Medical education in the era of climate change

In the days after Hurricane Maria made landfall on Puerto Rico, four Yale physicians began an ambitious effort to send thousands of pounds of medical supplies to the storm-ravaged island. Despite having had no prior experience with disaster response, these doctors worked with contacts in Puerto Rico to generate a detailed needs-assessment, determining exactly which medical supplies were needed on the island. Using social media, traditional media, and professional connections, they solicited large-scale donations of medications and supplies, coordinated airplanes to the island, and remotely managed ground transport of specific supplies to the sites where they were needed. Their efforts were noticed by medical centers in over twenty states, who drew from this organizational model to initiate their own grassroots humanitarian efforts across the nation.

Two of the central figures in these efforts, Dr. Marietta Vázquez and Dr. David de Angel Sola, described the steep learning curve that they had to overcome as they figured out in real-time how to organize a disaster response. The success of their relief effort was largely the result of resourcefulness, passion, and weeks of 20-hour workdays, but their achievements are not typical. Without formal training in disaster response practices, physicians may struggle to provide the best possible care in the low-resource settings following major incidents.

“Most of the physicians who showed up initially when there wasn’t a plan were unable to help. Their trips in many ways were pointless,” said Dr. de Angel Sola. Many physicians eager to provide support after major incidents are stymied by lack of knowledge or experience, while others are constrained by legal uncertainty about providing post-disaster care.

In medical school, we’re taught the indications for a dialysis regimen, the reasons to order a CT scan, and the signs that a deteriorating patient should be transferred to intensive care. But as physicians-in-training, we are rarely taught how to respond to disaster situations, nor how to be effective doctors when the sophisticated infrastructure that we’ve learned to depend upon is unavailable. Instead, we learn to hope that situations like those experienced at hospitals in San Juan don’t occur in our backyards.

“I don’t think we were prepared at all,” said Dr. de Angel Sola. “We had never received this type of disaster training because nobody had envisioned that something at this level would happen,” “We were fish out of water,” added Dr. Vázquez. “I would have benefited tremendously from knowing about basic disaster response skills.”

In the past, it may have seemed superfluous to add such skills as low-resource medicine, triage, and disaster response to an already bulging medical curriculum. Yet as the climate changes and extreme weather events occur more frequently, these skills may become an essential piece in the toolkit of conscientious physicians. Beyond the direct effects of extreme weather events lie the less obvious health impacts of climate change. From the emergence of novel patterns of infectious diseases such as cholera, Zika, and Chikungunya, to increased rates of cardiovascular and respiratory disease, health care providers face a redrawn epidemiological map. Challenges like heat-related illness, malnutrition, conflict over limited resources, strains on mental health, poor sanitation, and population displacement are all exacerbated in the wake of a major disaster, and all are faced disproportionately by marginalized populations, the politically and socially oppressed, and the medically frail.

This past hurricane season — when simultaneous disasters in Houston, Florida, Puerto Rico, and the Virgin Islands stretched the capacities of NGO and government responses alike — demonstrated that there may come a time when local groups must respond to disasters in the absence of federal aid. That time has already come for the people of Puerto Rico.

After responding so admirably to a major disaster, Dr. de Angel Sola and Dr. Vázquez now agree that curricular focus on disaster preparedness “should be a high priority … not just at the medical school level, but in residency as well.” “This absolutely needs to be a part of medical education,” said Dr. Vázquez.

The American Medical Association (AMA) policy addresses an “obligation to provide urgent medical care during disasters” and emphasizes that this obligation “holds even in the face of greater than usual risks to their own safety, health or life.” Despite this, the Liaison Committee for Medical Education (LCME), the body that oversees medical school curricula, does not specifically require students to learn the skills necessary to provide high-quality medical care during disasters, or to organize disaster responses from afar. Thus, it is left to the initiative of students and young physicians to seek out training in disaster response and preparedness; however, given the substantial time demands on these learners, such extracurricular training is rarely pursued.

Given the emerging threats posed by climate change, all US medical schools should include coursework on providing health care in resource-limited settings as well as essential skills such as disaster preparedness, triage, and the organization of grassroots disaster responses that don’t rely on NGO or governmental aid. In addition, multidisciplinary courses on environmental justice will be necessary to explore the ways in which climate change will disproportionately affect the most vulnerable of our patients. Being stewards of health in the 21st century will require an understanding of these subjects traditionally considered outside the purview of medicine. Developing mandatory, standardized training for disaster preparedness and response with accreditation may also alleviate medico-legal issues that currently limit ad-hoc physician involvement in disaster response.

During this past hurricane season, we confronted yet again the fact that climate change is increasingly leading to medical problems, and that the medical establishment may be under-prepared for this new reality. “This process was very humbling because we wanted to do so much more than we did, and we couldn’t. We just couldn’t,” said Dr. Vázquez. “It was so clear that this needed to be used as an example, since others were struggling to help just as we had.” If we future physicians are to truly protect the well-being of patients, distribute care equitably to those most in need, and minimize the health impacts of climate change, let medical school curricula reflect our changing roles as physicians caring for a changing world.

Tyler Greenway and William Hancock-Cerutti are medical students.

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