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Burning Up Illustration by Salini Perera.

Burning Up

The climate is boiling over and so is our health-care system; there's a future in which communal care addresses both problems.

In the trough of a relentless heatwave last summer, I woke up feeling an ache in my lower back. Without much thought, I dismissed it and assigned it to the fact that I was sleeping on a stiff mattress in a rented studio. Discomfort had become a norm that summer.  The day was almost 40 degrees during a season of record-breaking heat waves. Hot enough for the steering wheel to scald your fingers. On a Sunday, days later, with medical centres closed in the village I was visiting in the French Riviera, I found myself at a pharmacy, curled forward onto the counter and feeling that I was deliquescing. My body begged to be wreathed in some kind of comfort, to be like a coiled snake resting on burning sand. Anything to alleviate the constricting throb of a blossoming UTI.

In the satisfyingly cool shop, the pharmacist asked me which symptoms I was experiencing and told me I would need to wait to find a doctor during the week. When I began an elaborate monologue about how I actually had a prophylactic antibiotic prescription with me, she gently stopped me and said she would happily sell me the medicine. “With your health condition, you’re, of course, at greater risk during a heatwave like this,” she told me. It seems so obvious now, but a problem can feel nebulous until it is named. In the surrounding hills, the landscape was desiccated, shaped by the absence of water, while my kidneys, affected by want, were also discontent reservoirs. Both the land and our bodies, the climate and our kidneys, are governed by and depend upon water. 

At 40 degrees, the waves that licked the shoreline were tepid. A hypnotising sheet of heat rose from the asphalt roads and wildfires ran up nearby hills. Cracked and parched, the land was arid. The whole of western Europe was experiencing record heatwaves, as was Canada. Last September, in Vancouver, my home for many years, seven millimetres of rain fell. During the same month in 2021, 155 millimetres of rain had fallen—a difference of 183 percent. These numbers point to a growing asymmetry in meteorological conditions that, in the past, characterised a season. British Columbia suffered from an intense, unprecedented drought last autumn, whereas in the fall of 2021, the southwestern area of the province was struck by flooding prompted by an atmospheric river. When this long stretch of water vapour streaming through the atmosphere hit land, it unleashed heavy rainfall. In the months leading up to the floods, a heat dome swathed BC and temperatures surpassed 40 degrees. Before the heat dome killed 619 people, farmers lost their animals in the floods, everyone living in Merritt had to evacuate, and highways became unusable, covered in debris or partly collapsed from mudslides, cutting access to and from the Interior.

Extreme heat can cause temporary health issues for anybody, but for those of us with pre-existing conditions, the sustained high temperatures that climate change is inflicting on our landscape can compound and worsen what we are already dealing with. They are associated with increased hospitalizations for pregnancy complications and heart problems; they can catalyse flare-ups for people with Type 2 diabetes and asthma; and they can increase kidney-disease related ER visits. 

Not only are the effects of climate change on people’s health increasing, they’re also impacting the health-care system in novel and alarming ways. In northern communities, for example, melting permafrost is jeopardizing the stability of health facilities and transportation infrastructure, as buildings are at risk of sinking and ice roads used to supply medicine are compromised. In an October 2022 interview with the CBC, one doctor told of an operating room in Grande Prairie, Alberta that had been forced to shut down due to potential contamination from wildfire smoke. Since 2005, an average of 412 health facilities have been either destroyed or damaged annually because of climate disasters, according to a United Nations Office for Disaster Risk Reduction report. As the health-care system crumbles and the climate degrades, we are far past the time to try to plug a hole in a sinking ship. We are facing two crises of governance simultaneously, and the secondary disasters caused by their marriage. In every sense, we are burning up.

I hold the theoretical knowledge that blood and protein escape from my kidneys, and for a little less than half of my life, I have known why. A geneticist and a nephrologist studied my sister and I when we were adolescents, and found mutations in our collagen genes. Very early in life, doctors had found an inexplicable microscopic hematuria (the presence of blood in the urine) in both of us, which remained an enigma for a decade. Through labyrinthine digging, specialists eventually understood and diagnosed a family history of renal issues. We were taught to calculate our water intake, and consider the salt and animals we eat. While no doctor had ever told us we should be careful in higher temperatures, we intuited an association between scorching days and kidneys becoming troubled by water loss. Last summer, especially, to avoid dehydration, I sought shade, moving from one tree’s shadow to another. Still, heat ravages the body. 

The link between climate change and health has been loosely identified since the mid-1990s, but serious research into that relationship only really started about ten years later. A 1998 study broadly predicted that it was likely that climate change would adversely impact humans through water contamination and disease vectors. By 2014, research on the situation had shifted definitively from “likely” to “certain”; a Health Canada assessment made clear how different regions and communities face unique risks, like hurricanes particularly affecting Atlantic Canada, and elderly people’s vulnerability to heatwaves. 

To learn about the effects of climate change on health, and what happens when our bodies are exposed to extreme heat, I spoke with Vivekanand Jha, Executive Director of the George Institute for Global Health in India. First, we sweat, a lot. Since that sweat is formed in our bloodstream, our blood volume decreases. Sweat collects its water from blood plasma, so the more the body tries to cool itself with sweat glands, the more it reduces its total blood volume. Kidneys are the central organ that regulate blood volume, so they quickly sense any exposure to extreme heat, altering their filtering function on an almost hourly basis and excreting less urine to conserve water. In India, Jha tells me, people reduce their exposure by only working very early in the morning and very late in the evening. Even so, with extreme heat, the kidneys’ function becomes maladaptive. Compiling fifteen years of data from Brazil, researchers learned that every 1 degree increase in temperature led to a near 1 percent increase in hospitalisations for renal disease in the population. Without treatment, things can quickly become too serious to meaningfully address. “It is not unusual for us to see patients for the first time only in the very advanced stages of disease, by which time it is almost impossible to do anything to reverse their condition,” says Jha. 

Kidney diseases disproportionately affect people forcibly living in the margins of a system that pushes them further and further away from receiving care. In Canada, access to effective care for kidney issues, like all health issues, is heavily racialized. A 2022 study from the Journal of the American Society of Nephrology found that Indigenous people in Canada who live in rural and remote areas are two to three times as likely to suffer from chronic kidney disease than the general population, and that Indigenous people across all areas of Canada have worse clinical outcomes than non-Indigenous patients. The same study found that a lack of medical resources in remote areas means that Indigenous people are often forced to leave their communities for specialty care, which in turn increases the risk of poor care due to systemic racism. A 2022 article from the Canadian Medical Association Journal showed that Black people in the US and Canada are more likely to have chronic kidney disease but frequently receive suboptimal care, and are less likely to receive a kidney transplant or home-based dialysis than non-Black patients. Environmental racism is a major driver of kidney disease in BIPOC populations; many of the neighbourhoods where racialized people live are treated as dumping grounds for hazardous materials, which can cause renal damage or cancer in those living nearby. They often have higher levels of air pollution, which may increase the risk of developing chronic kidney disease; and they may have less overall infrastructure, like tree canopies, to alleviate the impacts of climate change. 

“It boils down to the issue of access and equity,” says Jha. People who are disenfranchised within the health-care system and live and work on the edge of the climate crisis are more susceptible to getting kidney damage but have less access to care. Jha references the risks faced by agricultural workers who work under the blistering sun, or people who are displaced because of natural hazards like droughts or floods, which so often hit poorer and non-white communities hardest. These people cannot escape the adverse effects of environmental change, he notes, but none of us are exempt from the damage that the climate can work on our health. Some people⁠—the wealthy, the powerful, those who can purchase temporary protection in the form of air purifiers and clean water⁠—might currently feel insulated from the effects of pollution, extreme heat and system collapse. But, Jha says,  “it’s going to come to them sooner or later.” 

The chaotic asymmetries of climate change echo the unbalanced state of health-care governance in Canada. Preventative and routine care, which reduce the risk of diseases by consistently assessing someone’s health state and needs, have slipped away in the face of compounding pressures like the respiratory viral infection that affected children all over Canada during the winter, and relentless waves of Covid-19. “In a lot of ways, we’re seeing big parts of our health system really facing collapse,” says Andrew Longhurst, a health policy researcher at Simon Fraser University. “I use the word [collapse] carefully and with intentionality, because it’s a big word. But what we’re seeing is a real fundamental strain on the delivery of health care.”

The weather does not only affect our bodies, but the people and places responsible for caring for them. A system that is already dangerously fragile is not well-placed to cope with the growing stressors of the climate emergency, and yet, year-on-year, the Canadian health-care system is tasked with exactly that. According to a BC Coroners review, the number of 911 calls doubled during the height of the heat dome in 2021. In a CBC interview, the president of the Ambulance Paramedics of BC union, Troy Clifford, stated that he was “not confident we have the capacity and the staffing to respond to another heat dome the way it needs to be [responded to].” In the year prior to the heat dome incident, senior leaders at the emergency dispatching agency raised serious concerns about understaffing and underfunding. 

Without access to primary care, people turn to emergency rooms and walk-in clinics for needs that should be addressed by long-term team-based care systems. Although BC did make significant efforts to deal with the backlog of postponed surgeries and medical imaging—MRIs to screen for cancer, or standard presurgery CT scans—from the first waves of Covid-19, Longhurst says the layered burdens on the system “mean that we’re not really making a lot of progress beyond keeping our head above the water.” The province of BC, as well as Canada more broadly, lacks doctors, nurses and other health-care workers, leaving patients without sufficient care, and health-care institutions without workers. 

A growing number of medical associations in Canada, including Doctors of BC and the Canadian Federation of Nurses Unions, have released increasingly urgent appeals to government officials to highlight risks to both patients and the health-care system at large as climate change wreaks havoc on their workplaces. Their concerns range from the effects of the climate crisis on medical professionals called upon to act as first responders to the carbon footprint produced by the health-care sector. A recent paper from the Canadian Federation of Nurses Unions warned that the combination of an aging population, constrained budgets, insufficient infrastructure and climate change would bring “grave and distinct challenges” for those working in the health-care system and that nurses had a “moral duty” to advocate for policies to mitigate these effects. They acknowledged that health-care workers, as trusted members of their communities, were well-placed to be able to help patients withstand the effects of the climate crisis, but that “global and local actions are needed ... to build resilience and adaptation strategies.” In practice, this might look like working with employers and unions to reduce carbon emissions from hospitals, to advocate for political action on the climate, to recognize patients’ needs arising from climate change and to actively prepare for adverse weather events.

The 2022 BC provincial budget proposed $148 million over the next three years to add 125 paramedics and $303 million toward a strategy to reduce surgical wait lists. It also pledged over $600 million to strengthen climate disaster-preparedness, which will support wildfire prevention, and “climate-ready” transportation systems. But patching a band-aid onto a perpetual crisis doesn’t address the immediate disaster we find ourselves in. “When we look at a lot of the best or high-performing health systems,” Longhurst says, “we know that effective primary care is increasingly delivered by teams of providers, not just by doctors.” 

Community Health Centres (CHCs), for instance, are non-profit organizations that adhere to a community-governed health model. They already exist in limited numbers in Canada, are generally funded by government grants or donations, and provide multi-disciplinary team-based care to a particular neighbourhood or community. Rather than always turning to busy doctors, patients can see a varied team of people who provide needs-dependent services. If you need to change medications, you could see a pharmacist, while to understand their interactions, you could see a clinical counsellor. CHCs also take an active role in their community’s needs beyond providing individuals with care—they engage in policy debates and advocacy work to enact systemic change, such as fighting for paid sick leave, for safe and affordable housing, or supporting communities weathering the effects of climate change. Research on CHCs in Ontario has shown that they can be more effective than other primary care models at reducing ER visits and supporting people with chronic conditions, as they can offer longer consultations, more comprehensive patient records and access to a nurse-practitioner. Longhurst notes that CHCs aren’t a panacea, but that the model is a force for positive change and could encourage health-care workers to be part of a team that promotes holistic, culturally-informed care, particularly in a time when so many are leaving the medical sphere due to burnout. 

Even discounting the pandemic’s effects on our healthcare system, many barriers exist within it for people who aren’t white or wealthy that CHCs might be able to mitigate. In BC’s Lower Mainland, a cooperative CHC launched a mobile clinic specifically for temporary foreign farm workers, providing Spanish language services and moving through the Fraser Valley to support geographically diverse patients in culturally-informed ways. Jha and Longhurst both say that assessments of the environment’s impact on health need to include clinical practitioners, doctors, social scientists and the communities themselves, in order to fully understand and respond to people’s needs. Doctors understand disease; policy researchers understand the uneven distribution of health care; communities know their landscapes and cultural contexts. 

It’s a model that health-care workers advocate for. The Canadian Federation of Nurses Unions suggested in their 2019 report that it’s paramount for nurses to have a collaborative approach to care, and recommended that nurses work alongside other experts “to promote monitoring of current and future threats,” as well as learn to counsel and assess their patients for climate-derived health impacts (psychological or physical), and push for less carbon-intensive facilities in health care. Within smaller communities, people can adapt and implement hyper-localised solutions that can create lives of abundance. 

“We really need efforts to support the development of climate-resilient health systems,” says Peter Berry, a senior policy analyst at Health Canada. In his view, a holistic approach that considers the whole health system— community health, mental health, housing and food security—cultivates community resilience. This might look like working to reduce the environmental impact of the medical sector by reusing reject water from dialysis, or sourcing local food for hospitals to reduce food transport emissions, or providing training to health-care workers on the effects of climate change on health. What is for certain is that without adaptation plans, health facilities are at risk of devastation. A Health Canada report that Berry coedited found that only 25 percent of health facilities have conducted a climate vulnerability assessment. Without checking key resources like water and sanitation or medical technology and waste management vulnerability, facilities won’t know their risks and limitations until a crisis is at their door.

Canada’s colonial project underpins the health-care system, and feeds the growing climate crisis we’re in. A model like CHCs, which attempt to strengthen communities by understanding their intricate webs, opens the path to building new futures and ways of being in relationship with each other that centre care and solidarity. It moves us away from disaster and fear and toward a future where we can believe in agency and hope.

Until the pharmacist offhandedly told me that people with kidney diseases are more susceptible to the health risks that a heatwave carries, I had been offering her a pre-emptive list of defences. After an eight-month stretch of not getting a urinary tract or kidney infection—my longest, most miraculous period of absence of either one yet—I was enumerating my preventative practices and rituals, exasperated to be back in the same place. No doctor or nephrologist had ever before explained to me the relationship between climate change and health. I have a non-life-threatening genetic kidney disease, which means that, among attentions like sporadically monitoring my blood pressure, a yearly creatinine levels test, and ideally limiting alcohol and meat consumption, I take care to drink two litres of water every day. Drinking enough water is important for anyone, but for people with kidney issues, consistently hydrating helps keep blood vessels dilated and prevents waste build-up in the kidneys; water ensures that the kidney and bladder are always flushed. I’ve had chronic UTIs and the occasional kidney infection for ten years, so I’ve spent time that would amount to days in an assortment of walk-in clinics in Vancouver. Still, during every visit, I’ve had to answer the same torpedo of obvious questions from a doctor with a corrugated frown. Was I sure I had peed after sexual intercourse, did I know I should wipe front to back? I would address them with a perfunctory script, aggravated by the patronising subtext that felt loud and obvious: perhaps I didn’t know how to take care of myself. Unaware that the unrelenting heat of that summer may have affected my kidneys, I was cycling through all other possibilities. If I had poured more cups of nettle tea, if I had succumbed to fewer salted snacks, if I had traded my tar-like espressos for water. If, if, if. These are the kinds of thoughts that run through my head when I can get care.

Once, days before I ended up on an IV drip in the emergency room thanks to a particularly bad infection, I had biked as fast as I could, every day after work, to the closest walk-in clinic. But each time the same sign was pasted on the door: No more patients accepted today. My at-home urine test strips had been positive for an infection, and I knew which antibiotics I could take, but I had no doctor to prescribe them. 

These infections have felt like mockery. Too unserious to justify a four-hour wait at the clinic, too low on the priority list to justify visiting an emergency room, difficult (and sometimes impossible) to treat without prescribed medication. Just serious enough that when I feel the flush of two embers in my lower back, I worry about the strain I’m forcing on my kidneys.

As I write this essay, I catch the bronchitis that everyone in my town is sharing and finish prostrate in bed with lower back pain. I go to the ER because again it is a Sunday. Being sick, unfortunately, is not a nine-to-five occupation. They take my blood, they perform a Covid test, they ask for my urine. I take fifteen grams of antibiotics. One of my recurring medication bottles reads “May cause dizziness. Avoid prolonged or excessive exposure to direct and/or artificial sunlight while taking this medicine.” (If there is one thing that is clear about the future of our climate, it is that it will be impossible to avoid the sun.) My last infection, weeks prior, was fought with just three days of medication; my nephrologist told me that a new hospital protocol requires reducing the length of treatment. I suspect the bacteria never left me. Beyond my bodily intuition, multiple studies have suggested that as average temperatures increase, so does antibiotic resistance: the climate crisis can cause bacteria to become more and more impervious to treatment.

For the six years I lived in Vancouver, I have little record of my medical results. Each visit to a walk-in clinic happened with a different doctor who would prescribe an arbitrary drug. When I moved back to Europe, where I grew up, my nephrologist asked for a detailed history of the strains of bacteria that had grown in me and the targeted medications I had taken so we could discuss potential long-term treatment options instead of more invasive treatments. Without years of continual care, I had nothing to give him. 

During all the time I spent in walk-in clinics, I dreamed of what communal care could look like: free, available medication, herbal medicine libraries, shared, accessible transportation. Communities who know what food can grow on their land, and are well-informed about which people are especially vulnerable to wildfire smoke and may need protective supplies. When I think of the moments of respite within the rage, they’re always conversations I’ve had—brief interludes that softened my despondence. A woman in the ER who shared the tale of how she met her lifelong love; how he would have laughed at the measly pillow she was given to sit on to get through the night. A friend who told me about uva ursi’s potent medicine. 

Collaborating within communities and across disciplines and practices is the only way forward and away from the fractured relationship between us, our ecosystems and, increasingly, our health-care system. When conversations with others feel more healing than fought-for medical treatment, the value of connection and potential for everyone to be supported emotionally and physically by their communities is obvious.

While I sit in waiting rooms, a tweet I read turns and turns in my head. A note about the illusion of safety; about those who look down on people who use drugs or who are disabled or who are poor. Those people who (think they) are safe climb into towers taller and taller, certain that they will never fall, and certain that their safety is imperishable. From above, the distance may feel comforting, but when there is nowhere left to climb, what will remain is those on the ground shouting that collective care means everyone. ⁂

Alexandra Valahu is a writer and audio producer. She was a research resident at the inaugural Mise en Place artistic residency and will be an artist-in-residence at La Baldi. Alexandra is also the nonfiction editor of Spotlights at Guernica.