David Peters, Editor-in-chief, JHH

Published in JHH12.1 – Future horizons

As far back as 2006 a BMJ editorial said: ‘The Stern report of 2006 highlighted the potentially great damage to the world’s economic system from unconstrained climate change.The greater risk, however, is to the vitality and health of all species including humans.The health professions have a crucial role in promoting public understanding of this fundamental association and health protecting responses to it.’ I wrote an editorial about it six years ago, (Peters 2008) but how actively are the ‘health professions’ rising to this challenge? ‘Not very’ according to Jonathon Porritt CBE. These are my reflections on a talk he gave for the College of Medicine in September 2014 at Guy’s Hospital, London.

Sir Jonathan (henceforth JP) was once described as ‘Tony Blair’s green guru’. Despite that distinction he remains, as he has been for nigh on 40 years, one of the most prominent international voices promoting sustainability issues. He was the dynamic chairman of the Ecology Party in the 1980s and later became the hugely influential director of Friends of the Earth (FoE); on his watch awareness of the ecological crisis exploded and FoE membership grew from 12,000 to nearly a quarter of a million. In 1996 he left and co-founded the charity Forum for the Future to persuade businesses to improve their environmental performance.This in turn attracted the attention of the aforementioned Prime Minister, who made Jonathon chairman of the new Sustainable Development Commission. He was nonetheless, and remains, critical of the government’s energy policy particularly around environmental issues and its pro-nuclear power stance.

What follows is my attempt to précis his influential ideas about how sustainability and health march so closely together.

Sustainability and health

According to JP, if only we could start getting the health story right we might at the same time find many answers emerging to sustainability problems. Because by setting out to view health policy in the light of climate change, far-reaching social and public health solutions begin to come into view, and vice versa. This synergy is a source of cultural energy for transformation which JP has written a book about.

The World We Made (Porritt 2013) is a book exploring how we could move towards a good, socially just and ecologically sustainable world and in it there are as many chapters about health as there are about diversity, transport, energy or manufacturing.

When JP led the Sustainable Development Commission, the Cabinet Office had set its sights on bringing sustainable development into all government departments’ policy[1]making. The Department of Health perhaps engaged more than the rest, for its Sustainability Unit became a principal source of advice about sustainability not just for the NHS but for wider arenas of government.

In Merchants of Doubt Naomi Oreskes and Erik M Conway (2010) point out that 97% of peer reviewed studies confirmed the hypothesis that climate change is primarily man-made. Though there is almost no residual doubt among scientists, the politics of climate change are far more problematic. Ever since the quest for a global agreement crashed and burned in Copenhagen in 2009 Ban Ki Moon has been striving to get climate change diplomacy back on track. But Secretary General of the UN though he might be, and desperate as he is to get some new energy going, politicians worldwide have shown no stomach for taking a strong lead on this issue. This, suggests JP, is because politicians have no choice but to co-operate with globalised industrial and energy sector interests. Scientists can keep insisting we are heading for disaster, but the global tanker won’t change its course until politicians begin to take a bold lead.

So where can we see signs of the driving forces for change? Amazingly, it could be China. Every year there are 40,000 to 50,000 protests about environmental issues in China, with local communities rising up in protest about air pollution, water pollution, waste issues and land grabs. China’s individual emissions are far lower than ours but its population is vast and as Chinese citizens have got richer two things have happened: they eat much more meat and they start to be more outspoken, especially about air pollution. This is driving a serious political groundswell for addressing climate change, because much as the new middle classes love the Chinese growth rates, they don’t want the price to be asphyxiation. Suddenly, the environment has become one of the biggest threats to social stability, which has always been something the Chinese government is hugely concerned about.

JP spoke about the century city politicians took to tackle London smog, and the Chinese government’s ambition to beat urban air pollution in less than 15 years. Perhaps they will, I thought; the short-term political expediencies and annual shareholder returns that make governments and corporations loathe to tackle climate change don’t so much bother immense single party autocracies like China. Their spreadsheets, unlike those of the free market West, can stretch decades into the future and their policy strategies take a far long view. Why else would they be buying up vast tracts in Africa?

Joining the dots

Here and there, human health issues are driving climate change mitigation plans. In the United States Obama, unable to persuade the Senate or the House of Representatives to confront climate change, instead had the Environment Protection Agency close down coal-fired power stations – not because of CO2 emissions, but because of their massive impact on health. Our politicians have to pull in the votes, and there could be many to pull in if strategic synergies saw governments scoring multiple benefits by ticking the low carbon strategy and the health priorities boxes at once; perhaps even ticking impact on transport or energy security or innovation.

An example? Compassion In World Farming’s Eat Less Meat Campaign urged us to eat no more than 90–120 grams of meat a day, yet the average consumption in the UK is around 300 grams. But if we want to live in a sustainable world, there are two things we can expect to do – eating less meat is one of them, flying less (demand has been increasing by 6% a year) is the other.

As per capita income increases globally as it has for hundreds of millions of people, meat consumption increases with it. If today’s demand for meat – roughly 250 million tons per annum – increases as is predicted to 360 million by 2030 and 480 million by 2050, a billion more tons of animal feed will be needed. The prospect of growing a billion extra tons is off any known scale of land availability, yet the Food and Agricultural Organisation (basically as JP reminded us, a mouthpiece for the food industry) puts out growth projections as if they were good news for the economy and all humankind!

Meat eating has a health impact, a climate change impact, an animal welfare impact and an environmental impact. Meat production and consumption cause environment problems, contaminating groundwater, land and air. About 18% of total greenhouse gases come from deforestation – some of it to create pasture for more beef cattle – and roughly 18% from meat and dairy production. We hear a lot about deforestation from NGOs, hardly anything about limiting meat consumption, because this issue is too personally challenging and politically unacceptable.

Obesity and climate change

Diabetic people develop co-morbidities in numbers that might one day bankrupt the NHS. Type 2 diabetes is obesity related, yet faced with a pandemic of obesity, the medical mainstream and the big healthcare companies continue to act as if better diagnosis and treatment are the way to eliminate diabetes. But this approach is no longer fit for purpose: the snowballing number of people with diabetes is too huge for this model to be sustainable. JP reminded us that the epidemic has been blamed on our ‘obesogenic’ culture. If that’s true (and the number suggests it is) then where would social and cultural prevention fit?

The World Health Organization has told us that at least a billion and possibly 1.7 billion people are seriously overweight; of these 300–350 million are obese. Overweight people, it says, cause one extra ton of CO2 to be emitted every year. The total emission of CO2 today, is about 75 billion tons per annum. However, CO2 isn’t just up there in the atmosphere, it’s tied up in all the biomass, trees, plants, crops; enormous amounts of CO2 are locked up in organic matter in the soil. Different ways of managing livestock – such as extensive grazing outside –would lead to ecological benefits, not least because more CO2 could be sequestered in the soil. Synergy: sort out the obesity problem and meat consumption and new ways to address environmental, energy and health issues open up.

Social prescriptions?

The Conservation Volunteers have a mental health intervention called Green Gyms. Green Gyms give GPs an opportunity to prescribe outdoor activities. The volunteers get involved in project such as cleaning up messy inner urban sites, or helping restore degraded woodland, or clearing a canal walkway. Instead of prescribing pills, GPs are prescribing access to nature and encouraging people to join in and address environmental problems. Green Gyms’ health evaluations show good outcomes compared with standard interventions. Synergy is at the heart of this kind of healthcare, but at the moment our political system makes synergy hard to pull off. JP felt it had been hard enough under Labour, but the Coalition Government had shown even less appetite for joined up policy. He told us that the Department of Communities and Local Government had actually banned interdepartmental meetings as a waste of time: a department whose tasks necessarily bridge to other departments wherever health, education, energy, transport are involved! As JP put it, our beautiful honed vertical silo system might have been constructed deliberately to prevent synergy in policy-making.

Profiting from prevention?

Can Big Pharma support prevention? Apparently it can when it tries. Nordis (one of the Big Pharma companies that sells diabetes medicines) has launched a programme called Changing Diabetes in six cities around the world. Changing Diabetes aims to bring forward new ideas and intervene earlier; but more than this it aims to create healthier cities through active travel strategies and better nutrition. In future, city mayors like Boris Johnson could do so much more to drive synergistic policies. At the moment, the business model for healthcare companies is based on selling medicines to more and more people. And their model of ‘prevention’ is based on developing, patenting and promoting lifelong drug regimes designed to mitigate the effects of established diseases or reduce biochemical risk factors already diagnosed. So, the more people are identified as at risk and diagnosed, treated and maintained on their drugs, the better the company books will look at the end of the year.

How then to monetise real, ‘primary’ prevention through business models that would allow companies to make as much profit for shareholders as they make from manufacturing and selling diabetes medicines? Right now (and despite the shining example set by Nordis) medicines markets can’t profit from the social outcomes, or cost benefits, of not needing to treat established disease that has been prevented by upstream approaches. On the contrary, preventing diabetes would undermine their sales of diabetic drugs.

The same goes for the energy sector. Energy companies make more money by selling more kilowatts and more tons of gas. To incentivise them to sell less energy requires a different reward mechanism. This is possible; in fact a dozen or so utilities in the United States have created The Megawatt Strategy. Instead of selling more megawatts or building more power stations to sell more energy to people in an ever-upward spiral of demand, the government incentivises these companies to sell less energy into the system if they invest in energy[1]efficiency and work with their customers to reduce consumption. And this system actually works.

Right now, frontline primary care clinicians are leading a change in the way we fund healthcare. But let’s be realistic about this, Public Health England is given only 4% or 5% of the total NHS budget for prevention; the lion’s share has always gone to the acute sector, because the system revolves almost entirely around treating established disease rather than prevention – prevention which in reality depends far more on education and social change than it does on doctoring. That’s why it has been so very difficult to prise the acute sector’s hands off their pot of money. The Sustainable Development Commission’s own work on shared budgets showed that in order to rebalance the acute versus prevention spend the NHS would need to target long-term changes in budget allocation actively. JP believes that if the Treasury were to set this agenda the system would gradually but inexorably find ways to adapt.

Pharma’s footprints

When the first news of the NHS carbon footprint emerged, by far the largest part of it (bigger than all CO2 emissions from NHS buildings) was from the pharmaceutical sector. Producing the huge amounts of drugs we consume is very energy intensive (and perhaps half the drugs prescribed are never actually taken). If Big Pharma made its production processes and distribution systems more efficient there could be massive reductions in waste and energy consumption. The good news on this front is that four out of the ten biggest selling drugs are already manufactured using energy efficient bio-technology. On the other hand, sales and marketing are a huge proportion of any pharma company’s total spend and, while the acute sector has seen substantial reductions in its total CO2 footprint (and we have seen reductions in other parts of the NHS as well), any reductions in pharma’s overall contribution has been very slow.

There ought not to be resistance on the part of the investment community to dramatic improvements in resource efficiency, through reduced waste in the supply chain, for example. If a company can reduce its cost base by smart innovation and better management it shouldn’t be any less attractive to an investor. However, the total market value of drugs today is truly vast and growing, and mass prevention campaigns would no doubt dent Big Pharma’s legendary profits. No wonder there is real nervousness that traditional business models dependant on ever-increasing growth and turnover might change.

It is hard to avoid the conclusion that Big Pharma companies have a vested interest in scenarios where more people get sick. Nor, whether intentional or not, can the Big Food industry – whose products full of bad fats, sugar and salt make people ill – deny that it paves the way for Big Pharma to develop lifelong drug regimes for treating the diseases that ensue.

Synergistic solutions

Better farming, makes for better food, and active transport systems involving better green spaces make for fitter, healthier human beings who want to live in a more energy efficient society. Evidence suggests that giving people access to the natural world and to green spaces can help build health and resilience. The evidence about this goes back to Roger Ulrich’s work in the 1980s (Ulrich 1984) when he looked at two groups, both of them recovering from gall bladder operations, but in two different wards: one looked out over a nice green leafy park, the other ward didn’t have a view out. The outcome? People looking over the greensward needed fewer pain meds, and had fewer wound infections and were discharged from hospital a day earlier on average. A day doesn’t sound like much, but if you extrapolate Ulrich’s finding across an entire health system, the efficiency gains for hospitals having green spaces become truly significant.

Yet policy-makers look these synergistic gift horses in the mouth, and despite the evidence green policy hasn’t provoked much detectable interest from government. Building the natural world into our healthcare systems and into healthcare policy could increase individual and community resilience and so save a lot of money. Nature, it seems, is good for the spirit and for the body as well. Those who don’t have access are now said to be suffer from Nature Deficit Disorder! Far too many people in our world today are chronic NDD sufferers, but perhaps the pharmaceutical companies can come up with a new drug to deal with it!

References

• Peters D (2008) Climate change and chronic disease: public health writ large. JHH 5 (1).
• Porritt J (2013) The world we made. London: Phaidon.
• Oreskes N, Conway EM (2010) Merchants of doubt. How a handful of scientists obscured the truth on issues from tobacco smoke to global warming. New York: Bloomsbury.
• Ulrich RS (1984) View through a window may influence recovery from surgery. Science 224 (4647) pp 420–1.