Integrating climate change education into physiatry: A critical need to protect persons with disability

As the effects of climate change intensify, extreme weather conditions are becoming increasingly common, and the health impacts of climate change will continue to disproportionately affect vulnerable populations. Persons with disabilities (PWD) are particularly vulnerable during extreme weather events that require evacuation and/or result in loss of access to electricity, water sources, health care supplies, and public services. In addition, there are a variety of other health impacts of climate change that are especially significant for people with underlying disabilities including heat and pollution-related illnesses, infectious diseases, noncommunicable diseases, and mental health sequelae. In 2019, citing their concern for this vulnerable population, the United Nations Human Rights Council passed a resolution emphasizing that extreme weather disasters disproportionately affect “access of persons with disabilities to food and nutrition, safe drinking water and sanitation, health-care services and medicines.”1 Given the unique vulnerabilities of persons with disabilities to the effects of climate change, it is important that strategies are developed to help reduce their increased risks of morbidity and mortality. The impacts of climate change on persons with disabilities generally fall into several categories including limited access to knowledge, resources, services, unique health conditions that make them more vulnerable, and increased difficulty during evacuations or migrations.2 Additionally, because climate change denial is prevalent in the United States, identifying climate change as a source of concern is challenging for some individuals, making it important to avoid political language and emphasize solution-oriented approaches. This is especially important because patients with disabilities often distrust the medical system. There are a wide range of potential strategies to mitigate these barriers that can be considered from a range of perspectives (health care provider, person with a disability, caregiver/family member). Physiatrists can be instrumental in addressing limited access to knowledge, resources, and services by counseling patients and their caregivers/families about appropriate disaster planning strategies and adaptations. However, physiatrists are often not as well trained in how to provide these resources and counseling, and would benefit from receiving more education on the matter. There are a variety of materials/toolkits available for persons with disabilities to help prepare for a disaster such as The Get Ready! Toolkit (written pamphlet) or the “Emergency Preparedness for All” video available on the cdc.gov website.3, 4 See Table 1 for resources that can be used by physiatrists and patients. As an example of how physiatrists may help address specific health vulnerabilities, they may prescribe cooling vests to patients with multiple sclerosis, spinal cord injury, or long COVID who may have difficulty regulating body temperature. Physiatrists may recommend home air filters, mechanical insufflators-exsufflators to assist with coughing (and have plans for backup power sources during power outages for people who require ventilators or supplemental oxygen), and provide education about pulmonary hygiene and/or appropriate use of inhalers or nebulizers to help prevent respiratory infections for those with lower respiratory reserves and higher risk when air quality is poor. Physiatrists can also review home safety and evacuation plans for people with limited mobility, and occupational therapists and physical therapists can perform home evaluations to ensure their patients can safely and efficiently exit their home in the case of an emergency.5 It is also important to acknowledge that climate change impacts patients without disabilities. As an example, endurance athletes are impacted by exertional heat illness putting them at risk for injury and physiatrists can provide recommendations on how to train and compete in extreme conditions.6 In this paper our focus is on the impact of climate change on persons with disabilities although the principles can be expanded to all patients. Despite these opportunities for improving patient care, there are not many formal medical training resources on the impacts of climate change, especially on persons with disabilities. Archived website Preparation for disaster resilience The availability of resources is limited in part by a historical lack of evidence and education of the health care worker. In a scoping review of the intersection of climate change and physical medicine and rehabilitation (PM&R) between 2008 and 2023, Newman et al. identified 38 articles that met inclusion criteria, 21 of which addressed the health impacts of climate change on those with disabilities.7 Although there has been an increase in the number of publications on this topic, there remains a critical gap in knowledge and understanding of the impacts of climate change on health. Although physiatrists and many other specialties frequently work with persons with disabilities, there is a dearth of clear guidance on the development of educational curricula, let alone best practices for assisting patients with disabilities as they navigate a changing world. There are several important ways in which physiatrists can be useful allies in navigating encroaching climate effects; however, for the purposes of this paper our main focus will be on the medical education of physiatrists on climate change and how it relates to patient care for persons with disabilities. Although some medical governing bodies have recognized the impact climate change has on patients' health, climate change education has yet to be broadly included in formal medical school curricula. In 2019 the American Medical Association created a policy supporting climate change education across the medical education continuum.8 A recent call to action by over 70 medical and public health groups also outlined the need for better training of medical professionals on climate change and the vulnerabilities of specific patient populations.9 There are no official Accreditation Council for Graduate Medical education (ACGME) core competency requirements directly related to climate change in either the current program requirements or the reformatted requirement effective July 2025.10 Furthermore, a scoping review on climate change in graduate medical education (GME) education found only 17 articles related to the integration of climate change into curricula and even fewer that explicitly provided descriptions or evaluations for those curricula; additionally, the majority of the articles were published in the specialty of emergency medicine.11 On the medical school level, there is interest in including climate change related curricula. In the Liaison Committee on Medical Education Part II survey, medical schools self-report whether or not the topic is covered in a required course. In the 2021–2022 academic year, 86 of 155 U.S. medical schools (55%) reported that they included the health effects of climate change as a topic in required courses.12 Even though climate change content is not required by the Liaison Committee on Medical Education, the fact that greater than half of medical schools include climate-related content as a part of their curricula demonstrates a growing interest in the content and arguably there is a need to ensure disability inclusion in that education. Although there have been discussions about the need for climate change curricula in GME there are very few published curricula and little to no evaluation of their effectiveness; at this time GME climate change curriculum is in its infancy.11 In an attempt to rectify this gap, Philipsborn et al. has provided the suggestions for competencies in a curriculum including “(1) knowledge of climate change and its effects on health, (2) climate change–related adaptations for clinical practice, and (3) implications of climate change for health care delivery.”13 Although this is a great first step, one notable opportunity for improvement is that there is little focus on addressing the unique challenges of PWD as it concerns climate change. To build on this, Kuczmarski et al. suggests a framework for integrating PWD into internal medicine curricula, however specific examples are limited to the pulmonology section.14 The climate-related medical needs of PWD expands well beyond concerns for respiratory illness. See Table 2 for disability-centered topics related to climate change effects on health. Bowel supplies (medications, ostomy supplies) Bladder supplies (Foley, suprapubic tube replacement, straight catheters, female urinary catheters, incontinence pads, urinals) Both the Association of Academic Physiatrists (AAP) and the American Academy of Physical Medicine and Rehabilitation (AAPM&R) have recognized the importance of climate change, and both have joined the Medical Society Consortium on Climate and Health.15 The AAP has published a pamphlet on climate change mitigation and preparation16 and AAPM&R's Guiding Principles on Climate and Health encourages education at its Annual Assembly as well as continuing medical education opportunities.17 In its position statement, AAP acknowledges the interest in and need for further climate change education; however, it stops short of proposing how to carry out such education.5 The International Society of Physical and Rehabilitation Medicine has also published a position statement encouraging physiatrists to work as advocates at different levels using a CCLEAR approach (Collaboration and communication, Climate Leadership, Education, Advocacy, and Research) similar to AAP.5, 18 CCLEAR provides guiding principles for how physicians can address climate change in an active manner; education is a key part of this approach yet there is still opportunity for growth.19 In fact, there is a lack of generalized medical education, and particularly, no targeted education at the resident level. In the recent revisions to ACGME's program requirements for PM&R by the triorganizational GME committee (including the American Board of PM&R, AAP, and AAPM&R), climate change education was not included as part of recommendations for change.20 Similarly, a review of online educational material from the major academic physiatry societies includes some information of the impacts of climate change on specific populations in a general sense, but no detailed educational material on addressing climate change. As an example, review of PM&R Knowledge NOW, an AAPM&R learning resource, produced only 11 results on the topic of climate change, many of which were only tangentially related to the subject.21-29 In an exploratory review performed of PM&R residency programs across the United States, it is evident that climate change is not a current part of the core mission of resident education. At this time, there is little to no evidence of climate change discussion in the curricula, didactics, or mission statements posted on websites of current U.S.-based PM&R residency programs. If there are programs that incorporate this into their curriculum, it is not publicly apparent. Of note, there are a few opportunities at the fellowship level for training including at the University of Colorado Anschutz School of Medicine, the Medical Society Consortium on Climate and Health, and the Tri-institute Climate and Human Health Physician Fellowship. However, this education need not be limited to specialized training programs given the imminent and society-wide threat climate change poses. In a changing climate, disability is but one potential vulnerability a given person may experience; socioeconomic disparities that co-occur or may exist independently of disability can also compound an individual's overall challenges. The sociological framework known as “intersectionality” was developed initially by the scholar Kimberlé Crenshaw to describe the ways in which a variety of factors such as gender, race, class, and other socioeconomic components can combine to shape individual experiences.30 The following section highlights a few of the many points of intersection between lived realities of disability, as well as other additional interacting oppressions that might collide with PWD to produce even more difficult situations. Physiologic and functional differences that result from a disabling condition create a particularly unique set of challenges in a changing climate. For example, certain disabilities such as spinal cord injury or multiple sclerosis may leave a person more vulnerable to extreme temperatures. In multiple sclerosis, symptoms can be exacerbated in warmer temperatures, known as “Uhthoff's phenomenon.”31 The sensitivity of patients with spinal cord injury to both hot and cold temperatures is well documented, as thermal regulation is impaired after spinal cord injury.32 Those with amputations may also be more at risk for complications such as overheating, skin breakdown, or skin infections due to reduced overall body surface area for evaporative cooling.33 Air particulate pollution can put patients at greater risk of stroke and risk of higher resting pressures in those undergoing cardiac rehabilitation.7 Outside of the direct effects of a warming climate, disability presents many challenges that are more indirect—the societal ruptures and the existing safety nets that break down under the pressure of environmental change are likely to disproportionally affect more vulnerable populations. For those using powered devices such as ventilators, power wheelchairs or scooters, or advanced computerized prostheses, power outages or fluctuations may present challenges to basic mobility and life-sustaining treatment. The need to rapidly mobilize in the event of an evacuation for severe weather, or even to simply relocate from an increasingly unlivable hometown or city, can be a significant challenge in a population with historical limitations to access to transportation.34 Even the simple economic limitations attendant to life with disability are likely to make basic needs more challenging to meet; need for food, water, and other necessary goods and increased demand on air conditioning or heating result in increased costs and expenses. Economic instability may also make it so that relocation to areas less under threat is not feasible. In addition, limited income and access to health insurance decreases access to health care supplies and equipment; these resources could be used to mitigate the effects of climate change. Even PWD who qualify for Medicare (most need to have social security disability insurance in place for 2 years) face significant barriers to receiving needed health care services and equipment. In addition to the lack of coverage for home modifications, Medicare guidelines allow coverage only for durable medical equipment such as wheelchairs to be used within the home, but they do not provide clear criteria or qualifications for use in the community; similarly, obtaining backup mobility such as a manual wheelchair for a primary power chair user is not a This that the of wheelchair that will be covered is limited and not for mobility the home and down weather, Medicare also not a range of equipment necessary for safety and for in a changing such as wheelchair home air conditioning and urinary let alone supplies for disaster limitations are important for physiatrists to as they navigate emergency planning and with patients. care remains an additional source of for with historical those with disabilities. 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