Becoming Climate-Informed Physicians Open Access

As pediatric trainees, we learn about the social determinants of health (SDOH) and how a patient’s health is not just something to be treated in the examination room. Access to healthy foods and environments, quality education, as well as safe spaces to grow, play, and learn all greatly impact our patients’ health and well-being. We apply this holistic lens to our daily practice while diligently learning how to triage, recognize, diagnose, and treat the spectrum of pediatric health. Enter climate change, a complex public health crisis that adversely affects SDOH, the cultural and economic fabric of our communities, and the physical and mental health of our patients.^1-4  By 2030, climate change may lead to 250 000 additional deaths per year from its effects on nutrition, infectious disease, and heat.¹  This challenge prompts some of the most pressing questions of our careers: How do we treat climate change? How do we prepare for something so dangerous yet so insidious?

While we are beginning to receive training in climate change–informed care at our institution, our most effective learning as physicians continues to come from listening to our patients.⁵  We are privileged to serve a resilient Bronx borough in New York City (NYC) with a longstanding history of environmental justice issues. The Bronx has a childhood asthma prevalence rate of 17% compared to the national average of 5.8%, and our Bronx families experience twice as many asthma-related hospitalizations as those in each of the other boroughs in NYC.⁶  One of the reasons the Bronx carries this asthma burden is high vehicular air pollution exposure.⁷  The borough is crisscrossed by highways like the 6.5-mile Cross Bronx Expressway, “one of the greatest examples of environmental injustice” in our nation’s history according to US Senate Majority Leader Chuck Schumer.⁸  Climate change is a risk multiplier, and our high-risk community is already feeling the effects.⁹ 

We see the effects of climate change in the 12-year-old boy admitted for an asthma exacerbation who spent much of the early summer of 2023 indoors to avoid Canadian wildfire smoke and who lost opportunities to enjoy math and football programs with his peers. Despite monitoring for air quality alerts and judicious mask use, his mother couldn’t turn on the air conditioning in their home during a heat wave to prevent an asthma exacerbation because there wasn’t one to turn on.¹⁰  We see the effects of climate change when choosing between delaying lifesaving vaccines and asking a mother to expose her 2-month-old infant to toxic air by traveling to clinic on a day with an air quality index of 460.¹¹  We ask ourselves, “Would it be better to delay the visit until next week when the skies will be clear?” We see climate change in our families with worsening allergy symptoms who are forced to stay off the playground and out of the park to avoid hazards like extreme heat and wildfire smoke. They are forced to shelter in place in their public housing units, already under duress after decades of underinvestment and rife with mold, peeling paint, rodents, and roaches. We see climate change in the increased frequency of clinic visits for medication refills and discussions regarding asthma control, with parents asking variations of the same question: “How can we prepare?”

In our training we work to address these questions because of the disproportionate effects of climate change seen in our practice. Throughout 2023, one author (C.E.M.) built and implemented climate change education sessions within our residency program focused on anticipatory guidance, disaster preparedness principles, and local community resources that can be offered to families to prepare for extreme heat, air pollution, and extreme weather, and to promote mental health resilience.¹²  We screen patients for SDOH vulnerabilities, while reminding ourselves that addressing these concerns improves their ability to respond to and recover from climate events. We acknowledge that understanding the evolving health effects of climate change is a dynamic learning process. However, by incorporating climate change–informed care into our practice now, we can support children and their families as they seek a healthier and safer future.⁵ 

As pediatricians, our practice is rooted in optimism for the children we serve. Fundamental to this optimism is the idea that there will be a future worth inheriting, yet climate change calls this future into question. Our youth are experiencing a mental health crisis exacerbated by the progressive nature of climate change and the new existential uncertainties it creates.¹³  Who will our children become without the ability to play, explore, and breathe as the emotional and physical burden of climate change falls heavier on them each year? We must acknowledge and accept the responsibility as physicians to prepare our patients for a future affected by climate change. We must strive not only to uphold the vision of a healthy future, but also act to ensure that it becomes a reality for all families. Inequities existed as public health priorities outside of and before climate change and have been worsened by crises like the COVID-19 pandemic. To respond, we must continue to narrow health and other societal inequities and address new inequities that arise because of climate change. We will not accept a reality in which children wake to hazy air outside their windows and wonder if the walk to school will mean another trip to the hospital. We can, and must, actively contribute to a better future.

We carry the health of generations on our shoulders, but we carry it together as a profession and as human beings. That responsibility must translate not only into our clinical practice, but also into action outside our clinic walls. We can prevent the worst health effects from climate change by preventing further planetary warming. That is why, in addition to learning about climate change and teaching our families how to respond to it, we recognize the expertise of community groups and learn effective advocacy skills from them. We are fortunate to have joined the strong grassroots community in NYC and New York State (NYS) advocating for climate policy. We were privileged to add our voices to the cries for climate justice during the 2023 legislative session in NYS. This session advanced what was already some of the most significant climate legislation in the United States.¹⁴  This builds upon the 2019 signing of NYS’s Climate Leadership and Community Protection Act, a policy that requires NYS to implement an 85% reduction in greenhouse gas emissions from 1990 levels and net-zero emissions statewide by 2050.¹⁵  Physicians and training programs can join local community coalitions to take similar action, improve their advocacy skills, and lend health expertise to these policy discussions. Physicians can encourage their respective medical societies to take climate action through policy statements,¹⁶  decarbonization, and fossil fuel divestment strategies,¹⁷  and to promote health equity in climate policy through the Medical Society Consortium on Climate and Health.¹⁸ 

Becoming a climate-informed physician begins when you decide to take the first step in education or advocacy, regardless of training or career stage. In our training program, we continue our education sessions, strengthen our community partnerships, practice our op-ed writing, and plan for future advocacy as we work to create the healthy future we want to see. We call on all residency programs to build similar capacity and graduate more climate-informed physicians. We recommend starting by doing what physicians do best, which is listening. Listen to your patients, children, grandchildren, and trainees. Listen to indigenous communities, low-income communities, communities of color, and communities affected by environmental injustice. When you are ready to join, colleagues will help with those first steps. Together we can build healthier and more resilient communities equipped for the challenges ahead.

The authors would like to thank Sandra Braganza, MD, MPH, Maida Galvez, MD, MPH, Perry Sheffield, MD, MPH, Lauren Zajac, MD, MPH, and Sophie Balk, MD, for their review of the manuscript.