As an emergency medicine resident at the University of Washington School of Medicine, Zachary Wettstein, MD, has seen the effects of wildfires firsthand. On days when its really smoky, he says, Im not surprised that Im seeing more people with shortness of breath. Densely smoky days certainly are growing as wildfire season worsens, experts say, spurred in part by such environmental changes as earlier snowmelts that can cause drier, hotter conditions.

A few years ago, Wettstein and his colleagues suspected that raging fires and the smoke and fine particulate matter they spawn also were causing increased cardiovascular problems. Whenever we have a bad wildfire season like we did last summer here, it definitely seemed like we were seeing an uptick in the number of strokes, he says. So he decided to study the issue. Sure enough: Wildfires brought increased emergency department visits not only for stroke, but also for ischemic heart disease and pulmonary embolism.

Wildfires are just one way climate change threatens to unleash health problems, particularly for workers who face long hours working outdoors. For example, ozone depletion can spark asthma, rising temperatures can cause dehydration and related conditions, and insecticides can infect farmworkers as changing conditions fuel the spread of new pests. In addition, extreme weather events pose serious risks to rescue teams, mold remediators, and others.

Climate change will be the new crisis of the next generation. Physicians need to be prepared.

Todd Sack, MD, Physicians for Social Responsibility

Robert Harrison, MD, founder of the University of California, San Francisco, School of Medicines occupational and environmental health program,points to firefighters as one group thats particularly vulnerable to the health effects of climate change. Harrison worries about exposure to intense heat and other risks, noting that firefighters battling wildfires in 2017 kicked up spores that cause valley fever, a potentially deadly disease that sickened several of them. Over the past two or three years, weve seen huge fires in California. We expect thats going to continue in the future, because wildfire season is so much longer, he says. The impact of the changing environment and specifically heat on the outdoor workforce is a very real threat.

In fact, as occupational and environmental health experts and others look ahead, some predict that climate change will soon become a top public health challenge. Todd Sack, MD, a member of the board of directors of Physicians for Social Responsibility, compares the coming onslaught to the devastation of HIV/AIDS in the 1980s. Climate change will be the new crisis of the next generation, he says. Physicians need to be prepared.

If you are looking for some of the first signs of the health effects of climate change, look at people whose work makes them particularly vulnerable, experts say. I would expect to see potentially more heat illness, Wettstein predicts. I think air quality is going to be a big issue, not just from wildfire smoke, but things like pollen and particulate matter that affect respiratory and cardiovascular disease. We may see people who work outdoors or those who work indoors and dont have filtration systems with more work-related cardiovascular and respiratory issues.

Other experts point to such threats as increased allergens and growing numbers of disease-bearing ticks and mosquitoes that could endanger those who work outdoors in such fields as construction, landscaping, and agriculture.

What's more, many of these workers face an additional socio-economic disadvantage, Harrison says. Migrant farmers and others arrive in the U.S. and then they take jobs in this country that I characterize as particularly vulnerable, meaning that theyre the highest hazard jobs. They typically remain voiceless and unseen. Many may come into primary care clinics where the provider might see an agricultural worker exposed to pesticides or heat illness, or they have chronic kidney disease, now thought to be possibly linked to chronic dehydration.

The growth of such hazards means trainees and practitioners will need to better understand occupational and environmental health issues as workers start turning up in their offices, clinics, and emergency departments.

[T]he provider might see an agricultural worker exposed to pesticides or heat illness, or they have chronic kidney disease, now thought to be possibly linked to chronic dehydration.

Robert Harrison, MD, University of California, San Francisco, School of Medicine

Education will need to expand to meet those needs, says Sheri Weiser, MD, professor of medicine and internist at University of California, San Francisco, School of Medicines Division of HIV, Infectious Diseases and Global Medicine at Zuckerberg San Francisco General Hospital and Trauma Center. When I started medical school, there was a big push to understand the social determinants of health for example that poverty, inequality, and social discrimination are all drivers of poor health. Understanding that led to a big change in the way we were all trained as health professionals, she says.Today, Weiser believes, recognizing and applying scientific evidence on climate change as a driver of poor health is the next wave of how students need to be trained.

Despite the need, squeezing climate change health issues into an already over-stuffed medical school curriculum is challenging, says Carrie A. Redlich, MD, director of the occupational and environmental medicine program at Yale School of Medicine.

Occupational and environmental medicine generally has a tiny, tiny place in a medical school curriculum to begin with, she says. There is a struggle to get space because everybody thinks their area is what medical school students need to know about. Although climate change is extremely important, its not seen like the basic medical sciences or clinical fields such as medicine, surgery, or pediatrics.

Lisa Howley, PhD, AAMC senior director of strategic initiatives and partnerships, notes that schools need to identify where it makes sense to weave in climate-change-related information. This integration should happen within and across many types of existing curricula, she says.

Occupational and environmental medicine generally has a tiny, tiny place in a medical school curriculum to begin with. There is a struggle to get space because everybody thinks their area is what medical school students need to know about.

Carrie A. Redlich, MD, Yale School of Medicine

Such changes are worth the effort, Harrison says, since the health impacts of climate change are going to become part of many physicians day-to-day life. For one, he believes, including environmental and occupational health questions when taking a patients history can capture vital information. The social history includes things like smoking and alcohol and should also include an environmental and occupational history. It doesnt take very long, and it needs to be part of that social history, he says.

At a higher level, expanding occupational and environmental health curricula could improve physicians responses to climate change overall. We need people who understand and can interpret the scientific issues and can apply that information as credible spokespeople to impact policy, he believes.

To achieve such goals, Harrison says hed like to see the creation of a national environmental and occupational medicine scholars program that would connect interested students with advisors and mentors at other institutions. I want to create a pathway that could support students wherever they are and match them with suitable mentors.

These and other changes cant come soon enough, he believes, given the centrality of the subject. The health impacts of climate change are connected to so many clinical diagnoses and outcomes that are covered in medical school and subsequent residency training, he notes. I view education and training about climate change as the single most important poster child for occupational and environmental medical education.

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Climate change threatens firefighters and farmworkers. And that's only the beginning. - AAMCNews