Introduction by Croakey: As the Australian Government orders a high-level review of the security threats posed by the climate crisis, millions are affected by floods devastating India and Bangladesh, and heatwaves in the United States.
Almost all countries are not on track to meet the net-zero greenhouse gas emissions goal established by the 2021 Glasgow Climate Pact, according to the 2022 Environmental Performance Index, an analysis by Yale and Columbia researchers that provides a data-driven summary of the state of sustainability around the world.
Coopes writes “the profession faced renewed calls for action” and a critical need for ecosocial understandings of health, from speakers across the globe.
Amy Coopes writes:
Ecosocial understandings of health which are intergenerational, justice and equity focused must be at the heart of clinical care in the Anthropocene, the current era dominated by humanity’s impact on the planet’s health, a global gathering of emergency doctors heard in Melbourne last week.
In addition, these understandings of health must be rooted in the notion that what is good for the planet is good for humanity – not the inverse.
Professor Tony Capon, who is planetary health chair at Monash University’s School of Public Health and Preventative Medicine, told delegates of the 21st International Conference on Emergency Medicine (ICEM) that the Holocene – the so-called ‘Goldilocks’ era for human habitation on Earth – had given way to the Anthropocene, as clearly evidenced during Australia’s so-called 2019-20 Black Summer.
It was also incumbent upon healthcare workers to systematise sustainability into their practice and think about the ‘secondary diagnosis’ of – and potential vulnerability or exposure to – climate change among their patients, delegates were told.
The climate crisis was centre stage at ICEM, occupying a full day of programming at the hybrid virtual-in person event, which brought together some 1,500 attendees from more than 60 countries for the first time since the COVID-19 outbreak began.
The specialty, which prides itself on being a sentinel of society’s health, has been outspoken for a number of years on the climate emergency.
The last time Australian and New Zealand emergency physicians came together in significant numbers for their annual meeting – just before the 2019-2020 bushfire crisis and ensuing global pandemic – they took to the streets of Hobart in a protest march to demand climate action.
Gathering in Melbourne last week, the profession faced renewed calls for action, with speakers from across the globe, including vulnerable Pacific nations already experiencing intensifying global warming impacts, laying down the gauntlet for emergency workers to confront the climate challenge head-on.
Reducing low-value healthcare
An overarching theme of conference discussions around the climate crisis was the importance of integrating it into daily practice, taking it from the abstract and political to pragmatic, personal and immediate – something that was impacting patients now.
Talks ranged over delegates’ direct experiences of climate effects, whether air pollution, urban floods and storm activity in India, sea level rise and cyclones in the Pacific Islands, North American heat dome events, ice melt in the Arctic or increasing vector-borne and other infectious disease outbreaks in the Mediterranean basin.
While the human race was healthier and living longer than ever before, Capon said it had been achieved at unprecedented exploitative expense to the planet and was distributed inequitably.
Transitioning away from a consumption-based, wasteful capitalist economic model to a circular, renewable paradigm would be central, Capon argued, telling delegates, “we know a lot of what needs to be done, we just need to get on with it”.
Part of the problem was a compartmentalisation – enabled and encouraged in large measure by our political leaders – of the environment and our impact on it, including artificial distinctions limiting Australia’s responsibility for emissions to the extraction of coal, and not its burning downstream.
This had been on prominent display during the pandemic, with Australia importing many millions of disposable personal protective equipment (PPE) items manufactured in China and using exported coal because it was cheaper than onshore solutions, while simultaneously dodging accountability for the emissions from its production.
Anaesthetist Associate Professor Forbes McGain, from Doctors for the Environment Australia, said PPE was just one example of healthcare’s many contributions to emissions.
In Australia, he said the sector accounted for seven percent of emissions, roughly the same quantum as the state of South Australia, with an average medium-sized hospital of a few hundred beds accounting for up to 10,000 houses’ worth of energy use and waste production.
He gave a host of concrete examples from daily clinical practice, including pathology tests, imaging, anaesthesia and puffers for asthma.
One full blood count, a test that is routinely done in significant volumes every day across the country, produced emissions equivalent to driving a car 770 metres, McGain said. A single CT scan – again, routinely done as part of everyday care – was equivalent to an 80-kilometre trip; an MRI 150km.
One hour of anaesthesia, with the volatile desflurane anaesthetic, produced the same volume of emissions as combusting 30 litres of petrol, McGain said, with significant emissions attributable to even the use of nitrous oxide (laughing gas) for procedural sedation in the ED.
Propellant-based asthma puffers were also a culprit, with one puff equivalent to driving a kilometre on the road in emissions terms. McGain said changing a patient from propellant to powder-based metred dose inhaler had the equivalent benefits for the environment to switching from a meat to plant-based diet.
With an estimated 40 percent of health care estimated to be of low value, Capon said reducing unnecessary testing and treatment would also be of significant benefit in emissions reduction.
The importance of people’s environment to their health was not a new concept, Capon told delegates to ICEM, pointing to Indigenous understandings the world over of wellbeing as synonymous and symbiotic with the land on which they lived, dating back tens of thousands of years.
Hippocrates, widely regarded as one of the foundational figures of modern medicine, had a keen appreciation for the environmental determinants of health, Capon explained, “making ecological deductions based on where and how people lived”.
This was nowhere more evident than in the events of the past few years, he said, pointing to the index pathogen spillover event which triggered the COVID-19 pandemic, as occurring “in the context of environmental and social change”, underscoring the significance of human ecology and its interaction with planetary health.
Capon said these ecosocial understandings of health had to be integrated into the biomedical paradigm and intergenerational health equity had to be the guiding principle, informed by Indigenous, local and transdisciplinary thinking and planetary consciousness.
Health in all policies
He was among a number of speakers who advocated for systems thinking and a health in all policies approach to the climate crisis.
Dr Selina Lo, who is consulting editor to The Lancet and executive director of the Global Health Alliance, spoke to the imperative of being good ancestors, underscoring that gender equality would be central to this task.
Lo said 80 percent of people displaced by the climate crisis were women, and women and children were disproportionately impacted by climate-driven disasters like tsunamis due to socially prescribed confinement to the home.
Laying down the challenge to delegates, Lo described community activism as a global public good and said the medical profession had to realise that science and health were “inherently political and we must act”, urging delegates to recognise and transfer their privilege.
She echoed many of Capon’s calls for a transdisciplinary, intergenerational planetary health that addressed inequities and justice, and quoted American writer and environmental activist Wendell Berry, who said:
“We have lived our lives by the assumption that what was good for us would be good for the world. We have been wrong. We must change our lives so that it will be possible to live by the contrary assumption, that what is good for the world will be good for us. And that requires that we make the effort to know the world and learn what is good for it.”
Presenting in the same plenary session, Assistant Professor Caitlin Rublee from the University of Wisconsin said a climate-resilient healthcare system had addressing health inequity as its primary mission, telling delegates poverty and the social determinants of health influenced lived experiences of climate change and one could not be addressed without the other.
Rublee advocated for health to be integrated into policy decision-making in all areas, giving energy as just one example.
Integration was a recurring theme of the talks, with presenters arguing that the time for climate siloes and tokenism was past and the crisis needed to be in focus at all clinical levels, from the medical school curriculum through to patient assessment and systems-level preparedness.
Dr Renee Salas, who is a Yerby Fellow at Harvard’s Center for Climate, Health and the Global Environment, delivered a practical, pragmatic-focused talk on ways clinicians could bring considerations of climate change into their everyday practice.
She said many common conditions seen in ED (asthma, cardiovascular disease) had the climate crisis as a ‘secondary diagnosis’ and encouraged doctors and nurses to think about and report this as well as to inquire about potential exposure pathways.
Salas floated the idea of ‘weatherisation’ prescriptions for homes built to withstand environmental stressors, and proposed systematic flagging of high-risk days for climate-related extreme conditions such as heat or air pollution so that vulnerable patients could be prioritised for screening.
“Add a climate lens to every aspect of care, it’s no longer good enough to look in the rear-view mirror,” Salas said.
Professor Tamorish Kole advocated for framing climate discussions with patients around immediate, tangible events, and this was extended on by Capon, who said doctors should be assessing their patients’ potential vulnerability and exposure to climate ructions and discussing risk mitigation strategies.
At a service level, Salas said 75 percent of healthcare providers globally reported already experiencing the impacts of the climate crisis and 56 percent expected to do so in the next few years. In light of this, she said upstream action on the determinants of the crisis – the burning of fossil fuels – was firmly within the remit of the medical profession.
This duty for advocacy was driven home by Professor Nick Talley, editor of the Medical Journal of Australia and a foundational figure in medical education, who said “we as doctors have to stand up”.
He took aim at the Australian media as playing a shameful role in the perpetuation of climate denial, describing conservative pay television network Sky News Australia a global denialist hub and haven for misinformation.
Despite this, Talley said the denialist voices were dwindling, pointing to Australia’s recent election result as evidence of an evolving public consciousness, which he said had occurred in spite of a concerted effort by the Murdoch press to discredit the issue.
Talley said he did not consider himself an activist but “this problem requires us all to speak out”, with the COVID-19 pandemic “a small taste of the disaster we are all going to face in coming decades”.
“We can and must lead,” said Talley. “Talking is not enough.”
“What will you say to the next generation when they ask what did you do about this crisis for health? You can make a difference. I hope you will.”
Global climate crisis
Speakers from the Pacific Islands brought the scale of what was at stake into focus, detailing a tenfold increase in disasters like droughts, storms, floods and earthquakes and a sea level rise more than twice the global average in the Solomon Islands, with more frequent and intense tsunamis, landslides and cyclones in neighbouring Fiji.
Fijian emergency physician Dr Deepak Sharma shared how, in the space of four years, two category five cyclones had devastated the tourism and agriculture-based island nation’s economy.
Though Pacific nations had contributed little, in relative terms, to the emissions responsible for the climate crisis, Sharma said they were bearing the brunt of its effects “and we can’t do it alone”.
“We can’t change our geography but we can prepare our health system, healthcare workers and people at large,” Sharma told delegates.
“We’re proud of our Pacific heritage and where we come from, but climate change is affecting us.”
In global terms, Canadian Association of Emergency Physicians president Kirsten Johnson said the trends were clear, with the past seven years the seven warmest on record and 2020 a record-breaking year for disasters, with an 18-20 percent increase on averages, totalling more than 300 in all.
Lower income countries were disproportionately affected, she added, particularly those home to armed conflict, which she said was itself driven by climate change.
Within countries, Johnson said marginalised and socially disadvantaged populations had been demonstrated to be at greater risk.
Kole, past president of India’s Society for Emergency Medicine and of the Asian Society for Emergency Medicine, said it was not just the increasing magnitude and frequency of extreme weather events that was the problem but that the intervening recovery period was getting shorter, compounding losses and increasing vulnerability.
“We have no option but to prepare for a new horizon,” Kole said, impressing upon colleagues that it was no longer good enough to merely react – they needed to anticipate and prepare for the next climate-related challenge.
Given pandemic-weary emergency staff were leaving the profession in droves, with burnout-related workforce shortages likely to be the new normal, at least in the short term, Johnson said this would be easier said than done.
Read @CroakeyNews thread (by @AlisonSBarrett) on the disaster medicine session.
Dr Amy Coopes was in virtual attendance at the International Conference for Emergency Medicine for the Croakey Conference News Service. Follow her at @coopesdetat for her Tweets from the conference, with additional coverage via @croakeynews and @wepublichealth.
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