Planetary health lens for primary care

Climate change and environmental degradation are rapidly becoming 2 of the most important determinants of future human health. Although limiting the rise in the average global temperature to 1.5°C above pre-industrial norms was agreed upon as the target of the Paris Agreement in 2015, in Canada we have already reached a national average temperature that is 1.2°C higher than the 1961 to 1990 reference value.^1,2 Climate models indicate the planet is on track to hit a median global warming of 2.8°C within the lifespan of children born today.³ This level of warming is expected to lead to increasingly dramatic, unpredictable, and likely irreversible harms to the planet and to humanity.

Humans cannot remain healthy in an increasingly unhealthy environment. The concept of planetary health was developed to remind us that human survival relies on protecting the planet’s natural ecosystems that provide us with clean water, land, and air and a stable climate.⁴ As the climate changes, health harms related to increasingly frequent and severe wildfires, heat waves, and drought and to the spread of vector-borne diseases will contribute to greater demand for health care and further threaten our already precarious health care systems, all while facilities and health care workers themselves will face these same threats.⁴

The health care sector, despite its mandate to protect health, is part of the problem, contributing 4.6% of Canada’s total greenhouse gas (GHG) emissions.⁵ Additionally, the Canadian health care system has some of the highest per capita GHG emissions in the world.⁶ Yet as providers we rarely pause to consider how our actions in health care translate into consequences for the planet; resource-intensive care has become part of our health care culture and many assume it to be necessary to ensure the delivery of safe, high-quality care. Other countries’ health systems have lower GHG emissions per capita with healthy life expectancy at birth equal to or exceeding that in Canada; clearly, high-quality, low-carbon care is possible.⁷

In fact, if one considers the accumulating short- and long-term negative health consequences of the current system, it becomes clear that environmentally sustainable health care is not only possible but is also necessary to provide care that does no harm. Funded by Environment and Climate Change Canada, CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis) is a multiyear capacity-building initiative that aims to address health care’s contributions to the climate crisis; it considers environmental sustainability a “pre-requisite, goal and outcome of high-quality care.”⁸ To embrace this idea, policy-makers and health care providers will need to make some fundamental shifts in how we think about health care. We can no longer afford to ignore the broader impact of our actions as individuals and leaders given the finite resources of the health care system and of the planet. We need to carefully consider how best to use these resources to benefit our own patients without compromising the ability of our system to provide high-quality care to others in a timely way, both for present and future generations.

Principles of environmentally sustainable health care

Most of us who work in health care are distressed by the physical waste and ever increasing quantities of single-use, disposable products we see in our system. When asked, most health care providers believe something should be done to address the problem,⁹ but it is difficult to know where to begin and how to have the greatest impact.

Traditionally, leaders and practitioners have thought of environmental action in health care settings just as we have in our personal lives, focusing on recycling, saving energy through retrofits, and buying more energy-efficient products. While these actions may reduce the amount of waste that ends up in landfills or decrease energy consumption in the short term, they can also create incentives that actually encourage more consumption. More importantly, the physical waste we see is just the tip of the iceberg since in health care most GHG emissions come from outside facilities, upstream in the supply chain.^5,10 In a study of the National Health Service in England, 62% of its GHG emissions in 2019 came from the supply chain alone.¹⁰ When we send someone for a laboratory test or prescribe a medication, large amounts of energy and resources are required to produce the supplies and equipment needed to manufacture, process, transport, and obtain these products.

Fortunately, adopting a planetary health lens can reveal many opportunities to reduce this hidden environmental impact through more sustainable clinical decision making. Every clinician can be a climate advocate simply by using existing tools at work in a new way, every day, with multiple co-benefits: increased equity, better patient outcomes, and lower time and cost burdens for patients and for providers.

The Centre for Sustainable Healthcare (formerly the Campaign for Greener Healthcare) in the United Kingdom has developed a framework that helps us identify opportunities for providing higher-quality, environmentally responsible, and economically sustainable care.¹¹ The framework brings us back to the fundamental roots of practice as primary care physicians as healers, using our basic skills of listening to our patients, trusting our physical examination findings, using sound professional judgment when ordering investigations and pharmacologic treatments, and using the healing power of time and longitudinal relationships. A new Canadian guide, Planetary Health for Primary Care,¹² expands on the 4 principles of environmentally sustainable health care: reducing unnecessary care, empowering patients, shifting our focus to health promotion and prevention, and choosing lower-impact alternatives. Figure 1 is a handout that summarizes the guide.

Figure 1.

Handout summarizing 4 principles of environmentally sustainable health care

Avoid unnecessary care. Medical advances in curing illnesses and in extending human lifespans have led to the perception of health care as an absolute “good.” However, there is a point at which the benefits of more and more health care are outweighed by associated harms, beyond which there are diminishing returns and increased exposure to harms.¹³ There is an optimal level of care that limits both underuse of effective services and overuse of inappropriate interventions, resulting in the highest quality health care for individual patients and populations. Low-value or unnecessary care is defined as “care that provides minimal or no benefit, considering the harms, the costs, alternatives and the preferences of the patient.”¹⁴ It is estimated that up to 30% of the investigations and treatments ordered in health care are potentially unnecessary and an additional 10% actually result in direct harm to patients.^15,16 There are subtle, often subconscious drivers of overuse: outmoded regulations, habit, training, fear, disinformation, time pressures, and assumptions about patient preferences. This unnecessary care can increase wait times, waste health care dollars, and increase workloads. Unnecessary care also has an enormous environmental cost, given the energy and resources needed to produce the materials required for each medication, investigation, and health care visit. Reducing unnecessary care is one of the most important ways to reduce our environmental impact while continuing to provide high-quality care to patients.

Empowering patients. Patient- and family-centred care is a cornerstone of safety and quality in health care. Engaging patients in shared decision making and encouraging them to be active participants in the management of their own health conditions have been shown to improve patient outcomes and are essential to the sustainability of health systems worldwide.^17,18 These approaches can also reduce the environmental impacts and costs of care by reducing unwanted care and helping patients be more independent and less reliant on intensive health care services.¹⁹

While the slow medicine movement may not be aligned with many current high-volume, rapid-paced practice styles, having the opportunity to embrace its principles would allow providers to practise more patient-centred care.²⁰ In a 2021 Canadian survey of the public, most respondents indicated they care about climate change and are interested in less carbon-intensive treatment and care delivery options where available.²¹

Shift to prevention. An important approach to reducing our environmental impact as a health sector is to shift our focus away from resource-intensive secondary and tertiary medical treatment and toward health promotion and disease prevention opportunities that have health, social, environmental, and cost benefits.^22,23 Our medical system is primarily designed to treat illness, with Organisation for Economic Co-operation and Development member countries devoting on average only slightly more than 5% of health care expenditures to prevention; yet an examination of the factors that truly affect peoples’ health reveals the most important determinants are those outside the formal medical system, such as income, environment, housing, nutrition, and early childhood development.^24,25 Dedicating resources to prevention is fiscally responsible and promotes greater health equity, allowing us to help the greatest number of people. Avoiding underuse of effective preventive care strategies such as vaccinations, appropriate screening, and management of chronic conditions to prevent long-term complications is as important to health care sustainability as avoiding overuse.²³

Choose environmental alternatives. It is often possible for clinicians to choose products and practices with lower environmental impacts. Using nonpharmacologic options when appropriate can reduce environmental impacts. When medications are necessary there are often lower-impact products available, such as dry-powder inhalers instead of metered-dose inhalers; long-acting formulations instead of short-acting formulations, such as intrauterine devices instead of daily oral contraceptives; and oral rather than parenteral formulations when appropriate.^26,27 Choosing virtual options for patient visits, meetings, and conferences can have important environmental benefits.^28,29 Favouring reuseable or environmentally preferable products generally results in total life cycle cost savings and increased resilience in the face of supply chain disruptions.³⁰

While these 4 principles can be applied by practitioners in any discipline,³¹ primary care providers are particularly well-positioned to embrace them given our expertise in health promotion and in collaborative, longitudinal, patient-centred care. Adequate access to high-quality primary care can help patients avoid more intensive secondary or tertiary interventions, which are associated with higher environmental impacts. In Canada 25% of emergency department visits are related to “ambulatory care sensitive conditions” such as diabetes, hypertension, and chronic obstructive pulmonary disease, reflecting inadequate access to primary care.²³ In private practice there are also fewer institutional barriers to address compared with inpatient settings and small, effective low-carbon solutions can be implemented easily. As trusted allies and gatekeepers, family physicians have a unique opportunity to limit overuse and its cascading effects.

Conclusion

Adopting a planetary health lens provides a new way to think about environmental sustainability in primary care. With many providers working together to incorporate the 4 principles of sustainable health care into our everyday work, we can help reduce the health sector’s environmental footprint with additional benefits for patients, providers, and the health care system.