Hospital emergency department, the man was found to have a temperature of 106 degrees. He was diagnosed with heat stroke.


In disparate parts of the city, in patients young and old, medical professionals are seeing the effects of climate change in their own practices. And for the first time, some 150 gathered Thursday to start planning a response.

Sponsored by the New England Journal of Medicine, Harvard Medical School, and all of Boston’s teaching hospitals, the Climate Crisis and Clinical Practice Symposium aimed “to bring the issue of climate change directly to the bedside,” said Bernstein, interim chief of the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health, and one of the event’s organizers.

The issue is especially salient in Boston because air and water temperatures and sea levels in the Northeast are rising faster than elsewhere.

“The climate crisis has created an unprecedented future that looks nothing like what we have experienced,” said Dr. Renee N. Salas, an emergency medicine doctor at Mass. General. “We are the ones that are experiencing this first and need to work collectively with the rest of the country.”

Thursday’s gathering at a conference center in the Longwood medical area was the first of eight similar efforts to galvanize health care systems to face the reality of climate change. Six additional symposiums are scheduled over the next year and a half in United States and one in Australia, as medical professionals grapple with the myriad ways that climate change affects health — especially for the most vulnerable, including children, the elderly, and poor and marginalized people.


Responding to climate change involves more than contending with more severe storms and disruptions of supply chains and power grids — although those will be big challenges to the health care system.

Global warming affects both health and health care.

Heat stress can lead to heart attacks, kidney stones, and preterm birth. Cholera, dengue, Lyme disease and valley fever are all increasing in incidence and also expanding their range. With warmer springs and later winters, the pollen season is getting longer and also more severe, because carbon dioxide prompts plants to release more pollen. That increases asthma attacks, as does air pollution.

The heat also affects the way medications work. Drugs for depression, heart disease, and kidney failure can be less safe in hot weather. People taking beta blockers for high blood pressure are more likely to faint in hot weather. EpiPens and albuterol can be rendered ineffective by extreme heat if left inside cars.

Dr. Gaurab Basu, a primary care physician at the Cambridge Health Alliance, told the group about a 27-year-old patient who developed end-stage kidney disease caused by chronic exposure to heat. The man, an immigrant, had worked on sugar farms in El Salvador.


But his case got Basu thinking about the many people doing physical labor outside, especially in urban “heat islands” where asphalt and concrete can make the temperature 10 or 15 degrees higher than elsewhere. They could be injuring their kidneys day after day without knowing it.

Salas, the doctor who took care of the man with heat stroke, noted that he came to the hospital with a diagnosis of fever. The EMTs’ account of the heat in his apartment tipped off doctors to the true problem. But doctors, she said, need to “add a climate lens” to their diagnostics.

The man survived, but Salas doesn’t know whether he suffered long-term harm. And she wonders about his wife, who was “left in the same conditions that nearly killed her husband.”

At Thursday’s symposium Salas recalled other cases where the “climate lens” was needed. The 4-year-old who came in with her third asthma attack in a week, apparently the result of high pollen levels triggered by carbon dioxide in the environment. The woman who came from Puerto Rico after Maria with a plastic bag filled with empty medicine containers, begging for refills. “We think about climate refugees happening in other places, but she was internally displaced,” Salas said.

Equally as serious as the physical threats are the dangers that climate change poses to mental health.

Trauma among people displaced from their homes by storms will do lasting damage. But even before any storm hits, heat is known to boost aggression and violence.


Extreme heat "makes all mental illnesses worse,” said Dr. Gary Belkin, a psychiatrist and visiting scientist at the Harvard climate group. Emergency room visits for mental crises and psychiatric hospitalizations go up during heat waves.

More broadly, many otherwise healthy people are suffering psychologically, with impaired concentration, loss of sleep, and inability to enjoy things resulting from the ceaseless background anxiety over climate change.

One the best ways to deal with those fears is take action, speakers said. The symposium’s organizers are urging doctors, in particular, to step up in public and private ways.

“We need to start talking about this in general, both to other providers and our patients,” said Dr. Lucy Marcil, a Boston Medical Center pediatrician. “Because if people aren’t aware of it, they can’t act on it.”

Dr. Caren Solomon, deputy editor of the New England Journal of Medicine and a physician at Brigham and Women’s Hospital, urges doctors to educate their patients about climate change when it comes up naturally in the exam room. For example, a doctor could mention that pollution caused a patient’s worsening asthma or that warming winters contributed to their greater risk of Lyme disease.

As one of the most trusted professions, Solomon said, physicians should also speak out publicly about the climate’s effect on health, contacting legislators, pressing for divestment in fossil fuel companies, and participating in public protests.


And they need to talk to one another.

Dr. Mary Rice, a pulmonary and critical care doctor at Beth Israel Deaconess Medical Center, said it has often been difficult to discuss climate change with her colleagues.

“Climate change for many decades was treated as a fringe issue even though the science has been so strong for so long,” Rice said. “One of the things we have to do as clinicians is get over that stigma and be confident that the science is strong.”

Felice J. Freyer can be reached at Follow her @felicejfreyer.