Why doctors and their organisations must help tackle climate change: an essay by Eric Chivian
BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2407 (Published 02 April 2014) Cite this as: BMJ 2014;348:g2407
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There exist business interests against using Earth's huge fossil fuel reserves.
Alternative multi-trillion dollar energy production investments are proposed instead, without any guarantee of sufficient output, long term sustainability, worldwide distribution of electricity produced, etc.
The German Federal Institute for Geosciences and Natural Resources has published recently an extensive study describing the vast energy reserves and resources still existing in all Continents.
Our civilization needs fossil fuels, and the solution for global warming is not to ban hydrocarbons but to use available safe methods of utilising them efficiently.
References
http://www.bgr.bund.de/EN/Themen/Energie/Downloads/energiestudie_2014_en...
http://www.bgr.bund.de/EN/Themen/Energie/Downloads/energiestudie_2015_en...
Competing interests: No competing interests
Eric Chvian's call to the profession must not go unanswered. Like the young officers of 1914 we must lead from the front. If every man resolved to take a COLD shower each day an appreciable amount of energy would be saved worldwide. Male doctors should lead the way - starting now when the weather is benign. We could not and should not ask or expect the ladies to do such a thing.
Competing interests: No competing interests
Avril Danczak in response to this article suggested we look for specific, measurable achievable, relevant and time-bound objectives for healthcare workers in response to climate change, and listed several.
I might add the following:-
As ordinary citizens:-
- cycle or walk rather than use engines
- wear another layer of clothes and turn down the heating in winter.
- switch to energy efficient light bulbs.
- cycle to work.
- fit solar panels, solar water heating and heat exchangers.
- get your home and workplace re-using and recycling as much as possible.
- get active in the Green Party. Incidentally the Green Party has some very enlightened policies on NHS management.
- get active in other political parties and seek to make their policies more Green.
- get active in Friends of the Earth, Greenpeace, and relevant petitions in 38 Degrees.
- work towards a more compassionate equal society - nationally and internationally - because people who are jealous of others' prosperity will not control their eco-impact.
- maintain your generosity of spirit.
As medical advisers to the public:-
- promote the above.
As participants in the health economy:-
- promote the above to colleagues and managers and seek influence in relevant committees.
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It is encouraging to witness an increased interest in the connections between health and climate change. It seems that the medical community is starting to realise that climate change is actually not an environmental problem but a human one. Just like fracking there are very real health implications which will become more salient over time, albeit not always in such a direct causal relationship.
Chivian’s article on this issue resulted in some interesting responses in the latest BMJ1. I agree with Emily Lear and Mark Davies that finances is a powerful tool to incentivize action on climate change at organisational level. In fact, I wish that every board member of every NHS Trust will read the Stern review on the economics of climate change. Stern showed that acting early will be more cost-efficient than trying to rectify the various impacts on our economy in the future, including the cost of health impacts 2.
Lear and Davies also suggest, as do most commentators, that doctors have a responsibility to act as leaders in moving towards a more sustainable NHS. It certainly resonates with reports by the NHS Sustainable Development Unit, according to which the biggest part of our national health carbon footprint originates from procurement, with pharmaceuticals, waste management and medical equipment representing a weighty part of the pie 3. By implication the clinicians who use equipment, prescribe drugs, and produce (and segregate) waste have the greatest potential to sway the carbon pathway of healthcare in the UK.
But this is where I find myself at odds with the case made for financial incentives. I do not question the fact that medical practitioners in management roles are forced to push for the most cost-effective treatment choice, often to the frustration of clinicians who work at patient level. However, in my daily practice I still see the majority of doctors making decisions based on patient outcome, rather than monetary implications.
To adequately incorporate environmental concerns in our healthcare system we need a clinician workforce that believes in climate change. With that I do not mean a belief that climate change is a reality. The recent IPCC report has provided enough evidence to substantiate that health implications are happening here and now. What I mean is that doctors have to believe that more carbon-conscious treatment choices have almost direct positive effects on the outcome of our patient population, if not individual patients.
A good example is the respiratory physician who has a choice of prescribing either a dry-powder inhaler or a metered-dose inhaler (when primary clinical outcome is comparable). MDI propellants have significantly higher global warming potential than carbon. If the pulmonologist recognizes that climate change negatively affects her larger subset of COPD patients, she will undoubtedly choose to prescribe the DPI. But she has to be convinced that morbidity and mortality will be improved because her choice of treatment modality is better for the climate. In other words, by keeping environmental sustainability on the shop floor rather than boardrooms, we will in fact be better doctors to our patients.
Feasibly, such a shift can only happen in two ways. The first is through the clinical guidelines we use. If bodies such as NICE truly adopt the message of climate change, the resulting guidelines will include environmental factors and therefore ultimately prevent a market failure in the health outcomes of our population. The second is to instil these principles at training level. Future generations of doctors need to understand that including environmental issues in our decision-making processes is not, as some may suggest, taking focus away from patient care. In fact, it is the opposite.
Lear and Davies are right when they say money talks, often with the loudest voice. However, we are still in a profession aimed at doing what’s best for the human condition. We are not mere merchants of healthcare but in fact stewards of health. Doing what’s right for our patients makes the most sense. A conviction that making sustainable choices is good clinical practice will move climate change from being a secondary issue, to the centre of each doctor’s professional conduct.
References
Chivian E. Why doctors and their organisations must help tackle climate change: An essay by Eric Chivian. BMJ 2014; 348; g2407. (2 April.)
Stern S. The Economics of Climate Change: The Stern Review. 2007 http://webarchive.nationalarchives.gov.uk/+/http:/www.hm-treasury.gov.uk....
NHS, Public Health and Social Care Carbon Footprint 2012
http://www.sduhealth.org.uk/documents/publications/HCS_Carbon_Footprint_....
Competing interests: No competing interests
Dr Mario S Sammut, in an earlier rapid response, may well be dismayed at Dr Chivian's exhortation of the medical profession to indulge in political activism based on a scare campaign.
This is not the first time for such antics by Dr Chivian. He boastfully recalls how he set up the IPPNW and how he was, with others, awarded the 1985 Nobel peace prize, this statement being approvingly repeated in Editor’s Choice. The prize, curiously, was in fact awarded to the organization rather to the founding individuals, and was called ‘the greatest blunder the Nobel committee ever made’.
IPPNW was a Soviet front organization, or something very like it, whose real purpose was not ‘to help people grasp what a nuclear war would really be like’ – there is plenty of such appalling evidence from Hiroshima and Nagasaki – but to call for unilateral disarmament by the west. Fortunately, in this treasonous quest it failed.
I drew attention to all this, with references, in a letter published in the BMJ, 14 September 1991, p651.
(http://www.bmj.com/highwire/filestream/329897/field_highwire_article_pdf...)
Competing interests: No competing interests
Dr Chivian’s essay is a powerful appeal to clinicians to acknowledge our vital role in the climate change debate. Anaesthesia has long been viewed as a source of considerable pollution within the medical profession but advances in technology and technique, such as low flow anaesthesia, soda lime and adequate scavenging, have improved our profile. Nevertheless, a recent study by McGain et al [1] suggesting that breathing circuits may safely be used longer than they are currently, suggests that there is still much more we can do to reduce unnecessary waste.
As Chivian rightly points out, climate change naysayers’ do generate a considerable amount of confusion, but surely even their arguments can be quashed by the financial implications of reducing environmental pollution and waste. A recent update of the 2008 ‘NHS Carbon Reduction Strategy’ [2] suggested that £40,299 per tonne of carbon dioxide per year could be saved by changing activities related to the packaging of medical equipment alone [3]. As anaesthetists, we now see the pollution we cause, rather than smell it.
We agree wholeheartedly that the focus of our input should be on the medical and health implications of environmental damage but let us use all weapons available to us: nothing speaks louder than money. In the UK our position is enviable; the NHS has a market monopoly. Let us demand more environmental concern and sustainability from our pharmaceuticals companies, medical product suppliers, equipment manufactures, delivery services and waste management companies, and. Not to mention from ourselves in our own daily practice. If we do, perhaps others will have no choice but to do so also.
1. McGain F, Algie CM, O'Toole J, Lim TF, Mohebbi M, Story DA, Leder K. The microbiological and sustainability effects of washing anaesthesia breathing circuits less frequently. Anaesthesia 2014; 69: 337-42.
2. NHS Sustainable Development Unit. NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health. 2009. http://www.sduhealth.org.uk/documents/publications/1237308334_qylG_savin... (accessed 03/04/2014).
3. NHS Sustainable Development Unit. Update: NHS Carbon Reduction Strategy for England: Saving Carbon, Improving Health. 2010. http://www.sduhealth.org.uk/documents/publications/1264693931_kxQz_updat... (accessed 03/04/2014).
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Dear Editor,
Chivian's article on climate change has generated debate, and I would agree with respondants who underline that a doctor's main duty is to efficiently seeing that patients are well cared for within the constraints of their work environment. However there are occasions when we need to ensure that thoughtless waste does not occur within the organisations which we work.
Currently St George's is launching its new helipad for emergency admissions and I hope that this will enhance patient care. It has been heralded by an email each of 30 days with a photograph of various staff members who are involved. Each email is sent to more than 13,240 staff members and their size has varied from 40-115kB. Estimates vary as to emissions per email but 50g for a large email is a commonly accepted figure. Hence the trust will have produced just under 20 tonnes CO2 through this emailing alone. (The average person in UK will produce 15 per annum)
Whilst I am sure that the effect on staff morale cannot be quantified, this is the kind of heedless waste of energy that we can address.
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In the last 2 days the head of the Care Quality Commission has told us that there are unnamed hospitals where he would not feel safe as patient. The president of the Royal College of Physicians then suggested that being ill anywhere was dangerous because resources, especially of doctors and nurses, were so overstretched. This suggests to some of us that the medical profession should focus on maintaining its own standards and protecting everyone from the idiocies of government and bureaucrats. I rather think that is what patients would expect also. Individual doctors can take whatever view they want on climate change, but maybe while they are working as doctors they should refrain from sixth form "activism".
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I was dismayed to read Eric Chivian’s essay exhorting the medical profession to indulge in political activism and to what is little more than a scare campaign.
As doctors we are more likely to campaign against energy policies than mean the poor, aged and vulnerable have to choose whether to heat or to eat and against sky rocketing food prices because arable land is being turned over to the production of biofuels to satisfy carbon reduction targets.
His clinical example of the precautionary principle, a feverish infant being given antibiotics before the result of CSF culture, is a poor analogy for climate change mitigation policies. A closer example would be having one’s arm amputated for a whitlow just in case it proves to be necrotising fasciitis.
The United Nations' Intergovernmental Panel on Climate Change (IPCC) has recently published the second part of its latest report, on the likely impact of climate change. What is interesting about this report is that, in spite of the standard warnings of imminent environmental apocalypse in the summary, the actual report itself drastically tones down the capability and the reliability of climate forecasts. It goes further and reduces the upper limit of the estimated cost of a 2.5C rise in average global temperature by a factor of ten from that quoted in the much touted Stern Report which was one of the main drivers for the ruinous UK Climate Change Act of 2008. In fact, it places a much greater emphasis on adaptation as opposed to mitigation than any previous UN report. This change of tack has been brought about not only by increasing scepticism amongst the general public but also by the ever widening divergence between observational data and the predictions of the current generation of climate models.
Climate has changed throughout our planet’s history and there is nothing that humans can do with current technology to stop it from continuing to do so. The latest IPCC report appears to suggest that we cannot be certain about what form this change may take. Adaptation carries a far better prospect of cost effectiveness. These measures, such as flood protection, target existing problems that may or may not become worse in the future. This means the benefits are available locally, immediately and regardless of whether global temperatures start to rise again or not. No ever elusive international treaties are required.
Richard Lindzen, Professor of Meteorology at MIT, when addressing the UK House of Commons Energy and Climate Change Committee in January this year said, “Nothing you can do will do anything to change your climate but it can seriously damage your economy”. Far better we use our resources to make sure that our children and grandchildren will be richer and better equipped to cope with anything that nature (and the climate) might throw at them. Anything else would be folly.
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Re: Why doctors and their organisations must help tackle climate change: an essay by Eric Chivian
Environmental damage is influenced by human industrial activities that are generally proportional to the population size. In the last quarter of the 20th century, the population grew faster in less developed countries, and, compared to the population increase, the carbon emissions increased faster in developing countries than in developed ones.
Nuclear power plants (NPP) emit virtually no greenhouse gases in comparison to coal, oil or gas. Nuclear energy is the cleanest, safest (if technology is on an appropriate level) and practically inexhaustible means to meet the global energy needs. Fossil fuels will become increasingly expensive in the long run, contributing to excessive population growth in fossil fuel-producing countries and poverty elsewhere. Natural energy sources like solar, geothermal, wind, hydroelectric power, electricity from combustible renewables and waste, will make a contribution, but their share in the global energy balance is too small to substitute for nuclear power. The global development of nuclear energy must be managed by a powerful international executive based in the most developed parts of the world. It would permit construction of NPP in optimally suitable places, disregarding national borders, considering all socio-political, geological and other preconditions, quality of working by local workers.
Consideration of all these factors would make nuclear accidents improbable. Moral principles aimed at preservation of life, wealth and human rights, based on modesty, mutual trust and birth control, should be propagated today.
More details and references: Jargin S. Nuclear facilities and nuclear weapons as a guarantee of peace. J Def Manag 2016;6:146. doi: 10.4172/2167-0374.1000146
Competing interests: No competing interests