Feeling the Heat

FEELING THE HEAT

Healthcare is a big contributor to global warming, and climate change has significant health risks. RCSI alumni and staff tell us about the threat to human health, and steps that must be taken to avert further impact

This year, on World Health Day, the World Health Organization (WHO) shone a spotlight on the health of the planet and how it’s connected to human health. The WHO’s message was clear: our global population depends on biodiversity and the ecosystem for resources such as clean air and water, food and shelter. All of these come from the planet, and if we keep destroying and polluting the way we do, our health will be at risk.

Health risks associated with climate change include allergies, asthma and respiratory problems linked to air pollution; heat exposure, heatstroke and the increased incidence of mosquito and tick-borne diseases resulting from higher temperatures; and threats to cardiovascular and mental health. The pandemic has reminded us of the interconnection between animal, human and planetary health. If aggressive deforestation and the wanton use of fertilisers and pesticides continue, we will be creating an environment in which the barrier of protection between animal and human health will disappear, and we will be much more vulnerable to the emergence of new viruses and zoonotic diseases.

One of the shocking figures cited by the WHO is that each year there are 13 million premature deaths linked to environmental risk factors including climate change. Seven million of those – that’s 13 people every minute – die from diseases such as lung cancer, heart disease and stroke linked to toxic air, with pollution coming from the combustion of fossil fuels and burning of biomass. Rising temperatures and floods caused by climate change put two billion people around the world at risk of dengue fever, and two billion people lack safe drinking water, causing 829,000 people to die from diarrhoea every year.

The WHO says the transition to clean, renewable and affordable sources of energy has to happen quickly. Cities, currently designed around cars, must become liveable in terms of active transport in order to tackle noncommunicable diseases such as obesity, and there needs to be an increased focus on sustainable food systems, so we stop polluting our rivers and oceans via the way we produce food.

The WHO’s view is that this is all possible if the right political choices are made and we come together to support those who stand for the healthy choices and balance out the lobbying from those who seek to perpetuate the unhealthy choices for the planet that have got us into this situation.

The warnings from the WHO are stark, and there is an urgent need to reboot our societies to create better wellbeing. But in the face of fake news, attacks on science, and economies that need to be reimagined post pandemic, it can be hard for doctors as individuals to know how they can play their part.

One RCSI alumna who has tackled the issue of air pollution head on in her constituency of Klottey-Korle in Accra is Dr Zanetor Agyeman-Rawlings (Class of 2003) who practised as a GP in Ireland for ten years before returning home to Ghana, where she has been a member of the national parliament since 2017.

Dr Zanetor Agyeman-Rawlings (Class of 2003), Member of Parliament, Ghana.

In 2019 she spearheaded a project at the Osu night market in Accra. The long-established market serves fish and meat alongside popular dishes such as kenkey, rice, kelewele, fried yam, fufu, as well as porridge, and is visited by travellers, drivers and government officials. But cooking with inefficient cookstoves and smoking ovens was causing air pollution, and Dr Rawlings was aware of health issues being experienced by the women working in the market.

“They complained about the exposure to smoke and soot from the cooking,” she explains. “I knew one woman who had died as a result of long exposure and others who had developed chronic lung disease. The idea was to improve their quality of life as well as to make tangible the concept of their carbon footprint and incentivise them to reduce their carbon emissions. The added advantage was the fact that they would be spending less money on fuel which meant their profit margins would be bigger. Eighty per cent of the market women were on board, while the rest didn’t quite get it. We went ahead, and those who were interested got their stoves retro-fitted. By the time the project was over, the rest of the women were clamouring to be part of it!"

“In order to quantify the benefits, we measured the particulate emissions before and after, so it was possible to see a very tangible reduction in carbon emissions. It’s been a very successful project, which has made a huge impact on the lives of the women in the market by empowering them in economic terms, as well as having a positive impact on their health and on reducing their environmental impact. Climate change is usually so abstract but this project has made it tangible, they spend less money on fuel and so make a bigger profit.”

“THERE IS A DIRECT CORRELATION BETWEEN THE STATE OF THE ENVIRONMENT AND THE WELLBEING OF THE PEOPLE LIVING IN THAT ENVIRONMENT.”

Dr Rawlings is continuing her work on projects in her constituency and elsewhere in Ghana, where she hopes to tackle the issues of burning rubbish in municipal areas (against bye-laws, but it still happens), water pollution due to illegal mining, the use of landfill causing the leaching of chemicals into the water supply and flooding during periods of heavy rainfall due to poor planning and the dumping of plastic in the drains. She is also working to promote the recycling of plastics into building materials.

“I am drawn to projects showing the impact of climate change on health,” she says. “There is a direct correlation between the state of the environment and the wellbeing of the people living in that environment. For me with my medical training some of these things are so obvious, but the women at the market were really complaining and it was almost as if nobody was listening.”

Here in Ireland also, climate change is on the political agenda, as evidenced by recent disagreements between the parties in government about the proposed ban on burning turf.

“Often tradition and culture are used as excuses for destruction, but traditions and cultures change all the time. There is nothing good about cutting turf and burning it or selling it for gardening compost,” said climate campaigner George Monbiot in a recent interview. “Turf is among the most important global carbon stores. It’s absolutely critical as a water store as well. It sits at the heart of an absolutely crucial ecosystem. Burning it is quite similar to cutting down a rainforest to burn the wood...the benefit you get is in no way commensurate with the harm that you do.”

At RCSI, Professor Debbi Stanistreet, Associate Professor of Public Health, has for many years conducted research in the area of household air pollution in low-income economies and is currently leading a project in Malawi, The Smokeless Village, funded by Irish Aid. At RCSI she is involved in several initiatives related to climate change.

Professor Debbi Stanistreet, Associate Professor of Public Health, RCSI.

“Work is going on across the University,” she says, “and we stand behind all the estimates around the danger of global warming and the need to keep the level of warming to 1.5C degrees or lower compared to pre-industrial levels. That is quite accepted within the scientific community as the way forward.”

Professor Stanistreet acknowledges that for those of us who live in high income countries, the urgency of addressing climate change is not always so obvious as it is in low-income countries.

Traditional stoves can result in significant smoke and air pollution in the home.

“But it is becoming more obvious as we see what is happening with different weather events closer to home, for instance in Germany and the US last year. It is definitely not a far-off threat, it is an ongoing disaster and we are seeing people and environments all over the world endangered, even if it is not immediately on our doorstep. There is a definite need to act as soon as possible.”

Professor Stanistreet notes that the links between climate change and health are not always immediately recognised, and yet the impact on health is (and will be) extensive.

“Air pollution throughout the world exacerbates and possibly even causes non-communicable diseases, so that means we are seeing increases in coronary artery disease, chronic lung disease and COPD. With warmer temperatures we have seen direct deaths related to heat and dehydration, and airborne allergies triggering asthma. We are also seeing lots of chronic kidney disease of unknown origin, where workers in extreme temperatures in Latin America, Middle East and Africa are becoming very dehydrated and developing chronic kidney disease, which is fatal in countries where there is no access to dialysis.

“There is considerable air pollution in Ireland from multiple causes including traffic and burning of peat and biomass. In Dublin, pollution from traffic is a serious issue and in some areas nitrous oxide levels have been known to rise above WHO thresholds. That affects all of us – in terms of cataracts, small-for-date babies, the increased risk of dementia, and the harm to children’s cognitive abilities. It is a problem for everyone. So we need to address it at home as well as abroad.”

Another concerning issue is climate migration, and the impact it will have on stretched resources. “We are going to be looking at 200 million climate migrants by 2050,” Professor Stanistreet explains, “We can see the complex effects of migration as a result of the war in Ukraine, so when we look at the scale of what could happen, migration due to climate change would be on a much greater scale. This will place huge demands on health services and housing, and impact on mental health. Throughout the world we’ll be seeing food shortages because of the pressure on the amount of food that can be produced and also the quality of that food. When you have food insecurity you have higher food prices and that’s going to contribute very much to health inequalities. Where there are health inequalities, the better off will have some protection from the impact of climate change but those who are most vulnerable and marginalised won’t, whether here in Ireland or as seen already in Africa.

“There are implications for infectious diseases too. As people are displaced, the disease-carrying vectors we might traditionally associate with sub-Saharan Africa will begin a geographical shift north, so we’ll see patterns of malaria moving north as temperatures rise. And then there are all the mental health and social issues, and the violence associated with forced migration and the loss of livelihoods.”

Professor Stanistreet says it is RCSI’s responsibility to raise awareness of the impact of climate change on health, and to encourage medical students and doctors to understand what action they can take in terms of mitigation and, where required, adaptation.

“Most obviously,” she says, “they can respond to the clinical implications, by treating conditions such as heatstroke and dehydration on the frontline. But I would strongly advocate for the role of prevention too, by reducing our ecological footprint and trying to prevent the problem from occurring in the first place. We should not be starting at the point where we are dragging people out of the river but we should be preventing them from falling in in the first place and thereby reducing the pressure on the health service.

“An obvious example is the huge rise in childhood obesity in the last 30/40 years; there is a need for all to be involved in prevention. That can include lifestyle change and education, but also thinking about structural change and why people in some communities are more prone to obesity. We know it’s a disease associated with socio-economic status, and all clinicians should be involved in that through individual patient care, and tackling underlying causes.

“The second way is through patient education and empowerment. If we want to reduce disease progression, we must empower patients to take on a greater role in the management of their own health.”

Professor Stanistreet believes doctors must first engage with prevention and empowerment before changes are made to health service delivery, green energy use and sustainable buildings.

“Then in addition, we should start looking at service delivery, and at the impact of clinical decision-making on the environment,” she says. “Doctors need to follow clear evidence-based guidelines to streamline the way they run their service.

“Finally doctors need to think about the preferential use of the treatment options and available medical technology. In the operating theatre, how many single-use items do we use? In the 1980s there was a consumerist attitude that everything had to be throwaway, whereas now we associate single-use with being clean and sterile. But actually we were clean and sterile before we had single-use! We used items and we sterilised them and used them again. We also need to look at procurement – if something is made in India and shipped here, that has an environmental impact by virtue of its production, wrapping, and shipping. Can we look at our practices and think about re-use and sterilising, and learn lessons from looking at low-income countries where they don’t have the same throwaway culture? There is some evidence of no greater infection risk, and of less environmental impact. We need to look at lower-carbon models of care right the way through health service, and quality improvement through sustainable healthcare.”

Professor Stanistreet praises the good work being done by the HSE and Department of Health on buildings and energy use, but says progress in areas requiring clinical leadership is slower.

“Within hospitals they are developing ‘green teams’, but they need clinical leaders to come forward and push the agenda. In terms of sustainable healthcare, there are lessons to be learned from the UK, where they are further ahead.”

Among other initiatives in which RCSI is involved are The Net Zero Carbon Surgery Commission, looking at evidence in relation to green surgery, CHIME – Climate Health in Medical Education – a programme in the seven universities across Ireland including Queen’s, and a collaboration with the Institute of Sustainable Healthcare, where RCSI is acting as a beacon institution, working to embed sustainable healthcare in the curriculum. RCSI is also involved in research into safe surgery in Africa headed up by Professor Ruairi Brugha, and Paniwater, led by Professor Kevin McGuigan, focusing on clean drinking water.

“In terms of the medical curriculum, there is a lot going on in Ireland,” says Professor Stanistreet. “The Planetary Health Report Card is a medical student-led annual survey which started in North America, and evaluates universities on their approach to planetary health by grading them. It is a very good tool and universities have to sit up and take notice. At RCSI we’ve improved and are the top university in Ireland this year.”

RCSI is also working in parallel with Irish Doctors for the Environment (IDE) to develop learning outcomes for teaching planetary health and integrate different topics around climate change into the medical undergraduate curriculum.

IDE is a group which promotes climate change advocacy in healthcare, and includes members who are surgeons, hospital doctors, GPs, paediatricians and psychiatrists, alongside representatives from pharmacy and physiotherapy. IDE has eleven committee members and 14 group committee chairs, with 200 members in its main WhatsApp group and close to 1,000 subscribers to its newsletter.

“Climate change is affecting people’s health and healthcare workers are at the frontline of that, with COVID-19 being a perfect example,” explains RCSI alumna Dr Rachel MacCann (Class of 2016), Infectious Diseases SpR and ICAT Fellow at St Vincent’s University Hospital (SVUH). “We break down the work that needs to be done into different areas because we are conscious that our members are busy with work and study.

“Our air quality working group focuses on how air pollution is affecting people’s health – linking air quality to negative health outcomes is perhaps something that has not been talked about much in Ireland. Our active transport group advocates for health through active transport – using walking and cycling as a means of getting from A to B rather than having to enforce exercise, so people are improving their health while reducing carbon emissions. Another group, run by anaesthetists, looks at reducing emissions by adjusting the use of anaesthetic gases in surgery, and our direct action group looks to take part in protests – some of the fun stuff like school strikes and Extinction Rebellion.”

Dr Rachel MacCann (Class of 2016) Infectious Diseases SpR and ICAT Fellow, St Vincent’s University Hospital.

Dr MacCann explains that one of the biggest overall factors impacting health in Ireland is air quality.

“In the winter when you have greater cloud cover you tend to have higher levels of air pollution, which can lead to admissions to hospital for pneumonias and RTIs. It’s the most obvious link between health and climate as we live in more congested cities and people spend more time in their cars.

“But although we don’t experience many extreme weather events in Ireland, last year during the heatwave we did see a spike in ED attendances, and that’s something that’s been seen before in previous heatwaves. As we see more weather extremes, looking back over the past few years we do see a correlation between those and ED admissions, cardiovascular disease-related admissions and stroke. One of our members, geriatrician Dr Colm Byrne, is doing research on the impact of air quality on stroke.”

And what about the changes that can be made within healthcare itself to lessen its impact on climate change? Dr MacCann says that with hospitals run by different groups, progress can be slow.

“We have a sustainable healthcare working group so we are building green networks within hospitals and I have been doing that with a group in SVUH. We have made good progress. e biggest challenge is getting buy-in from the top down on di erent projects.

“Our inhaler recycling programme was a huge success, and we did a fascinating audit in the endoscopy unit which showed that 70% of the waste in one of the bins could have been recycled, so there are lots of opportunities to change. What we are desperately trying to do is get this ingrained at the CEO and hospital board levels, and that’s where we’d like to see more work in the coming years. It’s the collective effort that will make the great overarching change.

“THE BIGGEST CHALLENGE IS GETTING BUY-IN FROM THE TOP DOWN ON DIFFERENT PROJECTS.”

“The HSE has appointed sustainability and energy officers through the different regions and we have been working with them here in SVUH and they are great. They attend our committee meetings and are seeking out projects on which they can work with us. Energy is low-hanging fruit, as it accounts for 46% of CO2 emissions from Irish healthcare settings. Making simple changes with the energy use in hospitals could make a huge difference. Changing lightbulbs to LED, changing the use of machinery – for instance in the labs they keep the hoods on overnight, but they don’t need to do that and it uses a lot of energy – replacing old equipment with newer equipment that runs more efficiently, turning off lights and computers … These are all very simple things that don’t take a huge amount of systemic change, but it does take someone to coordinate them.”

For Dr MacCann and her colleagues in IDE, there are worries around how the Irish healthcare system will respond to increased pressures as the result of climate change or another pandemic.

“There are two ways of looking at a doomsday scenario,” she says. “We are already working in a system that’s bursting at the seams, and we are very reactive as a healthcare body in Ireland, as we have seen with COVID-19. When there is a crisis, it’s all about fixing it up and trying to get through the crisis period, but we’re not making systemic changes to be resilient. Because of that, I don’t know if the healthcare system is prepared to deal with any increased pressures from climate change or another pandemic. Will it be able to cope again with the negative health impacts, as routine operations are cancelled, waiting lists get longer, and there is more unequal access to healthcare, and these factors impact the pressure cooker in which we work? The impact can be seen in poorer health outcomes in terms of respiratory diseases, and when people have difficulty in accessing affordable housing they may live in either worse housing conditions or highly dense areas and that leads to different health outcomes too. I think the broad socio-economic impact on healthcare is something we probably will not have seen before.

“Another interesting issue is the effect on mental health, which is not as often talked about but is one of the most broad-reaching impacts of climate change. Fear and anxiety related to land loss, to farmers having to adjust their daily working lives and their income, to fishermen losing their jobs are some of the negative mental impacts from the consequences of climate change. They are subtle but everything is interlinked.”

Food in hospitals is another topic on IDE’s agenda. “One of the biggest types of waste in healthcare is food,” says Dr MacCann, “and ften you see patients don’t finish meals or that food is discarded in the canteen. We have been trying to make changes, and one of our working groups is looking at sustainable diets. They are advocating for the food pyramid to include more plant-based options, as it does in Canada, because nutritious and sustainable meals go hand in hand, and many hospitals are not delivering on either. There is lots of room for improvement in Irish hospitals and other healthcare institutions.”

But right at the top of IDE’s priority list is policy change. “The government’s climate change action plan published in 2019 did use a lot of our suggestions and a lot of our work, though whether it is implemented or not remains to be seen. We have asked the government to include climate change and healthcare in all of its policies,” says Dr MacCann.

“IDE is a great, passionate group of people, we are doing this in our spare time, I wonder what we could achieve if we were doing it fulltime! It speaks to human nature what lengths people are prepared to go to in the context of climate change and human health.”

In terms of the way forward for RCSI, Professor Stanistreet points to the UN’s 17 Sustainable Development Goals. www.undp.org/sustainable-developmentgoals. “We recognise that we need to take action on all of them, including most importantly the first one, which focuses on alleviation of poverty if we are to achieve global health. The ultimate problem is massive inequality.” ■