Sustainable Healthcare

Knut Schroeder, Trevor Thompson, Kathleen Frith, David Pencheon

• Publisher: BMJ Books
• Year: 2012
• ISBN:
  9781118342534
• Edition: 1
• Topic: Medicine
• Subtopic: Health Policy

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

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).

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Case study 1.1 The fate of a child with diabetes in rural India

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 insu...