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How heat alerts could help clinicians intervene for people at high risk in New England

Dr. Rebecca Rogers highlights hydration tips for Luciano Gomes, who works in construction.
Martha Bebinger/WBUR
Dr. Rebecca Rogers highlights hydration tips for Luciano Gomes, who works in construction.

A half dozen clinicians at Cambridge Health Alliance got the first test alert on June 1. The 83-degree day didn’t trigger an official heat warning in Boston. But in this New England climate, when temperatures rise past the mid-70s, heat-related hospitalizations and deaths rise, too. And, a sudden pre-summer heat surge can be especially bad.

“People are quite vulnerable because their bodies haven’t yet adjusted to heat,” said Dr. Rebecca Rogers, a primary care physician at the network’s Somerville clinic.

The alerts come from a pilot project run by the nonprofit Climate Central and Harvard University’s Center for Climate, Health and the Global Environment, or C-CHANGE. Clinicians at 12 community-based clinics in seven states received the first emails when temperatures in their area reached the 90th percentile. A second alert went out when temperatures reached the 95th percentile.

For Rogers at the Cambridge Health Alliance, that alert was on July 6.

A logo for the series Beyond Normal, which is about how climate change is affecting New England summers.
Sara Plourde / NHPR

The emails specified which patients to prioritize: Outdoor workers, individuals who are older or those with heart disease, diabetes or kidney disease are especially vulnerable to heat-related health problems. So are youth athletes and people who can’t afford air conditioning or who don’t have stable housing. Heat has been linked to complications in pregnancy as well.

“Heat can be dangerous to all of us,” said Dr. Caleb Dresser, the director of health care solutions at C-CHANGE. “But the impacts are incredibly uneven based on who you are, where you live and what type of resources you have.”

The pilot reminds clinicians to talk to patients about protecting themselves on dangerously hot days, which are happening more frequently because of climate change. Heat is already the leading weather-related cause of death in the U.S.

“What we’re trying to say is, ‘You really need to go into heat mode now,’ ” said Andrew Pershing, the senior vice president for science at Climate Central. “It’s going to be more dangerous for folks in your community who are more stressed.”

What this means for patient visits

With help from the alerts, Rogers is making time to ask each person whether they can cool off at home and at work. That’s how she learned that one of her patients, Luciano Gomes, works in construction.

“If you were getting too hot at work and maybe starting to feel sick, do you know some things to look out for?” Rogers asked Gomes.

“No,” said Gomes slowly, shaking his head.

Rogers told Gomes about early signs of heat exhaustion: feeling dizzy, unusually weak or sweating profusely. She handed Gomes some tip sheets that come with the email alerts. They offer general information about how to avoid heat-related illnesses as well as specific guidance for patients with asthma, chronic obstructive pulmonary disease (COPD), dementia, diabetes, multiple sclerosis and mental health concerns.

Rogers pointed Gomes to a color chart that ranges from pale yellow to dark gold. It’s a sort of urine hydration barometer.

A urine color chart to assess hydration that C-CHANGE provides its patients.
Courtesy Harvard T.H. Chan School of Public Health C-CHANGE/Adapted from Healthdirect Australia
A urine color chart to assess hydration that C-CHANGE provides its patients.

“So if your pee is dark like this during the day when you’re at work,” she told Gomes, “it probably means you need to drink more water.”

Gomes nodded. “This is more than you were expecting to talk about when you came to the doctor today, I think,” Rogers said with a laugh.

The tip sheets are available in English and Spanish. An interpreter translated the visit and the information into Portuguese for Gomes, who is from Brazil. He knows heat. But he had questions about the best ways to stay hydrated.

“Because here I’ve been addicted to soda,” Gomes told Rogers through the interpreter. “I’m trying to watch out for that and change to sparkling water. But I don’t have much knowledge on how much I can take of it?”

“As long as it doesn’t have sugar it’s totally good,” Rogers said.

Rogers creates heat mitigation plans with each of her high risk patients. But she has questions the research doesn’t address yet. For example: Should patients taking medications that make them pee more often reduce their doses when it’s hot? And if so, how much?

Deidre Alessio, a nurse at Cambridge Health Alliance who is receiving the alerts, has a number of patients who sleep on the streets or in tents and search for places to cool off during the day. Alessio recently looked for a directory of cooling centers in the cities and towns around Greater Boston and couldn’t find one.

“Getting these alerts make me realize that I need to do more homework on the cities and towns where my patients live,” she said, “and help them find transportation to a cooling center.”

Some heat-related health problems set in overnight if the body can’t cool down. Clinicians may recommend putting an air conditioner in a bedroom if a patient can only afford one unit. It can be hard to find resources for patients who can’t afford any air conditioning at all.

Alessio and Rogers pay special attention to patients who live in heat islands where day and nighttime temperatures may be significantly warmer than the general Boston area on which the alerts are based.

And Dr. Gaurab Basu, another colleague who is getting the alerts, goes beyond conversations about cooling and hydration. He routinely asks patients about their social connections and whether they live alone.

“I’m really concerned about folks who are lonely or isolated,” said Basu, mentioning research on the 1995 Chicago heat wave. “One of the major variables in whether people survived was whether they had other people they could turn to.”

For now, Basu, Rogers and Alessio are only addressing heat risks with the patients they see during what’s become known as the “heat season,” which extends beyond the summer months. They may be missing high risk patients with appointments at cooler times of year. Most clinics and hospitals don’t have heat alerts built into electronic medical records, don’t filter patients based on heat vulnerability, and don’t have systems in place to send heat warnings to some or all of their patients.

“I would love to see health care institutions get the resources to staff the appropriate outreach,” said Basu, who is also co-director of the Center for Health Equity, Advocacy and Education at Cambridge Health Alliance. “But hospital systems are still really strained by COVID and staffing issues.”

'Not your grandmother's heat'

Early heat warnings directed at people at greater risk for illness and injury are new in the U.S. Kristie Ebi, who runs the Center for Global Health and the Environment at the University of Washington, has been studying early heat warning systems for 25 years. She calls the pilot an excellent start and suggests including pharmacists as another trusted source of medical advice.

Ebi’s concern is that too many people don’t take heat warnings seriously. She points to a survey of Americans who experienced heat waves in four cities — only about half of respondents took precautions to avoid harm to their health.

“We need more behavioral health research,” she said, “to really understand how to motivate people who don’t perceive themselves to be at risk to take action.”

"This is not your grandmother’s heat. ... We have to accept that our environment has changed. This might very well be the coolest summer for the rest of our lives."

Record-setting heat waves in Phoenix and other areas of the Southwest are certainly getting more attention. Ashley Ward, who directs the heat policy innovation hub at Duke University, shares some blunt advice.

“This is not your grandmother’s heat,” Ward said. “The heat regime that we are seeing now is not what we experienced 10 or 20 years ago. So we have to accept that our environment has changed. This might very well be the coolest summer for the rest of our lives.”

Ward is working with a group at Duke University Medical Center on ways to add heat alerts to electronic medical records — but in a manner that doesn’t overwhelm patients or clinicians.

Organizers of the heat alerts pilot are also testing the language and frequency of their messages, so they won’t become too routine. The alerts take into account both temperature and humidity conditions that contribute to heat-related deaths.

Pershing and Dresser, two of the key pilot organizers, say they hope it also spurs action on climate change.

“We’ll be dealing with increased exposure to heat for the rest of our lives,” said Dresser. “To address the factors that put people at risk during heat waves we have to move away from fossil fuels so that climate change doesn’t get as bad as it could.”

This story was originally published by WBUR. It was shared as part of the New England News Collaborative.

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