name is Erica Moseson. I don't have any financial disclosures. Lesson objectives for today is the first part of my talk is just going to kind of catch everyone up because I'm sure everyone's coming to their knowledge of air pollution and climate change from different places or maybe you're all experts but it'll be real quick air pollution and climate change 101 so you can leave here and go add a climate change and clean air advocacy to your busy full-time practice and then we'll go through engagement options and just talk about kind of incorporating advocacy as part of our practice and not feeling like you have to do everything you can just do a little bit and it'll still be good all right so 101 climate change is sickening and killing our patients now air pollution is sickening and killing our patients now and at levels deemed safe and that's an important thing to understand the burden of climate change and air pollution is not equally shared it costs all of us money and there are solutions that would benefit from clinician advocates like you so where are we now the IPCC tells us that we if we want to stay at 1.5 degrees we need to get our emissions down but the emissions that we've already made don't actually sentence us to getting to 1.5 degrees so we can actually make some changes right so what we all need to be fighting for including everyone in this room we have seven years to be getting our co2 emissions to 45% down from 2010 levels and to get to net zero by 2050 but the nice thing is if you are have trouble with delayed gratification all of this will make people healthier now so if you want to see immediate benefits you can do that so climate change 101 so if we kind of continue with high emissions this is what NOAA projects our average maximum temperatures are going to be by the end of the century I mean I think we've all taken care of people with heat stress in our clinics and ICUs and we know that this is going to kill a lot of people we also know that catastrophic wildfires are spiking our air pollution to levels that are beyond what we understand is healthy for human beings and this is happening with increasing frequency and increasing intensity and will continue to happen with increasing frequency and increasing intensity we know that catastrophic flooding events not only are causing displacement and loss of you know lives from the immediate effects of the storms but we're also seeing mold exacerbated illnesses following we know that the air pollution that's generated from our combustion of fossil fuels for both energy and transportation not only emits carbon dioxide which makes us sick but also emits particulates and a whole host of other pollution that kind of makes a lot of our population second hand smokers against their will so I think we all remember from high school biology that when you put carbon dioxide into the air that's plant food right so warming climates and increasing carbon dioxide are leading to increasing pollen production and longer and more intense allergy seasons so in North America we get about a month longer ragweed season and the pollen is produced is both of greater quantity and more allergen allergen inducing and finally the mental health toll of climate change is increasingly understood these events both catastrophic climate events and then the grief anticipatory grief and psychological distress of a warming and changing climate is very very real a study showing suicide rates spiking after catastrophic climate events like Katrina we know that climate anxiety is increasingly a part of our children's lives so for example I have had the honor of having awoken in the middle of the night by my husband and had to flee a wildfire or a fire with my children and I think there are just increasingly apocalyptic scenarios that we are all facing so in 2020 I'm during the Labor Day fires this was the atmospheric the NASA satellite over my home state of Portland Oregon of Oregon and I was looking at these fires and just thinking about what happens when they move and the air quality index outside my home was beyond the index and I was in my home with three young children and thinking about these effects right so my daughter is composing letters to the firefighter who the firefighters who helped put out the fire and that we left and then you have other you know my other children are you know wondering about the mother bunnies losing their children bunnies and let me tell you I really really identify with the mother bunny in this drawing so I think a lot of us are worried about the effects of climate change not just on us but on our kids right so the other thing I want to let you know so that was climate change 101 you're all caught up good job so now air pollution 101 so all the things we do to generate energy in our lives right to air condition this lovely building for the transportation sector for for you know any kind of energy generation we need I just want to let you know that you can all already talk about it if you can all talk about smoking right most of this leads to similar effects as secondhand smoking so when we burn fossil fuels we generate particulate matter and we generate sulfur dioxide oxides of nitrogen and eventually generate ozone and all of these things if you think about it kind of lead to populations that become secondhand smokers it's been catch all up on particulate matter teensy tiny particles smaller than a human hair they get inhaled they go into our lungs across the alveolar membrane and circulate around our bloodstream causing disease in every organ system and from womb to tomb and again I guarantee you probably just think of whatever your favorite study is related to cigarettes and it's probably been shown to have a similar effect related to p.m. 2.5 so we're talking about intrauterine growth restriction premature deliveries we're talking about causing asthma and children we're talking about hospitalizations for asthma COPD we're talking about heart attacks strokes all sorts of things there there are studies in Mexico City looking at MRI changes in children's brains related to p.m. 2.5 exposure ozone so ozone is actually a secondary pollutant it's kind of formed in the downstream after oxides of nitrogen react with methane and other things that come from our you know combustion and agricultural activities it is good up high I think we think of the ozone is good that's good way up high as an ozone layer it's bad nearby right and unfortunately this one's a little stubborn it has not been able to go to be brought down as some of our other efforts the Clean Air Act have done so this was a study looking over a decade of patients looking at rates of emphysema from exposures to ozone and this study was done that had about half the cohort actually were smokers so they were actually able to compare the exposure to ozone to the expose to kind of pack years of cigarettes and they found that for ozone exposure 10 years of the high levels of ozone exposure hits you around the same as 29 pack years of smoking in terms of percent emphysema on CT scan for oxides of nitrogen right so these are emitted by power generations industrial and traffic sources in the outside air on the indoor air gas stoves are a big culprit for this and this has a whole host of respiratory effects respiratory infections again linked to premature mortality morbidity and both respiratory and cardiovascular disease this is one representative of many that looked at Detroit Michigan versus Windsor Ontario kind of on two sides of the the border and they just looked at multiple air pollutant levels and looked at asthma event rates for people in the ERs exposed so here's their map of oxides of nitrogen so you can see Detroit on the top Windsor Ontario on the bottom and then they looked at the asthma event rates and you have a just linear increase as the oxides of nitrogen increase the asthma event rates increased as well and so you can see this relationship and I want to just point out that the EPA standard for what is safe on an annual basis is 53 parts per billion and this starts at 10 11 12 13 15 you're starting to see the increase already there and I would point out that in small homes and multifamily buildings with gas stoves you can have nitrogen dioxide levels far in excess of this theoretical annual standard so I think sometimes when people think about big air pollution events we can think about big events in history so anyone who watched the crown might remember the big smoke right and so this was an event where an inversion basically just trapped all the air pollution London was making on the population and so oxides of sulfur dioxide spiked and then you also see you know sulfur dioxide spiked mortality went up they were looking tracking weekly mortality in London and then even when the air pollutant fell you actually still had an elevation in mortality and that we see in all sorts of different types of air pollution right so there's a lag effect too so I think think about this again smoking right when our patients quit smoking or move out of the house of a smoker it's not like the next day their health goes back to normal it takes them a while for that toxic effect to improve if it ever fully does okay that's super dramatic right it's all better now the air looks clear we're here in Hawaii it's so pretty well unfortunately globally we now have p.m. 2.5 has actually surpassed cigarettes in terms of the thing that is taking most life years off all of us as humans on this planet and I think we're familiar with thinking about this in certain places like India and China where the the smog is is you know remains famous but then what about in the US right and so this is one of many many many studies looking at Medicare beneficiaries so this is over 60 million Medicare beneficiaries and they looked at the p.m. 2.5 per zip code of each residence this is all-cause mortality and what they find is again a linear response right and then if you look here at the levels of p.m. 2.5 and micrograms per meter cubed and the levels of ozone again these are you know often below the legal limit so our EPA still I think I showed this slide last year at chest and this is still where we're at the EPA sets its standard at 12 micrograms per meter cubed the American Thoracic Society Environmental Health Policy Committee and advises 8 micrograms per meter cubed and the EPA is now considering dropping its standard somewhere to between 9 and 11 but the WHO sets its standard at 5 and again this burden is not shared equally right so we know that in each zip code not everyone breathes the same air right the freeway goes through one half of the zip code and not the other and so you see here that members of the black community are at much increased increased risk of mortality related to air pollution compared to other populations and this is not explained by other cofactors like eligibility for Medicaid so I think this is something that if you want to get involved in clean air advocacy which I hardly hope you do and climate advocacy it is just really really important to understand our history so if you haven't read the book the color of law I highly recommend it it's gripping it's quite a page-turner but it really goes through the history of the homeowners loan corporation and how we basically restructured US mortgages to create neighborhood level assessments and determine a mortgage risk of certain areas right and they explicitly labeled black neighborhoods or neighborhoods with high immigrant populations is too risky for mortgages and actually ended up resegregating certain neighborhoods and requiring racially exclusive covenants to basically secure funding for new buildings and so this net effect was this massive transfer of wealth from certain communities that have been continued to be historically disenfranchised to native-born white communities and you can actually look up these maps and I really recommend that you do this so you can actually if you live in any of these areas you can go to this website this project called mapping inequality and actually look up the historic redline maps for your neighborhood because what has happened is we have redlined our air right so this is a study of children looking at in who kind of been raised in areas of higher air pollution because when you have lower home prices racial segregation what happens is that's where the cheap land is right so when you're gonna build the new freeway you're gonna build the new smokestack you're building it in communities that already have the lower land prices but that's because of you know redlining and so this study looked at the distance from a freeway of people who are living who had you know Hispanic children right so non-hispanic white kids were more likely to live farther from the local the closest freeway or road than kids who are Hispanic and then the increasing amount of native ancestry meant that you lived even closer to the road so those are the kids living closest and then what you had is you had increased exposure to oxides of nitrogen and the greater the percent native ancestry the closer you were and then those kids were twice as likely to have ever reported asthma as those living further away so just I think one thing that's really important about clean air advocacy is I think the more local you get the better so this is where I'm from Portland Oregon okay so this is our the one of the historically redlined districts in our city where my this is where my office is located and this is the view out my office at Emanuel Hospital right and this is about Harriet Tubman Middle School which is located on Flint Street and this is a study that was commissioned there to look at the air pollution while they were trying to decide about reopening the school and so you can see this is the school right here here's my hospital right over there and they looked at air pollution close to the the road right so here's the oxides of nitrogen level that are here at the school and then here this is the closest DEQ station which is supposed to be monitoring the air pollution on the freeway which you can see is it's even lower than what's being monitored at the school and then this is the DEQ station in Selwood Oregon which is our Selwood Portland which is a little farther away a very nice leafy suburb or not suburb part of the city the other thing that's in there is elevated volatile organic compounds right so carcinogens like benzene are far in excess of what is safe to breathe and so what happened is they built this amazing air filter on the top they had Portland State University engineering professors build this truly elaborate Guggenheim style air filtering air filtration system on the roof and I've been told by atmospheric chemists in Portland that if you want to breathe the safest air in Portland you can breathe the air inside this school but think about the neighborhood like what about the neighborhood what about all the people growing up in this area right so that brings me to this young woman Asia Allen who I first met in a manual ICU when a respiratory therapist I have her permission to tell this story just HIPAA has been observed she's signed all the things where I first met her in a manual ICU when she had a silent chest and her heart rate was 180 and one of the very senior respiratory therapists was pulling me in the room to consider intubating her and she was on BiPAP had very wide terrified eyes and her wonderful mother was at her bedside and she has become my patient and she grew up in this neighborhood Albina right and this these were her schools Boise Elliott right by I-5 Benson Polytechnic right by I-84 and she grew up in a time of massive construction making new railway lines etc you can see the rail yards are right here so what do we do right we have decided that certain kids can be secondhand smokers right and we have entire neighborhoods in areas of massive disadvantage so I think this is something that is kind of part of all of our professional identities and the nice thing is that policy works right so in California they passed a lot of diesel legislation and have been working at cleaning up the air so this is kind of over the years as California's enacted more stringent air quality controls with California Air Resource Board and more as the air pollution levels have fallen kids have actually done better so there is some hope right our oxides of nitrogen are falling our PM 2.5 is falling ozone like I said still stubborn stubborn ozone but oops I'm sorry the nice thing is as the nitrogen dioxide falls and the PM 2.5 falls you see the FEC and FEV1 in the kids is increasing right and so this is hope right over time your kids are less and less likely to have lower levels of lung function than predicted for their age the other thing is as we clean up our buses this can also be seen so this was in Seattle where they actually worked on transitioning to ultra low solar diesel and they also worked on putting diesel oxidative catalysts in the engines of the buses and they monitored over you know around 300 kids they put little pollution sensors on them they drove around in front of the bus with a Prius with a window open to monitor the ambient air pollution and they were looking for missed sick days and they enriched this population for our kids with asthma because they assumed that kids with asthma would miss fewer sick days and it worked so the technology lowered the PM 2.5 in the engines the catalytic the ultra low sulfur diesel engines also had decreased you know ultra fine particulate matter and the punchline was it wasn't just the kids with asthma who missed more who had who benefited and stopped missing as many sick days all kids benefited right so in kids who who all the kids have were 8% less likely to be absent when we switch to ultra low sulfur diesel and they also with the use of a catalytic converter they had a 6% reduction in the risk of being absent over the last month obviously the biggest associations were in kids with asthma and then if you estimate spread this because the the EPA mandated this transition to ultra low sulfur diesel but they estimate that over 14 million fewer absences per year occurred across the United States because of just that transition and I should say this study was actually done in a cohort of fairly wealthy well-off white families in the Seattle area so it's it's a thing that you know it affects all of us and it affects all communities so that was climate change and air pollution 101 you now know all you need to know to be effective clean air and climate advocates in 20 minutes so now let's go out of the clinic in the ICU and into the community for engagement options so I would say if you're a busy clinician you don't necessarily have time to like go out and build entirely new communities all the time so just think about where you already have community and engage right so the Parks Department in your local community and make sure you include all parks maybe try to get parks into new places your you know church community school community your hospital like where you work you know you can advocate for you know electric vehicle chargers in all these locations you can advocate for planting more trees you can advocate for a whole host of things that will help both improve clean air and help reduce carbon emissions now and I would also say what you want to do is use your community to engage together right so this was you know at ATS this last year I went around with you know former colleagues Matt Drake of OHSU and Kelly Vranis you know asthma doctor and ICU doctor and we just kind of went around so the power of actually showing up in your legislators office or your representative's office and just saying hi I'm a doctor like let me tell you about some patients who've suffered from a heat dome from air pollution from asthma it's really powerful when people have some doctors walk in and say this is a problem and we are here and we want you to fix it you know we're not here telling you to you know buy us something we want you to make this better think about your community in other ways think about this meeting right here at chest right so this is back this is a Francisca Rosser she's a pediatric pulmonologist at University of Pittsburgh and we were at 18 the ATS last year and it happened to be in Washington DC so we were already there like let's walk to Capitol Hill let's have a little cleaner and climate rally so we did right dr. Gooby was there too and so and then you know I'm fully trying to show up as myself all the time these are my kids they wanted some signs they wanted to walk over with the doctors over to Capitol Hill too that's fine my son really liked this very grim sign he was very excited about it so I was like fine there you go do it and then again but be your full self right if you've got a really nice scientific heart take that sign this is my daughter Selena and she thought this sign was really fun I don't think she could even read it but she marched around and waved it around and these things have power right and I would say you are already an expert in translating science into messy life so the sub elitism and the imposter syndrome is very real I have it right now speaking to you but this is something you're already an expert in right like you're already an expert in taking these studies and doing whatever and helping the person in front of you trying to figure out which study applies to them and and what do you do like how do you make life-and-death decisions with imperfect data and that's what you do every day in the ICU and clinic this is me explaining to a patient that though they might think a vaccine is uncomfortable this is what an ET tube looks like right I would also say you really want to connect with values and human stories so I had a conversation with a behavioral scientist Destiny Amon who it really kind of changed my approach so start with the stories start with the shared values so for example if you live in a community that's very concerned about national security like for the military base you're like absolutely me too like I don't want to be dependent on foreign oil let's put it let's get an electric vehicle infrastructure going here right you do not have to change people's minds you just want to switch the behavior to something that cleans up the air and stabilizes the climate don't spend any time trying to change someone's mind about what the government means or what anything means just that's just the switch right I would also say there's a lot of resources right so there's a whole host of resources on clean air you don't have to like invent the wheel the first time I went to testify for something I prepared like I was giving grand rounds you don't have to do it. There's a lot of data and everything out there saying that clean air is better, air pollution is bad, and you can get some reports that can be helpful. So one example is American Lung Association commissions a report called the State of the Air Every Year. You can actually look up your zip code, find out if it's got a grade, like A, B, C, D, or F, or whatever, and then you can just talk to your community about it. So find out who represents you on the local neighborhood association and say, hey, neighborhood association, we got an F. Let's plant some trees, or non-pollen producing trees. Let's put in some EV chargers. Let's do whatever. Let's ban some leaf blowers, because our air pollution is bad. Let's just get it down. Talk to your city folks, your county. Find out who actually represents you at all these hyper-local areas. You will have so much more of an impact. And also your statehouse, like your local representative or delegate, depending on what state you're coming from, your senator, and globally, too. And I would just say, a little effort goes a long way. Anything that is worth doing is worth doing badly. And so whatever time you have is enough. The world will be saved by B-plus work. If you're waiting to get it perfect, it's too late. We've got seven years. And you just want to start by starting, and it will become a journey. And all these things are individual. So I'm just going to share my journey, and then everyone has a very, very different one, but just kind of some examples. So I was fairly worried, as someone who cared about clean air and a climate, as things started to roll back. I used to think there were these adults in charge that would run everything, and there was the Clean Power Plan, and that was going to solve air pollution, and I could just kind of keep being a doctor and have my kids. But that was not the case. So the American Lung Association in the state of Oregon knew the Oregon legislature was considering a couple of bills for diesel pollution and Tobacco 21 and that sort of thing. So I went around with them, and they just thought it was weird, because I'd show up and talk to them about tobacco one day, and then I'd show up and talk to them about diesel the next day. And they're like, weren't you just the person who was here on tobacco? And I said, it's the same problem. Don't light things on fire, and breathe them into your lungs. And so that's how I kind of got started. And then I took my local Oregon Thoracic Society chapter, where we used to just kind of have our annual meeting and do different things. I'm like, let's do some advocacy. Let's write testimony for this bill in the state legislature. And so we started doing that. We just started, I literally took what the ATS had said at the national level, and I just kind of localized it for Oregon, same citations, references, whatever, submitted it. And so we just started doing that. Started going to some town halls. So this is hyper-local, their neighborhood. This is my husband, and this is the Southeast Examiner. It's literally just for my neighborhood of Portland. And we'd have these town halls, and we'd talk about diesel and maybe how people should worry about it. And we'd testify, and DEQ would have a hearing about air pollution, and you can imagine the cast of characters that shows up for that in Portland, Oregon. But there was a doctor that showed up and said, you know, this isn't healthy, but bring your friends. And so I brought a fancy OHSU asthma scientist and researcher who could talk about the biology of asthma. And he showed up and talked about it. But this is also my life, too. I am a full-time clinician. So when I pull up in Trigma or Amayon or whatever, this is what stares me in the face. The other thing is I have these guys, and they are my children, and they're amazing, and they also get my time. And so starting to kind of feel concerned about balancing this is really, really important. And so one thing that came out of the pandemic—so this is our unipiper here in Portland, Oregon. One thing that came out of the pandemic that was a good thing was that the opportunities to advocate have actually improved. It used to be that I had to take a day off or find a day off and literally burn fossil fuels on my way to the state legislature in Salem, which is like an hour, an hour and a half away, to walk around. This has really limited the voices that our legislators heard because they could only hear from people who had the time to suddenly on a Tuesday go somewhere. So you can actually get more involved. So this was a hearing on an OSHA standard for trying to get more respiratory protections for our outdoor workers and during wildfire events. This is our county. So looking at your county—so this is a state county. I was post-call. I had been awake all night. I rolled out of bed, threw on a white coat, jumped on a Zoom, and said, breathing smoke is bad. It was about a, like, wood smoke standard or whatever. I finished my testimony, said, thank you very much, and I went back to bed. This is a full-time clinician. This is how you do it. And this is a climate and health standards for existing buildings that I participated on in our city and just kind of helping people understand the risks of gas stoves and what can be done and what works and what doesn't work can be helpful. And then obviously you can testify at the national level with your society. But the most important thing to be able to say yes and do any of these things is to put your own oxygen mask on first and know that you can say no, because it's hard to get involved in this if you don't know that it's okay to say no, and it's very okay to say no because you won't do it if you're—you'll do it for a year and then you'll burn out and quit because you'll be so tired. So you have to say no. So this is a very important phrase to learn that one of my mentors taught me. I do not currently have the bandwidth to give that project the attention it deserves. You acknowledge it's super important. It's a really great project. You're delighted they're on it. You don't have the ability right now because one of your kids is home with COVID, the other one's got whatever, you have, you know, a week of ICU call. It's okay. It's okay. Something can be really, really important and not your problem, right? Or not your problem now. So one of the other things I did is I started a podcast because I got tired of going and saying the same thing over and over again to different places, so I just started saying it into a microphone. And then I wanted to learn about things and then I would learn about them and tell other people about them and I thought that was kind of silly because I could just record the conversation and then just share that. You just get efficient. That's what you've got to do when you're working full time. So for example, Asia really wanted to share her story. So I worked with her on our podcast to talk about Asia and Albina, her historically red line district, and at the same time I went through the history of diesel policy in the Portland metro area and all the different parts of her childhood where we had chosen as a community not to act and the impact that had had on Asia. And she actually, Neighbors for Clean Air is a diesel advocacy organization, kind of made a little cartoon about her life. They put her on their board and so you really have this patient who's actually lived the experience being the voice at the table, which is so much more important than me, right? And so I would just say that advocacy can be part of our practice and I think there's really good reasons to do this. So first of all, it's good for our patients. It's good for us. And then if you are really in one of those burnt out phases where you don't really care about humans anymore, it saves us all money, right? So think about as much inhalers cost, hospitalizations, all those things, Medicare expenditures are going up, Medicaid expenditures are going up. If you show up at the state legislature and you walk in the door and say, hey, I'm a doctor and I've got a way to save you on your Medicaid costs. That's like the biggest part. Everyone will be like, what? Great. Give me in. You're like, okay, here's my secret. Clean up the air, right? Like fewer inhalers, less whatever. They will love you. They won't, but it's a way in the door. And again, you are already likely very good at this, right? This is what you do every day is you translate science into the messiness of everybody's life, and it's the patient stories that make you keep going. So start with those stories. And then the other thing is, you know, if not you, who? Right? Again, we got seven years, guys, to get those CO2 emissions down and clean up the air. So in conclusion, air pollution causes disease from womb to tomb in almost every organ system. Everyone deserves healthier and stable climate. You can already do this. Advocacy helps with burnout. And I would just say, just start, like literally just start by starting. And I think I really encourage you to come to our air pollution session at 1030 because you'll get much more than the 101. You'll actually hear from the real experts like Dr. Gooby. And then if you want, I have the Air Health Podcast. I've also put a handout in the session for this app that has a lot of the references and links to everything that you can go through and including my little recommended steps for step one, step two, step three. And you can follow on socials if you're on there. So here's some of the image sources, references. So thank you. All right. I now... So we're going to do like a discussion and conversation at the end because I am so excited to introduce to you Dr. Adelie Martinez. She is a second year pulmonary and critical care fellow at University of California, San Francisco. Her background prior to her medical training was in health policy and advocacy at the local and state level. And under the mentorship of Dr. Nita Talker at UCSF, her research focuses on addressing the impact of chronic stress and environmental exposures on asthma outcomes. Okay. Wonderful. Thank you so much for the introduction. As mentioned, my name is Adelie Martinez. And today I'm going to walk you through what is health advocacy from the individual to a system level. We're going to explore some steps needed to translate your research into policy change. And I'll review some forms of advocacy that you can do as a busy clinician in training. Just before I get started, are there any fellows in the room? So just me. Okay. Great. Any other like residents? Okay. One. Nurse practitioner. Okay. Great. Hi, Erin. So I'll start by just giving you a little bit of my background to give you a sense of my credentials, things that you can't really see on my CV. And I just want to start by saying this is something that's really important to me on a professional and a personal level. So I grew up in this community here in San Diego, California, Barrio Logan. If you've ever been to a conference in the San Diego Convention Center, this is about a mile south on Harbor Drive. And that's my son there looking at one of the beautiful murals on the Coronado Bridge. So I'll talk a little bit more about Barrio Logan in our session later on today. But it is one of the historically redline neighborhoods. And in 1964, due to some construction, the neighborhood of Logan Heights was split up and Barrio Logan was isolated. You can see a little bit in the picture here that we have the Coronado Bridge above the neighborhood park. And then on the far side, you have the Interstate 5 that also runs through the neighborhood. And then on the other side, you have shipyards and some other industrial buildings and smokestacks. And so unsurprisingly, this community has some of the highest rates of asthma or the highest rates of asthma hospitalizations in San Diego County and is the reason I have asthma because I grew up in this neighborhood right across the street from this park. And so while the community has a lot of disadvantages, it really was a beautiful community to grow up in. There's a lot of cultural pride and there's a lot of community activists who have been fighting for us since the 50s and 60s. And so that's what I grew up with. That's my foundation and that's what I've tried to incorporate into my work, not just as a physician, but also as a health advocate. And most of my background has been on advocacy, health policy, and immigrant rights, health care access, racial justice, and climate change. And as advocacy becomes more visible in medical education, there's a lot of debate on the scope that we as physicians, what our responsibility is for advocacy, centering on our boundaries, as we just talked about. But in reality, you don't have to sail across the Atlantic Ocean to be a climate and clean air advocate. And so for our discussion on clean air and climate change, I'll start by defining health advocacy, which are activities related to ensuring access to care and navigating the system, mobilizing resources, addressing health inequities, influencing health policy, and creating systemic change. And as we just talked about, physicians are uniquely positioned to contribute to the transformation of the system. And I'll use the UC Berkeley Health Advocacy Framework to run us through the different ways that we can be advocates as physicians and as researchers. The framework has two axes. In the vertical axis, we have the types and levels of advocacy. And in the horizontal axis, we have the approaches to advocacy. Starting with the vertical axis, we have agency and we have activism. So agency encompasses a variety of activities that include navigating the system, providing information, education, connecting to community resources, referrals to social programs. In other words, a health advocate is an agent working within the constraints of the system to assist in gathering resources for patients, families, and groups of patients. An activist, on the other hand, this is someone who raises awareness on the issue, mobilizes resources for change, directly making change and evaluating that change. And this can result in more systemic, wide, long-term policy change. Oh, I went backwards. Did I? No, here we go. Great. And then in the horizontal axis, we have the types of advocacy that we have. So a health advocate can do advocacy that's more directed and that's shared. And so in shared advocacy, we have providers who really engage the community and take the community's perspectives and put them front and center. So for an environmental researcher or physician, they're really biomedical experts alongside the community versus direct guidance. So we act as experts and provide this expertise guidance to patients and to policymakers. And so when we put this all together, we have four quadrants. And I just want to start off by saying that all of these four quadrants are important. It's okay to be a directed agent or in shared agency. You don't necessarily have to strive for the shared activism right away. It's really important to have people in all of these four quadrants. And so some examples. So for directed agency, we're really comfortable as physicians being in this one quadrant here where we direct referrals and access to services and support. We tell the patient what we recommend. We give them medications. We refer them to resources and we expect patients to follow through. And if they don't follow through, we call that non-adherence, right? But really, I want to encourage us all to move towards the other four quadrants. So in shared agency, can you be someone that is engaging with a patient group or community organization to identify the needs that they say are important and then help provide those services? Or can you be in directed activism? Can you be the one that is lobbying for clean air legislation sitting in on those EPA meetings? Or can you be a shared activist? Can you be the physician that works in partnership, support a community to lobby for their own needs and their own change? And you're really just there providing the physician name and the privilege and being a voice for the community. So what does this look like? Here are some examples of shared activism. These are all out of UCSF. So you see me there in the corner there. I was invited to speak on a rally specifically for immigration rights. In the bottom corner, we have Dr. Nita Talker and her project that we'll talk about more in the later session. And then in the far side of the screen, we have UCSF physicians that were taking care of and supporting five activists that were doing a hunger strike against police brutality. So that's the way that we can be shared activists, really have a community at the forefront of the conversation, and we're there to support and to raise awareness. And a lot of examples of directed activism were provided in the last presentation. So I won't dwell on this too much. But here are just some examples of directed activism that I've been a part of. And we already touched on this a little bit in the previous presentation. How do you translate your research into policy change? So as physicians and researchers, we are uniquely positioned to identify issues and generate data to support policy solution. But we know that policymakers are not completely influenced by data alone. A lot of times data is ignored. And so we really have to make sure that we raise awareness, we talk about the financial impacts that is very important for policymakers. And we also make sure to raise hell, essentially, and show that this is something that the constituents are interested in. And there are a few steps that I'll talk about, including defining the problem, including the root cause, building a coalition, understanding the political and institutional structure, proposing a policy solution, and communicating that message. So first, define the problem. We talked about this at length in the last presentation. We really have to think about what is the root cause and who are the people most impacted. We have to raise the voices of the marginalized communities that are most impacted by climate change and what's the available data. And a lot of times we don't spend enough time in this section here of building a coalition. We need people from all different realms of advocacy to join forces with us. Not just physicians, but community organizations, do we have local supervisors or congresspeople that are members of the EPA that would be in support. And one thing that I would recommend if you're really thinking about translating your research into policy change is making this power influence analysis. Very simple. Powerful, less powerful. Opposed, supportive. Put everyone you can think about in this chart, and that helps you figure out who you want to bring into your coalition and who you're trying to convince. And you really have to take the time to understand the political structure. And so in collaboration with community organizations or legal advocacy organizations, you have to identify a sponsor. If you want your research to translate into a bill or policy change, these legal advocacy organizations know exactly who is that person in the legislature that is going to be in support, who's going to be able to support your bill, and going to be able to sponsor it and put it on the table. And then identify supporter, who are the people, the policy makers that would be in support, are there any other professional organizations like CHESS, ATS, with lobbying power that can help support this, and any industry organizations with lobbying power that would be in support and also opposed. And then understand the structure. So usually when you're passing a bill, I wish I had a picture of the schoolhouse rock bill in this slide, because it really is a lesson of how to make a bill into law, but you have to understand that it goes through so many steps, so many committees. What is the committee that's going to be in charge of reviewing this first? Once it passes that committee, what committee comes next? And once it goes through this part of the legislature, where does it go after that? And it's important to know every step of the way, because you have to be there every step of the way advocating and making sure that it goes through. And I have personal experience doing this, so this is a picture of me pre-pandemic before we could do this virtually, and when I was called as an expert witness on a bill in California. And this was done in collaboration with a community partner who asked me to participate. So it's also really important, in addition to us, to have community members that can share their voices and really lead the prioritization of policy and intervention. And then we just really provide the data as backup. And again, financial impact, very important. And then it's also super, super important to make sure that you are able to communicate your message loud and effectively. And I can't stress this enough. We need to lead with stories first, and then back up with research. People don't care as much about the data as we do, and so we have to make sure people's stories are out there with media campaigns, rallies, demonstrations, written pieces, and petitions. So some tips for advocacy while in training. So we're very busy, so I usually join forces with medical students, master's in public health students, or other resident organizations that are also interested in the same topics. I seek out faculty and mentors with similar interests, like Dr. Talker, who has been a great mentor to teach me how to do this even more effectively. And then tailoring your research and your academic programs towards addressing issues of clean air or climate change. And I think one of the biggest tips for me is when I present myself to a community organization, to a town hall or a meeting, I come as myself. I do not wear UCSF in big letters on my chest. I do not wear my white coat. I come as an individual who is interested in this topic. I build those relationships first. I don't lie about who I am, but I just say, like, look, this is who I am. This is why I'm interested in, and by the way, I'm also a doctor that does research in this. So that really builds a lot of trust in us as people coming from an institution, and I'm able to build stronger relationships that way. Also written advocacy is important, so op-eds, letters to the editor, perspective pieces, social media. And I also have been tailoring my discussion sections of manuscripts to really focus on what is the long-term impact that this has on communities, so that we have it, like, written in our manuscripts that are then published. And medical education. So I've worked—before this, I was a chief resident, and so I've worked closely with other chiefs in the residency and then also through the medical school to make some curriculum changes. So thank you so much.

health advocacy

access to care

health policy

health inequities

systemic change

UC Berkeley Health Advocacy Framework

directed agency

shared agency