This story was produced as part of the nine-part series “Are We Ready? How Schools Are Preparing – and Not Preparing – Children for Climate Change,” reported by HuffPost and The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education.

On a gray, drizzly January afternoon, more than 80 students gathered inside room M106 at Stanford School of Medicine for a lecture on how the changing climate affects children’s health.

Stanford physician-scientist Kari Nadeau, who focuses on allergies and asthma, discussed young patients she’s treated whose symptoms may be linked to climate-related stresses. She talked about a 12-year-old whose depression, insulin resistance and asthma seemed to be getting worse as a result of air pollution and extreme heat. She challenged the student audience to come up with possible diagnoses, and asked, “What can we do to improve the health of this child?” 

Her lecture was not part of regular coursework. It was the third in a series of 10 lunchtime lectures organized by two Stanford medical students to address a gaping hole in their school’s curriculum: the health impacts of climate change.

This lunchtime series marks the first time Stanford School of Medicine has addressed climate change in its teaching, to show how it affects different fields of medicine — including pediatrics, women’s health, infectious diseases, and nutrition.

Anna Goshua, a second year medical student at Stanford, developed the series together with a classmate. It was born out of frustration with the lack of training on climate change and health at their school, despite the growing evidence that disasters fueled by climate change had increased hospitalizations and emergency department visits. 

Ten climate change-fueled disasters in 2012 across the U.S. –  including hurricanes, fires, disease outbreaks and heat waves – led to 917 premature deaths, over 20,000 hospitalizations, and close to 18,000 emergency department visits, according to a  September 2019 study.

“It’s dangerous, to say the least, for us to walk into our collective future unprepared,” said Goshua.

That danger couldn’t be more apparent as the world faces a disease pandemic that is both a symptom of climate destruction and exacerbated by it.

Little training

The climate crisis affects people’s health in myriad interconnected ways, starting from birth. Every child born today will have their health defined by climate change, according to the November 2019 report on health and climate change in the British medical journal Lancet, which examines the impact of climate change in health globally. By their 71st birthday, the report found, their physical and mental health will be burdened by other hazards such as food shortages, spread of diseases from insects, like Lyme disease, lack of safe drinking water, droughts, floods and wildfires. 

It is clear some of these hazards are already biting. Ten climate change-fueled disasters in 2012 across the U.S. ―  including hurricanes, fires, disease outbreaks and heat waves ― led to 917 premature deaths, over 20,000 hospitalizations, and close to 18,000 emergency department visits, according to a September 2019 study.

And now the coronavirus pandemic, responsible for thousands of deaths in the U.S. alone, has added a new dimension to the consequences of climate-warming pollution. Alongside anxiety, heart disease and stroke, the health impacts of air pollution include aggravated asthma and weakened lung function. That means there are far more people with pre-existing respiratory conditions which put them at greater risk of dying from COVID-19. 

But very few American medical schools appear to offer training on the health consequences of climate change. There is no reliable way to know exactly how many schools teach classes on climate change and health. But when the authors of a 2018 research article searched a database of 150 schools’ curricula for climate-related keywords, they returned zero results. 

There is a growing awareness, however, among some schools at least, that more needs to be done to prepare future doctors.

“We are the ‘Class of Climate Change’ that is going to be graduating into a health environment that already looks drastically different from what it did in the past.”

Harleen Marwah, a medical student at George Washington University

In 2017, Columbia’s Mailman School, home to the first program on climate and health at a public health school in the United States, launched the Global Consortium on Climate and Health Education, an international alliance of 200 medical, nursing and public health schools and programs, with the mission to train health professionals across the world to respond to the health impacts of climate change. 

The aim is to collectively build resources ― such as slides, videos and online courses ―- for educational programs on climate and health in medical and healthcare institutions. Today, 134 schools and programs in America are members of the consortium.

Yale School of Public Health and the College of Medicine at the University of Illinois at Urbana-Champaign are among those offering programs and coursework at the intersection of climate change, medicine and public health. 

At the school of medicine at UCSF, individual departments — including infectious diseases and obstetrics-gynecology — have woven climate-health issues into lectures. Professors are holding discussions on topics such as cardiovascular health and changing air quality; mental health disorders related to extreme weather; and reproductive health and the environment. 

Arianne Teherani, professor of medicine and educational researcher at UCSF, created a curriculum plan in “sustainable healthcare education” in 2016, to teach students in medicine, pharmacy, nursing and dentistry at UCSF not only about environmental changes and their impact on health, but also the impact of the healthcare industry on the climate.

“We have to move fast to accept and apply the basic evidence that this topic impacts every single organ system, it impacts every single clinical rotation that students do,” said Teherani. “There has to be a way to latch it into what they’re already learning.”

“While most medical providers see climate change as a major problem, we don’t necessarily see it as a problem for how we do our jobs.”

Aaron Bernstein, co-head of Climate MD, an initiative at the Harvard T.H. Chan School of Public Health

In 2019, the American Medical Association, the largest association of physicians and medical students in the U.S., adopted a new policy to educate medical students, as well as doctors, on the health impacts of climate change.

Fighting for more instruction

Still, the response remains piecemeal and small, and for many students, the pace of change is far too slow. In this absence of action, some student-doctors are organizing to fight for the inclusion of climate change in their studies. 

Over the last year, more than 100 students from 34 medical schools and programs across the U.S. have come together to form a volunteer grassroots coalition called Medical Students for a Sustainable Future. 

Its mission, said Harleen Marwah, a medical student at George Washington University who is leading the coalition, is to provide support to participating students so they can coordinate efforts to push for climate change teaching.  

“We are the ‘Class of Climate Change’ that is going to be graduating into a health environment that already looks drastically different from what it did in the past,” said Marwah. “Thinking ahead, planning for the future, how critical climate change is to that future— these are things that are top of mind for a lot of medical students.”

At UCSF, students including Colin Baylen, Karly Hampshire and Nuzhat Islam have formed an interdisciplinary student group called Human Health + Climate Change. The group organizes panels, bringing together faculty experts on topics such as the climate-health emergency caused by wildfires; the links between climate change, migration and health; and the impact of the climate crisis on under-resourced communities. 

The students also created a Planetary Health Report Card, to analyze medical schools’ coursework and resources for climate-health training and award a grade to schools and programs based on their strengths and weaknesses. They gave UCSF a ‘B’ grade ― the school won points for its planetary health electives and a climate-based fellowship, but did not score well on community engagement. Students at another 15 medical schools in different parts of the country are now looking to follow UCSF’s lead and produce their own report cards.

One reality of research on climate change and its health impacts is that it is still quite young, said UCSF’s Teherani. Changes in the curriculum must also account for the developing science, the uncertainty of climate change and sea level rise in the future and acknowledge that scientific predictions cannot be exactly precise and will instead present a likely range of possible futures, said Teherani.

“It is okay, for example, for physicians to understand here is what we know and here is what we don’t know. It is okay for us to identify gaps in knowledge on this subject area, address that with patients, and also be asking ourselves how do we reconcile with that uncertainty on a personal level.” Arianne Teherani, professor of medicine and educational researcher at UCSF

“It is okay, for example, for physicians to understand here is what we know and here is what we don’t know,” she said. “It is okay for us to identify gaps in knowledge on this subject area, address that with patients, and also be asking ourselves how do we reconcile with that uncertainty on a personal level.”

Although progress is being made to standardize and formalize climate-health education, “I don’t see anything happening at the pace and scale we need,” said Caroline Wellbery, a professor in the school of medicine at Georgetown University in Washington DC, who studies climate change and health in medical education.

Centuries-old structures in American medical education are tough to tinker with, she added. “Traditions and longstanding education formats exert influence and by and large, institutions themselves are resistant, not impervious, to change,” she said. This is especially the case with climate change, where the impacts are “sweeping, multifactorial and long-range,” she added, which can make it difficult to get the case heard for the day-to-day relevance of climate change on patients. 

“While most medical providers see climate change as a major problem, we don’t necessarily see it as a problem for how we do our jobs,” said Aaron Bernstein, co-head of Climate MD, an initiative at the Harvard T.H. Chan School of Public Health to teach doctors and medical students how to talk to patients about climate and health. “It absolutely matters what we do on a day-to-day basis. And that knowledge has not been put out effectively to folks who are in medical education.”

But when it comes to understanding the health consequences of climate change, people are most likely to trust their primary care physicians, making it crucial for physicians themselves to be equipped with tools and knowledge they need to maintain that trust.

“We’re trying to bring climate change to the bedside so that clinicians see it as a part of their day job,” said Bernstein.

That continues to motivate Goshua to pursue the Stanford lecture series until her school catches up. Goshua and her classmate are currently administering a survey among attendees to determine how effective the course has been in changing student knowledge, attitudes and skills relating to climate change and its health risks. 

The pair hopes that the data they will collect will both improve the course and inform school administrators and faculty on the need and value of climate change education.

“The bottom line is we can’t ignore our climate reality and we need to adapt as quickly as possible,” Goshua said.

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Imagine that you have just entered a room with 12 2-year-olds in it. Three are using a chair as a drum. Two are taking turns snatching a stuffed teddy bear from each other, and whoever isn’t holding the teddy bear is crying. Two more are quietly looking at books, while another is scribbling in one with a black crayon. One has just had an accident in his newly minted “big boy pants” and you can smell it from where you’re standing. Two are building a block tower that is probably about to fall on top of the one playing with a toy car.

Now, imagine you have been tasked with taking care of this group for the next eight hours. That means keeping them safe, clean, and fed at a bare minimum. It would be preferable if you could also play with each of them one-on-one for a while to make sure you have a clear sense of where each is developmentally. Oh, and be sure to arrange some art projects, outdoor exploration, and reading time since loosely organized activities like these help toddlers develop their self-expression, explore their worlds, and learn basic pre-academic skills.

Don’t forget that children’s brains are 80 percent developed by age 3, so the experiences you provide will affect their brain structure for the rest of their lives. No pressure. And yes, of course you’ll be paid: $9.77 per hour, the national average for child care workers.

Would you stay?

For caretakers in seven states, including Louisiana, Maryland, and New Mexico, this scenario is not imaginary. The maximum legal adult-to-child ratio for groups that could include 2-year-olds in these states is set at a maximum of 1:12—the highest in the nation. In 23 states, including Florida, Kansas, New Jersey, and Washington, it’s 1:10 or higher.

None of the above regulations match the maximum ratios recommended by the National Association for the Education for Young Children (NAEYC), an organization focused on improving the quality of care for children under the age of five. For groups where at least some of the children are 2.5- to 3-years-old, NAEYC recommends no more than nine children per adult; the recommended ratio drops to 1:6 when some children are younger than 2.5 years old.

States consider a range of different factors in coming up with ratios, such as the number of older children in a group and the type of child care facility in question, making apples-to-apples comparisons difficult. The ratios reported above represent the maximum number of children one adult could watch if at least one child in the group was 2 years old. Only 18 states meet or beat NAEYC’s standards for the entirety of the 2-year-old year, according to a 50-state scan by the Teacher Project and the Hechinger Report of licensing requirements for child care programs in each state.

It’s not just the standards for adult-to-child ratios that are inadequate. While most states have basic safety regulations in place that specify things like cleanliness of diapering areas, and storage of potentially toxic cleaning supplies, and that someone on staff hold first aid and CPR certifications, there are few regulations governing what constitutes educationally enriching and developmentally appropriate care for 2-year-olds. Few states have rules that would compel providers to read to children, for example, or provide toys that have been shown to help children learn math concepts.

The Hechinger Report–Teacher Project review found just six states that require caretakers to follow clear guidelines on developmentally appropriate learning strategies for children from birth to age 3. Delaware, for instance, mandates that caregivers at licensed child care centers follow lesson plans based on age-specific educational guidelines put together by the state’s Department of Education.

The guidelines lay out learning strategies for children from birth to 6 months, 6 to 12 months, 12 to 24 months, and 24 to 36 months. One of the primary goals for 2-year-olds is to help them learn to use sounds, gestures, and actions to communicate their wants and needs. A caregiver should draw their attention to facial expressions and gestures made by other children, for instance, by saying something like, “Look how happy Sarah is that you shared your crayons with her,” as outlined in the guidelines. The guidelines also cover age-specific goals relating to memory, problem solving, and self and social awareness, among other areas.

In most states, such guidelines are provided as an optional, rather than required, resource. In fact, many of the documents, like Massachusetts’, explicitly state that the standards should not impact the state’s child care regulations.

Since 62 percent of 2-year-olds had working mothers in 2016, according to U.S. Bureau of Labor Statistics data, most are cared for by providers other than parents for some portion of their day. The lack of clear standards helping to shape what that care should entail has created an uneven system of care based on a fairly low bar for quality.

“The basic measure for what states want for infants and toddlers is not too great in this country,” said Patricia Cole, who oversees policy in areas affecting early care and learning at Zero to Three, a D.C.-based nonprofit.

Early childhood experts like Cole don’t recommend a rigid system of tightly defined learning targets for 2-year-olds. It’s most appropriate for caregivers to respond to young children in developmentally appropriate ways that facilitate their exploration of the world around them. But lower staff-to-child ratios and better enforced guidelines on developmentally appropriate learning could help them do that.

The lack of clear system likely stems from the deep American ambivalence over how much government should intervene in the lives of very young children and how much should be left to families, said Rhian Evans Allvin, executive director of the National Association for Young Children.

“I believe that the neuroscience in early learning should have ended that debate 20 years ago,” she said. “Yes, it’s about the support to families. It’s also about little kids walking into kindergarten having a chance to be on par with their peers.”

Brain development is a complex process and isn’t thought to be complete until age 25, according to cognitive development experts. Nevertheless, a massive amount of development takes place in the very early years. Synapses—the connections that allow different parts of the brain to communicate—develop rapidly and can be affected by a child’s environment, as explained by the Urban Child Institute, a Tennessee-based nonprofit focused on promoting children’s health.

By age 2, children have developed 200 percent more synapses than they will have as adults, since part of a growing brain’s work is to prune connections that aren’t used. Since synapses strengthen with repeated use and strong connections are less likely to be cut later, which synapses get strengthened as a toddler can make a big difference in the long-term wiring of the brain.

“Genes provide a blueprint for the brain, but a child’s environment and experiences carry out the construction,” the Urban Child Institute report states.

Most of a young child’s experiences are dependent on the older people he or she interacts with throughout the day. However, the Hechinger Report–Teacher Project scan also revealed that most states are not aggressive in ensuring child care programs hire highly qualified staff. Indeed, only a handful of states require caretakers of 2-year-olds to have any specialized knowledge in child development. A 2016 state-by-state analysis of early childhood employment conditions by the Center for the Study of Child Care Employment at the University of California, Berkeley confirms that finding. In most states, anyone with a high school diploma is eligible to work as a child care provider. Twenty-three states have absolutely no minimum education requirements for home-based child care providers.

The challenge with upping requirements on caregivers to ensure quality care is that their pay is often minimum wage or only slightly higher. In fact, most child care workers earn about the same as fast food cooks and 15 percent live in poverty, according to the Economic Policy Institute, a nonpartisan think tank. In every state, child care workers would need to spend more than half their income to pay for center-based child care for their own two children, according to a 2016 report on the cost of care nationally by Child Care Aware, an organization advocating for more family-friendly child care policies.

Given the low pay and the extensive demands of the job, very few child care providers find attending to the needs of large groups of small children for a few dollars an hour to be a tenable long-term job prospect. The field is notorious for its high turnover, according to Marcy Whitebook, who heads Berkeley’s Center for the Study of Child Care Employment.

“When children are in a setting where teachers are constantly changing or very stressed, or really just don’t understand child development, children suffer the consequences,” Whitebook said. “It’s skilled work. It’s not like, ‘Oh, if you can babysit, you can take care of young kids.’”

It’s not that we don’t know what better standards look like. The United States Department of Defense has been recognized for its ability to provide consistent high-quality care at the hundreds of child care centers it operates for families of military personnel in the U.S. and abroad. The DOD establishes ratios, group sizes, health and safety standards, and stringent training requirements for staff caring for toddlers. Every staff member is required to complete foundational training that covers 15 topics relating to toddler care, including cognitive development and family engagement. In subsequent trainings, staffers gain deeper understanding of developmentally appropriate practices, like how to encourage strong verbal growth and gauge a toddler’s attention span, among other relevant topics, said Carolyn Stevens, director of the Office of Military Family Readiness Policy.

“Sometimes we tend to underestimate what our 2-year-olds can learn,” Stevens said. “Learning to pour milk into a cup, serving themselves a portion of a meal—these are all connected to promoting life skills” that children are ready to start practicing at a very young age, she said.

More recently, the DOD has been working with researchers at Purdue University to develop curricula that separately addresses the needs of infants, 1- to 2-year-olds, 2- to 3-year-olds, and 3- to 5-year-olds.

Of course, just changing the rules wouldn’t be enough to fix the country’s child care quality problem. Upping the academic standards without corresponding support and training for caregivers could be an exercise in futility. And adhering to the high-quality standards recommended by advocates would cost a lot of money: Paying qualified caregivers to work with fewer than nine children at a time is not cheap. Any effort to improve regulations would have to go hand-in-hand with an effort to find new revenue sources and increased political will.

Still, tighter regulations would set the bar higher and could galvanize governments into doing what’s necessary to meet that bar. Right now, the bar is so low in most of the country that a 2-year-old could step over it.

Zoë Kirsch and Sarah Butrymowicz contributed reporting for this story.

This story was produced by The Hechinger Report, a nonprofit, independent news organization focused on inequality and innovation in education, and by the Teacher Project, an education reporting fellowship at Columbia Journalism School dedicated to elevating the voices of students and teachers. Read more about early education on The Hechinger Report and sign up for our weekly newsletter.

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