Tracking and Preventing the Health Impacts of Extreme Heat
The response to the 9/11 terrorist attacks included building from scratch a bioterrorism-monitoring system that remains a model for public health systems worldwide. Today we face a similarly galvanizing moment: weather-related hazards cause multiple times the 9/11 death toll each year, with extreme heat often termed the “top weather killer,” at 1,670 official deaths a year and 10,000 attributed via excess deaths analysis. Extreme cold and dense wildfire smoke each cause comparable numbers of deaths. By rapidly upgrading and expanding the health-tracking systems of the Centers for Disease Control (CDC), Veterans Health Administration (VHA), and Centers for Medicare and Medicaid (CMS) to improve real-time surveillance of health impacts of climate change, the U.S. can similarly meet the current moment to promote climate-conscientious care that save lives.
Challenge and Opportunity
The official death toll of extreme heat since 1979 stands at over 11,000, but the methods used to develop this count are known to underestimate the true impacts of heat waves. The undercounting of deaths related to extreme heat and other people-centered disasters — like extreme cold and smoke waves — hinders the political and public drive to address the problem and adds difficulty to declaring heat waves as disasters despite the massive loss of life. Similarly, the lack of integration of critical environmental data like “wet bulb” temperature alongside these health impacts in electronic data systems hinders the provision of medical care.
National Accounting
The national reaction to the 9/11 terrorist attacks provides a roadmap forward: improved data and tracking is fundamental to a nation’s evidence-based threat response. Operated by federal, state, and local public health professionals who comprise the CDC’s National Syndromic Surveillance Program (NSSP), surveillance systems were developed across the nation to meet new challenges in disease detection and situational awareness. Since 2020, the CDC’s Data Modernization Initiative (DMI) has provided a framework for this transformation, with the stated goal of improving the nation’s ability to predict, understand, and share data on new health threats in real time. While the DMI has focused on the pioneering role of new technologies for health protection, this effort also offers a once-in-a-generation opportunity for the public health and medical surveillance establishment to increase their capacity to address pressing future threats to the nation’s welfare, including the evolving climate crisis. Increasingly, extreme weather is responsible for both near-term disasters (more frequent and intense heat waves, dense smoke waves, and cold waves) and the long-term exacerbation of prevalent health conditions (such as heart, lung, and neurological disease). Its increasingly severe impacts demand a detailed and funded roadmap to attain the DMI’s goals of “real-time, scalable emergency response” capability.
Patient Care
Syndromic surveillance systems track the impacts of events at a population level, but other resources are needed to directly help individual patients during a disaster. Electronic health records (EHRs) allow medical providers to track relevant information that could help diagnose arising health conditions. Some medical systems have begun tracking nonmedical information to assist in diagnosis, such as the social determinants of health (e.g., housing and food availability) that are linked to improving patient outcomes. However, the environmental conditions a patient has experienced are not typically linked to health records. Improving the links between environmental conditions and EHRs will help patients—for example, by determining if a new asthma diagnosis is related to recent smoke waves—and also support syndromic surveillance.
A similar effect occurs with death records. Death records are typically logged at the patient level with free-form text that is mostly up to a medical professional who is often under time pressure. Text for each death record is later coded to fit into specific cause codes as it is aggregated into population-level datasets such as the National Vital Statistics System. Information about the environmental conditions that contributed to the death can be lost at any step along the process, resulting in the undercount of climate-related mortality. Improved tracking at the individual level will improve accounting at the national level.
Plan of Action
In order to track the health impacts from extreme weather events and thereby enhance the provision of medical care during such events, both disaster and health data must be improved.
Recommendation 1. National accounting for health impacts of the climate crisis
The National Syndromic Surveillance Program provides a world-class starting point for better tracking of climate health impacts, both in terms of technology and a dedicated and knowledgeable workforce. The following plan will permit the evolution of this underlying infrastructure to provide health systems and policy makers with real-time and forecast impacts.
To modernize real-time monitoring of health impacts:
- CDC should actively support efforts within the NSSP to expand tracking of more conditions tied to the health impacts of extreme weather events. In parallel, new research initiatives are needed to link these new surveillance syndromes with health system burden and health outcomes to improve the real-world predictive utility of these efforts.
- CDC should work with the Department of Education to track school closures and student absences, and with OSHA to track work-related injuries during extreme weather conditions. The National Institute for Occupational Safety and Health (NIOSH) at CDC will be a key partner in developing worker tracking as they already conduct surveillance including worker absenteeism and mortality. Similar programs should be constructed for schools, for example, leveraging the student attendance counts already collected by states to make a school-absenteeism surveillance program (e.g., by expanding existing efforts like the School-Based Active Surveillance Program or the Youth Risk Behavior Surveillance Program, which each track limited data for different goals).
- CDC should develop guidelines and funding for cities and states to expand their individual syndromic surveillance capabilities. Achieving uniformity across the nation is a major difficulty with expanding the NSSP, and CDC should work with the NSSP Community of Practice to develop, then promote, best practices through partnership with jurisdiction-specific syndromic surveillance.
To improve forecasting capabilities of health impacts:
- Congress should fund the CDC to expand its Center for Forecasting and Outbreaks Analytics (CFA) to include forecasting of environmental conditions and their health impacts. The HeatRisk service is exactly the kind of program that should also be available for smoke and cold—it clearly integrates the best science of health impacts of extreme weather events with best practices for public communications.
- Congress should fund the CDC to expand the CFA to make forecasts of operational needs for hospitals. Many hospitals now operate on a just-in-time system of stocking medical equipment that relies on typical-use rates that rapidly change during an extreme-weather event. A key piece of this operational forecasting should include potentials for cascading failures, as extreme-heat-caused failure of the electric grid is predicted to have major cascading failures in the health system.
To improve the ability to track health impacts:
- CDC should develop guidance and training on reporting environmental conditions as contributing factors on death certificates, similar to their toolkit on Death Scene Investigation After Natural Disaster or Other Weather-Related Events and other existing training. The guidance and training could be developed by analyzing existing practices from across the county. Additional training for medical providers are listed in a separate memo.
- CDC’s National Center for Environmental Health, as part of their Disaster Epidemiology and Response program, should develop guidance for states on reporting heat-related deaths to the National Vital Statistics System that includes information about how free-form text from medical examiners is coded by state-level health officials. This recommendation builds on the prior recommendation—both are needed to ensure that heat-related deaths are appropriately counted at the national level.
- CDC should expand its use of excess-death and flu-burden methods to provide official estimates of the health impacts attributable to extreme heat beyond those reported on death certificates. Such methods exist and have been used for heat; they should be standardized and regularly applied at the federal level.
- CDC should work with the Environmental Protection Agency (EPA) to expand its BenMAP software to include official estimates of health impacts attributable to extreme heat. The current software provides official estimates of health impacts attributable to air pollution and isused widely in policy. Specifically, EPA should expand its BenMAP software to: (1) include the ability to model deaths due to heat and cold and their consequences (e.g., wildfires, industrial accidents); (2) add the capability to run in real time on real-time environmental data feeds; (3) include forecasting in the tools based on short-term forecast feeds and longer-term climate models; (4) integrate the outputs as a health-impact “nowcast” available with other data feeds such as the Heat and Health Tracker, the Heat Related EMS Activation Surveillance Dashboard, and/or the HeatRisk tool.
- Develop an extreme weather event impact self-report tool and database similar to the USGS “Did You Feel It?” web-based local data collection system. The resulting qualitative data will permit more in-depth understanding of the personal, family, community, and health system impacts of weather-related emergencies.
- Several actions are needed to support the preceding recommendation, including additional interagency (EPA/CDC/National Oceanic and Atmospheric Administration (NOAA)) collaboration and data sharing. Research is needed to develop the health-impact functions for the BenMAP tool, which could be solicited in a research call such as through National Institutes of Health (NIH) Climate and Health initiative, conducted by CDC epidemiologists, or tasked to a national lab. Additional software development is also needed to cover real-time and forecast impacts in addition to the historic impacts it currently covers.
Recommendation 2. Improving Patient Care
To integrate environmental conditions into EHRs nationwide:
- Environmental conditions should be integrated with EHRs as part of data modernization efforts within federal medical providers. Examples include the Federal Electronic Health Record Modernization program and Veterans Health Administration (VHA) EHR modernization effort.
- The major EHR providers should pilot the incorporation of environmental data into EHRs beyond the federal medical systems. University medical centers would be ideal test partners for this before expansion to all hospitals nationwide.
- Federal agencies promoting the uptake of EHRs, such as the Centers for Medicare and Medicaid Services (CMS) Promoting Interoperability Program, should include the integration of environmental data in electronic health records in the tools they promote.
- CDC should add “Tracking Disasters” as a key priority in its Data Modernization Initiative and use that program to encourage tracking of disaster-relevant data, such as environmental conditions, along with health records.
To support patients during extreme heat:
- Expand the definition of medical devices to include items that protect against extreme weather. For example, air-conditioning units and other strategies that reduce personal risk of heat illness should be eligible for purchase with health savings accounts and with Medicare/Medicaid.
Conclusion
Deaths from extreme conditions, already high, are forecast to increase in the coming years and decades and potentially define a new modern era. It is vital to prepare our health system for these threats, including accurate accounting of their toll, and better prepare healthcare providers and the public for the conditions they will face.
This idea of merit originated from our Extreme Heat Ideas Challenge. Scientific and technical experts across disciplines worked with FAS to develop potential solutions in various realms: infrastructure and the built environment, workforce safety and development, public health, food security and resilience, emergency planning and response, and data indices. Review ideas to combat extreme heat here.
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