Creating Climate-Resilient Hospitals

New York City health care systems did their best to prepare for Hurricane Sandy in 2012.

Some had built flood barriers that could handle a storm tide of up to twelve feet — more than two feet higher than had ever been recorded in the area. Then the storm hit, and the tide crested to fourteen feet. Water gushed into hospital buildings and stalled backup generators; the power went out. Staff had to evacuate an estimated 6,500 patients. Five hospitals in the city closed.

Sandy became a regional wake-up call about the need to shore up the physical infrastructure of health care facilities against climate-driven extreme weather events. Hospitals can’t provide needed care if storms or heat waves knock out power, winds tear off the roof, plunging temperatures freeze pipes, or wildfires choke clinics with smoky air.

“Making sure the walls are intact can help your patient’s health, just like giving them an inhaler for their asthma,” says Tess Wiskel, an HMS instructor in emergency medicine at Beth Israel Deaconess Medical Center. “Thinking about the infrastructure and resilience of health systems will improve patient care and prevent unnecessary morbidity and mortality.”

Climate change already raised the risk of damage to hospitals’ physical infrastructures by 41 percent worldwide and 38 percent in the United States between 1990 and 2020, according to an analysis by XDI (the Cross Dependency Initiative), part of a group of companies committed to quantifying and communicating the costs of climate change. The report estimates that one in twelve hospitals will be at high risk of partial or total shutdown from extreme weather events by the end of the century, including 477 in the United States. Researchers are also documenting hospital damage from extreme weather events and calculating the interrupted care in the months that follow.

“I do think health care systems are waking up to this,” says Gregory Ciottone, HMS associate professor of emergency medicine at Beth Israel, founding director of the BIDMC fellowship in disaster medicine, and a global expert on medical preparedness for disasters. “The conversation is intensifying as we see dramatic weather-related events in the United States and globally.”

The action, however, does not yet reflect the stakes.

“I think it is essential for hospital leaders to examine what mitigation efforts are necessary to ensure their facilities do not fail during climate emergencies and become unable to serve their communities,” says Paul Biddinger, chief preparedness and continuity officer at Mass General Brigham and an HMS associate professor of emergency medicine. “Unfortunately, I don’t think this issue is receiving adequate attention yet.”

Facilities that receive Medicare and Medicaid funds are required to run hazard vulnerability analyses each year, but studies suggest that only about 20 percent of U.S. health care systems have assessed climate threats to their infrastructure, Biddinger says. Plus, hazard calculations based on historical weather data fail to account for the climate of the present and future, as Biddinger and colleagues — including first author Joshua Baugh, MD ’15, an HMS assistant professor of emergency medicine — wrote in the Rhode Island Medical Journal in 2021.

Given the importance of the issue, HMS community members have taken leadership roles in raising awareness, crafting guidance for medical centers, and building and retrofitting with climate change in mind.

Learning from the front lines

Toolkits, reports, and other materials can help health systems by centering the problem and sharing information and best practices.

Faculty and students at HMS and the Center for Climate, Health, and the Global Environment (C-CHANGE) at Harvard T.H. Chan School of Public Health, including Wiskel, partnered with the nonprofit Americares to conduct a national survey and produce the Climate Resilience for Frontline Clinics Toolkit, updated in August 2024. Cambridge Health Alliance is among the pilot sites. The Health Care Climate Council, which counts Mass General Brigham among its members, includes infrastructure in its publication “Climate Action: A Playbook for Hospitals.” Groups such as the WHO, U.S. Department of Health and Human Services, and National Oceanic and Atmospheric Administration have also provided alarm raising and advice.

HMS-authored papers offer further data and case studies. In the last year alone, Ciottone and colleagues published best practices incorporating lessons learned from the Los Angeles wildfires, Hurricane Helene, and extreme heat, droughts, and fires.

Recommendations run the gamut, including acquiring backup power and communications systems; raising critical infrastructure above likely flood heights; installing particulate filtration; hiring a disaster medicine expert or naming a weather resilience lead who can advise on risk and infrastructure improvements; procuring emergency supplies in advance in case of medical supply chain failures, such as those that followed Hurricanes Maria and Helene; and procedures for repairing and reentering facilities after weather-related damage.

The need for action extends to Boston. Alexandra Tarabochia-Gast, MD ’17, coauthored a 2022 study in GeoHealth that quantified flood risks to hospitals along the Eastern seaboard. Greater Boston ranked third for predicted impact of a Category 2 hurricane, after only the Miami and New York metro areas. Ciottone cites recent summer droughts, small-scale local wildfires, and smoke that reached the city from Canada as local examples of climate-related challenges. The Boston Globe reported that four emergency departments in the city had to turn away patients during a historically cold weekend in February 2023 after pipes froze and burst, flooding the facilities.

Building for the future

Partners HealthCare (now Mass General Brigham) took into account the destruction Hurricane Katrina wreaked on health care facilities along the Gulf Coast in 2005 when it designed and constructed the new Spaulding Rehabilitation Hospital, completed in 2013. The hospital’s essential mechanical and electrical equipment, including backup generators, are on the roof. Its first floor was installed thirty inches above the five-hundred-year flood line in preparation for projected sea level rise during the eighty-year life of the building. Triple-glazed windows and sunshades insulate against extreme heat and cold, and they can be unlocked for ventilation in an emergency. Berms, drainage systems, and a green roof can mitigate heavy rain and flooding. There is storage for at least four days of essential supplies. These and other innovations led the Health Care Climate Council to call Spaulding “one of the most sustainable and resilient hospitals in the country.” Partners made the full request for proposal used for the design available for others to adapt.

The effects of Hurricane Sandy in the New York metro area motivated Partners to commission a study of its vulnerabilities to Boston’s future climate, and Mass General Brigham continues to incorporate findings into its decision-making. Several hospitals began redesigning their HVAC systems to handle higher cooling loads and increase redundancy in case of a power grid failure; others retrofitted facades and roofs to withstand wind speeds previously relegated to places like Miami but now expected in New England.

“Some of the projections were startling and resulted in construction principles we would otherwise have never employed,” Baugh, Biddinger, and their coauthors wrote in their 2021 paper.

A clinical building being erected at Mass General is designed to withstand predicted increases in sea level, precipitation, and days over 90 degrees in the next fifty years. It can also operate self-sufficiently for up to four days and double its occupancy to absorb patients from older, less resilient parts of the hospital during an emergency, Biddinger says.

Boston hospitals also learn from other health systems’ successes. Mass General Brigham is considering procuring the same flood barrier that Tampa General Hospital used to protect itself during Hurricanes Helene and Milton.

Taking the long view

Protecting infrastructure requires money, and it must compete with hospitals’ other financial priorities. Yet experts cite several reasons to invest.

First, they reiterate that climate change is inescapable and, as in patient care, prevention is cheaper than post-disaster repairs.

“Crossing your fingers and hoping something doesn’t happen is not a good disaster preparedness strategy,” quips Ciottone.

Wiskel learned to change people’s thinking by changing their verbs: “not ‘floods could do this to our hospital,’ but ‘floods will.’” 

Second, costs may not be as high as feared if they’re incorporated into plans early. Spaulding estimates its climate resilience features accounted for as little as 0.3 percent of the construction total because they were embedded in the initial design.

Third, individual health care systems do not need to prepare for all eventualities all at once. They can identify the climate risks that apply to their region and prioritize them by likelihood, expected impact, and what the facility is currently prepared to handle, experts advise. Decisions can be slated for the short or long term and for retrofitting or new construction.

Finally, preparing for climate and other emergencies — including but not limited to infrastructure considerations — raises hospitals’ financial, operational, and energy efficiency, says Ciottone.

Such preparedness involves considering the infrastructure that allows staff and patients to get to hospitals, planning and practicing emergency procedures, and coordinating with other health care institutions and local government. It’s all part of bolstering a health care system that is both crucial and fragile.

“The U.S. hospital system is already beyond capacity in many places, and if one hospital fails in a crisis, others are severely affected,” says Biddinger. “We are all extremely interdependent.”

Stephanie Dutchen is editorial director in the HMS Office of Communications and External Relations.