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Keywords:

  • emergency medicine;
  • emergency services;
  • hospital;
  • emergency medical services;
  • disaster planning;
  • climate;
  • weather;
  • greenhouse effect;
  • health policy

Abstract

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

There is scientific consensus that the climate is changing, that human activity plays a major role, and that the changes will continue through this century. Expert consensus holds that significant health effects are very likely. Public health and health care systems must understand these impacts to properly pursue preparedness and prevention activities. All of medicine will very likely be affected, and certain medical specialties are likely to be more significantly burdened based on their clinical activity, ease of public access, public health roles, and energy use profiles. These specialties have been called on to consider the likely impacts on their patients and practice and to prepare their practitioners. Emergency medicine (EM), with its focus on urgent and emergent ambulatory care, role as a safety-net provider, urban concentration, and broad-based clinical mission, will very likely experience a significant rise in demand for its services over and above current annual increases. Clinically, EM will see amplification of weather-related disease patterns and shifts in disease distribution. In EM’s prehospital care and disaster response activities, both emergency medical services (EMS) activity and disaster medical assistance team (DMAT) deployment activities will likely increase. EM’s public health roles, including disaster preparedness, emergency department (ED)-based surveillance, and safety-net care, are likely to face increasing demands, along with pressures to improve fuel efficiency and reduce greenhouse gas emissions. Finally, EM’s roles in ED and hospital management, particularly related to building and purchasing, are likely to be impacted by efforts to reduce greenhouse gas emissions and enhance energy efficiency. Climate change thus presents multiple clinical and public health challenges to EM, but also creates numerous opportunities for research, education, and leadership on an emerging health issue of global scope.

There is abundant evidence and clear consensus among climate scientists that human activity is changing the world’s climate. Lay opinion in the United States has begun to reflect this concern. Projections for future climate change include a global average surface temperature rise of 1.8 to 4.0°C, sea level rise of 0.18 to 0.59 m, and significantly increased weather variability.1 These changes will very likely have net negative health effects through a range of direct and indirect exposures, both globally and in the United States, and place greater demands on acute care, disaster response, and public health services.2,3 These increased demands are likely to burden health care generally and emergency medicine (EM) in several areas specifically. EM’s clinical care mission is very likely to be influenced as the populations at greatest risk disproportionately rely on emergency departments (EDs) for care, EM sees many weather-sensitive diseases, and shifting disease distribution will bring new presentations to the ED. EM’s prehospital, disaster response, and public health missions will almost certainly be affected, as the specialty has a primary role in emergency medical services (EMS) management, and EM-trained physicians have substantial roles in developing and managing the nation’s disaster response capabilities. As a hospital-based, energy-intensive specialty, EM is also likely to be significantly influenced by climate change mitigation efforts. Other specialties are likely to bear substantial burdens, and systemwide preparation is required, but EM will face several specific challenges, and specialty-specific preparation is indicated. Despite these projections, there is no EM-specific literature on climate change preparedness and prevention. The objective of this article is to identify climate change impacts on EM and chart appropriate actions to address those impacts.

Health effects of climate change

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

Climate change health effects in the United States have been extensively reviewed elsewhere.3–7 The purpose here is to provide a brief overview as a segue to a discussion of impacts on EM’s core services.

Expected health effects include heat-related illness such as heat stroke;3,8–10 exacerbations of climate-sensitive cardiovascular and pulmonary disease, including acute coronary syndrome, asthma, and chronic obstructive pulmonary disease (COPD);8,11 injuries from severe hurricanes and other extreme weather events;5,12 water- and food-borne diseases causing gastroenteritis; and increased incidence of vector-borne and zoonotic diseases such as Lyme disease, hantavirus pulmonary syndrome, and dengue hemorrhagic fever.7,13–18 Anxiety and depression associated with population displacement,19,20 and indirect health effects from interruptions of medical and psychiatric care, are also significant concerns.7

Health effects will vary by region and will disproportionately affect certain populations.21,22 Vulnerable groups include infants, elders, the overweight and obese, patients with chronic cardiovascular and pulmonary disease, those taking certain antipsychotic medications, and socially and economically marginalized.23 Places at particular risk include urban areas, the coastal and low-lying areas and islands, the desert southwest, vector-border regions, and the Arctic.26,27 While health consequences in the United States may be less severe than those in the developing world, burdens are likely to be significant for prevalent concerns.4,7 Moreover, multisystem failures in major events, on a par with those that occurred in the aftermath of hurricane Katrina,28 could have devastating effects on public health and the economy.29

The World Health Organization (WHO), using conservative estimates, believes that climate change already causes over 150,000 deaths a year globally, based on models of a study of health effects of thermal extremes, weather disasters, diarrhea, malaria, and malnutrition.30 These impacts are expected to accelerate.4,7,30–33 Preparing for these health effects has become a top priority both domestically and globally; the Centers for Disease Control and Prevention (CDC) has identified climate change as a top domestic health priority,34 and WHO marks climate change as a key global health concern as well.35 Both agencies have called for health system preparedness.

Effects on EM’s clinical mission

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

Emergency medicine provides urgent and emergent care for the acutely ill and injured and acts as the nation’s health care safety net. Table 1 highlights important characteristics of the specialty, its role, and its current patient base.36–53 Climate change is important to EM clinically for several reasons, each of which is briefly elaborated on below.

Table 1.    Characteristics of EM Relative to the U.S. Health Care System as a Whole
Descriptive DomainSpecifics for EM
Size and patient baseEM physicians constitute 5% of the U.S. physician workforce. There are an estimated 41,000 EM physicians in the United States (32,000 in 1999` with 9,000 additional board certifications since37), compared with 720,000 physicians overall.38
PenetrationIn 2005, there were a total of 115.3 million visits to hospital-based EDs,39 and one-fifth of the U.S. population visited an ED.40
GrowthAnnual ED visits increased 20% from 1995 to 2005, while the number of EDs declined from 4,176 to 3,795, resulting in an average census increase per ED from 23,119 to 30,388.40
Scope of practiceEM is responsible for all urgent and emergent conditions. In 2005, 35% of ED visits were for injuries, and 85% of visits were for acute concerns.40 EM provides substantial mental health care: one-quarter of all patient transfers from EDs in 2005 were for psychiatric, mental health, or substance abuse care.40
Urgency of complaintsBy triage category, over 85% of visits triaged at least semiurgent, requiring care within 1–2 hours, with 15% requiring immediate or emergent care.40 12% of ED patients were admitted to the hospital in 2005; of these, 16% went to an ICU.40
Populations seen and prevalence of care for underservedEM is primarily urban: 85.5% of ED encounters occur in metropolitan statistical areas (MSAs).40 Those at extremes of age (infants, nursing home residents) use EDs at significantly higher rates than the general population, as do African Americans.40 Homeless people visited at nearly twice the national rate of other ambulatory care sites.40
Public health rolesIncreasingly, EDs perform sentinel, syndromic, and other frontline, surveillance activities for outbreak detection.41–48 EDs perform triage and serve as incident command posts and evaluation sites in disasters. EM providers are disproportionately represented among medical directors of EMS and in the National Disaster Medical System (NDMS).49–53 EM professional organizations influence national health policy.

1. Climate Change is Highly Likely to Increase the Incidence of Many Conditions Seen in the ED  A host of diseases commonly seen in the ED exhibit climate sensitivity. Not all are equally sensitive, as detailed in Table 2.3,5,10,17,54–63 Some, such as viral respiratory infections, are likely to be less prevalent as a result of climate change, but the net impacts are expected to be adverse,61 and demand for EM’s clinical services will likely rise as a result. Several examples are detailed below:

Table 2.    Prevalent Climate Sensitive Diseases and Impacted Medical Specialties
DiseaseEpidemiologyPrimary SpecialtiesClimate SensitivityClimate Change Effect(s)Confidence in Estimates*
  1. *Confidence derived, where possible, from expert consensus as published in the literature, particularly the EPA’s recent update of the health effects of climate change in the United States. Where expert consensus was not known, confidence was determined by the strength of the climate-health association as noted in the literature and by the number of studies predicting congruent effects.

  2. COPD = chronic obstructive pulmonary disease; EPA = Environmental Protection Agency.

• Heat illness • Heat-sensitive chronic conditions• 240 hyperthermia deaths annually54 • Increased excess mortality from approximately 7%– 60% during heat waves • Increased ED admissions for respiratory and renal disease10• EM • PediatricsVery high• Increased heat wave frequency and severity • Increased incidence of heat-related illness • Persistent effect modification of morbidity and mortality from heat-sensitive chronic diseasesVery high3
• Weather-related injuries • Intentional injury associated with violent crime• 29.6 million nonfatal injuries requiring ED care, including 1,314,000 intentional injuries; 161,000 fatal injuries in 200255 • 649 weather-related deaths per year 10-year average 1997–2006 and 3,849 direct weather-related injuries in 200656• EM • Family practice • PediatricsHigh for injuries related to extreme weather events and for intentional violence associated with violent crime57• Increasingly frequent and severe weather, increased incidence of weather-related injuries • Increased heat wave frequency, severity and increased prevalence intentional violenceHigh5
Respiratory disease: • Asthma • COPD• Average annual asthma prevalence 20 million (including 6.2 million children) 2001–2003 • Annual asthma attack rate approximately 55% in patients with active disease • 1.8 million asthma ED visits (including 0.7 million pediatric) • Annual average 4,210 asthma deaths58 • COPD prevalence 10 million in 2000 • Annual average 1.5 million ED COPD visits • Annual average 119,000 deaths59• EM • Family practice • Pediatrics • Internal medicine • Geriatrics • Pulmonary• Asthma: high • COPD: moderate• Increased aeroallergen production and higher ground-level ozone production • Increasing incidence of COPD and asthma exacerbationsHigh
Gastroenteritis• Highly underreported • Estimated annual incidence 210 million cases • Estimated 900,000 hospitalizations annually • Estimated 6,000 annual deaths60• EM • Family practice • Pediatrics • Internal Medicine• Depends on pathogen • High for bacteria • Moderate for parasites • Relatively low for viruses61• Increased incidence of water- and food-borne bacterial and parasitic gastrointestinal infection • Possible decrease viral infection incidenceModerate61
Urolithiasis• Lifetime prevalence of 12% in men • Lifetime prevalence 7% in women • Approximately 1% of ED visits • Total 1,140,000 ED visits in 200062• EM • Urology • Family practice • Internal medicineModerate• Increased ambient temperature associated with dehydration and decreased urine volume • Higher stone incidence in populations not previously at riskModerate
Vector-borne and zoonotic disease• Widely variable depending on disease • Lyme disease average annual prevalence 21,460 from 2003–200563• EM • Family practice • Pediatrics • Internal medicine • Infectious disease• Depends on pathogen • Moderately high for vectors of: —Lyme disease —West Nile virus Western Equine encephalitis —Eastern Equine encephalitis —Bluetongue virus61• Increased ambient temperatures and northward ecosystem migration associated with northward range expansion for I. scapularis16Moderate61

From 2001 to 2004, EDs provided 61.4% of acute care for dyspnea in the United States (personal communication, S. Pitts, National Center for Health Statistics, 2009). Higher temperatures are correlated with several common causes of dyspnea, including asthma, COPD, and allergic rhinitis. Of the three, asthma shows the clearest associations. Beggs and Bambrick64 hypothesized that the global asthma epidemic is an early manifestation of climate change. Asthma is more prevalent in warm climates,65,66 and asthma exacerbations show seasonality.67 There is an association between asthma exacerbations and rainstorms,68–71 which will increase in frequency in the northern half of the United States from climate change. There is also an association between asthma mortality and aeroallergen exposure.72–74 Higher temperatures will result in greater ozone burdens (see Figure 1),75 increasing the incidence of both asthma76 and asthma exacerbations77 and COPD hospitalizations.78

image

Figure 1.  Ozone burdens. The first image depicts baseline summertime average daily ozone burdens from the 1990s, in which orange and red areas are at or over the upper exposure limit of 75 ppb (parts per billion) over 8 hours. The second three images are projected percentage changes for the 2020s, 2050s, and 2080s, based on the A2 CO2 scenario (regionally oriented development at a moderate overall pace globally and continued population growth) relative to the 1990s. Changes are in relation to a baseline from the 1990s. Five consecutive summer seasons were simulated in each decade.76

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Aeroallergens, including pollen, trigger asthma and allergic rhinitis, both commonly seen in the ED. Higher pollen counts are another manifestation of climate change as a result of increased ground-level CO2, higher plant metabolism, and longer growing seasons.11,79,80 In a corollary concern, cases of contact dermatitis from poison ivy are likely to increase in incidence with climate change.81 Wildfires, increasingly prevalent secondary to climate-related changes in the hydrologic cycle,82 are associated with respiratory irritation and greater health system demand,83 including a significantly higher rate of ED visits for respiratory symptoms, undifferentiated dyspnea, and asthma.84

Kidney stone incidence is also correlated with ambient temperatures. Kidney stone disease has an especially high prevalence in the Southeastern United States,85 and urolithiasis is a common ED complaint.62 The etiology of acute renal colic is multifactorial, but warm climate and dehydration leading to low urine volume are risk factors, and the incidence is geographically variable. Mean annual temperature has been estimated to account for 70% of the geographic variability in urolithiasis incidence.86,87 A recent analysis concluded that there will be a climate-related increase of 1.6–2.2 million lifetime cases of nephrolithiasis by 2050, with a 25% rise in health system costs associated with this diagnosis.88

2. The Patients Who Rely Disproportionately on the ED Are Also Particularly Vulnerable to Climate Change Table 2 details the specialties that care for several prevalent climate-sensitive diseases in the United States. As noted in Table 1, EM provides disproportionate care for a number of marginalized groups, many of whom are also vulnerable to climate change health effects. The ED is also accessed disproportionately by individuals at the extremes of age, groups that are particularly vulnerable to climate change. Patients with mental health concerns, particularly exacerbations of psychiatric disease, are commonly seen in the ED and have multifactorial vulnerability to the hazardous exposures associated with climate change, not only from their diminished capacity but also as a result of increased psychotropic medication use, several classes of which predispose patients to heat-related illness and death via sweating impairment.89

3. Climate Change Is Almost Certain to Alter the Severity of Several Environmental Exposures Such as Heat and Ground-level Ozone, Increasing the Proportion of Disease Exacerbations  Climate change will change the distributions of hazardous environmental exposures, with shifts in the measure of central tendency and variance. For example, the theoretical distribution of extreme heat events with climate change is detailed in Figure 2. For ozone, the shift in central tendency is most dramatic, as detailed in Figure 390 (which refers to Germany but similar patterns are expected in the United States91). For extreme precipitation, primarily variance will shift. Regardless of specifics, for each hazardous exposure more extremes are likely to result, increasing prevalence and severity of disease exacerbations. EM disproportionately cares for patients with severe disease and thus will very likely experience a higher demand for its services. Heat, precipitation, and storms serve as examples.

image

Figure 2.  Theoretical shift in the distribution of extreme heat events with climate change. IPCC. Climate Change 2001: Synthesis Report. A Contribution of Working Groups I, II and III to the Third Assessment Report of the Intergovernmental Panel on Climate Change. Figure 4-1. Cambridge University Press.33

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image

Figure 3.  Projected ozone concentrations 2031–2039 relative to 1991–2000 for Germany.90

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Heat waves are associated with increased ED visits over baseline,92 and hospital admissions rise by roughly one-third during heat waves, primarily for the diagnoses of heat stroke, heat exhaustion, dehydration, acute renal failure, and degenerative neurologic conditions.92,93 All-cause deaths also increase,10 primarily among elders, the poor, and marginalized urban dwellers, typically from cardiovascular and cerebrovascular disease.94–97 Death from cocaine overdose is more likely on hot days as well,98 and ambient temperature and heat waves are strongly correlated with increases in violent crime and associated injuries.57 Higher temperature and associated rises in ozone concentrations are also associated with increased ED visits for chest pain and other cardiovascular syndromes.99

Extreme precipitation is primarily associated with injury morbidity and mortality100 and gastroenteritis outbreaks.101,102 The mechanism(s) responsible for the observed findings are not known and require verification with additional study. Nevertheless, projections suggest that more frequent extreme weather events will increase outbreak incidence.103 Higher ambient temperatures are likely to amplify this effect.61 Outbreaks of gastrointestinal disease are associated with significantly increased demand for ED services.104

Severe storms are associated with injuries and often cause population displacement. Hurricane Katrina exemplifies typical health outcomes. Katrina made landfall in Mississippi on August 29, 2005, and by September 5, 2005, a total of 229,338 Gulf Coast residents had been displaced into Louisiana and several surrounding states105; ultimately the diaspora included more than 1 million evacuees.106 The storm reduced New Orleans hospital capacity by 80%.107 Morbidity and mortality followed patterns similar to those of other disasters.108 Mortality, at 1,836 deaths,109,110 was dwarfed by morbidity: there were 14,531 visits for health problems in evacuation centers in September 2005, mostly for chronic disease exacerbations, and 9,772 visits to health care facilities, most commonly for injuries.105 In areas that received large numbers of evacuees, EDs did experience significantly increased service demands,111,112 although off-site activities helped blunt the expected surge in hard-hit sites such as Houston.113 Of note, emergency physicians (EPs) were the last to leave New Orleans during Katrina. Overall, EPs were pivotal in the response, from on-site triage and care, care during transport, triage and stabilization on the receiving end, and ongoing care for displaced populations in their new environs.105,114,115

4. Novel Diseases Frequently Present to the ED, and Climate Change Is Likely to Introduce Unfamiliar Vector-borne and Zoonotic Diseases Into New Geographic Areas  Disease distribution is likely to shift as ecosystems migrate or are disrupted and as environmental exposures change. Certain infectious diseases that were rare or unknown may be introduced, while others that have been largely eliminated from the United States may return. These include but are not limited to Lyme disease, hantavirus pulmonary syndrome, plague, dengue, West Nile disease, Rocky Mountain spotted fever, and malaria.13 Lyme disease migration illustrates the potential range expansion: as the climate warms, habitats suitable to Ixodes scapularis expand northward,116 as illustrated in Figure 4. Ecosystem disruption, such as persistent droughts in the desert Southwest, may lead to increased burden of diseases such as Valley Fever, transmitted when Coccidioides spores are aerosolized in dust storms;117 hantavirus outbreaks in the Four Corners region may become more frequent as precipitation patterns change, increasing food availability for the mice that transmit Sin Nombre virus.118 Expansion of dengue in Central America has been observed, and there is concern it will extend into the Southeast as it is endemic on the United States-Mexico border119,120 and shows significant climate sensitivity.121

image

Figure 4.  Range of suitable conditions for Ixodes scapularis, the Lyme disease vector. As the climate warms and there is increased precipitation in the northern latitudes, I. scapularis’s range is expected to expand northward. Yellow areas indicated projected suitable habitats.95

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Effective preventive measures are available for many climate-sensitive infectious diseases, but if these measures falter there is a high potential for significant outbreaks. Changes in disease distribution are likely to be gradual, and surveillance activities should detect changing patterns of disease distribution so ED personnel will be aware of emerging threats. However, the initial hantavirus outbreak caught the medical system largely unaware,122 and the West Nile surveillance was initially hampered by lack of capacity,123 although effective public health responses were initiated in both cases.

In conclusion, there are a host of potential effects on EM’s clinical mission. EM’s other core activities, including its prehospital and disaster response, public health activities, and hospital and EMS management activities, are likely to be affected as well. These are detailed below.

Effects on EM’s prehospital mission: EMS and disaster response

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

At the local level, climate change is likely to bring increased EMS demands, while regionally and nationally it will likely heighten the need for disaster response and Disaster Medical Assistance Team (DMAT) deployments. Heat waves and other extreme weather conditions are associated with higher levels of EMS activity,124 and multisystem failures such as power outages during heat waves dramatically increase EMS demand125 and, potentially, the need for a regional disaster response. Disasters engage EM providers on a regional and national level, particularly those in the National Disaster Medical System (NDMS), through DMAT deployments, and in triage and care for evacuated patients. EM providers are heavily represented among medical directors of EMS agencies and in NDMS,49–51 and EDs perform triage and serve as incident command posts and evaluation sites in disasters. In recent years, DMATs have been called on to respond to a growing number of water-related disasters, consistent with the climate change trend of more frequent severe precipitation events.126 The NDMS’s role was apparent in the response to Hurricane Katrina, as was the role of EM in general, as noted above.

Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

Emergency medicine has a significant public health role including leadership, administration, policy formation, and advocacy.127,128 Many leaders at the CDC and other agencies that coordinate disaster response are EM trained, and although the entire specialty is called upon to serve in times of disasters and severe resource constraints, these leaders help bridge the gap between clinical and public health concerns.

EM clinicians also play a role in public health activities in EDs, including surveillance and outreach. Increasingly, EDs perform sentinel, syndromic, and other front-line surveillance activities for outbreak detection.41–44 ED surveillance will be increasingly common and important, as illustrated by a recent study of ED visits and wildfires in southern California.84 There is also significant opportunity to couple early warning systems based on modeling and remotely sensed data, such as those administered by the National Weather Service, with community-based interventions to preempt disease outbreaks in susceptible populations and with ED surveillance. For heat-related concerns, vulnerability maps are becoming increasingly sophisticated, allowing vulnerable populations to be targeted with great specificity for home visiting programs, transport to cooling centers, and other strategies for preventing heat-related illness.

Effects on ED, hospital, and system management

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

Mitigation activities will include all sectors of the economy. Efforts to reduce greenhouse gas emissions from the health care sector are likely to significantly affect EM, among other medical specialties. Health care, a large component of the economy, employs one in eight Americans directly or indirectly and accounts for approximately 16% of the Gross Domestic Product.129 Hospitals and other health care–associated buildings rank second to food services in intensity of energy use130 and account for more than $8.3 billion in annual energy expenditures.131 Approximately half of hospital energy use is for shared systems such as heating and cooling, but energy-intense, continuously operating areas such as the ED, intensive care units, and operating suites require a disproportionate share of the remainder (personal communication, T. Leonidas, Seattle, WA, 2008). EM is thus one of many hospital-based specialties that will be affected by the larger climate change response, although all of health care will have to contend with sustainability issues and energy constraints.132–134

In addition to hospital-based energy use, EM also generates emissions through EMS, which provided 19 million patient transports in 2005. Emergency care consumes substantial amounts of fuel and is a significant source of transport-related greenhouse gas emissions from the health care sector.40 There is great heterogeneity in the organization of EMS services nationally, with significant redundancy in some systems from overlap between EMS and fire and division of response and transport functions. Some systems rely more heavily on air transport, which is more fuel-intensive. Deployment strategies also vary widely: some EMS systems are dynamically deployed, increasing the need to idle in the field in exchange for reduced response times. Understandably, EMS systems have been organized around minimizing response time rather than limiting emissions, and there is little research regarding the impact of various parameters such as vehicle size and type, fuel mixture, deployment strategy, dispatch management, and related issues on EMS operations and emissions. Preliminary research suggests that some EMS systems have substantial carbon footprints, however, and that transport is the largest, but not the only, source of their emissions.135 Dependence on petroleum for transport has also been identified as an important preparedness concern.134 Strategies to reduce emissions and petroleum dependence are likely to garner increasing attention going forward.

Health system prevention and preparedness

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

Minimizing dangerous climate change and preparing for its effects are significant challenges that require systemwide enhancements in both public health and health care.29,136,137 Both prevention and preparedness activities are key. Prevention through reduction in greenhouse gas emissions can limit further climate change and is an imperative for all sectors of the economy, including health care, energy, and transport.33,138 A number of other prevention activities have been discussed in the literature.29

Preparedness is equally important, as prior emissions have resulted in a climate change commitment.139 Important preparedness measures include anticipation of increased clinical service and disaster response needs, scenario-based planning to prepare for multisystem failures, enhancing capacity for surveillance, predictive modeling, vulnerability mapping, early-warning systems, and improving health communication strategies.136,137,140

A dialogue on health system preparedness has started in earnest.141–145 A recent review called for a robust national initiative, including emergency preparedness and provider training in affected medical specialties.138 The primary care specialties of family practice, internal medicine, pediatrics, and geriatrics are all likely to be impacted.145 Psychiatry, infectious disease, urology, pulmonology, and critical care are also likely to experience rising clinical demands.146 Some of these specialties have begun preparation; the American Academy of Pediatrics recently acknowledged the import for its specialty in a policy statement.147 There is no EM-specific literature on preparedness or prevention in relation to climate change.

EM’s ability to meet preparedness and prevention needs

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

In many respects, EM is well equipped to meet the challenges posed by climate change. The all-hazards approach adapts well to the health threats climate change will bring, and EM enjoys a strong public health orientation. EM is a large specialty with national penetration, strong professional organizations, and established continuing medical education (CME) offerings to an engaged membership. Clinically, EPs are adept at offering timely interventions and risk communication. From a public health perspective, there are abundant opportunities for surveillance activities in the ED.

It is important, however, to acknowledge the specialty’s vulnerabilities. More than any other specialty, EM is fundamentally dependent on hospital support systems and interactions with other medical specialties. This makes EM vulnerable during system failures, as evidenced by ED crowding, ambulance diversion, and prehospital care fragmentation as detailed in the Institute of Medicine report of 2006.148 EM is hobbled by its unfunded mandate to sustain a health care safety net despite falling levels of health insurance coverage, and clinically, EM is a reactive specialty, although it exhibits significant proactive elements in its public health leadership. Finally, as a hospital-based, 24-hour, 7-day-a-week operation with a mobile component in EMS, EM is very energy dependent. With strains on the global petroleum supply,134 and looming controls on carbon emissions, energy use is likely to become an increasingly significant cost center and ultimately a threat to EM preparedness.

Cost is a significant concern regarding both prevention and preparedness, for EM and other specialties anticipating increased service demands. While some prevention activities such as improved energy efficiency may bring substantial savings that can be applied to capital improvements, some preparedness activities may require new funding streams. Potential funding sources for specific response activities are noted in the discussion below.

Priorities for the em response to climate change

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

In their discussion of general health system preparedness, Jackson and Shields138 present several relevant recommendations, including CME, patient education, advocacy within the health community and with elected officials, and modeling of carbon literate behavior. They also recommend that hospitals undertake energy audits, pursue energy and water conservation and energy efficient construction, and plan for locally relevant disasters. While some EM providers and EDs may be pursuing components of this agenda, there is no national organized support for such activities in EM’s professional organizations. No organization or specialty has initiated high-level interdisciplinary coordination of preparedness activities.

There are several other priorities for EM that reflect its unique role:

1. Provide Health System Leadership. Leadership will necessarily be interdisciplinary, but individual specialties can play a convening role, and as yet no specialty has taken the lead in coordinating the health system response. National EM organizations can provide leadership by authoring a position statement on EM and climate change, sponsoring relevant continuing education, and supporting members in developing carbon literacy.

2. Green EMS. EMS is fundamentally petroleum dependent and has significant emissions from electricity use and indoor climate control. Little is known about overall emissions from EMS or about preparedness threats from petroleum dependence; assessment of EMS’s energy profile is a key first step. After assessing petroleum dependence, EM could develop and pursue a program to reduce EMS petroleum dependence and greenhouse gas emissions, reviewing a host of factors including vehicle types, deployment strategies, proportion of air transport, on-board technologies, and dispatch management. Funding for these activities could come from various quarters, including savings on operations from improved fuel economy; research funding from the Environmental Protection Agency (EPA), CDC, National Institutes of Health (NIH), and other federal sources; automakers; and foundation support.

3. Green the ED. A deeper understanding of EM’s energy use, alternatives, and contingency plans will facilitate preparedness for events in which energy is scarce and demand for ED services are high, such as during an electricity blackout precipitated by a summer heat wave. As innovations are often pioneered in the ED before systemwide deployment, greening the ED could serve as a high-profile initiative to test a range of innovations and focus attention on green building overall. Many innovations are likely to pay for themselves over time: energy audits often identify significant energy efficiency opportunities in existing structures, and green new building routinely achieves significant cost savings in the long run. Federal and state tax credits are often available for increasing energy efficiency and green building initiatives.

4. Model Carbon Literacy. Approximately half of the world’s greenhouse gases are emitted by 10% of the world’s inhabitants.149 Worldwide, physicians are major consumers of energy for professional and personal uses and are well-situated to affect public attitude. As an energy-intensive specialty, EM can model energy-efficient choices in management and purchasing decisions, in advocating for green building when facilities are built or upgraded, in its national and regional meetings, and in its research activities. Such choices offer the benefit of reduced energy costs in addition to decreased emissions.

5. Engage Scenario-based Preparedness Planning. Multisystem failures can have significant health consequences. Using scenarios, researchers should identify areas in which redundant systems are necessary to preserve operations in the case of blackouts during heat waves, water treatment failure during floods, fuel scarcity after storms, and other disasters more likely with climate change. In particular, EM should consider implications for ED crowding, EMS use, disaster response, and overall system demands. Funding for such research is available from federal agencies such as the CDC and foundations.

6. Promote Local Climate Change Preparedness. Effective climate change responses are often organized at the local level and include identification of relevant exposures, vulnerable populations, and intervention needs. EM providers are in a unique position to promote local preparedness given their community standing, professional authority as medical providers, and knowledge of local response systems. Partnering with local emergency managers and health departments to develop and evaluate locally relevant scenarios would allow for leverage of scarce preparedness funds.

7. Leverage Concern Over Climate Change to Promote Safety-net Care. Climate change preparedness offers the possibility of co-benefits for the health system: predictive modeling and early warning systems can reduce health care demand and costs, surge capacity can reduce ED crowding, and energy efficiency can reduce costs and enhance preparedness. There is precedent for leveraging ancillary issues to effect policy changes related to ED crowding and ambulance diversion150,151 and for removing toxins from the health care environment.152 As public concern over climate change and its health effects increases, highlighting co-benefits of climate change prevention and preparedness may become an effective fulcrum for EM’s other policy interests, particularly if health reform focuses attention on activities to promote population health.

8. Support Surveillance of and Research on Climate-sensitive Conditions. The ED is one of several places where surveillance for climate sensitive conditions should be deployed. To guide surveillance, much research is needed into several climate-sensitive clinical outcomes, particularly the extremes that present to the ED. Key priorities include specific dose–response relationships in climate-sensitive conditions, research into predictive health and early warning systems, the changing distribution of infectious diseases, health communication around climate change, and efficient fuel and energy use. Interdisciplinary research should be a priority. As with other activities, there are several potential federal funding sources, including EPA, CDC, NIH, and the National Oceanographic and Atmospheric Association (NOAA). Several prominent foundations have also identified climate change as an important priority for future programming.

Conclusions

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References

The health system must prepare for the health effects of climate change. EM is one of several specialties that will be significantly affected. Climate change will generally enhance system stressors, resulting in both greater baseline system strain and periods of severe stress that may overwhelm an already burdened system. In the United States, the most concerning scenarios are those that include multiple system failures: blackouts during prolonged heat waves, levee failure during a severe storm, delayed evacuations of vulnerable populations, and interruptions in fuel supply during mass population movements. As recent history has shown, such systems failures can have dramatic consequences for our specialty. EM must anticipate and prepare for these eventualities to the extent possible so we can handle them effectively, with alacrity and grace.

References

  1. Top of page
  2. Abstract
  3. Health effects of climate change
  4. Effects on EM’s clinical mission
  5. Effects on EM’s prehospital mission: EMS and disaster response
  6. Effects on EM’s public health mission: leadership, policy, advocacy, and surveillance
  7. Effects on ED, hospital, and system management
  8. Health system prevention and preparedness
  9. EM’s ability to meet preparedness and prevention needs
  10. Priorities for the em response to climate change
  11. Conclusions
  12. References