7
Reflections on the Day
In the final session of the workshop, Ray Baxter, Frank Loy, and Sanne Magnan reflected on the day’s presentations and discussions. Magnan then invited other workshop participants to provide their final comments. This chapter summarizes these concluding thoughts.
REFLECTIONS OF RAY BAXTER1
For Ray Baxter, the messages that “rang out” throughout the presentations and panels were that the health effects of climate change are real, they are here now, they are neither fair nor equitable, and they can be prevented.
Regarding the real and present nature of the health effects of climate change, Baxter referred to Jonathan Patz’s discussion of the diverse and powerful set of health effects related to urban heat, extreme weather, air pollution, allergens, vector and water-borne disease, the water and food supply effects of climate change, mental health, and climate-related refugees and political instability. Although the ensuing presentations and discussions did not address every instance of any one of these effects, panelists did cover an extraordinarily diverse array of health effects related to climate change and the specific forms that these effects are taking in certain communities. These included heat in Louisville (Panel 1); extreme heat, tick-borne disease, and drinking water in Milwaukee (Panel 2); storms in New York City (NYC) and Baltimore (Panel 3); and deteriorating air quality, drought,
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1 This section summarizes closing remarks made by Raymond J. Baxter, former senior vice president, community benefit, research and health policy, Kaiser Permanente.
and groundwater pollution in California and the effects of climate change on traditional foods for native peoples (Panel 4). Additionally, Baxter noted that although fire had not been mentioned, fire and the health effects associated with it have become a regular fact of summer life in the West.
Also with respect to the reality that the health effects of climate change are here now, Baxter referred to Georges Benjamin’s “fierce urgency of now” characterization. Baxter said, “We cannot let that fall off the radar screen of the people we are trying to reach.”
In addition to the real and extant health effects of climate change, another theme that surfaced throughout the sessions, Baxter continued, is that these effects are experienced inequitably. He recalled that Benjamin, at the beginning of the workshop, pointed out the issue of ethics and morality around inequity and inequitable effects. His remarks were followed by both Patz and the Panel 1 speakers also framing climate change and its health effects as a moral issue. The Milwaukee framework (i.e., Panel 2) also explicitly embraces the issue of equity, Baxter added, as does New Hampshire’s use of the Centers for Disease Control and Prevention’s Building Resilience Against Climate Effects (BRACE) framework (Panel 3), which identifies vulnerable populations at risk as part of its way of focusing. This is also occurring in Baltimore (Panel 3), where climate resiliency work being done acknowledges how a legacy of racism and segregation still shapes inequity and vulnerability related to climate change.
As a specific example of how climate change impacts populations differently, Baxter mentioned the vulnerability of frail older adults in NYC health care institutions during Hurricane Sandy (Panel 3).
He also called out Patz’s description of global inequity—“we are the generators,” he said, yet it is the most vulnerable people living in the least developed parts of the world who bear the greatest and first effects of the health effects of climate change.
Regarding the message that the health effects of climate change can be addressed, Baxter referred to Patz’s “simple solution,” which is to reduce carbon emissions. Doing so immediately creates a healthier environment and can be done, Baxter said, “whether you believe in climate change or not.” He added that doing things that address the principal causes of ill health, for example, walking more and eating better, will also help the environment.
The politics are not impossible, Baxter continued. The Kentucky (Panel 1) and California (Panel 4) examples stood out to him as demonstrations that idealistic goals can be reached, and also in the case of Gundersen Health System (Panel 2), that the economic effects can be positive, not just theoretical. Furthermore, the examples in New Hampshire, New York, and Baltimore (Panel 3), among others, demonstrated to Baxter that it is possible to plan and prepare in a comprehensive manner.
Is Local Action Enough?
Two key questions remained for Baxter. The first pertained to local action. Specifically, is local action enough, and can it be scaled? He said that sometimes it seems as though the more locally focused people are, the more optimistic they are. In contrast, the more globally focused they are, the more negative they are.
In his opinion, Kentucky’s vision of a just transition to a low-coal or no-coal future could potentially have a big effect by serving as a model for others (Panel 1). “It could demonstrate,” he said, “a change that is, in a way, beyond belief.” He found it “powerful” that the work being done in Kentucky could have this effect even though their local actions in and of themselves will not change what Baxter called the “global facts” about climate change or its effects on health.
Similarly, Baxter suggested that both the Gundersen and Kaiser Permanente models (Panel 2 and 4) were models that drive the vision for an entire sector of the economy and if scaled, adopted, and spread could make a significant difference well beyond local actions.
Additionally, the comprehensive planning and preparedness examples in New Hampshire, Baltimore, and NYC (Panel 3) were cases that, he said, “defy our common cynicism about our ability to plan together across sectors and address such big problems.” He mentioned the NYC example of scaling up from previous hospital cooperation around bioterrorism; in Baltimore, expanding the use of data; and, in New Hampshire, the use of the BRACE framework, which specifically draws on learning from other interventions.
A conclusion Baxter drew from the workshop presentations and discussions was that a “huge gap” remains between local projects and commitments and “the kind of global change that ultimately will be needed.” He asked, what happens at the regional level? What are the roles of government and public policy now? How far can unique private projects go? “Climate doesn’t respect governmental boundaries,” he said, “whether they are local or state or national. So what does that require of us in the approach going forward?”
The Balance Between Prevention and Adaptation
Baxter’s second question was: what is the balance between focusing on prevention and mitigation versus focusing on adaptation and resilience? How should this work be prioritized? He found the Louisville example interesting (Panel 1) because of its comprehensive urban heat program that includes not just reforestation, but also addresses carbon reduction and heat generation. He observed that some of this balance seems to depend on
whether one is a major generator or extractor. Major generators and extractors potentially have, he said, “very big levers to pull” that can have big effects on prevention. Entities with few levers to pull or with few resources, in contrast, are “almost forced into the resilience and response mode.” But again, he asked, is it enough to leave these effects to chance?
Elected officials in particular cannot afford to be second guessed, he continued. NYC has no choice but to prepare for “the next” Irene or Sandy and therefore must focus on resilience (Panel 3). But, he asked, what is its role in generating and contributing to the problem (i.e., the next Irene or Sandy)? He observed that there had been little discussion about the extensive programs aimed at reducing vehicular traffic and increasing mass transit. Yet, in his opinion, those types of programs are probably part of the total and balanced effort that is required.
Again, he cited New Hampshire (Panel 3), this time as an interesting example of a blend of local, topical approaches spread across the state and the use of a comprehensive framework (i.e., the BRACE approach). Baltimore too (Panel 3) has adopted an interesting approach by blending all-hazard mitigation planning with specific climate change planning and using an explicit equity lens, he said, “for all of it.” Activities in Milwaukee (Panel 2) and New Hampshire (Panel 3) have elements of this, too. Finally, Kaiser Permanente (Panel 4) uses what Baxter described as a “burden of harm measuring stick” for its prioritization of environmental activities.
Baxter commented on the perception of a shifting locus of responsibility and action for climate (e.g., to local government or to individual communities or private actors). He argued that while it certainly may be the case that local actors are best suited to effective action, especially around resilience, he counted only three workshop speakers who talked about how the emissions and practices of their own institutions contribute to the problem and what their institutions intended to do about it. “We cannot leave ourselves only on one side of the problem,” he said. California, he pointed out, is “an outstanding example” of what can be achieved when communities, innovators, businesses, and government policy are aligned around the problem, around the evidence, and around the solutions (Panel 4). But moving away from California and looking broadly across the United States, he asked whether local projects and plans will add up to the regional and global change that is needed to address the fundamental drivers of adverse climate change. Or, he asked, “Will those individual actors and communities and organizations and jurisdictions default almost entirely to disaster preparedness in a narrow, somewhat self-serving kind of resilience planning that is, by force, almost totally defensive and may tend to be largely reserved for the privileged and the advantaged, while the planet at its larger level continues to deteriorate?” The challenge of resilience planning versus
mitigation will continue to persist. “Neither one of these is a reasonable choice,” he concluded.
REFLECTIONS OF FRANK LOY2
Loy agreed with Baxter that although some things were established over the course of the day-long workshop, others were left open. “We have established the seriousness of the problem,” Loy began. He referred to Patz’s presentation, as well as Benjamin’s opening comments, as being particularly helpful in addressing what can be done at both the local and national levels. He questioned, however, why, given what he described as “the overwhelming evidence of the problem and the very thoughtful approaches that we heard,” it is so hard to address this problem at the scale it deserves. The answer, in Loy’s opinion, is threefold.
First, the problem appears to many people to be in the future. In some places, he said, “you can actually feel it and sense it, in terms of wild fires and water problem[s].” But often, he observed, “you can’t, so it looks like something ‘out there’.”
Second, some people feel that, he said, “it is not really true.” This is a serious issue that is exploited by those who benefit from it and who provide, Loy said, “ammunition for that thought.” A third factor that “hurts our ability to address this problem,” Loy continued, is a sense of hopelessness. The feeling that there is little that can be done about something that is happening now and all over the globe is, he said, a “terrible problem for those of us who are trying to address it.”
In addition, Loy stressed the importance of acknowledging that those who care about the problem have made mistakes in the past. For example, as alluded to earlier in the workshop (Panel 1), while, in his opinion, it was right to get rid of coal as a fuel, the problem for those who were going to bear the brunt of the change was not adequately addressed.
Loy also agreed with Lisa Abbott (Panel 1) and other speakers who had stressed the need for process. “You can’t just get to where you want to go by being right,” he said. “You have to have a process that involves the people.” He asserted that experts in the environmental community, and sometimes the health community, are “not as good as we ought to be at really believing in that process and really working that process.”
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2 This section summarizes closing remarks made by Frank Loy, chair, Roundtable on Environmental Health Sciences, Research, and Medicine and U.S. Representative to the 66th Session of the General Assembly of the United Nations.
Where the Health Community Fits
When people not deeply familiar with the science of climate change want to get a sense of what “really is true and what is baloney,” Loy said, they may not be able to seek out scientists for answers, but are likely to turn to trusted leaders from other walks of life who have nothing to do with climate change, he said. These include leaders in the faith community, leaders in the higher education community, and leaders in the health community. Doctors and nurses, Loy said, are respected figures in every community, including communities that have few other respected figures. This is why it is so worthwhile, in his opinion, for the health community to pay attention to this problem. Through their efforts, he said, “one can build the kind of base of support that is needed for action.”
Loy mentioned being part of an organization that has analyzed attitudes about climate change among the U.S. population and has found correlations with sex (with women more likely to acknowledge climate change), level of income, and geography. But the most predictive correlation they have found thus far is with party affiliation. The only kind of individual who might be able to impact this correlation, Loy remarked, is not someone who, by reason of their profession, is on one side or the other. Rather, it is someone, he said, who has a “totally different point of entry,” such as someone from the health community.
Loy concluded, “From all aspects that I can see, what we are talking about is a public health problem of absolutely first order. This society of public health professionals is the one that can address it most effectively and help us out of this dilemma.”
DISCUSSION
Following Loy’s remarks, moderator Magnan opened the workshop to anyone who wanted to further reflect on the day’s presentations and discussions. George Isham began the discussion by referring to Loy’s remarks, as well as other speakers’ remarks, around the idea that health will be the “savior” or the winning rationale for addressing environmental challenges. He remarked on the interesting contrast with the way the Roundtable on Population Health Improvement usually thinks about rationales, about ways to identify persuasive rationales to mobilize more effective action in other sectors in response to some of the issues that are being seen in health care and public health.
In addition, Isham reflected on dialogue around climate change. Specifically, in his opinion, dialogue that occurs at the level of party politics typically is not very constructive from either point of view. Yet, when dialogue occurs at a technical, scientific level, it doesn’t resonate broadly beyond the
technical field of expertise from which it arises. To improve this dialogue, he suggested, first, one should think about the logic model, or framework, in which various climate change factors interact and not be limited by thinking that the outcome is either only health or only the environment. Second, he suggested more communication in “that middle field” between politics and scientific expertise that begins to lay these issues out in broad, more publicly understandable forms that communicate both to the general public and across “technical silos.”
Finally, Isham said he had been encouraged and energized by the examples presented at this workshop and hoped that “we have the wisdom” to begin building bridges of communication, not just between the health and environmental sectors, but beyond.
Marthe Gold of The New York Academy of Medicine wondered aloud why climate change has become political and even partisan. She suggested that one reason the messages about the threats of climate change may not be resonating may simply be political affiliation and, she said, “being a good team member.” But another reason why the message is not resonating, Gold continued, may be that what is needed is a stronger and more personal way to influence the political discourse. She agreed with Baxter that this is not going to work “simply on a local level.”
As far as how to influence politicians and the public, Gold recalled Benjamin’s suggestion early in the workshop that the way to motivate people is to provide them with a positive view of what life would be like if the climate were better. In her opinion, that suggestion is optimistic. She explained how prospect theory has taught that, in fact, people respond more strongly to things that they might lose than to things they might gain. Thus, “the sky is falling” may be a better approach. But these different approaches need to be tested, she said. A difficulty with climate is that there is a “great swath of the public” that has not experienced the type of serious climate-related environmental problems, such as flooding or fire, that people living, for example, on the east or west coasts or in low-lying countrysides have experienced. Even though people tend to respond more strongly to things that are going to happen immediately, with climate, they tend to delay. The question then becomes, how can the problem be framed to bring more immediacy? She has always been a proponent of what the media and entertainment industry can contribute and wondered whether there might be approaches in that arena that need to be considered.
Finally, reflecting on Loy’s remarks on the role of health professionals, as well as Benjamin’s remarks earlier in the workshop, Gold wondered whether there is a way for health care providers to not only inculcate the notion of what people can do individually to promote their health through exercise, diet, and so on, but also talk to their patients about their roles as citizens. She concluded, “We seem to, in this day and age, be less activated
as citizens. I wonder what people think and whether the Roundtable might consider whether the health professions have something to say about people being good citizens.”
Regarding Loy’s remarks on the correlation between attitude toward climate change and party affiliation, Matt Cahillane mentioned a study conducted in New Hampshire showing that, among independents, when asked if they “believed” in anthropogenic climate change, the response depended on the previous day’s temperature (Hamilton and Stampone, 2013). On days when the temperature had been similar to the day before, respondents were more likely to respond that they did not believe in human-caused climate change. In contrast, on days when the temperature the day before had been either warmer or cooler, they were, he said, “straight up there with the Democrats in believing in it.” For him, these results highlight the short memories and malleability of Americans. He suggested, “maybe we will have the chance with some of those independents.”
Gary Gunderson of Stakeholder Health and Wake Forest Baptist Medical Center commented that before this workshop started, he had been anticipating “the most depressing thing ever,” but now was “feeling convicted” as a grandfather, as a person of faith, and as a health professional. Although proud of being part of a group of driven, mission-oriented health care systems, he said, “our faith partners have not raised this with any of the clarity that we heard numerous times today.” The “prophetic witness” for this, he said, is coming from Kaiser Permanente, which is not a faith-based system, but obviously has a deep moral drive.
Maureen Litchveld offered four key reflections. First, while she considered this to be an enormously successful meeting, she wondered whether it would help the communication process to juxtapose the successes with the failures. While this workshop featured success stories, she suspected that there must be case studies of failures as well. Second, while the local examples presented at this workshop provided good, illustrative ways to characterize assets, she was unsure whether the same characterization of assets has happened at the national level. Third, when considering risk communication and the principles around risk communication, while there was much discussion around who would be good messengers, she stressed the importance of also looking at culture, not just from an ethnic perspective, but also from a community perspective (e.g., community of scientists, community of health professionals, community of policy makers, community of farmers). Working across cultures would be helpful, she remarked. Finally, she offered what she called a “global sense of hope.” She mentioned that she would be co-chairing, at end of the April 2017, an expert panel that would be creating a Caribbean-wide roadmap to climate change. Those countries, she said, are taking on the responsibility to act.
In closing, Magnan said that she, too, felt encouraged by the day. When
thinking about climate-related disasters and their increasing frequency, she found it compelling to think about an asset-based approach on advancing a health agenda, as opposed to a deficit-based approach. In addition, she felt encouraged by the discussion around communication and the importance of entering conversations not by leading with the issue, in this case, climate change, and perhaps not even with health, but rather with what matters to the constituent. She stressed the importance of asking, “What do you value?” Then, “What do I value? Where is the Venn diagram? Can’t we do both?” This communication principle is something, she said, “we are learning over and over again.” In her opinion, the adage, “check your agenda at the door,” which Halida Hatic had stressed during her presentation (Panel 1), is particularly pertinent to this issue today.
Finally, Magnan echoed the message of hope that Baxter and Loy had expressed. Paraphrasing Jim Collins (Collins, 2001), she said, “Face [the] brutal facts, but never lose hope.”
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