Introduction to planetary health in primary care

Please note: This is the first article in a planned series on Planetary Health. Subsequent articles will explore the other aspects of the framework discussed in this article.

Author

Dr. Ilona Hale MD, FCFP (biography and disclosures)

Disclosures: Received honoraria from Divisions of Family Practice, Cascades Canada, Therapeutics Initiatives, Health Quality BC, Interior Health Authority, RCCBC, UBC, Alberta Pharmacists’ Association, and UBC Sauder School of Business Physician Leadership Program. None of these have influenced the information in the article or represent any potential conflict of interest. Received funding from Interior Health, Health Research BC, RCCBC, and UBC Department of Family Medicine. These grants were for work unrelated to the current article. Received sessional support for creating the Planetary Health in Primary Care Toolkit from the Division of Family Practice. Mitigating potential bias: Recommendations are consistent with Choosing Wisely and other standard practice guidelines.

What I did before

For as long as I can remember, I have considered myself an environmentalist — standing up for old-growth forests and keeping my personal footprint as small as possible — but I rarely allowed my environmental values to cross over into my clinical work as a family physician. In medicine, the environment has always been viewed as something peripheral to our core mission of treating sick patients, and until recently, there has been relatively little interest from within the medical community. Although many health-care providers are disturbed by the extent of medical waste, the unspoken assumption has been that this is a necessary by-product of high-quality medical care. Producers of single-use medical devices, new tests, and treatments have led us and patients to believe that more is always better and safer — a sign of medical progress.

The little education we received in school on environmental issues was focused on public health aspects such as air and water pollution. Efforts towards environmental stewardship within health-care facilities mimic personal actions and have generally been limited to energy efficiency initiatives, active transport, recycling, and eliminating toxic health products like mercury.

For many years, I failed to recognize the unique potential I had to make a difference to the environment as a clinician, from within my own practice.

What changed my practice

In 2009, the Lancet Planetary Health Commission declared climate change to be the greatest threat to health of the 21^st century.¹ Increasingly frequent forest fires, floods, and heat domes have made it abundantly clear: in order to have a healthy population, we need a healthy environment including clean air, clean water, and a stable climate. Environmental issues are health issues. We are witnessing a frightening glimpse of what is to come. Climate change increases demand for health-care resources through increasing air pollution, climate events, and infectious diseases. At the same time, system capacity is reduced due to evacuations, damaged infrastructure, supply chain disruption, and provider burnout.² Provincial and regional health leaders have now recognized this important threat and have identified climate change and sustainability as key strategic priorities.

Paradoxically, the health-care system itself is part of the problem, contributing to around 5% of Canada’s greenhouse gas pollution.³ Contrary to previous assumptions, several studies exploring the breakdown of health-care’s carbon footprint revealed that approximately 80% of our impact comes from outside of our facilities, upstream in the supply chain where materials required to deliver care are produced.² Consider, for example, all of the supplies required to collect, store, ship, process, and dispose of each lab sample. In Canada, 25% of our entire health-care footprint comes from the medications we prescribe.⁴ Environmental action in health-care is not just an operations or procurement problem of reusing and recycling; intervening only at the end of a product’s life cycle has relatively little impact. As clinicians who are ordering the tests and treatments that drive consumption of health-care products, we are directly responsible for most of these upstream impacts and therefore have an important opportunity to rethink and reduce within our own practices.

Canada is second only to the United States in terms of energy used to deliver health care.⁵ Many other countries in Europe produce only a fraction of the greenhouse gases to achieve similar, or better, health outcomes, indicating that high-quality, low-carbon care is possible.

The UK Centre for Sustainable Healthcare developed a framework to provide more insight into how we might achieve this goal by reimagining environmental action in health-care. It identifies four key principles:

1. reducing unnecessary care,
2. empowering patients,
3. shifting towards health promotion and disease prevention, and
4. choosing environmental alternatives.⁶

There is considerable overlap between these recommendations and many of the basic principles of high-quality care. Using a planetary health approach in clinical practice not only allows us to reduce environmental impacts but also offers many co-benefits: better health outcomes, lower costs, decreased workload, and a more resilient and sustainable system.

What I do now

Last year, I worked with a multidisciplinary, pan-Canadian team to produce a Canadian toolkit for Planetary Health in Primary Care, which introduces concepts applicable to all specialties using the four principles of environmentally sustainable health-care described by the UK Centre.

Figure 1. Principles of environmentally sustainable health-care⁷

Principles of Sustainable Healthcare (p 1). Sustainable Primary Care Toolkit. Available from https://cascadescanada.ca/resources/sustainable-primary-care-toolkit/

I now use these principles to guide my clinical practice, thinking about the environmental impact of everything I do. I believe that doing this can help me become a better doctor. The subsequent articles in This Changed My Practice series will explore these four principles in more depth with more practical clinical ideas and examples.

Some simple actions we can all start doing immediately:

1. Switch patients from metered dose to dry powder inhalers whenever appropriate. Resources:
   • Climate conscious inhaler prescribing in outpatient care (View on CASCADES Canada)
   • Asthma and COPD as-needed inhalers (SABD): where refills matter! (View on This Changed My Practice)
   • Mitigating the climate impact of asthma therapy (View on This Changed My Practice)
2. Pause before ordering investigations, especially routine labs and ask:
   • “Will it change the outcome?” “Am I choosing wisely?” (View on Choosing Wisely Canada)
3. At medication refill visits, ensure each prescription is still needed.
   • If not, consider deprescribing (View on Canadian Medication Appropriateness and Deprescribing Network)
4. Use shared-decision making tools like:
   • the PEER Cardiovascular Decision Calculator or
   • the Canadian Task Force on Preventative Health Care tools to ensure patients understand the risks and benefits of tests or treatments. On average, this takes 2.6 minutes.
5. Ask patients, “What matters to you?” and respect their preferences and values. This has been shown to result in more appropriate care (View on Health Quality BC)
6. Eliminate unnecessary disposable products starting with exam table paper and unnecessary gloves. Resources:
   • End of the roll for examination table paper? (View on BC Medical Journal)
   • Gloves off campaign! (View on CASCADES Canada)
7. For many more examples, see the Planetary Health for Primary Care (View on CASCADES Canada)

I have realized that, in addition to taking personal actions to reduce my own carbon footprint, I have a unique opportunity to help each of my patients reduce their own impact without any adverse effects on their health through the decisions we make together.

These tangible actions — however small — help me and others to retain hope, optimism, and joy in work and act as an antidote to the increasing despair, helplessness, and eco-anxiety so many people are now experiencing. Knowing that these individual actions are part of a larger transformative movement within health-care and society at large gives a sense of meaning and shared purpose.

Outside the clinic I have become a passionate advocate, sharing these principles with anyone who will listen. Increasing numbers of providers and leaders are becoming interested in solutions as the urgency of the situation intensifies. This framework provides a clear view of the path we need to follow to turn this threat into an opportunity for positive change.

Handout

View and download the handout of some simple actions we can all start doing immediately. Download PDF.

References

1. Costello A, Abbas M, Allen A, et al. Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission [published correction appears in Lancet. 2009 Jun 27;373(9682):2200]. Lancet. 2009;373(9676):1693-1733. doi:10.1016/S0140-6736(09)60935-1. (View or View with UBC)
2. The Lancet Countdown on health and climate change. The Lancet. Accessed May 16, 2024. (View)
3. Tennison I, Roschnik S, Ashby B, et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health. 2021;5(2):e84-e92. doi:10.1016/S2542-5196(20)30271-0. (View)
4. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and health damages from the Canadian healthcare system: An economic-environmental-epidemiological analysis. PLoS Med. 2018;15(7):e1002623. Published 2018 Jul 31. doi:10.1371/journal.pmed.1002623. (View)
5. Romanello M, Napoli CD, Green C, et al. The 2023 report of the Lancet Countdown on health and climate change: the imperative for a health-centred response in a world facing irreversible harms. Lancet. 2023;402(10419):2346-2394. doi:10.1016/S0140-6736(23)01859-7. (View or View with UBC)
6. Mortimer F. The sustainable physician. Clin Med (Lond). 2010;10(2):110-111. doi:10.7861/clinmedicine.10-2-110. (View)
7. Hale I. Sustainable Primary Care Toolkit. Accessed August 28, 2024. (View)

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Introduction to planetary health in primary care

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