By Stuart Foxman
What’s the most critical health issue facing your patients? Individually, it varies. Collectively, we’re all vulnerable to the same thing: climate change and its impact on the environment and health. That was the theme of a keynote panel at Choosing Wisely Canada's virtual national meeting in May.
Choosing Wisely Canada (CWC) is the national voice for reducing unnecessary tests and treatments in health care. It’s part of a global movement that now spans 20 countries. The CWC campaign revolves around recommendations developed by national clinician societies. It mobilizes health care providers and their organizations to adopt the recommendations and make them part of routine practice.
The keynote panel connected the dots between the carbon footprint of the health care system, waste in practices, and the ultimate harm to patients and the planet.
Consider first the potential impacts.
Panelist Anna Cooper Reed, a Fellow at the Centre for Sustainable Health Systems in Toronto, presented findings from the Lancet Countdown on Health and Climate Change, which calls climate change “the biggest global health threat of the 21st century.” It listed just some of the possible consequences in Canada: wildfire-related asthma; flood-related deaths; heat-related illness and death; increased severity and duration of allergies; relocation and stress from coastal erosion; displacement to Canadian shores from drought and famine abroad; impacts on mental health; and less availability of traditional foods in the Canada’s north. And there’s more.
In the summer of 2021 alone, B.C. experienced 570 heat-related deaths and had nearly 33,000 residents displaced by wildfires, noted Cooper Reed, a PhD student at the Institute of Health Policy, Management and Evaluation at the Dalla Lana School of Public Health, University of Toronto.
Efforts to reduce greenhouse gas (GHG) emissions are essential in all sectors — and the health care sector is a major source.
Cooper Reed noted four percent of Canada’s GHG emissions come from health care. She said that if the global health care sector was a country, it would be the fifth-largest emitter on the planet.
If Canada meets its climate targets, an estimated 112,000 Canadian lives could be saved between 2030 and 2050 due to air quality improvements alone, says the Canadian Association of Physicians for the Environment.
In the U.K., the NHS is the first national health system to commit to net zero, which is a state of carbon neutrality where emissions of carbon dioxide are balanced with their removal.
Dr. Natalia Kurek, Senior Clinical Lead for the Greener NHS National Programme, told the session attendees about the system’s pledges to be at net zero, for the emissions they control directly, by 2040. They want to get at least 80 percent of the way there by 2028-2032. And they want to reach net zero for the emissions they can influence by 2045.
For the NHS, and any health system, an environmental footprint comprises everything from building energy to water use, to medical equipment use, to chemical waste, to staff commutes and patient travel.
The only way to reduce emissions is by looking carefully at how care is delivered, said Dr. Kurek, who was previously a clinical advisor at the Institute of Global Health Innovation, Imperial College London, and co-published a report called Health in the Climate Crisis: A Guide for Health Leaders.
For instance, focusing even more on prevention can keep people healthier at home with less need to consume care-related resources and travel for care.
Making practice more sustainable
In reducing footprints in health care, the challenge is to continue best practices and re-think other ones. The big question, said Dr. Kurek: “How can we ensure the quality of the care is high and carbon-friendly?”
Reducing unnecessary tests and treatments intersects with a healthier environment in a few ways. Over-treatments have a cost in resource use and waste, noted Dr. Edward Xie, the third keynote panelist and an emergency physician and clinician investigator at University Health Network in Toronto.
A “climate-positive health system” would have more appropriate diagnoses, said Dr. Xie, who also served on the board of Canadian Association of Physicians for the Environment (CAPE).
Looking at specific treatments, there may be opportunities to become more sustainable. For instance, Dr. Xie pointed to metered dose inhalers (MDIs) for asthma. Is every MDI necessary? Are there alternatives? Are patients using them properly?
These are key questions considering the number of people using MDIs and their emissions. MDIs use HFC propellants, which act as potent GHGs when released into the atmosphere. The Centre for Sustainable Health Systems notes the environmental impact of MDIs: the global warming potential of inhaler propellants is many times higher than that of even carbon dioxide, and MDIs containing 100 doses have a carbon footprint equivalent to a 290 km car ride.
The urgency to get to net zero will require top-down approaches, like national policies, but also bottom-up approaches, said Dr. Kurek. Each health care professional can play a role at the individual and team levels, she said. They can all be advocates for change and take action locally.
In thinking about climate change and the doctor’s role, he said, “Clinicians have a responsibility not just to the patient in front of them, but to everyone who will need health care.”
