Climate change is a health issue: what can doctors do?

The visit to Australia by Dr David Pencheon, Founding Director of the National Health Service (NHS) Sustainable Development Unit, in April-May 2018 generated considerable interest and engagement. Dr Pencheon's overarching messages were that climate change is a health issue and that doctors and health systems have an opportunity, and responsibility, to lead climate action. This article distils Dr Pencheon's presentations into three themes: (i) carbon accounting; (ii) transformational change in our systems of healthcare; and (iii) a health system fit for the future. For each theme, we highlight promising initiatives that are already underway in Australia that are starting to transform our health system into one fit for a future environmentally sustainable world. We suggest practical ways in which doctors can lead the transformation through personal action and influence broader systems.

The Lancet Countdown: tracking progress on health and climate change.

The Lancet Countdown: tracking progress on health and climate change is an international, multidisciplinary research collaboration between academic institutions and practitioners across the world. It follows on from the work of the 2015 Lancet Commission, which concluded that the response to climate change could be "the greatest global health opportunity of the 21st century". The Lancet Countdown aims to track the health impacts of climate hazards; health resilience and adaptation; health co-benefits of climate change mitigation; economics and finance; and political and broader engagement. These focus areas form the five thematic working groups of the Lancet Countdown and represent different aspects of the complex association between health and climate change. These thematic groups will provide indicators for a global overview of health and climate change; national case studies highlighting countries leading the way or going against the trend; and engagement with a range of stakeholders. The Lancet Countdown ultimately aims to report annually on a series of indicators across these five working groups. This paper outlines the potential indicators and indicator domains to be tracked by the collaboration, with suggestions on the methodologies and datasets available to achieve this end. The proposed indicator domains require further refinement, and mark the beginning of an ongoing consultation process-from November, 2016 to early 2017-to develop these domains, identify key areas not currently covered, and change indicators where necessary. This collaboration will actively seek to engage with existing monitoring processes, such as the UN Sustainable Development Goals and WHO's climate and health country profiles. The indicators will also evolve over time through ongoing collaboration with experts and a range of stakeholders, and be dependent on the emergence of new evidence and knowledge. During the course of its work, the Lancet Countdown will adopt a collaborative and iterative process, which aims to complement existing initiatives, welcome engagement with new partners, and be open to developing new research projects on health and climate change.

Sustainable Development Goals (SDGs), and their implementation: A national global framework for health, development and equity needs a systems approach at every level.

INTRODUCTION: The Sustainable Development Goals (SDGs) are a set of global goals for fair and sustainable health at every level: from planetary biosphere to local community. The aim is to end poverty, protect the planet and ensure that all people enjoy peace and prosperity, now and in the future. SOURCES OF DATA: The UN has established web-sites to inform the implementation of the SDGs and an Inter-Agency and Expert Group on an Indicator Framework. We have searched for independent commentaries and analysis. AREAS OF AGREEMENT: The goals represent a framework that is scientifically robust, and widely intuitive intended to build upon the progress established by the Millennium Development Goals (MDGs). There is a need for system wide strategic planning to integrate the economic, social and environmental dimensions into policy and actions. AREAS OF CONTROVERSY: Many countries have yet to understand the difference between the MDGs and the SDGs, particularly their universality, the huge potential of new data methods to help with their implementation, and the systems thinking that is needed to deliver the vision. The danger is that individual goals may be prioritized without an understanding of the potential positive interactions between goals. GROWING POINTS: There is an increasing understanding that sustainable development needs a paradigm shift in our understanding of the interaction between the real economy and quality of life. There would be many social, environmental and economic benefits in changing our current model. AREAS TIMELY FOR DEVELOPING RESEARCH: We need to develop systems wide understanding of what supports a healthy environment and the art and science of making change.

Could the Transition movement help solve the NHS's problems?

Background: The NHS Five Year Forward View identifies a range of approaches for addressing the NHS's challenges. The Transition movement helps communities to reframe and rebuild their world by working on issues such as climate change, food, community relationships and localizing the economy. Methods: This paper describes Transition using five short example projects and, informed by these, identifies mechanisms by which Transition could potentially help reduce pressure on the NHS. Results: Transition is characterized by people self-organizing to address local challenges with benefits arising from both the outcomes and the process of the projects. Transition may be able to help the NHS reframe change, prevent disease, improve staff well-being and increase local economic resilience. Discussion: The evidence base for the relationship between Transition and health is growing but is not yet well developed. This reflects the complexity of establishing an evidence base for wider determinants of health. There is substantial potential learning for those in the NHS about change outside formal institutional structures. Conclusions: Transition provides new ways of thinking and acting to develop greater 'community intelligence', which could help the NHS in the face of increasing pressures.

Improving health and well-being independently of GDP: dividends of greener and prosocial economies.

Increases in gross domestic product (GDP) beyond a threshold of basic needs do not lead to further increases in well-being. An explanation is that material consumption (MC) also results in negative health externalities. We assess how these externalities influence six factors critical for well-being: (i) healthy food; (ii) active body; (iii) healthy mind; (iv) community links; (v) contact with nature; and (vi) attachment to possessions. If environmentally sustainable consumption (ESC) were increasingly substituted for MC, thus improving well-being and stocks of natural and social capital, and sustainable behaviours involving non-material consumption (SBs-NMC) became more prevalent, then well-being would increase regardless of levels of GDP. In the UK, the individualised annual health costs of negative consumption externalities (NCEs) currently amount to £62 billion for the National Health Service, and £184 billion for the economy (for mental ill-health, dementia, obesity, physical inactivity, diabetes, loneliness and cardiovascular disease). A dividend is available if substitution by ESC and SBs-NMC could limit the prevalence of these conditions.

Making health care more sustainable: the case of the English NHS.

The NHS is the most revered organisation in Britain: 'the proudest achievement of our modern society'. It is certainly the largest, although since its inception in 1948 it has operated in a government-funded environment of restricted resources. Nevertheless, it has also benefitted from a generally effective model of intervention centred on a hospital care system integrating specialist and emergency care and a primary care system which functions as both a source of treatment and a gatekeeper to specialist care. New circumstances, including environmentally-generated risk and a shifting disease reality, challenges the adequacy of this model. This paper argues that these new circumstances, some of which have seen a legislative response by government, mean that the NHS has to apply sustainable development thinking programmatically throughout its management and operations. It is also argued that the organisation needs to refocus towards prevention particularly in order to stem the rising tide of non-communicable disease. This paper sets out the thinking and actions of the Sustainable Development Unit, which has the task of developing and implanting sustainability concepts in the NHS. It is argued that the cause of sustainable development calls for a mix of cultural and technological shifts, new incentives and a rolling programme of innovative change. Some examples of success are presented.

Learning to treat the climate emergency together: social tipping interventions by the health community.

Accelerating the decarbonisation of local and national economies is a profound public health imperative. As trusted voices within communities around the world, health professionals and health organisations have enormous potential to influence the social and policy landscape in support of decarbonisation. We assembled a multidisciplinary, gender-balanced group of experts from six continents to develop a framework for maximising the social and policy influence of the health community on decarbonisation at the micro levels, meso levels, and macro levels of society. We identify practical, learning-by-doing approaches and networks to implement this strategic framework. Collectively, the actions of health-care workers can shift practice, finance, and power in ways that can transform the public narrative and influence investment, activate socioeconomic tipping points, and catalyse the rapid decarbonisation needed to protect health and health systems.

Changes in travel-related carbon emissions associated with modernization of services for patients with acute myocardial infarction: a case study.

BACKGROUND: Little attention has been paid on the carbon footprint of different healthcare service models. We examined this question for service models for patients with acute ST elevation myocardial infarction (STEMI). METHODS: We estimated carbon emissions associated with ambulance (patient) transport under a primary percutaneous coronary intervention (pPCI) care model based in tertiary centres, compared with historical emissions under a thrombolysis model based in general hospitals. We used geographical information on 41,449 hospitalizations, and published UK government fuel to carbon emissions conversion factors. RESULTS: The average ambulance journey required for transporting a STEMI patient to its closest care point was 13.0 km under the thrombolysis model and 42.2 km under the pPCI model, producing 3.46 and 11.2 kg of CO(2) emissions, respectively. Thus, introducing pPCI will more than triple ambulance journey associated carbon emissions (by a factor of 3.24). This ratio was robust to sensitivity analysis varying assumptions on conversion factor values; and the number of patients treated. CONCLUSIONS: Introducing pPCI to manage STEMI patients results in substantial carbon emissions increase. Environmental profiling of service modernization projects could motivate carbon control strategies, and care pathways design that will reduce patient transport need. Healthcare planners should consider the environmental legacy of quality improvement initiatives.

The environmental footprint of health care: a global assessment.

BACKGROUND: Health-care services are necessary for sustaining and improving human wellbeing, yet they have an environmental footprint that contributes to environment-related threats to human health. Previous studies have quantified the carbon emissions resulting from health care at a global level. We aimed to provide a global assessment of the wide-ranging environmental impacts of this sector. METHODS: In this multiregional input-output analysis, we evaluated the contribution of health-care sectors in driving environmental damage that in turn puts human health at risk. Using a global supply-chain database containing detailed information on health-care sectors, we quantified the direct and indirect supply-chain environmental damage driven by the demand for health care. We focused on seven environmental stressors with known adverse feedback cycles: greenhouse gas emissions, particulate matter, air pollutants (nitrogen oxides and sulphur dioxide), malaria risk, reactive nitrogen in water, and scarce water use. FINDINGS: Health care causes global environmental impacts that, depending on which indicator is considered, range between 1% and 5% of total global impacts, and are more than 5% for some national impacts. INTERPRETATION: Enhancing health-care expenditure to mitigate negative health effects of environmental damage is often promoted by health-care practitioners. However, global supply chains that feed into the enhanced activity of health-care sectors in turn initiate adverse feedback cycles by increasing the environmental impact of health care, thus counteracting the mission of health care. FUNDING: Australian Research Council, National eResearch Collaboration Tools and Resources project.

Health sector leadership in mitigating climate change: experience from the UK and NSW.

The threat to human health from climate change means that all levels of government and private and public agencies will need to change their current practices to reduce carbon emissions. The health sector will also need to respond and change practice. The National Health Service in the United Kingdom is developing a systematic and strategic approach to reduce its carbon footprint, as described in the recently released NHS Carbon Reduction Strategy for England. The work is being led by the Service's new Sustainable Development Unit. While the Australian health care system has not yet embraced a shared vision for carbon reduction, there are examples emerging of how the sector is contributing to reduce greenhouse gas production. Examples from two NSW area health services to reduce energy use and promote active transport are presented. In both countries, these changes are supported by new legislation and policy.

Local action on outdoor air pollution to improve public health.

OBJECTIVES: The National Institute for Health and Care Excellence, jointly with Public Health England, have developed a guideline on outdoor air pollution and its links to health. The guideline makes recommendations on local interventions that can help improve air quality and prevent a range of adverse health outcomes associated with road-traffic-related air pollution. METHODS: The guideline was based on a rigorous assessment of the scientific evidence by an independent advisory committee, with input from public health professionals and other professional groups. The process included systematics reviews of the literature, expert testimonies and stakeholder consultation. RESULTS: The guideline includes recommendations for local planning, clean air zones, measures to reduce emissions from public sector transport services, smooth driving and speed reduction, active travel, and awareness raising. CONCLUSIONS: The guideline recommends taking a number of actions in combination, because multiple interventions, each producing a small benefit, are likely to act cumulatively to produce significant change. These actions are likely to bring multiple public health benefits, in addition to air quality improvements.