Patrick_Kirsten_headshotCrop4Kirsten Patrick is Deputy Editor at CMAJ


This morning I swam at my local YMCA with Canada’s Minister for the Environment and Climate Change. Minister McKenna and I belong to the same Masters Swim Club. I don’t see her as much as I used to….well, I see a great many photos of her on my Twitter and Facebook feeds, but I don’t see her much in the pool. She’s a busy lady and last week she attended the ceremony for the signing of the Paris Climate Change Agreement on behalf of Canada at UN Headquarters in New York. It was Earth Day – 22 April – and 175 Parties (174 countries and the European Union) signed up to the agreement that day. This number of signatories far exceeded the historical record for first-day signatures to an international agreement. It was joyous occasion in which Canada could and did participate with pride. Like a wedding on a perfect spring day.

But just as a wedding is an ideal thing and marriage a real thing, and confusing the ideal with the real never goes unpunished (with apologies to Goethe), so we must not think that climate change is sorted now that all our countries appear to have drunk the cool aid. The agreement still has to be ratified by individual governments, and in order for that to happen ….well, frankly – and especially when it comes to the U.S. Senate – the economic case for investing in policies that will reduce greenhouse gas emissions usually needs to be made. Convincingly. And then these nearly 180 countries have to enact the agreements, meet the targets and stay in the happy family of signatories. And agree some more in years to come. Personally I’m a fan of taking out a little insurance that’s closer to home, through personal actions like not owning a car; through supporting local initiatives; and through advocacy.

In early 2015 I wrote a CMAJ editorial about what physicians can and should do to influence action on climate change. Editorials are only 700 words so I had to choose my angle carefully. I chose to point out that physicians are powerful advocates for change, skilled at weaving public health interventions into daily practice, and therefore able to work with the global movement to combat climate change while doing their regular jobs. As subsequently outlined in full detail by Watts and colleagues of the Lancet Commission on Health and Climate Change in their June 2015 article, “Health and climate change: policy responses to protect public health,” physicians can align themselves with emerging policies, support other sectors, and work with patients at the individual level, to influence behavior change that will simultaneously reduce carbon emissions and improve population health. And why should we? Because “many mitigation and adaptation responses to climate change are no-regret options [that will also] lead to direct reductions in the burden of ill-health.”

Unsurprisingly, I received some negative responses to my editorial. One letter-writer suggested that the editorial “was most disappointing in that it ventured into the realm of agitprop and thus was out of character for a CMAJ article…[and]…as inappropriate in the journal as a partisan political party advertisement. The matter is totally beyond the scope of the CMAJ and should be left to the judgement and conscience of the individual physician.”

The World Health Organization would seem to disagree. The WHO (despite pursuing some parallel goals for a couple of decades) was late to the climate science and negotiations parties. However, in the latter part of the last decade WHO launched its series of health impact assessments “Health in the green economy“, which commented on the recommendations of the 2007 (4th) IPCC report and highlighted missed opportunities to greatly improve population health through careful consideration of health impacts of climate change mitigation policies. In 2013, at the 19th UN Framework Convention on climate change conference of parties (COP19), the WHO sent a large delegation to talk about the health co-benefits of some strategies to mitigate and adapt to climate change.

Indoor and outdoor air pollution is increasingly a big contributor to deaths and disease burden globally. Air pollution and global warming do not have the same causes (particulate matter in the one case and greenhouse gases – mainly CO2 – in the other) as another letter-writer pointed out [accusing me of conflating the issues of air pollution and climate change although I did not mention air pollution – the subject of subsequent editorial]. However, when it comes to fossil fuels there is really no carbon dioxide without particulate matter. Some fuels are ‘cleaner’ than others, yes, but at the end of the day, reducing greenhouse gas emissions from industry and the transport is likely is likely to reduce air pollution too so why not back climate change strategies for their knock-on health co-benefits?

On March 15th this year the WHO published its 2nd global assessment of the burden of disease from environmental risks. It’s an exhaustive crunch of strong and not-so-strong evidence that explores the relationship between environmental risks, including risks linked to climate change, and burden of disease. More than 100 diseases and injuries are covered. “23% of global deaths and 26% of deaths among children under five [were] due to modifiable environmental factors [in 2012]. Heading this list are stroke, ischaemic heart disease, diarrhoea and cancers.” And we are not talking about deaths attributable to tobacco smoking, alcohol use or diabetes or other known (non-environmental) causes, only to “all the physical, chemical and biological factors external to a person, and all related behaviours, but excluding those natural environments that cannot reasonably be modified.”

23% of deaths could potentially be avoided if environmental hazards (including, crucially, indoor and outdoor air pollution) were eliminated. That’s not a small proportion. They won’t all be eliminated through enactment of the many agreements that make up the Paris Agreement; I’m not suggesting that. But as emphasised in the preface to the recent WHO assessment report, the health sector really needs to work WITH those who are working on climate change policies. “Acting together on coordinated health, environment and development policies can strengthen and sustain improvements to human well-being and quality of life via multiple social and economic co-benefits. Repositioning the health sector to work more intersectorally on effective preventive health policies is the way forward to address environmental causes of disease and injury, and, ultimately, in transforming the global burden of disease.”

Surely working with other sectors to improve population health is something we in the medical profession can ALL get behind, whether we agree on the importance of human activity in causing climate change or not.