Is the Extreme Heat Getting to Our Heads?
One way or another, the climate crisis threatens pretty much all of us -- and the threats extend far beyond the physical. When we consider disasters involving extreme heat and flooding, we may think first of injuries like heat stroke, dehydration and drowning, or increased vulnerability to infectious disease vectors. But the climate crisis and associated disasters also cause severe and potentially lasting psychological injury. For example, increases in average seasonal temperature, and in particular in the frequency of very hot days, are associated with increases in interpersonal conflict and other forms of violence. And a growing database of research shows strong links between weather disasters and consequent depression, anxiety, and post-traumatic stress disorder. Moreover, the climate crisis is quintessentially unjust: carbon emissions, the primary driver of climate instability, are highest in wealthy communities, while the destructive consequences of global warming hit poor communities and communities of color first and worst. The threats that I experience, as a white man belonging to the wealthiest 5%, pale in general compared with those faced by most of my patients and their families. Individual cases can be useful in helping us really see how the level of threat varies by community. Below I will present the case of a former patient of mine, a woman in her late 20s. As I present this case, I'm partly talking with myself, trying to retrace my personal education as a psychiatrist: from competency in biological and clinical knowledge, to an understanding of relevant social and political determinants of health, to my eventual awareness of how these seemingly distinct modes of understanding are in fact inseparable. In the process, I have become committed to political action aimed at system change, because of my conviction that such work is necessary to address the health harms -- especially the mental health harms -- caused by this crisis. Case Study  For context, the case I present here is from the Metro Boston Program for Assertive Community Treatment (PACT) team, where I served as a team psychiatrist for several years. PACT is an interesting service model that provides in-home multidisciplinary services to patients with chronic severe mental illness. While not originally designed to save money, PACT has been adopted by state and other public mental health departments as a means of managing so-called "high utilizers" -- people whose health problems cost the system inordinate amounts of money as a result of emergency department (ED) visits and psychiatric hospital admissions. On this particular team, more than 90% of our caseload were poor and of color, the great majority African American. In mid-2019, a few days into yet another record-breaking heat wave, I visited Alana, a 29-year-old African American woman with schizophrenia, adult-onset diabetes, and chronic asthma. She lived alone in a one-bedroom subsidized apartment in one of Boston's poor, pavement-rich, food-deserted, historically red-lined neighborhoods. She invited me in to talk in her small living room. She appeared more fatigued, more distracted, and more disheveled than usual, and told me she'd slept poorly for the past several nights since the latest heat wave began. In fact, the temperature in her apartment was around 90 degrees; the air quality was poor and there was no appreciable air circulation. She had a window air conditioner in her bedroom, but she'd stopped using it a few weeks earlier after receiving a threatening-looking bill from the electric utility in a bright orange envelope labeled "URGENT." Her budget barely covered her monthly rent and utilities even in normal weather, and the previous month she had been unable to pay the balance on her utility bill because of the increased charges resulting from her AC use during an earlier heat wave. The next morning, I learned from my team that Alana had presented to the ED during the night with an exacerbation of chronic asthma: cough, wheezing, and shortness of breath. Her respiratory symptoms eventually responded to nebulizer treatment and she was "medically cleared" -- she was sent home with inhaler refills and instructions to follow up with her primary care physician. But our team's mental health worker who met her at the ED and drove her home immediately recognized that she was in significant distress. Her persecutory delusions and auditory hallucinations had already begun to increase shortly after her ED visit, and over the next few days she became severely agitated and reclusive such that we were finally forced to seek inpatient psychiatric admission. The Factors at Play  Biologically, this was a vulnerable patient with a serious mental illness who suffered an acute exacerbation due to a prolonged period of disruption of basic neurovegetative function. She had no AC, or no money to pay for it. In fact, she became threatened by bills in bright orange envelopes. And for good reason, since our poorest, most marginalized neighbors are at significant risk of being evicted, for even small or temporary issues like late utility payments. In these and other ways, the climate crisis, caused primarily by human extraction and burning of fossil fuels, harms people according to race, income, and zip code. I live less than 5 miles away from Alana, but inhabit a different universe. I will turn up my AC or go to a local park for some shade and fresh air. Alana, if her paranoia receded enough to enable her to venture outside, would suffer even more severe asthma symptoms as a result of the heat islands (paved areas that magnify heat intensity and concentrations of respiratory toxins) that are so widespread in her community. These inequities are old; but the climate crisis reveals them and exacerbates them tremendously. Understanding these health injustices has led me to make personal changes. I have divested my retirement and college savings plan investments from fossil fuels; I compost and recycle; and drive as little as possible, using an electric vehicle when I do. I have also learned that personal changes are not enough. Science tells us that keeping human-caused global warming within the range that is compatible with most forms of life will require "significant transitions in land and ecosystem, energy, urban and infrastructure, and industrial systems." Change on this scale requires political action. That is why I have also learned to organize politically. With informed colleagues and passionate, inspiring student leaders, I have helped develop institutional campaigns on college campuses and teaching hospitals, promoting divestment from fossil fuels with re-investment in community development and renewable energy. I am an active supporter of Green New Deal initiatives such as those proposed by Rep. Alexandria Ocasio-Cortez (D-N.Y.). In fact, I have come to see that political initiatives like the Green New Deal are fundamentally about human health, and health justice. I hope I have helped you see, the way I have, how poverty and systemic racism looks like an asthma exacerbation that leads to a psychiatric admission. And I hope you will join me in political action to change this. Jim Recht, MD, is an assistant professor of psychiatry at Harvard Medical School in Boston.