The Earth Has A Fever

A Doctor’s Perspective On Climate Change — Dr. Santosh Pandipati, MD, FACOG

As my family and I nervously await the U.S. election results and I consider how so much of our species’ global future hangs in the balance on this one historic election, I recall presenting a grand rounds lecture seventeen years ago at the University of Washington Medical Center. I was a third-year ob/gyn resident; my talk was entitled “Challenges to the Survival of the Human Species.” I focused on climate change and overpopulation; many attended the talk, which was well-received. I reprised the talk two years later as a maternal-fetal medicine fellow at the University of Colorado Health Sciences Center. Although the environmental concerns that I presented were disturbing, no one, including myself, had felt that the threat would become so grave so quickly, and certainly not within our very lifetimes. Indeed, at the time I had felt that perhaps the title of my talk might even have been too dramatic. Upon finishing my training I busied myself with major milestones of life that preoccupy many of us: marriage, building a family, developing my career. Primarily due to insufficient time I had largely put my environmental concerns aside, although I still paid peripheral attention to the latest developments in climate science. My concerns about climate change have resurfaced over the past several years, in part due to the visible activism of Greta Thunberg, 350.org, the Sunrise Movement, and a new generation of activists and politicians who have finally begun to engage with this matter in earnest. The recent wildfires that surrounded my home town in Northern California a few months ago poured accelerant onto my existential dread.

Recently, I delivered a mother at 24 weeks gestation via classical C-section for preterm labor, ruptured membranes, and beech fetal lie — bread and butter for a practicing maternal-fetal medicine physician. I knew our superb neonatal team would do their very best to reduce morbidity and mortality risk for the neonate, and if lucky, the baby would be discharged from the NICU many months hence, ideally with minimal longterm physical and neurologic sequelae. I thought of the enormous cost and efforts of a whole host of clinical workers, from physicians to nurses to all kinds of therapists to countless others who would be invested into ensuring that a single human being would be given the best chance to survive with a decent quality of life. As with all such cases that would of course not be the end of care for that baby, but just the start, and with success, the child would eventually become an independent and self-sufficient human being. This whole future vision rolled out in my mind as I was delivering her, and I pondered the thousands of times every year a similar story would be repeated in the United States alone. I wondered about the world that child would grow up in, and whether that world would truly be able to sustain her, much less my own children. I was struck by the hypocrisy of all the arduous efforts we make in safeguarding the most premature of human beings while we as a global civilization existentially jeopardize the wellbeing of all future generations from our use of fossil fuels.

Carl Sagan’s Legacy

Among my fondest memories of childhood are watching episodes of Carl Sagan’s Cosmos in 1980 with my father. We had emigrated from India and moved to California the year prior, and we were quickly discovering the joys of First World living. We watched the show on a small black and white television set that my parents were proud to have purchased with their very first hard-earned American dollars, firmly placing us technologically ahead of all of our family members back in India. Though I was just 5 years old and far too young to truly grasp the factual basis of the series, its emotional tone struck deep chords in my psyche that resonate to this day. Sagan’s legacy for me is that human beings’ conscious lives are a precious, fragile, and integral part of the universe we live within; science has a place in fostering this profoundly meaningful sentimentality by revealing the connections between processes large and small that bind us to each other and to our planetary refuge in a vast, lonely, and unrelenting totality.

My discovery many years hence that Sagan was a somewhat controversial figure shocked me. Sagan’s critics claimed he had compromised his scientific objectivity by tangling himself in the morass of international politics surrounding nuclear proliferation, and lost his way in passionately seeking evidence for alien life — allegedly improper etiquette for a man of science. Rather, they berated, that dispassion, coolheadedness, and objectivity ought to be the aspirational ideals of proper scientists. To me this criticism was utter rubbish, for what was the point of advancing radio astronomy simply to publish papers in journals read only by hundreds or perhaps at most thousands while ignoring the more profound implications of where the science led? Sagan ingrained in me the value of making connections between science, technological advancement, personal meaning, and existential risks to humanity. Sagan was, and remains, a hero of epic stature.

Unbeknownst to Sagan and most everyone except, it now seems, the actual fossil fuel-producing companies themselves, humanity’s survival stands on a climatic brink exponentially more daunting than nuclear winter. What was once insidious in onset 250 years ago has now reached an eruptive and nearly unstoppable momentum. I have come to realize that limiting my career focus to maternal-fetal medicine would miss a major opportunity to influence a much bigger sphere of humanity. Our fundamental mission as healthcare providers is to protect the health of our patients, and it is well past time for the women’s healthcare community to recognize that global climate change is the greatest emerging threat to women’s health, and indeed to the health of all people. The sequelae of climate change are set to produce a worldwide public health disaster, the impact of which will be far-reaching and devastating, dwarfing all of our current public health concerns.

Climate Truths

While I am no climate scientist nor public health expert, the key points are quite simple. The Earth is unequivocally warming due to rising levels of atmospheric greenhouse gases (GHG) from human activities (1,2). The primary culprit is carbon dioxide (CO2), the rise of which is unprecedented during the entire period of human evolution (3–6). Carbon dioxide concentrations were last at their current levels 15–20 million years ago, when average temperature and sea level were respectively ~3–6°C and 25–40 meters higher than they are today (7). Alarmingly, there has been an acceleration in GHG emissions since the first UN Intergovernmental Panel on Climate Change (IPCC) report published in 1990, with more than half of all historical CO2 emissions having been released in the past 30 years. Matching this trend, the warmest years on record have occurred since 1970, with ten having occurred since 1998, and the four warmest years being 2015, 2016, 2017, and 2018 (8–10). With unabated “business-as-usual” human activity, current projections by the IPCC portend that by 2100 CO2 concentrations will reach levels nearly two and a half times higher than 2019 levels, resulting in average surface temperature increase by more than 3–4°C. The ongoing as well as anticipated impacts of climate change include: sea level rise; ocean acidification; more intense droughts, flooding, and storms; more frequent hot and fewer cold extremes, resulting in increased frequency and intensity of heatwaves; and more wildfires as well as extreme weather events (1,2,11). The magnitude of these effects will ultimately depend on what steady-state level of GHGs are achieved, and thus, what average temperature eventually results. However, it will take thousands of years to achieve equilibrium, and there will be no “new normal” with regards to climate within the lifetimes of any human beings who are currently alive, nor will there likely be for tens to hundreds of generations.

Impacts on Human Health

All of these altered environmental conditions pose dire threats to the habitability of the planet, and the survivability of life as we know it. Indeed, the negative impact on Earth’s flora and fauna from climate change is already underway. It is estimated that up to 1 million species of plant and animal species are now facing the risk of extinction this century, and the current rate of extinction is already tens to hundreds of times higher than that seen over the past 10 million years (12). Besides this current mass extinction, there have been five other major mass extinctions in the history of life on Earth. Alarmingly, four of these five mass extinctions have now been linked to the emissions of greenhouse gases from geophysical processes (13,14). There is nothing in the record of life on Earth to reassure us that humanity has any protected or sacred place in the evolutionary tree; our species will be vulnerable to climate change just as countless millions of other species have been and will be in the future.

Anticipated adverse impacts due to climate change specific to human health are wide-ranging, and include increased exposures to extreme weather events, including wildfires, droughts, flooding, and extremes of temperature; altered food-, water-, and vector-borne infectious disease; reduced food, water and air quality; decreased food security; and most alarmingly, mass migration of billions of people due to political, economic, and resource instability leading to loss of access to healthcare resources and further exacerbating the collapse of public infrastructure (1,2,11,14–17). Some of the effects on morbidity and mortality include (15,16):

• direct effects, including death from heat, heat stress, and heat stroke
• direct injuries, loss of life, and depression and anxiety from extreme weather events
• poor air quality leading to respiratory complications (such as asthma, allergies) as well as cardiovascular disease
• poor water quality and lack of access to clean water leading to increased diarrheal diseases such as cholera
• food insecurity from rising levels of CO2 leading to decreased levels of protein, micronutrients, and B vitamins (and hence, nutritional quality) of rice, wheat, and other crops, as well as reduced yields of vegetables and legumes, in turn leading to undernutrition, stunted childhood growth, and vulnerability to non-communicable diseases
• geographic spread of mosquitoes and other vectors that can disseminate diseases such as malaria, dengue, yellow fever, Zika virus, etc.
• repercussions from climate-induced migration, including adverse mental health outcomes, lack of access to reliable healthcare, food and water, and violence

Impacts on Vulnerable Populations: Women’s Health

The populations who will feel the initial brunt of climate change will be the most societally disadvantaged, such as children and the elderly, as well as various minority groups. These populations are invariably poor and are already living in environmentally marginal circumstances (18). Among such populations, women have been recognized as a uniquely vulnerable group, since in many parts of the world they lack adequate access to family planning services, educational resources, and sufficient income (19–21). Additionally, given the differing roles men and women play in most societies, as well as women’s unique reproductive burden, climate change impacts are expected to have a differential impact on women versus men (19–21). In many cases, adverse impacts are likely to be worse for women than men by widening health disparities that already exist in many parts of the world. Examples of adverse health effects to be felt disproportionately by women include (19–24):

• respiratory and cardiovascular disease from greater exposure to poor-quality air, especially due to particulate air pollution from both indoor sources (e.g., cooking and heating sources), as well as from outdoor environmental sources
• anemia and malnutrition from food insecurity and increased nutritional needs due to childbearing and menstruation
• pregnancy-related complications (e.g., intrauterine growth restriction, preterm birth, congenital anomalies, stillbirth)
• lack of access to prenatal care, contraception, and family planning options
• physical and sexual violence, as well as anxiety, depression, and other mood disorders related to climate-induced migration and environmental disasters

Women mediate the interplay between population growth and climate change through their reproductive behaviors, which is where our role as women’s health providers becomes crucial. If contraception was more readily available in both developed and developing regions, CO2 emissions could be reduced by 30% by 2100 while simultaneously eliminating more than 100,000 maternal deaths per year, resulting in significant benefits for regions of the world with high fertility rates, as well as those with high levels of vulnerability to climate change such as Sub-Saharan Africa and South Asia (2,25–29). Of course, meeting unmet contraceptive demand will result in a greater reduction in per capita emissions from developed nations than in developing nations. However, reducing fertility rates in developing nations would prevent the birth of millions of people who would inevitably become victims of the worst ravages of climate change, but also significant contributors to future GHG emissions due to increasing adoption of high GHG-emitting consumption lifestyles akin to those seen in developed nations (2,18,25).

Women’s traditional role as family caregivers in many parts of the world places them in unique decision-making roles that can impact climate for better or worse repeatedly throughout the day, including in the use of appliances (e.g., for lighting, cooking, heating or cooling, heating water, laundry, etc., including time and frequency of use), purchases of household goods, establishment of family dietary habits and patterns (e.g., frequency and amount of consumption of meat, dairy, and vegetables), and the education and shaping of their children’s energy consumption habits (20). The modern food production industry has significantly contributed to environmental degradation, climate change, and health crises due to insufficient food consumption in over 800 million people worldwide while also resulting in an epidemic of obesity, cancer, diabetes, cardiovascular disease, and other ailments in millions more worldwide (30). Aligning the food industry and people’s food-eating habits to plant-dominant diets simultaneously promotes health, sustainability, and climate change mitigation.

The Crucial Role of Healthcare Providers

Consideration of the interconnections between climate, population groups, and health is not in our usual mindset as healthcare providers, as we have historically focused on cultivating one-on-one relationships with our patients. However, we can no longer ignore climate change as it threatens to undo all of our diligently-acquired gains in reducing women’s morbidity and mortality related to pregnancy, infectious diseases, and chronic medical illnesses.

Core principles of provider engagement must include assertive political advocacy, provision of contraception and family planning methods, and nutrition and lifestyle counseling. Providers must advocate for political and social environments where women are free to limit the number of children they have, to pursue higher education and employment equally compensated to men, to participate in political leadership, and are free of societal and economic constraints so as to enable them to make healthy nutritional and lifestyle choices for themselves and their families. Providers, medical societies, and scientific institutions must combat corrosive political interests that seek to undermine scientific discovery and education, as well as politicians who sabotage the sacrosanct relationship between provider and patient.

As healthcare providers, we stand at a unique vantage point that overlooks the intersection of our patients’ health with environmental science, energy use, agriculture, land use, and public policy. Amazingly, advocating for interventions we have always emphasized — women’s empowerment over their own reproductive health, better diets and lifestyles to reduce risk for chronic medical illnesses such as cardiovascular disease, diabetes, and cancer, and reducing pregnancy-related complications to mother and fetus — brilliantly dovetails with the fight against climate change. Thus far we have failed to have a macroscopic vision of this reality. We have failed to actualize the power we and our patients collectively possess to influence the narrative. But it does not need to remain this way. By educating women about the impact of their daily decisions, advocating for equal pay and career opportunities and thereby providing the means for self-reliance and resiliency, empowering them with contraception, and elevating their leadership roles within families and communities, women can become powerful agents in the mitigation of, and adaptation to, climate change (19–21,31).

1.5°C: Our Time is Limited

We will have to limit temperature increase to 1.5°C by 2100 to avoid the worst outcomes. We can only emit 340 gigatons (Gt) of CO2 before we exceed our 1.5°C budget, which amounts to only 8–10 years of current emissions (32, 33). Currently global civilization is on a “business-as-usual” pathway, and we may have already crossed critical climate tipping points; it may be too late to prevent portions of the Earth from becoming uninhabitable by 2100. Amazingly, simply meeting the unmet demand for contraception, providing universal access to 12 years of education for all girls and women, and modifying our diets, have been estimated to collectively reduce global CO2 emissions by 180 Gt by 2050 (34) — enough reductions to “flatten the curve” of global warming and to buy us invaluable time to devise more definitive technological solutions. These interventions are well within the purview of women’s healthcare providers.

The adverse health outcomes previously listed are not fixed in stone — they represent an initial phase of adversity to the human species, but this adversity will quickly become an existential threat as temperatures rise and tipping points are reached. In the past few years it has become apparent that rising heat will lead to increased rates of fetal congenital anomalies such as heart defects (35), and fetuses exposed in utero to natural disasters such as Hurricane Sandy and Hurricane Katrina have altered neurodevelopmental outcomes and higher central adiposity, let alone their mothers having higher rates of anxiety, depression, and PTSD (36–38). It is clear that the climate crisis is already leading to a continuum of adverse health effects that will ripple across future generations of humanity with unpredictable effects (39). If we know all this already, what then will happen to human health as GHG and particulate emissions continue, warming continues, oceans rise, storms intensify, food and water become scarce, and people migrate leading to unprecedented economic and political calamities? Greta Thunberg famously stated that “our house is on fire.” From a physician’s point of view, it is more akin to the Earth having a fever. And what happens to a human body with a 1°C rise? And what happens if our temperature keeps going up? Our civilization, our agriculture, our species never evolved under the climactic conditions we will face in the coming century and beyond. It is far past time to ask if this uncontrolled experiment is one we truly want to conduct. Is there not enough “interim-analysis” data to abort this experiment now? And for the critics who still willfully choose to disbelieve it is imperative to emphasize that the solutions proposed will actually lead to a better world than before. Fighting climate change is not, and does not have to be, a zero-sum game.

Where Do We Go From Here?

Carl Sagan wisely surmised that we alone in the vastness of the universe are aware of our own physical limitations in space and our mortal limitations in time. Despite these constraints we somehow possess an unmatched and remarkable capacity for insight that can allow us to transcend these very spatial and temporal boundaries. If only for this reason the persistence of our individual and collective human consciousness has the utmost meaning and importance. Indeed, this provides a more than sufficient reason to fight for the survival of our species — including that of a 24-week premature infant. Millions of daily interactions between women and their care providers results in a potent force that can be conscripted into a global fight against climate change. Healthcare providers have an opportunity, as well as an ethical obligation, to be a part of the solution. Climate change-mediated effects may pose far greater dangers to the well-being of all humans than any traditional ailments or public health threats that we have historically targeted for intervention. Exactly what we do as a species, how we do it, and how quickly we do it will be the key determinants of humanity’s survival in the face of what has become no less than an existential crisis. Our individual time is limited and precious, and now it seems, perhaps so too that of our species. Let us collectively get to work fixing the problems that threaten to destroy not only human health, but our global civilization as well.

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