wired.com

Rose Eveleth

01.18.2022 07:00 AM

Last summer, a doctor wrote “climate change” in his patient’s chart. But is medicine really ready to address systemic health impacts?

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Last June, a heat dome settled over British Columbia, shattering the region’s heat records for five consecutive days and hitting temperatures of over 120 degrees. The dome was responsible for at least 500 human deaths (and potentially a billion marine creature casualties) and stretched the health systems in the region to their breaking point.

And at one rural hospital in Nelson, British Columbia, doctor Kyle Merritt began to feel like there was more he should do than simply treat all the patients coming in with heat stroke and exhaustion. “I was upset with what I was seeing,” he says, “I felt like it should be documented in some way.” So when a 70-year-old woman arrived with heat stroke, he wrote “climate change” in her medical chart as the underlying reason she had to be admitted to the hospital.

It was the first and only time Merritt chose to include “climate change” as an underlying condition in a patient’s chart. “It was the first patient that I felt like it was really clear cut,” he says. Had the conditions outside not been so extreme, he might have been able to discharge her and let her recover at home. When we spoke, Merritt emphasized that it was a decision he made in the heat of the moment. He never expected it to become national news.

Months later, when speaking with the founders of a small organization called Doctors for Planetary Health, Merritt shared the story of his decision to write “climate change” in the patient’s chart. When they asked to use that story in a press release accompanying a planned climate rally, Merritt didn’t think anyone was going to read the press release about this little thing that happened.

But read it they did. Eventually, Merritt’s story was all over the news, often under erroneous headlines claiming he had “diagnosed” a patient with climate change (the phrase appears in her chart as an underlying cause, not a diagnosis). The story was covered by national publications like NBC News, The Hill, The Daily Mail, along with a host of right-wing news sites like GOP USA.

Some praised the decision for bringing necessary awareness to the connection between climate change and health. “When I saw this, I thought, ‘Yes, this is what we need. We need more attention to the social determinants of health,’” says Keisha Ray, an assistant professor at the McGovern Center for Humanities and Ethics at UTHealth. Others claimed this was “the latest example of team-left lunacy.” Some columnists argued, incorrectly, that the patient probably didn’t get proper treatment because her doctor “diagnosed her” with something incurable. (Merritt admitted the patient to the emergency room and she was treated for her condition.)

When I read the story, my question was less about Merritt and more about the patient herself. Did she know she was the center of this news blip? Had he talked to her about climate change, or the fact that he was writing it in her chart? Did she give permission to be in the press release? And what are the ethics of turning a patient into a public point?

Doctors use case studies all the time to communicate with one another, and with the press. And for good reason: People connect with and remember stories far better than generalized facts. But using a patient to explain a concept, or to help educate doctors on how to treat someone more effectively, is different from using a patient’s story to make this broader, public point about climate and health. Even Merritt admitted that writing “climate change” in this woman’s chart didn’t do much to help her or other patients suffering during the heat dome. “It’s not like some other doctor was going to look at it and make sure they were never exposed to climate change,” he says. “Practically speaking, it doesn’t really do that much.”

Medicine has a checkered history when it comes to using patient stories and protecting privacy. For decades, doctors paraded patients in front of the public without their consent. In 1906, for example, a famous doctor named Wilfred Grenfell published the story of a 9-year-old boy who had accidentally shot himself in the knee. Grenfell used the boy’s full name, image, and identity, telling the tale with gusto each time he spoke to the public and his colleagues—even distorting the facts of the case, turning “slight” bleeding in the original chart into “shocking” bleeding and a “heterogeneous mass of bloody rags”—in order to entertain donors, make himself seem more heroic, and maintain his status as a celebrity doctor. Fast forward to today, and issues of patient privacy are still very present. In 2012 the ABC show NY Med, which at the time starred celebrity doctor Mehmet Oz, broadcast the death of a patient without his family’s consent. His widow won $2.2 million in a suit against the hospital.

Given that history, the question of how much to anonymize a patient in these tales is well-trod territory for medical ethicists. “As long as the physician doesn’t give any kind of identifying information, then it would be ethical. You want to always maintain the patient’s privacy,” says Ray. “But you also have to think about how minor information can be pieced together, where someone can figure out who this patient is.”

In Merritt’s case, the details provided to the press go like this: We know the patient’s age, her background medical conditions, the type of home she lives in, and that she was admitted in June. Kootenay Medical Center, where Merritt works, serves less than 4,000 patients. “That’s a lot of identifying information,” Ray said, when I told her the facts that had been publicly confirmed. “Small towns don’t tend to have a lot of physicians, so you could very well be one of three physicians.”

This feels increasingly important when a story is used in a way that might be construed as political —calling for action on something like racism or climate change. In a world where private citizens can be outed and harassed for being associated with a cause or a side, doctors who want to use a patient’s sickness to make an activist point might need to be a little more cautious. “I worry that the sensationalism of this story may encourage people like journalists to go seek this patient out,” says Ray. “And I also worry that because climate change is still very political and it still is considered a left-leaning idea, that it may encourage conservative media to go and find this person and pit them against each other.”

That hasn’t happened in this case. But Merritt says that if he were to do it over, he might have done things differently. As it unfolded, he didn’t tell the patient he was writing “climate change” in her chart. In fact, they didn’t discuss climate change at all. “If I had known when I had written that in the chart that it was something that I was doing to try and tell the story, I don’t know. I may have talked to the patient more about it and asked their permission,” he says. “But of course, at that time when I did it, I had no idea that it would ever become a story of any kind.” To this day, Merritt believes that the patient has no idea she is the one in the story.

Beyond the specifics of Merritt and his patient, the story raises big questions about how medicine can and should handle systemic impacts on health.

Merritt wrote “climate change” in a bout of frustration, wanting to document what he was seeing in real time. Other doctors have taken different approaches. Nyasha Spears, a physician at St. Luke’s Hospital in Duluth, Minnesota, takes nearly the opposite tack that Merritt did—rather than quietly writing in a chart to make a broader point, she talks to her patients constantly about climate change and the environment. “As a family doctor, my jam is habit change. This is what I do,” she says. “So my thought with climate change is, can I start peppering my conversations with patients all the time with an argument that habit change is good for them on a personal level, but also good for the environment?”

In the case of Merritt’s patient, this talk might not have done much. There was nothing she could do about her conditions, no habit change she could make to avoid the scorching heat. Like many in her community, she likely couldn’t afford to install air-conditioning in her trailer, and beyond that there was little to be done. In cases like these, Ray says that maybe a climate change talk isn’t warranted. “They can feel helpless because there’s nothing that they can do,” she says. “They are literally living, and just living is making them sick.”

This reality can make things feel bleak for both doctors and patients. And to address these connections between health and structural conditions like climate change and racism, doctors will need to ask not simply what they can do for each individual patient, but also what they can change about medicine to account for and reckon with these links. Today, there is no diagnostic code for climate change, no way to link these cases up or track them in any way, but perhaps there should be.

“There’s all sorts of ICD-10 codes that are completely inane,” says Spears. “If you ever want to entertain yourself, you just start looking at ICD 10 codes. ‘Fall from a spacecraft’ is one. And so it would make perfect sense that there would be an ICD-10 code for climate change illness.” Being able to track these additional, systemic determinants of health could make it easier to prove the links, and do something about them.

Having more data doesn’t always mean making change—the impact that race and income have on health have been well proven for years, but still haven’t adequately been addressed. And Ray says that adding these codes shouldn’t stop with climate. “If you live in a poor area, then you are likely living with more environmental impacts. Are we going to start now having a code for low income? Is there going to be a code for: You don’t have enough money to live in a safe home and so you are experiencing environmental toxins? Is improper housing also going to be coded? So I just wonder how far we are willing to take it.”

This might be the silver lining in the story of Merritt’s patient. When we spoke, he told me he had recently gotten an email from Health Canada, asking to talk to him about creating a diagnostic code for climate change that doctors could use to track these impacts.

Writing “climate change” in one patient’s chart isn’t going to save the world, or even a single life—Merritt is the first to admit that—but it can start a conversation about how much the medical system is willing to adapt to the threats that its patients truly face. “I’ve learned a lot about how big of an impact a story can make,” he says.