Climate change, cardiac arrest, and the price of inaction [PODCAST]

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“We have to start understanding these as the real costs of climate change. We are paying these costs now. In my state of Oregon, people are going to start getting sick and dying in the next few days of the wildfire smoke choking the air. When they show up to the hospital with a severe heart attack, or stroke, or respiratory exacerbation, maybe it will be attributed to the wildfires, but probably everyone will just be focusing on getting through their shift, and the context of this one death, this one illness, will be missed. But make no mistake, the coming wave of hospitalizations, ER visits, and deaths is not random; it is due to climate change.”

Erika Maria Moseson is a practicing, board-certified pulmonary and critical care physician.

She shares her story and discusses her KevinMD article, “Apocalypse now: climate change, cardiac arrest, and the price of inaction.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Erika Moseson. She is a pulmonary and critical care physician, and she’s the founder of Air Health Our Health, an educational website on the importance of healthy air and a stable climate. She wrote the KevinMD article “Apocalypse now: climate change, cardiac arrest, and the price of inaction.” Erika, welcome to the show.

Erika Maria Moseson: Thank you so much for having me.

Kevin Pho: So we’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Erika Maria Moseson: Absolutely. I’m a pulmonary and critical care medicine doctor, which means I split my time between the ICU, taking care of patients on life support and ventilators, which is obviously huge right now with the COVID-19 pandemic and is a large part of my life, and I also see patients in the clinic who are suffering from lung diseases, everything from asthma to occupational exposures. I love it. One of the things I love about my job is that I get to be in the clinic and be someone’s doctor for a lifetime, and then I also get to be in the ICU and do all the really exciting things in medicine: having patients who need emergency procedures and life support, and really trying to rescue people when they get very, very sick. I find that whole spectrum very satisfying.

But one thing I started to really notice, the more I did this, is how many of these patients who were critically ill were there because of air quality, really. Most dramatically, I think we’re familiar with smoking, right? If you’re smoking and sucking cigarettes into your lungs, that has a lot of toxins in it, and in particular particulate matter, PM2.5, which I focus on a lot. That can make people very sick over their lifetime, and acutely, it can set their kids up for lifetime diseases. But a lot of other things, from occupational exposures to just the chronic burden of diesel exhaust and air pollution that’s in all of our communities, actually make a lot of people sick, and that’s almost invisible to us.

So one of the things I did when I started Air Health Our Health was just trying to make the invisible visible. The air is kind of invisible most of the time, except in cases of severe wildfires, but it actually really determines a lot of our health. I think sometimes people think, “Oh, that heart attack in the nonsmoker came out of nowhere,” or “That stroke came out of nowhere,” and it really doesn’t come out of nowhere. A lot of the time, it comes from the chronic toll of unhealthy air.

So I just wanted to start a website, and then the podcast, actually, where I interviewed different scientists who looked into this, on everything from the changing pollen burden in our air, to the changing diesel in our cities, to what it means to live under an airport, to what vaping does to the lungs, including wildfire smoke. So I view it as part of my mission to avoid having people need to meet me professionally, by cleaning up the air they breathe.

Kevin Pho: All right, so let’s transition into your KevinMD article, which I’m sure is going to talk more about this issue, “Apocalypse now: climate change, cardiac arrest, and the price of inaction.” For those who haven’t read that article, can you just walk my audience through it and share why you decided to write it?

Erika Maria Moseson: Yeah, absolutely. Out here on the West Coast of the United States, I think essentially our entire coast was on fire at the end of the summer and in the early fall. The satellite images from space were heart-stopping. You just saw fire up and down the coast, and we were just pouring smoke into the air. Everyone was looking at the AirNow quality indicators, where many of us were, which were showing air quality beyond the hazard index.

One of the things I focused on a lot is one particular element of smoke, which is PM2.5, a form of particulate matter that’s so small. Particulate matter is sized based on microns, so 10 is 10 microns, and PM2.5 is anything less than 2.5. The visible smoke is, I think, easier for us to see, but it’s these smaller particles that are actually really, really deadly, because they get all the way into our lungs and out into our bloodstream and circulate all over our body, causing disease. They actually cause massive inflammatory changes in the blood vessels. Chronically, they can lead to atherosclerosis, but we know from studies with traffic that spikes in this PM2.5 can actually cause heart attacks and strokes in the short term. So when you get this massive bolus of all this smoke, it only makes sense that you would actually have acute effects, right? Wildland firefighters actually are often more at risk of having a heart attack.

One of the studies I focused on, just as a more dramatic example of this, is on sudden cardiac death, which is literally just dropping dead, probably from an arrhythmia or a sudden plaque rupture event, and that goes up after exposure to wildfire smoke. They looked at this in California after some of their wildfires several years ago, and I’ve also looked into this in other arenas.

On this article, I just remember sitting there, as a pulmonary critical care doctor, in my house, for which, having a lot of privilege, I had purchased a very nice whole-house air filtration system, and thinking about my three kids, and realizing that one of the main drivers of these completely catastrophic wildfires is the fact that our climate is changing. It’s getting warmer, things are drier, and we have these forests that are filled with fuel for a whole variety of historical reasons. And thinking of myself as both a mom and an ICU doctor, and someone who has done science and understands the science on climate change to some degree, that this is built in, at least for the next 30 to 40 years, and just wondering, when are we going to do something? When are we, as physicians and scientists and a community, going to decide that having massive waves of our own populations getting sick and dying from the smoke from these events? People can be sick for years following some of these smoke events. And thinking about the massive burden on the health care system, so not even just the acute death and the cost of fire being destructive, but actually the health toll that it’s going to take, which is potentially only going to increase.

I think a lot of the time we don’t think about the cost of inaction. We just think, “Oh, well, fixing climate change is going to mean we need to buy different trucks, and we’re going to have to put in electric charging stations, and that costs money, and I don’t have money.” But if we don’t pay attention to how much we are spending by not taking action, and the devastation that’s causing economically. There are entire parts of our country that rely on tourism that were essentially shut down for a month because of the smoke and the fires. So there is a huge economic cost, even if you’re not worried about the lives, which, of course, we all are. But just thinking about the cost of doing nothing on climate change, it has been too high for a long time, and it’s becoming impossibly high.

Kevin Pho: So you talk about these small, 2.5-micron particles that can arise from smoke. What are the biggest producers of something like this? Is it purely from cars, from factories, from wildfires? For those of us who are away from wildfires, what are some typical sources of these particles?

Erika Maria Moseson: Yeah, well, it really depends where you live. There are different emissions inventories depending on where people live. Around the United States, a lot of it comes from the transportation sector and then energy production. Frequently, your local American Lung Association chapter could probably point you in the direction of the local state or community inventory, or your local department of environmental quality.

Chronically, a lot of it is from traffic-related air pollution. The passenger vehicle sector has been getting a lot cleaner, but transportation unfortunately still often relies on these bigger diesel trucks, or trains and ships, and those frequently have a higher proportion of our emissions now. And obviously power generation, right? If you’re living near a coal-fired power plant, that can also be a large source.

The thing that’s hard is we know that PM2.5 causes disease over the short and long term. You can see premature birth, so I can say it’s womb to tomb, right? You can see premature birth, you can see heart attacks and strokes, and you can see cognitive changes later in life. Children who are exposed to high levels of traffic-related air pollution in the first year of life are more likely to have asthma by age seven. It gets really granular: You can actually see MRI changes in children’s brains based on their exposure. You can have kids cough their sputum into a cup, measure black carbon in the macrophages, and actually correlate that with lung function.

Also, ozone is another element that gets produced. It’s a secondary pollutant that reacts with some of the primary pollutants, and it independently can cause emphysema. Even if people have never smoked, you can actually get pretty significant emphysema from breathing these things. So it’s this chronic burden, and increasingly, the more I learn about it, it just reminds me of tobacco. Once upon a time, we thought, “Well, tobacco can’t be that bad. Everyone smokes, right?” And then it’s, “Oops, it turns out it is that bad.” “Well, maybe, maybe smoking yourself is bad, but secondary smoke can’t be that bad, right?” Nope, it turns out that’s a big deal.

So unfortunately, I always try to tell my patients that our lungs don’t really care what you mean to do. They’re not that smart. They can only breathe in what’s actually coming into them. So it is a real burden. I think it’s interesting: I was interviewing someone on our podcast, and in Europe now, air pollution has surpassed smoking as a cause of death in terms of modifiable, well, hopefully modifiable, risk factors. There are now more Europeans dying from traffic-related air pollution than from cigarettes, which is wild, because I remember studying abroad my junior year in Italy, and everyone was smoking.

Kevin Pho: So there’s certainly a difference between smoking, secondhand smoke, and pollution from traffic, which you can’t really see. Is this something that you can measure? And in terms of solving it from an individual household perspective, is it a matter of just buying air filters? How can we tackle this as an individual?

Erika Maria Moseson: Yeah. One of the hardest things, from a fairness perspective, is that one of the biggest determinants of indoor air quality is outdoor air quality. Unfortunately, one of the sadder elements of this is that people who are more well-off tend to try to get themselves housing in places with cleaner air, and then the people who are left to live by the freeways and the train tracks tend to already have different things going against them in life, and then it gets compounded by this chronic burden of illness. We see, for example, that Black kids are more likely to die of asthma than their wealthier or wider community counterparts, and there are a lot of inequities in air pollution. That’s hard, because it’s hard to move your house, right?

But if you do have a house, air filtration systems can work. This is something where you actually have a resource on my website on different air filter systems. There’s a lot of pseudoscience out there, and there are a lot of things that people will sell you, like ozone generators, that are probably not good. But air filtration systems can be helpful.

There are monitors. The criteria air pollutants under the Clean Air Act, which include PM2.5, do require monitors. The department of environmental quality will have very nice, very highly calibrated, sophisticated monitors. The issue is there aren’t that many of them, and it turns out traffic-related air pollution can be a very hyperlocal phenomenon. A lot of these things can fall off pretty close to the roads. So there are some DIY monitor networks that you can participate in. You usually are sacrificing accuracy a little bit, but they can give you a little more granular data. A lot of people with the fires were looking at a system called PurpleAir, because there are a lot of people who participate in it. Again, those monitors are potentially a little less accurate, but if there’s a bunch of them in an area, they can probably give you a big-picture view.

Other basic things: If you’re driving in a car, heavy traffic seems to be where a lot of people are exposed. I personally have a lot of drivers in my lung practice, and I think a lot of this has to do both with auto-pollution from driving some of these bigger diesel engines their whole life and with just sitting in traffic a lot. So it seems having your windows up and recirc, per the research on when you’re driving, probably protects you, or does seem to drop the particulate burden inside. A lot of these studies actually come out of London, because they have such a high burden of PM2.5, and they’ve studied their cab drivers.

The other thing is, it does seem that there is auto-pollution from the engine that you’re driving. So if you swing an electric car, it’s good for the planet, good for your wallet, and also probably exposes you to a little less particulate matter. I think in London, when they looked at the difference between a cabbie driving one of the classic black cabs versus one of the newer hybrid cabs, they had lower exposure. And then obviously, when it’s very fulminant and dramatic, an N95 mask or a respirator can actually decrease the particulate matter burden you’re breathing.

But overall, there are all these individual things, but those individual actions are individually also a lot more expensive than taking a more community-wide approach to just decrease the burden up front. I’m convinced that the savings in health care costs and maintaining an economy alone would make it a wise investment. That’s why I encourage people to think about actions to clean up the air as investments. I always remind people that the Clean Air Act had over a 20 percent annualized rate of return. Who wouldn’t want that for their retirement portfolio, right? You invest money to clean up the air, and you generate a lot of health and economic activity.

Kevin Pho: We’re talking to Erika Moseson. She is a pulmonary and critical care physician and the founder of Air Health Our Health, and she wrote the KevinMD article “Apocalypse now: climate change, cardiac arrest, and the price of inaction.” Erika, from an individual clinician standpoint, what are some things that we can do to help address the issues that you bring up?

Erika Maria Moseson: Well, I think one thing that surprised me is that a lot of the time, as doctors, we spend so much time becoming experts in what we do, and then we think that there are always experts above us who dive down into these smaller areas. But I think we need to remember to turn away from just talking to each other, become advocates, and speak to other people in our community about these things.

I remember, personally, I got asked by the American Lung Association at one point to go talk to some legislators at our local state capitol about diesel, and it’s so wild how much of a lack of scientific education there is. I think we do so much science training that we all think of ourselves as, “Oh, well, I only know a little bit of science,” but we as doctors are actually maybe the most scientifically literate person that most people know, right? For most people, in their day-to-day lives, the person who’s maybe been the most exposed to science is their doctor.

So there’s that ability, as a doctor, to translate the scientific speak and the studies to our patients and what it means in their real lives. And then I also think there’s a role for the doctor to be the doctor for their community, too, for air quality, to speak to city councils or your local congressperson or legislator, whoever, and explain why these things matter, because obviously the industries and the businesses will always have their perspective. So there’s that role of physician as advocate, both to translate science to patients but also to share with the bigger community.

I think COVID-19 right now is a perfect example of this. I think it’s been shocking to a lot of us how profound the lack of understanding about basic scientific principles is, and how wishful thinking doesn’t make results different. So I think doctors getting outside our comfort zones, recognizing that we actually are experts at our community levels, and being able to share that knowledge to help people see how important clean air is, and to help people see how important virus-free air is, is really important.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Erika Maria Moseson: Don’t light things on fire and breathe them into your lungs.

Kevin Pho: Well said. Thanks again for sharing your time and insight, and thanks again for being on the show.

Erika Maria Moseson: Absolutely. Thanks for all you do.

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