The idea of a link between planetary health and a role for the medical profession is not new. A leading influential proponent of this was Norwegian GP, Per Fugelli, who died in 2017. In 1993 he wrote: “Global environmental disruptions can have serious consequences for human health. It’s time for doctors to give a world diagnosis and advise on treatment”. He urged colleagues to get involved in initiatives to promote planetary health.¹

Many years later could it be that this idea might be starting to gain traction? In the midst of all the day-to-day trappings of general practice where does the enormity of such a global issue fit in? Dealing with the health of human civilisation and the state of the natural systems on which it depends may not seem a priority when faced with 15 appointments; a week’s paperwork that has backed up as you’re still trying to recruit a replacement receptionist; coping with FEMPI cuts, under sixes and new MTOP services – and all the rest.

In December Forum² our editorial set out to initiate debate by putting a name to the face of climate change in a typical Irish general practice: cases of heat stroke, fractures after unusual snowfalls, injuries as a result of storms, respiratory conditions due to poor air quality, and mental health fall-out in rural populations hit by floods or droughts. 

Even if you’re not all that connected to nature, you don’t really consider rising sea levels, and other than having a decent diet, don’t dwell too much on where your food comes from, a closer look at how some of your patients ended up in your surgery may bring the issue of planetary health a little bit closer to home. You might be prompted to scan through key points of some of the major climate change reports from the last six months: the IPCC Climate Change report,³ the World Meteorological Organization Greenhouse Gas Bulletin⁴ and the UN Environmental Emissions Gap Report.⁵

A trusted voice in health leadership

Our December editorial proposed that GPs could be a trusted voice in health leadership, advocating for science and for public policies that put peoples’ health and wellbeing first in the debate and action on climate change.

In Ireland, two new organisations have recently been set up. Irish Doctors for the Environment www.ide.ie held its first meeting in December with a focus on sustainable behaviour change. In this issue (see Insight page), Dr Aoife Kirk explains the aims and objectives of IDE.

Another recently formed group is Plant Based Doctors Ireland www.plantbaseddoctorsireland.org  One of its leading members is Dr Sean Owens, a final-year GP trainee in Dublin. Its first major conference takes place in the Catherine McAuliffe Centre at the Mater Hospital, Dublin on March 9. This will include talks by GPs on the role of plant-based nutrition in primary care. There will also be presentations by specialists in cancer, diabetes, inflammatory bowel and cardiovascular disease. Details and tickets are available through its website.

The RCGP has developed a policy and some practical resources for GPs.⁶ It says: “there is now recognition that health also depends on the ‘biosphere’, the global health systems affecting food and water supplies, the pattern of vectors and infectious diseases as well as the physical safety and comfort of human populations.”

It believes that general practitioners “have a role in raising awareness in relation to climate change and health as well as promoting appropriate lifestyle choices and this should be seen as a wider duty of care”.

One of the RCGP’s recent initiatives was to develop a Green Impact for Health toolkit.⁷ The idea behind this is to help each general practice improve its sustainability and environmental impact. This provides a list of actions for general practice and advice on how to perform them. There is also an award scheme.

Planetary Health Alliance

The RCGP is a founder member of the UK Alliance in Climate Change and the international group, the Planetary Health Alliance, which also includes WONCA, the world body for national colleges of general practitioners and family physicians, of which the ICGP is a member. 

In 2017 WONCA established a working party on the environment and has developed a policy on planetary health and sustainable development goals.⁸ According to WONCA: “As family doctors we are in a unique position to promote knowledge about planetary health and behaviour changes which can improve both individual and planetary health. We must strive to integrate sustainability into our individual behaviour, clinical practice, and in our meetings”.

A global declaration for family doctors will be launched this month by WONCA in conjunction with the Harvard-based Planetary Health Alliance’s Clinicians for Planetary Health Working Group. 

The latest issue of the Lancet Planetary Health,⁹ which attracted much attention internationally, includes a diverse range of articles and commentaries. The journal has been rolling out a body of original research and is encouraging more, to highlight the work of researchers who are focusing on how to create a more sustainable and healthier future. The BMJ has also recently put out a call for submissions on planetary health.

One of the Lancet articles highlights the lack of engagement from the medical profession on planetary health. “Health professionals... are ideally placed to raise awareness of and educate about planetary health... the clinician’s voice has been inexplicably quiet on global-ecological change. Why is this so and what can be done about it?”

The article points out that health professional training has been “notoriously slow to change”. In fact, clinical educators at faculty and dean level have generally resisted the inclusion of planetary health in curricula either because they haven’t engaged with the issue or the focus is on treatment over prevention.

Planetary health in clinical training

One group, the Sustainable Healthcare Education Network, has been experimenting with practical ways of incorporating planetary health into clinical training, according to the Lancet. It has started to gather evidence to support adding sustainable healthcare to the UK national medical curriculum. It is also helping to develop teaching materials and educational activities.

WONCA’s policy on planetary health also addresses this issue, highlighting the need to rethink medical education. It is “imperative that planetary health be included in the core curriculum of medical schools, family medicine residencies and further professional development”.

According to a Lancet article on ‘Planetary health: countering commercial and corporate power’ it is estimated that the lack of response to climate change and pollution causes seven million deaths a year.¹⁰ Many governments’ strategies are ineffective, with a lack of consistency and general disconnection from the problem. Underpinning the challenges to governments in making decisions about taking action are commercial interests. 

The Lancet article argues that strong interdisciplinary forces could make an impact. This includes mobilising health practitioners, researchers, politicians and others who have an effect on health. Furthermore: “The political role of the public health sector should be reclaimed and strengthened. Health institutions must reclaim their political role in protecting and promoting planetary health.”

Health diets from sustainable food systems

The background to the Lancet initiative on planetary health is that three years ago the Rockefeller Foundation, a private US philanthropic organisation, and the Lancet formed a joint commission to explore the scientific basis for creating planetary health as a new field. This followed publication of an online report: ‘Safeguarding human health in the anthropocene epoch,’ launched by Judith Rodin, the then president of the Rockefeller Foundation.¹¹

However, the aspect of the Lancet publications that drew the most attention here recently was ‘The EAT – Lancet Commission report on health diets from sustainable food systems’. There was considerable media debate on the nitty gritty of the guidelines, such as the recommended equivalent of half a rasher a day and one and a half eggs a week, which attracted much public fire. In a country so dependent on the food industry, this narrow focus was not surprising.

Late last year the University of Exeter College of Medicine and Health organised a day-long conference on ‘Waking up to planetary health’. The welcome address by Dr Tim Malone, a sustainability and health researcher at the Royal Devon and Exeter Hospital, presented a stark message. He said the 21st century is the first time in the planet’s evolution where human activity, that of a single species “not only directly challenges its own survival and that of many other species, but also threatens the very fabric of much of the planet’s ecosystem”. 

Also speaking was North Devon GP, Dr James Syzmankiewicz. He had written to the BMJ last year along with colleagues, Drs Niall Macleod and Simon Jones in response to an editorial on climate issues. He implored colleagues to speak out on climate change.¹² He said that doctors value evidence-based interventions to help their patients and hold a position of respect and a powerful voice collectively. “Interesting isn’t it that despite this, when it comes to the most important health issues of our generation, we are barely whispering?

“We believe it is our duty as doctors to co-ordinate high-level sustained lobbying of our governments and industries to address these issues. We are some of the most trusted voices in society and have more power than we think. So we have the ability to change the future if we have the will.

“So what is the ask of you as a doctor? It is quite simple, be brave enough to challenge yourself and your organisations. Ask yourself is what I am doing part of the solution and, if not, what do I need to do to make it so?” 

References

1. Casassus, Barbara (2017). “Per Fugelli”. The Lancet. 390 (10107): 2032. https://doi.org/10.1016/S0140-6736(17)32737-X
2. Bressan, J. Healthcare and climate change. Forum 2018; 35(10): 5
3. IPCC Climate Change Report 2018. www.ipcc.ch/sr15/
4. WMO Greenhouse Gas Bulletin, November 22, No 14, 2018 library.wmo.int/doc_num.php?explnum_id=5455
5. UN environment Emissions Gap Report 2018. www.unenvironment.org/resources/emissions-gap-report-2018
6. www.rcgp.org.uk/policy/rcgp-policy-areas/climate-change-sustainable-development-and-health.aspx
7. www.greenimpact.org.uk/giforhealth
8. www.wonca.net/News/PlanetaryHealthandSustainableDevelopmentGoals.aspx
9. The Lancet. Planetary Health. January 2019; 3(1): el-e47. www.thelancet.com/journals/lanplh/issue/vol3no1/PIIS2542-5196(19)X0002-9
10. Sula-Raximi et al. Planetary health: countering commercial and corporate power. January 2019; 3(1): 12-13 
11. Safeguarding human health in the Anthropocene epoch: report of the Rockefeller Foundation-Lancet Commission on planetary health. 2015; 386(10007)
12. Response re: Global warming must stay below 1.5c. BMJ 2018; 363: k4410