 And let me welcome and introduce our guest speaker today. It's my great privilege and honor to introduce my colleague and friend, Dr. David Jones, who's going to talk to you about physicians and the climate crisis, history, politics, and ethics. Dr. Jones completed his AB at Harvard College in 1993 in history and science, and then pursued a PhD in the history of science at Harvard and received an MB at Harvard Medical School both in 2001. After an internship in pediatrics at Children's Hospital and Boston Medical Center, he then trained as a psychiatrist at Mass General in McLean Hospital and then worked for two years as a staff psychiatrist at the Cambridge Hospital. He then joined the faculty at MIT in 2005 as an assistant professor of history and culture of science and technology. And from 2004 to 2008, Professor Jones directed MIT Center for the Study of Diversity in Science, Technology, and Medicine. In 2009, he was appointed as a McVicker Faculty Fellow in recognition of his sustained contributions to undergraduate education. He also has taught as a lecturer in the Department of Global Health and Social Medicine at the Harvard Medical School, where he was awarded the 2010 Donald O'Hara Faculty Prize for Excellence in Teaching. In 2011, he left MIT to join the Harvard faculty and became the inaugural A. Bernard Ackerman Professor of the Culture of Medicine, a joint position between the Faculty of Arts and Sciences and the Faculty of Medicine. In 2018, he received the Everett Mendelson Excellence in Mentoring Award from the Graduate School of Arts and Sciences. And in 2020, he was named a Harvard College Professor. His initial research has focused on epidemics among American Indians, resulting in the book Rationalizing Epidemics, Meanings and Uses of American Indian Mortality Since 1600, published in 2004 by the Harvard University Press. His next project, Broken Hearts, The Tangled History of Cardiac Care, published in 2013 by Johns Hopkins University, examined the history of decision-making in cardiac therapeutics. He is published widely in the New England Journal of Medicine, American Journal of Public Health, Bulletin of the History of Medicine, and Journal of the History of Medicine and Allied Sciences, and among other venues. And topics have included human subjects research, Cold War medicine, HIV, planetary health, race, and the COVID-19 pandemic. His research has been supported by the Robert Wood Johnson Foundation, National Institutes of Health, and National Endowment for the Humanities. His teaching at Harvard explores the history of medicine, medical ethics, and social medicine. His three books in print are Rationalizing Epidemics, What's the Use of Race, Modern Governance, and Biology of Difference, and Broken Hearts. For those of you who are interested, David wrote some absolutely terrific pieces in the New England Journal in the past two years about the COVID pandemic and how history is relevant. And I'll see if we can get those in the chat. But when I asked him, what would you speak about, this was the topic he offered. And since we have had nothing on this in the entire lecture series, it's my great pleasure and thrill to have David here. And hopefully sometime we'll be able to see you in person. Excellent. Well, thank you so much for this invitation to speak. I'll be talking about an issue that I've just started to work on, both from my own teaching and research. So I look forward to hearing your reactions, thoughts, and advice. Over the past months, physicians concerned about the climate crisis have been on an emotional roller coaster. Last fall, during the COP26 climate conference, physicians received unprecedented attention as activists communicated the ways in which climate change would be a threat, would be a public health crisis. But since that time, there has been one report after another suggesting that humans will fail to act in time to avert a catastrophe. Have physicians somehow failed to inform the public and energize political action about what might become the greatest health threat of the 21st century? This raises a more general question for medical ethics. When physicians become aware of a significant threat to health, what obligations do they carry, either as individuals or as members of a profession, to advocate for social and political change that could improve health? Now, this question about the ethics of professional obligation is one that has come up repeatedly for me over the past 15 years. In 2005, Harvard Medical School revised its curriculum and implemented a required two-month social science course. I have led the social medicine portion of this curriculum. The basic idea of social medicine is that health care will be more effective and more likely to achieve health equity if physicians attend to the social, economic, and political contexts in which patients live, fall sick, and seek medical care. Or, as The New York Times wrote in its recent obituary for Jack Geiger, doctors should use their expertise and moral authority not just to treat illness, but also to change the conditions that made people sick in the first place. When we teach social medicine at Harvard, we often ask the students to read this article, which lays out the different opportunities for social action by physicians and asks them to think about what they see as their professional obligations and professional aspirations. It is clear from their responses that there's a wide range of feelings among medical students about this notion of professional obligation. When Paul Farmer used a lecture, he would call on students to make a preferential option for the poor. Some students would cheer, others would protest, arguing that a required course at a medical school should not push Marxist liberation theology. The advent of accountable care organizations after 2010 allowed us to preserve Paul's mission, but market it differently. We explained to students that if you are going to be held accountable for the outcomes your patients achieve, you need to focus your attention on the patients who are at risk for the worst outcomes, and that's usually the poor. Students have no problem with this logic as it engages with their own self-interest. So what obligations do physicians have to advocate for social change or element for health? I can imagine how a philosopher might go about thinking about this, but that's not my talent. I approach this question instead as a historian. I look for precedents that might shed light onto this question and inform our judgments, and I have been especially interested in this as we confront the climate crisis. As I said, by many measures, the events of last fall were a triumph from medical advocacy about the climate crisis. In a show of force, the editors of the world's leading medical journals came together to publish a powerful statement about the climate crisis. Health concerns featured prominently at the summit and in media coverage of the summit. Many of the physician advocates returned home afterwards and were energized about the prospects for meaningful action to improve the climate. But now, six months later, it's hard to remain optimistic. In fact, we seem to be backsliding. Carbon dioxide and methane are now both at record levels. The war in Ukraine has left the United States racing to export more liquefied natural gas to Europe, even though this is a leakier mode of transportation than the Russian pipelines. Sarah Palin and her call to drill baby drill are running for office again. As a society, we clearly need to do more. And so my question for today is, do physicians need to do more as well? In a time I have this afternoon, I'll briefly describe a few precedents in which medical advocacy contributed to concerted social and political action. These demonstrate what is possible. I will then trace the history of physician advocacy about the climate crisis with an eye on the ethical arguments embedded in this effort. I hope these comments provide a basis for constructive thought about my core question. Physicians have been advocating about the climate crisis now for 30 years. Their efforts have not achieved the desired success. Do we have an obligation to do more or to do something different? And if so, what? Now, the early history of physician advocacy for social reform remains lost in the midst of time. Many historians of social medicine trace the field back to the mid-19th century and the work of Rudolf Verkau. Some go back to Johann Peter Frank and his idea of the medical police. I'm now advising a PhD advisor who was an early modernist whose work will push this back further into the 18th century and possibly even into 17th century Italy. And I suspect that earlier examples could be found, whether in Europe, the Muslim world, or in China. The trail becomes easier to follow after the 1840s. Social reformers, notably Karl Marx and Friedrich Engels, used the poor health of workers to motivate their own political arguments. Public health reformers like Edwin Chadwick rallied city administrators to implement reforms to improve urban sanitation. They tackled water, sewers, and other health threats. Diseases that had once been common, especially tuberculosis and cholera, could be controlled. Well, what was the secret of the success of these late 19th century reformers? In part, it was the obviousness of the problem. 19th century cities were nightmarish places. Urban denizens were disgusted by the conditions in which they lived and the multi-sensory assault that they faced. In the aftermath of the Civil War, US reformers capitalized on new faith in the power of urban and national governance. Their interventions, including waterworks and sewers, provided tangible benefits that everybody could enjoy, clean water, clean food, and several generations later, eventually clean air. New health threats soon followed, most significantly the advent of cigarettes. Physicians were slow to recognize the risk. Many of them smoked themselves and were reluctant to believe that tobacco could be dangerous. Some were even complicit in the marketing of cigarettes. Thankfully, as has now been well-documented, a few thoughtful and brave physicians recognized the signal in their clinical data and published reports that documented the health risks of tobacco. They also advocated on a national stage with surgeon general Luther Terry releasing his report on smoking and health in January 1964. This precipitated a slow but now very significant change in American behavior. Smoking rates have fallen from over 50% in 1960 to roughly 15% today. Another success played out in parallel, the effort to improve highway safety. Consumer advocate Ralph Nader receives a lot of credit for this work, but many others contributed, including physicians, most famously William Haddon. He helps to develop what has become known as the public health approach to social problems. Researchers can document the impact of a health threat, identify structural solutions, and then marshal the political reform needed to implement them. In this case, the automotive industry and public's works departments implemented seatbelts, speed limits, and guardrails, and these and many other interventions have substantially reduced the number of deaths per mile driven. The 1960s gave rise to another advocacy effort, one directly relevant for the climate crisis, the medical crusade against nuclear war. In 1961, a group of physicians based in Boston founded Physicians for Social Responsibility. In a fascinating act of advocacy, they published a series of articles in the New England Journal of Medicine in 1962 to call attention to the horror of nuclear attacks. One of the articles described in great detail what would happen if Boston was attacked in the way that the Soviet military had planned in the case of a nuclear war. Essentially anyone who lives in the suburbs of Boston would be annihilated instantly. They convincingly argued that there could be no meaningful medical response to a nuclear attack. In large part, because an attack on American cities would destroy most of our medical infrastructure and workforce in the early moments of the nuclear attack. They argued that the only possible way to survive a nuclear war was to prevent a nuclear war. This advocacy campaign lost some steam in the late 1960s but was revitalized in the 1970s through a collaboration between U.S. and Soviet cardiologists who established a new group in 1980, international physicians for the prevention of nuclear war. Just five years later, they were awarded the Nobel Peace Prize. Now you could ask, it'd be hard to prove but it's reasonable to argue that this physician advocacy did have an impact on the eventual nuclear detente between Ronald Reagan and Mikhail Gorbachev. And it's certainly possible that their efforts contributed to the growing consensus that no one would win a nuclear war. Now of course there are countless other cases in which physicians have engaged in advocacy to achieve social and legislative reform. Reproductive rights, gun control, substance use, LGBTQ rights, distracted driving, vaping, many others. Again, there's concern now that there's backsliding on some of these fronts but the effort has been made and sustained over many decades, often with considerable legislative and social successes. Medical societies, not just individual physicians have often engaged although usually more cautiously than individual physicians have done. Now these cases each raise an important question. Was this health advocacy for social change ever felt to be a professional obligation? Something that all physicians should pursue as part of a career in medicine? Or was this kind of advocacy something pursued only by a few motivated physicians? I don't know if histories have yet been written at the resolution that would be required to answer that question. Whether about urban sanitation, tobacco control, road safety, nuclear war, abortion, or any of the others. For instance, even basic questions. When did physicians make talking to patients about tobacco a routine part of a clinical history and physical? Did any physicians ever bring anti-nuclear advocacy into the exam room? I don't know but you could recover this especially through careful oral histories. It could be the case that an obligation for social and political advocacy has never been widely felt and that has been mostly seen as a domain of a few motivated individuals. And this brings me to the climate crisis. Physician concern with the environment is of course as old as medicine itself. One of the most famous Hippocratic texts, Errors, Waters, and Places advised physicians to attend to all aspects of the environment, to the seasons, the direction of the winds, and the quality of soil and water. When Europeans established global empire starting in the late 15th century, health concerns were front and central for them. Imperial powers wanted to know that they needed to know how to make the tropics a safe place for European rule and economic exploitation. And there are many examples of this literature. James Lin's essay on the diseases incidental to Europeans in hot climates published in 1768 sought to assuage the anxieties that Europeans had about moving to the tropics and teach them how to manage those fears. Such work eventually gave rise to the field of tropical medicine, a medical specialty that made imperialism possible. Now this work from Hippocrates through Lin asked an important question. How should you think about disease risk when you move to a different environment? But the inverse question has also become important. How do you think about disease risk when the climate changes around you? Now a case could be made that this kind of thinking began in 17th century London with the dawning recognition of the toxic effects of coal powered industrialization. It certainly became a substantial concern during the dramatic changes in urban life triggered by the industrial revolution in 19th century European and North American cities. Now I don't think anyone has yet written a full history of physician involvement in the debates about air pollution. There certainly were many physicians who sounded the alarm about the consequences of burning coal and the smoke and sulfur dioxide that was produced. But there were also many physicians who took the side of industry. One for instance, who worked in Birmingham, sorry about my dog in the background. One who worked in Birmingham, Alabama, a steel town, argued that smoke was safe because it was sterile. It had been produced in the fires of a furnace and therefore was free of bacteria. Now in the world of early 20th century public health, which was fully in the thrall of bacteriology, there was a certain logic to thinking that smoke must be safe because it was sterile. It's clearly not how we would think about the problem today. Now the discourse on the health effects of environmental pollution and degradation really came into its own in the 1960s. Many factors contributed to this. One was the fear of atmospheric testing of nuclear weapons. Another was the enormous impact of Rachel Carson's Silent Spring. And another was the occurrence of dramatic and lethal smoke emergencies, most famously the great fog of London in December 1952. It killed thousands of people. Physicians and epidemiologists expanded their studies on the health effects of air pollution, first in England and then in the United States. The World Health Organization soon followed this lead. Legislative action followed as well, most famously for the case of the United States with the Clean Air Act amendments of 1970, which create the EPA and empower it to take on the challenge of air pollution. Some of those precedents are now being challenged in the Supreme Court and it remains to see what will happen with the Clean Air Act. And you could also make the cases that has been recently done by historians that the Clean Air Act amendments were passed not primarily to improve the atmosphere but as part of Nixon's political strategy, Hubert Humphrey had claimed the environment as his own campaign issue. And so Nixon decided he had to do something aggressive on the climate to outrank Humphrey and ensure his reelection in 1972. Now, the first UN conference on the human environment held in June, 1972 focused attention on the threat of environmental pollution. Physicians start to write explicitly about the health risks. Australian immunologist turned ecologist Stephen Boyden feared that quote, trends in the relationship between human society and the total environment constitute a serious threat to the survival of civilization and mankind. Boyden said that this was a problem that humans had brought on themselves. The use of fossil fuels had increased to such an extent that the integrity of the biosphere as a whole is now considered by many ecologists to be in jeopardy. Some physicians, however, continued to see the weather and climate as something beyond human control. George Birch, for instance, was a prominent American cardiologist who himself had studied the impact of weather on the heart disease, especially on the incidence of myocardial infarction. Writing in JAMA in 1972, he noted that quote, climate and weather important environmental factors that influence the health of the people of America receive relatively little attention as health problems. Although pollution may be controlled, climate and weather cannot be and therefore man cannot escape entirely the stresses of weather and climate. As he explained, to a large extent, we are truly at the mercy of the elements. Man must learn to maintain the best possible health in spite of his climate and weather by providing a satisfactory artificial environment, housing with heating, air conditioners and fans, proper clothing and healthful working conditions. The idea that weather just happened and that we simply needed to adapt to it remained widespread in the 1970s and 1980s. For instance, over the course of the 1980s, researchers in the Centers for Disease Control published a series of reports about heat-related mortality in American cities in the summer. They highlighted the particular risk faced by city dwellers who were poor, elderly or had pre-existing conditions. But none of these discussions invoked any notion of global warming or climate change. In a case of remarkably unfortunate timing, on June 30th, 1995, CDC researchers reviewed over 5,000 heat-related deaths between 1979 and 1992 and concluded that such mortality was readily preventable. A disastrous heat wave struck Chicago two weeks later and killed over 500 people. In the aftermath, some remarkable statements were made. Chicago's deputy health commissioner displayed a startling ignorance of the CDC's reports, noting, what we have not appreciated before is that heat can kill, even though that had been documented just two weeks previously by the CDC. Other officials, however, were paying closer attention. Back in 1987, the UN's World Commission on Environment and Development, chaired by physician Gro Horrell Bruntland, alerted epidemiologists and others to the ways in which our abuse of the Earth's ecosystem threatened human health. A series of important reports were published in 1989. In April of that year, Lancet published what I think is the first editorial that my colleagues and I at least have found in a prominent medical journal explicitly about the health effects of the climate change. It warned of a global environmental disaster on the order of the AIDS pandemic or nuclear war, but more certain since it proceeded from physics rather than politics. The author argued that there was no time for further research. Fundamental changes had to be made in transportation, energy, and agriculture to protect the ecosystems on which human survival depended. In December of that year, the Environmental Protection Agency submitted its own report to Congress about the potential effects of climate change. The nearly 500 page report contained one brief chapter on health effects. The author of this chapter, Janice Longstruth, later described how she had found a voluminous literature on climate and health going back as far as the time of Hippocrates. In her chapter, she described the basic findings, focusing on vector-borne diseases and called for more research. In that same month, Boston physician Alexander Leith published his own analysis in the Newland Journal of Medicine. He noted that while the subject of climatic and environmental changes that result from human activity has been much in the news recently, the impact of environmental change on health and the survival of humans has received relatively little direct attention. Now, Leith himself had been active in both Physicians for Social Responsibility and International Physicians for the Prevention of Nuclear War. And in 1986, he had updated IPPNW's 1962 analyses of the medical consequences of a nuclear war. He highlighted new research on the estimated casualties of a nuclear attack, the short and long-term effects of radiation, and the new problem of post-blast immune dysfunction. A full third of his article examined what looked to be the most deadly consequence of any nuclear war, global starvation from the disruptive agriculture, disrupted agriculture that would follow a nuclear attack. He became interested in the climate crisis around that time and saw direct parallels between nuclear and climate advocacy. Like the authors of the 1962 articles about the consequences of nuclear war, he believed that the Physicians could educate the public and political leaders that political reform would follow. As he wrote in a 1996 memoir, if people understood the health threats of environmental degradation, they would personalize the consequences of these threats to their own health and survival and demand appropriate controls through government regulations. In pursuit of this mission to educate with the expectation that political change would follow, he described a series of health consequences of the climate crisis, increased mortality related to heat, air pollution, ultraviolet radiation, infectious diseases, and again, especially the disrupted agriculture and the resultant global starvation. He wrote that the overall consequences of the climate crisis would be disastrous. In the early 1990s in the lead-up to the Earth Summit in Rio, reports about climate change appeared frequently. In 1990, the IPCC released its first report on the scientific consensus, one that mentioned possible health consequences only in passing. The WHO prepared its own report, Our World, Our Health, as a briefing document for the Rio Summit. After the June conference, the Union of Concerned Scientists delivered a stark warning to humanity, pointing out that a great change in our stewardship of the Earth and the life on it is required if vast human misery is to be avoided and our global home on this planet is not to be irretrievably mutilated. The emergence of this new domain of climate advocacy created challenges for groups like Physicians for Social Responsibility and IPP and W. They debated whether they should keep their attention on the existential threat of nuclear war or possibly sensing the end or hoping for the end of the Cold War. They wondered whether it made sense possibly to redirect their attention to the climate crisis and both groups had active debates about what to do. Physicians for Social Responsibility decided to create a task force on the environment and after a contentious meeting held at MIT in 1992, it published its own report in 1993 with Eric Chivian as one of the lead authors. Chivian, who spearheaded this effort, then created a Center for Health in the Global Environment at Harvard Medical School in 1994. Many physicians in Europe, North America and Australia worked along these lines in the 1990s. They published articles that highlighted the health of threats of global warming, largely following the talking points laid out in the initial work by Longstreath and Leaf. Lancet was especially active in this area, for instance, publishing a series of 11 articles in on health and climate change from October to December 1933. The Journal of Medicine and War published a special collection dedicated to climate change in 1995. Individual researchers also published reviews and commentaries that sought to keep the problem in the public eye. It's not clear to me what effect any of this advocacy had. And while I have not yet completed a systematic analysis, my sense is that there isn't that much new in the big picture medical writing about this issue. Details have been filled in with research over the past 30 years and the causal claims that physicians have made become more convincing. But the basic arguments generally cover the same basic ground. Climate crisis and increased temperature will disrupt the food supply, change the distribution of vector-borne diseases, create climate refugees and others. Ozone depletion received a lot of attention early on in the late 1980s, early 1990s, but that has dissipated in light of successful controls of chlorofluorocarbons. Acid rain also received attention in these reports in the 1980s and 1990s, but again, that issue has faded from view. I think those are the two success stories and an otherwise grim history of the continuing concern about the health effects of the climate crisis. The effort received an infusion of energy over the past decade. In 2014, with funding from the Rockefeller Foundation and then the Welcome Trust, Lancet editor Richard Horton convened a commission on planetary health. This led to a new round of publications in both Lancet and The Economist and a new journal dedicated to the problem, Lancet Planetary Health. Another group of advocates channeled some of this energy to establish the Planetary Health Alliance, which is now hosted at the Harvard School of Public Health. This is in large part a platform for education. It hosts workshops, publishes research reports and advocates for actionable steps that can be taken by individuals and their societies. And it looks like the University of Chicago has a similar center, the Energy Policy Institute, which collaborates with researchers at Berkeley and Rutgers to produce the Climate Action Lab. And the Climate Action Lab is engaged in research and education about the societal as well as the health costs of the climate crisis. Climate advocacy has also been shaped by the renewed efforts to work for race justice that have come in the aftermath of the murder of George Floyd. This has led to increasing discussions of the problem of environmental racism in the climate crisis. As with so many things in American society, the burden of disease and risk that will follow climate change will not be distributed equitably. This was demonstrated powerfully by Hurricane Katrina in which the French Quarter and the wealthy white neighborhoods were largely spared while the majority black lower ninth ward was flooded and devastated. Researchers have now shown how the long history of racism has left many legacies for environmental health in this country, affecting everything from the distribution of asthma to who's at risk for heat related mortality. We must recognize the social construction of vulnerability, especially the disastrous structures of social inequality and systemic racism that influence our relationships with environmental risk. And all of these advocates have now produced many resources for physicians who might want to engage with the climate crisis. The Lancet Countdown on Health and Climate Change prepared this policy briefing for the United States. It encourages healthcare systems to adapt to become more resilient in the face of climate change. It calls on doctors to advocate for policies that will mitigate the effects of climate change, especially on the most vulnerable people. It even gives concrete advice for how doctors can discuss the climate crisis with their patients for the conversations about the risks of heat, about air quality, about preparing for natural disasters or how to manage the growing problem of climate anxiety. Victor Zhao, now president of the National Academy of Medicine, published a manifesto last year to call on the healthcare system to decarbonize itself. He noted that healthcare is responsible for 8.5% of the U.S. carbon footprint. And described several approaches to addressing this problem, making the supply chain more efficient, improving healthcare delivery, making sure that medical education takes these problems seriously, and then working on policy financing and metrics to make sure that we're doing the right thing. Now, a cranky skeptic might look at that number and say, oh, that's interesting, healthcare is actually a relatively green industry. In 2021, healthcare reached a new high, consuming 19.7% of the U.S. GDP. That suggests that its share of carbon emissions, 8.5%, is less than half of its share of economic activity. I think that's a bit of a rhetorical sleight of hand. Even if healthcare is relatively green, there is much that could be done within healthcare to improve things, especially in the pharmaceutical sector, which accounts for the largest share of healthcare's carbon footprint. I'm currently working on a paper with a colleague to estimate how much of this carbon footprint is contributed by the problem of non-adherence, specifically of prescriptions that are filled by patients, produced in the carbon footprint, but never actually ingested. And I think that number is going to be substantial. But that said, the main goal of climate advocacy in healthcare isn't to clean up and decarbonize medicine itself, but to use arguments about the health effects of the climate crisis to motivate broader social and political reforms. Unfortunately, recent surveys have shown that most physicians are not yet ready to engage. This survey of several thousand international physicians found that well between 86 to 90% of survey respondents believe that physicians have a responsibility to alert both the public and political leaders about the health effects of the climate crisis. Only 37% of them said that they were actually willing to do so and that they would need further information before being willing to engage. And over half of physicians simply said that they simply did not have time in their work to engage here. Physicians have long since recognized and described the health effects of the climate crisis, which are likely to be dire. They have recognized the ways in which this risk is not distributed evenly. People who are already the most marginalized in society are the ones who are most likely to suffer. And physicians have identified credible interventions, things that could be done at the clinical and policy level to try to improve our future prospects. But advocates, myself included, I'm guilty as charged, mostly seem to be focused on continuing to do the kinds of things that we have done for a generation. Educating the public and our leaders, publishing articles, describing the health effects of climate change, and then hoping that decisive action will be taken. Of course, as is often said, one definition of insanity is doing the same thing again and again and expecting a different result, but I'm afraid that's what we seem to be doing in this case. The historical record has repeatedly made clear that while it is always important to collect more data and better evidence, evidence itself will never be enough to bring about social change. New evidence might help us refine the arguments and propose new interventions, but the case for climate action is already quite strong. In fact, after one of the IPCC reports last winter, several scientists even called for a moratorium on further climate research, since it's not clear what, if any, difference more evidence would make. Since we haven't acted on the abundant evidence that we have right now, why should we think that we will act, we'll make a little bit more evidence? Now, I don't know if they meant this seriously or if this was just, again, a rhetorical gambit to bring attention to this problem, but I think there is something to be said for their basic position, given how much we know, is it likely that knowing a bit more will make a difference? Well, what more could be done? And this is where I come up short. Physicians could engage in more legislative advocacy, but given the current political gridlocking Congress, and the opposition of certain Democratic senators to any action on climate change, it seems that legislative advocacy at this moment in the United States might be an exercise in futility. The war in Ukraine, of course, makes a bad situation worse. Some of you might have seen that Biden yesterday announced a plan to allow summer sales of ethanol, knowing full well that doing so will worsen problems with air pollution and smog in the summer months, which is why summer sales of ethanol have long been banned. Physicians could also target local communities to build grassroots interest in the climate crisis, and many are already doing that. But will enough physicians see this as their professional obligation and mobilize to make a difference? And will local communities prioritize health effects amid many other competing interests? Again, it's hard to be optimistic. Everyone's preoccupation these days has been to decrease the price of gasoline, even though increasing the price of gasoline is probably an excellent policy intervention if you cared seriously about the climate crisis. In England, some physicians have mobilized as part of the Extinction Rebellion, which began staging protests and civil disobedience at London in 2018. In September 2019, for instance, some doctors and nurses blocked the entrance to the United Kingdom's Department for Business, Energy, and Industrial Strategy. Some glued themselves to the door to prevent people from coming and going. Others staged a die-in. Several of these physicians were arrested for their civil disobedience. This prompted Richard Horton, still the editor of the Lancet, to come to their defense. He posted a strongly worded video manifesto in which he argued forcibly that physicians had an obligation to do more. As he said, doctors and all health professionals have a responsibility and obligation to engage in all kinds of non-violent social protests to address the climate emergency. That is the duty of a doctor. Well, physicians, or really all humans, need to do something more, something new. You don't need a crystal ball to foresee a future of enormous regret. I think it's a reasonable prediction that in 10 years, 30 years, 50 years, that physicians, researchers, and the public will look back at 2022 and wish that we had all done more then to prevent the future that these people will be living in 2030, 2050, or 2070. And if you can reasonably foresee that future regret, wouldn't any moral person want to act now to change that course, to prevent a future that we will all regret? I think so, but I just don't know what exactly we could do to change that course. I remain stuck in my own silo, conducting historical research that seeks to understand why societies haven't done more to respond to threats like air pollution over the past century or to the climate crisis today. But I suspect that such research will have a modest impact at best. In 2019, several other historians and I published this piece in which we argued that in as much as history ever teaches a straightforward lesson, the message of this particular history may be that more evidence alone will not compel action given how non-rational our current policy sphere seems to be. The imperative for climate action requires physicians to mobilize politically. As they have done with many cases in the past and become fierce advocates for major social and economic change, a truly ethical relationship with the planet that we inhibit so precariously and with the generations that will follow us demands nothing less than major social and economic change. I just don't yet know what more we could do to make that happen. And I look forward to hearing your thoughts and perspectives. So thank you very much for your attention. I'm looking forward to the conversation. Well, David, I kind of, first of all, the talk was terrific and it was really everything I hoped because it was a beautiful summary of what's gone on and how you're 100% right that it's not a question of just getting more information. As a matter of fact, I think that in some ways your talk is a magnificent example of thinking about it, over time and the fact that there is more than enough information, the challenge is how do we move from there to advocacy? And I don't have the easy answer. I think we start and I mean, if you think about how you can look to people like Malcolm Gladwell and creative intellectuals, how you start social movements and how things are changed by disruptive and are not linear, but I don't have the easy answer. On the other hand, those of us who've traveled throughout the world, all you have to do is go to a country like India and be exposed to the air pollution there and you just get like, it literally and figuratively takes your breath away and say, oh, please God, whatever we can do to prevent this. So I'm going to open it up for questions. I certainly don't have the answer, but I'd be happy to navigate the chat. So Tarek, you're on deck. Okay, good. Thanks. So basically, I would say I have three separate quick question. One would be like, is it because we haven't made a concrete connection between climate change and health? Everything looks a little distant, abstract. May or may not happen, like multiple step process. It's not like, if you get needle stick, you're gonna get infection, something like that. So for patient, it's hard. I mean, they out of, they do, everyone does things out of self-interest or self-preservation. So they're not gonna make abstract thought process. So that's one. And number two, have you looked at some of the guidelines of different societies, how we do things like in the OR, which is a lot of wastage, we do things which are done by joint commission or other societies and we are doing it, which don't have hard signs and we should change something in an immediate way. So we don't dispose so much. Like everything is disposable. We try to throw away things. We don't have to clean them. And the final third question would be, would it affect the outcome or the state stature or whatever you wanna call a patient, the patient, if, where should we draw the line so that doctors don't become activists and affects patient relation? So what should be the benchmark of the science where the societies have a position papers or the position when he says something, be that climate change doesn't look like he's an activist but he's doing a professional job. So thanks. Yeah, those are all great questions. As I'm gonna answer, I'll just say one quick thing and response to the comment that Mindy made. You know, air pollution in the US at least is one success story. Many cities, you know, Chicago because of railroads, Pittsburgh and St. Louis because of steel had air in the not too distant past 1930s, 1940s that was as bad as the worst of the air is now in India. And the US did make concerted action to change that over the objections of industry in part because Richard Nixon was a schemer and saw reasons to do so even though he was a Republican who had no prior interest in the environment. And so sometimes it's unexpected events, again, a non-rational policies here that does lead to decisive action. As for Tariq's questions, the first one, is it lack of, is it the health effects of climate crisis field too remote? Historically, I think that is certainly true. And, you know, the contrast, you know why was there public support for investments in infrastructure and waterworks in the late 19th century? That was because the effects of that were not seen at all as remote. During contaminated water, get explosive diarrhea from cholera, it could be dead 24 hours later. And so there was a very immediate cause and effect of both the insult and also the intervention. All of a sudden major cities in Western Europe and North America had, you know, clean water, clean running tap water and everyone could appreciate that. Whereas, you know, telling people to switch to electric cars, no one is going to perceive a health-related benefit from that or if more people compost it or we're better about recycling, no one is going to experience an immediate climate benefit. So the issue of distance between cause and effect is significant. Recently, there's been some change in the public dialogue around that, mostly because of the seeming intensification of storms of various sorts. Fire, forest fires are worse. Hurricanes contain more water and more powerful winds. You may be experiencing this sort of that, I will, but apparently North Dakota is now forecast to get 30 inches of snow, which is an unusual blizzard for mid-May. And these things do have health effects. People die from hurricanes, people die from forest fires or from the air pollution that comes off the forest fires. And so if these things really do intensify as predicted, it could be that that will be the mechanism by which the effects feel approximate enough to motivate change. But again, it will never be as immediate as obvious as it was with urban water in the 19th century. As for guidelines, you know, do groups like JCO make hospitals do things that make things worse. I was astonished when I looked at the analyses of the carbon footprint of healthcare because I assumed that OR waste must be like the number one cause because it's so dramatic at the end of every operation to see how much stuff gets thrown away and a certain percentage of medical waste gets incinerated. But apparently the problem really is in pharmaceuticals. You know, most pharmaceuticals are fossil fuel derivatives, you know, the great pharmaceutical revolution in the 1950s with antibiotics and psychiatric medications, those were all coal tar derivatives. And so most drugs that get produced have a carbon backbone and most carbon backbones are coming from oil or coal. And apparently that's where the lion's share of healthcare as carbon comes from. And that's one that physicians actually really could do something about. There have been longstanding concerns about over prescription by physicians, non-adherence by patients. Potentially you could reduce a lot of healthcare as carbon footprint with no adverse effects because what you'd be cutting is the stuff that isn't needed anyway or isn't being consumed anyway. The challenge is figuring that out. You can't predict in advance which of the prescriptions the patient is going to consume or not. So it's hard to do, but there's a lot, there is some low hanging fruit out there. And then the last question about will activism disrupt a sense of professionalism in patient-doctor relationships? A few years ago, I think the answer I would have given was that that distinction between activism and professionalism shouldn't exist that activism should be seen as part of the professional obligation of physicians. It's not considered unprofessional anymore to ask patients if they smoke. It's considered appropriate medical care to ask patients if they smoke. But the events of the past few years have made it clear how sensitive or how easily the patient-doctor relationships can get politicized. Whether it was Florida's efforts to try to bar physicians from inquiring about guns in the homes which was enacted and then thrown out by courts or the recent efforts to ban gender-conforming care. And so that patient-doctor relationships like so much in this society have become politicized. And so I think in 2022, I would have to agree with Tariq that that is a concern if physicians did start to tell their patients to stop driving gas guzzlers that would be seen by a lot of patients in the United States as inappropriate and unprofessional activism. Maybe physicians could head that off through education and advocacy by explaining why it is that they ask these questions but that would require concerted work and that would be working against a lot of headwinds, I think. Thank you. John, I'll let you take the floor. Unmute yourself. I really liked your report. The only problem that I see is Fox News isn't included or any of the major producers of fossil fuels, exon, et cetera. So my question is possibly seen as kind of naive and silly, but why not start thinking in terms of meetings, monthly meetings in Chicago at AMA headquarters where a panel, a quote unquote expert panel of doctors and climate people meet with Fox News one month, Exxon and Shell another month. In other words, based on the people that I am in contact with and of course all of that's limited because of COVID. It's astonishing how many Americans have so little trust in scientists of any kind, including doctors and the doctor problem has been compounded by the reluctance to be vaccinated. So all the academic stuff is great and obviously needs to be done but is it possible that what we're missing is we don't have the equivalent of Rush Limbaugh daily meeting with exposing Americans to the kind of experts who could help change the tenor of the whole conversation in America? In some way, I agree completely. I think that's the source of a lot of pessimism that people feel now about this. In some way, what you're describing is outreach to two different groups that I would have to be handled distinctly. So one is, is there a way you could engage with the various fossil fuel interests, whether it's Exxon mobile, coke industries, coal mines and would it be possible to educate them and get them on board with a vision in which they decided to decarbonize themselves? The challenge there is that you're asking people, companies to act massively against their financial self-interest. And there are some people who have called for policy in which all carbon that's currently in the ground stays in the ground and we should stop using coal and petroleum. There are obviously pragmatic obstacles to that. No one has figured out how to make a 747 fly with solar power yet. But you know, people are working on those questions. But what that would require is asking people to leave vast assets undeveloped. You know, the total value of the world's fossil fuel reserves is enormous and be very hard for the people who own those reserves just to leave them there. There are various low-grade things going on. I've known some people who have been involved with a form of quiet activism in which when the coal economy was suffering a few years ago, you can actually purchase coal or coal rights quite affordably. And so people worked with Nature Conservancy and others and started basically secretly raising money and secretly buying up coal land on the cheap. And then they would buy the land and then flip it into a conservation easement so it could never be developed. And so apparently some share of coal reserves in Virginia have now been bought up and covered by conservation easements. I think that's sort of small change in the global fossil fuel but things like that could be done. But that requires convincing people to leave a lot of money in the ground. You could not be convincing them to do that if they didn't see petroleum simply as an asset but as an asset that was going to cause horrendous health consequences and everything else down the road. And if you could put a carbon tax on some of these resources it would change the companies how the companies value their assets. And that would be useful but for a variety of different reasons carbon taxes are unpopular in the US. Could you do anything about entities like Fox News? And part of the problem is free speech and Fox News can say whatever Rupert Murdoch wants Fox News to say and there's not much that could be done. Will his children pursue a different political course than he has? I don't know that remains to be seen. Presumably people like Tucker Carlson say what they do because they believe that there is a market for it and energizes their viewers. Could you educate their viewers in such a way that they no longer wanted to hear anti-climate crisis diatribes from Fox News? That would force Fox News to change its tune. And the question is, well, how do you get access to those people to try to convince them that there actually is a scientific consensus that the climate crisis is happening? And again, you know, there's been some hope. Farmers are close observers of the climate and there's a growing number of farmers who are expressing concern about what's going on. Fishermen are close observers of ocean conditions and there's growing concern amongst them. And the Gulf of Maine for reasons that aren't clear is the body of water on earth that is warming up faster than any other. And that will likely wiped out the main lobster fishery within my lifetime. And so things like that are starting to get attention of people who might otherwise be Fox News viewers. And so in slight reason for hope, but it's hard to be too excited, but it's a very difficult challenge. We have to figure out some way to break through to both of those groups. Jake, you have something to add to the conversation. Thank you so much for this fantastic talk. I really greatly appreciate the comment that we need more clinicians just to change their opinion about this as an issue that is within not just their purview, but their responsibility to address. I think that changing ideology is a really important aspect of addressing climate change as a existential crisis that we have to face. To your question though of what do we do about this? I think that with these kind of system level issues that I mean, you just mentioned farming and fisheries and there's so many other areas that this could be tackled from that the question for healthcare then becomes how can we lead from example? How can we focus on our own sector? Because this is a problem that's going to need to be tackled sector by sector. We can't just put in one big law that's going to just handle climate change. And so I guess my question for you then is is there any kind of precedent where organizations within healthcare have started to come together to talk about what can be done on a systems level approach within healthcare, within individual hospitals, within different organizations starting to network to talk about what can be done, how can we lead by example? Because again, I think that ideology change is important as a kind of like a ground level to think that we need to do something about this but then the next step is what can we do within our sector to then use that almost as like a presentation to say, look, this is what other sectors should be doing as well. And then I think you're also right about the need to again push for some more policy change at a higher level of the issue. But I think that kind of in the immediate the sense of urgency I think that we need to be focusing on is like what can we do right now? And I'm just curious again, is there any effort out there at the moment to try to put some sort of network together to address that? So a bunch of different issues there. So the, I think there are emerging efforts, both within institutions, between institutions and also in professional societies to do this. I think a lot of professional organizations now have working groups having conversations about this. I think many healthcare entities also have working groups. This is hard not to because the problem is definitely a glooming. Has there been much action? Is there much to show for it? Not much that I have seen, but there certainly could be stuff that I've been missing. And you'll see news stories periodically. I've heard this was either about Cleveland Clinic or Intermountain Health or the big one in Puget Sound talked about in a very screen initiatives that they're doing. And I think you're right that there is some kind of virtual signaling that could be done. So even if healthcare acting unilaterally is not gonna solve the national carbon footprint, if physicians were to say, well, you think this is really important and here's what our own institutions have done, that would both be constructive and it would also signal the importance of this in a way that might be more persuasive than simply telling people that it's a problem. I assume there are some things that would be low hanging fruit that would signal to patients. Any healthcare institution that has a big parking lot could put solar panels over the parking lot. There's no reason not to do that. And the solar panels are so cheap these days. And that would be a very subtle signal. You know, every time you go to the doctor's office that someone thinks clean energy is important or you could put in windmills healthcare institutions in the Midwest. The physicians could have conversations with patients about things that patients could be doing. And again, that would again, would get it into the patient's consciousness that this is an important issue. And there are some healthcare institutions in Boston I know have been talking about trying to improve their, to make their supply chains greener. You know, could they do more to recycle? Could they purchase more recycled disposable products? You know, getting a lot of the gowns that come in going, hospitals have to make the decision. Are they going to go for cloth gowns that get laundered or do they go with disposable gowns? I don't know what goes into those purchasing decisions. One of the things that's so frustrating is that figuring out the differential carbon cost of those two strategies is actually quite complicated. You know, what's the cost of laundering versus what's the cost of disposables? And so, you know, economists and supply chain people need to provide better information that can then inform better decisions by hospitals. But I think if hospitals were ever to make a policy change and they'd say, you know, we wanted to make this change and here's why. And they announced that, again, it would be good press that would help again, convey this idea that healthcare is taking this issue seriously and other groups should as well. I do expect we'll see more and more of that over the coming years. You want to talk to Dr. Bob? I was gonna say just briefly, in terms of what the AMA could do. Oh, you know, the public reach of the AMA's voice comes and goes over time. Traditionally, it has not been a progressive institution. Obviously been taking a lot of efforts recently to be more progressive. Most of the public action I was seeing coming out of the AMA recently has been about issues of race and racism, which is wholly appropriate. Could the AMA start to work to get more attention to the climate crisis or through the climate crisis and environmental racism? I could certainly imagine that being done. JAMA just announced its new editor yesterday. It'll be interesting to see what direction she decides to go with that journal. Also along the lines of what medicine could do to lead by example, wouldn't it be better for the environment if professional meetings continued on Zoom like they have been? Yeah, and again, the interesting question is what's the carbon footprint of the great national, international commerce of physician meetings? So yeah, and in doing that and reducing air travel by anyone, not just physicians is again, a relatively low hanging fruit that certainly my being with you by Zoom today while slightly less satisfying does spare the carbon cost of a round trip flight from Boston to Chicago, which is significant. Lots of physicians or at least prominent physicians like to fly business class. And the minute you start flying business class the carbon footprint of that flight becomes enormous. What would need to be considered is what if anything significant would be lost by that sociality and collegiality between individuals? The notion that physicians ought to travel to meet with each other has been embedded in the profession for a long time. You start to see surgeon travel clubs in the late 19th, early 20th century and a variety of them have existed ever after. Surgical travel is the most, used to be the easiest to justify because this was actually a method of technique transfer. You could see how someone that could operate and it was easier to convey that in person than just by publishing the description. But a lot of that could now be done fully online. There's very good video technology. You could film surgical technique. It's not the same as being there. If the medical profession switched wholly to online meetings, it would certainly spare physicians massive exposure to advertising by the pharmaceutical and device industry and that'd be a good collateral benefit. There probably would be something hard to quantify that would be lost in the collegiality. The one example that's on my mind is the case of international physicians for the prevention of nuclear war. That was an organization that was grounded in relationships between cardiologists and largely in Boston, Leningrad and Moscow. And those built enduring relationships and sometimes they have interesting effects. So some of you might have seen this news coverage just recently, James Mueller who's a local cardiologist here in Boston who had been a Russian studies major in the 1960 before going to medical school. And so when Bernard Lau and set up IPPNW and started to have meetings with Chazov, his counterpart in the Soviet Union, he brought Mueller along as the translator or as an interpreter. So Jim has been involved with this since the mid-70s, has very deep connections to senior Soviet and now Russian medical and scientific leaders. And so just last week was invited to speak at the Russian Academy of Sciences in a talk that was broadcast to some extent throughout Russia uncensored. And so he spoke about the war in Ukraine and the threat of nuclear annihilation. I worry about what will happen to the people who invited him to give this talk, but that was a valuable moment of public advocacy. And I don't think that could have happened if he hadn't built those relationships over the decades from being in person. But of course that talk was made possible by Zoom technology. I mean, he didn't fly to Moscow to give this talk right now. He did it virtually. And so there is an enormous amount that physicians could do. And if physicians were to signal, we've decided this is important. We're gonna stop traveling to fancy resorts for our conferences. That could have a big public impact. It would save time. It would save money. It would save carbon footprint. You would lose something hard to quantify, but maybe we'd learn how to manage that. We'd be sacrificing something, giving something up. Yeah. And it's a trade-off. What share of what takes place at a medical conference is truly educational and that could be done mostly online. What are the social benefits? What's the value to what extent does it maintain morale? To what extent does it help the campaign against burnout? You need to think hard about the kinds of things that would be lost if we switched to fully online. You can certainly imagine a partial implementation of that. So if you were going to a conference and you were really just going to the conference to hear talks and get CME credit, you wouldn't miss that much by doing that online if it was well done online. So some share of the travel could be dropped, I think, without costs. But we would have to think about the things that would be lost by that. Well, that was absolutely terrific, David. And I think we should give you at least a little bit of downtime before you have the next session, just also for all of us to process. But I think if anything, this COVID era has shown that we are living in a period of tremendous change. The last two years have brought around a lot of change. And the way I look at it is the fact that, what did they say in crisis opportunity? So the way change really happens is it often isn't linear, it's disruptive. All of a sudden, people can't go into the office and all of a sudden, video technology and telephone technology, which has been around for a long time, becomes a viable alternative. So I would argue that we should be using this time to be innovative, creative and thoughtful. So one of the other things, just on a personal level is, it used to be if you had a conference like this, it was one and done, right? Because everything was in person, if you missed it, it was gone. Now I think for the foreseeable future, things will at least, once they go back, will probably be hybrid to good advantage. And I think that the other thing you said is the fact that information is not gonna change, you have to actually, advocacy requires a more activist potential. And I think living through a time where we have been as a society, both politicized and in some ways, radicalized. I mean, it's hard to walk away from the racial issues that are everywhere in medicine. So I just think that this was a terrific talk and a lot of food for thought. And I'm gonna hit you up for your bibliography, which I think is an amazing resource that I think this group and others like it would really benefit from. So I wanna thank you and give you at least a little time to go stretch your legs and get something to drink before you come back at 130.