Expert Q&A: Rabin on climate, respiratory health, and reducing health care’s environmental footprint

Changes in air quality—from wildfire smoke and extreme heat to everyday air pollution—can impact respiratory health, particularly for individuals with lung disease and those who are sensitive to poor air quality. As a pulmonologist, Alexander Rabin, M.D., sees firsthand how environmental conditions can worsen breathing problems and, in some cases, drive hospitalizations.

Rabin is a clinical associate professor of pulmonary and critical care at Michigan Medicine, a lung specialist at the VA Ann Arbor Healthcare System, and a member of the U-M Institute for Healthcare Policy & Innovation (IHPI). His work spans patient care, research, and education, with a focus on understanding environmental influences on lung health and examining ways health care systems can reduce their environmental footprint. Rabin took on a leadership role with IHPI’s new Sandy-Hassmiller Climate & Health Initiative, which aims to foster interdisciplinary research, train emerging leaders in the National Clinician Scholars Program (NCSP), and connect clinicians and scientists to address climate-related health impacts.

In this Q&A, he discusses respiratory health and air quality, efforts to reduce health care emissions, and areas where additional research and collaboration are needed.

As a lung doctor, how does your understanding of climate and health shape the care you provide?

A: When you treat lung disease, you see very clearly how the air we breathe affects health in the short and long term. During my medical training, I was surprised that environmental health was seldom discussed, even among lung specialists, and it motivated me to incorporate my environmental interests into daily patient care.

As a pulmonologist, I spend a lot of time thinking about air quality, both indoors and outdoors, because the lungs are directly affected by environmental exposures. In practice, this means having conversations with patients about air quality in their homes, workplaces, and communities. 

Outdoor air quality has become a more frequent topic of discussion, particularly given the massive wildfires we’ve seen over the last few summers. For many patients, poor air quality has taken a major toll on their daily lives, and in some cases, it has caused lung disease flare-ups serious enough to send them to the hospital.

Who is most vulnerable to poor air quality?

A: People with preexisting lung disease, such as asthma, chronic obstructive pulmonary disease (COPD), or lung fibrosis, are among the most vulnerable to poor air quality, but they are not the only ones affected. Young children who spend a lot of time outdoors, older adults, and people with other chronic health conditions are also especially sensitive. Living near sources of pollution like highways, factories, power plants, or in historically disenfranchised neighborhoods puts people at a higher baseline risk for developing respiratory health problems.

Why should health care providers pay attention to and discuss how climate can affect health? 

A: Some clinicians are hesitant to speak publicly about issues that are often viewed as political, but the health effects associated with environmental conditions are increasingly evident in clinical care. Climate change acts as a threat multiplier, worsening existing health problems and vulnerabilities. We know patients are experiencing extreme heat, severe weather events, and wildfire smoke. Children are staying indoors and people with chronic conditions struggle to breathe on poor air quality days.

There are practical ways to approach conversations about climate and health. We can focus on reducing harm by helping patients prevent asthma flare-ups, monitor air quality, find reliable information, and prepare medications for weather-related disruptions. These are the kinds of conversations that health care providers are already trained to have.

My first step into the climate-related policy discussion was testifying before a state energy committee about a clean energy issue about ten years ago. I was struck by how few health professionals were speaking on an issue with clear public health implications, and by how closely policymakers listened when clinicians spoke about health-related impacts. That experience highlighted the vital role clinicians can play in sharing information and research to guide discussions about air quality, water quality, and other policies that affect patient health.

What is health care decarbonization, and where have health care providers seen opportunities to reduce emissions?

A: Health care decarbonization refers to efforts to reduce greenhouse gas emissions generated by the health care system. These emissions generally fall into three categories: emissions from on-site operations, emissions from electricity use, and supply chain emissions, which make up the largest share—nearly 80%. Decarbonizing health care is complex because patient safety always comes first, but there are meaningful opportunities to reduce emissions without compromising care. For example, at U-M, switching from one commonly used anesthetic gas to another significantly lowered emissions without affecting patient outcomes. At the VA, reusing a single albuterol inhaler with cleaned spacers during breathing tests reduced both waste and emissions. More broadly, hospitals generate an enormous amount of waste, and there are many places where thoughtful changes can make a real difference.

Your current research explores the environmental impact of inhalers. Why is this an important issue, and why isn’t switching to more climate-friendly options always simple?

A: Inhalers are an example of a meaningful change that health care providers can consider to reduce carbon emissions. The most commonly used inhalers in the U.S. are metered-dose inhalers, which currently make up about 70% of the market and use propellant gas to deliver medication. These propellants, called hydrofluorocarbons, are powerful greenhouse gases also used in air conditioners and refrigeration equipment, and even small amounts can have a measurable climate impact. In fact, use of a single metered-dose inhaler has roughly the same climate impact as driving a car up to 200 miles.

There are alternatives, including dry powder inhalers, which don’t use propellant gas, and soft-mist inhalers, which rely on a mechanical misting system. These options can be more environmentally friendly, and we’re actively studying when and how switching makes sense. However, our research shows that this isn’t always straightforward. In one study, some patients who switched inhalers experienced slightly worse health outcomes, which raised important questions about how to balance patient safety, effectiveness, cost, and environmental impact.

Different inhalers work better for different patients, and education and proper technique matter a great deal. Inhalers are a good example of why health care decarbonization is complex: changes meant to reduce emissions can have unintended consequences. That’s why this research is so important to help identify climate-friendly solutions that are also safe, effective, and equitable for patients.

You’re part of IHPI’s Sandy-Hassmiller Climate & Health Initiative. What does your role involve, and what types of research or collaborations are most needed right now?

A: I’m honored to be part of the IHPI Sandy-Hassmiller Climate and Health Initiative, which couldn’t come at a more important time as climate-related health impacts become more visible. The initiative is designed to support early-career researchers and students, spark collaboration across disciplines, and drive research and policy changes that can reduce carbon emissions and protect patient health. 

My role focuses on helping shape key research topics and improving how scientific findings are shared with the public. Making discoveries is important, but communicating findings clearly helps ensure they are useful to policymakers and the public.

Climate and health is still a growing field, and many researchers are relatively new to it. Through this initiative, we aim to bring together environmental engineers, public health experts, health services researchers, communications professionals, and others. Collaboration across these groups can generate strong research and support its translation into meaningful policy action.
 

More about Alex Rabin’s work

• Switching inhalers could have good effects on the climate, but bad effects on health | Michigan Medicine
• Rethinking Inhalers in the Era of Climate Change, JAMA
• It’s Time for Health Professionals to Break the Climate Taboo, Annals of the American Thoracic Society
• Budesonide-Formoterol Metered-Dose Inhaler vs Fluticasone-Salmeterol Dry-Powder Inhaler, JAMA Internal Medicine

More about the IHPI Sandy-Hassmiller Climate & Health Initiative