“Climate change is the biggest global health threat of the 21st century.” (1) I first saw this quote from the Lancet-UCL Commission in 2010 when an older student gate-crashed an anatomy lecture to further alarm medical students in their third week of university. Nine years on and I have quoted this report thousands of times, because, whilst there is now a continuous flow of evidence of the health effects of climate change, the message is still the same, indeed it now carries an even stronger sense of urgency.
The 2018 Report of the Lancet Countdown: Tracking Progress on Health and Climate Change warns us that climate change is already affecting the health of people world-wide through changes in heatwaves, vector-borne diseases, weather-related disasters and food security. (2) In 2017, 157 million more vulnerable people were exposed to heatwaves and 62 billion more hours of labour were lost due to heat compared with 2000. (2) Over half of global cities surveyed expect climate change to seriously compromise their public health infrastructure. (2) What’s more, 30 countries are now experiencing downward trends in agricultural yields, which reverses decades long trends in improvements. (2) Humanitarians working for Médecins Sans Frontières are also documenting these trends in their field work in locations all around the world. (3)
On the other hand, responding to climate change presents the opportunity to improve public health, with well-designed climate change mitigation policies providing health co-benefits. (4) Ceasing combustion of fossil fuels for energy, heating, cooking and transport reduces air pollution, which currently causes 7 million premature deaths annually. (5,6) Poor diets and physical inactivity are two of the biggest lifestyle factors contributing to burden of disease. Switching from cars to cycling and walking as forms of transport and decreasing meat and dairy consumption can reduce incidence and prevalence of type two diabetes, stroke, ischaemic heart disease, breast cancer, colorectal cancer, dementia and depression. (7–10)
The health community plays a crucial role in responding to this public health emergency: to ensure there is widespread understanding of climate change as a public health issue; to lead action within the health sector; and to work with policy makers to take the necessary measures in primary, secondary and tertiary prevention. Indeed, there are already many examples of individuals, institutions and organisations taking action that the global health community can learn from. I’ll outline four areas in which the health community are already making a change in health and climate change.
Formal education on the interlinkages of health and climate change in university curricula and medical training programs is still lacking. The International Federation of Medical Students’ Associations (IFMSA) is working to address the knowledge gap, creating a Training Manual on Health and Climate Change (11) and setting a vision to have an element of climate-health included in the curriculum of every medical school by 2020 and to have an integration of climate-health in all aspects of medical school life by 2025. (12)
The provision of health services can carry a large environmental footprint. To mitigate this, the UK’s Sustainable Development Unit was formed, reducing GHG (greenhouse gas) emissions of the UK National Health Service by 18.5% from 2007 to 2017, whilst clinical activity increased by 27.5% over the same time period. (13) Over 4000 hospitals around the world have committed to the Global Green and Healthy Hospitals Agenda, which includes 10 interconnected goals for the health sector to address and promote greater sustainability and environmental health. (14) In addition to this, 175 institutions, representing the interests of over 17000 hospitals and health centres heave joined the Health Care Climate Challenge to commit to decarbonising their own energy supply. (15)
Health professionals are also becoming political. Health organisations led the push for Canada to commit to a total coal phase-out (16,17) and the formation of the Powering Past Coal Alliance, which now comprises of 30 national governments, 22 sub-national governments, and 28 businesses or organisations committed to phasing out coal. (18) Many leading health organisations in the United States have opposed threats to roll back environmental protection under the Trump Administration. (19–22) The Australian Climate and Health Alliance has developed a Framework for a National Strategy on Climate, Health and Well-being for Australia, outlining policy directions to be taken at the federal, state/territory and local level that meet Australia’s obligations of the Paris Agreement and protect the health of Australians. (23) Health organisations published briefings alongside the 2018 Report of the Lancet Countdown, directed at policy makers of the European Union and of countries including China, India, Brazil and Spain. (24) With President Bolsonaro posing a threat to the Amazon and climate change, the health voice in Brazil has been particularly strong. (25,26)
Health institutions have also joined the divestment movement, moving their money out of investments in fossil fuels. Commitments have been made by the American Medical Association, the British Medical Association, the Canadian Medical Association, the Royal Australasian College of Physicians, the Royal College of General Practitioners and the New Zealand Nurses Organisation. (27) The total number of organisations and institutions from across all sectors that have committed to fossil fuel divestment is almost 1000, with an approximate value of US$7 trillion. (28)
In its Special Report on Global Warming of 1.5 oC, the Intergovernmental Panel on Climate Change cautions of the increased health risks even with 1.5 or 2 oC of warming by 2100. (29) However, we are currently far off track from achieving either of these goals, with the gap between how much greenhouse gas emissions have been reduced and where they should be widening, with a threat of warming of 3 or 4 oC (30) which risks human civilisation as we know it. (31)
The health community is rising to the challenge of climate change and there are many examples of action already happening all around the world. However, a much greater response is required in order to divert from our current trajectory. We need urgent action from the health community and all sectors of society to address the public health emergency of climate change and ensure improved health for all.
Dr. Alice McGushin, MBBS BMedSci (Hons) MScPH
Consultant, Lancet Countdown: Tracking Progress on Health and Climate Change, Vice Chair, World Organization of Family Doctors Working Party on the Environment, Junior Medical Doctor
Early one morning in the spring of 1994, in a room deep inside the grandiose marble walls of the Rayburn House Office building in Washington, a group of 7 distinguished, successful, well-educated gentlemen sat before the US House of Representatives subcommittee on Health and the Environment, chaired by Rep. Henry Waxman.
Each of these gentlemen was the CEO of a major US tobacco company and was there, for the first time, as a witness, part of Waxman’s ongoing attempt to deal what he called in his introductory remarks: “the single most dangerous consumer product ever sold”. The appearance of the CEOs from companies such as Phillip Morris and RJ Reynolds, representing ubiquitous cigarette brands such as Marlboro and Camel and many others, in itself was momentous.
It represented a seismic shift from an old way of operating, in which many US representatives and tobacco companies enjoyed close, mutually beneficial relationships. Waxman said as much, as he brought his introduction to a close:
“…This hearing marks the beginning of a new relationship between Congress and the tobacco companies. The old rules are out, the standards that apply to every other company are in. We look forward to hearing the testimony this morning, and to working with these companies to begin to reduce the extraordinary public health threat that tobacco poses. An old proverb says that a journey of a thousand miles must begin with a single step. Today is the first step. Many more are to come as we deal with the most serious health problem facing our Nation.”
This statement was carefully worded. In it he not only made it clear that tobacco represents an extraordinary threat to public health, but also that he hoped that in recognition of this great threat, tobacco companies might work with government to reduce it.
Following these remarks, all 7 CEOs raised their right hands and agreed under oath that their testimony would be “…the truth, the whole truth, and nothing but the truth.”. What happened next in that room would become a powerful illustration of how utterly futile any hope of a collaborative effort was.
The first question to the group, from Rep Wyden, was simple: “…Yes or no, do you believe nicotine is not addictive?” Each of the CEOs in turn leant towards their personal silver microphone, and one after the other, answered: “I don’t believe that nicotine or our products are addictive”, “I believe nicotine is not addictive”, “and I too, believe that nicotine is not addictive…”. The CEOs were unanimous in their denial.
Days after this testimony, documents would be leaked to the public that showed these companies had known that the exact opposite was true for decades. A top executive had mulled in an internal memo in 1963, over 30 years earlier: “We are then in the business of selling nicotine, an addictive drug effective in the release of stress mechanisms.” The tobacco executives had listened to Waxman’s concerns for the public interest, sworn an oath to tell the truth, and immediately, unanimously, lied to protect their businesses.
In the years that followed, through a combination of leaks and lawsuits, in particular the Master Settlement Agreement (in which 46 US states settled their Medicaid lawsuits against the tobacco industry for recovery of their tobacco-related health-care costs), as many as 14 million internal documents were divulged, detailing a wide range of tactics the industry employed to sow doubt about the links between smoking and disease, and using its economic power and marketing prowess to manipulate the media, the scientific community, the public and governments (World Health Organisation, 2009). This behaviour was reflected in the language of the WHO’s historic Framework Convention on Tobacco Control, as parties to the FCTC agree that there is a “fundamental and irreconcilable conflict” between tobacco and public health policy interests (World Health Organisation, 2005).
However one of the most important lessons from the tobacco documents is one which I believe we have failed to learn. What was exceptional about the tobacco industry?
Was it that they sold a harmful product? No. Other global industries sell and are largely dependent on products that are also harmful to population health.
Were their staff motivated by some uniquely evil intent? No. A comprehensive review of findings of the tobacco documents suggested that the main motivation for tobacco industry tactics was profit, and within that, three interlinking goals: Avoiding any new regulation, avoiding negative PR, and avoiding litigation (Bero, 2003). I would argue that this motivation is the opposite of exceptional. These goals are in fact core objectives for any large publicly owned company, core objectives that the CEO is answerable to shareholders for. And for some of these companies, just like for tobacco, these objectives may be at odds with population health.
Getting back to the earlier question: What was exceptional about the tobacco industry? Nothing, other perhaps than the fact they got caught.
So, if there are other industries that rely on profits at the expense of population health, and that share these basic objectives, not to mention in many cases sharing the same law firms, PR firms, advertising firms and lobbyists, why would we expect them to act differently from the tobacco industry if their profits are threatened by regulation, litigation or negative PR? This is not to say the private sector in general can’t play a role in improving population health. But we must be clear in recognising that for some industries there is an irreconcilable conflict of interest between population health and profit. This conflict exists from the very top, as such a company’s Board of Directors have a fiduciary duty to protect shareholders investments.
Indeed, the evidence is mounting that where there is a conflict of interest, other industries exhibit similar tactics to those previously observed with tobacco companies. The alcohol industry is largely dependent on drinkers that consume to harmful levels (Casswell et al., 2016; Viet Cuong et al., 2018)and has also lobbied extensively against policy best buys such as restricts on marketing and availability, or tax increases (Hawkins et al., 2018; Martino et al., 2017; McCambridge et al., 2018; Savell et al., 2016), and misleading the public on the risks associated with alcohol consumption (Petticrew, Maani Hessari, et al., 2017; Petticrew et al., 2018). The gambling industry? Much the same (Cowlishaw and Thomas, 2018; Mandel and Glantz, 2004; Petticrew, Katikireddi, et al., 2017; Thomas et al., 2016). Believe it or not, there is still an asbestos industry, with a history of lobbying and fighting lawsuits on liability for asbestos related injuries (Rosner and Markowitz, 2017). Exxon Mobil internal memos long acknowledged the link between fossil fuels and climate change, but the company commissioned advertorials in leading newspapers questioning this same link (Supran, 2017). Coca Cola funded research groups to divert attention away from the links between SSBs and obesity (Barlow et al., 2018).
In spite of such examples, these industries remain close partners with government in many countries, including via self-regulation, or even drafting legislation on the very harms their products are causing, in ways that we would no longer allow the tobacco industry to. We failed to learn the most important lesson of the tobacco industry example: That their motivation was not exceptional at all, but rather based on profit from sales that happened to be at odds with population health.
I would argue that this situation both undermines population health and runs the risk of bringing undeserved negative attention to public private initiatives with industries that don’t share such a conflict of interest.
So what can we as public health researchers, practitioners or advocates do to address this?
This of course is no small challenge, and may not always be the popular, political or most fundable of directions. However it is clear that if we are to truly improve population health, particularly in an era of increasing focus on the benefits of public private partnership, I would argue that these issues must be wrestled with.
Dr Nason Maani Hessari, BSc MPH PhD FRSA
Research fellow within the Department of Health Services Research and Policy at the London School of Hygiene & Tropical Medicine
CEO - Chief Executive Officer
PR - Public Relations