Climate science is understood in varying degrees by most people, while the essence of the climate crisis has now gained mainstream acceptance. We learned about non-renewable energy and greenhouse gases as far back as primary school. The milestone Charney Report¹ to the US government in the late 1970s predicted that a doubling of carbon dioxide would accompany 3℃ warming with a probable error of 1.5℃.¹ Over time, as the world has continued to warm as predicted, this report has become accepted as a major milestone in our understanding of the consequences our actions have for the climate. 

In 1988, Shell was not only aware of the potential threats posed by climate change, it was open about its own role in creating the conditions for a warming world. Accurately, it predicted “significant changes in sea level, ocean currents, precipitation patterns, regional temperature and weather.”² Similar documents by ExxonMobil, oil trade associations and utility companies have emerged in recent years.^3,4

Those who don’t understand climate science often have livelihoods which depend on not getting the science. Fortunately society is largely made up of decent people who just want to do well for their family and their community. Society largely trusts and values healthcare professionals. We are comfortable with critically evaluating and disseminating science, how that interplays with a person’s symptoms and signs and how to relay this back in a meaningful and understandable manner. 

The Charney Report exemplifies how good science works: establish an hypothesis after examining the physics and chemistry, then based on your assessment of the science, make strong predictions. Charney et al also acted sceptically, trying to find factors that might invalidate their conclusions. And the science has not changed except, unfortunately, the reality is increasingly worse than the original predictions. 

The most recent Intergovernmental Panel on Climate Change (IPCC) report Climate Change 2021: The Physical Science Basis was considered a “code red for humanity”.⁵  Global temperature has risen more since 1970 than in the 100,000 years prior. Record breaking heatwaves and wildfires were observed in North America during the summer of 2021. In addition we know that 30% of the world’s population is exposed to deadly heatwaves more than 20 days a year.

Were we to hope to limit global warming to 1.5℃, there would still be some inevitable and irreversible long-term impacts of warming. These include sea level rises, the melting of Arctic ice, and the warming and acidification of the oceans. Drastic reductions in emissions can stave off worse climate change, but will not return the world to the more moderate weather patterns of the past. Ten years ago, if countries had acted on this science, governments would have needed to reduce emissions by 3.3% each year. Every year we fail to act, the level of difficulty and cost to reduce emissions goes up.

The 1.5℃ is an important marker as beyond this it is expected that 70-99% of coral reefs would die, double the likelihood that insects (vital pollinators) lose half their habitat, ice-less summers in the Arctic Ocean once per decade, 1 meter added in sea-level rise and 6-16 million people would be affected by sea-level rise in coastal areas by the end of this century (see www.unep.org).⁶

Healthcare

If healthcare were a country, it would be the fifth-largest emitter of greenhouse gases on the planet. Places of healing should be leading the way, instead of contributing to the burden of disease. We have to weigh up the safety of the individual patient against the sustainability of our healthcare systems as our planetary systems fail. 

Health Care Without Harm is an organisation working to transform healthcare worldwide to reduce its environmental footprint (see https://noharm.org).⁷

The NHS is proving to be a leader in this field by committing to net zero healthcare emissions by 2040. Without an overall plan for measuring or cutting healthcare emissions, progress will be glacially slow. 

Only 15% of healthcare waste is actually classed as ‘hazardous’, which covers waste that could be a source of infection, or is radioactive or toxic. Sometimes the yellow bin is the nearest bin.

In the hospital environment, a significant amount of disposable materials in fact have reusable options including theatre caps, tourniquets, anaesthesia drug trays, plastic kidney dishes, sats probes, surgical gowns, oxygen tubing, face masks, heating blankets, airway equipment, laryngoscopes and fibreoptic scopes. The UCLA Medical Center switched to using reusable isolation gowns in 2012, diverting almost 300 tons of waste from landfills, and saving more than $1.1 million in purchasing costs over a three-year period.⁸

After the first wave of Covid-19 in the UK, the NHS started a pilot project to introduce reusable type IIR certified face masks. Reusable PPE masks were separately stored and laundered, in accordance with the manufacturer’s instruction after use. Based on their calculation of 200 face masks replacing 10,000 single use, the NHS saved up to £800,000.⁹

Beyond being politically active in asking for a sustainable health service and beyond seeking out sustainable procurement, what does sustainable healthcare look like in the consultation? Consider the above case studies that illustrate why healthcare professionals have been asked to take a leadership role in the climate crisis. Open burning and incineration of healthcare wastes can, under some circumstances, result in the emission of dioxins, furans and particulate matter. Lack of awareness about the health hazards related to healthcare waste, inadequate training in proper waste management, absence of waste management and disposal systems, insufficient financial and human resources and the low priority given to the topic are the most common problems connected with healthcare waste. Many countries either do not have appropriate regulations or do not enforce them.

Case Study 1

Thomas, 18, lives in a commuter town, travels to work by car and suffers from asthma. He has an intermittent wheeze, cough, chest tightness and sometimes shortness of breath. He takes a brown preventer inhaler every day and a blue reliever inhaler as required. 

Environmental factors: Air pollution kills more than four times the number of people who die from AIDS, malaria and tuberculosis combined. Car pollution is the greatest contributor to this. Active transport, including walking and cycling, is good for patients with asthma. 

Environmental treatment considerations: Pressurised metered-dose inhalers (MDI) are a method of choice for delivering drugs into lungs for the treatment of asthma and chronic obstructive pulmonary disease across the globe. HFC-134a and HFC-227ea propellants, which are currently used in these inhalers, have a global warming potential respectively 1,300 and 3,350 more potent then carbon dioxide. In the UK inhalers were responsible for 4% of the carbon footprint of the NHS in 2018.¹⁰ This figure reflects the high rates of MDI prescribing in the NHS, where 70% of inhalers prescribed are MDI, compared to 10-30% in Scandinavia. Low carbon alternatives are available in the format of dry powdered and soft mist inhalers. Low carbon inhalers are suitable for a majority of patients and there are no links between inhaler type and outcome, including mortality.

Outcome: Thomas is advised that using any method of transport beyond car – such as train, bus, walking, cycling or a combination of all – has improved outcomes for not only cardiorespiratory disease management, but also cancer, dementia, diabetes prevention etc. By jumping on his bike, Thomas sets an excellent example for the rest of his team at work, as well as his family and community. The roads are that bit less busy and he is starting to feel healthier. Regarding his inhalers, updated global asthma guidance advises against relying on the blue inhaler, and its associated heavy carbon footprint, and he changes to a dry powder combination inhaler which improves his asthma control.

Case Study 2

Joe, 53, arranges for a blood pressure check. He works too much, is stressed, drinks too much alcohol and finds that he does not have time to prepare meals. He now has hypertension and is prescribed anti-hypertensive medication. Having started the anti-hypertensive medication, Joe returns having suffered a number of side effects including dizziness, headache and constipation. 

Environmental factors: The upstream environmental costs of medications are considerable including the water costs, manufacture, packaging, transport and biproduct pollution. While many pharmaceutical companies are based in Ireland, the ingredients come from afar. Medications are the major source of carbon emissions in primary care.

Environmental treatment considerations: Taking a sleep history could lead to simple tips, such as avoiding blue screens after 8pm or coffee after lunch, that would not only lead to a better night’s sleep but also reduce insulin resistance, blood pressure, anxiety and stress. He could attend a cooking class and move towards a whole-food plant based diet, in line with European Society of Cardiology guidance. He could join the local park run or attend a gym. He could build in 10 minutes to his working day to try mindfulness, stress management or meditation. The grade 1 evidence for chronic disease lies in optimising lifestyle. Social and lifestyle prescribing also bolsters community health as much as individual health.

Outcome: Joe is referred to a local cooking class and the combined increase in plants, reduction in highly processed foods which are high in saturated fats and salt, as well as his improved sleep sees his blood pressure normalise. He is delighted with his modest weight loss and his family members are delighted with their healthier meals. There is less upstream pressure on resources and less subsequent pollution, carbon emissions and water use as he is not on any medication. Best of all, Joe is empowered and he causes a ripple effect of positivity with his friends and family.

Dinner party conversations

The climate crisis is not a subject that is actively avoided but is something that we don’t generally talk about. The first step towards acknowledgement is having dialogue and raising awareness. Ultimately when faced with debating climate change and particularly the crisis, it is not about winning the argument, it’s about winning hearts and minds. 

So here are the common retorts:

It’s just natural weather cycles! Fortunately we hear less of this as the science is overwhelming, the effects are now evident in Irish weather and we are seeing floods, storms and wildfires in many parts of the world 

This is the responsibility of our governments! This is true because our governments are considered our leaders, who set policy and manage the economy. But we are also leaders – in our clinics, in our hospitals and in our communities. There are significant health co-benefits to climate action, including active transport, diet, improved air quality etc. In order to credibly work with other sectors on reducing emissions, healthcare must step up and be accountable for its own carbon emissions 

Sure, what difference is little old Ireland going to make? The footprint of Ireland’s five million citizens is equivalent to 200-300 million Sub-Saharan Africans. We are the third highest per capita polluting nation in the EU. If a province in China or India, with a similar population size has a carbon footprint far lower than ours, why should they cut their emissions if we don’t?

We’re doomed anyway! Aspects of the doomed mentality may affect us all but ask, therefore, what had that person done before they arrived at that conclusion? Had anything been tried to mitigate against the climate crisis? Furthermore, when we see on our screens the famine in Madagascar that has occurred directly and exclusively because of the climate crisis, it is a reality check that tells us that tragically, in other parts of the world, some populations are doomed. 

It’s the fault of the farmers! Yes, methane production from agriculture is the biggest reason why Ireland is considered a ‘laggard’ in tackling the climate crisis. Agriculture was responsible for 37.1% of greenhouse gas emissions in Ireland in 2020.¹¹ However farms are transitioning to better management of grasslands, tillage land and non-agricultural wetlands, from the current model of chemical farming to regenerative farming. As consumers, our food choices heavily influence what farms produce. 

It costs too much! Here is an analogy. A room in the house is on fire. But it’s okay because we’re in the next room. Do we have time to buy a fire extinguisher? Will it cost too much? We know that the costs of tackling this problem are in excess of 100 times more than preventing it.

Prevention is better than cure

Prevention is not only better than cure, it is the only feasible solution to the ailments of the health system of the future and the planet. The status quo is clearly not an affordable option going forward. A contemporary version of this quote from Erasmus would inevitably sound less succinct. For example “modern medicine is devoid of cures, only expensive management of complications. Prevention is too difficult to consider as it involves not only en masse change, but an admission of our current failings”. 

By rethinking our healthcare system where problems are prevented rather than managed, we can start to reimagine a future where school strikes for climate action aren’t needed, where coastal communities can live free of fear of floods and famine, and where our healthcare system is not continually firefighting on a daily basis. We can be a part of that change by, as Ghandi said, being the change we want to see in the world. We can do this by: 

• Being mindful of our own carbon footprint (what we eat, if we fly, how we commute, how much we consume)
• Bringing sustainability into our consultations (with all of the co-benefits above)
• Advocating locally and nationally for change.

In this way we can reimagine our purpose as healthcare firefighters to ambassadors for a healthier planet and healthier patients.

References

1. https://phys.org/news/2019-07-charney-years-scientists-accurately-climate.html
2. www.climatefiles.com/shell/1988-shell-report-greenhouse/
3. www.scientificamerican.com/article/exxon-knew-about-climate-change-almost-40-years-ago/
4. www.ucsusa.org/sites/default/files/attach/2015/07/The-Climate-Deception-Dossiers.pdf
5. Intergovernmental Panel on Climate Change (IPCC) report Climate Change 2021: The Physical Science Basis https://www.ipcc.ch/report/sixth-assessment-report-working-group-i/
6. https://www.unep.org/explore-topics/climate-action/facts-about-climate-emergency
7. Health Care Without Harm https://noharm.org
8. UCLA Medical Centre: https://practicegreenhealth.org/tools-and-resources/ronald-reagan-ucla-medical-center-reusable-isolation-gowns
9. NHS: https://cleanmedeurope.org/wp-content/uploads/2021/03/Alexis-Percival_Reusable-facemasks-Greener-NHS.pdf
10. https://rdtc.nhs.uk/prescribing-support-document/inhaler-carbon-footprint-significance-focus-action-jan-2021/
11. www.epa.ie/our-services/monitoring--assessment/climate-change/ghg/agriculture/