Climate and Health Equity with ESG
Climate Health Inequities: An Industry Call-to-Action
As climate change continues to increase the prevalence of extreme heat, poor air quality and dangerous weather, vulnerable and disadvantaged communities are experiencing the brunt of related health risks.
Across the U.S., researchers have noted drastically shorter life spans among people living in neighborhoods once subjected to redlining, a discriminatory lending practice. National data shows Black populations are exposed to as much as 30% more air pollution than white populations, with disproportionate exposure also seen among other communities of color.
Additionally, access to clean water — a basic human necessity — is not a guarantee for all, with children, older adults, communities of color and low-income populations bearing a higher burden of water-related health issues.
“Not having clean, drinkable water connects directly to lack of brain development. It affects your nervous system, your growth,” said Michellene Davis, president and CEO of National Medical Fellowships, an organization working to achieve opportunity and access equity in healthcare by increasing the number of minority physicians. “We see (health disparities) showing up in real-time as a result.”
Researchers expect water quality and access to worsen with climate change, yet it’s only one of many areas where severe consequences are likely. Healthcare organizations have an imperative to advance climate-related health equity, as it fits squarely in line with their fundamental purpose to protect and promote health for all. Using the ESG framework as a compass, they can play a large role in alleviating these disparities through improved sustainability and access efforts.
“Everything from air quality to more extreme weather events, to water quality and food security – these are impacting us now,” said Dr. Jeff Sperring, CEO of Seattle Children’s. “(The disparities) are only going to get worse if we don’t accelerate our work.”
For Atrium Health in Charlotte, N.C., heat and small particle air pollution are two major climate impacts affecting its patient population, according to Dr. David Callaway, chief of crisis operations and sustainability. Specific neighborhoods and ZIP codes lack tree canopy, and among rural, largely Hispanic day laborers who work long hours outdoors, there are elevated rates of heat stroke and heat illness. Economic strain compounds the health consequences even further.
“To adapt to rising air pollution or heat, you need to use more air filters, more air conditioning, you need stable housing,” Callaway said. “For people who have lower incomes, if you go from spending 30% of your income on housing and utilities to 70%, that decreases your ability to invest, save and have upward mobility. That has follow-on effects on your health.”
Similar issues affect people living on the opposite side of the country, in Sacramento, Calif., where UC Davis Health is based. But the concern there isn’t sparse tree canopy, rather the spread of fires. The sun torches the landscape, contributing to what CEO Dr. David Lubarsky calls “the Great Burn.”
“There is a tremendous amount of wildfires and wildfire fodder in Northern California, and they markedly can impact people’s health,” said Lubarsky. “Direct health impacts are clear around exacerbation of asthma, chronic obstructive lung disease and heart attacks, but (lesser-known) are the long-term impacts of inhaling particulate matter and what that means for people’s health.”
There are also indirect impacts to consider, such as, what would be the impact of limiting time outdoors on children’s social development? These questions will require better exploration, documentation and action as climate change unfolds. However, there’s no question that in the coming years, health systems will be treating higher volumes of climate-affected patients.
“Concrete jungles really do impact health,” Lubarsky said. And these environments are not limited to the coasts. “Lack of greenery elevates the temperature by many degrees in the inner city compared to surrounding neighborhoods. We need to be cognizant of that and expect that we’re going to need to do a lot more treatment for heat stress, heat stroke (and related illnesses).”
At the same time, even theoretically simple lifestyle changes that physicians prescribe to patients, such as increased exercise and healthier eating, will become harder to achieve. Severe flooding and storms can overwhelm public utility infrastructure, contaminate vital water supplies, shut off electricity, impact crops and more.
“The cost of produce goes up, underserved communities’ (access) to fresher foods decreases. This all wraps around,” Lubarsky said.
While healthcare organizations must prepare to accommodate higher volumes of patients experiencing climate-related health issues, they should also explore actions to prevent and limit harm from poor environmental conditions.
A well-ventilated facility could be set up for community members in locales traditionally underserved, for instance, a school gymnasium with upgraded ventilation, Lubarsky said. This would allow for mass re-location in the event of extreme weather.
To contribute its own influence, Atrium Health is establishing a sustainability program that involves providing education to their employees about sustainable practices to implement in daily life, as well as providing assistance in installing energy efficiency or sustainability practices in their homes. There are plans to scale the program across 70,000 teammates.
Partnerships are also central to Atrium Health’s sustainability strategy. In working to reduce Scope 3 emissions, or those related to the supply chain, the organization has built coalitions with producers and GPOs to identify common metrics and reporting standards.
Partnerships with suppliers and companies in other sectors are necessary to truly move the needle on health equity, Callaway said. Atrium Health is working with government officials, community leaders and major businesses in Charlotte to create and track interventions. All of these stakeholders rely on healthier workforces to contribute to their communities, Callaway asserted, and it’s health systems’ job to make this strong health argument.
“By aligning efforts, we can create large-scale interventions, (collectively) track those metrics rather than doing them all independently, and then start building out a five-year, 10-year or 20-year plan for the region,” he said.
At Seattle Children’s, battling climate health inequities involves greater virtual care utilization and taking more services directly out into communities, according to Sperring. This has the two-fold benefit of reducing carbon emissions by patients traveling to Washington from Montana, Idaho and Alaska, as well as expanded access to those for whom traveling isn’t an option.
Additional tactics include improving the nutrition of cafeteria food, incentivizing team members not to commute, eliminating the use of some climate-harming anesthesia gases and managing its water usage in significant watershed areas. But one of the most impactful actions is getting involved in regional partnerships, said Sperring.
“We have our climate alliance here in Washington state, where Providence, UW Medicine, Seattle Children’s, Franciscan Health and others have come together to learn regionally how we can do this work, learn from each other and collectively put pressure on suppliers,” he said, calling for similar action on a national level.
While Seattle Children’s, University of California Health and Atrium Health have each signed the White House Pledge to reduce greenhouse gas emissions 50% by 2030, and reach net zero emissions by 2050, “being carbon neutral isn’t really the outcome here,” Sperring said. “The outcome is actually making a difference in our community.”
With a similar objective, National Medical Fellowships is focused on increasing diversity in medicine in ways that improve not only access to quality care, but also equity of opportunity.
“We are not advancing diversity in medicine generally – we are advancing diversity in medicine of those who have been prevented and prohibited from accessing medical education, who were from communities made vulnerable as a result of historic disenfranchisement and underinvestment,” Davis said.
By building a more diverse workforce as well as increasing diversity in medical research, the healthcare industry can better address the impacts of climate-related health inequities, Davis said.
Determining how effective their efforts are is something healthcare organizations will need to figure out along the way. While there are best practices for reducing carbon emissions and improving sustainability, actually quantifying the impact of climate actions on health equity is complicated, according to Callaway.
“We don’t necessarily have linear, one-to-one predictions of an action and an outcome – if we do X, we expect Y will happen,” he said. “The environment is so complex that we don’t really know, so we need to take an action and study action while we’re taking it.”
This is what Atrium Health is doing through its social impact strategy, to which it devoted $2.5 billion over the next five years. The work includes providing mobile outreach, increasing presence in healthcare deserts, and addressing food insecurity, and was expanded during the pandemic through the use of geographic information system (GIS) mapping.
Atrium Health has looked at certain social determinants of health, starting with the ZIP code during the pandemic and then drilling down to census-level data, to create heat maps in terms of income, race, family history, historical health use, housing stability, crime rates and other variables. But in addition to these more traditional measures, the organization is building metrics around environmental factors such as number of days with extreme heat and poor air quality.
“We’re bringing that in and overlaying it on the information that already exists within our social impact team,” Callaway said. “That will give us our baseline for impact.”
Further, as value-based care adoption continues, there is opportunity to factor the environment into contracts. Pollution is a safety hazard, for example, and the amount of pollution generated in the delivery of care could be factored into determining the quality of that care. This idea, which is gaining some attention in the UK, is that the carbon intensity of care would be considered alongside the patient outcomes, creating a truer assessment of quality.
Callaway said quantifying value in this way will begin to shape things like CMS reimbursement and Joint Commission accreditation standards. Some of that work is starting in academic spheres, he added. One way healthcare might begin to see it play out is if the government decides to incentivize more efficient care with less environmental impact, assigning metrics to these standards and then providing a runway of time to transition to meet them.
Regardless, Lubarsky said, healthcare organizations should work with local officials toward improving disparities — for starters, by not seeing trees and parks as voluntary expenditures, but as necessary investments for community health.
As the consequences of climate change intensify, health systems must demonstrate the authenticity of their commitments to diversity, equity and inclusion. Addressing the clear disproportionate impact on historically marginalized and under-resourced groups will certainly involve undoing past damage, but there is still opportunity to prevent further damage.
“If we see a higher level of pediatric cancer (at an urban hospital compared to) hospitals out in the suburbs, we owe it to the community as healthcare providers to bring it to the attention of elected leadership,” Davis said, adding that community members must be given a seat at the table to help make decisions.
Organizations can work on creating data-driven adaptation plans, and begin intentionally structuring systems to mitigate the disproportionate climate effects. With partnerships, progress can happen effectively, quickly and at scale.
“You cannot have social justice or eliminate health inequity without environmental justice,” said Callaway. “No matter how many clinics we put into neighborhoods, if we’re still polluting the water, the air, if kids can’t go outside and play because it’s 140 degrees – there will be no equity.”
In this conversation with Modern Healthcare Custom Media, Dr. Georges Benjamin, executive director of APHA, explains the important role public health departments must play in reducing the impacts of climate change and the opportunity for hospitals and health systems to partner with them going forward.
In this commentary, Eugene Woods, president and chief executive officer of Atrium Health, challenges his fellow healthcare leaders to help make the healthcare sector the standard-bearer in terms of reducing its carbon footprint.