A University of Maryland Health Researcher Probes the Climate Threat to Those With Chronic Diseases

Amir Sapkota keeps a close eye on weather anomalies such as late onset of snowfall or early snowmelt because, for one, they can prolong the forest fire season and lead to a variety of health hazards. 

“It’s also an occupational hazard,” said Sapkota, a professor and chair of the Department of Epidemiology and Biostatistics at the University of Maryland’s School of Public Health in College Park. He studies how climate change affects chronic ailments such as kidney and diarrheal diseases. 

Prolonged wildfires can lead to increased hospitalization and mortality, he said, especially at a time when global warming is fueling severe weather events such as heatwaves and hurricanes, and causing climate disruptions including changes in the duration and timing of the onset of monsoons. 

Sapkota joined the University of Maryland in 2007 after finishing his post-doctoral training in environmental Epidemiology at the International Agency for Research on Cancer in France. He feels connected to Baltimore City, where he studied as a doctoral student and earned his Ph.D. in environmental health sciences from the Johns Hopkins Bloomberg School of Public Health. 

Originally from Nepal, Sapkota’s research focuses on the intersection of climate change and health, such as the impact of air-pollution on the heart and the lungs, and how climate disruptions can increase health risks for kidney patients needing dialysis or exacerbate health burdens for low-income groups. 

“Growing up in Nepal, which is extremely vulnerable to climate-related disasters, and seeing what climate extremes can do to communities and people’s livelihood, attracted me to this field,” Sapkota said, adding that people who contributed the least to climate change end up getting most impacted by it. 

“That applies to a lot of countries in the Asia Pacific region, in Sub Saharan Africa and a lot of low-and-middle income countries,” he said. 

Sapkota said the climate change-driven stresses on health systems in the developing world influenced his research, which aims to develop public health adaptation strategies that can minimize risks to people living with diarrheal or kidney diseases in the United States. 

More than 850 million people worldwide suffer from pre-existing health conditions, such as chronic kidney disease—a protracted health condition made worse by poor living conditions and other social vulnerabilities such as lack of access to health services. 

Climate change-related hazards such as hurricanes, heatwaves and flooding can further impact people with poor kidney health, “indirectly by interrupting access to treatment or directly by increasing the risk of death and disability,” Sapkota said in a recently published article.  

“I was primarily working on cancer risks associated with indoor and outdoor air pollution,” he said in an interview, adding that he became interested in climate change when health professionals were beginning to notice it around 2007. “I felt that there was an acute need for linking climate change with health impacts and collecting scientific evidence on how it’s impacting communities.” 

Joining the University of Maryland’s School of Public Health in 2008 provided the opportunity for Sapkota to lay the groundwork for linking public health and climate change. 

“That’s how it all started. We partnered with the Maryland Department of Health and got some funding from the Centers for Disease Control (CDC) to examine how climate change related extreme weather events are impacting the health of Marylanders and how that health impact differs based on whether you’re living in Baltimore, Prince George’s County or Montgomery County. In other words, factoring in race, ethnicity and socioeconomic status,” he said. 

This led to Sapkota and his team at the school of public health to focus on diarrheal as well as renal diseases, with a view to study disparities in climate change-driven health burdens and developing early warning systems to minimize fatalities resulting from extreme events. 

“When you have end-stage renal disease, your kidneys don’t work anymore and dialysis, or a kidney transplant, are the only treatments available,” Sapkota said. Dialysis helps the person with acute kidney disease remove extra fluid and waste products from the blood and can be done in a hospice, at a dialysis center, or at home. In the U.S. the common practice is to undergo dialysis three times a week, Sapkota said. 

“During a heatwave, we start losing bodily fluids from perspiration and we tend to take more liquids to keep hydrated. But people with kidney failure cannot do that because they need to then get it out of their body through dialysis,” Sipkota said. So, they become extremely vulnerable to heat waves because they need to minimize their liquid intake as their kidneys are not able to filter the blood. 

Hurricanes are another example, Sapkota said, which can knock out electricity in parts of the city, leaving medical facilities inoperable. Storm surges and excessive flooding can damage infrastructure, including health facilities that provide dialysis treatment. “High winds can damage electrical grids and interrupt lifesaving medical and dialysis services,” Sapkota said.   

Hurricanes are known to increase mortality among patients with kidney failure for the 30 days after the event. A 2022 study looked at patients requiring dialysis and registered in the United States Renal Data System who initiated treatment between Jan. 1, 1997 and. Dec 31, 2017 in one of 108 hurricane-afflicted counties nationwide. It concluded that these patients have a higher mortality risk in the 30 days after a hurricane. 

The Maryland Climate and Health Profile Report, compiled by Sipkota and his team in 2016, reported that extreme heat and extreme precipitation events significantly increase the risk of bacterial infections in Maryland, with coastal communities around the Chesapeake Bay and Eastern Shore more at risk compared to inland communities. The study reported, among a range of other findings, that the risk of hospitalization related to extreme heat events was highest among residents of Baltimore City. 

In January, Sapkota, along with another researcher, published an article in Nature and proposed a framework for medical facilities providing dialysis treatment in the United States to anticipate weather-related stresses ahead of time and prepare for the next steps. 

“Such preparedness involves, for example, making sure that the clinics have a backup generator to continue to provide life-saving treatment to vulnerable patients,” Sapkota said. “For somebody who lives with acute kidney disease, not having that electricity means not having access to dialysis treatment, which could be the matter of life and death.” 

It’s similar to the “Code Red/Code Blue” program in Baltimore City in which the mayor’s office issues code red alerts in cases of extreme heat events expected within days, he said. The alert mobilizes police departments, fire departments and other agencies, and requires opening up cooling centers for people who don’t have access to cool environments. “They can go into those sheltering spaces, which also provide drinking water to minimize risk of heat exhaustion, especially among the vulnerable groups,” Sapkota said.  

He said it was not enough for city managers to put shelters in place. They also have to anticipate any disruption that might prevent residents from accessing the space. “Providing transportation to such cooling facilities, particularly from areas known to have a higher concentration of homeless people, becomes just as important as having places for people to seek shelter,” he said.  

In the article, Sapkota and his colleague argued that power outages or disruptions in water supplies are major threats to dialysis treatments. “A survey of 81 U.S. dialysis facilities after a large-scale power outage in 2012 reported that only 32 percent had backup generators,” it said. 

The article proposed a Ready-Set-Go framework for climate adaptation, and prescribes a number of steps that he said would allow health sector managers and practitioners to put a climate resilient health management system in place that presupposes climate change would continue to mount stress on public health systems in a number of ways.  

“We put forward the idea of specific IDs for the patients with their treatment history so that, in case they have to go to a different clinic for dialysis or a treatment in case of a weather emergency, the care providers can look up their case information readily, “ Sapkota said. 

Valuable time and resources are frequently wasted in establishing what the treatment ought to be in an emergency situation, he added. “But if the patients are carrying their medical information, it becomes like a seamless process.”

The framework recommends, among a range of measures, identifying backup facilities that provide in-center dialysis treatment and notifying patients in advance as well as, “managing hotlines, evacuating patients, coordinating with shelters and distributing aid and dialysis supplies.”

Sapkota said the Ready–Set–Go framework is a guiding template that can be applied across the health sector and provides guidance for the clinics, patients and health sector administrators. “Despite mitigation efforts, the frequency and severity of climate change-related extreme events is expected to continue to increase in the near future,” he argued in the article. “A robust response is needed to enhance patient-level, facility-level and community-level preparedness to anticipate, prepare for and respond to these threats and minimize their impact on kidney health.”

Sapkota is also collaborating with academics and researchers at Nepal’s Kathmandu University to develop a similar early warning public health system. “I am collaborating with Nepal Health Research Council and we are developing an early warning system for the Asia Pacific region focused specifically on diarrheal diseases,” he said. 

The necessity for such a system is clear in such places as Nepal and India, where a sizable percentage of the population don’t have access to clean water and sanitation and people are forced to defecate in open spaces.

“Bacterial pathogens that cause diarrheal diseases are found in human feces,” he said.  “During extreme precipitation, that fecal matter and the bad bacteria gets into that drinking water supply and into the rivers, lakes and streams in those areas where people do not have access to piped water. That’s how they get sick.” 

Bacteria love to grow in warmer temperatures, Sapkota said, and it multiplies faster as temperature increases. “With climate change heating up global temperatures, this situation is a disaster in the making.”

In a research paper, Sapkota and a team of Nepalese researchers obtained 13 years of diarrheal disease data from Nepal and investigated how the disease rate is associated with seasonal weather, including disruptions in monsoon rainfall. The study found that monsoon season was associated with a 21 percent increase in diarrheal disease rates wherein “higher-than-normal monsoon rainfall was associated with increased rates of diarrheal disease, with considerably higher rates observed in the mountain region.”

These disasters will disproportionately affect the highly vulnerable and disadvantaged population in the U.S. as well as in places like Nepal. To save lives, reduce fatalities and lower healthcare costs, healthcare systems need to develop climate adaptation measures to enhance the resilience of patients in the face of expected increases in natural disasters, he said.