This article is part of our new series on the Future of Health Care, which examines changes in the medical field.

As climate change moves from a model of the future to the reality of the present, health care systems across the country are facing a difficult set of questions. What are doctors supposed to do when wildfires, rising floodwater or other natural disasters threaten their ability to provide care for patients? How can these institutions be resilient in the face of these disasters?

To Ramé Hemstreet, these aren’t abstract questions. Mr. Hemstreet is the vice president for operations and chief sustainable resources officer for Kaiser Permanente, the California-based health care system. The state is already dealing with the effects of climate change: During the wildfires in Northern California in 2017 and 2019, Kaiser Permanente had to evacuate more than 100 patients from one facility in Santa Rosa and find a way to care for the surrounding communities.

“The climate crisis is a human health crisis, and we’re already living that in California,” Mr. Hemstreet said.

For the last decade or so, Mr. Hemstreet and his colleagues at the company have been trying to move it away from fossil fuels, largely to reduce the company’s contribution to climate change. But, it has also become clear that depending on fossil fuels is a hindrance to providing health care, as the effects of climate change are increasingly part of the lived experience of many Americans.

Around the country, hospitals and health care systems are trying to answer the central question of how to care for patients when climate change threatens their ability to keep hospitals open. Many of the changes to improve resilience are not sleek, tech-forward responses to crisis. Rather, they often represent common-sense solutions: moving technical equipment from basements where floodwater could damage it up to higher floors; organizing patient transfers in advance of catastrophes; improving energy efficiency; better air filters; and more backup systems and redundancies, just in case.

Since 2012, Boston Medical Center has lowered its energy use by nearly 40 percent and reduced its greenhouse gas emissions from all sources of energy by 90 percent while caring for more patients. Some of those reductions have come from a cogeneration plant for electricity and heat, which operates 35 percent more efficiently than separately relying on the electric utility for its energy needs. The hospital has also bought enough solar power from a solar farm in North Carolina to account for all of its electricity.

B.M.C., the largest safety-net hospital in New England, serving the uninsured and underinsured community in the Boston area, has also extended its sustainability efforts beyond renewable electricity and heating, including a rooftop garden at the hospital that grows about 6,000 pounds of food a year for its food pantry, inpatient meals and a hospital-based farmer’s market, and a biodigester that converts food waste into water.

Robert Biggio, an engineer who served in the merchant marine and now is the senior vice president of facilities and support services for the hospital, learned resilience on the high seas. “Being on a ship in the middle of the ocean, people can’t get to you,” he said. “You don’t have a choice about being resilient.”

While it is often argued that sustainability and climate-friendliness is too expensive, all of the system upgrades — including a cogeneration plant and a chilled-water loop cooling system, rather than a costly new tower — have saved B.M.C., a nonprofit, significant amounts of money.

“Reducing waste is more efficient and also improves resiliency,” Mr. Biggio said. “They do go hand-in-hand.”

Health care in the United States is responsible for a tremendous amount of waste and a significant amount of greenhouse gas emissions. For every hospital bed, the American health care system produces about 30 pounds of waste every day; over all, it accounts for about 10 percent of national greenhouse gas emissions.

Much of the waste comes from the shift toward single-use disposable items, apart from the personal protective equipment that is intended only for single use. Many hospitals are contracting outside companies to clean and reprocess many of these items; Kaiser Permanente made a commitment to recycle, reuse or compost 100 percent of its nonhazardous waste by 2025.

As for greenhouse gas emissions, hospitals have to have backup power, which is usually provided by diesel generators. These run on fossil fuels and produce fine particulate matter, known as PM 2.5, which contributes to asthma and other illnesses. Air quality around hospitals, which have to test their generators regularly, is often poor.

A recent study found that, compared with white people, people of color are more exposed to PM 2.5 from all sources, and Black Americans are the most affected. As a result, these communities, which often lack access to health care, are more likely to suffer from the health consequences of this exposure. PM 2.5 is also responsible for 85,000 to 200,000 excess deaths a year in the United States (according to the study), and long-term exposure to PM 2.5 is correlated with hospitalization for Covid-19.

During fire season and heat waves, power can go out or electric utilities may shut off power to avoid sparking fires or creating systemwide blackouts, both of which mean that hospitals have to run on their generators.

That hospitals are partly responsible for this pollution, Mr. Hemstreet said, is an unacceptable irony.

Kaiser Permanente has been buying utility-scale renewable energy since 2015, and in 2018 finalized a deal to buy 180 megawatts of wind and solar power, as well as 110 megawatts of battery storage, which is being built. Since 2010, it has put 50 megawatts of solar power on its facilities and is installing a nine megawatt-hour battery at the company’s Ontario, Calif., campus that would allow most of the facility to go off the grid entirely.

In New York City, space limitations and less abundant sunshine make ambitious installations more difficult, but heat waves present a similar challenge — the possibility of blackouts and rolling outages taking out air-conditioning, with higher temperatures endangering some older adults and those who are sick, especially.

Like B.M.C., NYU Langone Health has built a cogeneration plant for electricity, heat and steam turbine-power air-conditioning. According to Paul Schwabacher, senior vice president of facilities management at NYU Langone, it is 50 percent more efficient than utility power.

The cogeneration plant construction was in process before Hurricane Sandy in 2012, which was an eye-opening experience for the hospital system. During the storm, floodwater reached the lower floors of the hospital, leaving behind 15 million gallons of contaminated water. More than 300 patients had to be evacuated from the hospital, including newborns in intensive care, carried by doctors and nurses down many flights of stairs.

The hospital was closed for two months after the storm, during which time there were about 100 electricians working on repairs, Mr. Schwabacher said. “We made lemonade,” he said, adding that they undertook repairs that would have been much more difficult while the hospital was open, like cleaning out all of the air ducts. They also rebuilt and expanded the emergency department, which had been flooded during the storm.

Since then, the hospital has built a new building, as well as restored older ones.

NYU Langone’s greatest effort toward resilience, however, is new flood barriers around the perimeter of the campus, which are intended to protect against a storm surge seven feet above the level caused by Hurricane Sandy. The campus also has a 12-foot-high steel storm barrier at the loading dock that can be hydraulically or manually raised; valves on drains and sewage lines to prevent back flows from flooding outside streets; and steel gates and doors to hold back floodwater in critical locations throughout the facility.

But building walls won’t keep the effects of climate change away. That will come from reductions in greenhouse gas emissions from society as a whole, Mr. Schwabacher said.

“We feel very, very confident that we’ll be protected, but we know that the next disaster will be different than the last disaster.”



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