Will Patients Listen If Health Care Providers Talk Climate Change?

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Mark Masselli ( 00:05 ):
The New England Journal of Medicine says, "In the coming decades, climate change could be responsible
for a quarter of million deaths in the world." Experts say the clock is ticking. Why aren't healthcare
providers doing more to ward off catastrophe?
Dr. Vivian Lee ( 00:19 ):
We've already seen the overall global temperatures have increased. Sea levels are already rising six to
eight inches. Glaciers are losing two to four feet of height each year, and we're all feeling the
consequences with the rising heat waves.
Margaret Flinter ( 00:34 ):
Dr. Vivian Lee is an author and senior lecturer at Harvard Medical School. Modern Healthcare named her
one of the 100 most influential people because of her thinking about climate change and how it
intersects with healthcare.
Dr. Vivian Lee ( 00:46 ):
A significant number of healthcare providers are reporting now seeing firsthand that their patients are
clinically impacted by climate change. And so articulating that and sharing that with the broader public I
think is important.
Margaret Flinter ( 00:59 ):
And this is Conversations on Healthcare.
Mark Masselli ( 01:10 ):
Well welcome Dr. Lee to Conversations on Healthcare.
Dr. Vivian Lee ( 01:15 ):
Thanks. Great to be with you.
Mark Masselli ( 01:16 ):
Yeah, I've been thinking about all of the work that we've been doing on our podcast, and I know you've
been on lots over the last couple of years during the COVID pandemic, we were fortunate to have Dr.
[inaudible 00:01:29] on in February of 2020, sort of giving us the preview of what was to come. And as I
think about the preview of what's succumb, we already experienced MERS and SARS in Ebola, right?
People knew a pandemic was coming, and yet it's fair to say that the public health system simply wasn't
prepared. You've done some great writing about climate change. What if you could just share with us,
given all the climate catastrophes that are in the world, what's your sense about the health and public
health system's readiness to address climate change?
Dr. Vivian Lee ( 02:05 ):
Well, that is such an important question because as we know with the warming of the planet and with
really the other effects that human behaviors are having on the planet, even besides climate change, we
know that health is really the human face of all this change, the human face of climate change. And the
WHO said early on, "Climate change is the greatest threat to global health in the 21st century." We've

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already seen the overall global temperatures have increased. Sea levels are already rising six to eight
inches. Glaciers are losing two to four feet of height each year. And we're all feeling the consequences
with the rising heat waves, with the flooding, with the hurricanes, the wildfires, the droughts. And so
what we need to think about in healthcare is the fact that our fundamental responsibility is to improve
health. We need to help our communities adapt through what will feel like more and more frequent
crises and crises that will layer on top of other crises.
( 03:11 ):
It won't necessarily even be just one crisis at a time. We have to be resilient ourselves. So our nurses,
our doctors, our therapists need to be protected in order to care for others. We really learned that
lesson during the pandemic. And our facilities themselves have to be resilient. They have to be resilient
to energy disruptions, for example, from hurricanes and flooding. So we need to be able to keep our
own facilities strong. And then as we think about all of that, it naturally follows that we have to do what
we can to mitigate. We have to do what we can to lower our own carbon footprint, to lower our own
emissions, to reduce the amount of waste that we incinerate and the pollution that we create every day
in order to do our share as well.

Mark Masselli ( 03:55 ):
Let me just push back a little on the human resilience because we saw here in the current pandemic, lots
of people just left the field who simply, this was too much pressure. The types of calamities that we
might see in the environment could be catastrophic as well. Tell me what your thoughts about what
human resilience really means in this environment where the tip of the spear, both on COVID and
climate, are our healthcare providers.

Dr. Vivian Lee ( 04:24 ):
Well, I think it's very important to separate when we use the word resilience, I think resilience is
sometimes intended to mean, oh, just toughen up, be stronger. And when I say the word resilience, I
talk about system resilience, not individual resilience. I'm not asking our frontline workers to be any
tougher than they already have been. What I'm asking for is for the system to do more to support
everyone in order to be able to get through these really difficult times. And we need to be able to do
that at a health system level and to do it at a societal level as we saw during the pandemic and in these
times of relative calm. And I say that knowing that there are many, still many crisis going on all over the
country and all over the world. This is the time when we need to start preparing for and planning for
greater emergencies and greater issues that are going to face us.
( 05:16 ):
So it's that system resilience that I think is really important. And then maybe just to say one other thing
about that with respect to the workforce, I also feel very strongly that times have been so tough and as
a result within our healthcare systems, many of those hospitals and clinics are facing enormous financial
pressures. And I think it's an important time to rally together to focus on a new North Star, a North Star
that can be maybe more inspiring. And one of those can be helping to save our planet, helping to save
our communities, doing what we can to improve air quality, to reduce the risks that our children and
future generations are going to face. And as healthcare providers, we can do a lot. We have enormous
amount of impact, and I think that positive North Star could be a rallying cry, could be a really a pivotal
move for us within healthcare right now.

Margaret Flinter ( 06:12 ):

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Well, Dr. Lee, thank you for that comment. And I want to maybe take it down to the level of the
individual healthcare provider in that exam room with a patient. The scientist tell us their air pollution
already is causing maybe 7 million premature deaths each year around the world. And some say that
physicians and nurse practitioners and other healthcare providers need to stop sitting on the sidelines
and point - blank tell patients, "Climate change is causing your lung disease." And I'd be really curious to
your take on that idea in clinical practice, we're so careful about making sure that what we say is
evidence - based and should be actionable and people can do something about it. So what's your take on
that idea? Is this a conversation that individual healthcare providers should be having with their
patients?

Dr. Vivian Lee ( 07:00 ):
Well, I think many people don't realize just how many of the health professional societies have already
included in their guidelines for care recommendations about climate change. So for example, the
American Medical Association, the AMA adopted a global climate change and human health policy that
encourages physicians to assist in educating patients and the public on environmentally sustainable
practices. And I'm going to quote them, "And to serve as role models for promoting environmental
sustainability." In the UK, the General Medical Council has established, that's the body that oversees all
the new doctors that come out of the UK, that the newly qualified doctors must be able to apply the
principles, methods and knowledge of sustainable healthcare to medical practice. So it's already baked
into a lot of the guidelines. I actually came across a very interesting publication that came out of
Wisconsin and Dr. Andrew Levandowski did this really interesting study.
( 08:00 ):
He's a pediatrician and following the American Academy of Pediatrics recommendations, which again
include discussing health effects of climate change with patients, he actually incorporated in his practice
in the peak of the pandemic at the end of 2020 and 2021 for the well - child visits. He included a 45
second script during the social history part of the well - child visits that basically said something to the
effect of, "In the last couple of years, the American Academy of Pediatrics has declared climate change a
health emergency. Some facts like air pollution alone has caused over 64,000 premature deaths in the
US. And just like I want your children to eat healthy foods and be in the right car seat, we now know that
decreasing our energy use, increasing energy efficiency and supporting clean energy initiatives are also
important for improving our children's health. Do you have any questions?" He did a survey very
interestingly of his patients, their and their family members before and after that visit.
( 09:08 ):
And included in there, by the way, questions about their political perspectives and the results were
really striking. Something like 89% to 91% overall reported that they were very likely to engage in energy
saving behaviors like swapping out to LED lights and also being very likely to support clean energy
initiatives. And while there was a difference between self - reported conservatives and liberals, the vast
majority of both groups supported these changes. So overall, and as he mentioned in a very interesting
webinar, he did not lose any patients as a result of doing that. So I think it's difficult right now because
these are not reimbursable conversations and everybody is already overwhelmed. So let's just face the
realities of that. But I do think that healthcare professionals are among the most trusted on this planet,
and I think it's clear that our professional societies have said that this is part of keeping our communities
healthy.

Margaret Flinter ( 10:07 ):

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Well, that is incredible, and thank you. I had not heard about that work in Wisconsin, and I think about
the pushback that there's been politically around things like counseling parents, about making sure they
lock up their guns or don't have them available where children can reach them. And to hear that it was
positive and without pushback, presumably in a multi - view holding population is very interesting. Thank
you for that.

Mark Masselli ( 10:33 ):
Well, that's such a great point, Margaret. And one wonders, as you get the conversations mature more,
whether or not that there won't be pushback certainly with on gun safety. And I wanted to pull that
thread a little because in the Lancet, there were article a number of physicians signed who took really
aim at the fossil fuel companies and that the government that subsidizes them and that group
demanded that world leaders pursue a health centered approach to solving climate crisis. I'm wondering
where you fall out on the spectrum in terms of that type of advocacy because as you said, this is really
about, as that one practitioner was talking about energy savings, this really goes at the heart of the
matter, which are these fossil fuel companies and what they're doing to help solve this problem?

Dr. Vivian Lee ( 11:29 ):
Well, I think physicians, just like all citizens, are entitled to express their views in the interest of
advancing health. I think in the past, there were opportunities. For example, I would say that I think that
many of us probably should have spoken up earlier and gotten more engaged around healthcare reform,
improving medical safety. For example, in the '80s and '90s. We are on the front lines and together with
nurses and other pharmacists, other healthcare professional are highly respected and our opinions are
generally well regarded. I know that from some recent surveys, some global surveys, some surveys in
Europe that a significant number of healthcare providers are reporting now, seeing firsthand that their
patients are clinically impacted by climate change. And so articulating that and sharing that with the
broader public I think is important. I also will say that a huge part of the challenge that we're facing here
is that what we're dealing with has to be recognized.
( 12:32 ):
It's a planetary problem. It's not even an American problem. It's a global planetary problem, and it's
about everyone. It's affecting everyone, and it really cannot be along artisan lines. It cannot be just
attacking and demonizing and being used for certain political purpose. It really has to be about positive
solutions. And so I think it's very important, for example, if we're talking about energy to really focus on,
we're a capitalist economy, so let's focus on how successful so far it's been in making a strong market
for renewables. There has been enormous demand and a real acceleration of technology there. And
today, energy from solar and wind are already lower. Energy costs are already lower than traditional
fossil fuel based energy. So let's talk about how we can continue to make that kind of progress moving
forward, because I think that's going to be the most vital to our success.

Margaret Flinter ( 13:32 ):
Well, I couldn't agree with you more, and we want to turn to those positive trends, but I do want to ask
you, climate change deniers seem to be pretty distributed across the population around the country.
And so much good work has been done by the professional societies, the AMA, the ANA, the American
Nurses Association, and I'm sure true of the other health professions, but we still have climate change
deniers. I'm curious, have you encountered such folks within the healthcare professions, and what do
you say to them? How do you deal with climate deniers within the healthcare professions?

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Dr. Vivian Lee ( 14:12 ):
Well, I think that, first of all, let me just say that I think that when we review the science and when we
talk to the community of people, not healthcare people, but people who are experts in climate science,
science is that irrefutable? It's just irrefutable. The percentage of people who still question, it's clear that
also that many of the events that we're seeing in the environment are related to greenhouse gas
emissions or carbon dioxide emissions, but not everything is. So for example, there are many complex
human behaviors that can cause changes in our environment.
( 14:46 ):
Like our family lived in Salt Lake City for several years, and we have now seen literally before our eyes
the evaporation of the Great Salt Lake. Part of that may be related to climate change. Part of it is just
simply overuse of the water. So there may be many factors that contribute to things that we're seeing
changes in our environment, but still, there's no doubt that climate change is happening and around the
world, there was a survey of healthcare professionals worldwide that found that 98% worldwide believe
that climate change is happening and causing significant concern for them in their patients.
( 15:24 ):
We probably have a lower percentage of that in the United States, but that number has been reducing
pretty steadily. And I think it's our job to continue to educate and to ensure that people are seeing the
data that our climate scientists around the world have been producing, and that we do our best to
explain it as clearly as possible and also to tie it to the kinds of new developments that we are seeing
that give us some hope that there is an opportunity to change the direction that we're moving in now to
a more positive future.

Mark Masselli ( 16:02 ):
Speaking about changing directions, certainly the healthcare facilities are an area that needs to improve.
They're the third most energy intensive in the commercial building sector. Only, I believe food service
and food sales rank higher. And I'm wondering what your thoughts are. What do you see in terms of
best practices out there in terms of reducing the amount of polluting emissions that are coming from
hospitals and laboratories and the like?

Dr. Vivian Lee ( 16:34 ):
Well, thanks for asking that question, because we do have enormous opportunities in healthcare. I
mean, we really should be, if we are looking after the health of our communities, we should be role
models in our communities for trying to reduce our impact on pollution as best we can. So one of my
favorite books that I love to recommend people who are new to this field is a book that came out in this
2015 called Greening Health Care by Kathy Gerwig, who was probably one of the, not the first vice
president for sustainability for any health system. She was with Kaiser Permanente for many years. And
she really takes you through, the reader through just a number of examples. But there's no question our
lights are on 24/7 in hospitals. We produce an enormous amount of waste. In the US today, about the
average patient in a hospital produces around, I mean, the patient doesn't produce, but as a result of
that stay, there's around maybe 30 pounds a day of waste generated per patient per day.
( 17:40 ):
And we still incinerate our waste. We incinerate our waste, and a lot of that is plastics, not exactly what
you want to be burning and spewing into the air. So there are a lot of opportunities for us to think about
how we can reduce our own impact on climate change, and many of them are very aligned with what
we want to do anyway in healthcare. We want to reduce waste in healthcare. That's actually adding to

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unnecessary costs of healthcare, for example. We really want to prevent disease and we really want to
focus on primary care and public health. All of those things help the community and reduce our carbon
footprint.

Mark Masselli ( 18:20 ):
Any hospitals that are leading hopefully with lead sort of the building standards, anything that you're
seeing that gives you hope that the industry as a whole is taking this seriously as they're planning for
future development of their facilities?

Dr. Vivian Lee ( 18:41 ):
Well, we've seen more than a hundred hospitals sign up to this new pledge to reduce the carbon
footprint significantly in the next couple of decades, which I think is really encouraging. And there are
some terrific examples. So I mentioned that Kaiser Permanente has been doing this for years, and there
are many examples there. When you talk about facilities, there are many systems, but one in particular
that I know because it's sort of right in my backyard here in Boston has been Boston Medical Center. So
more than I'd say maybe 15, 20 years ago, they started making these investments in renewables in solar
facilities, kind of going in shared purchasing agreements, for example.
( 19:27 ):
And these have saved Boston Medical Center millions of dollars per year, just the energy alone, right?
$10 to $12 million per year, which is pretty significant, especially in these days when we are all worried
about our expenses. And they've done really just practical things within their facilities, like swapping out
for LED lights and putting in motions detection sensors, things that we have in our own homes because
we really don't need all those lights on in all those rooms 24/7 every day.
( 19:57 ):
And so it's been, I think doing good and doing well has been the example in those facilities investments.
We also have a lot of examples that we can look to in the UK. The National Health Service in 2020
declared that they were going to be net - zero by 2040 roughly. And so there are hundreds of hospitals
there that have each, you can look at them online, they've each put forward their sustainability plan.
Whether it's facilities, whether it's switching to safer anesthetics, whether it's moving to green
ambulances, electric vehicles, those kinds of things. Lots and lots of examples from around the world.

Margaret Flinter ( 20:35 ):
Well, Dr. Lee, I'm sure I'm not the only person throughout the pandemic that was aghast at all of our
shedding of our PPE on a daily basis multiplied by millions across the country, but it had to be done. But
I think we all hope should there be a recurrence that we're onto a better future in terms of those
products. But I think your point about the economic argument is huge. Certainly, obviously, healthcare is
seeking to reduce its cost and its carbon footprint. And I'm curious, given the influential voice that you
have in this area, are there efforts underway at CMS as our kind of largest national payer of the
healthcare bills, if you will, or organizations like the Joint Commission on more of a standard setting
point of view to really make an impact in this area?

Dr. Vivian Lee ( 21:27 ):
Oh, absolutely. There's been just tremendous national leadership, which it is just wonderful. National
leadership, both in terms of starting to set expectations. There's a carrot and stick element I would have
to say in terms of the narrative, but Health and Human Services is charged stakeholders to cut our

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greenhouse gas emissions in half by 2030 and to get to net - zero by 2050. We have over a hundred
hospitals, plus other major companies that have already signed on there. We have the Joint Commission
is already put forward some expectations in terms of making sure that hospitals will establish a
sustainability chief, that there will be ways of measuring carbon. I think the most important thing is we
have to really actually put in place measurement standards and then have plans strategies for how to
reduce those carbon footprints. I think that these are all vital.
( 22:25 ):
What's really critical right now is that we have the ability to create consistent standards across hospitals
for how to measure, and that these standards are not onerous. We know that our IT departments are
already overworked. We have a lot of reporting quality measures, all important that are challenging.
And so how can we working together with HHS, with CMS and within the private sector create a set of
standard measurement approaches, perhaps importing them from overseas, the UK for example. We
have very similar suppliers who have the measurements already in hand, so how can we just import
some of those capabilities into our procurement offices, for example, so that this can be a transition that
we can make that is not as burdensome and to make it as simple and in scalable as possible.

Mark Masselli ( 23:23 ):
Dr. Lee, we could talk to you about so many areas because you're so knowledgeable, have such great
expertise. I do want to turn our attention to health technology. You just finished serving as president of
health platform at Verily, a Alphabet company. Love to know a little bit about that work, but in that role,
you helped launch and grow several new successful businesses in the area of digital health. Saw so much
transformation happen in this space during COVID. It really was a force multiplier. There was a silver
lining of COVID at all. It moved the technology opportunities ahead as some of the regulatory barriers
were let down. I wondering if you could look into your crystal ball and tell us what you see for the future
of technology and health.

Dr. Vivian Lee ( 24:11 ):
Okay, well, how many hours do we have? That is such a great question. I really appreciate that question
because of course, that is something that I have been thinking about a long time in which I'm pegging a
lot of hope, not only for healthcare itself, but also for the topics that we started with around
sustainability and creating a better planetary health as well. One of the ways in which I think about it,
and in my time in the Alphabet family, I was really privileged to have an active role in this is about how
technology is really enabling what I call the co - production of health. And I borrowed this term from
others. I didn't invent the term, but it's really the idea that in order to produce health, we need to have
co - production. It's about the patients and their families working together with their clinicians, their
health systems, and how do we enable that through technology.
( 25:10 ):
Part of it is, for example, surfacing information and insights. So in the case of say, somebody who has
type two diabetes, how do we allow them to use a continuous glucose monitor, maybe take some
pictures of their meals and snacks, layer a little bit of artificial intelligence on top, which can look at
some of the history and say, "Vivian, maybe you shouldn't have that second slice of pecan pie. This is
what it did to your blood sugar the last time you did that." Or even maybe more subtle things like, "This
soy milk is a little bit better for you in your coffee than skin milk, or a couple of eggs might be better
than a bowl of cereal," for example. Using the technology to enable people to care for their own for
themselves and to have that insight, co - produce health is vital.

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( 25:57 ):
And there's the other side of that, which is to leverage the same kind of insights to help our clinicians be
more efficient, be more effective, less frustrated at the work that they need to do, reminding them of
say some of the latest developments in the medical literature that they might need to know for a
particular patient, but maybe haven't had time to read about in the journals. Or in the case of climate
change, alerting patients automatically if it's going to be a bad air day and what they can do about it, for
example, without your nurse having to call or you having to call your patients or see them in an
emergency.

Mark Masselli ( 26:26 ):
What's your sense of ChatGPT and how artificial intelligence moving away from the devices to the
software that's going to have a profound impact. Do you have any concerns about what that
transformation might look like?

Dr. Vivian Lee ( 26:41 ):
Well, generative AI is taking the world by storm, because the progress has been so much faster than any
of us expected. And so I think you can read it every day, but it truly is mind - blowing in the true sense of
the words. And so first, we have to just recognize that this is a tool that we don't fully understand in all
of its implications. We just don't. And it will start to play out. It's a tool and like all tools, it can be used
for good or it can be used for evil. It's just a tool. One of the areas that I'm very optimistic about, I hope,
is it's potential to educate and to educate people to make the world's information as accessible as
possible, truthful information. Sal Kahn did a TED Talk last month, which I is really worth watching. If
your listeners or viewers haven't seen it yet.
( 27:42 ):
It's really inspiring about how the generative AI capabilities today can really improve education. We
know that it can help patients, it can help clinicians generate reports and provide potential differential
diagnoses. There's a lot of ways in which it can make information more accessible. It has to be more
accurate than it is right now. And of course, there's a lot of work being done to achieve that. But overall,
we still just have to recognize that it is a tool, and the more we understand about that tool as clinicians
or physicians or people in healthcare, the more we can use that tool for good. And that's really what I
hope we can do. I hope we can really leverage that capability for good.

Margaret Flinter ( 28:23 ):
Dr. Lee, maybe just one quick look into the future for you since we've been future focused in our
conversation. Your book is titled The Long Fix, Solving America's Healthcare Crisis with Strategies that
Work for Everyone. We hope people will read it. But you propose that we pay doctors, hospitals,
pharmaceutical companies to keep people healthy instead of the fee for service model with a value -
based care. So give me your best case scenario looking forward. We see the NASM report on primary
care. We see CMS looking to move a hundred percent of its traditional or original Medicare, as they call
it, recipients into value - based programs within the next several years. Do you think it's going to happen?
Do you think we're going to make a transition to a value - based system?

Dr. Vivian Lee ( 29:10 ):
Well, I think no matter what, we can't afford more expensive care that produces worser outcomes. We
just can't afford that, and we can't afford care that's actually going to continue to widen the gaps and

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widen health disparities. So we have to move to some model where we get better outcomes at lower
costs. Our society just can't sustain it. I think that there are some very good examples of where it has
made a difference, and I think there's really great opportunities for how it could do better, for example,
in the field of pharmaceuticals. Other countries, Canada, the UK, Europe are already paying, setting
pricing based on how effective a medication or a device is in terms of improving health.
( 29:52 ):
More effective, you get paid more, less effective, you get paid less. We have that capability. We know
that information, but today in this country, our researchers are actually even barred from doing that
kind of research under certain federal grants. So that's an example of something that we could do today
that would actually lead us to be paying for better outcomes and lowering our overall expenses. It's just
a matter of our collective will and everyone's understanding of what this actually means.

Mark Masselli ( 30:20 ):
Dr. Lee, thank you so much for your work and ideas and all that you're doing to bring them to life. And
also thanks to our audience for joining us as well. There's more online about conversations on
healthcare, including a way to sign up for email updates. Our address is chcradio.com. Again, thank you
for taking the time and we continue to follow your work.

Dr. Vivian Lee ( 30:42 ):
Thank you so much for having me.

Mark Masselli ( 30:43 ):
All right. Appreciate it.

Margaret Flinter ( 30:45 ):
Thank you, Dr. Lee. This copyrighted program is produced by conversations on healthcare and cannot be
reproduced or retransmitted in whole or in part without the express written consent from Community
Health Center Inc. The views expressed by guests are their own, and they do not necessarily reflect the
opinion of conversations on healthcare or its affiliated entities.

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