Welcome everyone I am Seema Wadhwa the executive director of environmental stewardship at Kaiser Permanente, and I'm thrilled to welcome you to the event today. Getting to net zero the HealthEquity imperative. We are proud to host this discussion with the national Climate and health leaders and discuss why getting to net zero can improve health and address disparities. I've been pleased to also introduce Kaiser Permanente, Senior Vice President and Chief Health officer, Dr. Bechara Choucair. Dr. Choucair leads our organization's efforts to address a social health of all of our members and communities. We serve. This work includes the creation of the nation's largest social Health Network integrated with Kaiser Permanente Healthcare Services to meet the housing, Food and transportation needs of our members.

He is also responsible for the organization's environmental stewardship work. Leading to Kaiser Permanente becoming carbon neutral in 2020? From January through November 21, 2021, Dr. Choucair served as a White House national vaccination coordinator, where he focused on coordinating the timely, safe and Equitable administration of COVID-19 vaccination for the US population. Doctor Choucair, thank you for joining us today. Thank you Seema and it's great to be with you all. There is no doubt that climate change impacts health. And there is no doubt that climate change this proportionately impact health, particularly communities of color, low income communities, and particularly communities who have been disadvantaged over the years. And as an organization, Kaiser Permanente is committed to HealthEquity and as an integral part of US, advancing HealthEquity is our commitment to being good stewards of the environment. And this is exactly why over the years we've been on this journey and we became the first hull system in the US to be certified carbon neutral back in 2020.

And that was with focus on scopes one and two. And This is why yesterday we've made the commitment to double down on our decarbonization journey, and we're making a commitment to reduce our carbon emission by 50% by 2030. And we are aiming to become. Net 0 by 2050 and we're signing on to the Health and Human Services pledge. And that's why I'm so thrilled to be here today.

With Admiral Rachel Levine. Admiral Levine is the assistant secretary for health. At the US Department of Health and Human Services, she overseas a slew of offices including the Office of Climate Change and HealthEquity Admiral Levine. I am so excited to have you here with us today, so welcome to Kaiser Permanente. Thank you so much. I'm really pleased to be here. Well, last time we both were together on a live event, that was when I served as the White House vaccination coordinator and the two of us held a national town hall.

Talking to pediatricians and family physicians with the AAP and the AAP to encourage physicians to talk to their patients about vaccinations. So it's been many months from now. So thank you for all what you have done and you continue to do to help us put this pandemic behind us. Thank you and thank you so much for your work for leading the vaccination campaign for the country over that past year. Absolutely fantastic work and working to distribute and administer. They're safe and effective vaccines to help our country get past COVID-19 I'm incredibly proud of how the federal government state government, local government health systems, not for profit.

All of us rolled up our sleeve and got this country vaccinated, so I'm incredibly proud of that. But today we're lifting up this really important moment, and we couldn't think of a better partner to celebrate our commitment with today than you, and the work that you're leading at HHS. So maybe we'll start by. Sharing with us. What is this HHS pledge all about? South? Just share with us and with the audience here today. Thank you so much so we know that climate change has significant health impacts and I love the term that you're using at Kaiser of Environmental Stewardship.

I think that that hits the mark exactly and so we need to all work together to make sure that our health systems are resilient to the impacts of climate change and also that they work to decarbonize. And so the pledge that we're asking. People to make to health hospitals and health systems to make is that they will do that exactly. That they'll become resilient to the impacts of climate change and they'll work with the metrics that you discussed in terms of decarbonizing, their hospitals and health systems.

And then we're going to have an event currently scheduled at the at the end of June to be able to go to the White House and to celebrate hospitals and health systems making that pledge at the White House. And then the work begins to actually accomplish. That and you all have gone. You know, the extra mile and accomplished much of what we need to do already. By in 2020? Well, so that's brings me to the next question. So once that pledge is signed on and people and health system signed on, what would come next like how's that working to evolve over the next few years to get us there? So we are currently part of a collaborative for the National Academy of Medicine, and I know you all are involved as well and so that is bringing together.

Many, many private sector partners to be able to to work on that and the National Academy of Medicine Collaborative under the leadership of Doctor Victor GAO. We'll be providing a lot of expertise and technical assistance to hospitals and health systems to actually accomplish what they've pledged to do. In addition, our new office, that which was mentioned of climate change and HealthEquity, will really Marshall much of the resources of the federal government to provide that assistance as well. Well, that's I'm glad you've mentioned the the office of Climate Change and HealthEquity really excited about this office. You want to share with us a little bit more about the office and what you expect from this office.

Absolutely so Under Secretary Becerra's leadership in the fall of 2021, we started this new Office of Climate Change and HealthEquity and it is to look at the health impacts of climate change that we've been discussing. But with that HealthEquity lens because we know that those communities that have historically suffered health disparities are also suffering significant health challenges. From the impacts of climate change, including heat, including forest fires, smoke from those fires. Sea level rise and more. Yeah, and we have been seeing this every single day. It's not just this is something to think about down the future. It's just happening today. I mean, you're think about the heat waves, the fires, the climate impact is just we really need to be prepared.

So thank you for bringing the expertise and the leveraging the resources from the federal government to help us help us with that. In addition to the Office of Climate Change and HealthEquity, there was a new office that also you've announced around environmental justice. Talk to us a little bit about that, sure, so that office was started actually in the last two weeks, and so our office of environmental justice is located within our Office of Climate Change and HealthEquity or Ochi, as we affectionately call it.

And so this office will be looking at those health disparities broadly about in terms of environmental issues. So it might involve climate change issues or problems from climate change, but other issues as well. For example, in several days I'll be going to. To Los Angeles and and going to an area that of a school that is located near a metal factory that shreds metal and they've had significant environmental issues for for decades. Now. Because of that, it also is on, I gather what is called the Almeda corridors, where there's tremendous traffic and that has caused significant air pollution for that area.

And the children that are at that school previously to this position, I was the Secretary of Health of Pennsylvania. And we dealt with significant lead poisoning issues in Pennsylvania. Pennsylvania has some of the oldest housing stock in the nation. Concerns about still about lead paint, and then again hits those same disadvantaged communities. So we're going to be looking at environmental challenges such as that. So how do you anticipate that this office would identify these communities? What kind of resources you'd be able to bring to these communities, or engage with these communities? Lift up the assets in those communities? How do you envision this work? To play out, sure. So we actually do know who where many of those communities are. So the communities in Pennsylvania I mentioned where I'm going in Los Angeles, you know, we've been to some states in the South that are having challenges because of sea level rise with, with sewage contaminating their their water supply and the water table. And so and that. So that's one of the climate change issues as well. And so we know where many of these issues are. So we want to engage local and state.

Of departments, and then we want to bring all of the resources of the federal government to bear working with partners across HHS. That might include the CDC, the NIH Center for Medicare, Medicaid Services, and others, as well as other departments such as the EPA Department of Transportation as well. To be able to again help these communities that have suffered health disparities from these environmental impacts. Great thank you and you've been on the West Coast. Now for a few days you've been visiting many of these communities.

Looks like you are going to be visiting some additional communities, and in the next couple of days, what have you been learning? What have you been hearing from community partners and folks in the community about climate change? Sure, so I was. I had the pleasure to visit Google yesterday and to meet with one of my predecessors, Dr Karen de Salvo at Google to talk about these issues of climate change and HealthEquity and how we can have a public private partnership with Google.

And potentially with other tech firms I was able to visit San Jose yesterday and to meet with the mayor who has is working to decarbonize San Jose, which will of course one of the biggest cities in the country and a an opportunity to do that. So and then with state health Department members today to to talk about their efforts and their office of climate Change and HealthEquity you know on the road trips I've done over the last month or so, I've been to Seattle. I've been to New York City. I've been to Albuquerque.

I've been to this area and they are all suffering from these health impacts from climate change. It's not an existential threat in the future, the communities are suffering those impacts now. For example, with severe heat issues that they experienced last summer, and that we're worried about experiencing this summer and again it hits those disadvantaged communities the hardest. Yeah, and we've seen that even within our own hospital systems with fires and the need to evacuate and to evacuate. Patient safely and do that very quickly. I mean, it's just those are real, real challenges that we've been seeing every single day. I think for a lot of people they think climate change is something you need to be thinking about down the line, but the reality is, we're thinking about this and we're feeling it every single day. That's exactly right. So is your sense that you're hearing the same stories across the country as you're visiting different parts of the country. It is. I think that there are some local variations, but again, I was really struck by the fact that from Seattle to New York to Albuquerque to.

California, in severe heat is an issue, and of course if you live in a community and you have means and you have air conditioning, you're going to be less impacted. If you're in a heat island and you have no ability to cool off, then you're going to be more severely impacted. Other more coastal communities, of course, are seeing impacts from rising sea level issues, and so all there is consistent themes that we're hearing, and that's what we want to do with our office of Climate Change and HealthEquity to to gather that information. Gather that data work across our department and other departments to work to address the impacts on health of climate change. Yeah, and I think I love the fact how clearly you're articulating the connection between climate change and HealthEquity, and I think we have no doubt that the impact of climate change is going to be disproportionate, and it is going to impact communities of color.

Low income communities, communities that are most vulnerable what? Device do you have for health systems as they think about their role in addressing climate change? Well, I think that the the health sector overall has a very important role to play. One is that the health sector accounts in the United States for 8.5% of our nation's carbon emissions, and so we're not going to be able to achieve President Biden's goals by 2030 without involving the health sector. I think we need to work at all levels. You know, all stages. In terms of that, in terms of the decarbonization think the toughest one is going to be the supply chain. That is where quote UN quote the rubber hits the road, both literally and figuratively. And so we're going to be gaining marshalling expertise from across the administration to help those hospitals and health systems.

Working with the National Academy of Medicine to achieve those goals, I think thank you for bringing up the the supply chain. We've been on a journey on with our suppliers and the supply chain. Leaders within Kaiser Permanente? And we had a chance to huddle earlier before we started this this life event with some of our leaders within Kaiser Permanente who are working on supply chain issues. And as you said this is going to be a journey, I don't think we know exactly how it's going to play out between now and 2050, but I'm so glad to see so many health systems and others across the country including the administration, focusing on how we decarbonize our supply chain and what would that look like.

It's a big chunk of our. Carbon comes from the supply chain and we have to come to it as a country. And honestly as a globe to be able to make a difference there. This is a global issue, so I was very pleased to represent the Secretary and the Department of Health and Human Services at COP 26 in Glasgow, Scotland. And that is where the United States formally signed on to the top 26 health program which commits the United States to those exact commitments that we talked about the building resilience to the impacts of climate change and our health systems. And also working to decarbonize. The president's memorandum stated that we're going to do this and the federal government that includes the VA that includes the Department of Defense that includes the Indian Health Service. And now we need to work it with a public private partnership to accomplish this across our nation. Thank you and and you've mentioned the National Academies of Medicine and we're obviously a proud partner and sponsor of the collaborative that's happening there. Can you tell us a little bit about how you think? This collaborative is going to continue to play out with health system.

Well, I think that the collaborative under Doctor Victor Shaw's leadership for the National Academy of Medicine is a critical partner and has a critical role in this effort. Because I think with the stature of the National Academy of Medicine and Doctor Shao, we can bring together many, many partners across the health sector. Not only hospitals and health systems, but tech, the pharmaceutical companies that many of those supply chain companies all working. Together to accomplish our goals, which are really absolutely essential for their health of our nation moving forward. Thank you and and we're obviously very proud to be part of that effort. We continue to engage and participate and bring our learnings and also come with a lot of humility to learn from others. Throughout this journey, the other aspect that we're also focusing on as we start thinking our journey to Scope 3 is really our investment portfolio and thinking about how we invest in a way that's help us towards that. Journey to to not zero.

Any thoughts or comments you have on that space? Well, you know. I think that the President has articulated and throughout the administration our secretaries have talked about is that we have to do all this in a fiscally responsible way, and we have to do it actually, that creates jobs and that helps our economy as we achieve carbon neutrality across across our nation. And so I think that that is going to be essential. We have to do this in a way that actually helps the finances. Of the of our great health systems and other companies. And that helps the economy of our nation. Thank you and a couple more questions before we wrap up. We have an amazing panel right after our fireside chat. There are ready to kind of take this discussion to the next level and talk about more about this intersection between climate health and climate change and HealthEquity. Just a couple of questions you've talked. You've got a chance to meet across the country. Lots of physicians who are interested in. Climate change and what role they can play.

We and the huddle earlier today you get a chance to meet Doctor Rita Nagaur, physician in chief here in Oakland, who shared with you how many of our physicians are so passionate and excited about playing a role in that space. What advice or comments do you have for physicians across the country? And we're both physicians here are very passionate about this space. Well, I think it is very important for a physician. Mission leaders, but other medical professions as well to be invested in this and that's why I love your term of of of environmental stewardship. We all really are stewards as healthcare professionals of our nation's health and the health impacts of climate change is really going to be one of the greatest challenges that we face in the 21st century.

So I think it really needs all of us working together. It's going to be critically important for physicians to be to be educated and informed about this. And then to work within their hospitals within their health systems with local state health departments to accomplish our goals absolutely and and my final question to you, the Admiral Levine. You oversee many offices and HealthEquity is integral to a lot of the work that you do day in and day out. Climate change is obviously an important part of that journey towards HealthEquity. What final comments do you have about this journey as a country towards helping us achieve health? Equity well, HealthEquity is really fundamental to everything that we're working on at the Department of Health and Human Services.

It is absolutely critical in one of the top priorities for Secretary Becerra, and so we don't want to make it just one more thing we're working on. We're working on COVID. We're working on mental health and then we work on HealthEquity. HealthEquity actually is is the foundation of all of the topics that we're working on. Whether it is COVID-19 long COVID, which my office is working on, whether it's mental health, whether it's overdoses.

Whether it's the impacts of climate change, HealthEquity is a fundamental principle for all of those, and we have to embed it into all the work that we're doing. And this is exactly how we look at our contribution as an organization towards this journey to HealthEquity. I think our commitment to addressing the impact of climate change is one part of that, but it truly is looking at all of the things that we do within our organization within the for all the things that we do for our two. 100,000 Plus colleagues, 22,000 plus physicians to the 12 and a half million members that we support and depend on us for their care and coverage. So the 68 million people in our communities we are committed to continue to be on this HealthEquity journal Journey. Admiral Levine. Thank you, thank you. Thank you so much for sharing this time with us here at Kaiser Permanente today. Thank you for your leadership on climate change. Thank you for your leadership at the Health and Human services. Department thank you for all what you've done to help us put this pandemic behind us.

We're so thrilled you're here, and now we'll turn it over to Seema to get us to the next part of this panel. Thank you, Admiral Levine and Doctor Choucair for that inspiring discussion. I am so excited about all of this work and the possibilities ahead. I'm honored to introduce our amazing panel of climate and health leaders for our next discussion here with us today is Doctor Don Berwick, President Emeritus and Senior fellow at the Institute of Healthcare Improvement, an organization he co-founded and led as President and CEO for 19 years. He is one of the nation's leading authorities on healthcare quality and improvement, Doctor Berwick. Also, previously held the position of administrator of the Centers for Medicare and Medicaid Services.

He is a pediatrician by background and has served as a clinical and public health professor as well as served on numerous health care and quality improvement boards and committees. He is currently serving on the steering committee of the National Academy of Medicines Action Collaborative on Decarbonization of the Health of the US Health sector. We're also joined by Doctor Colin Cave ahead of next surgeon and the medical director of External Affairs, government relations and Community Health for Northwest. Permanente he also previously served as a chairman of the board for the Medical Group, calling heads up, Northwest Medical groups, regional and national leadership efforts in addressing climate change, greenhouse gas emissions, and enacting their own climate action plan. In addition, he serves on the Board of Oregon for Climate Action. We are also thrilled to have Mishka Mitchell, President and CEO of Emerald Cities Collaborative, complete our panel. She leads a national nonprofit network of organizations. Working to advance sustainable environments while creating sustainable just and inclusive economies, she has over 18 years of leadership experience in climate, justice and equitable and inclusive neighborhood development. Before joining Emerald cities, Mishka served as vice president of Camden Community Partnerships, a nonprofit community and economic development organization in her hometown of Camden, NJ.

Thank you all so much for joining us today, so I'd really like to start by asking each of you. They're quick reflection on Admiral Levine's comments. Having HHS involved in addressing health impacts of climate change is truly a momentum shift for this work, so I'd love to get your reactions on what spoke to you about this conversation. And let's turn it to Doctor Don Berwick first. Ohh thank you so much. Uh Siemens. The light to be with you and with uh Colin and Mishka as well. Well, a lot of things about Admiral Levine's comments impressed me the. The biggest thing though is, is is the fact of high level federal focus on this problem. There are tremendous number of issues competing for attention in the public arena and in the private sector and in healthcare, and to have the assistance surgery for health step forward as she has and with the support of the Secretary and the President in such a forceful way, is is an extremely important resource for getting action going on this.

You have to have some empathy today for the many demands that are being made both on clinicians and on executives and leaders in American healthcare, and they need signals. They need leaders to step forward. Like Admiral Livian has and say this is important, we need to do it. That's going to help give us momentum and the establishment of the new office is is a structural step in that direction. The other thing that really impresses me is the learning system that's now being established and I must credit Admiral Levine with her leadership. There she has shown up. Repeatedly in the National county medicine context in which I'm on the steering committee, as you said Seema, she's present she. She participates, and she's encouraging the kind of learning altogether that is going to need. This is not a problem for silos. This is a problem for collaborative action and the model of interaction between the federal government and the private sector that we're seeing under the edges of that collaborative. With Admiral Levine support is is really thrilling, so there's a lot of promise here. Great, and let's let's mishkat be great to get your reactions next.

Alright, thank you Seema and thank you everyone for allowing me to be here today. Certainly I am thrilled. And you know, very enthusiastic just to hear Admiral Levine talking points today. You know, I echo, you know the sentiments about thinking how this federal response really is different in creating this structural change to think about how. You know HealthEquity and climate justice really are more than just buzzwords, and you know, really taking it from something that you know has, you know, been in the framework for for many, many years. But being able to put those federal resources behind it in order to have sustained action? You know we are all right that in order to tackle this climate crisis, it's going to take an innovative thinking and innovative ways. And, you know, collaborative ways to come. Together to really be able to tackle this in a different way, and so the you know the climate change and HealthEquity office.

And then you know a subset, a different office around environmental justice really helps to put that framework together as the first step to really think about how to tackle this as a comprehensive problem. Thank you, those are definitely really important reflections. You know, one of the other things I'd love to delve a little deeper into is we've had many heard from many people that climate change disproportionately impacts and is a HealthEquity issue, so Mishka from your perspective and actually before we shift to this question, Doctor Kavi realized we didn't give you an opportunity to share your reaction. So please, let's hear from you first. I appreciate that because I'm very excited about this. You know there have been a lot of people that have been leading in this space, but they're surprisingly there. Still so many who are on the sidelines. With some notable exceptions, the physician and clinician community has been one of those groups on the sidelines for too long, so by the Admiral and her department giving voice to this, we're now normalizing not just the fact that you know there's global warming and climate change.

But we're normalizing the fact that this has a great effect on on all populations with disproportionate effect on populations of color. The other great thing about this is that. When one branch of government sees what another branch of government is doing, it elevates it to everybody. We learned a lot about providing medical care in an innovative way during the pandemic. So much so that in fact I can't imagine going back to the way it was for us to continue this, though it's going to require some regulatory and legislative changes, and so by normalizing HealthEquity in in climate change, I think we have a really good chance of continuing all the innovation and the forward movement that we've managed to very quickly put together in the past two years.

You know, if a person isn't classically one of our patients, it doesn't really matter. Is the communities that we serve, sink or swim together as as the saying goes, we're all in the same flood. I think what the Admiral is trying to do and and her team is get everyone into the same boat. So I'm just very excited. Thank you and you know, as I was starting to to reflect in terms of you know, although we may all be in this boat together, some of those impacts are felt differently and Mishka it be wonderful to get your perspective given the focus of your organization, you know there's as I mentioned, there's absolutely conversations on how impacts are disproportionate, but I'd love to get behind the stats and the data where you might be able to share to us.

What does this really look like and what are you seeing? In the front lines that you'd like to share with others so that we can, we can make this something very real for everybody. Thanks Emma, and I think you're absolutely right and thinking about how we get behind stats in the data because, you know, we all have been talking about building a culture of health and we know that frontline communities are often disproportionately impacted and that the health impacts of those communities already show it that they're you know, disproportionately have impacts like asthma or low birth weights or hospitalization.

So like the data is already here and. And we know those things, but what does it really mean when we're talking about the impacts of climate and when it comes to these frontline communities and you know, for us? And when we think about it for frontline communities, it really means that those inconveniences that those communities already have to bear the brunt of whether we're talking about environmental injustice impacts from, you, know the histories of these communities to the adverse impacts.

Have been left to their health that those inconveniences become commonplace, and so, like when we're thinking about, for instance, in a place like my hometown of Camden, NJ, they're on the East Coast, where combined sewer flooding has already been commonplace. It means that not only you know are people thinking about what the impacts are? Every time it rains. But now these storms are more frequent, the flooding is. More impactful and these our communities that generally may not have home insurance in order to be able to make repairs after these floods and so home owners are worried about the impacts of the mold when they may already have asthma. It means that the you know, urban heat, island effect and many of the black, indigenous and commute other. Communities of color are impacted by, you know, these rising temperatures in these communities here in the Northeast just two weeks ago, we had a heat wave and they were the local community was giving out box fans to put in people's windows and you know, that's something that maybe many of the viewers have been thought about or that their children may have never even seen because they have central air and they're used to being able to just turn the switch and cool their homes.

Now and so you know, for these communities that are already disproportionately impacted by you, know the histories of environmental injustice. These climate impacts really do impact their ability to be able to live, you know, lives that are going to be able to bring them quality and joy. And so how do we make sure that as we're thinking about this, what we hope is addressed? Just transition to a green economy. On that, we are ensuring that the bipad communities are able to have equitable access to the resources that are coming from the federal funding or from the government and other resources, and that they're also able to participate in the economy itself. So if I could follow up from that and and thank you for taking a moment to to really help illustrate what this looks like. How can HHS health care and our audience members work with communities to help support and drive real change? Great question and I would say the number one thing that HHS and other you know partners, institutions governments can do is to start with talking to the communities themselves and begin to be able to Co create those solutions that put the communities at the center of creating what's going to be sort of the just solution for for their communities.

Equity needs to be at the center. And I was very glad to hear Admiral Lavigne, you know, talk about environmental justice and think about how HealthEquity and that word is really being put at the center of the office and the work that they plan to do that. It can't be an afterthought, as we're putting the plans together. So I would, you know, begin with cocreation. It's going to take collaborative efforts on thinking outside the box about how a public private partnerships. Are able to work together to come up with the solutions in order to come up. You know, we haven't gotten into this climate crisis overnight, and it's really going to take all of us working together in order to make a difference. Thank you, I think that's some very solid actionable advice, so you know Don and Colin. You both come at this from different areas of expertise. I'd really like to understand from both of your perspectives why our environmental impacts of climate change such an important part of the discussion around HealthEquity.

You know, we're building off of what Mishka was saying. HealthEquity really needs to be centered. So how does that? It from your perspectives and Colin, we'll start with you this time, thanks great. I think it's really important to understand that 80% of actual healthcare occurs outside of the exam room. It's about 20% of of healthcare occurs in our clinics. So that means that everything else, social determinants of health resources, or lack of resources, those things that lead to aces adverse childhood events, traumas when you're a child. Those all impact the health of you. At that time, but also for generations forward. If, for whatever reason things happen and you don't graduate from high school, you are going to have a shorter life expectancy. Statistically, it's going to cost four times as much to care for you Healthwise over the course of your life as well, so these things really matter that as Michael was saying, the economy and health are absolutely interconnected. If if there's a a flood or a fire or a heat wave, there's obviously direct physical effects that we feel, but these events also affect the economy in our communities.

If you don't have access to your school because of burned down, your house burns down, or you don't have a job because the the business got flooded out that directly impacts the economy of the individual and their ability to fund or not fund certain things is going to affect the health of them. And their family. So as global warming destroys our environment, unfortunately it destroys our economy. And with that directly our health. You're muted seema. Thank you Don. It would be great to get your perspective as well, thanks. I agree with everything that both Michigan and Collins said. I mean the the basics here. We have to be concerned about this because it's important because of the size of the effect that the World Health Organization has now declared climate change to the single most significant threat to human health on the planet. The science is pointing us there, and so we we have to be concerned about this for everyone. But as Michael pointed out, the effects are unevenly distributed, as are many of the forms.

A burden and suffering in our planet, unequally distributed according to wealth and and socioeconomic background and race. In this country the we should be. We need to put resources where the gains are the most and the gains of the most among the people most affected. This of course, is in the context of inequity as a global issue in the American healthcare scene, and you can't be interested in quality and health anymore without being interested in equity.

Did the science doesn't let you escape that issue. Uh, there is another point I'd like to make though, and this is it's not 0 sum at the university at Berkeley. There's a professor John A Powell, who has written and spoken a lot about what he calls targeted universalism, which is often if you meet the needs of the people most in need. You end up meeting everyone's needs, and I and I think, framing this is somehow a win lose situation where if we help the minorities have this advantage, populations were somehow taking it away from others.

Is is actually a misconception helping mitigate the effects of. Climate and carbon on people of color and marginalized communities will help us all. You know, I I'd like to build off of that in terms of those impacts, so you know, there's there's a lot to be understood. Although there's a lot of information out there already when it comes to how climate change harms health. You know, for instance, many people don't know the fact that heat kills more people than any other extreme weather than all other extreme weather events combined. So Colin, from a physician's perspective, what does? What do you see first hand? What are you witnessing? You know, I know, we're in the northwest and you had some extreme heat events earlier earlier last year.

I'd love to know what that really looks like. Yeah, Umm you know I live in Portland. I was born in Vancouver, Canada 2021. It was a horrific heat wave we've not seen before and it followed the great fire season and of 2020 in Oregon. The heat wave last year had over 1400 deaths associated with it, over 100 each in Oregon and Washington and over 800 in British Columbia.

Started as a with meteorologist called Heat Dome. Ironically, this is pretty much compared to how a pressure cooker works, and it sat over the area for several days. Portland, OR is known for its rain people avoid us for that fact, but there was a day on June 28th when my temperature read 116 degrees in Portland, OR Canada, registered 121 degrees, its highest heat ever. So what does this mean? Well, environmentally, you know Mount Rainier lost a third of its snow cap at what we saw structurally buckled, roads, closed, bridges, public transportation closes. So people couldn't go to work. Fruit was baked. And the binds crops were destroyed in the northwest, drove up food prices. Obviously set off wildfires. Seattle and Portland were particularly poorly able to handle this because these are two of the three cities with the least amount of air conditioners, because usually you don't run into 116 degree heat and a majority of the deaths that occurred in the northwest occurred in homes without air conditioning, 1100 people were hospitalized because of the heat, and Oregon and Washington.

And when you get that kind of. Overload the EMS system is overloaded and waits for non heat related or for any related medical condition increased so the strain on the resources affected people with other conditions like heart attacks for instance. How this affected people differently? If you had resources, as Michael was saying that you have an air conditioner, and if you don't have an air conditioner, you have resource, did you go to the hotel? A great majority of the hotel rooms were booked in Portland when they would usually be much less than that, but. And then there are those that don't have access to air conditioning and actually have to continue to work in a a survey of Washington, farmworkers showed that 2/5 had no access to shade, and a quarter had no access to cool water while they were working a death of a farmworker in Saint Paul, Oregon. Sebastian Francisco Perez led to a huge outrage and a lot of intense and appropriate scrutiny on on how we were treating people to work outside. But don't forget, this followed the fire season of 2020.

As we were heading into a pandemic and you talk about the same populations being subject to economic justice as to climate justice, we look at the health justice and you know, 1000 a million acres in Oregon were destroyed. 11 people killed, thousands of homes destroyed, 40,000 people were evacuated, 500,000 people were evacuation zones, including our hospital. It didn't have to get evacuated, but it came really close. An entire towns were destroyed in Oregon. Phoenix talent, Detroit. States these are not wealthy places, so when this towns were literally destroyed, we now have at the beginning of a pandemic with no vaccination. These people that had to be housed in large centers, shelters in the middle of a pandemic. You talked about insult on injury, so so we really are amplifying the haves and the have nots. And as Don was saying this affects everybody. So we really need to make sure that our resources get to those that need it. That we listen as Misha was saying to what people need and what they want.

So calling everything you shared, it's a lot. It's very real. It's very now. I'd love to understand from your perspective, what can physicians, nurses and others do to help prevent some of these impacts? How do we make a difference? Yeah, there's basically three ways. Innovate, anticipate and educate to innovate. We need to lead on issues of waste and awareness. We started a simple policy weight. Don't waste that means surgeons can't open single use surgical instruments unless they actually need it and has saved a lot of money standardizing trays. There's a lot of things that can be done. Healthcare without harm does a great job of helping to educate physicians and hospitals on this. Find ways to reduce emissions while maintaining or improving outcomes. The great Anesthesia Department at Kaiser Permanente Northwest. Several years ago stopped using des fluorine and switched over to seebo fluorine and for our 600,000 plus members every year that saves the equivalent of 1000 metric tons of CO2 equivalent being released into the air.

Anticipate despite our intentions and efforts, we will be providing care in a climate changed world. Part of our mission. You can't. We can't meet our mission if we can't do that, so we have to anticipate what we will need to provide ongoing care to our patients when there are supply chain disruptions. Rd closures. Remember, we had buckling roads and 116 degree heat mass evacuations up to and including our hospitals. If you don't have a plan, you need to get one now. You can't wait for it to happen because it's way too late and it happens way too fast. And finally, educate our patients and our colleagues. Listen to us. We need to make sure that we're asking them about what resources they have. Do they have a plan if they need to evacuate and make sure they know what to do when the air quality gets bad or heat becomes a major issue and so that they can take care of themselves and in other areas of the country.

Flooding and mosquito borne diseases so innovate, anticipate and educate. Thanks, I appreciate keeping it really simple in terms of where we can focus. So Don turning to you for a moment. You come with a deep background and working with I, I and the quality movement. I'd really like to understand. You know how? How is this work? Being embedded into the quality movement and where do you see see those links. Very strong links. The first. What is the nature of quality itself? Quality, the simplest definition of quality I know is meeting the need. You decide what you'd like to help with and then where that need is. That's where you go back in the turning points of the quality movement, say the National County Medicine report crossing the quality chasm in 2001 we didn't actually have climate and the the environmental threats to talk about. Now on the screen, the needs we were talking about are still are here for patient safety. For patient centered care. In organizations for following the science, when we give patients medicines and surgery. But now that we understand so much more about where the burden of illness is coming from than meeting than quality means doing something about it.

So equity now is also come to the foreground. And of course those overlap as we've talked about. Excellence isn't divisible, and if you want to be excellent in the care we give, we have to go. We have to be excellent in meeting the the causes of of distress and that now includes climate change as we've heard. I think there's a more direct connection because some of the basic tenets of modern quality, like for example, that higher quality cost less that you actually focus on reduction of waste reduction of what's unnecessary as part of the quality agenda, as column is just saving is absolutely part of both the quality movement and environmental stewardship. We have tremendous evidence of overuse of care that doesn't help people, for example, and that idea of making care, focus on all, and only what the patient needs and. Second, what matters to people? That's a carbon reducing idea, the the idea of that Professor Bernard Lounge spoke about for decades of his work about focusing on what really matters, would lower carbon footprint.

So there's a very close relationship, and in the methodologies quality improvement uses, metrics well, encourages constant testing and cycling through plan, do study, act cycles. It includes vast amounts of cooperation. Cross boundaries so that we can track the system. All of these attributes are the modern quality movement. They absolutely apply here. We need to learn our way together through quality improvement to reduction of of the carbon footprint and greenhouse gases. So I see this is absolutely central and a proper evolution of our attention and yet right. The Institute for Healthcare Improvement. IHI the organization that I had the privilege of meeting years ago and now I'm a senior fellow at.

It is thoroughly devoted to this now as part of its agenda. So building off of that, what one question I'd like to add is you know how? How do we go from that learning point to understanding that emissions are just as harmful to a patient's health as are medical errors? I've made a great strong case of of the why. We I I think that's where leadership like like Kaiser Permanente is showing and and doctor Kevin Mushka really matters. We need people with gravitas and respect and and and trust in the public to be bringing this message forward not. Hectoring or lecturing or yelling, but saying look, this is the truth and we need to defend the truth right now at a time in our country when sometimes science is under is under siege. But if we follow the science and we as professionals speak about what we now understand about the causal relationships here to both equity and health outcomes and climate, we will be trusted. So it's not a time for silence, it's a time to speak up for the truth.

So moving to that speaking for the truth piece, I'd like to ask one last question of all of you, and you have all brought such amazing perspectives. You know, as we as we are focusing on this key issue of equity, what are your thoughts on how we can further advance health making that connection between HealthEquity and reducing greenhouse gas emissions? These are two very important elements. Of of what lies ahead for us and I'd love to get each of your perspectives on how we connect them together and Mishka. I'd love to start with you please. Sure, thank you and you know first, I would say I think you know, having venues and opportunities to have this.

These kinds of discussions are a great start and I am very encouraged by the commitment of Kaiser Permanente and thinking about what the change at Health and Human services and these new departments will mean. Because both of those institutions I feel like really have been great at thinking about health at both an individual scale and a community scale. And I think that that is what's going to be needed, as we're thinking about tackling HealthEquity and greenhouse gas emissions when we're thinking about frontline communities. You know, we understand that those communities that the individuals in those communities are often less resources, but the communities themselves are often also less resourced, and so you know, being able to provide the resources and technical assistance that the Community is need in order to be able to.

Access resources to begin to have these conversations to tackle their own greenhouse gas emissions and to provide services to their citizens, we need to be able to think about the solutions on both of those scales, and I think these discussions really are the first step to being able to tackle that. Thank you Don. Loved to get your perspectives as well. We need to lean in and get action so some of the things that really matter first is Misha said several times the voice of the marginalized and affect communities needs to be elevated.

We need to make sure that people have power. This is about a transfer of power toward people who have been denied power and and his needs have been. Neglected far too much, so voices for communities, second voices for youth. I am now convinced that the political and social energy we may need to get this job done maybe more in the hands of young people than ever before. Young people. It's their futures we're talking about, and I sense a willingness. And if we can reach out across generational boundaries and help youth mobilize, that'll be positive. A third would be beginning. It would be data. It matters in understanding these texture differences. We just stratified stratify our metrics so as we measured greenhouse gases and the effects of pollution we we we need to be able to look at at communities that are especially effective.

We just had a meeting this morning with the Washington State Medicaid people who have a climate watch program that they're starting, which will allow a very fine grained view of effects. That's going to matter finally, and maybe a little bit edgily. We got a demand off it. Versity here green washing won't help. And we need to hold ourselves to account. For actually changing permissions, actually getting to the answer, nature will know if we are greenwashing and nature will be unforgiving and so there's a level of discipline here attached to metrics and goals that we really think I think is a very important part of the comments.

We need to make. Thanks for the chance to speak with you. Thank you Don and and I really that's going to stay with me. Nature will know. So Colin, I'd love for you to to leave us with your thoughts on. To wrap up this conversation, absolutely, I think you're going to see a common theme here. This is all about paying attention. We can't have arrogance for years and years and years. The medical community has been just arrogant. Now we need to listen to those communities who are in need. To get them what they say they need, not what we tell them they need or we think they need. Again, this is a common message. I think all three of your panelists have sent today. And you know, if you look at what happens if a hotel needs workers, but those workers can't afford to live in the area of the hotel and they have to live 30 minutes away and drive in, then you know we are driving up emissions by making them drive into work.

Affordable housing is key. If a child has an asthma flare and his mother or father who's working in the fields has to give up that day to take them in because it's a a bad air quality day and they have to go to the ER. That family loses that day of pay. That worsens an already poor economic situation and we get into those cycles that we talked about before. Secondly, we need to ensure that how we practice medicine is done in a way that reduces our emissions. We talked about a couple of examples at the very beginning. Actually, the the Admiral mentioned that the US healthcare industry is responsible for 8 1/2% of the admissions in this country. We as physicians and clinicians and healthcare professionals have to lead by caring what we do, caring about what we order and making sure that we understand the impact of every order.

That we make. And again, a great place to start in understanding the link is realizing that even with our best intentions and all the money that we have in technology, only 20% of a person's Healthcare is decided on what happens in that clinic. We really have to go outside our clinic walls. We have to go upstream. We have to go into the communities and understand that a person's health. Is influenced by so much more than us as healthcare professionals. If all we're doing is the healthcare, so we, as healthcare professionals have to get out and make our voices louder. Be honest. As Don says, hold us ourselves accountable, but hold others accountable to make sure that we can make sure people have access to having a home and being in school and having options in case of climate disaster. And that will be able to continue to perform our mission of caring for our communities. I'm in a climate change the world while doing our best to mitigate how much climate change there is.

I've really enjoyed it today. I really appreciate my my other two panelists and thank you for having me see my. Thank you, what an amazing discussion. So many great themes, so many lessons and thoughts to carry forward. And while this might be the end of today's conversation, it absolutely is not the end of the discussion. This is the first in a Kaiser Permanente discussion series about getting to net zero and how the health sector can move the needle on climate change and the health of the communities we serve. They really appreciate the authenticity and the different viewpoints that all of our panelists brought. Also very delighted to have had the to have had Admiral Levine share with us along with Doctor Choucair and not only thanking you for your time today, but also really wanted to thank everybody for the important work and for using your voice to make a difference. Of course. Also, thank you to everybody who tuned in today. We are so thrilled to bring this conversation. To you. Thank you..



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