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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Sustainable Healthcare sets out a vision for medical care of high quality, manageable cost and low impact on the planetary systems which sustain us.
In tackling the major challenges of our age, such as resource depletion, loss of biodiversity and climate change, health services can play a central role, moving from being part of the problem to becoming part of the solution. Sustainable Healthcare explores questions such as:
- What is the relevance of sustainability in healthcare?
- How does climate change threaten human health?
- How can we create low carbon care pathways?
- How can healthcare organizations deal better with their waste?
- How can death and dying become more sustainable?
- How can we engage ourselves and others with this agenda?
Written by an international team combining clinical, educational, practical and policy expertise in sustainability and health, this book provides a synopsis of our current predicaments, and explores some of the emerging solutions. Containing case studies and resources for further information and action, Sustainable Healthcare is a practical guide to making healthcare more sustainable for all healthcare professionals, managers and students.
"Once in a while one comes across a book that makes a deep impact. Sustainable Healthcare is such a book and very timely in the context of modern healthcare and developing green policies.... The book is clear in ideas of critical thinking, scientific evidence and practical suggestions for transformative action.... An additional strength in this book are the summary key papers and reports including key points from the chapters. In addition, there is a comprehensive list of references in each chapter.... The authors cut through the jargon and challenge the rhetoric of both fear and denial.... The authors give examples of how we can engage with sustainability such as, diet and exercise, prescription management, contraception management and family planning and end of life care.... The book provides useful sources, references and key actions for individuals, healthcare organisations and policy making departments."
—A review by Prof Davinder Sandhu, Postgraduate Dean, Health Education South West, Severn Deanery, UK
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Table of Contents
Title Page
Copyright
Preface
Acknowledgements
About the Authors
Chapter 1: Greening the gaze
The revolutionary road
The verge of collapse
Living within boundaries
Five contemporary predicaments
Crises in healthcare
Greening the medical gaze
Sustainability defined
Social sustainability
Sustainability and health services
Ethics and exemplars
Sustainability positive
About this book
Chapter 2: Climate science in context
Dealing with crises
Making sense of environmental science
The impact of humans on the environment
Climate change denial
Effects of climate change on ecosystems and health
Summary of the evidence and call to action
Staying abreast with emerging evidence
Chapter 3: Engaging with sustainability
The sustainable picnic
Understanding systems
Earth as a system
Resilience in health
Promoting resilience
Gauging engagement
Carbon dependence syndrome
Dissecting denial
Connecting with the Earth system
A lexicon of sustainability
Concluding thoughts
Chapter 4: A vision for sustainable healthcare
Redefining value and health in healthcare
Why should health services become more sustainable?
What is sustainable healthcare?
Components of a more sustainable and holistic health sector
The co-benefits of sustainability actions
Monitoring and reducing carbon emissions
Working in partnership
Alternative ways of financing healthcare
Efficiency at the start of sustainable practice
Chapter 5: Low-carbon clinical care
More sustainable care is better care
Key areas for making clinical care more sustainable
Providing effective contraception
Preventing disease and promoting better health
The effects of clinical decision making
Rational and responsible prescribing
Avoiding medicine waste
‘Leaner’ service delivery
Educating and empowering patients
Calling for collaborative action
Chapter 6: Food for people and planet
A brief history of the ‘Western Diet’
Food and human health
Food and the global environment
Putting food on the healthcare table
Food in hospitals
Food policy for people and planet
Summing up about food
Selected useful resources
Chapter 7: Travel and transport: moving to better health
Transport in the health sector
The health and carbon effects of travel and transport
Reducing travel-related carbon emissions in healthcare
Reducing the need to travel
Better ways to travel
Incentivising active travel
Institutional travel plans
Moving into action!
Key actions for implementing institutional travel plans
Chapter 8: Healthy buildings, healthy spaces
The building in healthcare
Healthcare estate: carbon and resource impacts
Barriers to making buildings more sustainable
Optimising energy efficiency
Using renewable and alternative sources of energy
Sustainability management of buildings in context
The future for sustainable buildings
Building a more sustainable future
Useful sources for further information
Chapter 9: Resource stewardship
Procurement in perspective
Using water more efficiently
Managing waste
Managing resources for the future
Further reading and information
Chapter 10: The Green Death
Death and sustainability
Heroic interventions
The different costs of care
The carbon costs of dying
The costs after death
Costing cremation
The bad news about burial
Toward a greener death
Embracing death
Talking about death
Advanced planning
The dementia question
Emotional and spiritual care at the end of life
The green funeral
The woodland burial
Policy perspectives
Chapter 11: The Green Academy
The university enterprise
The sustainable healthcare curriculum
Teaching methods
Organisations supporting sustainability education
Sustainability in medical research
The green conference
Engaging the workforce
The role of professional organisations
Turning night into day
Sustainability networks
Chapter 12: The journey towards sustainable healthcare
The health professions are ready to act
Strategies for sustainable development
Preparing our systems
Making sustainable healthcare happen
Final thoughts
Index
This edition first published 2013, © 2013 by John Wiley & Sons Ltd.
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Library of Congress Cataloging-in-Publication Data
Sustainable healthcare / Knut Schroeder ... [et al.].
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-470-65671-6 (pbk.)
I. Schroeder, Knut.
[DNLM: 1. Delivery of Health Care. 2. Climate Change. 3. Conservation of Natural Resources. W 84.1]
362.1– dc23
2012030887
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover design by: Rob Sawkins at Opta Design. Image adapted from iStock File #:5977539 © 2008 appleuzr
Preface
Should people working in the health sector be interested in sustainability? The answer, we think, is a resounding ‘yes’. We, an authorial team comprising a primary care clinician (KS), a medical teacher (TT), a public health specialist (DP) and a science educationalist (KF), have been exploring the interface between medicine and sustainability for many years. In that time, general public interest in this area has increased a lot, but within the health sector it has received relatively little attention. We have written this book as a synthesis of a growing, but disparate, body of expert knowledge, and also with the hope of bringing sustainability to its rightful place at the centre stage of healthcare policy and practice.
The earth system is a wonderful yet ultimately vulnerable thing. It provides us with endless benefits upon which we are entirely dependent and which we can easily come to take for granted. These ‘ecosystems services’ include fresh water, clean air, fertile soils, carbon-based and renewable energy sources and a stable and relatively predictable climate. Less tangibly, we draw spiritual sustenance from nature in all its beauty and diversity. The science is now unequivocal—this planetary system is under stress due to human activity. We unpack these stresses, such as climate change and the loss of biodiversity, and consider the various consequences for human health and the healthcare system—a system that itself struggles to contain costs, deal with the soaring prevalence of chronic illness and bring humanity to technological care.
This book describes a new paradigm to tackle these pressing predicaments—a collection of ideas and perspectives (mostly developed by others, but some of our own) that fall, however untidily, under the banner of sustainable healthcare. This brings to the foreground the prevention of disease and the creation of individual and community resilience. It champions lean systems of clinical care that maximise efficiency and common humanity and minimise resource use and the creation of waste products (including greenhouse gases and toxic pollutants). A consistent and heartening observation is that many interventions that improve individual health (such as fresh, local and mainly plant-based food) are also good for the health of the planetary system—creating what are termed ‘virtuous cycles’.
We have written for a readership busy with the myriad tasks of delivering care. We have tried to keep the book concise and balance ‘need to know’ with ‘useful to know’ information. We have read and appraised much of the science so you don't have to, and tried to draw balanced conclusions in a field where there is considerable uncertainty. At times we have applied the precautionary principle—advocating action where the price of inaction seems incalculable. We cut through some of the jargon and challenge the rhetoric of both fear and denial, which often pervades the topic. And we focus on the essential questions, offering a synopsis of the main issues which we support with key references and links to sources of further information. In short, this is a book of first resort.
We write with a wide readership in mind including health professionals, educationalists, health service managers and healthcare students for whom it might provide an outline curriculum in sustainable healthcare. We hope this is a positive book that inspires reflection, engagement and—crucially—action. We think that there are smarter, safer, fairer and more sustainable ways of doing things in the health sector, which are well worth the effort for the benefit of current and future generations. Who would have thought even 10 years ago that in many countries smoking would be banned in public places? A similar shift in public policy and human behaviour, involving innovative technology and better models of care, needs to happen to develop health systems that can sustain us through the challenging decades ahead.
For feedback, comments and suggestions for improvements please email [email protected].
Knut SchroederGeneral Practitioner (Family Physician), Concord Medical Centre; Honorary Senior Clinical Lecturer, University of BristolTrevor ThompsonGeneral Practitioner (Family Physician), Wellspring Healthy Living Centre; Reader in Healthcare Education, University of BristolKathleen FrithPresident, Glynwood and former Managing Director, Center for Health and the Global Environment, Harvard Medical SchoolDavid PencheonDirector, NHS Sustainable Development Unit
Acknowledgements
We owe much gratitude to a number of people who helped tremendously with writing this book by providing us with key resources and materials and reading part or all of the manuscript. In alphabetical order, we are particularly grateful to:
Annie Anderson, Ari Bernstein, Stefi Barna, Jonathan Broad, Timmy Bouley, Peter Cawston, Adrian Davis, Bob Fox, Ian Fitzpatrick, Howard Frumkin, Lynn Gibbons, Michelle Gottlieb, Chris Johnstone, Phil Insall, Katy Mahood, Janet Maxwell, Frances Mortimer, Hubert Murray, Scott Murray, Chris Payne, David Peters, Ian Roberts, Katherine Rusack, Marion Steiner, Jerome Thomas, Ash Tierney, Sarah Walpole and Sarah Webster.
We would also like to thank Mary Banks, Adam Gilbert, Chrisma Ng, Jon Peacock, Sangeetha Parthasarathy and everyone else at Wiley for their patience, gentle guidance and their belief in this project. Many thanks also to Kevin Dunn for expert copy-editing.
We would also like to acknowledge the industry and dedication the many researchers, writers, clinicians and activists whose endeavours we have drawn on in the writing of this book.
About the Authors
Knut Schroeder works part-time as a Family Physician and is Honorary Senior Clinical Lecturer at the Centre for Academic Primary Care in the University of Bristol, UK. He had never really considered the link between climate change and health until he attended a conference on ‘Climate Change and its Impact on Health’ in 2008, hosted by the Royal College of Physicians. This instilled a growing interest in the relationship between health and sustainability and prompted the idea for writing this book. Knut is a Board Member of the UK Self Care Forum, which aims to support people in making better (as well as more sustainable) choices about their health. He also works with the NHS Institute for Innovation and Improvement to help family practices work more efficiently and more sustainably. Knut enjoys spending time with his young family. Whenever work and family commitments allow, he is out and about running or cycling, or writes about topics that he feels passionate about.
Trevor Thompson is a Family Physician at the Wellspring Healthy Living Centre in Bristol, UK, which supports a diverse inner-city population with a range of community-based and medical services. He is also a senior teacher at the University of Bristol Medical School with responsibilities across the curriculum. Trevor has been reading on the theme of sustainability for many years and since 2006 has run an undergraduate course on the ‘Global Environment and Human Health’. Teaching is often the best way to learn and his writing here draws extensively on his educational practice which seeks to engage both hearts and minds. Trevor is clinical co-lead for the Sustainable Healthcare Education Network, supporting green educational initiatives across the UK. He is an active cyclist, sailor and grower.
Kathleen Frith is a creative, visionary leader working for a smarter, more sustainable world and President of Glynwood, one of the United States' leading sustainable agriculture and food organisations. With a deep passion for the natural world, Kathleen studied marine biology and received a Master's degree in Science Journalism from Boston University. In 2001, she was recruited to Harvard by the Center for Health and the Global Environment at Harvard Medical School, where she helped shape the Center's programmes to educate and inform people about the links between human health, the ocean, food systems and the environment, serving as the organisation's Managing Director during the last two years of her tenure. In 2009, Kathleen produced the award-winning film Once Upon a Tide, a live action and animated educational short that screens around the world. In 2010, Kathleen started the Harvard Community Garden, Harvard University's first garden dedicated solely to the production of food. Other initiatives while at the Center included the creation of the Center's Healthy Oceans, Healthy HumansProgram, the launch of Center's Healthy and Sustainable Food Program and work with National Geographic to help restore a healthy, sustainable seafood resource. Kathleen has produced a number of award-winning reports and publications and serves as an advisor for a number of environmental and community organisations.
David Pencheon is a UK-trained public health doctor and is currently Director of the National Health Service's Sustainable Development Unit for England. David was previously Director of a Public Health Observatory in Cambridge, England. He has worked as a clinical doctor in the NHS, a joint Director of Public Health, a Public Health Training Programme Director in the East of England, with the NHS R&D programme, and lived in China in the early 1990s contributing to the work of Save the Children Fund (UK). His main interests and areas of research and publication are: sustainable development, large scale transformational change, health and climate change, underpinning action and policy with good information and evidence, training and professional development, organisational development, medical informatics and decision support for health professionals, carers and the public. He blogs mainly via the BMJ website. He was awarded an OBE in the New Year's Honours List 2012 for services to public health and the NHS.
Chapter 1
Greening the gaze
Health professionals have a lot on their minds: caring for patients, managing teams, keeping up to date with clinical developments and responding to broader agendas of quality and cost containment. This book offers up a quietly revolutionary invitation to rethink this enterprise by considering medicine in its rightful place within a much bigger planetary system. Here, we call this new way of thinking sustainable healthcare and believe it can help us deliver services of better quality, at lower costs and with less impact on the systems that sustain us. To this point in time the health sector has taken planetary health for granted, but now a body of evidence shows an earth system under stress. Half the rainforest is gone, extinction rates are soaring, the oceans are increasingly acidic and the planet is running a fever one degree above pre-industrial levels. We are just starting to realise how these planetary ailments impact on human health, with climate change famously described in the Lancet as ‘the biggest global health threat of the 21st century’ [1]. Though many health professionals are alive to these global issues, in the health professions, as in society at large, sustainability competes with many other pressing and more proximate concerns. Thus, there is a danger that we are collectively sleepwalking into a public health catastrophe. This book offers a new synthesis of sustainability and health, leading in later chapters to many ideas for practical action. Firstly, though, we want to explain why we need a revolution in our health systems, why nothing short of a revolution is going to be enough and what sort of a revolution we are talking about. Luckily it is a revolution from which we all stand to benefit.
The revolutionary road
Nineteenth century medicine witnessed the emergence of germ theory, which revolutionised our understanding of infectious disease. This new theory dispatched the then prevalent miasmatic paradigm, which held that disease arose from bad air. In the twentieth century, classical mechanics was revolutionised by quantum theory, in which, for instance, matter could be both particulate and wave-like. Such paradigmatic revolution requires two conditions. Firstly, there needs to be a build-up of anomalies, difficulties that cannot be solved by the dominant paradigm and which call its completeness into question. Secondly, a new paradigm must be waiting in the wings that accounts for the problems of the day and offers some hope of resolving them. We argue that the time for such a paradigmatic revolution in medicine is upon us. Biomedicine, despite its huge successes, cannot, of itself, provide solutions to the long term health needs of humanity. So, what are these anomalies and predicaments that are great enough to signal the need for a revolutionary new approach?
The verge of collapse
Readers in New York or Glasgow or Sydney may be forgiven for thinking that it is business as usual in healthcare. People value medical care and hold healthcare professionals in high esteem, with the enterprise enjoying enduring governmental support. There are plenty of patients, plenty of things to do to help them and a reasonable amount of money available to pay for it all. In many ways, then, these readers are right. It takes a lot of imagination to think beyond our immediate circumstances, to think globally and think in terms of our common and distant future. Because while, as we shall see, there are challenges facing us right now, there are more and greater challenges ahead. The greatest would be the collapse of civil society through some sort of man-made environmental calamity, as in science fiction movies like The Day After Tomorrow. This possibility feels remote. It probably also felt remote to the many societies which have experienced such collapses in recorded history [2]. Take for instance the fate of the Easter Islands communities. These remote islands were first spotted on Easter Day 1722 by the Dutch explorer Jacob Roggeveen. He encountered a small population, with small and leaky canoes, living on an island devoid of trees, but sporting 300 stone platforms and 887 giant, long-eared, and intently gazing, stone statues. How, thought Roggeveen, did these Polynesians voyage in such vessels from their nearest neighbour, Pitcairn, 1300 miles away, and erect such monuments without rope and wood? Paleobotanical research has demonstrated that the islands were originally thickly wooded with a huge and now extinct species of palm. So what happened? We know that from around AD 900 settlers arrived and used trees for firewood, cremation, sea-worthy canoes and timber for shifting statues. They also cleared woodland to create fields to feed their workforce and a population of around 15 000. We know that by AD 1600 this complex tribal society had all but collapsed. All native land birds and mammals were extinct, all the trees gone and the stone quarries abandoned. The priestly caste was replaced by militia and the islanders turned to cannibalism. Of course, some people survived but by most reckonings in a much impoverished culture. Captain Cook visited the islands in 1774 and described the inhabitants as ‘small, lean, timid and miserable’. The Easter Island story concerns a tiny geographical locale. But today we face the collapse of a planetary system that will affect us all.
Living within boundaries
When we look back on the Easter Islanders cutting down their trees and subverting their culture, we feel incredulous that people could be so short-sighted. But how will future generations look back on us? Will ours be branded the Age of Stupid [3]? Collapsing cultures consistently fail to play by the rules—rules that contemporary science is starting to name and understand. In 2009, the journal Nature published a feature based on the work of the Stockholm Environment Institute on planetary boundaries [4]. In a number of distinct domains, these boundaries define the estimated limits of what we can do without causing serious adverse changes to the planetary system (Table 1.1). The Institute proposes, for instance, a boundary for the loss of biodiversity of ‘ten species lost to life per million species per year’ and a boundary of 15% of global land cover converted to cropland (the current figure is 11.7%).
Table 1.1 Domains of actions to avoid serious adverse changes to the planet. (Reprinted by permission from Macmillan Publishers Ltd: Rockstrom J., Steffen W., Noone K., Persson A., Chapin F.S., Lambin E.F., et al. A safe operating space for humanity. Nature. 2009;461(7263):472–5. Copyright © 2009).
If we can keep within these boundaries, say the authors, we have a chance of maintaining the favourable earthly conditions of the Holocene. The Holocene is a geological epoch, beginning about 12 000 years ago, characterised by a stable interglacial climate. Geologists now speak informally of the Anthropocene, a new period which marks the time from which we can observe the impact of humanity on the global system: its oceans, soils, atmosphere, climate and biosphere (Chapter 2). The bottom line is not comforting. We are, through our activities, already approaching or surpassing all of the planetary boundaries cited by the Stockholm Institute. For instance, the authors of the article in Nature give a threshold of 350 parts per million (ppm) of atmospheric carbon dioxide to contain global warming at less than two degrees above pre-industrial levels. Yet, in February 2012, the official figure from Hawaii's Mauna Loa observatory put the figure at 394 ppm [5]. So even though it may seem business as usual in healthcare in the richer world, the system as a whole faces a number of serious challenges that fundamentally threaten its operation.
Five contemporary predicaments
In this section we take a wider look at the general human situation through the lens of five contemporary predicaments. These are predicaments we are unlikely to sort out with the same style of thinking that helped to create them, but which are explicable and potentially solvable from a sustainability perspective (Figure 1.1).
Figure 1.1 Five contemporary predicaments.
Material inequality
Although the diversity of the human situation means that inequalities in material wealth are inevitable, the degree of inequality within humanity is anomalous. More than a billion people currently live in what the World Bank defines as extreme poverty with an income of less than US$ 1.25 (£0.79) per day. Nearly half of the world's population lives on less than US$ 2 (£1.30) per day [6]. These income levels are not sufficient to meet basic human needs and are not remotely enough to support any advanced medical interventions in settings where people have to pay for services. For instance, a child developing insulin-dependent diabetes in an impoverished rural area may not receive insulin therapy because the cost would be beyond the means of the child's family (Case study 1.1).
An eight-year-old girl called Sudha was admitted with DKA (diabetic ketoacidosis) soon after her diagnosis with Type 1 diabetes. On discharge, I explained to her parents the importance of insulin for survival. Sudha's poor and illiterate parents were very attentive. Finally her father asked:
‘Doctor, if I understand you correctly, does Sudha have to take insulin injections every day for rest of life?’
‘Yes.’
‘What would happen if she stopped taking insulin?’
‘Well, she would slip into coma and if left unattended, would die.’
Three months later Sudha had died. Her father had quite intentionally stopped giving her insulin. To the outsider he appears inhuman, cruel and criminal. But for him, the choice was between the starvation of his other children versus treatment of a diabetic child.
The average annual family income in India is Rs 50 000(£750/US$ 1185). The cost per annum for insulin and syringes alone is Rs 15 000 (£200/US$ 316). If blood glucose monitoring is included the cost is doubled.
With no health insurance cover, poor families find it difficult to commit over a quarter of their monthly income to the treatment of a diabetic child. The logic of poverty overpowers the logic of life.
Quoted, with permission, from a letter to one of the authors from Dr Sharad Pendsey, Consultant Diabetologist, Director, Diabetes Clinic and Research Centre, Nagpur, India and Managing Trustee, Dream Trust (www.dreamtrust.org).
In contrast, the world's wealthy are getting wealthier (as admittedly are the world's poor). The United Nations University's survey of the World Distribution of Household Wealth documents the divide with stark statistics [7]. In 2000, the richest 1% of the world adult population owned 40% of global assets, while the poorest half owned only 1%. Income correlates with success in all of the United Nations' Millennium Development Goals, including child health, universal education and putting an end to hunger [8]. The reasons for these differences in material wealth are complex and go far beyond the scope of this book. But although differences are material, the solutions may not be. This degree of material inequality indicates a profoundly dysfunctional global system. The United Nations, for instance, estimated in 1998 that the millennium goal of basic education for all could be attained by an additional global investment of US$ 6 billion (£3.8 billion). In that same year people living in the USA spent US$ 8 billion (£5 billion) on cosmetics, the people of Europe US$ 11 billion (£6.9 billion) on ice cream and the world community US$ 780 billion (£492 billion) on the military [9].
Population and consumption
In October 2011, the world population reached seven billion from a pre-industrial baseline of one billion, and the US Census Bureau estimates that the population will rise to nine billion by 2040 [10]. This growth equates to creating a new city of a million people every five days from now to 2050 [11]. One reason for this growth has been the Green Revolution (Chapter 6), which has been fuelled by new, energy-intensive ways of making nitrogenous fertilisers and the development of new disease and drought-resistant strains of grain [12]. An estimated 50% of people today depend for their calories on food grown using such artificial fertilisers. More people require more food, space, water and energy. Because some people consume much more than others, there is a good argument that the chief metric should be not population numbers per se but the per capita impact of each person on the earth's resources. The richest billion people on the planet consume, on average, 32 times as much as the remaining six billion [13]. The signs are that people in poorer countries now aspire to the sorts of lifestyles adopted in richer countries. Hence, any global transition to the western lifestyle will have a much greater impact than would be implied by population growth alone. Take, for example, an increasing appetite for meat in China and India (Chapter 6 gives an exposition of the environmental impact of animal protein). Rising consumption is, therefore, a greater threat than rising population. Fuelling such consumption is the rising tide of economic migration from poorer to richer economies, a tide that will certainly run stronger as climate change has its differential effects on the poorer world. This predicament lies in uneasy paradox with our first problem of inequality. We need the rich to consume less and the earth's poorer citizens to draw more on resources than they do already (these twin concepts of contraction and convergence are explored further in Chapter 3). An advantage of convergence is that family size tends to reduce as communities emerge from the extremes of poverty, easing population pressures [14].
Resource depletion
The resources of the earth, such as fossil fuels, are limited and even the energy we can extract each year from the sun is finite. In 2005, analysts reported that we had consumed half of all the earth's extractable reserves of conventional oil and gas [15]. They warned that remaining reserves would be more costly and more risky to exploit, as we saw for instance with the Deepwater Horizon disaster of 2010, in which an explosion led to oil gushing unchecked from the seabed and the biggest spill in United States' history [16]. This peak oil narrative holds true for conventional oils and gases, though the picture has become complicated because of the recent emergence of alternative hydrocarbon sources and extraction methods, such as shale oil and hydraulic fracturing. At current levels of consumption, supplies of conventional fuels are likely to be depleted by the end of the century, with much uncertainty over how alternative fuels, nuclear power and renewables will fill this energy void [15]. Experts predict substantive changes in the world economy as a result, including in the health sector [17]. If the supply of fossil fuels diminishes and prices rise, this will have severe implications for the delivery of healthcare, yet there is scant evidence that we are prepared for this transition. Imagine, for instance, running hospitals using 50% less energy than at present. Although such a situation might be desirable from a sustainability perspective, it would herald some fundamental changes in the way we realise our hospitals—changes that we need to start planning for now. The picture is set to be clarified in the next decade as the potential of alternative sources of hydrocarbons is established, though these will only worsen the problem of carbon emissions.
Water scarcity may turn out to be a bigger threat to global security than diminishing fossil fuels. Rivers such as the Rio Grande, the Nile, the Indus and China's Yellow River struggle to reach the sea throughout the year. We are taking water from rivers, lakes and aquifers faster than it can be replaced by the hydrological cycle [18]. Hydraulic ‘fracking’ for shale oil, our best hope for obtaining fossil fuels as conventional oil supplies decline, is an intensely thirsty process, pumping millions of gallons of water deep underground. Since fracking also forces chemicals underground, it has the potential not only to deplete but also contaminate supplies. The UN Food and Agriculture Organisation (FAO) estimates that 1.8 billion people will experience water scarcity by 2025. City communities such as La Paz in Bolivia, which draw their summer supplies from glacial melt water, are particularly vulnerable as glaciers recede due to global warming. Other resources in danger of depletion include rare earth metals such as neodymium (which makes the powerful magnets used in wind turbines), phosphates used in fertiliser production and uranium for nuclear fission. Like the Easter Islanders we are set to run short of the raw materials that underpin the processes of our civilisation.
Climate change
In October 2011, an independent and previously sceptical team of climatologists from Berkeley, California, confirmed findings from other centres that the average surface temperature of the earth has risen by one degree since 1950s [19]. This observation persists after adjusting for the possible confounding effects of urban heat islands, which are metropolitan areas that are considerably warmer than their surrounding rural areas. We know that the cause of this warming is mainly carbon dioxide from the burning of fossil fuels and that no other mechanism could account for the rapidity of the change (Chapter 2). The earth's poles are particularly sensitive. According to data from the US National Centre for Atmospheric Research, the extent of arctic sea ice has declined by 30% since 1979 [20]. With the melting of continental ice in Antarctica and Greenland comes the possibility of rising sea levels and the inundation of coastal communities. If evidence of current global warming is incontrovertible, it is much less certain how global warming will proceed as the century unfolds. We also do not know whether change will remain gradual or hit a tipping point as the earth system flips into a new and hotter state. The potential impacts of climate change on human health are huge and mediated particularly by loss of food security, through flood and drought, direct effects of extreme weather, expanding habitat for disease vectors such as malaria and the inevitable health consequences of mass migration from stricken areas [1]. Because of these pressing effects on health the whole of Chapter 2 is devoted to understanding the science of climate change and its impacts.
Loss of biodiversity
Perhaps we can rescue the climate, but once a species is extinct there is no going back. The current rate of extinction is thought to be between 100 and 1000 times the estimated background extinction rate (there are difficulties knowing for certain of the extinction of creatures such as ants at large in the Amazon basin). Many organisms are already ‘functionally extinct’ because they exist in numbers too small to have noticeable presence within their local ecosystems. Iconic examples include the Yangtze River Dolphin and the Iberian Lynx. The sociobiologist E.O. Wilson estimated in 2002 that, at current rates, one-half of all species on earth would be extinct in 100 years [21]. People seem remarkably unaware of the scale of what is happening—the greatest extinction event since the one 65 million years ago, when the dinosaurs and half of life on earth were wiped out by a meteorite or volcanic upheaval, or both. In our times a quarter of mammals, a third of those vulnerable amphibians, a quarter of corals and a quarter of freshwater fish are threatened [22]. Humanity has a long history of causing extinction of large mammals through direct predation; this still accounts for why so many species of fish and other cetaceans (marine mammals) are endangered. On land the mechanism of contemporary extinction has more to do with the depletion of habitats, as marshes are drained and forests cleared. Around half of the original six million square miles of tropical forest present in 1947 has now been destroyed. Current projections suggest that by 2030 we will be left with just 10% of the original coverage [23]. In specific pockets, such as Haiti, the tropical canopy is almost completely gone.
The impacts of such losses are incalculable and it takes particular imagination to grasp the impact of all this on human health. There is, for instance, the loss of plants and animals which might have turned out to have been of direct medicinal use. In his book The Future of Life, E.O. Wilson relates an anecdote in which a Bornean tree is discovered to yield a medicine active against HIV [21]. On returning to the remote swamp from where they gathered their sample, collectors found the tree had been felled and no more could be found. Luckily a specimen showed up in the Singapore Botanic Garden. What is harder to appreciate is how by removing species we ‘damage ecosystems, collapse food webs and ultimately undermine the planetary life-support system on which our species depends’ [24]. This is why we study systems in more depth in Chapter 3.
Crises in healthcare
So far we have defined five predicaments that confront us: inequalities, over-population with rising consumption, resource depletion, climate change and loss of biodiversity. We could add more, such as soil erosion, oceanic acidification and armed conflict. These predicaments are, of course, intimately interwoven. For example, fossil fuels have fuelled the development that stimulates population growth, which impacts on land use and, hence, biodiversity. We cannot solve these predicaments by simply doing more of what we are doing already. The threat to our lifestyle is our lifestyle. For instance, we will not be able to address the issues of material inequality by striving to bring the consumption levels of everyone up to the level of those in the wealthiest countries, as we are already exceeding the carrying capacity of the planet. These big picture predicaments are often removed from the daily work of healthcare professionals in the world's richer countries, though certainly not for those working in poorer ones.
Healthcare is a part of the global system like any other ‘industry’ and faces its own related suite of pressing predicaments [25]. Here we cite five crises in health, drawing on the Oxford English Dictionary definition of crisis as a ‘time of difficulty, insecurity, and suspense’ (Figure 1.2). Having defined these crises we go on to show, in this chapter and in the book as a whole, how sustainable healthcare offers at least the hope of solutions to the troubles of our times—solutions that the healthcare community will have a central role in bringing to life.
Figure 1.2 Crises in healthcare.
Crisis of chronicity
We know that the global population is growing. It is also aging. Japan, for instance, is estimated to be the ‘oldest’ nation that has ever existed, with one in ten of its citizens being over 75 years of age [13]. This demographic explains, in part, the shift in healthcare's orientation from the treatment of acute illness to the management of chronic disease. Chronic disease has always been with us but is emerging as the primary preoccupation of many healthcare systems, especially in higher-income countries. Take diabetes as a sentinel diagnosis, the prevalence of which is rising rapidly across the world. The number of people diagnosed with Type 2 diabetes in the United States rose by 33% between 1990 and 1998 [26]. Projections suggest that 29 million people will live with this condition in the United States by 2050 [27]. Diabetes is significant because it underpins trends in many other chronic health problems, such as heart disease and stroke. But why is diabetes becoming such a big a problem? The answer lies in a complex mix of demography, keener diagnosis and the worldwide emergence of another global health crisis—obesity. According to the World Health Organization (WHO), more people die from being overweight than from malnutrition [28]. The 500 million world citizens who are obese are at greater risk of diabetes, cancer, heart disease and a prodigious number of other ailments [29]. A particularly worrying trend is the emergence of obesity in children (Chapter 6). Healthcare systems across the world also face high burdens of cancer, autoimmune disease, respiratory disease and chronic infectious diseases such as HIV/AIDS and tuberculosis. Though we do not understand all the causes of these diseases, science has shown strong associations with modern sedentary lifestyles and the western diet. Being still is dangerous for our health. Never have we moved our bodies around the world so much without actually moving our bodies. In later chapters we will see how lifestyles and diet also contribute to our global environmental ills.
Crisis of cost
Richer nations invest vast and increasing sums of money in healthcare, most of it in the treatment of the chronic conditions referred to earlier. This expenditure continues at a time when most governments are seeking ways of spending and borrowing less. These two trends seem impossible to reconcile. European nations spend around 9% of their Gross Domestic Product (GDP) on healthcare; the United States spends an exceptional 17.4% [30]. The US Congressional Budget Office estimates that if the United States health budget continues to grow at current rates, the nation will be spending an unthinkable 31% of its GDP on healthcare by 2035 [31]. The high cost of healthcare is down to another complex mixture of factors as people live longer and accrue diagnoses. In the United States, for instance, one in two adults live with a chronic condition [32]. As medical science progresses, we find more things to do at higher cost. For instance, MRI scanning is now almost a routine procedure. And new drugs, especially for life-threatening disease, are often inordinately expensive: for example, 21 tablets (5 mg) of the myeloma treatment lenalidomide (Revlimid®), the subject of Adam Wishart's mordant documentary The Price of Life [33], cost the United Kingdom taxpayer an improbable £3570 (US$ 5643) [34]. In systems that are based on reimbursing physicians through private insurance companies, there are strong reverse incentives to cost containment. The more things health professionals do, the more they get paid. And the more insurance companies pay out to providers, the more they pass on in premiums. Predictably, these premiums can soon become unaffordable, so that in 2009 an estimated 50.7 million persons in the United States had no health insurance whatsoever [35]. In 2007, 625 of personal bankruptcies in the United States were due to medical fees that could not be paid [36].
Crisis of compass
If healthcare is unsustainably expensive in the rich world, we could at least hope that we are benefitting from the very latest scientific medicine and that this colossal expenditure is resulting in our better health. However, existing data do not uniformly support this optimistic hypothesis. On the contrary, evidence suggests that spending on healthcare is being invested in interventions that do not improve health. For instance, the Dartmouth Atlas Project has shown that patients who live in regions of the United States with a higher intensity pattern of care where they receive more visits, undergo more imaging examinations and are more frequently admitted to hospital, show no better survival rates than those living in regions with lower-intensity healthcare [37]. Billions are spend each year on coronary angioplasties and stents, yet a randomised controlled trial, published in April 2007 in the New England Journal of Medicine, found that these two procedures do not prolong life or prevent heart attacks in patients with stable coronary disease when compared to pharmaceutical approaches [38]. We also know from comparing data between nations that there is a poor correlation between expenditure on healthcare and longevity. For example, although Chileans and Americans enjoy similar average longevity (78.6 versus 78.3 years), healthcare spending per capita is, according to the Organisation for Economic Co-operation and Development (OECD), six times greater in the United States—and 25 times greater than in the famously low-cost Cuban system [39]. These data suggest that a high proportion of healthcare funds is being misspent, however well meaning and culturally reasonable the reasons behind this spending may be. This is, in part, due to the conflation of healthcare as part of a system of care, with healthcare as profit-driven industry. An independent review calculated that US pharmaceutical companies spent US$ 57.5 billion (£35.6 billion) in 2004 on promoting their products, giving them weighty influence over the delivery of care which is, inevitably, dominated by medication, even in less overtly commercialised systems [40]. And medication use is on the up in many clinical fields. For instance, the health service in England issued 39 million prescriptions for antidepressants in 2009, compared with 20.1 million in 1999, with no evidence that England is a happier country as a result [41].
Developments like these herald what we call the ‘crisis of compass’—a crisis in the purpose and direction of the healthcare enterprise. And what if ‘care’ is not only ineffective but actually harmful [42]? In 2009, there were 1.2 million visits to US emergency rooms due to the misuse of prescribed medications [43]. Even when used correctly, medicines can cause grave harms which are often not initially apparent. According to research published in The Lancet, between 88 000 and 140 000 excess cases of serious coronary heart disease occurred in the United States over the market-life of the anti-inflammatory rofecoxib (Vioxx®) before it was withdrawn in 2004 [44]. Even health promotion may have unforeseen problems. For instance, the United Kingdom's £96 million per annum National Breast Screening Programme is mired in controversy as epidemiologists debate whether it causes more harm than good [45]. So judicious use of investigations, medications and surgery will remain at the heart of good medicine. But, as we argue in Chapter 10, just because some treatment is possible does not mean that it is desirable. The direction we advocate is toward better health with, paradoxically, less healthcare, putting a firmer emphasis on broad, holistic and mainly preventative interventions. A welcome and convenient truth is that such interventions, be they preventative or therapeutic, are also, typically, much kinder on the planetary system.
Crisis of compassion
One of the effects of delivering so much in healthcare is that health professionals have become very busy, with more patients having more ‘done’ during shorter hospital stays and clinic visits. Whilst our therapeutic systems have advanced, there has not been a corresponding advance in our ability to meet the human needs of those in our care. In fact, by some indicators, the clinical frontline of medicine is uncomfortably short of humanity. The UK's Care Quality Commission found in 2011 that almost half of hospitals did not meet basic standards for nutrition and dignity in the care of elderly patients (Box 1.1 shows some extreme examples) [46].
Of course, individual doctors and nurses would never condone these depressing stories of neglect, but neither can we argue that they are exceptional. In a medical culture that focuses primarily on targets, costs and demonstrable physical disease, the humanity of individual patient care can get marginalised. In United Kingdom hospitals, a culture of ‘shift working’ has risked the fragmentation of individual care, as has the demise of ‘personal lists’ in family medicine, where patients receive the majority of their care from a single doctor. When suffering from routine ‘minor’ medical problems, patients want easy access to care, but when they are more seriously sick there is no substitute for caring longitudinal relationships, physical touch and attention to basic things such as nutrition, pain relief, dignity and privacy. Empathic skills, such as the ability to convey a sense of hope, do not figure highly in the modern medical curriculum and the evidence, though conflicted, points to medical students becoming less empathic as they progress through the clinical years [47]. Health professionals in training are also not themselves always treated with dignity and compassion. According to correspondents to an American Medical Association article on humanism, hospital Residents reported sarcasm, dysfunctional mentors, excessively long working hours, ridicule when seeking time off due to ill health, and doctors driven by the need to pay off huge educational loans as being common problems [48]. It is a paradox that while compassion is a relatively unlimited and ‘free’ resource, we are busy driving it out of the system, draining our limited and ‘expensive’ resources in the process. We need to consider compassion as another element of quality in healthcare which may sit in healthy tension with indicators such productivity and throughput (Box 1.1).
Crisis of carbon
The carbon crisis is, understandably, not one recognised by most health professionals, but is in fact the crisis dealt with most directly in this book. Healthcare consumes a great deal of energy on powering buildings, transport and the procurement of goods and services. The US Government's energy efficiency office, Energy Star, estimates that healthcare organisations in the United States consume US$ 8.8 billion (£5.5 billion) of energy per annum [49]. The NHS Sustainable Development Unit (SDU) attributes a full 3% of the carbon footprint in England to NHS-related activity [50]. While energy in Western societies appears to be plentiful and relatively cheap, we are facing two major challenges. Firstly, as stated earlier, the amount of energy at our disposal is likely to reduce as the century unfolds and the supply of cheap conventional fossil fuel begins to dwindle. Secondly, the effects of carbon dioxide emissions from fossil fuel consumption are powering climate change, and climate change is set to be a major challenge to global health (Chapter 2). So, healthcare is part of the problem in common with all other industries, and will also be called upon to be part of the solution. We come back to this predicament repeatedly in the book, particularly in Chapter 5 on ‘low carbon care’.
And so we conclude this catalogue of crises: of chronicity, cost, compass, compassion and carbon. As with the global predicaments detailed above, these five crises in healthcare are, of course, strongly interconnected. While cheap energy has helped build the freedoms of modern culture, we have often built these without respect for the ‘planetary boundaries’ that constrain us. Our wit in harnessing fossil fuels has allowed the human population to grow and consume exponentially, but those same fuels have allowed our habits to become sedentary and our diets industrial. Healthcare has also become more industrialised, bringing affordable medicine to millions. But where unchecked, such healthcare has also led to grossly inflated costs and prolific activity that contributes directly to carbon emissions—often without confirmed benefits to human health.
As argued already, these predicaments cannot be solved by the system that created them. We need new ways of thinking and acting. The sustainability paradigm we offer here is of course not new; it has roots back to the conservationists of late nineteenth century America, such as John Muir and Henry David Thoreau. In the twenty-first century, sustainability has moved from the fringes to the mainstream of politics and academia. Many institutions now have cross-faculty institutes concerned wholly with responses to global environmental change [51]. Even the British Medical Journal carried ‘The Greening of Medicine’ as its cover headline in January 2012. Sustainability cannot be cast as a paradigm in the formal scientific sense. The predicaments it addresses are set on too broad a canvas and our response is as much about political will as scientific theory. What is new here is the application of these ideas at the heart of the modern medical enterprise, where up until recently they have been largely overlooked. And what is paradigmatic is that sustainability requires us to see all things differently, considering, for instance, not just cost but carbon cost of common things like medicines and clinic visits. We call this new way of seeing ‘greening the medical gaze’.
Greening the medical gaze
In his influential book The Birth of the Clinic (1963), Michel Foucault (1926–1984) introduces the concept of the ‘Medical Gaze’, which refers to what doctors see when they view a patient and their predicament [52]. Seeing is more than a purely physiological process of light and neuronal pathways; it is a process of meaning-making. Health professionals learn how to ‘read’ visual objects such as microscope slides, X-rays, laboratory reports and even people for signs of diagnoses such as anaemia; we have borrowed this concept and applied it to our current situation, calling for an extension, or ‘greening’ of the medical gaze. While in the eighteenth century the medical gaze lighted upon the sick man in his home, in modern medicine it focuses on the results of clinical examination, blood tests and medical imaging in the clinic or hospital bed [53]. What we need now is a gaze that includes in its sweep how medicine sits within the Earth system as a whole, a subtle but revolutionary change of perspective from atomistic to holistic and from unbridled to sustainable development. This gaze does not supplant biomedicine. Rather it fits it into a necessarily bigger picture.
Sustainability defined
Environmental sustainability is too complex an idea to succumb to a unitary definition but, where the term is broached, consistent themes emerge. Sustainability is about looking after things now so that they can be enjoyed not only by us up to the end our lives but also by future generations. There is a sense of the long term, which is the antithesis of political expediency. The focus is on resilience, permanence and cycles rather than linear and unremitting growth: a steady-state approach rather than a frontier mentality. A seminal sustainability text is called, simply, The Limits of Growth [54]. Sustainability is concerned with relationships and how the different aspects of the earth system, such as climate, oceans, animals and plants, best work together. It is concerned, on one hand, with resources and how we can preserve them, and, on the other hand, with waste products and how we can best reduce or dispose of them. Thinking sustainably acknowledges planetary boundaries (Table 1.1) and seeks ways for humans to thrive within them. It views humans as guardians and stewards, not owners. The sustainability paradigm is values driven, seeing it as, for instance, unfair if the Earth's resources are exploited by some communities at the expense of others, including communities as yet unborn, with no choice or voice. We unpack the sustainability paradigm in more depth in Chapter 3, where we draw on the insights of systems theory. Sustainability then is not a single theory but a collection of tools, or lenses (theoretical, scientific, ethical and political), that bring possibilities into our field of vision that have until now gone unnoticed in our peripheral gaze—the perfect antidote to a ‘crisis of compass’.
Up to now the medical sector has taken the gifts of the planetary system for granted. But by considering the sustainability perspective, health services will, for example, consider fossil fuel a precious resource that could provide hydrocarbons for medical plastics and pharmaceuticals into the deep future. To use fossil fuels as fuels does not make a lot of sense. If instead we go for active travel, walking and cycling instead of flying and driving we help keep oil and coal in its ideal environment—under the ground. And, at the same time, we improve our mood, become physically stronger and healthier, and stop emitting the exhaust gases which contribute to climate change and bad air in our cities. Observe how a single sustainability approach (active travel) is able to tackle a number of major predicaments at the same time. This is referred to as a virtuous cycle: what is good for the environment is also good for health (Chapter 3).
