Features

Climate change: the health impact

20 March 2020

Climate change poses a huge challenge to public health. While awareness is growing, there’s much to be done. Journalist Linsey Wynton looks at the depth of the emergency and in turn asks how healthcare can help save the planet.

In June last year, more than 1000 medics, including leading public health figures, called for urgent government and public action on the climate crisis (Jones et al, 2019). Retired haematologist Bing Jones, who organised the signatories, compared our collective response to climate change with someone going to the toilet, seeing blood and refusing to accept the diagnosis and treatment (Taylor, 2019). GP Aarti Bansal said: ‘The planet has a fever… its systems are breaking down. We have a decade to prevent this fever from getting out of control and we owe it to our children and all life to act like we do in any emergency’ (Taylor, 2019).

Now a new report from the WHO, Unicef and the Lancet Commission has given an equally stark warning: there is a 93% chance that global warming will exceed 4°C by 2100, with ‘devastating health consequences’ (Clark et al, 2020). The result would be a rise in ocean levels, heatwaves, malnutrition and infectious diseases such as malaria. The report also placed the UK 133rd globally on providing a climate fit for future generations – currently the nation is on track to emit 115% more carbon dioxide than it should by 2030.

Back in 2009, The Lancet had already declared climate change ‘the biggest global health threat of the 21st century’ (Costello, 2009), as previously reported in Community Practitioner (Griffin, 2018). And right now the changing climate is leading to more frequent extreme weather events such as heatwaves and flooding, and the potential spread of infectious diseases to the UK. Almost 900 people were killed by last summer’s heatwaves (NHS England, 2020a).

The causes of climate change and air pollution are often closely related: burning fossil fuels emits greenhouse gas emissions and blights the air. Air pollution has been linked to serious conditions including heart disease, stroke and lung cancer, contributing to around 36,000 deaths annually (NHS England, 2020a).

The huge challenge to public health is in more than one direction, however. The hub of healthcare, the NHS itself, produces 5.4% of the UK’s greenhouse gases (Bawden, 2019). NHS chief Sir Simon Stevens recently said: ‘As the biggest employer in this country comprising nearly a 10th of the UK economy, we’re both part of the problem and part of the solution’ (Health Care Without Harm (HCWH), 2020). ‘With almost 700 people dying potentially avoidable deaths due to air pollution every week, we are facing a health emergency as well as a climate emergency’ (NHS England, 2020a). 

Part problem, part solution

So how exactly can healthcare help? For starters, it can address its own part in climate change. Will Clark, executive director of HCWH, says: ‘Overall, around 20% of the NHS footprint is driven by energy consumed within its estate, which includes fossil fuels for heating. Around 70% of the NHS footprint comes from the supply chain and other commissioned services. Within that, pharmaceutical use accounts for over 20%.’

Paul Wilkinson, professor of environmental epidemiology at the London School of Hygiene and Tropical Medicine, says: ‘It’s generally recognised we prescribe too many drugs – there are alternatives to reduce prescribing that would be good for the environment, patients and for the NHS drugs bill.’

‘Food is another procurement issue,’ says Chris Naylor, senior fellow in health policy at The King’s Fund. ‘So thinking is needed about where food served in hospitals is sourced from. The NHS is also having a push on stopping the use of single-use plastic coffee cups.’ (See Unhealthy footprint, right, for more figures).

In January this year, measures were stepped up – NHS England announced its Greener NHS climate reduction strategy and appointed an expert panel to highlight the key steps required to reach net zero emissions. While the government has already committed to the UK reaching this target by 2050, the NHS is the world’s first major health service to announce such a plan (NHS England, 2020a). The NHS panel will consider changes including technology to scrap millions of outpatient appointments, sparing millions of road miles (NHS England, 2020a).

Meanwhile the majority of local authorities (LAs) in England have declared a climate emergency (Local Governement Authority, 2020) and many are taking action including supporting cycling, boosting electric vehicle charging points, increasing recycling, planting more trees and wildflowers and investing in energy-saving measures.

NHS Scotland is about to publish a Sustainable Development and Climate Change strategy on how it will move to net zero by 2045 (Scottish Government, 2020). NHS Wales Shared Services aims to reduce its carbon emissions at sites by 3% per year and to achieve zero waste (Welsh Government, 2019). And Northern Ireland’s Department for the Economy (2019) has launched a call for evidence (ending 20 March) on meeting the UK’s net zero emissions target by 2050.

Experts agree that all healthcare staff must understand the health implications of climate change and act urgently.

Specialty registrar in public health Dr Sarah Woodhall conducted a study with LAs on how they’re preparing for climate change. ‘The people I interviewed said the health impacts of climate change weren’t fully appreciated, among professionals or the public.’ Improving this understanding is vital, she says.

Professor Wilkinson says: ‘As the country’s biggest employer, it’s vital that the NHS is in the vanguard of action on climate change and that it gives the message to encourage others to take action – in relation to the risks and reducing carbon footprints.’

 

 

Fuelling breathing issues

‘In the UK, the biggest climate change-related health risk for children is exposure to poor air quality in urban areas, caused mainly by road traffic,’ says Will. ‘Babies and children are especially vulnerable to air pollution as their lungs are still growing and developing,’ he continues. ‘It impacts neurodevelopment and cognitive ability and can trigger asthma and childhood cancer. And pregnant women who are exposed to polluted air are more likely to give birth to premature, small, low birthweight children.’

A recent study found a link between young children’s exposure to significant levels of traffic-related air pollution and structural changes in their brain at age 12 (Beckwith et al, 2020). And a fresh inquest into the death of nine-year-old Ella Kissi-Debrah is due to determine whether air pollution contributed to her fatal asthma attack (Oppenheim, 2019).

Alarming then, that more than one million children in London attend schools where air pollution levels are beyond recommended limits (Watts and Clark, 2019). Campaign group Mums for Lungs has been urging parents idling in cars to turn off engines outside school gates. And School Streets, where drivers  – other than residents and disabled people – are barred from entering during school drop-off and pick-up times, are growing.

Like children, older adults are also more vulnerable to the effects of air pollution, explains GP Dr Murugesan Raja, Manchester Care and Commissioning clinical lead for respiratory medicine. ‘For [all ages] with asthma, they have more episodes, especially when pollution is quite high. And children tend to breathe in a lot more as they’re more active.’

Dr Raja advises families to walk to school: ‘Walking is better for children even when traffic is slow and the pollution is quite high, because the air is still diluted. When you’re in the car, the exposure is a lot more. The air in the car is a lot more polluted from the cars in front, behind and to the sides of you. People are surprised to find this out.’

Professor Wilkinson adds: ‘In the UK we are probably losing five to six months of life expectancy on average from birth because of air pollution.’ Reiterating the need to reduce car travel, he says: ‘We will never get down to zero in relation to particles from the transport sector.’

What’s the government doing? Ahead of the UN climate talks in Glasgow this November, the prime minister recently announced that new petrol, diesel and hybrid cars will be banned from 2035 (ITV, 2020). Sales of coal and wet wood for wood burners, two of the most polluting heating fuels, will also be banned from 2021 (BBC, 2020).

Ironically, propellant-based inhalers used to treat asthma also cause pollution. Chris at The King’s Fund says: ‘The NHS is having a push on shifting to low-carbon inhalers. Some have a carbon footprint 18 times less than traditional gas-based inhalers.’

Will adds: ‘Substituting carbon-intensive drugs with less intensive ones could reduce the NHS England carbon footprint by 4%.’

However, dry-powder inhalers are not suitable for young children, who need a spacer to ensure the deposit reaches the lungs, not just their mouth. Dr Raja says: ‘For adults there is no question, but for children it would be the judgement of the clinician, parent and the child on “can they be trained to use that inhaler?”’

 

 

Protecting mental health

It may not be the first consequence of climate change you think of, but mental health can also be affected. ‘There is good evidence of the effect of rising temperatures on psychiatric admissions, particularly of people with dementia and psychosis,’ says psychotherapist Judith Anderson, a retired consultant psychiatrist and Climate Psychology Alliance (CPA) executive member.

‘For some people, there can be increased violence,’ she says. ‘There is also a sudden trauma with climate change-related floods where people are left homeless and children lose possessions – the most vulnerable will be affected most.’

Public Health England (PHE) looked at the mental health impact of flooding incidents on those whose lives were disrupted, and is sharing its findings with LAs to highlight the role of local preventions and interventions (PHE, 2020). Meanwhile, residents in Fairbourne, on the Welsh coast, are set to be the first UK climate refugees as sea levels rise (Wall, 2019).

Mental health is not only affected by a direct climatic event. As climate change intensifies, so too does eco-anxiety, says psychotherapist Caroline Hickman from the University of Bath, also a CPA executive member.

‘Eco-anxiety is directly linked to levels of awareness on the environmental crisis. Anxiety is often the first emotional response. What follows is often anger, fear, frustration then grief, disbelief and despair,’ she says.

‘Children and young people are more sensitive to eco-anxiety because it’s their future and they are incredibly tuned into injustice and the impact of climate change on biodiversity and animals.’

Caroline praises schools that teach children about climate change, adding that children must have space to express their feelings after learning the facts.

‘They need to be listened to and have their fears taken seriously. I’ve heard of children being taken to GPs and being prescribed anti-anxiety medication. That is saying to that child: “You should not feel the way you do and this is your individual problem.” Their response is actually an emotionally healthy, congruent response – it’s not an illness.’

Caroline is contributing to forthcoming Royal College of Psychiatrists guidance for parents and health professionals on eco-anxiety. She advises parents with concerned children to form local support groups, adding: ‘We need to talk to children sensibly and say: “Yes, this is scary, but there are things we can do, for example, we can reduce our plastic consumption, or we can raise money and send it to the koala bears.” ‘Ecological relationships are good for our mental health – planting vegetables and trees, creating bug hotels and wild spaces in the garden. But you can’t go straight to taking action. They need their feelings to be contained first.’

Judith adds: ‘Older adolescents are worrying if it’s worth going to school, or university or having children in future – that is a real issue for women in their 20s and 30s.’

Judith advises health professionals, including community practitioners (CPs), to be climate aware: ‘If you are not aware of the things your clients are, you won’t be able to validate what they’re feeling.’

She adds that professionals including CPs can draw on skills for helping families manage grief. ‘CPs will be able to relate to other situations where the grief does not go, like where someone discovers their children have the same genetic problem. The difference with climate change is it affects all of us.

‘The most important thing is that the children do not feel alone or they will feel worse. We know that children can be very resilient if somebody takes them seriously. We also need to create resilient communities to manage this.’

‘We need to start looking at climate change as a health opportunity. Prevention is always better than cure’


How are others doing it?

Sussex Community NHS Foundation Trust has a Care Without Carbon policy with speech and language therapists and community dieticians using electric bikes. Departments are encouraged to reuse office supplies, including furniture, and staff are encouraged to walk, cycle and use public transport. 

Care Without Carbon, 2020

Greater Manchester Health and Social Care Partnership has highlighted that 1200 early deaths in the region are caused by air pollution. It has introduced more public bus stops on main sites, discounted staff travel, extra cycle spaces and showers, and more electric vehicle charging points.  

Clean Air Greater Manchester, 2020; NHS England, 2020b

Raigmore Hospital, NHS Highland Trust, Scotland, switched from Desflurane to equally effective Sevoflurane anaesthetic gas (which is 60 times less polluting) in 2019, saving £73,000 a year.

McArdle, 2019

Great Ormond Street Hospital (GOSH) and Global Action Plan (GAP) developed the Clean Air Hospital Framework. GOSH also cut tonnes of plastic glove waste.

GAP, 2019; GOSH, 2019


Hand in hand

Ultimately the best way for healthcare to cut emissions is to keep patients healthier (Bawden, 2019).

Chris at The King’s Fund says: ‘Highlighting things that are good for the climate and good for health are obvious win-wins. Many social changes needed to achieve a low-carbon society benefit public health.’

Dr Richard Smith, chair of the UK Health Alliance on Climate Change, which represents all major health bodies and 650,000 UK healthcare professionals, agrees. ‘Health is the best way to engage people with the emergency because they’re directly affected and can act, making changes like using cars less, walking and cycling more, and eating less meat and more fruit and vegetables.’

Dr Smith continues: ‘Health professionals who work with children, teenagers and families have a unique opportunity to influence the next generation to develop attitudes and behaviours that are good for their health and the health of the planet.’

NHS Scotland has a campaign: Our NHS, Our People, Our Planet. Rebecca Campbell, specialty registrar in public health and co-chair of the Scottish Managed Sustainable Health Network, says: ‘There can be no good human health without good planetary health. It can be helpful to frame more sustainable choices by focusing on the co-benefits. This is the approach we are taking in Scotland.’

Will sums it up: ‘We need to start looking at climate change as a health opportunity. Prevention is always better than cure.’ And it goes beyond reducing environmental risks. He says: ‘More active lifestyles can help tackle some mental health conditions, which are becoming more prevalent in children and young people. Diet is another major opportunity – rates of obesity and diabetes in children are rising. More than one in five children starting primary school in this country are overweight or obese, and food production and consumption is also a big driver for climate change.

‘It’s generally children from poorer backgrounds that are most at risk [from the effects of climate change]. A prevention-based approach is key, but it needs to be focused on the most vulnerable [to be most effective].’

Dr Raja emphasises the importance of exercise such as parkruns: ‘You can walk, you can talk, you can run, and all those things have a great effect positively on the physical and mental health of patients – you see less obesity, less diabetes, chest problems and cancers. My job would be a lot easier if people were more physically active.’

It’s also about looking after yourself, and understanding we all need to take climate change and its health consequences seriously. Psychotherapist Judith says, ‘I tell adults you have to put your own oxygen mask on first – self-care is essential because it’s a long emergency.’ 

 


Resources 

Keep up to date with the latest on climate change and healthcare.  


References

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BBC. (2020) Wood burners: most polluting fuels to be banned in the home. See: bbc.co.uk/news/uk-51581817 (accessed 24 February 2020).

Beckwith et al. (2020) Reduced gray matter volume and cortical thickness associated with traffic-related air pollution in a longitudinally studied pediatric cohort. See:
https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0228092 (accessed 26 February 2020).

Care Without Carbon. (2020) Care without carbon. See: carewithoutcarbon.org/ (accessed 20 February 2020).

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Clean Air Greater Manchester (2020) Clean air plans. See: cleanairgm.com/clean-air-plans (Accessed 19 February 2020).

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ITV. (2019) Ban on new petrol and diesel cars brought forward to 2035 as UN talks launched. See: itv.com/news/2020-02-04/ban-on-new-petrol-and-diesel-cars-brought-forward-to-2035-as-un-talks-launched/ (accessed 20 February 2020).

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NHS England. (2020b) Boosting Healthy and Sustainable Travel in Manchester. See: https://www.england.nhs.uk/greenernhs/whats-already-happening/boosting-healthy-and-sustainable-travel-in-manchester/ (accessed 20 February 2020).

Oppenheim M. (2019) Ella Kissi-Debrah: Mother wins fight for new inquest into daughter’s death which she blames on air pollution. See: independent.co.uk/news/uk/home-news/ella-kissi-debrah-inquest-death-air-pollution-high-court-rosamund-a8896116.html (accessed 26 February 2020).

PHE. (2020) PHE press office. 

Scottish Government. (2020) Protecting Scotland's Future: the Government's Programme for Scotland 2019-2020. See: https://www.gov.scot/publications/protecting-scotlands-future-governments-programme-scotland-2019-20/pages/5/ (accessed 6 March).

Sustainable Development Unit. (2018) Areas of focus. See: sduhealth.org.uk/areas-of-focus (accessed 20 February 2020).

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