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05/20/2022

Comment: Response to HHS's Environmental Justice Strategy RFI (May 20th)

(Again, my letter to HHS in response to their Environmental Strategy RFI.) 

May 19, 2022

To: Dr. John Balbus, Mr. Joseph McCannon, Mr. Arsenio Mataka and Dr. LaToria Whitehead

From: David Introcaso, Ph.D. (dmintr@gmail.com & 202.907.7426)

Re: Comments in Response to OASH's RFI Titled, “2022 HHS Environmental Justice Strategy and Implementation Plan Draft Outline” 

Please accept these comments in response to OASH's RFI, “2022 HHS Environmental Justice Strategy and Implementation Plan Draft Outline.”

First, I congratulate the OASH for publishing this long over due RFI.

Background Comment

OASH's Office of Climate Change and Health Equity (OCCHE) is likely aware approximately two weeks prior to the publication of this RFI, STAT News published my latest climate-related essay titled, “HHS's Failure to Address the Health Harms of the Climate Crisis Constitutes Environmental and Institutional Racism” (Here.) (My previous climate and health related articles are: here; here; here; here; here; here; here; here; and, here.)

In sum, the STAT News essay noted substantial research evidence supports the conclusion that innumerable and unrelenting health harms imposed by Anthropocene warming or the climate crisis disproportionately harm minority populations, or disproportionately Medicaid beneficiaries and the elderly or Medicare beneficiaries. The essay also noted HHS has and continues to substantially contribute to climate crisis-caused health harms. The health care industry, whose excessive carbon emissions account for 8.5% of total US emissions and 25% of global health care emissions, receives approximately 40% of its revenue from HHS programming. The health harm caused by the health care industry's carbon emissions have been estimated to be commensurate with the number of preventable medical error deaths, or upwards of 98,000 deaths annually. This number is substantially underestimated since research published last year by Harvard and others estimated over 10 million premature deaths worldwide, twice the previous estimate, attributable to PM2.5 pollution resulting from fossil fuel combustion with the greatest mortality impact occurring in the Eastern US among other locations globally.

As a result, I argued HHS has failed to enforce the 1964 Civil Rights Act, has failed to enforce 1969 NEPA legislation and President Clinton's Executive Order (EO) 12898, among others EOs.

RFI Comments

Remarkably, none of the 18 “priority actions” identified under the six proposed strategic elements: Services; Partnerships and Community Engagement; Policy Development and Implementation; Research and Data Collection; Education and Training; and, Performance Measures (Evaluation) identify or discuss remedying the primary cause of environmental injustice: the climate crisis. My comments here therefore exploit the opportunity under “Additional Information” that states in part, “respondents are welcome to address additional areas of interest not listed.”

First and Foremost: Recognize and Address the Health Care Industry's Carbon Emissions

The RFI states HHS's mission is to foster “sound, sustained advances in the science underlying medicine, public health, and social services.” It states “people of color” and related others “are often exposed to unhealthy land uses, poor air and water quality,” etc. It states further President Biden's January 2021 EO 14008 directs HHS to make, “achieving environmental justice part of its mission” in part by “developing programs . . . to address . . . climate related . . . impacts on disadvantaged communities.”

Nevertheless, the RFI says nothing about at least reducing the health care industry's harmful carbon emissions. There is no related conversation in the 1,800 word RFI. For example, the words “carbon,” “carbon equivalents,” “emissions,” “decarbonizing,” and “greenhouse gasses” do not appear in the document.

This is mystifying in part because the current HHS “Environmental Justice Strategy and Implementation Plan,” published in 2012 and cited in the RFI, notes the Obama Administration's 2009 EO 13514 that, as stated in the 2012 plan, “established an “integrated strategy towards sustainability in the Federal government and makes reduction of greenhouse gas emissions (GHG) a priority for Federal agencies” and required Federal agencies to develop an annually update a “Strategic Sustainability Performance Plan.” The 2012 plan stated further, “through the Performance Plan,” HHS will accomplish reductions in GHG emissions by “reducing greenhouse gas emissions through technological, programmatic and behavioral change.” EO 13514 also established a series of deadlines for federal agencies including HHS to meet GHG emission reductions. However, it appears HHS never addressed.

As I argued in my March essay HHS cannot address environmental racism or environmental justice by continuing to ignore the racially disparate health impacts caused by the climate crisis, the most severe and pervasive cause of environmental injustice, the health industry's contribution to the crisis and HHS's financial support thereof.

In addition, the RFI appears to suggests climate crisis-caused health harms are limited to certain or discrete “extreme weather events” and/or “adverse environmental exposures” or experienced by a limited number of “disadvantaged communities.” This assumption is patently false. As I noted in March, research published in Science Advances last year found minority populations, regardless of geographic location, were disproportionately and continuously exposed to higher levels of 12 of 14 sources of PM2.5 - largely the result of fossil fuel combustion. Again, climate crisis health impacts are literally innumerable and unrelenting. They are persistent. Last August UNICEF concluded, “nearly every child around the world [emphasis added] is at risk from at least one of these climate and environmental hazards,” including flooding, heatwaves, vector borne diseases, water scarcity and exceedingly high levels of fossil fuel combustion- caused air pollution.

As for remedying the health care industry's carbon emissions, OCCHE staff is also aware last June I published with Walt Vernon, the only engineer participating in the National Academy of Medicine (NAM's) Action Collaborative effort (discussed below), an essay in STAT News that argued Secretary Becerra could immediately and significantly advance environmental justice by publishing an interim final rule that would immediately require health care providers, via revisions to Conditions of Participation (CoP) regulations, to both publicly report their carbon/carbon equivalent emissions via the EPA's Energy Star program and publish plans to achieve net zero in the requisite time.

Reform the Medicaid and Medicare Programs

The World Health Organization has termed the climate crisis, “the single biggest health threat facing humanity.” Nevertheless, the RFI ignores the Medicaid and Medicare programs or the disproportionate harmful health effects the climate crisis is having on these programs' beneficiaries. For example, as Vijay Lamaye and his colleagues concluded in a 2019 study published in GeoHealth, two-thirds of immediate Hurricane Sandy health care costs were incurred by the Medicaid and Medicare programs. The RFI's “policy development and implementation” strategic element says nothing about these programs. There is also evidently no Medicaid and Medicare-related “research and data collection” necessary nor any climate-related Medicaid and Medicare provider “education and training” that would be helpful. How is this possible?

This is as remarkable as the House Select Committee on the Climate Crisis's 2020 “Solving the Climate Crisis” report that over 500 plus pages fails to discuss either Medicaid or Medicare, or make any related policy recommendations. This is also as remarkable as related HHS planning efforts. None discuss the Medicaid or Medicare programs in context of the climate crisis. For example, HHS's recently published “Climate Action Plan” makes no mention of either Medicaid or Medicare. It is remarkable that none of of CMS' numerous health equity RFIs published over the past year mention the climate crisis. It is remarkable CMS' current efforts to create new strategic visions for Medicare and Medicaid/CHIP make no mention. In addition, the climate crisis is not one of ASPE's 15 priority topics, not one of the Surgeon General's five priorities and not the topic of any of the Surgeon General's over 50 public health reports. As I discussed in a December 2019 essay published in The Hill, it is also remarkable neither MACPAC nor MedPAC, independent agencies given broad authority to make Medicaid and Medicare policy recommendations, have never discussed the climate crisis over their 38 combined years of policy work.

Concerning climate crisis-related policy reforms, for example, OCCHE staff is aware of climate crisis-related Medicaid and Medicare policy reform recommendations noted in several climate and health articles published in the December 2020 issue of Health Affairs. Staff is also aware of several pages of recommendations made by Drs. Georges Benjamin and Howard Frumkin, and endorsed by over 60 health-care related organizations, in an April 2021 memo to Secretary Becerra title, “Climate Change, Health and Equity at the Department of Health and Human Services.” (As a related aside, since there has never in human history been a worse time for the biosphere, HHS leadership should read Howie Frumkin's and Sam Myers' 2020 edited work, “Planetary Health: Protecting Nature to Protect Ourselves.” Reading it would motivate HHS leadership to argue the US, now thirty years late, sign the UN's Convention on Biological Diversity treaty. The US is the only UN member state that has not.) I made seven related recommendations in an October STAT News article in context of the NAM's current effort to decarbonize health care industry (again, see below) including again creating a regulatory pathway to eliminate the health care industry’s carbon emissions and enforcing climate-related civil rights protections. I'll add, since Dr. Nick Watts, NHS's Chief Sustainability Officer, made a brief presentation during OCCHE/NAM March 29th virtual meeting, since the NHS has been working for well over a decade to eliminate its carbon footprint, HHS would be wise to learn from their largely successful efforts to date.

The HHS Office of Civil Rights Needs to Meet Its Responsibilities

Referring again to my March essay, the HHS Office of Civil Rights (OCR) has never addressed much less recognized the climate crisis. This would be surprising if it was tragically not the case that the OCR, established in 1967, has not lived up to its responsibilities. See, for example, Professor Ruqaiijah Yearby's 2014 essay titled, “When Is Change Going to Come? Separate and Unequal Treatment in Health Care Fifty years After Title VI of the Civil Rights Act of 1964.” As I noted, in late February the United Nations’ Intergovernmental Panel on Climate Change (IPCC) released its bleakest warning yet. The 3,500-page report concluded that, “everywhere is affected, with no inhabited region escaping dire impacts from rising temperatures and increasing extreme weather.” António Guterres, the UN Secretary-General, appropriately termed the report, “an atlas of human suffering.” The day the IPCC report was released the OCR published a memo on cybersecurity.

How Is Environmental Justice Forwarded With a $0 Budget

It appears the OCCHE, not the OCR, has responsibility for forwarding environmental justice at HHS. Rhetorically, what expectation can stakeholders and the public have concerning OCCHE's ability to address environmental justice when the Congress did not approve the OCCHE's beyond modest $6 million FY 2022 budget request and when it is at least uncertain whether OCCHE will receive FY 2023 funding.

The National Academy of Medicine's Action Collaborative Must Make Policy Recommendations

The OCCHE currently co-chairs a NAM effort titled, “Action Collaborative on Decarbonizing the US Health Sector.” The NAM effort was initiated in 2020 and the Action Collaborative formally launched last September. Its over 50 named participants are substantially industry executives including those from the AHA, the AMA, BIO and PhRMA. Their work is not transparent, there are no set deadlines and when or if the Action Collaborative makes national policy recommendations is unknown. What effect their recommendations is will have is uncertain because NAM reports are been frequently ignored by federal policymakers, for example, the NAM's primary care work.

Per a recent Modern Health Care Q&A with NAM President, Dr. Victor Dzau, the Action Collaborative has it appears decided its next step is to solicit its 60 network members, that Dr. Dzau defines as a “coalition of the willing,” to measure their carbon emissions to determine baselines via to-be-determined metrics and report their findings. Whether these will be made public is unclear. This effort will result, Dr. Dzau stated, in a toolkit to help additional organizations address their carbon footprint. After this, or as Dr Dzau stated sometime in 2023, “well see where we are as a group.”

Considering health care is a $4 trillion industry accounting for 20% of the GDP with, for example, over 6,000 hospitals, and considering health care is a significant contributor to total US carbon emissions, the US, after China, is the second largest carbon emitting nation, is one of the largest per capita emitting nations and is responsible for upwards of 40% of total historical emissions, Dr. Dzau's plan is massively under scoped. Possibly worse, if Dr. Dzau's recent comments suggest the NAM will not be making policy recommendations, the question begged is what legitimate purpose is OCCHE serving? Why is the OCCHE co-chairing or even participating if the Action Collaborative makes no policy recommendations? If true, is this not the textbook definition of “regulatory capture?”

All this aside, the NAM effort presently appears to be the only opportunity to mitigate the health care industry's emissions, the only opportunity for HHS to address the leading cause of environmental injustice. This is largely because it appears the Senate will fail to move the House-passed Build Back Better bill or pass its climate crisis-related provisions as stand alone legislation. Speaker Pelosi, per her recent comments the Aspen Ideas: Climate meeting, believes the House completed its climate crisis work. Current conventional wisdom has the Democrats loosing Congressional control in November. The Biden administration has regressed to an “all of the above” energy policy strategy. CMS appears satisfied to simply issue climate-related RFIs and disabuse the gerund, “exploring.” Secretary Becerra is unwilling to fulfill his OCCHE's launch promise to “double down on necessity” - made further evident by the Secretary Becerra's s recent Earth Day announcement soliciting health care providers to “pledge” by June 3rd that they will reduce their emissions by 50% using a very lenient 2008 baseline. Beyond being incoherent, for example his additional request for Scope 3 emission inventories neglects defining reporting standards, the effort amounts to text book virtue signaling.

NAM Action Collaborative participants, particularly Dr. Don Berwick, who serves on its steering committee and chairs its policy, financing and metrics work group, has the ability and obligation to speak truth to power (parrhesia). As Noam Chomsky phrase it, Dr. Berwick has to know “power knows the truth already, and is busy concealing it.” The truth is it is impossible for HHS to address environmental justice without the health care industry achieving net zero emissions - that is altogether within both the health care industry's near and long term financial interests - as soon as possible. Regarding the economics of renewable energy, both the Congress has heard related testimony and among others, Bloomberg Green has written extensively about, the fact that renewable energy resources are today by far the cheapest, and most secure, forms of energy. Just ask Professor Scott Z. Jacobson, Stanford's Director of Atmosphere/Energy Program. Better yet, read his Cambridge University Press 2021 textbook, 100% Clean Renewable Energy and Storage for Everything. (It is beyond remarkable that Professor Jacobson has not been called to testify before Congress over the past two years.) In part, as a former CMS Administrator, Dr. Berwick knows this. He needs to lead his Action Collaborative colleagues in stop concealing the truth and make requisite and enforceable policy recommendations starting with related reforms to Conditions of Participation.

RFI Responses Should be Made Public

Like Notice of Proposed Rule Making (NPRM) comments in response to proposed rules, HHS should make public stakeholder or public comments in response to this RFI.

Conclusion

Despite the OCCHE noting HHS's support of and participation in last November's UNFCCC meeting during its May 5th call concerning Secretary Becerra's industry pledge solicitation, COP 26 will likely represent another failure. Coal use, deforestation, ocean warming and acidification and woefully inadequate international climate financing all continue unabated. Recently published research shows there is strong likelihood within the next five years UN member states we will fail to meet the 2015 Paris Climate Accord goal to limit global warming to an average of 1.5C. To make matters worse despite the fact the International Energy Agency warned a year ago that in order to limit warming to 1.5C, no new coal, gas or oil development could be permitted, The Guardian recently reported that should 200 “carbon bomb” planned projects go online they will equal nearly 20 years of current global emissions. A recent spate of scientific studies, termed by Inside Climate News as “apocalypse papers,” concluded in part that despite the ongoing and accelerating sixth mass extinction significantly caused by the climate crisis, we currently face an epidemic of at least 15,000 additional “zoonotic spillover” viruses over the next few decades. In the US, President Biden's climate ambitions are, as Bloomberg Government recently concluded, “all but dead.” The Supreme Court appears prepared to curb the EPA's ability to regulate carbon emissions. The 9th Circuit Court ruled in 2020 in a Juliana v the US procedural matter that the 20 child/young adult plaintiffs do not have a constitutional right to a survivable climate. (However, a related state case, Held v Montana, similar plaintiffs' allegations of climate-related health harm will be heard next February.). The climate crisis is significantly responsible for several Western states experiencing extreme or exceptional drought, the worst in at least 1,200 years. Four weeks ago there was another fatal self-immolation in protest of the federal governments refusal to address the climate catastrophe - this time in front of the US Supreme Court. If, or when, global warming exceeds 2.0C, the UN currently projects warming to 2.7C this century, climate scientists have concluded we will have reached what has been termed “Hothouse Earth” where a sufficient number of tipping points or cascades, for example uncontrollable permafrost melt - that harbors roughly two times the CO2 already in the atmosphere, will have been breached causing runaway or uncontrollable global warming.

HHS's mission, as the RFI states, “is to enhance the health and well being of Americans by providing effect health and human services.” It can neither do this nor address environmental justice absent eliminating the health care industry's carbon emissions - and take a leadership role in ensuring the federal government lives up to both its national and international responsibilities in maintaining a survivable climate for all life on the planet.

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