The Intersection of Climate Change and Child Health with Dr. Gabriel Cisneros and Dr. Maya Ragavan

Clinicians for Climate Action | University of Pittsburgh School of Medicine

Clinicians for Climate Action | X.com

Taking a Deep Breath: The Concerning Connection Between Poor Air Quality & Children’s Health by Dr. Gabe Cisneros | PennEnvironment

Health care has a massive carbon footprint. These doctors are trying to change that | NPR

Climate Change and Health | Centers for Disease Control and Prevention

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Voiceover: This podcast is for informational and educational purposes only. It is not medical care or advice. Clinicians should rely on their own medical judgements when advising their patients. Patients in need of medical care should consult their personal care provider. Welcome to "That's Pediatrics", where we sit down with physicians, scientists, and experts to discuss the latest discoveries and innovations in pediatric healthcare.

Dr. Amanda Poholek: From UPMC Children's Hospital of Pittsburgh, welcome to That's Pediatrics. I'm your co-host, Amanda Poholek, Assistant Professor of Pediatrics.

Dr. Arvind Srinath: And I'm your co-host, Arvind Srinath, Associate Professor of Pediatrics.

Dr. Poholek: Today our guests are Dr. Gabriel Cisneros and Dr. Maya Ragavan. And our topic today is Clinicians for Climate Action. Dr. Gabe Cisneros is a board-certified pediatrician and fellow of the American Academy of Pediatrics. He's also the medical director of UPMC Children's Express Care and co-chair of the Pennsylvania American Academy of Pediatrics Advocacy Committee. Dr. Cisneros received his medical degree from the University of Pittsburgh and completed his residency at the University of California San Francisco Fresno. He co-chairs both the Advocacy Committee and the Climate and Environmental Health Committee of the Pennsylvania Chapter of the American Academy of Pediatrics. He's a founding member of Clinicians for Climate Action and leads the Communications Committee.

Dr. Maya Ragavan is an assistant professor of pediatrics in the Division of General Academic Pediatrics. She completed her medical school from Northwestern University, pediatric residency from Stanford Children's Hospital, and a general academic pediatric fellowship from Boston Medical Center. Her work spans several topic areas including climate justice, intimate partner violence prevention, language equity, and the provision of culturally affirming care. She serves as the Associate Vice Chair for Diversity, Equity and Inclusion Research for the Department of Pediatrics, Associate Core Director for the University of Pittsburgh Clinical and Translational Science Institute, and Associate Program Director for the General Academic Pediatric Fellowship program. She also co-chairs the Health Equity Committee for Clinicians for Climate Action. This year she received the 2023 Pitt Sustainability Award for her commitment to leadership and sustainability as a faculty member with the University of Pittsburgh.

Thank you both so much for joining us today. That was a lot of amazing things to get through in introducing both of you. You're both so highly accomplished, and we're really excited to have you on today to talk about Clinicians for Climate Action. Usually we start by asking our guests to share a little bit about their path to CHP, and maybe you could also add on a little bit about your involvement with Clinicians for Climate Action.

Dr. Gabriel Cisneros: I guess our path began back in 2020 during the pandemic. It was a really difficult time with COVID, and at the same time there was this other situation that was coming to a head, climate change.

And for me personally, there was a particular situation that occurred where my daughter, she was back home with my mom, her grandmother, sitting for a week. The last night that she was there, there was this unusual electric storm that occurred and subsequently a wildfire and they had to evacuate, and it was kind of a very scary situation. And after that, it was like a wake-up call, I guess, that this was something that really hit close to home, literally and figuratively. And so taking a step back, thinking, "What's going on here? What do we need to do to take on this climate crisis?"

And so that's I think when Maya and I started to connect and thinking about our roles as pediatricians, what is our role in addressing this crisis? How can we protect children and ensure that they have a promising future? And so that's kind of where things started moving.

Dr. Maya Ragavan: And so I think I have always done a lot of health equity research and climate change. There's so many health equity considerations because marginalized communities are disproportionately impacted by the climate crisis, both in the United States and abroad. And a lot of the work that I do around partner violence, it's so interwoven with climate change.

I started getting interested in climate change advocacy though, just as a parent of a four-year-old who was feeling so overwhelmed by the climate crisis. And I spent some years just wrapped in my own angst about it and then really wanted to channel that anxiety into advocacy. And so that's when Gabe and I started working on some of the initiatives that we've been working on.

I also really wanted to spend some time intentionally thinking about, as a pediatrician, what is it that I should be doing? How can I advocate for climate change in the clinical setting, and then more broadly, at the policy level. Because, and we can talk about this more later, but climate change very much is something that needs to be solved at the structural level, at the policy level.

And so we've talked a lot about what is it that we do at the individual patient level that is affirming, not scary for kids, and really centers the fact that it cannot be our individual patients who solve the climate crisis, they're the ones that are disproportionately impacted, it is not their responsibility. And it's our responsibility as pediatricians to use whatever power we have to advocate for policy change. So those are some of the things that got us started.

Dr. Poholek: Yeah. So interesting how you both started from this place as parents of young children, but also as pediatricians, thinking, "Okay, this isn't just about my kid, it's also about all these patients that I'm interacting with and how can I do. So given that framework, can you tell us a little bit about what is Clinicians for Climate Action and how exactly did you formalize these feelings into an actual group?

Dr. Cisneros: The group was really born out of a fellowship that we took on, myself and two colleagues here at UPMC. It was called the Climate Health Organizing Fellowship.

Dr. Srinath: Nice.

Dr. Cisneros: It was through Cambridge Health Alliance. And over a period of six months, we basically met online and learned how to organize healthcare professionals and a way towards addressing climate.

And so we decided what we really wanted was structural change at our healthcare system. And so we formed our group, Clinicians for Climate Action, and we brought other interested healthcare professionals into the group and came up with a letter calling on healthcare leadership for a number of actions, specifically to join the White House in Health and Human Services Climate Pledge, committing to reduce greenhouse gas emissions 50% by 2030 and net-zero by 2050. To join Practice Greenhealth, which is an organization that provides the framework for reducing greenhouse gas emissions. Also to incorporate sustainability into healthcare, into the health curriculums.

We had a petition that we sent out to our colleagues, the different healthcare professionals that we knew and worked with, and asking them to sign onto this letter. And ultimately we had over 300 signatures and sent it to leadership. And to our surprise, within a day we had a positive response from the CEO of UPMC-

Dr. Srinath: Wow.

Dr. Poholek: That's amazing.

Dr. Cisneros: ... in support of what we were asking for. And in addition to that, basically a list of interested healthcare professionals, doctors, nurses, students, allied healthcare professionals, all interested in pursuing this work. So from there, we've really branched out and taking on different projects, finding ways that we can improve sustainability within our own individual workplaces.

Dr. Srinath: Wow, wow.

Dr. Poholek: Amazing.

Dr. Ragavan: Yeah, and I'll add to that, that was an amazing description of how we formed. The focus of Clinicians for Climate Action is on decarbonization in healthcare. And the reason that we are focusing on that is US healthcare systems have the second-highest carbon emissions out of all commercial businesses in the US. If the US healthcare system was a country, it would be the 13th highest carbon emitter in the world. And so I think as physicians, as healthcare clinicians, we have a lot of opportunity to work on decarbonizing our own healthcare systems and to make sure that we're promoting sustainability within our healthcare systems.

And so I think especially because healthcare systems are there to help children thrive, and so it's really aligned perfectly with some of the climate justice work. And so that was another reason that we decided to focus specifically on that area. And there's so many pieces to the climate crisis and how to address it, but Clinicians for Climate Action does focus specifically on healthcare decarbonization.

Dr. Poholek: Got it.

Dr. Srinath: So it's really interesting and really cool just from people who are trying to enact change and form groups, to hear the roots of this group formation. Not only with your personal experiences, but also professional experiences and educational experiences too.

I'm trying in my head to figure out which question should come next, so I'll let you decide which one is triaged higher is, can you talk about the role of physicians, ourselves, in enacting policy or advocating for policies to prevent or delay or to mitigate against climate change? And two, segue into initiatives for your group, specifically towards decarbonization.

Dr. Ragavan: Yeah, I can start, and then, Gabe, do you want to-

Dr. Cisneros: Sure.

Dr. Ragavan: Is that okay?

Dr. Cisneros: Yeah, go ahead.

Dr. Ragavan: Okay. I think there's so many opportunities for healthcare clinicians to be involved in addressing the climate crisis, and on so many different levels. And so I think fundamentally, being the person in the room that says, "Hey, what about thinking about sustainability?" So anytime we're talking about extreme heat or flooding or any sort of extreme weather pattern, I think linking it to climate, saying the word "climate," because often that's not happening, so being the person that does that is really powerful. And that's not something where you have to join a committee. I mean, it's just something that you do on a day-to-day basis.

But what I've found is being the person to say, "I know that we're talking about flooding and how flooding may impact our building. Let's remember that because of the climate crisis it's going to get worse, so how can we think about sustainability for our building?" Things like that I think are really, really powerful, and we can do that on a daily basis.

Incorporating pieces of climate change work into your clinical profession or your clinical practice, excuse me, that really focuses on supporting kids' health. And so for example, when I do sports physicals I always talk about heat prevention.

Dr. Srinath: Nice.

Dr. Ragavan: I always talk about, "Making sure that you have a water bottle or that you stay well hydrated because the heat emergencies are only going to continue, so I just want to make sure that you're protected." And so doing it like that I think brings a climate lens to your clinical visits without talking about mitigation, it's more talking about adaptation and prevention to make sure that we're keeping kids healthy.

Dr. Srinath: That's huge.

Dr. Ragavan: And so those are two things. And then there are so many things to do on the policy level, when we think about institutional policy, state policy, federal policy. So I'll turn it over to Gabe to talk about that.

Dr. Srinath: It's huge. Thank you.

Dr. Cisneros: Yeah. Like Maya was saying, through the Pennsylvania chapter of the American Academy of Pediatrics, we have opportunities to meet directly with our representatives in the legislature and more locally as well, to just talk about this situation and help educate decision makers about how important this is to child health, help connect those dots. Because they're so busy and maybe don't have all the information that they need to make these important decisions, that we can serve in that role.

As professionals, we have an important platform I think that we should utilize and help ... Because people are thinking about this and asking questions, and we have an important role with our education to really clarify things. And I think sometimes there's a lot of confusion, misunderstanding, and so we can be those voices that help explain and help lead towards positive outcomes.

Dr. Ragavan: I'm sorry, can I add one more thing?

Dr. Srinath: Please. [inaudible 00:13:19].

Dr. Ragavan: That was amazing. And Gabe is an amazing advocacy expert and he does a lot of advocacy work. The one other thing I will say about what we can do as pediatricians, so I know this is going to sound a little cliche because people say this a lot about climate change, but the young people are where it's at. They are the ones that are leading the charge. So we, as pediatricians, can support their work.

Some of the first advocacy that I got involved with around climate was working with a youth activist, and I learned so much from him and his work. And I think that as pediatricians, as people that are supporting the voices of children, we can also support that their incredible work that they're doing in the climate change space and in the climate justice space, because there's a lot of young people that are activists in that space too. So I just wanted to put that out there too, that I think we can do a lot to support their work and support the work that communities are doing.

Dr. Srinath: I really appreciate you two bringing it down to the level of tangibility for pediatricians, because this is an issue that is really unfathomable to a lot of people. And the question is, where to start? And for the healthcare providers listening, for the families listening, for the children listening, it's thinking about what we can do now, versus we have to talk to one of you to talk about policies for advocacy and things like that, which, I mean, things can stop pretty quickly and it's hard to get over that activation energy. That's huge. So you helped me organize my thoughts better.

Now, can you talk about the group's initiatives, what you've done and where you plan to go?

Dr. Cisneros: In terms of where people can learn about ways to become involved, I would direct them to our group's website that we keep updated, lots of different ways to connect. We want to take people's ideas and run with them. We don't have all the answers. I think people know best ways that they can contribute, and so we would just want to foster that energy and interest and enthusiasm.

We have our own ideas about things that we'd like to get done, and if people want to join us in those efforts, we have different committees centering around, as mentioned before, education, teaching, trainees about climate and health. If people want to be more involved on the advocacy level, there's certainly opportunities to do that as well. Really, I would just encourage people to think about where in their workplace they identify areas that can be improved. And take small actions, I think that when scaled up can really make an important difference.

Just a specific example. There's a pediatrician, Dr. Mary Ann Rigas, she's president of the Pennsylvania Chapter of the American Academy of Pediatrics. And she practices in Central Pennsylvania and has developed a community garden at their practice and it's very successful. They're providing healthy foods to the community. And so we've taken that idea and are trying to incorporate it in our own practice. And the reason that relates climate is because it talks about issues of where our food comes from and sustainable agriculture, as well as healthy eating and being outside.

So it turns out, when you do this work that there end up being a lot of co-benefits. One thing also can help improve in a lot of other ways. It's what makes it so interesting and fun and a great way to just meet people and build on all the great work that other people are doing.

Dr. Srinath: Nice.

Dr. Poholek: I wanted to shift back a little bit to something you were talking about earlier with education and trying to educate policymakers, educate other physicians in how to think about climate change. Can you share with us a little bit about the intersection of climate change and child health, and what is known about how climate change is impacting child health?

Dr. Ragavan: Yeah, I can start, and then ... So climate change impacts every facet of child health, it's interwoven with child health. And so you can think about it at the direct level. So related to heat, related to weather emergencies, the physical trauma that children that are in disasters experience. You can think about it then at the next level, it's related to pollution, which is related to asthma, to allergies, to Lyme disease. And then also the mental health impacts of the climate crisis that a lot of young people are facing, both related to just being scared of what is going to happen to our world. And kids that are in areas that have undergone a extreme weather event, then the trauma impacts of that as well.

And so really it's just so interwoven with child health and every facet of child health. You can't unlink the two. And so that's why, as pediatricians, I think it's really such an opportunity for us because really every facet of child health the climate crisis will impact.

Dr. Cisneros: Yeah. And Maya, I think you said it all. I'll just say that in 2020, all the leading medical societies, journals, were basically raising the alert that this is a very important health issue. The World Health Organization says it's the single greatest health threat facing humanity, so we really have to act accordingly, give it the attention that it deserves.

When I think about this as it relates to children, children just need a sense of security and safety and stability. And I think more than anything the climate crisis introduces this whole new way of living in a way that we can't really fully understand and predict, and so we're learning as we go along. And so what we want to do is change the way that we operate in a way that can help mitigate some of those changes and maybe make for less severe outcomes in the future for them.

Dr. Poholek: Kind of a follow-up to that, I guess my question is, in the process of doing this advocacy work and the education aspects, are there areas where you find people are surprised or unaware, or is it more that people are generally like, "Yeah, yeah. I know about climate change," and it's so overwhelming and so large that it's hard to think about it because it feels very difficult to figure out how to overcome it.

I guess I'm kind of curious, what's the response in general to the process of educating people about the impact of climate change in child health? And what are the challenges that you feel like you're facing in that process and what do we need to do to address those challenges?

Dr. Cisneros: I would say it's probably both of those things, but also a lot of excitement to take it on. I think people want to do something. A lot of time we bring this up and they're like, "Oh, I'm so glad you're doing this." Maybe they're busy and they can't take on other things because commitments to work and family, and that's totally understandable, we're all super busy too. But if there is some way that they can contribute, I think they're actually excited to become involved, and so we try to take advantage of that and not stifle it.

Dr. Poholek: Yeah, yeah.

Dr. Ragavan: Yeah. No, I totally agree. And I agree, I think it's both. I do think that this can feel really overwhelming, but I think that there's small things that we can do as clinicians. And so please reach out to us because we can point you in the direction of the small things you can do. I mean, you can join the listservs of some of the state level advocacy groups like PennEnvironment or PennFuture, and they always need clinicians to sign on to things. It really helps them out a lot, and that's a small thing you can do. Again, we haven't talked a lot about individual level mitigation, but if you have questions about getting solar panels, there are so many things that we can do and we can point you in the right direction, so please let us know.

And I'll also say that the other thing about climate is it relates to every other child health issue, so no matter what your passion is, what you're dedicated to, climate probably relates in some ways. My work has been for a long time in intimate partner violence, and violence and climate are really interwoven. There's actually just a study that came out that showed that ... It was a global study that showed that intimate partner violence was related to heat, in so far as as the temperatures increased, intimate partner violence also increased because we know that there's a link between violence and climate. And so that's just one example.

But I would just encourage everybody, because I know everyone here is so passionate and dedicated to child health that whatever you are passionate about, climate is related. So please let us know how we can support you in including climate work into the work you're already doing.

Dr. Poholek: Fascinating. Yeah, that's really important, I think, to let people know that there's an option to reach out to. Yeah.

Dr. Srinath: In closing, can I ask you two, where do you see your group going? What are your future plans? Any initiatives in the process right now that ...

Dr. Cisneros: I'm excited about trying to inspire other healthcare systems to follow our success.

Dr. Srinath: Nice.

Dr. Cisneros: Currently, as I understand it, UPMC is the only health system in Pennsylvania that has signed this Health Sector Climate Pledge, and it would be so great to have Allegheny Health Network and Penn State, and not to specify anyone in particular, but other organizations basically continue the work that we're doing, because I think that would just really amplify what we're trying to accomplish. Bring in more people, more hands on deck. I think it's a movement, really, and everyone can play a role in a positive way, so that's really our hope.

Dr. Srinath: That's awesome.

Dr. Ragavan: Yeah, no, it is really exciting where this group is going. One of the things that I'm really excited about is bringing in community voices, so leveraging the community-partnered work that I do to bring in community voices and hear how they would like Clinicians for Climate Action to continue and what things they think would be helpful for healthcare systems to do.

There's a lot of incredible community-partnered work in environmental justice in Pittsburgh. I mean, we're so lucky with the wisdom and the expertise of the community-based organizations and community leaders in Pittsburgh, so I'm really excited about moving that forward with the health equity lens to it.

Dr. Poholek: Yeah, it would be great also if we could include the website information so people know how to reach out to your group and get additional help. Could you share that information with us?

Dr. Cisneros: The website is www.c4ca.pitt.edu. And thanks to University of Pittsburgh for letting us use your platform. Also, we're on Twitter, or X, @ClinicianClimat without an "e" at the end.

Dr. Poholek: Fantastic. Thanks so much,

Dr. Srinath: Doctors Ragavan and Cisneros, we really, really appreciate you taking the time to speak with us. What your group is doing is not only inspiring, but bringing a tangibility to, I'll take Amanda's word, overwhelming issue, and giving avenues for people to work both at the ground level as well as from a bigger picture too. And we really appreciate your help and support and what you've done so far.

Dr. Cisneros: Thanks so much for having us. This is great.

Dr. Ragavan: Thank you so much. This was awesome. Thanks.

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