Cite as: Singh G. Climate change and childhood. Sushruta 2020 (Jul) vol 13; issue 2: ePub 09.04.20
When I was a child, I was a proud member of the World Wildlife Fund for Nature. I would pore over my issued green wallet and the gleaming silver-gold coins with endangered species imprinted where the Queen’s head should be. Saving the world was a noble goal, and as a young person, I was earnest about it.
Today, as a practicing paediatrician, I see it less as a quaint interest than a matter of life and death. In the two and a half decades since I first worried about deforestation and species extinction, my worst fears have come true. Humanity has wiped out 60% of animal populations since 1970 and up to half of all mature tropical forests since 1950 1. At this rate, extraordinary creatures like tigers and rhinos will inhabit only our myths. The generation before mine ignored the unfolding crisis, and focused instead on economic growth at all costs: churning out mountains of needless stuff, and throwing that stuff away, burning ever-more fossil fuels in the process. My generation could have changed things, but we were lulled into complacency, as fashion became faster, products more dispensable and far-flung countries easier to fly to.
We knew about the dangers of climate change as early as the 1950s, and yet did nothing to reduce emissions. Industry knew, our governments knew, the environmentalists knew - everyone knew. And we all still know. We know that the coming transformations of our planet may well undermine the very possibility of civilisation. And we know that the coming changes will be worse for our children, and worse yet still for their children, whose lives – our actions have demonstrated – mean nothing to us. We have failed to appreciate the danger, and we have failed to act. We have failed to put aside our own interests for those who come after us.
As a paediatrician, the real tragedy is in prognosticating the health of children in the warming years to come. As the WHO-Unicef-Lancet commission 2 asks, is there “A future for the world’s children?” What kinds of lives will they eke out on a planet scorched and scarred? Are we expecting them to play in gardens turned to deserts? To climb the charred remains of trees? To eat from tins where we used to pluck fresh fruit? Instead of a carefree, creative existence, they will migrate long distances in search of a safe home. But safety will be hard to find. A climate-changed world is a conflict-ridden one with mass displacement triggered by rising sea levels and desertification, putting pressure on the few places still hospitable to life. In 2016 the number of malnourished people in the world reached over 2 billion. 3 If the near future promises population increase, food shortage and nutrient collapse what number will this rise to?
As temperatures rise, malaria, dengue and Lyme disease will spread. In overcrowded conditions, diseases once considered vanquished - such as TB and cholera - will return emboldened. Much of the progress that medical science has made on these fronts could be wiped out in a single generation.
This is not hyperbole; in a wicked twist of injustice, those living in the nations that have contributed least to this crisis – Bangladesh, Ethiopia and the small island nations - are at this very moment facing situations just like those described. How long before the entire world’s children suffer the same fate?
The dangers to the wellbeing of our children are so considerable it makes me question whether I ought to bring children of my own into such a world. If I did, one thing is certain: I would be enraged. I would not leave the streets or the doors of politicians until someone could give me an answer for why we have been so horribly betrayed.
The Extinction Rebellion and the school climate strikes have brought this crisis to international attention. And yet states’ response to protestors has been to arrest them. How dare we imprison those who stand for the future of our children? Politicians criticise climate protests for ‘significantly disrupting the lives of others’. But it’s only disruption if you’re distracted by something else: mindless consumption or endless profit. These protests and climate strikes are not disruption - they are vital.
We have cost our children the earth. It is difficult to look at this fact and not flinch. But doing so illuminates. The danger posed to our children brings into relief a dimension of the crisis that has been largely absent – the moral dimension. In “Laudato Si”, the encyclical on the environment and human ecology, Pope Francis quotes St. Bartholomew: “to commit a crime against the natural world is a crime against ourselves, and a sin against God”. 4 He urges that environmental problems require us to look not just for technological solutions but for a change at the very heart of humanity - otherwise we are dealing merely with symptoms.
I am not a Catholic, but this is a language I can understand. As a doctor, there is no greater threat to the health of my patients than the viability of our heartbreakingly beautiful, fragile, planet Earth. All paediatricians – and arguably all doctors - should be climate activists. We should be standing side-by side with the Extinction Rebellion and with striking children.
Could I have done more to help save the planet as a child? Probably, as Greta Thunberg is demonstrating. 5 Can I do more to help save it now? Absolutely. And I urge my colleagues to join me. It is easy to complain that the problem is too vast and each of us is too small. But even in the face of overwhelming odds, action is still possible.
For my medical colleagues, there is much we can do.
First, we must join calls on our governments to tell the truth about climate change, declare an ecological and climate change emergency and make serious moves to radically reduce emissions.
Second, we must lobby to ‘green’ our medical institutions: to divest from fossil fuels and go plastic-free immediately.
Finally - and most essential– we must back a vision for the world that puts planetary health at the centre. We must push for an economic model that does not privilege profit and growth for the few, but that encourages abundance for the many. Such models are being developed as I write. 6 Models that might, just might, secure a world for our children to inherit.
Everything is changing about the natural world, and everything must change about the way we conduct our lives. The weight of science and morality insists we act, and that we act now.
Barrett, M., Belward, A., Bladen, S., Breeze, T., Burgess, N., Butchart, S., ... & de Carlo, G. (2018). Living planet report 2018: Aiming higher.
Clark, H., Coll-Seck, A. M., Banerjee, A., Peterson, S., Dalglish, S. L., Ameratunga, S., ... & Claeson, M. (2020). A future for the world's children? A WHO–UNICEF–Lancet Commission. The Lancet, 395(10224), 605-658.
World Health Organization. (2018). The state of food security and nutrition in the world 2018: building climate resilience for food security and nutrition. Food & Agriculture Organisation.
Francis, P. (2016). Laudato Si': On Care For Our Common Home. Perspectives on Science and Christian Faith, 68(4), 266-268.
Thunberg, G. (2019). No one is too small to make a difference. Penguin.
Van den Bergh, J. C., & Kallis, G. (2012). Growth, a-growth or degrowth to stay within planetary boundaries?. Journal of Economic Issues, 46(4), 909-920.
Climate Change Policy
From Negligence to Implementing a Carbon Tax
Jay Anil Patel1,2, Olivia June Bloodworth1, Vishal Ashokkumar Unadkat1,3, Seetal Assi1,4, Ashni Asit Badiani5 1School of Medicine, University of Southampton, Southampton, UK 2London School of Hygiene and Tropical Medicine, London, UK
3Imperial College London, London, UK
4Kings College London, London, UK
5School of Medicine, University of Liverpool, Liverpool, UK
With the UK leaving the EU in 2020, its policies to combat climate change currently remain undecided. One policy discussed in this report is a carbon tax. This report finds that implementation of a carbon tax will require a favourable political climate, public attention and an appropriate cost, with a starting price of £40 per tonne of CO2 emitted, gradually rising to £100-125/tCO2 (1). Also, to be politically acceptable, there must also be ‘revenue recycling’, with some of the proceeds of the carbon tax being redirected to public services (2,3).
Climate change, carbon tax, revenue recycling
Cite as: Patel JA, Bloodworth OJ, Unadkat VA, Assi S, Badiani AA. Climate Change Policy: From Negligence to Implementing a Carbon Tax. Sushruta 2020 (Jul) vol13; issue 2; ePub 09.04.2020
Since the industrial revolution, humankind has made unprecedented development, with health, technologies and economies improving. The lives of people have improved immeasurably. Yet, we have exploited the environment to a breaking point, and urgent action is required to combat the worsening situation. With the United Kingdom (UK) leaving the European Union (EU), one such policy being discussed is implementation of a carbon tax. This report will address the evidence on climate change; why it did not reach the policy agenda earlier; and the implementation of a carbon tax policy to combat the deleterious effects of climate change.
Currently, the UK uses the EU’s Emissions Trading System (ETS) system which is a ‘cap and trade’ system, where companies receive or buy emission allowances, which are tradable (4). All of one’s emissions must be covered by this allowance and exceeding them incurs heavy fines (4). The UK has also maintained a carbon price floor since 2013, which producers were required to pay if the EU ETS carbon price fell below this threshold (5). However, with Brexit, the UK may need to revisit its carbon emissions strategy because the ETS may no longer be applicable.
The Evidence Base
The scientific consensus is that climate change is real and man-made, with around 97% of scientists holding this view. Data on the impact of climate change is provided by the Intergovernmental Panel on Climate Change (IPCC), which consists of working groups I, II and II who assess the physical
scientific basis for climate change, the impact of climate change to natural systems and how to mitigate the effects of climate change respectively. The findings of their most recent report, the 5th Assessment Report, are reported below (6):
Average global temperatures have risen and humans are “extremely likely” to have caused this rise.
Greenhouse gas emissions (nitrous oxide, carbon dioxide and methane) have risen since pre-industrial times, with the majority being due to humans.
Global sea levels have risen and polar ice sheets have melted.
There have and will be greater risks of extreme weather events due to global warming.
Rising temperatures and extreme weather can and have caused crop failures.
Rising temperatures will further threaten endangered species and ecosystems.
Policymakers aim to prevent global temperatures from rising by more than 2°C compared to pre-industrial figures because above this temperature, scientists feel that there will be irreparable damage to the planet (7).
Failure to Make the Policy Agenda
McDonalds meets Misinformation – the role of democracy, capitalism and profit maximisation
According to Forbes, six oil companies are in the largest 25 companies in the world (8). Clearly, they have large financial interests in the climate change agenda considering that the fossil fuel industry is a large driver of anthropogenic (man-made) climate change. These companies worry that tougher environmental regulation would affect their bottom line. In response, they have lobbied governments, paying US Congressional climate change deniers US$1.87million between 2007 and 2015.
Similar to the tobacco industry, oil and gas producers have attempted to sow seeds of doubt about the deleterious effects of their activities upon the planet through the funding of research and misinformation. ExxonMobil funded 39 studies which “misrepresented the science of climate change” in 2005 (9) and funded the production of Sceptics’ Handbook, a pamphlet denying man-made climate change, which altered the evidence base and made some people sceptical about climate change. It also shifted the Overton Window, which defines the spectrum of acceptability of public policies, away from climate change action, allowing looser environmental regulations to continue; therefore, oil and gas companies could continue to operate freely and maximise their profits. Also, the economic capital of energy giants allows them to threaten to move their operations overseas if their demands are unmet and has allowed them to spend $1billion since the Paris Agreement on lobbying (10).
The media and its framing of climate change:
Yet, the framing of climate change has been critical to the inaction regarding it (11). Firstly, it has become a partisan issue, preventing action. The left has largely wanted to tackle climate change, whereas the right has either displayed ignorance or an unwillingness to tackle climate change. In the UK, the partisan divide has impeded political progress, with Labour supporters 56% more likely to be extremely or very worried about climate change compared to Conservative voters (12). To this end, the role of the media, who are able to shape the thoughts and preferences of the public to dictate the political agenda, has been critical in framing climate change as a partisan issue (11). Overall, this political polarisation of climate change has prevented action to mitigate or adapt to its effects.
Despite scientific consensus over anthropogenic climate change, there are sceptics and deniers. According to Schwartz (13), climate change sceptics and deniers display “wilful ignorance” of modern scientific evidence. They often dislike the economic and political implications of climate change, hence they choose to not believe in it (14). For these people, tackling climate change does not warrant the politico-economic trade off.
The Policy Agenda
Shaping the Policy Agenda
Firstly, for climate change action to be taken, it must be on the policy agenda. Kingdon states that implementation of policies requires action within windows of opportunity, which require (15):
focusing events which attract public attention towards the issue.
a favourable political climate.
a solution to the problem.
Producing a Favourable Political Climate
The first challenge must be to convince the population of the deleterious effects of climate change and that action must be undertaken. Yet, considering the vested interests of corporations and the apathy of some individuals towards the subject, there may be some people who will be unchanging in their beliefs. However, 46% of Europeans did not feel that “climate change is a very serious problem” – if some of these people are open to changing their opinion, it will add further weight to the masses of people demanding further action (16). Therefore, those who understand the importance of climate change must undertake concerted action to highlight the issue to policymakers.
Ultimately, politicians are responsive to voters, hence greater public support for an issue will encourage political action. However, the political climate must also be appropriate for action. Considering UK Prime Minister Johnson’s previous statements labelling Extinction Rebellion climate change activists as “uncooperative crusties” and his previously sceptical views over anthropogenic climate change, this may prove difficult.
Also, the power of focusing events must be harnessed - including sudden, adverse weather events - which are more likely due to climate change, and the publicity gained by activists including Greta Thunberg and Extinction Rebellion (6,7,15,17).
A Potential Solution – A Carbon Tax
Having placed climate change action high up on the political agenda, a solution is required. One such response is a carbon tax, which taxes greenhouse gases emitted. It can be applied to manufacturing, power plants, transport and the household energy industries. Burning fossil fuels is a negative externality, with the societal costs of environmental damage outweighing the price paid by consumers and producers. Therefore, there is often overconsumption of these resources above what is societally optimal, hence a carbon tax should reduce the amount of greenhouse gas emitted by raising their costs.
The UK government had previously suggested a price of GB£16 per tonne of CO2 produced if there had been a no-deal Brexit (18). However, this figure appears to be too low – Burke, Byrnes and Fankhauser suggest that to allow the UK to reach its net-zero emissions target by 2050, a carbon tax would need to cost around £40/tCO2 in most sectors and rise to £100-125/tCO2 by 2050 (1). It may reduce greenhouse gas emissions through several mechanisms, such as by: encouraging the energy industry to switch to cleaner forms of energy, with similar measures reducing UK coal usage by 91% since 1990 (19); reducing the amount of energy used by industries; and promoting efficient energy usage.
Political Implications of a Carbon Tax
Practically, a carbon tax would be relatively simple to implement in the UK, with fuel-use currently being monitored and reported in the EU ETS system (5,20). However, implementing new taxes remains politically challenging, with the Gilets Jaunes movement arising in opposition to fuel price increases and Australia having repealed their carbon tax (2,5). Despite this, a carbon tax would generate £20 billion in annual revenue for the government (1). If recycled appropriately, these revenues would increase the willingness of the public to accept this new tax, with Swedish citizens more likely to accept a carbon tax if accompanied by income tax cuts (2,3).
Practical Implementation of a Carbon Tax
To be effective at reaching a net-zero emissions target by 2050, a carbon tax must be set at around £40/tCO2 in most sectors and rise to £100-125/tCO2 by 2050 (1).
To be politically acceptable, the carbon tax must increase gradually over time, allowing people and companies to alter their energy usage patterns, such as by switching to greener energy sources or increasing their energy efficiency (21).
To be politically acceptable, a carbon tax must recycle revenue back into the economy (2,3,5). It is also essential that policymakers explain how these resources are being used to ensure public acceptability of the carbon tax – for example, these resources could be used to reduce income taxes, provide a carbon dividend or subsidise green technologies (21).
Drawbacks of a Carbon Tax
However, some people argue that implementation of a carbon tax will lead to negative economic and environmental consequences, with firms moving abroad to nations with less strict environmental regulations (20,22). However, these effects are likely to be modest, with the majority of greenhouse gas emissions in developed countries produced by non-traded sectors, including electricity, transport and construction, which cannot be outsourced overseas to nations with looser environmental regulations (20,22).
Also, a carbon tax may be regressive, harming the poorest in society, who spend a greater proportion of their income on energy and fuel (21). Appropriate recycling of revenue to the poorest in society may overcome this challenge (21).
1. Burke J, Byrnes R, Fankhauser S, Beauman C, Bellamy O, Bowen A, et al. How to price carbon to reach net-zero emissions in the UK [Internet]. 2019 [cited 2020 Mar 4]. Available from: www.cccep.ac.uk
2. Beiser-McGrath LF, Bernauer T. Could revenue recycling make effective carbon taxation politically feasible? Sci Adv. 2019 Sep 18;5(9).
3. Jagers SC, Martinsson J, Matti S. The impact of compensatory measures on public support for carbon taxation: an experimental study in Sweden. Clim Policy [Internet]. 2019 [cited 2020 Mar 4]; Available from: https://www.tandfonline.com/action/journalInformation?journalCode=tcpo20
4. EU Emissions Trading System (EU ETS) [Internet]. 2015. [cited 2020 Mar 4]. Available from: https://ec.europa.eu/clima/policies/ets_en
5. Geroe S. Addressing Climate Change Through a Low-Cost, High-Impact Carbon Tax. J Environ Dev. 2019;28(1):3–27.
6. Pachauri RK, Allen MR, Al E. Climate Change 2014 Synthesis Report [Internet]. Rajendra K. Pachauri (Chair), Myles R. Allen (United Kingdom), Vicente R. Barros (Argentina), John Broome (United Kingdom), Wolfgang Cramer (Germany/France), Renate Christ (Austria/WMO), John A. Church (Australia), Leon Clarke (USA), Qin Dahe (China), Pur J-P van Y (Belgium), Technical, editors. 2014 [cited 2019 Dec 4]. Available from: http://www.ipcc.ch.
7. The impacts of climate change at 1.5C, 2C and beyond [Internet]. Carbon Brief. 2018 [cited 2020 Mar 3]. Available from: https://interactive.carbonbrief.org/impacts-climate-change-one-point-five-degrees-two-degrees/?utm_source=web&utm_campaign=Redirect
8. Forbes Magazine. The World’s Largest Public Companies [Internet]. Global 2000. 2019 [cited 2019 Dec 4]. Available from: https://www.forbes.com/global2000/list/#tab:overall
9. Royal Society. Letter from the Royal Society to ExxonMobil. 2006.
10. InfluenceMap. Big Oil’s Real Agenda on Climate Change [Internet]. 2019 [cited 2019 Dec 4]. Available from: https://influencemap.org/report/How-Big-Oil-Continues-to-Oppose-the-Paris-Agreement-38212275958aa21196dae3b76220bddc
11. Stecula DA, Merkley E. Framing Climate Change: Economics, Ideology, and Uncertainty in American News Media Content From 1988 to 2014. Front Commun. 2019 Feb 26;4.
12. Social Research N. British Social Attitudes 35: Climate Change.
13. Schwartz SA. The Denier Movements Critique Evolution, Climate Change, and Nonlocal Consciousness. Explore [Internet]. 2010 [cited 2019 Dec 4];6(3):135–42. Available from: http://dx.doi.org/10.1016/j.explore.2010.03.005
14. Krugman P. Betraying the Planet - The New York Times. New York Times [Internet]. 2009 [cited 2019 Dec 4]; Available from: https://www.nytimes.com/2009/06/29/opinion/29krugman.html?_r=1
15. Kingdon J. Agendas, alternatives and public policies. 2010.
16. Stokes B, Wike R, Carle J. Global Concern about Climate Change, Broad Support for Limiting Emissions - Pew Research Center [Internet]. Pew Research Center. 2015 [cited 2020 Mar 2]. Available from: https://www.pewresearch.org/global/2015/11/05/global-concern-about-climate-change-broad-support-for-limiting-emissions/
17. Belam M. Greta Thunberg: teenager on a global mission to ‘make a difference’ . The Guardian [Internet]. 2019 [cited 2020 Apr 8]; Available from: https://www.theguardian.com/environment/2019/sep/26/greta-thunberg-teenager-on-a-global-mission-to-make-a-difference
18. Burke J, Byrnes R. What the UK can learn from carbon pricing schemes around the world [Internet]. Carbon Brief. 2019 [cited 2020 Mar 4]. Available from: https://www.carbonbrief.org/guest-post-what-the-uk-can-learn-from-carbon-pricing-schemes-around-the-world
19. Department for Business Energy and Industrial Strategy, National Statistics. 2018 UK Greenhouse Gas Emissions, Provisional Figures [Internet]. 2019 [cited 2020 Mar 4]. Available from: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/790626/2018-provisional-emissions-statistics-report.pdf
20. Aldy JE, Stavins RN. The Promise and Problems of Pricing Carbon. J Environ Dev [Internet]. 2012 Jun 18 [cited 2020 Mar 3];21(2):152–80. Available from: http://journals.sagepub.com/doi/10.1177/1070496512442508
21. Burke J, Byrnes R, Fankhauser S. Policy brief Global lessons for the UK in carbon taxes. 2019.
22. Aldy JE, Pizer WA. The Competitiveness Impacts of Climate Change Mitigation Policies. Harvard Proj Clim Agreements [Internet]. 2015 Jan 26 [cited 2020 Mar 3]; Available from: https://www.belfercenter.org/sites/default/files/legacy/files/dp73_aldy-pizer.pdf
Air Pollution: A Tale of Two Cities
Ramyadevi Ravindrane MBBS, iBsc
London School of Hygiene & Tropical Diseases, London, UK
This article describes the battle with air pollution in two large cities, London and Delhi. Air pollution is a major cause of morbidity and mortality across the globe, particularly affecting those in large, urban environments. Action has been take to reduce pollution levels and some improvement have been seen, but not to a significant enough degree. We as healthcare professionals have a responsibility to advocate for greater change to be made.
cite as: Ravindrane R. Air pollution. A tale of two cities. Sushruta 2020 (Jul) vol13; issue 2; ePub 01.04.2020
Air pollution and Health
Having lived in London for the last ten years with many summers spent in bustling Indian cities, I often worry how much pollution I have been exposed to. It’s not uncommon on my walk home from the underground station to smell the pungent fumes from car exhausts. Likewise, I recall countless times looking up at an urban skyline in India to see grey smoke waft through the air. Newspapers often liken living in a large city to smoking over a hundred cigarettes a year (1). However, these seemingly sensationalist headlines hold truth. Chronic exposure to ambient air pollution has devastating effects on health and those living in large, urban areas are often the most exposed.
Air pollution is the amalgamation of harmful chemicals in the air due to natural or human causes. Outdoor or ambient air pollutants include carbon monoxide, nitrogen oxides, sulphur dioxide and particulate matter (small particles produced in part by burning fossil fuels) which are emitted from vehicle exhaust, fumes from industry, heat and power generation and agriculture. Another chemical, ground level ozone, is a key element of smog, which is produced when chemicals such as those found in vehicle exhaust fumes react in sunlight.
Breathing in these pollutants on a daily basis has disastrous consequences on our health. 91% of the world’s population live in areas where the air quality is below the standard set by WHO. Ambient air pollution lead to significant levels of morbidity and mortality through cardiovascular disease, respiratory disease and cancer. WHO figures show that 29% of all deaths and disease from lunch cancer and 4.2 Million premature deaths in 2016 were due to outdoor air pollution (2). Chronic exposure to particulate matter leads to cardiovascular and respiratory disease, nitrogen dioxide can cause airway inflammation and ozone can lead to worsening of asthma and stunted growth in children (3).
Not only is ambient air pollution directly damaging to health, but it also acts as a mechanism of climate change. Carbon dioxide, though not directly damaging to health, is the major by-product of burning fossil fuels and is a powerful greenhouse gas, trapping heat in the atmosphere. Particulate matter worsens this problem by settling on surfaces such as ice caps and snow reducing their reflective properties causing less light to be reflected from the earth’s surface and increasing surface temperatures.
London is a city with a long history of air pollution. 1952 was the year of the Great Smog, a week long episode of extreme air pollution in which the air was thick with a polluted fog. It contributed to the death of at least 4,000 people. As a result, the Clean Air Acts of 1956 and 1968 were created. These acts banned emissions of black smoke from urban residential areas and factories which were forced to switch to smokeless fuels (4). The act was successful in reducing visible pollution due to particulate matter. However, despite the clearing of the skies, air quality in London is still of serious concern with current pollution levels exceeding limit values set by the European Union (4).
The latest report by the London Air Quality Network for 2018 showed that large reductions in carbon monoxide have been seen over the last twenty years. There has also been a decrease in nitrogen dioxide levels between 2017 to 2018 and particulate matter 10 and 2.5. Nonetheless, it is important to bear in mind other nitrogen dioxide levels are still exceeding set limits causing the majority of the 9,400 premature deaths per year linked to ambient air pollution in London (5) (6). With one third of London’s schools being in close proximity to roads with illegally high levels of nitrogen dioxide we need continued vigilance against this threat (3).
Steps are being taken to tackle this problem through the London Local Air Quality Action Plan. This initiative gives responsibilities to each London borough to monitor and put in place schemes to reduce air pollution. The key areas being addressed are transport and green infrastructure. Encouraging active travel is one component, specifically creating cycle super highways and more pedestrianised areas such as the Van Gogh Walk in Lambeth. The congestion charge zone is being used to create an ultralow emission zone as of April 2019. This means that any vehicles entering the congestion charge zone will also need to meet a minimum exhaust emission standard or pay an extra charge. Possibly most significantly there will be a UK wide ban on new petrol and diesel cars as of 2035. Green infrastructure refers to green spaces designed to promote healthy living, mitigate flooding, improve water and air quality, cool the urban environment and promote ecological resilience. By increasing the numbers of and access to green spaces it is hoped air quality will improve through reduced industrial and transport related emissions and reduced dispersion of pollutants (3) (7).
Everyday in Delhi approximately eighty people die due to air pollution related illness (8).
In 2016 Delhi experienced one of its worst episodes of Diwali smog. Pollution levels were some of the highest Delhi had seen over the preceding 17 years with PM 2.5 fourteen times the allowed standard. According to the Centre for Science and Environment pollution levels were higher than those recorded in the Great Smog of London 1952 (9). ‘Diwali smog’ is the peak of extreme air pollution, largely due to particulate matter, that occurs as a result of the combustion of fireworks in celebration of the Hindu festival. The smog of 2016 was particularly extreme due to a mixture of fireworks, vehicle exhaust fumes, fumes from burning garbage and burning of paddy residues in neighbouring states coupled with a lack of wind. This left particulate matter stagnant in the air and a smog that lasted ten days (10). Emergency action was required, schools were shut down, the Badarpur power plant was closed and construction was halted for ten days.
The incident in 2016 lead to long term steps being taken to address the air pollution crisis affecting Delhi. Areas of priority included reduction in emissions from diesel fuelled vehicles, waste burning, construction and power plants. The Delhi Clean air action plan laid out key action needed in order to tackle this worsening issue (9). Specific measures included laws against visibly polluting vehicles, more pedestrianised zones and improved public transport systems (11). Badapur coal fired power plant was permanently shut down in 2018 (12). Polluting industries were targeted, with industrial units not compliant with environmental and waste management policies shut down and sanctions placed on industries using poor quality fuel such as furnace oil which emits extremely high levels of sulphur when burned. Waste management was a key issue with greater vigilance over already banned open burning of waste and crop burning. Legal frameworks were put in place to ensure proper recycling of construction waste. Banning of diesel generator sets and limitations on use of brick kiln which are fired by coal was also recommended (9).
Some improvement was seen with decreasing average levels of particulate matter and sulphur dioxide from 2016 to 2017. Results of the Air Quality Index (AQI) showed the number of days with very poor or severe air quality had decreased and satisfactory days nearly doubling from 2016 to 2017 (13). However, despite this a repeat episode of severe smog was seen in 2019. A Public health emergency was declared. The AQI in New Delhi was un-recordable indicating levels over 999 (normal air quality between 0-50). On November 3 PM 2.5 levels were 23 times higher than the WHO air quality guidelines (14).
The effect of air pollution on health is well established. Thousands of people around the world, particularly those in major cities, are suffering ill health and early death due to unacceptable levels of exposure. Governments are attempting to take action, but change is not occurring fast enough. As a society we need to realise that a paradigm shift is required. This is not a crisis to be averted for future generations, this is a crisis we are living through now. On an individual level better choices to reduce fossil fuel combustion such as active travel are required. However, there is a limit to what one person can do. We as healthcare professionals have a responsibility to advocate for our patients not just in the clinical setting, but also in the wider community on public health matters such as this. We must put pressure on our governments to rapidly divest from fossil fuels, increase legislation on air pollution levels and invest in renewable fuel sources. If we do not we will only continue to see patients suffering from preventable illness on a mass scale. Change can happen, as we have seen with successful initiatives to reduce pollution to date, but we cannot be complacent.
8. India environmental portal. Indiaenvironmentalportal.org.uk. [internet]. [cited 29/03/2020] Available: http://www.indiaenvironmentportal.org.in/content/439810/increasing-deaths-due-to-air-pollution-in-delhi-and-mumbai/
9. Sunita Narain, Anumita Roychowdhury. Towards a Clean Air Action Plan, Lessons from Delhi. Centre For Science and Environment. New Delhi. Centre For Science and Environment. [updated 2016, cited 29/03/2020].
10. Najar, Nida. Barry, Ellen. Nytimes.com. [internet]. New York Times. [updated 25/1/2016, cited 29/03/2020]. Available: https://www.nytimes.com/2016/11/25/world/asia/india-delhi-fireworks-air-pollution.html
11. Ministry of Environment. Indiaenvironmentalportal.org. [internet]. Centre for Science and Environment. [updated 08/10/2018, cited 29/03/2020]. Available: http://www.indiaenvironmentportal.org.in/files/file/Comprehensive%20Action%20Plan.pdf.
13. Central Pollution Control Board. Annual Report 2017-18. [internet]. Ministry of Environment, Forest and Climate Change. [updated 2018, cited 29/03/2020]. Available: https://cpcb.nic.in/openpdffile.php?id=UmVwb3J0RmlsZXMvOTIyXzE1NjQwMzg5OTFfbWVkaWFwaG90bzE0Mjg2LnBkZg==
14. Mansoor, Sanya. Air Pollution Turned India's Capital Into a 'Climate Emergency.' It's Part of a Global Trend Killing 7 Million Prematurely Each Year. [internet] Time. [updated 6/11/2019, cited 29/03/2020]. Available: https://time.com/5718012/new-delhi-pollution-2019/
How to build Climate Resilient Health Systems
Reinforce the framework instead of reinventing the wheel
Sojung Yoon MBBS MSc Public Health
London School of Hygiene & Tropical Medicine, London, UK
World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians
Climate change will have adverse affects on health at a population scale. Health systems need to be strengthened in order to better address changing health needs and increased demand. Frameworks exist to guide the improvement of health systems, however, they do not necessarily address adaptations to be made for climate change. This article reviews the WHO Operational Framework and identifies where this can be built upon to tackles changing health needs due to climate change.
cite as; Yoon S. How to build climate resilient health systems - Reinforce the framework instead of reinventing the wheel. Sushruta 2020 (Jul) vol 13; issue 2: ePub 01.04.2020
Climate change is acknowledged as the biggest public health threat in the century. The consequences of human actions, notably the burning of fossil fuels, are affecting all countries in the world. According to the report of the Intergovernmental Panel on Climate Change (IPCC), climate change is expected to significantly increase health risks, especially in low-middle-income countries (LMICs).(1) Also, it will disproportionately affect vulnerable groups in each country, such as the poor, children and the elderly, and people with pre-existing comorbidities.
With a rising exposure to climate change and a limited capacity to adapt to impacts, health systems of low-middle-income countries already face challenges. Climate change is different from other traditional public health issues in that it has effects over extended periods in a global scale, is subject to multiple uncertainties, is strongly mediated by social determinants of health, and causes diverse and interacting health impacts. Therefore, it requires strengthening health systems in collaboration with different actors at various levels.
The concept of ‘resilience’ has been proposed to equip health systems facing climate change and other challenges such as a pandemic, natural disaster, or conflict. Building resilient health systems is to raise the capacity of health systems to absorb, adapt, and transform exposed to a shock, and still to protect and improve population health. (2, 3)
This editorial will review the current World Health Organization (WHO) framework gaps and what can be complemented to build climate resilient health systems from people centred perspective with lessons of adaptation responses in the world.
WHO Operational framework and knowledge gaps
WHO has identified six “building blocks” in health systems that are necessary to support the delivery of Universal Health Coverage and to improve health. Starting from this framework and considering a comprehensive health response to climate change, WHO has outlined the operational framework with ten components (Fig. 1).
This framework suggests that climate resilience should be incorporated into every sector of the health system, and as a systemic approach, interconnections between the various components are emphasised to reinforce one another. All building blocks should become climate resilient, and the health sector should extend its sphere of operations beyond itself to other sectors (e.g., water, energy, food, and agriculture).
Figure 1. Ten components comprising the WHO operational framework for building climate resilient health systems, and the main connections to the building blocks of health systems
This framework can be useful in several ways. It presents a simple way to discuss the key functions of health systems. It provides a common language and a shared understanding. As it relies on already well-known six building blocks, it is easy to adapt to different contexts and ensuring all essential functions of health systems are covered.
Nonetheless, many gaps could emerge from addressing the adaptation of health systems with this framework. These building blocks are considered a set of inputs that contribute to the health system. Consequently, this framework neglects the links between inputs, outputs, and outcomes. How much can be expected and done from systemic changes? What is happening in the process by which inputs are transformed into outputs?
Also, it is difficult to identify the interactions between the building blocks and different actors at various levels. Are all building blocks equally important, if not, which one would be prioritised when there are trade-offs? How can climate resilience policies be aligned with a global governance framework with the partnership? How can different actors, including local and community level, reinforce each other, and collaborate against fragmentation? To address these gaps, lessons from adaptation responses in real-world need to be learned, not to ‘reinvent the new wheel,’ but to ‘reinforce the old one.’
People centred perspective
Climate change includes the interrelationship between different aspects: human beings and ecosystems. Resilience is not just about absorbing shocks from outside but also harnessing the changes in the existing systems. People centred perspective highlights the capacity of people improving their livelihood in the face of environmental disturbances. This resilience is underpinned by human agency and empowerment by centring people as the main actors in the policy and practice.(4) Especially because social and economic determinants of health actively mediate the effects of climate change, it is essential to put people's values and needs in the centre of health systems and to ensure people's participation in the policy process.
Despite growing knowledge, there is a lack of enough understanding to address the links between climate change and health. It is not only about scientific evidence, but rather the capacity to combine and integrate different types of knowledge and how to prepare this knowledge for adaptation.
Evidence suggests that local and indigenous communities have been successfully adapting to climate change by developing context-specific practices and building the resilience of their communities.(5, 6) Local knowledge is considered to provide an effective strategy for adaptation.
In African Sahel, local farmers have developed several adaptation measures, including the early warning system for extreme weather events with the wealth of local knowledge on predicting weather and climate. They also have successfully achieved sustainable livelihoods by adapting to variabilities in their farming and livestock keeping.(5)
Climate change adaption strategies can recognise the value of indigenous knowledge systems developed in a specific context, also because of uncertainties in the current scientific evidence base. Considering that indigenous people in most parts of the world contribute little to climate change, but are at most risk of its outcomes, their participation is essential based on the principle of justice. When their knowledge and experience are incorporated into climate change health practice, adaption will be more effective and sustainable.
Community participation and delivery
Community participation in the process of developing adaptation strategies has been emphasised in literature. 7, 8 Community empowerment can activate local capacity to improve resilience and consider equity in health systems. Most studies suggest that sea-level rise will cause the relocation of residents at risk of floods.(9) In contrast, coastal communities in the Philippines preferred to stay and implement adaptive measures themselves to minimise the risk of floods.(8) They adapted to flooding by constructing stilted houses and raising floors with coral stone. People in Funafuti, Tuvalu, wished to remain as well because of their culture and identity.(10) Both communities considered migration as the last option, opposite to the strategy by authorities. It implies that bottom-up adaptation measures can be completely different from top-down approaches. Community-based adaptation engages people to actively cope with the health impacts of climate change, leading to the climate resilience of health systems. Furthermore, community participation is crucial for adaptation policies to gain public acceptance.
Nevertheless, not all adaptation measures by communities are sustainable in the long term. As above, in the Philippines, many islanders used coral stone to raise their floors for adaptation to flooding. This measure can temporarily reduce the impacts of climate change; however, it might increase the vulnerability of communities in the long run.
Addressing climate change and implementing adaptation responses in health systems requires engagement between various levels and types of governance. Horizontal and vertical collaboration could play an important role, and these collaborations require a synergistic relationship between stakeholders. Multilevel governance has been proposed as it enables combining decisions across different levels and sectors, and different institutional types at the same level.(11) It is based on participation and coordination with accountability and transparency across and within levels.
An increasing number of cities and local governments have pledged mitigation and adaptation initiatives underpinning health co-benefits. The Covenant of Mayors (CoM) is an initiative in which local authorities voluntarily commit to reduce CO2 emission. As of 2020, it involves 10,009 signatories covering 318 million people, mainly in Europe. The development of multilevel governance has facilitated the participation of small municipalities. Provinces and regions have committed to providing financial and technical support to these municipalities. Results from monitoring inventories in 2017 showed achievement of 23% reduction in CO2 emissions compared to 2005.(12)
Although climate change impacts through ecosystems, thinking resilience of health systems goes beyond that and stays with the people inhabiting these ecosystems. People centred perspective can address the social determinants of health and underline the capacity of people to adapt to changes. However, there is a lack of research on people centred perspective on climate change and adaptation. The critical lesson from the world is working ‘with’ people and putting their values in the centre of health systems.
Climate change is a significant threat and requires the resilience of health systems.
People centred perspective can be enabling to address adaptation measures by putting people’s value and needs in the centre of health systems.
Lessons of recognising the local knowledge, enhancing community participation, and multilevel governance can be learned from the world.
Building climate resilient health systems depends on social values and requires the consensus of people in the society.
Resilience depends on social values regarding what we consider important and how we allocate resources. When there are trade-offs and priorities among social, economic, and environmental objectives, who decides, based on what kind of values? These questions should be discussed with the consensus of people, not be left to experts with the framework.
1. An IPCC Special Report on the impacts of global warming of 1.5°C above pre-industrial levels and related global greenhouse gas emission pathways, in the context of strengthening the global response to the threat of climate change, sustainable development, and efforts to eradicate poverty. Intergovernmental Panel on Climate Change; 2018.
2. Blanchet K, Nam SL, Ramalingam B, Pozo-Martin F. Governance and Capacity to Manage Resilience of Health Systems: Towards a New Conceptual Framework. Int J Health Policy Manag. 2017;6(8):431-5.
3. Operational framework for building climate resilient health systems. Geneva, Switzerland: World Health Organization; 2015. https://apps.who.int/iris/handle/10665/189951
4. Tanner T, Lewis D, Wrathall D, Bronen R, Cradock-Henry N, Huq S, et al. Livelihood resilience in the face of climate change. Nature Climate Change. 2014;5(1):23-6.
5. Nyong A, Adesina F, Osman Elasha B. The value of indigenous knowledge in climate change mitigation and adaptation strategies in the African Sahel. Mitigation and Adaptation Strategies for Global Change. 2007;12(5):787-97.
6. Mahoo H, Mbungu W, Yonah I, Recha J, Radeny M, Kimeli P, et al. Integrating Indigenous Knowledge with Scientific Seasonal Forecasts for Climate Risk Management in Lushoto District in Tanzania. Copenhagen, Denmark: CGIAR Research Program on Climate Change, Agriculture and Food Security (CCAFS); 2015. Contract No.: CCAFS Working Paper no. 103.
7. Pearce T. Adaptation to climate change and freshwater resources in Vusama village, Viti Levu, Fiji. Regional environmental change. 2018.
8. Laurice Jamero M, Onuki M, Esteban M, Billones-Sensano XK, Tan N, Nellas A, et al. Small-island communities in the Philippines prefer local measures to relocation in response to sea-level rise. Nature Climate Change. 2017;7(8):581-6.
9. Ayeb-Karlsson S, van der Geest K, Ahmed I, Huq S, Warner K. A people-centred perspective on climate change, environmental stress, and livelihood resilience in Bangladesh. Sustain Sci. 2016;11(4):679-94.
10. Mortreux C, Barnett J. Climate change, migration and adaptation in Funafuti, Tuvalu. Global Environmental Change. 2009;19(1):105-12.
11. Romero-Lankao P. Climate Change and Cities: Second Assessment Report of the Urban Climate Change Research Network. Cambridge, United Kingdom and New York, NY, USA; 2018.
12. Kona A, Bertoldi P, Monforti-Ferrario F, Rivas S, Dallemand JF. Covenant of mayors signatories leading the way towards 1.5 degree global warming pathway. Sustainable Cities and Society. 2018;41:568-75.
Figure 1. Ten components comprising the WHO operational framework for building climate resilient health systems, and the main connections to the building blocks of health systems
The Bushfires Downunder - A Medical Emergency, Now and Later
Although Australia is accustomed to bushfires on a regular basis the extremity of the latest episode was unprecedented causing worldwide concern for the people and ecosystems of the country. This article describes the causes of bushfires alongside the environmental impacts. It reflects on the heroic manner in which the Australian peoples rallied together to overcome their adversity, concluding on lessons to be learned for future generations.
cite as: Chaturvedi S. The Bushfires downunder - A medical emergency, now and later. Sushruta 2020 (Jul) vol 13; issue 2: epub 01.04.2020
An unprecedented catastrophe was created by the uncontrolled bushfires in Australia. Between September 2019 till Jan 2020 estimated 19 million hectares of land and 6000 buildings were burnt, killing at least 40 people and about 1.25 billion animals, driving some endangered species like Koalas to possible extinction.The mammoth blaze has killed 30% of their habitat.
Government pledged $ 50 millions for fire affected wildlife. The count of injured human and animals still remains a wild guess.
Bushfires are considered necessary part of life cycle for several trees and plants as part of natural ecology in some countries like Australia. Loose flammable bark and combustible oil in their green leaves may promote the spread of fire. A good example is eucalyptus.
Although bushfires are integral part of Australian environment, these fires were more extreme than ever known before. The horrific wildfires were clearly visible to satellites in the space as tracked down from International Space Station. The smoke was rising at least 17 km high traveling above most of the atmosphere and weather. It moved about 11,000 km across the South Pacific ocean, to as far as Chile and Argentina.
NASA estimated emission of 306 million tones of carbon dioxide. As its direct result, in some parts, air quality dropped 20 times the hazardous rating. The estimated cost of the Bushfire is likely rise far above A$ 4 billion of 2009 Black Saturday fire. State of emergency was declared in various parts of the country.
The most likely link to these devastating fires can be the climate change which has impacted on its early start in the season and late finish.
The tragic loss of lives and properties and destructive impact on the environment has raised serious concerns in every section of the community. Whist tourism sector revenues have fallen by more than a billion dollars, it has undermined Australia's reputation to the tune of $38 billon in the international higher education market as parents are thinking twice of sending their children to Australia.
Medical community was alerted to not only its present role of emergency care but to predict its far reaching consequences on human health. The immediate focus on communicable diseases resulting from water, food and air pollution became public health priority. There was increased sediment concentration in drinking water in the run off areas with lead in excess of current drinking water guidelines. First the draught, followed by bushfires and now the rainstorm has washed ash along with other detritus into rivers killing the fish and turning the water in silty black.
Although bushfire smoke affects health, it's full unprecedented impact both in short and long term needs further exploration. There was 51% increase in ambulance calls for breathing difficulties due to smoke haze and 25% increase in exacerbation of asthma and COPD since November last year. Toxic particles of high level and carcinogens, with its prolonged exposure also raise the fear of spike in lung cancer in the next decade and beyond. WHO estimated that ambient air pollution contributes to 4.2 million premature deaths globally each year. In Australia, atmospheric PM (particulate matter) 2.5 contributed to 2800 premature deaths (2% of all deaths) in 2016.
A recent study in China concluded that long term exposure to high concentration of ultra fine particle of PM 2.5(air quality measure) found in bushfire smoke are linked to stroke in relation to the dose of exposure.
Australian medical community and government agencies set up Breath Easy Clinics with respiratory physicians. More emergency consultations were created for both in person and through video conferencing in bushfire affected regions working in coordination with the 1st responders like police, firefighters, ambulance and Australian Defence Force at national level. Mental health conditions like depression, anxiety and post traumatic stress disorder were acknowledged by funding extra sessions of mental health consultations. The profound gravity across months alerted the country for its future planning and at the outset allocating A$ 5 million in research grant for long term impact on physical and mental health.
The projected lifetime adversities are likely to include mental health issues, risky/high level alcohol consumption, non communicable diseases, family violence and environmental damage. The main impact seems to be delayed when people have a chance to stop and reflect on their experiences. A prospective study of 1526 people who suffered losses in 1983 Ash Wednesday bushfire found that after 12 months 42% were defined as potentially psychiatric cases using General Health Questionnaire, about double the expected community prevalence. Fortunately after 2 years half of these numbers showed human resilience and improved.
Strong recommendation was made to introduce disaster management in the medical curriculum to prepare generation of doctors for increased climate events culminating in public health emergencies.
Generosity of ordinary people was commendable digging deep in their pocket from all walks of life. Australian Indians in their usual spirit of selfless service donated nearly half a million in addition to providing hands on food vans. There were many fundraising events bringing the solidarity amongst all Australians. Sydney attracted 70,000 people to support the performance of local and international stars raising well over A$50 million.
The aftermath of bushfire is likely to be traumatic as well, counting the considerable cost to the community. human, animal and environment, above insurance claims, and rebuilding life both individually and nationally, will be a mammoth task. Nevertheless if there is any comfort, the positive effect of bushfire is in triggering germination by heating the soil and cracking the seeds.
This experience has most definitely left no room for complacency. Australian specific effects of climate change are recognised and include:
Significant linear association between exposure to high temperature and greater mortality in large cities of Sydney ,Melbourne and Brisbane.
Estimated annual productivity losses from heat stress of A$ 616 per employed person in Australia.
2177 reported deaths from extreme weather conditions in the past 100 years.
An observed 13.7% increase in dengue carrying mosquitos to transmit disease to humans in Australia between 1950 and 2016.
Australian Medical Association joined other organisations around the world including British and American Medical Associations along with Doctors for the Environment Australia, in recognising climate change as a health emergency. It has called on Australian Government :
To adopt mitigation target within Australian carbon budget.
To promote health benefits of addressing climate change.
To develop national strategies for health and climate change.
To promote an active transition from fossil fuel to renewable energy.
To establish a National Sustainable Development Unit to decrease carbon emission in health care sector.
Last month, the board of a public hospital in New South Wales rejected a $15 million donation from a coal mining venture, saying the project’s potentially negative effects on the local population’s health made it unethical. The board’s decision should be widely and loudly applauded especially at a time when Australia is grappling with its worst-ever bushfire season that has come at the hands of climate change.
There is a proud history of health professionals standing up on issues of importance. Asbestos, smoking and climate change are some of it which will now occupy the minds of Australian researchers and possibly around the world.
The February miracle rain of 350mm in some parts of Australia has finally helped to bring the blaze under control. As all the emergency warning are being downgraded people are gradually returning home for yet another phase of grief sifting through their fire damaged property.
Poetry in the midst of a Crisis
The National Health Service UK: In Battle.
Prithwish Banerjee MBBS Dip Card MD FRCP FESC
Consultant Cardiologist & Lead of Cardiology & Heart Failure Services
University Hospitals Coventry & Warwickshire
Honorary Professor of Cardiology, University of Warwick & Coventry University
Cardiovascular Lead, West Midlands NIHR Clinical Research Network
Illustration by Tumpa Banerjee, MBBS, MRCP, MRCGP
General Practitioner, Croft Medical Centre, Leamington Spa
Attracting workers from across the world
To practice medicine as an art unfurled,
Working arm in arm with a flood of skills
The NHS is a place for no ordinary thrills.
A quiet dedication runs at the core
Genuine care, excellence, ethics and more;
Fairness and respect, every patient is our own
Equal attention for all, celebrity or unknown.
Teams within teams innovating all the time
Working for principles and pleasure not just the dime
Decisions are always based on clinical need
Ego or arrogance can rarely breed.
Let’s be honest there are challenges galore
The service can be difficult to sustain at the door
It’s a unique model though of health for all
Whether they are rich or poor, short or tall.
Another key aspect is the family doctor’s role
Their warmth and support reaches down to the soul
Guardians of health of the families they know
Working with nurses and specialists through winds and snow.