National Heart, Lung, and Blood Advisory Council September 2022 Meeting Summary

I. CALL TO ORDER

Dr. Gary H. Gibbons, Director of the National Heart, Lung, and Blood Institute (NHLBI), called the meeting to order at 12:02 p.m. He welcomed members of the National Heart, Lung, and Blood Advisory Council (NHLBAC) and the Board of External Experts (BEE) to this joint meeting.

II. ADMINISTRATIVE ANNOUNCEMENTS

Dr. Laura K. Moen, Director of the Division of Extramural Research Activities at NHLBI, made the required announcements for the Council meeting, including the publication of a notice in the Federal Register as well as reminders to Council members regarding conflict of interest and lobbying activities.

In addition, Dr. Moen stated that the meeting objective is to engage the NHLBAC and BEE as representatives of the NHLBI research community to advise the NHLBI on opportunities to advance and build upon the Strategic Vision in the rapidly evolving and cross-cutting area of Planetary Health.

III: Summary of Dr. Bullard’s Presentation: “The Quest for Environmental and Climate Justice: Why Health Equity Matters”

Dr. Robert D. Bullard is the Distinguished Professor of Urban Planning and Environmental Policy at Texas Southern University. He has been described as the father of environmental justice, and is the author of seventeen books addressing sustainable development, environmental racism, urban land use, industrial facility siting, community reinvestment, housing, transportation, climate justice, emergency response, smart growth, and regional equity.

Dr. Bullard opened his presentation by noting that environmental justice embraces the principle that all people in the community are entitled to equal protection of the environmental, energy, health, employment, education, housing, transportation, and civil rights laws.

Dr. Bullard noted the important connection between dumping, pollution, and race to challenge environmental discrimination using civil rights law. He noted Black communities have been historically targeted for and disproportionately impacted by waste dumping, environmental degradation, and pollution.

Climate change affects every region in the United States. The discussion about climate change is also one of justice, equity, and public health. Therefore, solutions cannot be driven by civil engineering alone but should account for social and behavioral science. Dr. Bullard also acknowledged that climate change will exacerbate disparities including health and economic inequities, and that multiple disciplines are needed to plan for resilience.

Dr. Bullard suggested that US geography reflects inequality and vulnerability and noted that the zip code is the most powerful predictor of health and well-being. There is an apparent distribution of prosperous zip codes in the upper half of the US map and distressed zip codes in the lower half. Distressed areas can often map with race and class. People of Color (POC) who have least contributed to the climate crisis feel the pain first, worst, and longest

Redlining, which occurred 100 years ago, shows up in terms of present-day pollution threats including higher levels of pollution and health threats. Dr. Bullard highlighted how redlining has denied neighborhoods greenery and left those communities hotter and, in some cases, 5-13 degrees Fahrenheit warmer.

Climate change health impacts will disproportionately affect POC, leading to higher vulnerability to heat- related stress, pregnancy risks, premature births linked to power plant pollution, and higher levels of

fine particulate matter. Dr. Bullard suggests that the justice framework must drive discussions between physicians, city planners, housing developers, and community-based organizations.

Studies show that climate change will widen the racial income and wealth gap and cause a decline in economic activity and an increase in energy insecurity. Over the years, Dr. Bullard predicts that energy expenditure problems will increase mainly for poor people. Moreover, grid failures and heat risks have a disproportionate health impact on POC with health disparities. He notes going forward, climate change will cause more power outages and impose more heat risks, stranding more people without power, heat, and clean drinking water. Additionally, he mentioned how climate-driven floods disproportionately affect Black communities and how flood risks will increase by 25% in the next 30 years, resulting in economic implications with respect to who can afford flood insurance premiums.

When a community is hit by a disaster, Dr. Bullard stated, the government's slow response quicks in a second disaster. This disaster can be avoided if scientists and policymakers address equity and build justice into the framework of climate change disaster recovery. He noted that aid does not always reach the people with the greatest need. Communities with lower property values are experiencing displacement and abandonment due to a lack of resources for restoring their homes in terms of quality, safety, and livability.

He noted that climate change will:

• pose significant health threats including cardiovascular disease, respiratory allergies, and asthma with an unequal burden among low-income and POC households. There is a pollution transfer, and POC face higher levels of fine particulate pollution regardless of the source. Research suggests Black and Latino populations are breathing air that has been polluted by white people.

• bring hotter days and heat is the number one weather-related killer. Schools will need more infrastructure to beat the heat and money will need to be directed to schools with the highest needs to make them climate resilient. In addition, outdoors workers will be exposed to extreme heat and POC will be most impacted, making climate change more than an environmental issue but also an economic issue because of the potential impact of workers losing their jobs.

• worsen drought and lead to more wildfires and smoke, exacerbating the asthma epidemic among POC. It will also increase the loss of natural land cover, and 74% of POC already live in nature-deprived areas.

Dr. Bullard concluded his talk with a call to action for the scientific community to build a sustainable model and develop an action plan to address health equity, environmental and racial justice, energy, food, and water security while ensuring resources and investments go to the communities that haven’t been supported in the past.

IV: Summary of Dr. Ebi’s Presentation: “Climate Changes Health”

Dr. Kristie L. Ebi is a professor at the University of Washington’s Center for Health and Global Environment. She has been conducting research and practice on the health risks of climate variability and change for nearly 25 years. She focuses on understanding sources of vulnerability, estimating current and future health risks of climate change, designing adaptation policies and measures to reduce risks in multi-stressor environments, and estimating the health co-benefits of mitigation polices.

Dr. Ebi noted that the elements of climate change risk are broken down into three elements in the 2022 report of the Intergovernmental Panel on Climate Change (IPCC). These three elements include: (1) hazards created by a changing climate, (2) who and what is exposed to those hazards (about 80% of health risks of a changing climate are happening in children), and (3) vulnerability to those hazards.

Vulnerability can be further broken down into the susceptibility of individuals and infrastructures, and the capacity of communities and health systems to manage. For example, there is the potential for disruption of health services by extreme events such as floods. Far too many are in sensitive areas, stressing the need for adaptation plans for cities and communities. Dr. Ebi continued her presentation by giving examples of various scenarios which can be anticipated as climate change continues with an eye toward understanding that the cost of action may be small in comparison to the cost of inaction.

First, Dr. Ebi noted that changes due to climate (such as rising carbon levels, rising temperatures, and rising sea levels) interact with a broad range of demographic, socio-economic, and environmental variables. She pointed out that together, these interactions affect traditional exposure pathways such as extreme weather events, heat stress, air quality, food supply, and safety. These factors tightly linked to hundreds of climate-sensitive health outcomes. There have been efforts to identify and follow the relationships among these variables:

• With regards to extreme weather events, the National Oceanic and Atmospheric Administration (NOAA) (which tracks billion-dollar climate-related disasters) reported 322 weather climate

disasters since 1980 that cost over 2-3 trillion dollars. One of the shortcomings of this tracking effort is that it overlooks other critical climate anomalies such as heatwaves, because these are not considered billion-dollar disasters (those being only linked to infrastructure). Hence, the impact of these climate events on human well-being does not factor into the equation. Extreme weather events such as flooding are known to be linked to a significant increase in the prevalence of mental health outcomes (anxiety, depression, PTSD). The impact is substantial and tends to persist over several years in affected populations.

• The impact of heat stress on health is well documented. With changes in climate, exposure to heat in vulnerable populations is dramatically increasing, according to the Lancet Countdown. Globally, children younger than 1 year were affected by 626 million more person-days of heatwave exposure, and adults over 65 years were affected by 3.1 billion more person-days of heatwave exposure in 2020 than in the 1986-2005 average. Beyond the impact on individuals, heat is an all-society problem that has a significant impact on the livelihood of coastal species (such as mussels and oysters), and the yield of vital crops (such as wheat). Reduced crop yield directly affects global food supply and safety, as well as outdoor workers' security.

• Wildfires have become frequent events in the last few years. In approximately 60% of the world’s countries, there was an increase in the number of days people were exposed to very high or extremely high fire danger during 2017-2020 compared with 2001-2004. Wildfires cause elevated Air Quality Index (AQI), which research has shown can lead to an increased risk of diabetes, lung, and heart disease. An AQI >60 is unsafe for anyone to breathe, yet wildfire smoke can cause an AQI > 100 for several days (sometimes weeks) at a time. Some US communities had AQI >750 during wildfire events (e.g., Seattle, California).

Dr. Ebi continued by explaining that the largest impact of climate change will be food safety and security. She pointed out that today, there are 820 million people in the world who suffer from food

insecurity, and these numbers are estimated to increase. There are two reasons for this: (1) crop yields have been significantly declining, directly due to greenhouse gas emissions over the century (this is well documented for maize, rice, wheat, and corn),and (2) higher proportions of carbon dioxide will directly affect food quality since plants use photosynthesis to break down carbon and use it to grow. Higher CO2 concentration will cause plants to generate higher concentrations of carbon-based elements (increase in carbohydrates, reduction in proteins (~10%), and B-vitamins (~30%)) and also make them more water efficient. However, by bringing in less water, these plants will also take on about 5% fewer micronutrients. Similarly, higher CO2 will impact the composition of grass (reduction in iron composition), affecting the nutrition quality of cattle relying on forage and the nutrient quality of the derived meat and dairy products. Together, these facts will lead to higher rates of nutrition deficiencies and related diseases in children and adults, including iron-deficiency anemia and zinc deficiencies which can lead to stunted growth and other developmental problems.

She discussed the 5 Reasons for Concern (RFCs) framework, which was introduced by the IPCC to illustrate the impacts of different levels of global warming on people, economies, and ecosystems across sectors and regions. The 5 RFCs include extreme weather events, distribution of impacts, threatened systems, global impact, and large singular events. The risk and impact of climate change on each RFC are determined as either undetectable, moderate, high, or very high. The transition point from one level to another is assigned a confidence level ranging from low to very high. All the reports studying transition points show a dramatic increase in where they occur, with a much earlier occurrence than what was projected in 2001.

Dr. Ebi continued by describing a similar framework established for climate-sensitive health outcomes; for heat-related morbidity and mortality, ozone-related mortality, malaria, dengue, and other diseases carried by species of Aedes mosquitoes. A risk and impact assessment study performed when considering three adaptation scenarios (limited, incomplete, proactive) showed a stark difference in the transition point occurrences under the three scenarios. A proactive adaptation, with proactive management and higher investment in health systems, would delay the impact of climate change on climate-sensitive health outcomes.

As she began to point out the opportunities to address climate change impact, Dr. Ebi noted that policies and programs are in place to manage climate-sensitive health outcomes, but they need to be more explicit about climate change. Different programs could be tested in different locations to decide which are the most efficient, and where human and financial resources should be invested to increase the resilience of communities and health systems.

Dr. Ebi noted one major approach for countries is the national adaptation plan (required for signatories of the UNFCCC). Unfortunately, due to a lack of training in climate change and health, only 52% of countries have a plan, and less than a quarter report high or very high implementation.

Dr. Ebi stressed that new partnerships are needed to tackle the research agenda for climate change and health outcomes. She suggested that one approach would be to establish Centers of excellence to bring climate experts and health scientists together to avoid errors in data interpretation. Challenges need to be addressed by both groups of experts to address policymakers.

She suggested the biggest challenge climate change and health research faces is the lack of funding and investment. However, not all efforts have to be expensive. For example, a robust working collaboration is in place between the National Oceanic and Atmospheric Administration (NOAA), the National

Aeronautics and Space Administration (NASA), the National Sciences Foundation (NSF), the Environmental Protection Agency (EPA), and the Electric Power Research Institute to study climate variability and human health. The initiative required a small amount of funding and resulted in large datasets. Dr Ebi also suggested that NIH could set up health-focused programs similar to NOAA’s RISA (Regional Integrated Sciences and assessments) program; these programs convene the scientific community, policymakers, and community’s stakeholders by region to tackle specific community and region-related issues.

V. DIRECTOR’S REMARKS

Advancing Heart, Lung, Blood, and Sleep Research with a Climate and Health Focus

Climate change has many effects on the Heart, Lung, Blood, and Sleep (HLBS) health with implications for high-risk communities. Cross-disciplinary interchange, collaboration, and strategic thinking are essential to get results in this field.

Extreme heat has been associated with a cardiovascular (CV) burden. Maps highlighting the location of the population that is most affected can be used to guide priorities and targeted strategies for our research agenda.

Research should target mechanisms of heat-related cardiovascular disease (CVD) by looking for gene expression profiles, studying the effect of exposure on biological systems, and understanding pathways' vulnerability. There is an opportunity to elucidate determinants of response to heat stress through mechanistic clinical studies. Furthermore, innovative sensor technologies must be developed along with data collection tools to measure the climate exposome.

Differences in heat exposure according to zip codes exacerbate CVD inequities in the US. Structural factors, such as the impact of redlining policies and urban heat islands, highlight the importance of engaging communities for adaptation. Integrating diverse data types is critical to better inform public health interventions.

Our “Systems Approach” to climate and HLBS health must connect all the vulnerabilities, and address how those vulnerabilities concentrate in certain communities. This challenge is an opportunity to pave a pathway toward adaptation, mitigation, and resilience.

Philadelphia's “Beat the Heat” initiative leveraged local partnerships by bringing people together across the stakeholder spectrum including those who are embedded in the community. The “Beat the Heat” initiative should serve as an exemplar that ensures an inclusive table and encourages the participation of those who can contribute to solution discovery, co-learning, and knowledge exchange.

More rigor and reach of climate science are needed along with community-scientist partnerships. Researchers need to embrace the expertise of climate scientists and citizen scientists.

CHARGE FOR THE WORKING GROUPS

Tell us how we can set research priorities, build capacity, and leverage existing resources so that NHLBI can successfully develop a research enterprise that can reduce threats from climate on HLBS health.

All three breakout groups were asked to consider the same questions for presentation and report out to the entire group when reconvened. They were also asked to keep the following in consideration as they discussed the questions:

• The broader implications of planetary health and global health for the NHLBI portfolio within the NIH climate and health initiative.
• How climate may affect HLBS clinical treatment and health outcomes across the lifespan and in different at-risk populations.
• How can we build collaborations and knowledge building resources focusing on intervention and dissemination of effective interventions for climate risks/impacts that are contextually relevant to patients and communities.
• How climate may affect access to health care and how needed HLBS expertise can effectively respond with relevant skills and knowledge that is geographically relevant to the climate risks in particular area. What training and capacity building is needed to develop and sustain these efforts going forward?

VI. COMBINED SUMMARY OF REPORTS FROM THE WORKING GROUP DISCUSSIONS

Drs. Kevin Thomas (Director and Associate Professor, Duke Clinical Research Institute, Duke University), Mercedes Carnethon (Mary Harris Thompson Professor and Vice Chair, Department of Preventative Medicine, Northwestern University) and Mohandas Narla (Vice President for Research, New York Blood Center) summarized the responses to the key questions for Group A (Heart), Group B (Lung and Sleep) and Group C (Blood and Implementation) respectively. The combined responses from the three groups are summarized below:

Most Compelling research questions in addressing the effects of climate on heart, lung, blood and sleep health?

• Studies involving larger cohorts to validate the consequence of the different climate change hazards on clinical manifestations

• Understanding the underlying mechanisms of heat-induced lung damage and developing research and treatment strategies to prevent the effects of climate change in vulnerable populations

• For researchers to be able to evaluate the unintended consequences of climate change on CVD and create a system that generates longitudinal real-time estimates of where things are.

• The impact of climate events (e.g., floods, tsunamis, wildfires) on populations and health (such as floods, tsunamis, wildfires, etc.) should be addressed, as well as how the migratory pattern of communities influences the ability to study them. Innovative ways are needed to study increased amounts of migratory communities across different geographical and healthcare settings.

Current gaps and barriers?

• Research priorities should focus on integrating climate data into existing datasets of sickle cell disease and other blood disorders, investigating and documenting epigenetic changes induced by hazard exposure, performing longitudinal studies starting with children throughout their lifespan, and developing evidence-based strategies to address the effects of climate change on blood disorders.

• The scientific community needs to acknowledge the difficulty of studying the impact of chronic exposure across the lifespan, starting with pregnant women and their unborn fetus, as well as, across infancy, childhood, adulthood and throughout old age.

How can we leverage current NHLBI Data Resources to capture environmental and contextual factors of the Climate Exposome and current disease endpoints?

• Capture geocoded data in addition to climate data by TOPMed and BioData Catalyst for future analyses.

• Take an interdisciplinary scientific approach that involves a large-scale team and recommends broadening community engagement to develop trust. Collaborations should be extended to other government agencies beyond the NIH and its institutes.

• Notably, geographical location (e.g., rural, suburban, US region) dictates access to healthcare and which environmental stressors are most prevalent. The NHLBI resources (e.g., TopMed, dbGaP, BioData Catalyst) should be leveraged in this research to obtain geospatial data overlaid on other scientific variables

• Existing logic models developed by large climate change research entities should be integrated to help differentiate the multiple domains of CV care affected by climate change. Data focusing on myocardial infarctions and coronary disease already exists in the vascular space, but there is a paucity of data on other CV diseases (heart failure, arrhythmia, health disorders in pregnancy, etc.)

How can we advance discoveries in the Human Systems Biology of the response to climate? What are the current gaps and barriers to addressing these compelling questions?

• Biomarkers of chronic exposure are needed to reduce bias in exposure assessment. The group experts suggested that researchers use stored lung tissue samples to study heat damage and look for biomarkers.

• More curated data sets are needed with granular data that includes geographical regions. These datasets will enable the assessment of threat inequalities and adapt interventional solutions.

• Additionally, climate change should be integrated not only as a threat but as a determinant of health. Integrating climate exposure is an important consideration in the lived experience of an individual and should be evaluated when considering interventions.

How can we build collaborations and knowledge-building resources focusing on intervention and dissemination of effective interventions for climate risks/impacts that are contextually relevant to patients and communities?