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Will we tackle our century’s defining threat?

By Mindo - 23rd Nov 2020

With the world focused on Covid-19, are the looming health consequences of climate change receiving sufficient attention? David Lynch asks experts for their views

Understandably the rapid spread of the pandemic and the resulting impact on patients has been front and centre for the global health community since early in the year.

However, there is another major challenge that the World Health Organisation (WHO) has described as possibly “the defining public health threat of the 21st Century”. Experts have long warned of the negative health impacts from climate change. Doctors in Ireland and abroad continue to grapple with the dilemmas it poses, despite the pressing needs of the pandemic.

In late January, the WHO declared Covid-19 a public health emergency of international concern (PHEIC). Whether the WHO should take a similar step with climate change is a question recently raised by doctors and public health experts (see panel).

Although it has fallen short of declaring a PHEIC, the WHO warns that climate change “threatens the essential ingredients of good health” – clean air, safe drinking water, nutritious food supply, and safe shelter. The Organisation said it has “the potential to undermine decades of progress in global health”.

“Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress alone,” the WHO estimates, adding that the direct financial damage could be two to four billion US dollars per year by 2030.

Climate Change Adaptation Plan

Both in 2019 and this year, Ireland has witnessed some significant health policy developments regarding climate change. However, the pandemic has slowed progress.

Last year, then Minister for Health Simon Harris announced a public consultation on the impacts of climate change upon the health sector. The consultation focused on scenarios where the environment and health outcomes meet, including UV/sun exposure, air pollution, windstorms, heatwaves, high precipitation/flooding, and extreme cold snaps.

The consultation fed into the Department’s Climate Change Adaptation Plan for the health sector (2019-2024). This plan applies to the Department itself, the HSE and all relevant external organisations providing services on behalf of the HSE and non-HSE health sector services, including general practice, private hospitals and nursing homes.

“The plan identifies the main climate change-related impacts and risks we expect to face in the health sector in the coming years and identifies concrete measures we can take to build resilience and to reduce our vulnerabilities,” according to the Department.

However, the Department spokesperson admitted that the pandemic has already slowed progress. “The imperative to respond to the Covid-19 pandemic, and the scale of the commitment on the part of the Department to this work, has had an impact on other areas of the Department’s work, including work on the implementation of the climate change adaptation plan,” the spokesperson told the Medical Independent (MI).

“The Department’s Statement of Strategy 2021-23, to be published before the end of the year and to be implemented from the new year, will set down how the Department intends to advance climate change-related work.”

To some fanfare, the Climate Action and Low Carbon Development (Amendment) Bill was published in October and was described by the Government as “an ambitious piece of legislation”.

It commits the State to move to a “climate resilient and climate neutral economy by 2050”. “The Programme for Government commits to a 7 per cent average yearly reduction in overall greenhouse gas emissions over the next decade, and to achieving net zero emissions by 2050,” according to the Department of the Environment, Climate and Communications.

“The Bill brings in a system of five-year economy-wide carbon budgets, which will outline a ceiling for total greenhouse gas emissions.”

Dr Rachel MacCann, Infectious Diseases Registrar in St Vincent’s University Hospital Dublin and Operations Officer for Irish Doctors for the Environment (IDE), told MI that positives aspects of the Bill included the “decision to strengthen the climate change advisory council by providing it with statutory powers”.

Among other things, the council will prepare the fiveyear economy-wide carbon budgets. Dr MacCann said strengthening of the council “is a necessary step to ensure that this current and all future governments abide by the commitment to make Ireland climate resilient and ensure a climate neutral economy is achieved by 2050”.

In terms of criticisms of the Bill, the IDE would have preferred the inclusion of stronger targets “and it should mention the UN sustainable development goals for some of these targets”. “The language used has been non-committal in parts, outlining that the Government has only to pursue the 2050 objective, not achieve it and the fact that carbon budgets do not have to be consistent with the 2050 objective.”

Dr MacCann noted that these issues have been raised by other members of Government and environmental representatives.

Dr Rachel MacCann

One specific action the IDE would like to see is the inclusion of healthcare professionals on the climate change advisory council. Dr MacCann said the council is composed of members from specialist areas, “which is brilliant, however, healthcare specialists have not been included yet in this group.”

“Climate change and health are interlinked and so it would be pertinent to include public health professionals and individuals with expertise on environmental health. We (IDE) are part of the Climate Health Alliance who are advocating that health professionals be included.”

Pandemic impact

Some observers have raised concerns that the pandemic may lead to less focus on climate change. However, Dr MacCann believes the impact of the pandemic on environmental health is “multi-factorial”.

“It has created public awareness about the link between environment and health, which is a positive thing,” she said. “For the first time, public conversations about our health and our environment have been at the forefront of discussion and have led to conversations about air pollution, active transport as well as mental health.

“We are realising that our health, our livelihoods and our environment are all interconnected and we have an opportunity to make long-lasting changes to the way we think about these interlinked factors.” Environmental health is not merely about some future moment, it is about issues that affect patients today.

In August, researchers from the RCSI University of Medicine and Health Sciences published a report that found that air pollution in the winter is associated with more hospitalisations for all strokes in Dublin.

During winter months in Ireland, particularly in Dublin, higher levels of fine particles, coarse particles, sulphur dioxide and nitrogen dioxide are found in the air. The sources of these are solid fuel burning, such as coal, peat, and wood, as well as road traffic – especially diesel engines. After accounting for other variables, such as temperature, humidity, day of the week and time, the researchers found that there was a statistically significant rise in the number of hospitalisations for strokes in Dublin zero to two days after a rise in air pollution.

According to the RCSI, the study marks the first time there has been a link demonstrated between short-term air pollution and stroke in Ireland. Has the pandemic and the public health restrictions had an impact on air quality and other environmental issues?

“Certainly there have been temporary improvements in air quality due to the lockdown,” Dr Colm Byrne, Clinical Lecturer in the RCSI Department of Geriatric and Stroke Medicine and the lead author of the study, told MI.

Climate change and health are interlinked and so it would be pertinent to include public health professionals and individuals with expertise on environmental health

“Looking at the Environmental Protection Agency’s air quality in Ireland report from 2019 we were in breach of air quality standards at St John’s Road near Heuston Station in Dublin but because of a reduction in traffic levels during lockdown we will probably be compliant this year despite not actually making any substantive improvements at that location.”

In terms of the broader influence of the pandemic on cycling infrastructure and other forms of active transport, Dr Byrne outlined some mixed trends. “I think that some local authorities have started to make improvements to cycling infrastructure, eg, DLRCC [Dún Laoghaire-Rathdown County Council] have made some great strides in Blackrock, Dundrum and along the coastal cycling route,” said Dr Byrne, who is also an IDE member.

Dr Colm Byrne

“But the lockdown has also coincided with a change in Government policy towards active transport so it’s hard to know if it is Covid-related or related to improved funding at national level.

“Nationally, I think it is great that there has been emphasis given to active transport in the Programme for Government, but there are questions about how skilled the local authorities are going to be in terms of implementing the infrastructure required.

“I think there needs to be a focus on training local authorities in how to design active travel, for example to look at the Netherlands or Denmark, before spending large amounts of money on infrastructure, otherwise it may end up being ineffectual.”

HSE workforce

When asked about specific actions that health authorities can do to promote active transport, Dr Byrne says they should look to their own workforce first. “I think the main thing the HSE could do is to promote active transport amongst its employees,” he said.

“Too many people drive when they could cycle, walk or get public transport. Most of our hospitals have inadequate provision for cycle parking, changing facilities etc and that is where we could definitely make improvements.

“Also there are little things like you receive a much higher mileage rate from the HSE if you drive rather than cycle as part of your job. “Also the HSE, Department of Health and professional bodies need to encourage cycling to both patients and staff. We need to set an example to patients. Additionally cycling can enable independence, especially people who have joint problems or mobility issues.”

While many individual doctors within the IDE and international organisations are active on climate change and environmental issues, the need for a greater focus in educational institutions has been raised.

“Public and global health training institutions should be giving more prominence to climate and other environmental changes in their curricula,” Prof Andy Haines, London School of Hygiene and Tropical Medicine, UK, told MI. Prof Haines was one of the authors of a March paper published in the BMJ titled ‘The health case for urgent action on climate change’.

“There is growing demand from medical and nursing students to cover the topic in their courses,” he said. “The curriculum is already very crowded so the two options are to have more standalone educational events on the topic or to integrate it into medical and nursing specialties – probably both are needed depending on the context.” In Ireland, the IDE has a working group looking at the question of including climate change in the medical curriculum.

“Our members Dr Ola Løkken Nordrum and Dr Sadhbh Lee have been liaising with medical schools in Ireland to develop a framework for its inclusion in the medical curriculum,” Dr MacCann told this newspaper.

Confronting ‘the tragedy of the horizon’

In the early weeks of the pandemic, the BMJ published a paper titled ‘WHO should declare climate change a public health emergency’. However, would a declaration of climate change as a public health emergency of international concern (PHEIC) carry much more than symbolic value?

“This is the most common question and counter-argument that I get from people who have read the paper,” Dr Andrew Harmer (PhD), Senior Lecturer in Global Health Policy at the Centre for Global Public Health at Queen Mary University of London, UK, and co-author of the BMJ March paper told MI.

“The answer to that lies with us… I guess. If we, and I’m not very good at this to be honest, generate enough interest in an idea and then use that interest to pressure an organisation, then it might change as a consequence.”

He added that the “aim of our article was to sow seeds”. “We try to argue how climate change could satisfy the conditions written into the IHR [International Health Regulations].

Dr Andrew Harmer

There is also heightened interest in revising the IHR as a consequence of the pandemic, so now might be a good time to try to focus attention on climate change and encourage thinking about the PHEIC in broader terms.”

Would declaring climate change as a PHEIC be a ‘one shot’ option for WHO? “Maybe,” according to Dr Harmer. “Would it be issued and then forgotten, with minimal value? Worse, what if it were issued at the wrong moment, thus losing its impact for further down the line when it may have had more impact? “I don’t know. I think the symbolic value of declaring climate change a PHEIC could be high, but it would have to be coordinated with other heads of environmental organisations.”

Others have argued that declaring climate change a PHEIC may dilute its impact for infectious diseases, he noted. “That may be true, but it assumes that PHEIC is significant; that member states listen and react to it.”

What is the main reason that the WHO has not declared climate change a PHEIC before now? “Money,” said Dr Harmer. “It has no dedicated budget for its work on climate change. Imagine that! The leading international public health organisation has no budget line for climate change. It focuses on air pollution and nods at the other aspects of climate change as best it can.”

With the current pandemic still raging across the globe, is there a risk that climate change may be further relegated from the global health agenda. “Yes, of course, why wouldn’t it?” said Dr Harmer. “Climate change suffers from what is called ‘the tragedy of the horizon’, ie, the consequences are beyond the vision of the current generation. This makes it very difficult to mobilise action now.

“The pandemic is right before our eyes, making it impossible to ignore. Bringing climate change back on our collective radar will be difficult, and we don’t have time to lose.

“My hope, fundamentally, is that the challenge of climate change can be brought back to centre stage. We need an international champion – name me one international organisation that is leading the climate change response? It’s difficult, right?

“WHO should lead the response. Health and climate change are a very effective way of framing the crisis we are facing. But… the organisation needs more money.

“And it needs a leader to take the issue seriously, who recognises the significance of the challenge, and who is prepared to re-orient the organisation towards this challenge. Climate change will impact all aspects of our health – it’s starting to do that now in many parts of the world, and that will just spread.

“Now is the time for the WHO to take climate change seriously. It should start by declaring climate change a public health emergency, because that is exactly what it is.

“Maybe being tied to the PHEIC legal instrument isn’t the most effective way to begin a climate change/public health strategy – I’m unclear in my mind about that.

“But the organisation has to take a lead somehow. It could make a bold commitment next year in Glasgow [at the 2021 United Nations Climate Change Conference]; it could make a formal declaration even if it doesn’t actually invoke the IHR [International Health Regulations].

“It could develop a strategy that goes beyond air pollution. Its relative silence on the issue of climate change is disappointing. On this issue, it’s failing in its public health mandate, in my opinion.”

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