General Practice and Climate

Change

Dermot Coffey

GP, Christchurch

The Lancet commission on Health and Climate Change

2009; 2015

Lancet Countdown 2018

2009- “Climate change is the biggest global health threat of the 21st century”

2015- “Tackling climate change could be the greatest global health

opportunity of the 21st century”

2018- “The voice of the health profession is essential in driving forward

progress on climate change and realising the health benefits of this response”

Brief overview/IPCC

IPCC 2018; Global warming of 1.5°C

NZ emissions context

NZ emissions over time.http://www.mfe.govt.nz/publications/climate-change/new-zealands-greenhouse-gas-inventory-1990-2017-snapshot

Political situation in NZ

Zero Carbon Bill

Health sector change- little focus on role of primary care, piecemeal with

some DHBs very active

Minister expectations for DHBs to “implement a strong response to climate

change…”- Primary Care needs to be part of this

Zero Carbon Bill/Climate Change

Response Amendment Bill

Completing Select Committee process

Experience from similar legislation in UK

To give a clear guide to meet NZ’s obligations under the Paris Agreement 2015

Global temp rise <2°C and aim for <1.5°C

Strengthen ability to deal with impacts

Financial flows support low-emission and resilient economies

Zero Carbon Bill

Set a new greenhouse gas emissions reduction target to:

reduce all greenhouse gases (except biogenic methane) to net zero by 2050

reduce emissions of biogenic methane within the range of 24–47 per cent

below 2017 levels by 2050 including to 10 per cent below 2017 levels by 2030.

Set a series of emissions budgets to act as stepping stones towards the long-

term target.

Require the Government to develop and implement policies for climate

change adaptation and mitigation.

Establish a new, independent Climate Change Commission to provide expert

advice and monitoring to help keep successive governments on track to

meeting long-term goals.

Zero Carbon Bill- problems

Health, well-being and equity not embedded within Bill

Te Tiriti o Waitangi principles not specifically mentioned

Too slow- stronger targets needed

Biogenic methane reductions too low

Lack of clarity regarding measures if targets not met

Lack of accountability of private sector

Lack of leadership

Healthcare emissions

• Data from the NHS’s Sustainable

Development Unit website

www.sduhealth.org.uk

• Healthcare sector responsible for about

5% of NZ’s total emissions

Procurement emissions

Procurement of

pharmaceuticals and medical

equipment under Pharmac

control in NZ

2014–15 Financial Year

Lifecycle assessment of Australia’s health-care system

$161·6 billion spent on health care

CO2e emissions of about 35 772 kilotonnes

Health effects

Heatwaves, drought, flooding

Displacement- sea level rise, change in farming practices

New diseases

Psychological

Role of NZ in Pacific- diseases, climate refugees

Co-benefits of mitigation

Dietary

Active transport

All the problems with private car- air pollution, noise pollution,

neighbourhood severance

Intensive farming- water pollution, nitrates

Mitigation of the adverse effects

Economic- Stern report

LESS MEAT (and dairy)

MORE PLANTS

55% lower

GHG emissions2

1. Steinfeld H et al. Livestock’s Long Shadow: Environmental Issues and Options. FAO of the UN; 2006.2. Tilman and Clark. Nature 2014 Nov 27;515(7528):518-22

GLOBAL GREENHOUSE GAS EMISSIONS (GHGe)

ANIMALS 20%1

Active Transport

Estimate in inactive populations, 10% of all cases of premature mortality is caused by physical inactivity ¹

Recent UK study over 5 years showed massive health benefits of active commuting particularly of cycling- 40% reduction in all-cause mortality, 45% reduction in cancer incidence- backing up previous studies ²

Shifting even 5% of short urban trips in NZ to active transport would save an estimated 116 lives per year due to increased physical activity ³

¹ Lee, I-Min et al. Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy The Lancet , Volume 380 , Issue 9838 , 219 – 229

² Gill JM, Celis-Morales CA et al. Association between active commuting and incident cardiovascular disease, cancer, and mortality: prospective cohort study. BMJ 2017;357:j1456

³ Lindsay, G., Macmillan, A., Woodward, A. (2011). Moving urban trips from cars to bicycles: impact on health and emissions. Australian and New Zealand Journal of Public Health, 35:54–60.

Household Transport

Survey

Ministry of Transport

Average trip length for drivers and passengers is 9km

80% of all trips are as a driver or passenger

Active transport

In Auckland estimated that each dollar spend on cycling infrastructure would generate savings of $6-$20 primarily from health benefits of reducing physical inactivity¹

Electric and low emissions vehicles are only a small part of the solution

Minimal active transport benefit

Particulate air pollution from vehicles only halved

Current funding

Active transport <2%

Public transport 13%

¹ Macmillan A, Connor J, Witten K, Kearns A, Rees D,& Woodward A. (2014).The societal costs and benefits of commuter bicycling: Simulating the effects of specific policies using system dynamics modelling Environmental Health Perspectives,122(4)

Air pollution

Responsible for estimated 1175 premature deaths/year in NZ ¹

Main sources

Wood & Coal fire- 655 premature deaths/year

Motor Vehicles- 256 premature deaths/year

¹ Kuschel G, Metcalfe J, Wilton E, Guria J, Hales S, Rolfe K, et al. 2012. Updated Health and Air Pollution in New Zealand

Study. Volume 1: Summary report. Prepared by Emission Impossible and others for Health Research Council of New

Zealand, Ministry of Transport, Ministry for the Environment, and NZ Transport Agency

Other co-benefits

Housing

Insulation

2:1 benefit:cost mainly due to health benefits ¹

Psychological

Full range of psychological disorders

?worse in younger people

Solastalgia- mental or existential distress due to environmental change

¹ Howden-Chapman P, Matheson A, Crane J et al. Effect of insulating existing houses on health inequality: cluster randomised study in the community. BMJ 2007;334:460

Economic benefit

Stern review 2006

Benefits outweigh costs

Transition to low carbon economy is feasible and brings both challenges and

opportunities

Impacts of climate change are not evenly distributed

Called for a proper price for carbon- taxation, trading or regulation

IPCC assessments 2007 & 2014 backed up

Our role

Personal emissions

Work/Practice emissions

Role of the College

Our wider role as healthcare advocates

Personal

Fly less

Drive less

Eat less meat

Divest

Anecdote personal vs systemic factors

Divest

Long history e.g. apartheid-era SA, tobacco

Kiwisaver

MAS

Booster SRI growth

Superlife Ethica

Our Practices

“Greening General Practice” ¹

Should it be part of Quality Standards?

Nothing in current Foundation/Cornerstone

Nothing in the new Quality Standards being piloted

Role showing social leadership

¹ oldgp16.rnzcgp.org.nz/assets/New-website/Dashboard/Resources/Guides-and-modules/Greeninggeneralpracticeweb2016.pdf

Practice points

Transport

Energy use

Procurement

Drugs

CME

Pharmaceutical use example- inhaler use

Metered dose vs dry powder inhalers

HFCs in MDIs give 500g eqCO2 per dose/2 puffs (vs 20g for DPIs)= 5km in a

Toyota Corolla (¬96g/km- NZTA)

4% of total NHS emissions ¹ (NHS longterm plan)- 70% inhalers are MDI

Preferentially start MDIs, switch, reduce overprescription, improve technique

and compliance with preventers, recover and recycle used inhalers²

² Greeninhaler.org

Procurement

Under control of Pharmac

A need for full life Enviromental cost of pharmaceuticals and equipment to be

taken into account.

Equipment- likely to increase the use of reuseable equipment in NZ

AUCKLAND → COPENHAGEN

40,000 km

DUNEDIN → ROTORUA

3,300 km

1. Prioritise local (NZ) meetings2. Combine CME with leisure travel3. Fly economy class4. Videoconference

https://calculators.enviro-mark.com/public?calculator=travel

RNZCGP

Slow to acknowledge or take any leadership in advocating for a proper

response to climate change

Position statement 2016 ¹ with recommendations for the College and GPs but

little or no concrete action since

Well behind other professional colleges (incl RACP, RACS) in terms of action

and advocacy

WONCA

¹ oldgp16.rnzcgp.org.nz/assets/New-website/Advocacy/Position-Statements/2016.12.1-RNZCGP-Position-Statement-Climate-Change-

Health-GP-in-NZ-and-Pacific.pdf

WONCA

Declaration calling for family doctors of the world to act on planetary health ¹

Learn, communicate, prepare, respond and advise

Lead by example

Advocate

WONCA Asia-Pacific Conference Auckland Apr 2020

¹ www.wonca.net/site/DefaultSite/filesystem/documents/Groups/Environment/2019%20Planetary%20health.pdf

RNZCGP

Sign OraTaiao call to action

Run as a carbon neutral business- CEMARS is a system used commonly

including by some DHBs

Clear directives about low-carbon principles and environmental sustainability

to GPs

Resources for patient education

Wider advocacy?

Our most important role?

Ethically as doctors we have an obligation to actively advocate.

Lack of opposition is not enough

Virchow: “Medicine is a social science, and politics is nothing else but

medicine on a large scale...the physicians are the natural attorneys of the

poor, and social problems fall to a large extent within their jurisdiction”

NZMA Code of Ethics 2014

Principle 10: “Accept a responsibility to assist in the protection and

improvement of the health of the community.”

Recommendation: “Doctors should accept a share of the profession’s

responsibility toward society in matters relating to the health and safety of

the public, health promotion and education, and legislation affecting the

health or well being of the community”

Recommendation: “Doctors have a role in ongoing efforts to achieve health

equity”

Advocacy for GPs

Unique position- dispersed group with often diverse views

Embedded within a community and see first hand effects of climate

change and mitigation on communities

Role to advocate locally

Direct experience of social contributers to health

Less beholden to an organisation and forced to “toe the party line”

Fragmented nature can make group action and systemic change

difficult

How

Any way you can. Join up! OraTaiao.org.nz

Be aware of what is happening locally esp GPs

Put pressure on our DHBs, PHOs, representative bodies and Prof Colleges,

Pharmac

Advocate to your local and national politicians- write, email, visit offices,

formally submit on proposals

Climate change is all encompassing- pick a few areas where you feel most

comfortable and where you feel the biggest difference can be made.

If advocating as a physician, always fall back on the effects on people’s health

and keep it evidence-based.

www.orataiao.org.nzwww.facebook.com/OraTaiao@OraTaiao#climatehealth

1. Demonstrate leadership in achieving a climate-

resilient net zero emissions health sector

2. Act for a just transition to a climate-resilient net

zero emissions Aotearoa/NZ that improves health

and achieves equity

3. Add our unique health and equity expertise to

urgent global climate action

Building a national coalition

Emerging activisms

43