Health and High Water | NEJM

In a 2010 interview for the New Yorker, when asked whether he ever considered not being a writer, the novelist Jonathan Safran Foer replied: “For a long time, I thought I would like to be a doctor. Such a good profession. So explicitly good. Never a waste of time. No obstetrician goes home at the end of a long day and says, ‘I delivered four babies. What’s the point?’” This exchange was published a year before I graduated from medical school, and I thought back to Foer’s answer often during my subsequent training, first as an internist and later as a gastroenterologist, grateful that my career would never require an elevator pitch.

And yet under the strange gravity of the Anthropocene era (our recently inaugurated geologic period, defined by the outsized impact of human activity), clinical medicine has begun to feel a bit weightless. Apocalyptic forecasts for the natural world are being rendered with increasing urgency, in the face of which the significance of my daily work has been increasingly difficult to grasp. At the end of a long day, I will have performed 16 colonoscopies, but the ice caps will still be melting and another bag or two of medical waste will be ready to burn. It raises questions that I’m surprised more clinicians aren’t asking of themselves or each other. What does it mean to engage with individual distress inside a hospital while bearing witness to cataclysmic distress outside it? In our time of rising seas, what, indeed, is the point?

The American Psychological Association recently formalized “ecoanxiety” as a mental health diagnosis. Although a report on the subject includes recommendations to “foster optimism” and “support national and international climate–mental health solutions,” it does not mention any specific carbon-reduction efforts, individual or collective, that might forestall climate change in the first place.1 The focus is on second-order problem solving. By pathologizing the existential questions raised by global warming rather than the warming itself, health care authorities position themselves as responsive rather than vulnerable to the coming upheaval.

But of course ecoanxiety will affect clinicians, too. In popular dialogue, the phenomenon has gone by many other names: climate depression, environmental grief, and futilitarianism, for example. In his recent book The Uninhabitable Earth, journalist David Wallace-Wells speculates on the likelihood that, as the predicted effects of climate change become manifest, these strains of nihilism will percolate from the periphery into the mainstream, and the work of the old world will become, for many of us, progressively harder to justify.2

In my own rudderless moments, I find myself again turning to writers for guidance. Rising tides function as a convenient metonym for climate change, standing in for the much more comprehensive disruption that looms for humanity, no matter our proximity to coastlines. It’s a potent image, and two very different books by physicians that centralize floodwater have been coming to mind often lately when I think about my professional life decades hence.

The first is Chris Adrian’s The Children’s Hospital (2006), a supernatural novel that tells the story of a latter-day Biblical flood, after which a renowned pediatric hospital transforms into a de facto ark. The bulk of the plot follows the actions of the hospital’s inhabitants (patients, families, and staff) who keep going through the motions of inpatient medicine despite the sudden end of the world.3 The second is Sheri Fink’s Five Days at Memorial (2013), a nonfictional account of the aftermath of Hurricane Katrina at a New Orleans hospital, where, after rescue efforts were delayed, several patients ultimately died under the care of clinicians who deemed their suffering too great. The incident’s legal and ethical ambiguities are meticulously detailed from a variety of perspectives, including those of hospital employees whose defense often rests on the horrors of the hurricane itself, and the sense that if you weren’t there, you couldn’t possibly understand.4

Beyond genre and style, these books diverge in their portrayals of how the clinical mission might react to a deeply threatened world. Each vision is colored by a different kind of absurdity. In Adrian’s novel, the postapocalyptic persistence of business as usual suggests an irrational blindness to obvious futility. In Fink’s reporting, the fraught line between palliation and homicide suggests an irrational resignation to circumstances in which persistence might not have been truly futile. Adrian’s story line hews more closely to conventional expectations for the role of medicine in times of crisis — that it should serve as a harbor, a beacon, a fixed set of values and practices to anchor society in a storm. But Fink’s account seems like the more accurate reflection of medicine’s inability to provide a reliable bulwark. Literally and figuratively, the storm finds its way in.

For clinicians who feel especially steady on their feet, expressions of ecologic nihilism might sound premature, hyperbolic, or perhaps a bit too literary. Equanimity, after all, is an ideal that many physicians are taught to strive for, the regulation of an internal thermostat detached from one’s immediate surroundings. Still, every set point is prone to dysregulation. Wallace-Wells points out that climate-related deaths mediated by resource inequality are an active phenomenon (10,000 deaths per day worldwide due to poor air quality, for instance) that will only worsen with time. The current disparity between resources marshaled for basic environmental health initiatives and those for high-tech, individualized medicine sets the stage for still more cognitive dissonance in an increasingly inequitable future.

Health care has been prone to inertia since before we all began caring so much about atmospheric carbon. This quality of stasis is distilled in Donald Hall’s poem “The Ship Pounding” (1996), a reflection on the experience of his wife, the poet Jane Kenyon, in receiving treatment for the leukemia that would later take her life. Like Adrian, Hall imagines the whole hospital as seaborne; unlike Adrian, Hall keeps his hospital stationary: “the huge / vessel that heaves water month / after month, without leaving / port, without moving a knot, / without arrival or destination.”5 This image of massive energy expenditure reads as a critique that is at once clinical and ecologic. Given the size of modern medicine’s footprint, it is often remarkable that we don’t progress farther or faster.

If and when the engines fail, perhaps medicine, too, will become a metonym, standing in for other, more desperate, less plausible sorts of caregiving. Perhaps clinicians, like writers, will begin to seek meaning through symbolism, seeing in the welfare of a single patient a reflection of that of the whole planet: precarious and heartbreaking, salvageable for a while but fated for dissolution. Assuming no change in our projected course, parallels constructed between patient care and environmental stewardship will be cold comfort for health care in the hot future.

Looking toward our more immediate horizons, however, such analogies could offer a sort of blueprint for an outrageous code of new biomedical ethics, by which we remain faithful to preserving all those smaller worlds without hastening the end of the larger one. Adopting these ethics would entail a profound reorganization of not only our shared professional priorities but also our standards of daily practice. Needless to say, the ecoanxious view is that we are poised for radical overhaul regardless, sooner or later.

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