Changing Degrees: Incorporating the Impacts of Climate Change on Health into Pediatric Residency Education and Practice

Abstract

The American Academy of Pediatrics (AAP) was the first major medical society to release a policy statement on the impacts of climate change on pediatric health. It is estimated that globally, children bear the burden of climate-induced disease. However, many undergraduate and graduate medical curricula do not cover this topic. This article builds on previous literature to propose a framework for such a curriculum as well as justify its relevance in light of current accreditation requirements. Some curricular topics include extreme heat and heat-related injury, degradations in air quality and pediatric respiratory disease, spread of vector-borne and diarrheal illness, and mental health effects. Lastly, it addresses clinical applications for this knowledge, including screening vulnerable patients, offering anticipatory guidance, and advocating for the medical benefits of planetary health.

Clinical Relevance

In 2019, the American Medical Association (AMA) passed a resolution encouraging the inclusion of the impacts of climate change on health at the undergraduate, graduate, and continuing medical education levels of medical training [1]. At this point in time, many medical undergraduate and graduate curricula do not cover this topic. However, there is a growing body of evidence demonstrating the relevance of these issues to not only the medical profession as a whole, but specifically, pediatrics. Children are inordinately vulnerable to the impacts of climate change. In fact, in the year 2000, the World Health Organization (WHO) estimated that 88% of the global disease burden attributable to climate change affected children under the age of 5 [2]. The reasons for this are complex and multifactorial, including physiological and developmental vulnerabilities, higher environmental exposure per body mass, longer future lifespans, and dependence on caregivers, to name a few [3].

In 2012, the American Academy of Pediatrics (AAP) added a chapter on global climate change in the third edition of Pediatric Environmental Health [4]. A few years later in 2015, the same year that the WHO called climate change the greatest threat to global health in the 21^st century [5], the AAP released a technical report and policy statement titled, “Global Climate Change and Children’s Health” [6]. In it, they further delineate the distinctive ways in which children are affected by climate change and urge pediatric providers to learn about these impacts in order to anticipate, recognize, and advocate for their patient population regarding these new challenges [6].

This was not the first time that the AAP addressed the topic of climate change. Eight years prior in 2007, the AAP published their first policy statement on the impacts of global climate change on health, becoming the first major medical society to do so [7]. As such, they have demonstrated recognition of their unique and well-placed position to addressing and combatting the effects of global climate change on child health.

Educational Relevance

In order to prepare the next generation of pediatric trainees to address this global burden, curricula on the topic must be integrated into current educational programs. While incorporating new material in already-saturated syllabi is challenging, pediatricians are mobilizing to officially recognize climate change as an important social determinant of health as it is known to worsen health and healthcare costs and disproportionately affects already at-risk communities [8]. This action is arguably morally critical for young physicians to achieve competency in systems-based practice as defined by the Accreditation Council for Graduate Medical Education (ACGME). This core competency delineates that “residents must demonstrate an awareness and responsiveness to the larger context and system of health care, including the social determinants of health…” [9]. Within our own cities, children of lower socioeconomic status are more vulnerable to the effects of climate change, and globally, children in low- and middle-income countries already bear the burden of climate-vulnerable disease [3].

One example of these disparities includes urban heat islands. Urban heat islands occur when the ambient temperature in urban areas is significantly higher than their surroundings, as a result of the lack of green spaces that allow for transpiration, building infrastructure, denser populations, and heat waste [10]. Heat stress is the highest cause of extreme weather-related mortality in the United States and contributes significantly to morbidity by means of heat stroke, dehydration, loss of productivity, and difficulty with learning [11]. Comparison between urban heat island mapping and census data have demonstrated that urban heat islands disproportionately affect communities of lower socioeconomic status, with high correlation to neighborhoods that were redlined in the 1930s [11].

Proposed Curricular Topics

In 2021, Academic Medicine published an article with a proposed curricular framework, including learning objectives, for teaching the impacts of climate change on health to medical trainees [1]. The framework below is similarly modeled and recast to include the evidence behind anthropogenic climate change, as well as pediatric-specific topics such as heat waves and heat-related illness, the impact of declining air quality and increases in pollen biomass on respiratory disease, the spread of vector-borne disease, flooding and infectious disease, effects on mental health, and the carbon footprint of the American healthcare system.

Evidence Behind Climate Change

In 2021, the United Nations Intergovernmental Panel on Climate Change (IPCC) published its sixth assessment report [12]. In it, they detail that since the industrial revolution in the late 19th century, the earth’s average temperature has risen over 1° Celsius. The majority of this warming has occurred in the last 40 years as demonstrated by the fact that each of the last four decades has been successively warmer than any preceding decade since 1850 [12].

Graphs depicting global atmospheric carbon dioxide plotted against global temperatures demonstrate a strong correlation since reliable record-keeping in the late 19th century [6]. Isotope-fractionation has been used to determine the earth’s climate in its millennia of history [13]. Never before had atmospheric carbon dioxide levels exceeded 300ppm, but now they have exceeded 400ppm [13].

Extreme Heat Waves and Wildfires

Most recently, the years 2003 and 2010 saw staggering heat waves that resulted in tens of thousands of deaths in Europe and Russia, respectively [14]. Predictive models estimate that such events are likely to become more commonplace as the global environment warms, from twice a century to as often as twice a decade [15]. Even currently, extreme heat is the largest cause of environmental mortality in the US [6].

Excess heat causes illness across a spectrum. On the mild end when the body remains normothermic, manifestations include heat rash or miliaria, exercise-associated muscle cramping, heat edema, and heat syncope [16]. The more severe end of the spectrum includes heat stroke, when core body temperature exceeds 40°C, and without intervention, ultimately death [16]. The pathophysiology behind severe forms of heat-related illness are partially a result of the body’s compensatory mechanisms to shunt heat away from the core via peripheral vasodilation [14]. Hypoperfusion causes tissue ischemia and end-organ damage, which is often exasperated by heat cytotoxicity [14].

Heat-related illness is increasing in frequency as the global climate warms [16]. It is estimated that children comprise 47.6% of those affected [16]. In fact, exertional heat-related illness is one of the leading causes of morbidity and mortality in high school athletes, particularly football players [17]. Children are also known to have inferior thermoregulatory ability, lower body sweat rate, lower cardiac output (shunting a larger proportion of output to the periphery to sweat), and rely more heavily on evaporative skin losses [18]. High temperatures are also known to exacerbate chronic illnesses such as asthma and diabetes [1]. Increases in premature birth, stillbirth, low birth weight, and congenital anomalies are also associated with heat waves [1,6].

Air Quality and Respiratory Illness

Climate change also contributes to declinations in air quality via three major ways: wildfire smoke, ground-level ozone, and pollen biomass. Longer dry seasons and shorter winter frost leaves vegetation dryer for longer, prime kindling for wildfires. It is estimated that 7.4 million children are affected by wildfire smoke every year in the US [19]. A large portion of wildfire smoke is composed of fine particulate matter, defined as particles less than 2.5ug in diameter, that deposits more deeply in the lungs and is linked to increases in asthma exacerbations, respiratory admissions, and childhood pneumonia [19]. Wildfire events contribute to more than 2,000 emergency room visits for children with asthma every year [19]. Exposure to fine particulate pollution is also linked to metabolic changes in pregnant women that is associated with things like low birth weight and preterm birth [19]. Substantial greenhouse-gas emissions and forest loss from wildfires are likely to accelerate climate change further leading to a reinforcing feedback loop.

Second, elevations in ambient temperature in combination with nitrogen oxide and organic compounds produced from fossil fuel combustion promote the formation of ground-level ozone or smog [20]. Exposure to smog has been associated with asthma exacerbations, increased emergency room visits and pediatric intensive care unit admissions for asthma, as well as an increased risk of developing asthma [6]. Asthma is already the most common chronic disease of childhood, affecting over 6 million children in the US alone [6]. Children are uniquely vulnerable because they have high minute ventilation and tend to spend more time outside [6].

Lastly, climate change has led to increases in the duration of pollen seasons as well as increases in pollen biomass [1]. Ragweed pollen production is already twice the production from the previous century [6] and one projection study predicts that continuations in high carbon dioxide emissions could double pollen biomass by 2060 [21]. As of 2018, about 7% of children in the US suffer from allergic rhinitis [22]. Increases in pollen biomass and allergic rhinitis seasons could increase the risk of asthma exacerbations [6]. Interestingly, thunderstorm asthma, a phenomenon that occurs when strong updrafts and humid conditions in a storm cloud uproot and disperse pollen grains, inciting increases in hospital admissions for asthma attacks, are also predicted to become more commonplace [23]. In one such report of thunderstorm asthma from Melbourne, Australia in 2016, there was a 10-fold increase in asthma admissions that overwhelmed the local healthcare system, likely contributing to the reported increases in mortality during that event [23].

Infectious Disease

Climate change also contributes to the spread of certain infectious diseases, including those that are vector-dependent as well as diarrheal illnesses. For example, every year in the US, about 300,000 people are affected by Lyme disease (caused by the bacteria Borrelia burgdorferi), which is the most common vector-borne disease in the country [1,6]. Boys between the ages of 5 to 9 are at the greatest risk [6]. The incidence and geographic spread of Lyme disease has been increasing in recent years, likely secondary to climate change driven extensions in the warm season, promoting the proliferation of its vector, the blacklegged tick (Ixodes scapularis) [1]. In a similar pattern and on a more global stage, malaria, which requires relatively high temperatures and high humidity for transmission, has been spreading altitudinally in endemic areas in correlation with warming temperatures [24]. Malaria overwhelmingly affects children under the age of 5, accounting for almost half a million deaths worldwide in 2012 [6]. Dengue virus, a disease that also predominantly affects the pediatric population, is the fastest spreading mosquito-borne viral disease globally, and increases in vector and disease spread are thought to be attributable in part to climate change [6].

Lastly, climate-driven alterations in weather patterns have exacerbated the frequency and potency of heavy downpours, overwhelming sewage systems and leading to flooding, a pattern that is predicted to worsen [1,6]. Contamination and the lack of clean water for hygiene leads to the spread of waterborne illness as well as fecal-oral transmitted illnesses such as cholera, cryptosporidiosis, poliomyelitis, rotavirus, and typhoid [25]. Diarrheal illnesses have also been demonstrated to peak shortly after periods of heavy rains [6,26]. Children who source their water from private untreated wells are at the highest risk of contamination [27]. It is predicted that climate change will increase the incidence of diarrheal illnesses, which are already the cause of significant mortality in children in low- and middle-income nations [6].

Mental Health

As discussed previously, climate change can have drastic impacts on health and environment. Extreme environmental events such as wildfires and flooding may become more prevalent, disrupting basic systems and creating housing, utility, and food instability. Traditionally, researchers have studied the mental health impacts of climate change via the direct psychiatric consequences of extreme weather events such as post-traumatic stress disorder (PTSD), depression, and anxiety [1,6]. Displacement as a result of natural disasters is an adverse childhood event and are known to have lasting mental health impacts, negatively impacting schooling and behavior [1]. Recently a survey of 10,000 young people across ten nations found that more than 59% of participants globally were very or extremely worried about the impacts of climate change, and 84% were at least moderately worried, an experience known as eco-anxiety [28,29].

Healthcare Sector

The medical code of ethics, attributed to Hippocrates, “primum non nocere,” is Latin for “first, do no harm.” Unfortunately, the healthcare sector itself is a significant contributor to carbon emissions. In the US, it is estimated that healthcare contributes to 9-10% of annual greenhouse gas emissions [30]. Combined, healthcare systems create over 7,000 tons of waste every day [31]. It is also estimated that the amount of disability-adjusted life years lost from healthcare pollution is equivalent to that due to medical error [1]. Globally, the healthcare sector is estimated to contribute to about 4.4% of annual emissions around the world [32]. Many hospitals are starting to institute “green” committees to help identify and divert sources of unnecessary waste and finding that such actions have significant fiscal benefits as well [31].

Clinical Relevance in Practice

While building awareness in these topics is critical for pediatric trainees, there are also many ways in which this knowledge can be applied in a pediatrician’s career. These include screening for climate-change related vulnerabilities, providing anticipatory guidance, and participating in advocacy.

During well child checks, physicians can screen for various factors that make families more climate change vulnerable and offer appropriate resources. For example, physicians can screen families for water insecurity, housing insecurity, or unsafe housing environments. Pediatricians can ask about water sources, as children who drink untreated well water are at greater risk for water-borne illness outbreaks [27]. Homes in areas prone to flooding may contain leaks predisposing to mold growth, or allergens like cockroaches and rats that can exacerbate asthma symptoms. Some clinics are lucky enough to have a medical legal partnership to help tenants access legal counsel in cases of landlord housing violations, which can be a valuable resource.

In anticipation of extreme heat waves, pediatricians can also screen for utility insecurity and help point families towards resources like the Low Income Home Energy Assistance Program (LIHEAP) that helps people access affordable air conditioning. In the wake of natural disasters, pediatricians can screen for depression and offer local counseling resources.

Pediatricians can also give anticipatory guidance to support the health of their patients as well as the planet. Educating families on local produce options or farmer’s markets that accept SNAP benefits encourages healthier and more affordable dietary habits that are environmentally friendly. Motivating children and families to walk or bike together where it is safe to do so, encourages exercise and carbon neutral forms of transportation. For children suffering from asthma, educating families to check local air quality metrics and pollen counts as well as anticipate seasons of higher burden can help reduce exacerbations. During sports physicals, pediatricians can teach families about proper hydration and signs of heat-related illness. In the summertime, physicians can teach families of young infants about vehicle heat safety, sun safety, and insect bite prevention. For children with complex care needs, pediatricians can help families develop safety plans in case of interruptions in power necessary for life-sustaining durable medical equipment.

Moreover, pediatricians can utilize this information to inform the public as well as governing bodies about the adverse effects of climate change on health and advocate for reform. Physicians can learn to write op-eds in their local newspapers, meet with their local and state representatives, and partner with climate savvy organizations. Membership in the AAP’s Council on Environmental Health allows pediatricians to participate in national collective action. There are many local and regional chapter opportunities as well.

Lastly, physicians can also help form the aforementioned “green teams” in their own hospitals or practices to help combat the carbon footprint of healthcare. A green team or even just an individual can advocate to their hospital to join Practice Greenhealth and make a commitment to sustainability. Green teams can join the free US Environmental Protection Agency (EPA) Energy Star Program for resources to identify energy efficient products and catalogue a building’s own energy efficiency progress [33]. They can advocate for efficient window shades and lighting, programmable thermostats to reduce energy waste during low building occupancies, practice water stewardship, and identify ways to decrease single-use waste [33]. Green teams can also help optimize healthcare food systems by minimizing meat and plastic bottle usage to promote sustainable and healthy meal options [33].

Conclusion

In summary, the impacts of climate change can feel overwhelming and immutable to both physicians and patients. Climate change impacts every child, but also has the potential to significantly widen disparities in health equity, both nationally and globally. Encouragingly, major medical societies have already demonstrated support for incorporating this material into trainee programs. Arming the next generation of pediatricians with the knowledge to understand and combat these effects has the potential for improving the lives of children everywhere and improving efforts towards a sustainable future.

Glossary

AAP

American Academy of Pediatrics

AMA

American Medical Association

WHO

World Health Organization

Author Contributions

Sophia Gauthier, MS, MD, researched and wrote the article.

Funding

none.