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How might droughts and monsoons in India and China lead to problems in American clinics?
Racism & Climate Change
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
Asia is home to almost 60% of the world’s population, compared to North America at 5%,1 and is the largest landmass in the world, covering 30% of the globe.2 The 2 largest countries in Asia, China and India, collectively have 3 to 4 times the population of the United States, and 29% of the land on the Asian continent.3
Clearly, understanding the impact of climate change in Asia and the contribution of Asia to global CO2 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 Asian flu or kung flu.
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.4 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 80% of the world’s disaster deaths due to earthquakes, tsunamis, floods, droughts, and cyclones.5 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 20% more rain in eastern India and Bangladesh alone.6
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 disaster preparedness and response to the general population is integrated into their planning.7 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.
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 depend on the river flow for water, rice crops and fish, and transportation.8 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.9 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 salination in outflow areas of the Mekong Delta, resulting in a decrease in fishing yields, as well as loss of farmable acreage.10 The Vietnamese government has predicted that by 2030 there will be substantially reduced crop production in the Mekong delta due to intrusion of saltwater, coastal erosion, and flooding.11
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.12 These chronic changes are no less important than the acute events. In fact, chronic sea level intrusion is likely to create considerable loss of farmable and habitable land, land that currently is home to 72 to 187 million individuals.13 This potentially creates a problem of mass population displacement.
Asian Contribution to Climate Crisis
As of 2017, China, India, and Japan surpassed the United States as the top contributors to CO2 emissions, the primary driver of global warming.14 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 reliant on coal sources for energy, with expansion of coal plants planned.15
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 air pollution.16 Estimates are that air pollution kills an excess of 1 million annually in India and 1.25 million annually in China.16,17 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.18,19 In addition, The Lancet has now officially listed air pollution as a contributor to dementia.20
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 global warming.21 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.
Using What We Know
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.22 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.
Dr Hwang is a year 2 psychiatric resident at Vanderbilt University. Dr Cooper is clinical associate professor in the Department of Psychiatry at the University of California, San Francisco. Dr Lim 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 The Tangled Roots of Racism and Climate Change.
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