is a year 2 psychiatric resident at Vanderbilt University

Barrington Hwang, MD

We are psychiatrists who are deeply committed to addressing the devastating impacts of climate change on mental wellbeing and its differential impacts on vulnerable minority groups. Some of us came to this project steeped in knowledge and information but from a relatively privileged and comfortable place. The process of bringing together the voices of the various authors in this series, each contributing their rich and varied cultural experiences, has deepened and enriched the awareness of our interconnection.

These conversations have been challenging, but these are some of the difficult conversations we must have as a profession and as a society. Those of us who have been buffered from the devastating impacts of climate change and environmental degradation by our privilege, wealth, and class must recognize that this protection is ultimately an illusion. We are all bound by our shared vulnerability and must face our shared humanity.

We must address racism and climate change together. Hop Hopkins of the Sierra Club 

: “It’s no exaggeration to say that racism and white supremacy harm all of us, because in addition to robbing us of our humanity, racism is also killing the planet we all share." He elaborates by saying, “we will never survive the climate crisis without ending white supremacy …You can’t have climate change without sacrifice zones, and you can’t have sacrifice zones without disposable people, and you can’t have disposable people without racism.”

The articles in this series have highlighted both the tribulations and resiliency of communities of color. In particular, the Indigenous voices speak to the need for rematriation: the renunciation of the current patriarchal, fractured systems and a return to Indigenous wisdom that recognizes the unity between all living beings and the continuity between prior generations and future descendants. This embraces the essential awareness that we are all dependent on the earth as our only sustainable home.

The nonprofit organization Crear Con Salud in Puerto Rico has demonstrated resiliency, community empowerment, and local leadership as it overcomes passive reliance on a distant, unresponsive, neglectful government. Voices from Black communities remind us to confront the hard reality of climate change and its intersection with racism by exposing the daily experiences of communities tarnished by environmental pollutants. The Asian experience opens our eyes to experiences beyond our own borders, challenging our American-centric view. This section underscores both the profound impacts of the climate crisis on Asian countries as well as the huge contribution of emissions by Asian nations. We have much to learn from each other as we move forward.

These varied experiences illuminate our shared burdens. Like a woven tapestry, individual-colored threads bind together in a whole that is stronger than the separate fibers. The challenge is to both honor and acknowledge individual community experiences, and to simultaneously join together in a collective effort.

Climate change is a universal threat endangering the entire world. It is not a problem for any one group but a problem for us all. We must find common ground from our shared values, emphasizing equality, respect, and compassion for all, with a forceful commitment to collective climate action.

An essential step must be to address the current homogeneity of groups combating climate change. We cannot sustain the current situation of predominantly White-dominated climate change groups and BIPOC (Black, Indigenous, People of Color)-dominated environmental justice groups focusing primarily on local issues. Our efforts must establish collaborative ways of working together. As mental health professionals committed to understanding deep emotional wounds and addressing complexities of relationships, we have the tools to assist in bridging the current gaps.

As this series has illustrated, climate change is a devastating existential threat that can also exaggerate pre-existing inequities and health/mental health problems. Yet it also opens the possibility of repairing centuries of embedded structural racism. The solutions that emerge from our shared values must hold to the fundamental principle that climate justice is social justice, and social justice is health and mental health justice. This inevitably will include reparative justice: the possibility of repairing damages inflicted by unequal social, racial, economic structures, and climate disruption.

The Biden/Harris administration has committed itself to addressing both the legacy of our racist history and our reliance on extractive fossil fuel-based economy. One of President Joe Biden’s first actions was to sign an executive order returning the United States to the Paris Agreement. In choosing his appointments, Biden has mobilized stellar leaders who embrace equity, strive to correct massive wealth disparities, and implement climate solutions.

Policies that address climate chance will have either direct or downstream health and social benefits for us all. But particular policies and regulations that have important impacts on communities of color include restrictions on oil and gas drilling on public lands, infrastructure projects with creation of green jobs, emission and toxic exposure regulations, and housing policies including improvements in substandard housing, transportation, and health access. There are signs that the new administration will integrate climate and environmental justice into policy planning across all levels of government, from community and local to state and national.

The business community is also moving forward, with several large corporations setting goals for carbon neutrality. Since a large percentage of emissions are due to the transportation sector, the dramatic steps taken by the domestic and foreign auto industry—setting net-zero carbon emissions goals and shifting production to electric vehicles—is 

 Other businesses are following suit, with Apple leading the way by pledging carbon neutrality by 2030. Additionally, Apple sustainability leader, Lisa Jackson, MS, is spearheading climate justice initiatives by putting equity and climate justice at the forefront of programs directed to support Black and Brown 

 Business leadership at this level can set the stage for others to follow.

Additionally, the growing attention to creating sustainable operations within the health delivery system is one of the ways of getting 

Mental health care professionals have important roles in creating solutions. The following recommendations are numerous and applicable across many domains. No one action, plan, or policy can address the enormity of the problems, but all in combination could decisively improve the future prospects of our communities.

While direct patient/individual recommendations are essential, climate change and the associated racial inequities are not individual issues. They must be addressed at broader systemic and community levels.

. It is important for us to examine and process our own feelings and confront our implicit biases about race, cultural differences, and climate. This is not a fleeting look but requires consistent self-reflection.

To care for diverse patients, we must incorporate culturally and linguistically appropriate material for patients with specific emphasis on climate-related mental health threats. Clinicians should integrate assessment of risk into discussions with our patients before predictable climatic events. The newly created 

 project is one attempt to expand the network of therapists and empower them to address climate related emotional issues (

We must develop ways to assist the growing group of individuals struggling with climate-related emotional difficulties and eco-distress experiences. We can offer our shared knowledge and emotional support skills and strategies. These include emotional regulation tools, group emotional supports, and integration of nature-based engagement activities into clinical suggestions for calming and sensory-affective modulation. This is particularly important for children, both for emotional regulation and to instill a sense of stewardship of the natural world.

Community/systems of care/public health model

. Our mental health system does not have the capacity to meet the increasing needs posed by climate change. We need to rethink our systems of care, expand, upon the current one-to-one treatment approach, and develop new models that focus on building the skills, resources, and social connections that are essential to prevent extensive psychological, emotional, and behavioral problems associated with climate disruption. This paradigm shift is founded on the awareness that emotional and psychic responses are not solely an individual issue, but are derived from real economic-political problems that call for social change.

There are many ways to lend emotional support to those who experience the inequities and racial disparities of the climate crisis. The Groundswell Climate Collective (GCC) is one such creative project that can be a model for 

 The GCC is committed to sharing the voices of people of color and developing community resilience. They utilize visual arts, writing, poetry, and other creative projects in efforts to prioritize youth engagement.

Additionally, we must develop collaborative relationships with other health providers, especially primary care, pediatrics, and obstetrics/gynecology. Psychiatrists can also serve as consultants and resources for paraprofessional and community leaders.

Table 2. Community and Climate Justice Groups

Fostering resilient communities is essential. Resilient communities are networks of local groups that develop emotional support and enhance community empowerment. Community Resilience relies upon strong social networks and attachments, a spirit of cooperation and altruism, trusted community leadership, and strong partnerships among schools, community organizations, faith groups, and health institutions. Providing adequate resources is essential, especially for underserved communities, and may require advocacy for funding sources (

Public health advocacy and policy: a call to action.

 There is no time to waste. Increased global temperatures have risen annually since mid-20th Century, and the polar ice caps are melting at an 

 Since the impacts of climate change on mental health are substantially influenced by social factors, influencing outcomes requires engagement in public policies. We must advocate for better governmental regulations, new laws, and funding of governmental and institutional activities as well as collaborative international agreements and treaties aimed at stopping climate change and eradicating racism.

Our professional organizations must be our voice in advocacy. Professional organizations can provide the tools and training to develop advocacy skills, and their political action committees can advocate for climate-friendly policies directly. Taking an important step, the American Psychiatric Association (APA) has recently allocated resources and attention to the climate crisis, establishing the Committee on Climate Change and Mental Health. However, there is more work to do. We must connect our organizations in order to strengthen our movement and increase its effectiveness.

Table 3. National Health and Climate Groups Committed to Equity and Environmental Justice

There are many national health organizations that focus on climate change and health with an equally strong commitment to addressing environmental justice, equity, and the impacts on vulnerable populations (

We began this series with the Persian poet Saadi’s words, which is inscribed on the United Nations Building. They remind us of our duties to each other we mobilize to address structural racism and climate change.

The sons of Adam are limbs of each other,

Having been created of one essence.
When the calamity of time affects one limb

The other limbs cannot remain at rest.
If thou hast no sympathy for the troubles of others
Thou art unworthy to be called by the name of a human.

Climate change and structural racism threaten us all. We must recognize our interdependence and interconnection with the entire world population and join collectively to face this existential threat. It is through effective collective actions that we can create a more fair, equitable, and sustainable future for ourselves, our children, and our grandchildren.

is clinical associate professor in the Department of Psychiatry at the University of California, San Francisco.

is in the psychiatry and behavioral sciences in the Vanderbilt University Medical Center. 

is Clinical professor of psychiatry and behavioral sciences at the University of California, Davis, and received the Kung Po Soo Award from the APA in 2015 for contributions to understanding Asian American patients with mental health issues. 

is the Asociación Puertorriqueños en Marcha Medical Director, a University of Pittsburgh Medical Center attending physician, and President of the APA Hispanic Caucus.

is a practicing psychiatrist at Garnet Health in New York. 

is a child and adolescent psychiatry fellow at Northwell Health. 

is a psychiatry resident at Garnet Health Medical Center in Middletown, New York.

 is the first woman Navajo psychiatrist to provide Indian Health Service clinical care in New Mexico and a Distinguished Fellow of the American Psychiatric Association. 

is Chairman of the Department of Psychiatry at Garnet Health Medical Center and is on the editorial board for Academic Psychiatry.

To see more on race and climate change, see 

The Tangled Roots of Racism and Climate Change.

General motors intends to lead the auto industry and the world to a net-zero-carbon future

. LinkedIn. January 28, 2021. Accessed May 7, 2021. 

. Climate.gov. March 15, 2021. Accessed May 7, 2021. 

Articles

Climate change is a devastating existential threat that can exaggerate preexisting inequities and health/mental health problems. As mental health professionals committed to understanding deep emotional wounds and addressing complexities of relationships, psychiatrists have the tools to assist in bridging the current gaps. 

Next Steps: Solutions and Recommendations For Healing

Vikram is a 38-year-old, married, Hindu South Asian immigrant father of 2; an otherwise healthy male patient who was referred by a local community leader. Vikram presents to the office on an extremely hot August afternoon for his first visit. He reports enjoying the drive into the city despite the traffic, heat, and smog, as he lives in a rural area. When asked about why he was referred, Vikram says that he has experienced disturbing suicidal thoughts. His local guru advised him that it would be helpful to meet with a professional, so he is only here for talk therapy.

He is self-employed as a farmer and is stressed by the effects of this past summer’s severe drought, which led to poor crop yields and lower income. He is from a farming region of northern India and moved to Kentucky for a better life 20 years ago with his wife when confronted with similar droughts. As the sole wage earner in his family, he is feeling overwhelmed and hopeless. Suicide, which betrays the Hindu belief that human life is precious, is disapproved of by his religion. Revealing any mental health struggles evokes a stigma for himself and would contribute to the suffering of his family. Yet if his crop yield does not improve, he fears he will be unable to provide for his family—another source of shame for him. Confronted with sparse resources, he fears he will have to relocate and leave his small, tight-knit immigrant community and find other ways to support his family.

Vikram asks, “What should I do? I thought I was getting away from such problems by moving here. I do not know if I can do it again. All I know is how to be a farmer. Are you going to prescribe me medicine? How does talk therapy work? We do not have this in my country.”

Unfortunately, Vikram’s case is not unique, and is similar to the crises faced by farmers in Asia. The approach to this case presents many questions: what role can psychiatrists in the United States play in addressing the issues highlighted by Vikram’s experience? By considering this question, we hope to open some possible avenues for action, reducing the impact of climate change and creating a viable future for our next generation.

The Impact of Climate Change on Asian Populations Globally

and is the largest landmass in the world, covering 

 The 2 largest countries in Asia, China and India, collectively have 3 to 4 times the population of the United States, and 

Clearly, understanding the impact of climate change in Asia and the contribution of Asia to global CO

 emissions is an essential part of understanding and slowing the impact of the international climate crisis. When Americans maintain an ethnocentric view of the world, it limits their understanding of the global context and the role they play in a world-wide problem.

As to historical context to the US-China relationship, in the 19th century, Congress passed the 1882 Chinese exclusion act, which precluded Chinese from immigrating to the United States. Other legislation, since repealed, prohibited Chinese individuals from becoming naturalized citizens, reflecting the concurrent fear of Asians referred to as the “yellow peril.” It is not surprising that today there are numerous anti-Asian hate crimes, spurred on by terms for the pandemic like 

Disproportionate Impact of Climate Crisis in Asia

Asia is the continent that has been hit hardest by climate change, both because of the impact of climate-related natural disasters, and due to mismanagement of resources, and other poor economic and political decisions. 

Vikram’s predicament is all too familiar to many farmers across India. Rising baseline temperatures have contributed to years of increased droughts, creating lower crop yields for many farming families. It is estimated that by mid-century, crop yields could drop by 30% in central and southern Asia. India has already had increased, epidemic-level suicide rates.

 As their lands become less habitable and farmers are no longer able to sustain a living, many impoverished individuals are pressured to move in search of limited job opportunities. Waves of climate refugees, often with no urban job skills, are descending on already impoverished urban centers. This creates enormous pressures, aggravates preexisting socioeconomic problems, and causes individual hardship, emotional anguish, community disruption, and hateful, retaliatory violence against new climate refugees.

While 60% of the world’s population lives in Asia, 40% of the world’s climate disasters have occurred on this continent in the past decade, resulting in a disproportionate 

 due to earthquakes, tsunamis, floods, droughts, and cyclones.

 All of these except earthquakes have become more severe and frequent because of climate change. Estimates suggest that by mid-century, South Asian monsoons will be much stronger, dropping 

Taiwan, the small island in the South China Sea, is located between 2 tectonic plates and has a long history of severe earthquakes. As a modern industrialized area with economic resources, the government has developed a complex disaster response and preparedness system that spans the national, regional, and local level. Providing 

 to the general population is integrated into their planning.

 Although not specifically designed as a climate change intervention, these programs show what is possible given governmental support for amelioration of natural disasters, which could include climate-driven disasters.

Other less wealthy areas on the Asian continent are not as well prepared to manage both inevitable natural disasters and those that are aggravated by climate change. Just as in the United States, different communities have disparate capacities to respond and recover from climate-related disasters, with the poor suffering the greatest.

Dr Hwang, along with students and other faculty, participated in required ongoing training for preparation and response to disasters at Yu Ying Elementary School in Su’Ao, Taiwan.

Glacial melting in the Himalayas has been accelerated by increasing temperatures, ultimately increasing the risks of floods and landslides during monsoon season. Long-term, permanent disappearance of glaciers will affect the flow of major Asian rivers, including the Yangtze, Mekong, and Brahmaputra. The Mekong River starts in China and flows through Myanmar, Laos, Thailand, Cambodia, and lastly Vietnam. An estimated 60 million individuals within these countries 

 for water, rice crops and fish, and transportation.

 The Mekong Delta is considered the Asian breadbasket, producing half of Vietnam’s rice and accounting for one-third of Vietnam gross domestic product. Recent political decisions to dam upstream areas of the Mekong River highlight both the human contributions to natural disasters and the impacts that extend past political boundaries, with policies of one country affecting downstream countries and communities. Damming and limiting flow to downstream countries further threaten communities dependent on the river and leads to downstream decreased rice and fish yields.

 The low-lying deltas in the southern parts of Asia produce 88% of the world’s rice supply and are at risk of disappearing.

Lower flows in combination with sea level intrusion contribute to 

 in outflow areas of the Mekong Delta, resulting in a decrease in fishing yields, as well as loss of farmable acreage.

 The Vietnamese government has predicted that by 2030 there will be 

 in the Mekong delta due to intrusion of saltwater, coastal erosion, and flooding.

Glacial melting also increases sea levels, putting many coastal cities such as Bangkok, Manila, Saigon, Jakarta, Surabaya, Yangon, and many others at 

risk of loss of coastline and increased risk of tsunamis

 These chronic changes are no less important than the acute events. In fact, chronic sea level intrusion is likely to create 

 of farmable and habitable land, land that currently is home to 72 to 187 million individuals.

 This potentially creates a problem of mass population displacement. 

As of 2017, China, India, and Japan surpassed the United States as the 

 Despite phasing out coal plants, the United States continues to have the highest per capita rate of emissions and continues to be in the top 3 countries, along with China and India, for coal power production. China currently has the largest number of coal power plants, representing half of the world’s coal use, and has quintupled its coal production between 2000 to 2019. It shows little sign of slowing down. India, the third largest producer of coal, has had the second largest increase in coal-producing capacity since 2000. Other Asian countries, including South Korea, Japan, Vietnam, Indonesia, Pakistan, Bangladesh, and the Philippines are heavily 

 for energy, with expansion of coal plants planned.

We must also consider the effects of human-induced air pollution on human populations. Cities in India, Pakistan, and China are listed in the top 15 worst places for 

 Estimates are that air pollution kills an excess of 1 million annually in India and 1.25 million annually in China.

 Prenatal exposure to more air pollutants is associated with increased rates of autism, attention-deficit/hyperactivity disorder, anxiety, depression, developmental delay, reduced IQ, and decreased brain white matter surface.

 has now officially listed air pollution as a contributor to dementia.

I, Dr Hwang, can relate to these air quality issues, because I lived in Yilan, Taiwan in 2015 and directly experienced air pollution while driving my 125cc scooter to and from Su’Ao, inhaling the emissions from the multitude of cars, motorcycles, scooters, and trucks in heavily congested urban traffic. I, like most of my fellow commuters, wore a mask to reduce the impact of breathing in these toxic fumes. However, the masks, though somewhat effective at screening out particulate matter, always had the residue of soot and did not eliminate the foul taste and smell of the diesel exhaust. Now, when I visit cities such as Los Angeles or walk behind the industrial zone of Nashville, I am reminded that air pollution is still an issue domestically. The human contribution to climate change is a local and a global issue.

The burning of coal is a major driver of 

 Commitments for phasing out coal use are being made by some countries, and both India and China are developing policies for reducing coal. These efforts are helpful, but insufficient and must be accelerated. International agreements are urgently needed to move from coal to clean energy sources and assist low-income Asian countries to develop alternatives.

Scooters in Taiwan parked near local park.

Returning to the case of Vikram, we are faced with the issue of what we can do as psychiatrists to respond to these urgent crises. Climate effects do not stop at political boundaries and neither should our efforts to address climate change. How can psychiatrists in the United States contribute to solutions for the Asian continent facing such a devastating disaster? Ideally, psychiatrists can ally with local community leaders and provide a comprehensive formulation using the Cultural Formulation Interview that takes into account societal, cultural, familial, and other factors to best capture the nuance in individual psychopathology and assist patients like Vikram who are suffering the emotional burdens.

 But we must also focus on broad systemic issues.

In the light of the profound severity and urgency, psychiatrists and mental health practitioners must act, utilizing our individual agency to create a collective voice to influence policy regarding climate change. We can engage the American Psychiatric Association by strengthening collaborations between the Climate Caucus and newly formed Committee on Mental Health and Climate Change with the Global Mental Health Caucus. We can bring these issues of international disparities to the newly formed Task Force on Social Determinants of Health to broaden the view to the international threats of the climate crisis and contribute to broader socio-political solutions. Advocacy cannot stop domestically in the United States, but rather must be a global effort.

Finally, the current anti-Asian sentiment and recent violence against Asians, unleashed due to the pandemic and fueled by former administration’s racist rhetoric, hurts all parties involved. The recent hate crimes against Asian-Americans are an assault on all humanity. Underlying unconscious racist attitudes contribute to the problems confronting ethnic minorities in the United States, whether that be COVID-19 or the climate crisis. When we focus only on our own nation, we miss opportunities for urgent and robust international collaborative action, and ultimately we all suffer. The costs are enormous—the costs are human lives everywhere in the world.

is clinical associate professor in the Department of Psychiatry at the University of California, San Francisco

is a retired health sciences clinical professor in the Department of Psychiatry and Behavioral Sciences at University of California, Davis School of Medicine.

To see more on race and climate change, see

1. Szmigiera M. Distribution of the global population by continent 2020. Statista. April 6, 2021. 

https://www.statista.com/statistics/237584/distribution-of-the-world-population-by-continent/#:~:text=As%20of%202020%2C%20about%2059.51,total%20population%20by%20continent%20here.and%20occupies

2. National Geographic Society. Asia: Physical Geography. Accessed May 17, 2021. 

https://www.nationalgeographic.org/encyclopedia/asia/

3. The Nations Online Project. Countries of the world by area. Accessed May 17, 2021. 

https://www.nationsonline.org/oneworld/countries_by_area.htm

4. Carleton TA. Crop-damaging temperatures increase suicide rates in India. 

5. United Nations Office for Disaster Reduction. Asia-Pacific suffering 80 percent of global losses due to disasters. October 2012. 

https://www.un-spider.org/news-and-events/news/un-asia-pacific-suffering-80-percent-global-losses-due-disasters

6. Brown O. Migration and climate change. International Organization for Migration. 2008. Accessed May 17, 2021. 

https://olibrown.org/wp-content/uploads/2019/01/2008-Migration-and-Climate-Change-IOM.pdf

7. Tso YE, McEntire DA. Emergency management in Taiwan: learning from past and current experiences. 2007. Accessed May 17, 2021. 

https://training.fema.gov/hiedu/downloads/compemmgmtbookproject/comparative%20em%20book%20-%20em%20in%20taiwan.pdf

8. Sasipornkarn E. A dam-building race threatens the Mekong River. Deutsche Welle. August 16, 2019. 

https://www.dw.com/en/a-dam-building-race-threatens-the-mekong-river/a-50049206

9. Soukhapon A, Baird IG, Hogan ZS. The impacts of hydropower dams in the Mekong River: A Review. 

10. Eyler B. Science shows Chinese dams are devastating the Mekong. 

https://foreignpolicy.com/2020/04/22/science-shows-chinese-dams-devastating-mekong-river/

11. VnExpress. Vietnam’s Mekong Delta to receive nearly $400 million to combat climate change. December 1, 2016. Accessed May 17, 2021. 

https://e.vnexpress.net/news/news/vietnam-s-mekong-delta-to-receive-nearly-400-million-to-combat-climate-change-3507275.html

12. SCMP Reporter. Explained: How climate change will affect Asia. 

https://www.scmp.com/week-asia/explained/article/2189340/explained-how-climate-change-will-affect-asia

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Climate Change 2014: Impacts, Adaptation, and Vulnerability. Contribution to Working Group II to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change

. Cambridge University Press; 2014:361-409. 

https://archive.ipcc.ch/pdf/assessment-report/ar5/wg2/WGIIAR5-Chap5_FINAL.pdf

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https://www.globalcarbonproject.org/carbonbudget/archive/2017/GCP_CarbonBudget_2017_eps.pdf

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https://www.carbonbrief.org/mapped-worlds-coal-power-plants

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https://earth.org/most-polluted-cities-in-the-world/

17. Chatterjee P. Indian air pollution: loaded dice. 

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19. Perera FP. Multiple threats to child health from fossil fuel combustion: impacts of air pollution and climate change. 

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https://www.usatoday.com/story/news/nation/2019/03/26/climate-change-coal-still-king-global-carbon-emissions-soar/3276401002/

22. Lewis-Fernández R, Aggarwal NK, Hinton L, et al, eds. 

DSM-5® Handbook on the Cultural Formulation Interview.

 American Psychiatric Publishing; 2016. 

How might droughts and monsoons in India and China lead to problems in American clinics?

Barrington Hwang, MD

Articles

Next Steps: Solutions and Recommendations For Healing

Global Problems Call for Global Solutions: Climate Change in Asian Communities