Environmental Health as a Broader Mandate for Clinical Care

One of the more pressing topics the ACOI Committee on Climate and Health has been engaged in across its meetings this term pertains to the idea of scope. At its center is the consequential question: should the committee remain defined primarily by climate, or would an environmental-health frame better describe physician responsibilities at the intersection of environment and illness?

Climate change is a defining health challenge, and any broader framing must preserve that urgency. However, climate hazards rarely arrive in the clinic as an isolated exposure or incident. They are encountered through any one of many factors such as breathing in unhealthy air, heat exposure, disrupted food and medication access, occupational risk, fragile infrastructure, and unequal ability to recover among many others. A re-emphasis of the importance of “environmental health” in our discussions importantly has not displaced climate health; rather, it has assessed climate change within the conditions through which environmental exposure manifests itself as clinical disease.

The distinction is more than semantic. A climate-centered lens directs attention to a profound driver of risk; an environmental-health lens asks how that risk is mediated by the places where people live, work, travel, and seek care. It includes air and water quality, housing, occupational exposures, toxicants, food systems, transportation, the built environment, and disaster preparedness, alongside climate-related heat, flooding, smoke, and changing infectious-disease patterns. The 2023 Lancet Countdown documented effects on heat exposure, food security, infectious-disease risk, and health-system capacity¹.

For internal medicine physicians, that broader lens is clinically clarifying. It prompts decisive questions: Can this patient avoid the exposure? Safely store medications? Take time away from work? Afford transportation, a high-efficiency filter, a rescue inhaler, or an unscheduled visit? Environmental health is not a separate discipline appended to clinical medicine; it shows the conditions that make illness more likely, disease control more difficult, and recovery less secure.

The committee's discussion also carries an ethical charge. Environmental hazards are not distributed equally, nor are the resources needed to mitigate them. The ability to remain indoors during smoke, reduce heat exposure, relocate after a flood, refrigerate insulin during a power interruption, or recover from missed work is shaped by income, housing, disability, geography, and historic disinvestment. The people with the greatest exposure often have the least practical freedom from and ability to mitigate it.

A broader mandate would allow the committee to address climate health without losing sight of the structural conditions through which hazards become inequitable. This does not make every social problem the responsibility of a physician. It does require recognition when environmental exposure, financial insecurity, and interrupted access to care alter a patient's health trajectory. Prevention and continuity have ethical meaning only when they are feasible for the patients we take care of and treat.

An environmental-health focus can remain disciplined and actionable. The committee can equip osteopathic internal medicine physicians to identify patients at increased risk during heat and smoke events; incorporate home, work, and environmental exposures into the history; develop contingency plans for oxygen, dialysis, and temperature-sensitive medications; and connect patients to public-health and community resources. It can also highlight food systems, migration, vector shifts, disaster preparedness, and the built environment. Climate action is a health-protection imperative, especially where chronic disease and structural vulnerability coexist².

This work is naturally aligned with osteopathic medicine. Whole-person care means recognizing that a patient's home, workplace, neighborhood, mobility, and material resources determine whether our recommendations can be carried out. Environmental health gives that principle practical form: better questions, anticipatory planning, and a more realistic understanding of what health maintenance demands of patients.

My Family Medicine rotation during my third-year of medical school made this discussion immediately apparent, and was what prompted me to apply to serve as the student liaison for this committee in the first place. During a period of smoke from Canadian wildfires, our clinic experienced an uptick in acute visits from patients with asthma and COPD whose symptoms had worsened as air quality declined. Increased dyspnea, cough, wheeze, and rescue-medication needs were readily recognizable. What was less visible at first, but equally consequential, was the pressure the smoke placed on patients' daily lives. For individuals whose work required time outdoors or in poorly ventilated settings, a flare could mean time away from work. For those who could not afford to miss a shift, replace filters, obtain medications, or seek additional care, the clinical instruction to avoid smoke exposure could be financially impossible to follow. Wildfire smoke is a well-established respiratory hazard, particularly for people with underlying cardiopulmonary disease³.

That experience changed how I understand environmental health. The smoke was not simply an overt manifestation of an air-quality index that often means very little to the average individual, nor was it a distant climate signal casting a haze as fires roared in Northern Ontario hundreds of miles away. It was an exposure that interacted with chronic disease, employment, cost, and access to care. It illustrated why the question before our committee is so important. A climate event can become a healthcare crisis not only through its physiologic effects, but through the financial and social conditions that constrain a patient's ability to protect themselves from it.

My clinical and service work across urban, suburban, and rural Michigan, together with global-health training, has reinforced the same lesson: environmental burdens seldom occur alone. They compound housing insecurity, transportation barriers, poverty, chronic illness, and gaps in follow-up. As student representative, I contribute where I can by discussing the clinical experiences I have encountered during our meetings, aim to support the curation of educational resources when possible, and bring a learner perspective via student engagement. I hope this work helps trainees understand that asking about smoke exposure, occupational heat, housing conditions, or medication storage is not a departure from internal medicine. It is a more complete practice of it.

The committee is still considering what its name and focus should be. The value of the conversation lies not in presuming its outcome, but in taking seriously what a professional society must ask of itself when environmental threats increasingly shape patient care. Climate change should remain a core concern. An environmental-health frame may give the committee a more inclusive and clinically faithful mandate, one broad enough to address climate hazards, yet specific enough to translate them into better care.

For me, that is the promise of this work: to help clinicians recognize environmental risk, anticipate its consequences, preserve continuity, and partner with patients and communities in ways that are practicable as well as principled. The committee can make an important contribution by giving osteopathic internal medicine physicians the knowledge and tools to respond with clinical rigor, humility, and moral seriousness.

References

1. Romanello M, Di Napoli C, Drummond P, et al. The 2023 report of the Lancet Countdown on health and climate change: the imperative for a health-centred response in a world facing irreversible harms. Lancet. 2023;402(10419):2346-2394. doi:10.1016/S0140-6736(23)01859-7.

2. Haines A, Ebi K. The imperative for climate action to protect health. N Engl J Med. 2019;380:263-273. doi:10.1056/NEJMra1807873.

3. Reid CE, Brauer M, Johnston FH, Jerrett M, Balmes JR, Elliott CT. Critical review of health impacts of wildfire smoke exposure. Environ Health Perspect. 2016;124(9):1334-1343. doi:10.1289/ehp.1409277.