Sustainable Healthcare

The greening of medicine

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.d8360 (Published 16 January 2012)
Cite this as: BMJ 2012;344:d8360

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The Greening of Medicine - Start by Picking Low Hanging Fruit

One of the easiest ways to progress the greening of medicine is for the NHS to serve plant based food and reduce, even better stop, serving animal products. Leadership that may inspire healthy behaviour changes in users.

The NHS is one of the largest purchasers of food in the UK. Evidence shows that as far as the climate it concerned, meat is heat.(1) Reducing Livestock production will limit the cattle related methane emissions and also reduce the deforestation that is contributing to global warming. It has been calculated that four-fifths of agricultural greenhouse-gas emissions arise from the livestock sector,(2) and globally 22% of greenhouse gas emissions are caused by livestock production.(3)

What’s good for the climate is also good for health.(4) A reduction in animal products in the diet would reduce consumption of saturated animal fats and result in a fall in ischaemic heart disease.(5) Eating plenty of fruit and vegetables and reducing meat consumption might reduce risks of some cancers.

Finally let’s not forget feeding grain to animals is an inefficient use of food energy in a world where millions of people go hungry.

References

1. Roberts I. The NHS carbon reduction strategy. BMJ 2009;338:b326.

2. Friel S, Dangour AD, Garnett T, Lock K, Chalabi Z, Roberts I, et al. Public health benefits of strategies to reduce greenhouse-gas emissions: food and agriculture. Lancet 2009;374:2016-2025.

3. Griffiths J, Hill A, Spiby J, Gill M, Stott, R. Ten practical actions for doctors to combat climate change. BMJ 2008;336:1507.

4. Popkin BM. Reducing Meat Consumption Has Multiple Benefits for the World's Health. Arch Intern Med 2009;169(6):543-545.

5. Roberts I, Stott R. Doctors and climate change. BMJ 2010; 341:c6357.

Competing interests: None declared

Philip Bickley, GP

NHS, Shanklin House Surgery, 190 Aston Lane, Handsworth, B20 3HE

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23 January 2012

Is it just me? Am I the only one? We live in a very different world to when I first came into general practice 20 or so years ago. We have economic meltdown, rising population, diminishing resources, rising CO2 levels and imminent runaway catastrophic climate change.

Our economy is struggling, we no longer have an empire, yet we have a health care system that thinks the NHS has an endless source of money. We need to be radically rethinking the whole system.

We strive to keep alive at all costs. 25% of my income is target driven through QOF- quality targets. I spend an inordinate amount of my time seeing patients who have been called and recalled to improve their blood pressure, tweak their renal function, lower their cholesterol etc. This largely involves giving them yet another pill. I am driven by targets, financial incentives, fear of litigation (if I do not follow current “best practice” guidelines) and fear of slipping down the published league tables.

But isn’t this a lot of this bollocks? Does anyone else see the obvious? A very large and increasing percentage of the patients I see, do not need another tablet. Their illness, be it hypertension, heart disease, depression, diabetes, tired all the time, is often a product of the unsustainable society we have created over the past few decades. What most of these patients need isn’t another pill. What they need is to move about more, eat a sensible diet and get a life……. We are primates, we need community, and we need exercise. Our digestive tracts are not designed for an unlimited bounty of processed foods and carbohydrates. More and more of us are doing less, eating more and family life is becoming more disjointed and dysfunctional. Blame 24 hr TV, computer games, facebook etc.

Yes we want an effective health service, however, with impending resource depletion, accelerating climate change, and economic recession, we need to be looking at sustainable health care.

The government and the NHS have a responsibility to shape health care provision and resources. Chasing QOF points and creating more and more centegenarians is crazy. Why are we doing this? What quality of life will they have? How will their care be funded?

The impending obesity time bomb will bankrupt an already struggling health service. People need to be encouraged to get off their back sides, eat less, get a life--get involved again in community-- away from the pharmaceutical industry driven mantra that there is a pill for every ill.

If you want primary care to lead on this, health care professionals should be able to prescribe allotments, swimming, aerobics, dancing, bridge clubs, teen gym, bowling, flower arranging- anything to encourage people to get off their sofas, make friends and have fun. These clubs and societies are often pre-existing in every town and suburb. People need community. People need exercise. More and more of us sit all day in front of a computer screen, eat processed meals then spend the evening sitting watching television or a computer screen and snack on yet more processed food.…..The human species was not designed for this. Let us rethink QOF and the priorities of health care provision for this decade and the future. The government needs to be actively pushing health promotion and healthy lifestyles through legislation and public information means. Should we really be prolonging life at all costs? Society cannot afford this. Do people really want to live until they are 120 and beyond? If the world’s entire population were to live with our living standards, we would need several planets. There is only one planet and the area of land on which we can grow crops is getting smaller and smaller. The current system cannot go on.

We need to look at sustainable health care. We need to look at quality of life- not just quantity. Who gets the funding if the budget is restricted- the 43 year old lady with breast cancer, the 83 year old with angina or the obese hypertensive smoker? In my view we should be shifting the priority from funding non-sustainable health care treatments to basic healthy lifestyle promotion and this should be an immediate priority. Living wills should be encouraged. People should be given the opportunity early to make their end of life wishes known. Do people really want to be rushed to hospital to die on a busy ward away from their homes and families or to end up decaying in a nursing home? These are some of the issues that we need to be addressing and the sooner we do this the better.

The emperor isn’t wearing any clothes. The current system is unsustainable. Am I really the only one out there seeing this?

Niall MacLeod

Competing interests: None declared

Niall MacLeod, general practitioner

Heavitree Practice, Exeter

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Thank you Ray Moynihan for a thought-provoking article. There are good reasons to implement some of the changes discussed in this article. Efficiency savings often make business sense as well as environmental sense. Techniques developed for reducing carbon emissions in the healthcare sector could be made available for adoption by others. In the UK, of course, the NHS will have a statutory obligation to reduce its emissions. One could even make a moral argument for the greening of healthcare, based on Gandhi's famous epithet to 'be the change you wish to see in the world' - although I fear such lofty ideals will become politically toxic if they demand cuts in services or compromise patient care. However, the greening of healthcare described above will not do much to mitigate climate change, for two reasons.

The first is that the proposed solutions in this article are nowhere near sufficient to achieve the stated aim of carbon neutrality. Some are tautological; for instance, it does not strike me as a piercing insight that purchasing sustainable products should be part of a sustainability strategy. Others proposed solutions, such as insulating buildings and reducing drug waste, represent only the low-hanging fruit of greening healthcare. Their implementation will allow healthcare system to approach but never achieve carbon neutrality. Even a perfectly efficient system will require inputs of energy, devices, drugs and so on, and for these to be made sustainable in turn requires radical change in energy, manufacturing, and many other sectors beyond the purview of healthcare policymakers. In short, achieving true sustainability will require far more profound changes than those described. The unfavourable comparison between thromobolysis and PCI in the article hints at how future 'carbon austerity' might require cutting not just fat but muscle. I fear it is naive to believe that no harm will come of such change, if it is even possible.

The second and perhaps less tractable problem is that, even should greening healthcare result in stunning reductions in carbon emissions, it will not make much of a dent in global emissions. Unilateral action on emissions seems heroic but foolhardy. The only means by which climate change will successfully be mitigated is a multilateral, legally-binding treaty which is ratified by all the major emitters. Sadly, this remains a distant prospect. Although some promising statements emerged from the Durban climate summit in 2011, it remains difficult to envisage the US or China ceding sovereignty to an supranational authority; especially with the Republican primary candidates recently falling over one another to deny the reality of anthropogenic climate change. Even the Democratic Clinton administration failed to ratify the Kyoto Protocol in 1997. It is also salutary to consider the Canadian environment minister's announcement in December 2011 that Canada, having breached its emission limits under the Kyoto Protocol, would withdraw from the treaty rather than face sanctions. I cannot agree with Mr Moynihan's assertion that 'the greening of healthcare is... scaling the policy agenda.' Austerity, not sustainability, dominates the political conversation in the UK and Europe. The current UK government's pre-election promise to be the 'greenest government ever' has gone the way of 'no top-down reorganisation of the NHS,' with changes to planning policy in favour of development and major expansions of road and rail networks demonstrating the coalition's commitment to economic growth over sustainability. And with sustainability remaining a niche interest amongst voters, immediate costs and distant, uncertain benefits, it's difficult to hold out hope that every democratic government that matters will muster the political will necessary to strike a global deal on emission reduction.

These inconvenient truths demand that, barring a radical shift in context, healthcare systems' response to climate change should be to focus on adaption, not mitigation. Better to focus on helping future victims of climate change than fight a loosing rearguard action against preventing it.

Competing interests: None declared

Richard Bagshaw, 5th Year Medical Student

University of Birmingham

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