Climate of Change

As the world warms, a new discipline prepares physicians to care for people and planet.

In the Summer of 2022. Emily Bruce, a Unitarian Universalist minister in her late 40s living on Boston’s South Shore, came down with COVID-19 for the second time. She eventually recovered, but even after her symptoms resolved she didn’t feel right. She was constantly tired and often short of breath. Although she had no history of allergies, her primary care physician referred her to an allergist. Her first visit lasted three hours. “It was the most amazing doctor’s appointment I’ve ever had,” Bruce says.

But after answering dozens of questions and undergoing a battery of skin tests, she was surprised by the allergist’s conclusion: “I think you have long COVID.” He sent her home with an inhaler and a prescription for Singulair.

Six months later, in June 2023—the start of what would become the area’s second-wettest summer on record—Bruce returned for a follow-up appointment. She told the doctor that while the medicine and the inhaler had given her some relief, she still found it hard to breathe on especially humid days. It often felt like a hand was pressing down on her chest.

“I’m telling all my patients: use your medication. Take a higher dosage if you need it,” he replied. “It’s not you. It’s the climate. And it’s only going to get worse.”

Bruce recalls feeling grateful for his bluntness, but also unnerved. Until then, climate change had been something happening to other people in other parts of the world.

“Suddenly the climate felt personally threatening in a way it hadn’t before,” she says.

 

Hotter, Drier, Wetter, Sicker

Every day, the headlines tell the story: pollution, reduced biodiversity, changes in land use, shifting infectious disease patterns, and other anthropogenic disruptions to the planet’s natural systems are impacting human health and well-being in myriad, unequal, and often dire ways. Wildfires spew toxic smoke that causes respiratory and cardiovascular damage. A warmer, wetter planet means mosquito habitats are expanding, as are the windows for transmission of the deadly diseases they carry, such as malaria, dengue fever, and Zika virus. Deforestation and infrastructure growth have fragmented habitats and disrupted host-vector relationships, enabling tick-borne illnesses such as Lyme disease and ehrlichiosis to spread widely and rapidly.

And then there’s heat. High temperatures caused by global warming are associated with higher rates of interpersonal violence, suicide, and heat-related illness and death, as well as exacerbated mood and substance use disorders. Lethal combinations of temperature and humidity are on track to make certain corners of Earth uninhabitable by humans.

The World Health Organization now estimates that nearly one-quarter of all deaths and disease burden in the world can be linked to the environment. This realization—that the health of humans and the health of Earth’s natural systems are interdependent—has given rise to the multidisciplinary field of planetary health, which aims to both understand and treat these impacts while making health care more sustainable. It also has led to calls for incorporating planetary health research and education into the health professions. In 2019, the American Medical Association declared that climate change and its risks to human health should be taught at all levels of medical education, and the World Organization of Family Doctors exhorted its members to raise awareness of and take action on planetary health.

That is also the year students at the University of California, San Francisco, School of Medicine devised the Planetary Health Report Card, a metric-based tool intended to evaluate—and hold accountable—health-profession schools on five categories: curriculum, research, community outreach, support for student-led initiatives, and campus sustainability. At Brown, a medical student-led needs assessment the year before had already identified shortcomings in the curriculum with regard to planetary health, despite the fact that 95 percent of first-year students felt doctors should know about the effects of climate change on human health. A handful of motivated students made sure The Warren Alpert Medical School was among the 13 institutions that piloted the PHRC.

That same year, Brown University unveiled plans to cut its campus greenhouse gas emissions by 75 percent by 2025 and to achieve net-zero no later than 2040. Student-led efforts were already making the Medical School greener through composting, single-stream recycling, sustainable event hosting, and the provision of sustainable menstrual products; the interest and advocacy group Alpert Medical School Environmental Coalition, or AMS ECo, was initiating collaborations with local environmental justice organizations. A first-semester course included lectures on lead poisoning and environmental justice, but the core curriculum contained no related content after that. This lack of an institutional, systemic approach to providing planetary health education and advocacy led the five students writing the report, which came out in 2020, to deliver the underwhelming overall grade of B-. (See Medicine@Brown, Fall 2021.)

That grade was a catalyst for action. Students drafted a proposal for longitudinal integration of planetary health into the curriculum, presented it to the senior administration, and got a green light. In March 2020—just one month after publication of the inaugural PHRC—the administration convened a Planetary Health Task Force.

One focus of the task force and related subcommittees was a two-pronged curricular integration effort: provide preclinical content for the entire student body and create opportunities for highly interested students to pursue planetary health in more depth. The former, a multi-year process, will culminate in an “integration toolbox” designed to facilitate the insertion of relevant planetary health content into all existing core lectures. All first-year students now hear an introductory lecture on planetary health as part of the Health Systems Science course. Environmental exposure screening questions have been added to the patient interview checklist in Doctoring, the required clinical skills and professional development course. And before they begin their clerkships, third-year students receive mandatory training to address hospital waste.

In terms of in-depth learning opportunities, one example evolved from a foundation laid in 2019 by Sarah Hsu ’17 ScM’22 MD’22, widely regarded as one of the School’s planetary health pioneers. As a first-year student, Hsu couldn’t find anything about the intersection of climate and health in her classes, so she designed a pre-clerkship elective. She recruited experts from Brown and beyond to give guest lectures, one of whom was Senior Associate Dean of Biology Education Katherine Smith, PhD, a disease ecologist. Smith, who had taught a popular undergraduate course on conservation medicine since coming to Brown in 2008, was game. But she knew she could only provide medical students with part of the story.

“While I could teach them about health outcomes caused by environmental change, I couldn’t teach them how to treat them,” Smith says. She invited other faculty members to lecture, complementing her knowledge of the dynamics of infectious disease emergence with clinical and public health expertise. One of them, Assistant Professor of Emergency Medicine Kyle Denison Martin F’19, DO, MPH, now co-leads the elective, called Planetary Health: Global Environmental Change and Emerging Infectious Diseases, with her.

When it comes to witnessing the deleterious effects of a degraded environment on health, working in the hospital emergency department gives Martin a front-row seat. “We’re the first to see the changes in patterns as a result of climate change and shifts in ecosystems,” he says. This has become especially clear during heat waves, which drive many people to the ED.

Two years after the first report card, the task force’s progress, while both gradual and ongoing, was significant enough for Martin, Associate Dean of Medical Education Sarita Warrier RES’08, MD, and student coauthors to report in Frontiers in Public Health their “student-driven, bottom-up approach to the development of a planetary health program.” The paper describes advances in curriculum development, community engagement opportunities, and research support, including the Ruth Sauber Medical Education Fund for Planetary Health, which enables a third- or fourth-year medical student to spend a gap year doing planetary health research. Smith, Martin, and three students from the committee on curricular integration presented their work at the annual meeting of the Planetary Health Alliance that November.

“The goal,” Smith says, “is that no one will come out of the Medical School without having breadth and depth of knowledge about planetary health, why it matters to them as future clinicians, and how it is relevant to all of the systems of the body and the diseases that we’re treating.”

Faculty on the Front Lines

Medical students may be, as Smith says, the “true drivers” of planetary health awareness, but several faculty members are leading efforts as well.

In 2019, as a global emergency medicine fellow doing research in South America, Katelyn Moretti F’20, MD, MS, knew that the migrants she was studying were fleeing conflicts and unstable governments, but she also understood that to some extent, those conditions were the result of environmental challenges. “A lot of instability comes from a changing climate,” she says. “Food sources become more unpredictable because water sources become unpredictable. Eventually people can no longer support themselves as farmers, so they leave.”

Soon after, at an emergency medicine conference, Moretti had an epiphany. During a lecture on the intersection of climate change and health, she thought, This is what I should be doing. “I pivoted to change all of my research and advocacy to focus on both the health impacts of climate change and how the health care industry is contributing to the problem,” she says.

Since that pivot, Moretti—now an assistant professor of emergency medicine—has lectured at the Rhode Island Department of Health, and last spring testified in front of a US Senate Committee on the Budget hearing on the health costs of climate change. In her testimony she stressed that climate change is a “threat multiplier” as well as a “threat magnifier,” adding that it has altered how she delivers care: instead of automatically recommending that a patient with depression or obesity take outdoor walks, for example, she first asks about where they live to determine if it’s safe to do so. Last year, she was named a co-investigator on a five-year, $6 million multi-institutional grant from the National Science Foundation that includes Brown. The funds will establish a “coastal resilience research hub” to help low-lying communities in New England become more resilient to climate change.

Alison Hayward, MD, MPH, an assistant professor of emergency medicine and coordinator of global emergency medicine education for her department, also has embraced activism. Along with Moretti, she has led waste-reduction and sustainability efforts in hospital emergency departments. And like her colleagues, she watches her emergency department fill up when the mercury rises.

“I chose medicine as a career because I was interested in serving vulnerable populations,” she says. “Heat-related illness affects the most vulnerable—children, the elderly, people living in poverty who may not have access to air conditioning. If I want to make a change and live my values, then I really need to be doing advocacy work and trying to make a greater impact.” A co-chair of the Political Action Committee for the Rhode Island chapter of the American College of Emergency Physicians, Hayward has spoken to lawmakers at the Rhode Island State House and offered written testimony.

Recently, in an effort to collaborate with physicians from disciplines beyond emergency medicine, Hayward moved the RI ACEP’s advocacy-focused Climate Change and Health Committee, which she chairs, to the Rhode Island Medical Society, and invites a wide range of physicians to speak about how they and their specialties are approaching the topic. Last year, the committee received a seed grant from Brown’s Office of Sustainability and Resiliency to organize a symposium on planetary health this spring.

“This will be a way of bringing many people across the community together to share knowledge and raise awareness,”  Hayward says. “There are so many different people across disciplines who are doing relevant work on climate change and health, and some of us don’t even know about each other.”

It’s All In Your Head

One of those people is Joshua Wortzel F’24, MD, a child and adolescent psychiatry fellow based at Bradley Hospital who studies the impacts of climate on mental health—as well as the impact of psychiatry on the environment (see sidebar).

Recently named chair of the American Psychiatric Association’s Committee on Climate Change and Mental Health and vice chair of the American Academy of Child and Adolescent Psychiatry’s Resource Group on Climate Mental Health, he hopes to make Brown into a national center for the study of climate change and mental health.

As a medical student at Stanford, Wortzel became fascinated by the correlation between temperature and various psychiatric conditions, particularly those that have to do with serotonin dysregulation. That interest continues. He is now examining national and local data to determine how monthly temperature fluctuations contribute to suicidality among children. He will also soon start recruiting subjects for a $15,000 pilot grant from AACAP to study the clinical impacts of climate distress on young people who are receiving psychiatric treatment.

Wortzel recalls a young patient who came to Bradley for reasons ostensibly unrelated to climate change. But as the two talked, the boy revealed that he believed he was harming the environment simply by being alive. “The patient felt like he didn’t know how to justify his existence and his use of resources,” he says, adding that a lot of kids feel that way, whether or not they have the language to say so.

With a strong academic interest in education, Wortzel feels it is urgent that climate-related concerns become part of his profession’s training, as he wrote in an editorial in American Psychiatry: “Psychiatry has always adjusted to teach to its time, and the climate health crisis can be no different.” As a fellow with the think tank Group for the Advancement of Psychiatry, he and colleagues developed a 6-minute video for psychiatry residents outlining some of the impacts of climate change on dementia and mental illnesses, on the effects of psychotropic medications on thermoregulation, and on individuals who suffer from eco-anxiety or have experienced environmental trauma.

Advocacy, too, is important to Wortzel. Last summer, he traveled by train to provide expert commentary at a US Congressional briefing to urge passage of a bill (referred to committee) to strengthen mental health services in the wake of natural disasters, and he continues to communicate with legislators in Washington, DC, to support more legislation about climate change and mental health. “It is important to be in the room where decisions are being made to try to influence those in power to make needed changes,” he says.

 

Torches and Pipelines

An overall curriculum redesign begun in 2023 has pressed “pause” on planetary health integration work at the Medical School, but only temporarily. The facts that Martin and Smith sit on the curriculum subcommittee overseeing longitudinal integration of planetary health (among other subjects) and that the Division of Biology and Medicine recently expanded its mission statement to include “the well-being of people and planet” signal the senior administration’s commitment to the topic. Warrier says the students on the planetary health curriculum integration committee will continue to have input on how the subject is integrated across all four years going forward, and on how to deepen relationships with community organizations.

For all the forward movement, however, the School has work to do. In the 2023 Planetary Health Report Card, authors Joseph “Reed” Junkin ScM’26 MD’26, Trina Swanson ScM’26 MD’26, and Emily Wang ’22 MD’26 dropped its grade to a C.

“That is a grade that nobody loves,” Smith says. “But it is real inspiration to do more, and we are poised to do quite a lot.”

In their comments, the students acknowledged meaningful progress in all categories, but they also identified opportunities to do better—in research support, cross-campus connections, and community service opportunities. A primary shortcoming, the lack of a centralized information platform, has since been addressed by a subcommittee of students and faculty: a new page on the Division website consolidates information on planetary health initiatives, researchers, and community engagement initiatives across Brown.

In addition, David Dorfman ’14 ScM’25 MD’25 (who has led AMS ECo and taught the Planetary Health preclinical elective) and Julia Santini ’21 ScM’25 MD’25 designed and implemented an entire lesson plan on environmental exposures for Doctoring. The lesson includes reading materials, a patient interview checklist, and, importantly, a list of regulatory agencies and other resources to which patients may be referred for help.

Martin and Smith say they intend to propose a planetary health scholarly concentration, which would enable interested students to conduct an independent scholarly project across all four years. And Martin is working to develop a clerkship elective whereby third- and fourth-year students could delve into education, advocacy, and research related to planetary health.

Students also continue to build on the community-engagement efforts of those who came before them. As an AMS ECo co-leader in 2022, Margaret Wang MD’25 (no relation to Emily Wang) partnered with a local organization to organize tree planting in areas of Providence that lack tree cover, a contributor to asthma, heart disease, and heat stroke. Wang, who has led the preclinical elective and helped write content for the Microbiology/Infectious Diseases slides, also was responsible for distributing compost bins to interested first-year students. Last fall, AMS ECo invited Brown Sustainability and Resiliency to give a “recycling and composting 101” talk to med students, and distributed composting bins, reusable shopping bags, and metal straws at the event.

Meanwhile, Nadine Nadaj MD’26 (the fourth AMS ECo co-leader), Emily Wang, and Clinical Assistant Professor of Pediatrics Celeste Corcoran, MD, continue to work with an organization that supplies fresh local produce that they and other medical students distribute to families in the Hasbro Children’s Hospital emergency department who are experiencing food insecurity. Wang is also working to expand the popular Children’s Health Advocacy Program, which she led during her undergraduate years and introduced last year at the Medical School. Through CHAP, students teach medically related topics—on sun exposure, healthy eating, and Lyme disease, for example—to kids in area elementary schools. The number of participating med students, Wang says, has tripled this year.

While students playing an active role in their education is a hallmark of Brown as well as its medical school, these med students see both pros and cons to such initiatives. Emily Wang considers student activism “empowering,” but according to Junkin, for all their dedication, “student turnover is a liability.” Margaret Wang agrees, suggesting that a dedicated staff and budget would facilitate swifter curricular integration and more formalized longitudinal relationships in the community. Nevertheless, Emily Wang is hopeful that planetary health will soon become mainstream, noting that the younger a person is, the more invested in the environment they’re likely to be. She looks forward to “passing the torch” to the passionate students who come after her.

All agree that as future physicians assessing a patient’s condition, they will need to take into account environmental factors the same way they do social determinants of health. “This is something that’s affecting everyone’s life, and it will affect the lives of our children and our children’s children in huge ways,” Dorfman says. “But that doesn’t mean we should say, ‘This is the end of the world.’ It’s a different world we’re going to have to live in. It’s important that we learn how to treat the illnesses that emerge from these changes if we want to be good doctors.”

Rev. Emily Bruce was fortunate to find a physician literate in eco-health, one who assessed her symptoms and determined her treatment within the framework of a changed planet.

“Once you open your eyes to it, you can’t unsee it,” Martin says. “Clinicians must be prepared to recognize the ways our planet and patient health are changing.”