Climate Change as a Public Health Crisis: A Conversation With Dr. Renee N. Salas

Interview by Sophia C. Scott

https://doi.org/10.56927/552980

HHPR Associate Editor Sophia Scott interviewed Renee N. Salas MD, MPH, MS. Dr. Salas is a Yerby Fellow at the Center for Climate, Health, and the Global Environment at Harvard T.H. Chan School of Public Health and Affiliated Faculty and former Burke Fellow at the Harvard Global Health Institute. She is also an emergency medicine physician practicing in the Department of Emergency Medicine at Massachusetts General Hospital and Harvard Medical School.

She was elected to the National Academy of Medicine (NAM) in 2021 for her work on climate change and health. She served on the original planning committee for the NAM’s Grand Challenge on Health and Climate Change and continues to serve on planning committees. She has testified before Congress for the full House Committee on Oversight and Reform on how climate change is harming health. She engages in research on how climate change is impacting the healthcare system and developing evidence-based adaptation.

Her Doctor of Medicine is from the innovative five-year medical school program to train physician-investigators at the Cleveland Clinic Lerner College of Medicine with a Master of Science in Clinical Research from the Case Western Reserve University.

Sophia Scott (SS): Thank you for taking the time for this interview, Dr. Salas. To begin, why do you consider climate change to be a health crisis?

Renee Salas (RS): When you go to a health care provider, we often focus on the primary reason that you are there – called a primary diagnosis. For the diagnosis of an asthma attack, there are many things that can make it harder for us to prevent or manage this disease – and we often consider those secondary diagnoses. Climate change is making it harder to treat asthma through pathways like longer pollen seasons with higher concentrations of pollen, more intense wildfires and smoke plumes, and higher ground-level ozone due to extreme heat. Thus, climate change can be viewed as a secondary diagnosis. 

This is just one small example of the frighteningly broad ways that climate change harms health, both directly and indirectly. Climate change is a metaproblem and threat multiplier, meaning it underlies other problems and makes them worse. Other example pathways include extreme heat, impacts on food and water, climate-intensified extreme weather like hurricanes and floods, and climate-sensitive diseases transmitted by mosquitoes and ticks. In addition, health care systems can be disrupted through mechanisms like infrastructure damage, power outages, and supply chain disruptions – making it even harder for health professionals to provide high-quality care.

Framed through the river analogy, I am pulling patients out one at a time in my emergency medicine practice – only to see many more behind them. Thus, it is critically important to walk upstream to figure out what's causing these patients to fall into the river in the first place – and to prevent it before it happens. When we walk upstream, we find the burning of fossil fuels driving both climate change and air pollution – highlighting the connections to disease management in our patients.  Framing climate change as a diagnosis means we need a new toolbox to address it, and this fundamentally includes policy. 

SS: Thank you for that response. After attending a five-year medical school program to train physician-investigators at the Cleveland Clinic Lerner College of Medicine, how do you think this program influenced your current work as a physician in terms of public health and climate efforts?

RS: Yes, I had the honor of being in the first class of this program, and the experience was formative in so many ways. There are only 32 students per class, and the program incorporates a research curriculum, problem-based learning, and competency-based assessments instead of traditional grades. It applied adult learning principles, which have been essential skills to my career whether on a clinical shift or immersing myself in the new field of climate change almost a decade ago. There are still many knowledge gaps in the field of climate change and health, and it is critically important that we create an evidence-based path forward. Given the Lerner College incorporated research principles throughout our training, this has given me the skills to advance plans to address these knowledge gaps. Lastly, the program also taught me about the importance of multidisciplinary collaboration, which is essential for my work in climate change. 

SS: You have served as the lead author of the Lancet Countdown on Health and Climate Change U.S. Brief since 2018, and you founded and lead its Working Group of over 70 U.S. organizations, institutions, and centers working at the nexus of climate change and health. What can be done in terms of policy to ensure that our response to climate change prioritizes and optimizes health and equity? 

RS: The Lancet Countdown produces an annual report that tracks the global impacts of climate change on health, and more importantly, the opportunities. We present the U.S. data in a companion report using a national, multidisciplinary working group. In our 2021 Brief, we focused on three policy areas that are important for health: (1) Adaptation – rapidly increasing the funding for health protections; (2) Economics and finance – incorporating health-related costs of fossil fuels into the social cost of carbon; (3) Mitigation – an urgent and equitable economy-wide reduction in greenhouse gas emissions. These are just three example priority policy areas, based on the indicator data that year, needed in our toolbox to address the diagnosis of climate change.

The health and equity benefits of climate action can provide motivation as it makes us – our children, parents, neighbors – the faces of climate change, not just polar bears and icebergs. In addition, climate policy can have untended impacts. For example, where electric charging stations are placed for electric vehicles has been shown to potentially worsen air pollution and inequities if they are still using fossil fuel-related energy sources. Thus, we need to make sure evidence guides our response to ensure that we are optimizing the health and equity benefits of our interventions. 

SS: You were also a Co-Director for the first Climate Crisis and Clinical Practice Symposium and co-led the broader Initiative in partnership with The New England Journal of Medicine. What is the significance of engaging the medical academic community in the work of climate policy?

RS: Action on climate change is a prescription for improved health and equity, and there is immense power in the medical community stepping forward in unity on this. A historical example includes the International Physicians for the Prevention of Nuclear War which won a Nobel Peace Prize in 1985 for bringing the medical community together.

In addition to ensuring that the health and equity benefits of climate-related policy are headlined, I also advocate for adding a climate lens to domestic health policy to further showcase these interconnected relationships. A climate lens is essentially understanding how climate change impacts what you are viewing today and in the future. Climate change threatens the goals of a high-performing health care system - equitable health care access, high-quality care, and affordable costs. Thus, there are numerous opportunities and interconnected solutions because protecting patients and increasing the resilience of our health care systems has benefits for not only climate change – but also for other problems like existing inequities or pandemics.

SS: As the lead author of the cornerstone Interactive Perspective for The New England Journal of Medicine, since this project launched the journal’s climate crisis and health topic page, how do you think it has expanded the conversation about climate change in the medical academic world since then?

RS: The ground has really shifted over the past few years within the medical community with ever-growing involvement. Not only are leading medical journals increasingly highlighting climate change, but esteemed medical institutions like the National Academy of Medicine, medical societies, and academic institutions – to name a few – are progressively engaging. Health professionals are realizing that we can’t achieve our mission in health care – to improve health, prevent harm, and advance equity – without addressing climate change. The medical community has largely been a sleeping giant on this issue, but we are awakening – and this is just the beginning. 

SS: What progress do you think still needs to be made in taking climate crisis action efforts to a local community-health level?

RS: The geographic diversity of how climate change harms health and disrupts health care systems, such as wildfires in the West and Lyme disease in the Northeast, means we need to have a local understanding of the threats. These different exposures are also impacted by community-level infrastructure and local and state policy. This means evidence must be as localized as possible to optimally inform interventions and policy. In addition, we must ensure that the communities that are most impacted are involved throughout the process and lead work. This mandates a hyper-local, systematic, and comprehensive approach that utilizes unprecedented collaboration – which will be fundamental priorities for a forthcoming endeavor.

SS: Please tell me about your experience testifying before Congress for the full House Committee on Oversight and Reform on how climate change is harming health. Do you think policymakers are sufficiently attentive to the intersections between climate and health today?

RS: Testifying before Congress allowed me to bring the often-unheard stories of my patients into the halls of power, putting names and voices to the faceless data. There has been a growing recognition of the connections between climate change and health, but we still have significant work to do. 

The COVID-19 pandemic has shown us that health is fundamental for a functioning and thriving society, and this parallel has helped increase the recognition for climate change. In addition, a growing number of events have forced us to see that the impacts of climate change are already here and now. For example, climate scientists determined that Pacific Northwest heatwave in June 2021, when Portland, Oregon reached 116°F, would have been impossible without climate change. This event led to an estimated 600 excess deaths in one week and heat-related visits to emergency departments that were 70 times higher than in 2019. These types of events showcase – through health harms, worsening inequities, and rising costs – that we must treat climate change as the emergency that it is. 

SS: As my final question, what are you proudest of in terms of your work in this field thus far? 

RS: I am inspired every day by the commitment and passion of so many colleagues around the U.S. and world who will not rest until we equitably improve the health of our patients and communities through action on climate change. We must ensure that health and equity are central. The health sector can model the unprecedented multidisciplinary and multisectoral collaboration that is required for this unprecedented challenge. We have the tools – we now just need to galvanize the will, and we are watching that unfold. Everyone has a part to play, so onward together!