Our fight against climate change

Dear Dr. Ladouceur:

Thank you for your excellent recent editorial on climate change. It is an important issue to raise with the CFPC membership. Please find below a response to your question about what we can do.

Motive, means and opportunity

In many ways, what family physicians need to do to address climate change is the same as every other person – critically examine their every action, ask whether there is a more sustainable approach and then choose it.

But Canadian family physicians can and should do more, not only because the responsibility “to advocate public policy that promotes our patients’ health” is embedded within the principles of family medicine but because we, more than most others, are among those with the greatest opportunity to do so.

We cannot plead ignorance. We have the intellectual capacity to understand the science and its implications for the health of our children. We have the critical analytic skills to recognize that the climate crisis is being driven by the authors of this “fairy tale of endless economic growth”* who profit from the status quo, enticing us to buy ever more, peddling single use medical devices in the name of patient safety, and threatening us with economic collapse if we don’t “do our part” in sustaining the existing, carbon-based economy (despite examples from countries like Germany which prove this to be false).

With our six-figure incomes, working within the healthcare system of one of the wealthiest countries in the world, we have the means, both privately and on a systems level, to make more sustainable choices. If we can’t buy less, at least we can “buy better”. And as is so often the case, those of us who can afford to make sustainable decisions like purchasing electric vehicles, doing facility energy or waste audits and investing in green technology will actually benefit financially in the long term.

As physicians we can use our powerful voices to influence change at every level. If we lobby our associations, they will be empowered to lobby governments. But change on the scale required will not be easy and we need to care enough to do it. Replacing a few lightbulbs and recycling a bit of trash is not enough. Ocean cruises, Black Friday consumer orgies and our ever-accumulating mountains of unnecessary medical waste are incompatible with a happy ending to this story. To fix the problem we need to make some sacrifices. If we don’t, future generations will indict us for our selfishness – for having had the motive, means and opportunity to help avert this crime against humanity and for doing nothing.

*(Greta Thunberg, at the United Nations Climate Action Summit)

Ilona Hale, MD, CCFP
Dave Hale, M Env Mgmt

Thank you for the invitation to consider our role as family physicians relating to climate change.
We see an ability to act at three levels: 1. personally, 2. in our offices/practices/local communities and 3. advocating for change at the provincial and national level.

You have highlighted in your article some of the things that individual family physicians are doing personally by changing their diets (1) and adopting active transportation (2) (cycling and walking instead of driving).

At the practice level, many interventions have appeared in the CFP (3) and are included in the https://greenhealthcare.ca/green-office-toolkit/. Establishing a clinic “green team” can help to support these office-based initiatives as physicians are often looked to for leadership.

The Climate Change Toolkit for Health Professionals, produced by CAPE, is a solid resource for both practice level and advocacy work: https://cape.ca/wp-content/uploads/2019/04/Module-8-FACTSHEET-READY-TO-U...

We know that translating clinical knowledge from study to practice takes time. Translating knowledge about climate change from basic science to practice and advocacy will also take time. Recognizing that time is not on our side in this issue, we need to create ways to decrease translation time by sharing with patients and colleagues. One example of an opportunity to share information with patients is through the use of shared information sheets, like those that CAPE has provided in their toolkit.

At the community level, family doctors are good candidates to become involved in teaching about the impacts of environmental degradation as we tend to be prominent members of remote and rural communities - communities that are already feeling the effects of climate change (4). We can also share the information with our colleagues in training. A recent article highlighted the formation of a medical student group called HEART that is calling on medical schools to provide more teaching on the subject of climate change (5). We’re in a position to teach learners about tools that are available to them such as Choosing Wisely, which helps support appropriate (and usually less) testing. Furthermore, as students learn by example, we can be role models by putting some of the above into practice.

To encourage local colleagues in the advocacy effort, it would be helpful to have templates of letters or presentations with key messages that can be used in presentations to local organizations, whether it's a clinic, hospital, or community. Another resource we recommend sharing among colleagues are letter templates that can be used for writing newspaper comments and communicating with politicians.

We would suggest that the CFPC create on its website a repository of links to other well informed organizations (like CAPE), toolkits for use in practice, and letters and tools of advocacy and education that could be used to support the busy clinician to support the climate change effort. Recent articles on green changes have been very helpful in inciting us to action - the Canadian Family Physician could encourage others as well by including a regular column or section to keep this issue at the forefront of our minds and family physicians at its leading edge.

We'll keep trying to effect change but it will take time - we think we have a large part to play.

References

1. Grant JD. Time for change: Benefits of a plant-based diet. Canadian Family Physician. 2017 Oct 1;63(10):744–6.
2. Green S, Kim S, Gaudet M, Cheung E. Doctor’s prescription for cycling. Canadian Family Physician. 2018 Oct 1;64(10):715–6.
3. Blau E, Asrar FM, Arya N, Schabort I, Abelsohn A, Price D. Greener medical homes: Environmental responsibility in family medicine. Canadian Family Physician. 2016 May 1;62(5):381–4.
4. Kipp A, Cunsolo A, Vodden K, King N, Manners S, Harper SL. At-a-glance - Climate change impacts on health and wellbeing in rural and remote regions across Canada: a synthesis of the literature. Health Promot Chronic Dis Prev Can. 2019 Apr;39(4):122–6.
5. Mercer C. Medical students call for more education on climate change. CMAJ. 2019 Mar 11;191(10):E291–2.

‘What can doctors do to mitigate the climate emergency?’.

In Fall 2018 the UNIPCC came out with their unequivocal dire warning that there is a limited time to reduce our carbon footprint, in order to keep global temperature rise to less than 1.5 degrees Celsius. Right now is the narrow window of time to change our ways. If we don’t reduce emissions substantively and soon, feedback loops will take effect, so that later human efforts will have little impact.

This was an ambulance siren deafening my ears, and demanding attention, STAT!

I’m a physician, I should know what to do in an emergency. And this is a Climate Emergency.

But there I sat, wondering what I could do in my little life to make a difference.

Then along came Greta. If you’ve been under a rock for the past year, and don’t know Greta Thunberg, she is a 16 year old girl from Sweden who has single-handedly started an international Student led movement of Climate Awareness and Strikes, starting simply by sitting outside her parliament every Friday to demand government action on Climate Change.
As she so pointedly says, ‘The only hope is in action’.

So here is my plan, feel free to adopt any and all ideas, and let me (and everyone else in your life) know if you have more suggestions.

There is so much that physicians can do, and I think ultimately must do. I believe as physicians we have a very unique and important voice to lend to the chorus demanding action on this Climate Emergency.

I think of actions as taking place in three overlapping spheres - ‘The three P’s’:Personal, Professional/Public and Political.

Personally:

On New Years Eve, our family chooses a word and lights a candle to help guide and inspire us for the upcoming year.
My phrase this year was ‘ Every Day Matters’ as a reminder that the twelve years the UNIPCC report gave us, will go very quickly - now 11 years. Ideally we as a human family will move more quickly than this.

I made a commitment to try and do something everyday towards mitigating climate change.

Step one: Educate myself
I decided that I would make an effort to read, watch or attend something every day, or at least every week so I could learn what actions are the most important.
I write a reminder in my calendar every Sunday to review what I’ve done and re-commit.

When I started the year, I actually didn’t know what actions would have the most impact- until I came across this article that ranks the carbon saving of personal changes you can make.(1)

A key thing I learned is that the ultimate goal is for each of us to live a carbon neutral life, and the sooner, the better. That means that the carbon we use is offset by natural systems that use up CO2, to keep CO2 levels stable.

A ‘Carbon neutral life’ means getting our personal carbon footprint down to 2.1 tons of CO2 equivalency (tCO2 e) per year. (CO2 is just one of the important Green House Gases (GHG), and so this number also takes into account other GHG like methane and nitrous oxide)(1).

The average Canadian has a footprint of over 13 tCO2e. If you take 1 transatlantic flight and eat meat, you are at 2.4 tCO2e per year- not carbon neutral, and this does not take heating, car use etc into account (1).

The top 4 things an individual can do are (1) :

I. Have 1 less child (Saves 58.6 tCO2e per year - developed countries);
2. Avoid Airplane travel (Saves 1.6 tCO2e per 1 round trip transatlantic flight);
3. Live Car Free ( Saves 2.4 tCO2e per year);
4. Eat Plant based diet (Saves 0.8 tCO2e per year. It’s estimated that each cow emits 25 Liters of methane per day in the process of fermenting their food-whether it is grass fed or grain fed- but that’s a whole other story.)
(For a complete ranking see article below) (1)

Divest from Fossil Fuels today.

Encourage your banking and academic institutions (and pension funds) to divest from fossil fuels.

Make donations to your Alma mater contingent on their divesting from fossil fuels. Let them know that is what you are doing.

Be aware that you vote every day with your wallet.

Support what you want. (Triple bottom line companies). Don’t ‘feed’ what you don’t want. (i.e. single use plastics).

Professionally/Publicly:

What is clear is that the urgency of the climate crisis calls for more than individual action.
We must work together across all society to bring in legislative changes that will decrease industrial/business contributions to Climate Crisis.
We must tax what we don’t want. We must not subsidize what we don’t want. (TransMountain received $320 million in subsidies in first half of 2019) (2).
Information from the International Monetary Fund (IMF), states that in 2015, Canada provided $40 billion US in subsidies to the fossil fuel industries. (3).

Here in BC, even if every individual did all they could to mitigate climate change, we would still not meet the modest target of 30% reduction in CO2 levels (below 2005 levels), by 2030. Mining and LNG Fracking are the biggest emitters of GHG’s in BC (4).
BC needs to ban or place an immediate moratorium on LNG Fracking and support workers in these areas to transition to sustainable well paying jobs. (Fracking is banned/ moratorium called in New Brunswick, Nova Scotia, Quebec and Newfoundland. Most recently banned in England due to concerns re: increased risk of earthquakes)

Get/Stay informed: Join the Canadian Association of Physicians for the Environment (CAPE) and/or Canadian Physicians for Extinction Rebellion, or any local group working towards Carbon Neutrality. (i.e. Climate Action Network)

Work within your health authority to reduce carbon footprint, single use plastics and increase awareness of the Climate Emergency.

Start a local CAPE group of Physicians for support, education and actions. ( I had CAPE Central office send out my email to other CAPE members in Victoria and we had our first meeting of 9 physicians get together this past week).

Keep the October 2019 issue of Readers Digest in your office. (we all likely received this as unsolicited mail to our offices, but it actually has an excellent simple article itemizing the health consequences of the climate emergency, from cardio-respiratory, infectious diseases, climate anxiety/despair, the threat of decreased global food production to mass migration due to fires, flooding etc.)

Put up a notice in your waiting room, inviting patients to think about ways to reduce their carbon footprint and/or engage with municipal.provincial federal levels of government.

Support student led Climate Strikes by showing up at rallies (Fridays For Future) and identifying yourself as a physician- wear a mask +/-stethoscope +/-lab coat +/- carry a sign. Let our young people know they are not alone.

Attend talks and/or Present talks to colleagues/community groups re: the health consequences of climate crisis.

Subscribe to on-line sources of credible information such as David Suzuki organization and/or 350.org- there are many more...

Politically:

Call and write your MLA and MP. ‘Let them know you are watching’. Write CFPC and other news media/newspapers with ideas. Support your local newspaper. Support independent journalism. Write your MP demanding urgent action for a Green New Deal for Canada.

The Climate Emergency is the biggest threat to human health and on a scale almost unimaginable. I believe Physicians should be front and center in educating ourselves, our patients and demanding that politicians act with the urgency this problem demands.
This is the most important patient advocacy issue of our time.

In summary:

Global GHG accumulation is the result of billions of individual and political decisions that get made every day. Weigh personal, professional and political decisions, based on the impact of their GHG emissions. I don’t want to have to look my children and grandchildren in the eye and explain why I didn’t do everything I could to leave them a livable planet.
As Greta says: “Keep hope alive through action”.

Dr. Jan Ray Victoria, BC, Dec 4, 2019
janet.ray{at}viha.ca

(1) Wynes,Seth and Nicholas, Kimberly 2017 The Climate Mitigation Gap: education and government recommendations miss the most effective individual actions Published 12 July 2017 c 2017 IOP publishing Ltd, Environmental Research Letters, Volume 12, number 7.

(2) Kane, Laura Times Colonist Wed Nov 20, 2019 P. D1 (Business section)

(3)https://www.imf.org/en/Publications/WP/Issues/2019/05/02/Global-Fossil-F...

(4) Hoekstra, Gordon, Https://Vancouversun.com/author/gordhoekstrasun Latest Figures show BC’s carbon Emissions continue to increase January 12 2018.

Thank you, Dr Ladouceur, from bringing this topic to the journal.

The WHO considers climate change to be the greatest health challenge of the century. As physicians, we are holders of knowledge in health matters, who act and advise with the best interests of our population in mind. As such, it behooves us firstly to educate ourselves on this critical health issue, and secondly be part of thoughtful solutions.

The CFPC can play a leadership role in providing such educational opportunities for family physicians, perhaps through the journal as well as through FMF and other live forums. We can learn about the ways our practice of medicine is impacting the climate (the health sector is estimated to contribute 5-10% of global greenhouse gases), as well as how the climate is impacting our health. We can learn ways to mitigate our impact on the environment, as well as how we can adapt our health systems to the changing climate. We can participate locally as well as help our colleagues globally where the impacts may be greatest. The CFPC can consider partnering with CAPE and other organizations to provide this education. Perhaps the CFPC can also develop ways to provide leadership and advise policy makers on the best way forward with solutions in the health sector.

A fundamental change in our world view is necessary as well. Our beautiful planet, even with it’s changing climate and natural disasters, is still our home, our vital source of nourishment and sustenance, our source of life. It is also home to myriad living and non-living beings, and who directly or indirectly sustain us as well. We must not fight our beloved Earth, but rather provide care and protection for it and all who call it home.

Healthy planet, health people.

The scientific evidence linking human burning of fossil fuel with climate change is overwhelming. Tens of thousands of Canadians were evacuated from their homes because of the wildfires in Alberta and British Columbia in 2017 and 2018. Salmon are becoming scare in BC rivers. These events are due to climate change.

In the future, farmers may have to give up on non-irrigated land in southern Alberta and Saskatchewan. Deserts will expand in the United States, Africa, India, and China. Anticipate flooding of low lying coastal parts of Canada, the United States, Europe, China, Bangladesh, several Pacific island nations; and the lower valley of rivers including the Fraser, St. Lawrence, Mississippi, Rhine, Po, and Yellow. Flooding will tend to occur during storms and high tides, as happened in the Netherlands in 1953, and in Venice in 2019.

Dr. Ladouceur asked, "What can we as the family medicine community ... do to be more involved in the fight against climate change?" I recommend that we lead by example, and that we advocate for positive change.

The use of a personal vehicle adds much carbon dioxide is added to the atmosphere. If possible, get around on foot or by bicycle. Such activity promotes cardiovascular fitness, weight loss, and raises HDL cholesterol. If you must drive, use a small gas-electric hybrid.

Eating meat, especially beef, requires the use of fossil fuel to produce fertilizer, to irrigate grass and cropland, and to power the plows, planters and combines needed to produce animal feed. We might as well eat a plant based diet. The Mediterranean diet has been shown to reduce the risk of MI and to prolong life. There is active research on the association between diet, intestinal microbiota, and health. Eating soluble fiber (found in plants) has health benefits.

We burn fossil fuel to heat buildings and water, and to cool buildings in the summer. Make sure buildings are well insulated, and that doors and windows don't leak. In the winter, wear a sweater and keep the thermostat at 16 Celsius. In the summer, don't crank the air conditioning up. Take short showers.

Air travel contributes to global warming. Travel only when necessary.

As a community, family doctors could do the following:
-minimize the numbers of meetings;
-note that we accept the link between burning coal, oil and gas, and climate change;
-urge the provincial and federal governments publicize their details of their support for the oil and mining industries;
-consider supporting the carbon tax;
-partner with family doctors and family medicine associations in other countries. Most of the people who will be displaced by climate change live in middle and low income countries. Most of the fossil fuel is burned in middle and high income countries.

Politicians shy away from imposing a carbon tax for fear of losing votes. Politicians may accept donations from wealthy corporations. Family doctors look after people over years, and are well positioned to advocate for measures which will preserve the equanimity and biodiversity of the planet.

We only have one planet. Let's keep it healthy, so that we can stay healthy.

I appreciated Dr. Ladouceur's article. One of the first proactive things we can do is to start talking to our patients about climate change, planetary health, and its connection to human health and mental health. By voicing our own concern about climate change and framing the discussion around health effects, we can have a role in improving patient understanding that this is a real thing (for the sceptics) and to act (for those who are already on-board but don't know what to do!). Actions such as active transportation, composting, reduced air travel, and dietary changes are important for us to model. And this can inspire our patients to do the same, ultimately translating to meaningful health and climate benefits in our communities. We can even be more proactive by being a voice within an organized group, such as CAPE, thereby sharing the message to wider forums such as other physicians in our communities.

But I submit that these actions will not translate to meaningful outcome without a coordinated commitment by our political and business leaders to step up to the plate also. We have got to where we are because governments have not heeded or acted on the warnings that have flown from multiple scientific bodies with increasing urgency for the best part of thirty years. And because of that wilful avoidance of the facts, we are now in an emergency situation with just 11 years to avoid a global climate catastrophe. So, whilst I agree that individual actions are important, our government needs to be held accountable; our elected representatives need to tell the truth and then act on it. Green-washing and focus on individual actions will not lead to enough change in the time we have. There needs to be enacted legislation and also recognition that for our planet to survive, some tough decisions need to be made.

This means that right now, on our professional watch, we need to step up and do more than just talk and sign petitions. Extinction Rebellion (XR) is an international decentralized organization that is mobilizing through non-violent direct action. XR started in November 2018 in the UK, and has developed subgroups including DoctorsforXR (https://www.doctorsforxr.com). I would encourage anyone who is interested in taking the fight for our planet to the next level to look in to their local XR group and think about joining....who knows, maybe a Canadian Doctors for XR is in the works....All hands on deck (retired and working!!)

https://extinctionrebellion.ca/

Rashmi Chadha MBChB MScCH CCFP (AM) MRCGP DCH DRCOG

Dear Editor,

Thank-you, Dr. Ladouceur, for appealing to Canadian family physicians for strategies to fight climate change and preserve our planet.

One idea is for CFPC and its provincial and territorial counterparts to demonstrate leadership at conferences, starting immediately. Serving predominantly plant-based meals, avoiding single-use plastics, and offering and accrediting “tele-presence” at conferences could all be done routinely. This would substantially decrease our carbon and environmental footprint as a group of health professionals (1–3). These efforts could be publicized to set an example.

Regrettably, at the Wednesday lunch of FMF 2019, for every 3 rows of plant-based offerings, there were 10 rows of meat (roast beef or chicken). This is in line with neither Canada’s Food Guide (4), nor the EAT-Lancet Commission (5). Thankfully, the packaging and utensils were mostly compostable. A large number of physicians flew across the country to attend the conference and it is unclear (after having inquired at CFPC) whether there were options for participating remotely.

In line with our CanMEDS-FM roles of leadership and advocacy, the Canadian public should view family physicians as exemplars in matters of health. We call on CFPC and its provincial and territorial colleges to immediately organize conferences to be consistent with current scientific evidence.

Dr. Tomislav Svoboda MD MSc PhD CCFP FRCPC, Associate Professor;

and Dr. Kimberly Wintemute MD CCFP FCFP, Assistant Professor,

University of Toronto

1. Coroama VC, Hilty LM, Birtel M. Effects of Internet-based multiple-site conferences on greenhouse gas emissions. Telematics and Informatics. 2012 Nov 1;29(4):362–74.
2. Tilman D, Clark M. Global diets link environmental sustainability and human health. Nature. 2014 Nov;515(7528):518–22.
3. Xanthos D, Walker TR. International policies to reduce plastic marine pollution from single-use plastics (plastic bags and microbeads): A review. Marine Pollution Bulletin. 2017 May 15;118(1):17–26.
4. Health Canada. Eat protein foods [Internet]. 2018 [cited 2019 Nov 14]. Available from: https://food-guide.canada.ca/en/healthy-eating-recommendations/make-it-a...
5. Willett W, Rockström J, Loken B, Springmann M, Lang T, Vermeulen S, et al. Food in the Anthropocene: the EAT–Lancet Commission on healthy diets from sustainable food systems. The Lancet. 2019 Feb 2; 393(10170):447–92.

I welcome the opportunity to respond to Dr. Ladouceur's challenge to the
family medicine community to become more involved in addressing the climate
crisis. We need to acknowledge the public health effects of climate change,
educate our membership and patients about mitigation and adaptation
strategies, advocate for meaningful political change and contribute to local
adaptation efforts. Fortunately, in terms of reducing our professional
environmental impact we need not reinvent the wheel. The Green Office
Toolkit:
https://greenhealthcare.ca/wp-content/uploads/2018/04/Green-Office-Toolk...,
provides a practical approach to 'greening' ones practice. Likewise, CAPE has
published the Climate Change Toolkit for Healthcare Professionals:
https://cape.ca/campaigns/climate-health-policy/climate-change-toolkit-f...,
and the comprehensive resource guide: Preparing Health Care Facilities for
Climate Change:
https://www.greenhealthcare.ca/climateresilienthealthcare/CCGHC-Resilien...
offers a wealth of related information.

In our small community hospital, the Green Action Group is working through
the Canadian Coalition for Green Healthcare's, Green Hospital Scorecard:
https://greenhealthcare.ca/ghs/.

I agree with the Lancet's proclamation in 2009 that climate change is the
biggest threat to the survival of humanity. The Lancet Countdown’s 2018
report underscores that concern, concluding that the pace of climate change
is outweighing the urgency of our response. Together, I believe that Family
Physicians can (indeed must), work together to tackle this existential
threat.

Reference: https://doi.org/10.1016/S0140-6736(18)32594-7

I felt I had to answer the question about what we can do as a medical community to be more involved in the fight against climate change, as this is an area in which I passionately believe and one which seems to be ignored by a portion of the medical community.

Dr. Ladouceur mentioned some of the individual contributions we can each make. Some of these include using active means of transportation to lessen our use of fossil fuels and eating less meat or no meat to decrease the impact of raising and harvesting animals for food. Other examples are decreasing our plastic purchasing and use, reducing our consumerism, and reusing items before thinking about recycling them or throwing them in landfills.

From a larger medical community perspective, we can attempt to influence our patients and colleagues by example and by discussions with them regarding healthier food and transportation choices which affect personal and climate health. We can encourage careful use of power sources in our clinics and hospitals by turning off computers, printers and lights when not needed, and turning down the heat in the winter and the air conditioning in the summer. We can adjust temperatures appropriately for nighttime and weekends when the clinic is empty. We can print on paper only when absolutely necessary and always two-sided on recycled paper. We can stop using paper patients’ gowns and sheets. We can take part in hospital planning to decrease the amount of garbage on patient food trays by using reusable plates, cups, and glasses, instead of disposable options.

We can attempt to influence our communities by participating in political meetings about anti-idling bylaws, active transportation corridors, and recycling programs. We can hold advocacy meetings at local libraries to teach the public about ways to change their environmental impact. Dr. Ladouceur also mentioned joining environmentally important organizations like Canadian Association of Physicians for the Environment, to support monetarily fights against pesticides, and other health and climate-related topics, as well as gain education for ourselves about other ways we can be more environmentally conscious. (They have an eight-module toolkit for health professionals on climate change advocacy).

If each of us incorporated these suggestions into our personal and professional lives (as well as many other suggestions which would come up in discussion), we could make some impact on changing our children’s future earth.

Nicola Wilberforce
Membership number 219230