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WSMA Reports
July 2, 2019

Health at Risk

By Rita Colorito

Every spring and summer, Tony Butruille, MD, a family physician in Leavenworth, deals with the impact of what the World Health Organization says is the "greatest public health threat in the 21st century" - climate change. Throughout Washington state, wildfires are the front-and-center concern, with the highest number of fires on record in 2018.

Leavenworth, a Bavarian-style city of some 2,000 people in the foothills east of the Cascade Mountains, has the state's greatest exposure to wildfires, according to the U.S. Forest Service Pacific Northwest office. At times last August, the air quality in Washington was the worst in the world, with Seattle experiencing several consecutive days of unhealthy air.

August has become a shut-in period for many of Dr. Butruille's patients as they try to avoid the smoke.

"Respiratory issues, asthma, COPD, and allergies all spike when you have drier conditions and more smoke and allergens in the air," says Dr. Butruille. "Those exacerbations are not only much more frequent, but can also be much more severe."

The dangers of wildfire smoke

According to the 4th National Climate Assessment, rising temperatures worldwide, driven by skyrocketing greenhouse gases, have led to a cascade of increasingly frequent and severe heat events, drought, and flooding, as well as sea level rise and spread of disease-carrying insects that impact the environmental and societal determinants of public health—clean air and water, sufficient food, and safe shelter.

Washington's Department of Natural Resources predicts 2019 will experience hotter, drier temperatures and an earlier and longer fire season— and it's not just the drier eastern half of the state. Some 40 percent of last year's 1,850 fires, and 49 of 50 unseasonal wildfires that occurred by the end of March, struck west of the Cascades.

Wildfire smoke poses the greatest risk to young children, pregnant women, the elderly, and those with asthma, allergies, and heart and lung problems.

"The more smoke and air pollution we have in our environment, the more cardiovascular, cerebrovascular, and pulmonary diseases we can expect to see," says Jeffrey Duchin, MD, a physician and health officer for Public Health – Seattle & King County.

Also impacted are those with kidney problems, says Annemarie Dooley, MD, a nephrologist in Bellevue.

"Your kidneys act as a giant sieve," says Dr. Dooley. "Small particulate matter, under 2.5 micrometers, penetrates very deeply into lung tissue, is absorbed through the bloodstream, circulates to the heart, and the kidneys get 20 percent of what's filtered through the heart every second."

Researchers are still determining other developmental and long-term effects of wildfire smoke on children, who breathe more air per pound of body weight than adults because their metabolism runs faster, says Chris Covert-Bowlds, MD, a family physician in Seattle.

"The concern is that their lung development may never reach its full potential," he says.

The cascading effects of heat

Climate change means another new normal for Washington—increased temperatures and extreme heat events. A report from the University of Washington Climate Impacts Group (CIG) finds climate change is likely to increase heat-related illness, including heat exhaustion and stroke. Nationwide, extreme heat kills more Americans than any other form of severe weather.

Between 1990 and 2010, King County saw a 10 percent increase in deaths on "extreme heat days," according to the National Climate Assessment. Recent heat waves have seen a significant increase in hospitalizations, especially for the elderly, says Dr. Duchin.

Increased temperatures play a major role in ground-level ozone and fine particulate matter (PM2.5), both widespread air pollutants in Washington that increase the risk of cardiovascular disease and death, including death from lung cancer. With high concentrations of these pollutants, Yakima and the greater Spokane area received failing grades from the American Lung Association's most recent air quality report.

Renal health also should be on everyone's radar, says Dr. Dooley. Heat stress can impact those with existing renal injury or at an increased renal risk, such as those with diabetes, as well as people whose kidneys are otherwise healthy. "You can form kidney stones just by being dehydrated without having any kidney injury, by working or even playing out in hot weather," she says.

Carbon dioxide in the atmosphere not only makes the trees produce more pollen, but the warmer weather and reduced rainfall is causing the pollen season to start earlier, last longer, and become more severe. "People are having asthma symptoms earlier and worse than ever before," says Dr. Covert- Bowlds, whose son has asthma.

The result is also more severe allergy flares, says Markus Boos, MD, a pediatric dermatologist with Seattle Children's. "We have clinics where it's wall-to-wall kids with atopic dermatitis," he says.

Vector-borne and infectious diseases

Warmer year-round temperatures worldwide are also driving the population of disease-carrying mosquitoes and ticks. In the United States, vector-borne disease cases tripled from 2004 to 2016, according to the Centers for Disease Control and Prevention. Washington state is home to more than 40 species of mosquitoes, many of them capable of spreading disease.

Higher temperatures have led to an earlier onset of the potentially fatal West Nile virus-carrying mosquitoes, according to the Washington State Department of Health's vector surveillance program. Since the first three human cases of West Nile reported in Washington in 2006, there have been an additional 92 endemic cases. King County had its first reported case of West Nile last summer.

The few reported cases of Zika virus were acquired elsewhere. The fear nationwide is that it's only a matter of time before the two types of mosquitoes that cause Zika move northward.

Warming sea temperatures and increasing ocean acidity fuel harmful algal blooms that can contaminate recreational water and shellfish. Warming waters are also becoming more hospitable to disease-causing pathogens such as vibrio, says Dr. Duchin. "Vibrio cases have risen dramatically in recent years; it's a disease that grows where a lot of our shellfish are farmed," he said. "People get nasty gastroenteritis— vomiting, diarrhea—from vibrio. And it also has a real economic impact."

Vulnerable communities

Communities of color, those with lower incomes, and indigenous people face the greatest and disproportionate climate risks, a CIG study found. These marginalized communities often lack the resources needed to manage their health or get the medical help they need, says Heidi Roop, a CIG climate change and equity researcher.

In Washington's agricultural sector, some 79 percent of outdoor farm workers experience a heat-related illness during summertime harvest. Those workers are vulnerable to heat-stress nephropathy, says Dr. Dooley. It's the leading killer of men under age 45 in Central America, where the majority of the population works outdoors.

Exacerbating the health of many outdoor workers during periods of high heat or wildfire smoke is that they often don't seek medical help for fear of losing their job, says Russell Maier, MD, a family physician in Yakima, and physician advisor to the dean of Pacific Northwest University of Health Sciences. "If they do come in, what we're seeing is more advanced respiratory illness. It's hitting them when they can least afford it."

In Seattle, and other highly populated cities, the air quality is always worse in lower-income communities, which often sit near major highways, says Dr. Covert- Bowlds. These communities often lack air conditioning necessary to deal with heat waves or times of wildfire smoke.

"Polar bears dying is sad, but kids in South Seattle struggling to breathe is the current face of climate change and air pollution," he says. "That human suffering is what drives us to keep at it."

Smoke and air quality aren't the only climate change-related health concerns, says Roop. "If people live in flood plains and in coastal areas with sea level rise, those all have impacts on people's health and their ability to live in a clean home absent mold and contaminated drinking water," she says.

The impact of climate change goes beyond the physical. Mental health issues are often not discussed, but are a significant burden of climate change, says Dr. Duchin. "Extreme weather events, like heat waves and floods and windstorms all have significant mental health effects, particularly post- traumatic stress disorder, anxiety, and depression."

Physicians must speak out

Physicians are in a unique position to advance the dialogue on climate change, but public health systems face a steep hurdle when it comes to addressing climate change.

"We don't have the resources in place to adequately track the health consequences of climate change," says Dr. Duchin. "It lends to this complacency and helps people to minimize the fact that this is the single largest health threat facing us and will be for centuries unless we get our act together quickly."

"Sometimes doctors get too focused on treating the disease without asking, 'What are people going to do to solve the causes?'" Dr. Dooley says. "We should be screaming red [alert] in the summer to get vehicles off the road. The problem is not only particulate matter from wildfire smoke, but from diesel emissions."

Every physician has a responsibility to get involved, Dr. Butruille says. "We are seeing the public health effects of climate change now," he says. "We're going to see more of them in the future and shame on us if we don't do what we can to both prepare for and mitigate the results."

Rita Colorito is a freelance journalist who specializes in writing about health care.

This article was featured in the July/August 2019 issue of WSMA Reports, WSMA's print newsletter. WSMA Reports is a benefit of membership. Non-members may purchase a subscription.

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