Izzy Braithwaite

From a BMJ Blogs series for the upcoming CleanMed Europe Conference - edited version at:  http://bit.ly/13EBL8D

The concept of sustainable healthcare and – related to that - how environmental change affects health are not generally taught in medical schools, but I was lucky enough to take part in a student-led national programme on the topic in my first year.   I had long been interested in global health and the environment, so was keen to find out more and get involved in this area.

The focus of my work has been with the Sustainable Healthcare Education (SHE) Network, for example contributing to a set of downloadable teaching resources and subsequently helping to collate a set of case studies on existing student-selected components.  I’ve also been involved in the most recent project on curriculum learning outcomes, organised in response to a request from the GMC, which has been a multi-stage consultation process. The three overarching learning outcomes proposed on the basis of the consultation are to be published online soon and cover: the relationship between the environment and health; the environmental sustainability of health systems; and the ethical and policy-related issues that arise from understanding these two topics, such as how the duty of a doctor to protect health applies to future generations.

As I‘ve read more about our impacts on the environment, climate science and the extent to which human health depends on ecosystems and climate stability, I’ve been surprised and concerned by how little of this information seems to reach the general public, including medical students.  To help change that, I’ve been running workshops and campaigns with a student group called Healthy Planet UK, in partnership with a larger network called Medsin.

Medical educators, students and clinicians wishing to set up more teaching in their medical school often encounter objections that there's not enough space in the curriculum or that these topics aren't relevant.  Yet the evidence shows that climate change is an increasingly important threat to global public health, and I think the scope for health professionals to help shift political narratives around environmental issues is often underestimated.  If my cohort of future doctors needs to know about tobacco or antibiotic resistance, then surely we also need to understand how changes to weather patterns and ecosystems are affecting, and predicted to affect, health.  Equally importantly, we need to be aware of the growing evidence base around the opportunities, termed 'co-benefits', to deal with burgeoning public health problems such as obesity and poor mental health in a way that's synergistic with the goals of sustainable development.

Given some of the details I had to learn in pre-clinical medicine, the argument that there's not enough space in the curriculum suggests it’s an issue of priorities.  Do we really think enabling tomorrow's doctors to tackle what may well be a bigger health threat than tobacco - especially considering the complete inadequacy of the political response so far - matters less than learning, for example, all the steps of the Krebs cycle?  My learning in this area has influenced the way I think about the rest of my education, and I think I'll be a better doctor for it; better able to understand the macro-scale influences on patients' lives, and to contribute to discussions about how health services could be better for both patients and the environment.  

To create lasting change - whether in sustainable healthcare, climate policy or other public health issues – tomorrow’s doctors require an understanding of the issues, to have had the freedom to discuss them and try out their ideas, and the skills for effective collaboration, including inter-sectorally.  Through the SHE network, we are seeking to create this space for students to learn, reflect and debate about the issues, and to develop the skills to help lead the transition to sustainable healthcare.


The fourth CleanMed Europe conference takes place at the Oxford Examination Schools from 17th-19th September, and Izzy will be talking about the SHE Network and Healthy Planet's activities during the conference.

by Grace Remmington, GRAVIS intern and one of the Healthy Planet COP19 Support team members.

This blog was originally posted at http://gravisindia.wordpress.com/2013/07/09/making-the-link-climate-change-water-security-and-health/, where you can also find out more about GRAVIS India's work


Since arriving in India, one of the things which I have been considering is the links between climate change, the water cycle and health. India suffers both extremes of the water cycle: some areas experiencing many drought years, others experience heavy flooding. The apocalyptic photographs of the flooding in Uttarakhand, with a death toll of at least 1000 people, stands in direct contrast with the area of India, the Thar Desert, that I have experienced.

Last Tuesday (2nd July), the UN’s World Meteorological Organisation (WMO) released its climate report on the last decade which exposed the climate extremes that have occurred between 2001 and 2010.  The report recorded an ‘unprecedented’ rise in climate pattern which is estimates has resulted in more that has 370,000 deaths due to heat waves, flooding, tropical cyclones and other phenomena.  The most notable of these was the 2010 flooding in Pakistan which affected over 2 million people.

However, what I have begun to notice, living and working in a very arid region, is that the WMO figure is really only the tip of the iceberg when it comes to climate-related, specifically water-cycle related, deaths. The real human cost is much higher.

The effects of events such as flooding are immediate and provide a very visual and panoramic spectacle of a climate-related disaster. In these cases, the links between extreme weather events, and their resulting problems, are easy to make; the immediate evidence is hard to deny.

For example, the link between climate change and increases in cases of malnutrition is evident. A low yield of crops after a failed rainfall is causally linked and the evidence is relatively hard to refute. A change in the rainfall, such as a failed monsoon, creates low soil moisture which affects crop yield, in turn causing farmers to have less access to both the food they grow and the food they can afford. This trend is easy to evidence for several reasons: firstly, it happens in a short, controlled timeframe and, secondly, the links between drought and fluctuation in climate are correlative. Therefore, the causal link from poor yield to reduced food security is a logical one.

The problem in recording climate-related deaths becomes more difficult in trying to hold to account the deaths in which the causal link is blurred by other variables and, very importantly, takes place over an extended period of time. There are many examples of these seemingly non-climate­ related events. The one I will use is one which has become increasingly apparent to me through my work with Gravis: the occurrence of Occupational Lung Disease (OLD).

The causal link between climate change and Occupational Lung Disease could be seen as the following: the event of poor rainfall results in a poor crop yield, which impacts on the ability to feed a household and livestock. Due to this shortfall in food and income, farmers must seek alternate employment. Often this need requires migration.

One of the most common alternative forms of employment in the Thar is mine work.  Workers migrate from rural farms to work in sandstone and marble mining, for example the mines near Jodhpur, where they work long days in the blistering heat with no shelter, little water and no toilet facilities. Further to the lack of provisions for basic rights in a workplace, the employers, through ignorance or negligence, do not provide adequate health and safety in the mines to prevent inhalation of the dust through practices such as wet drilling (as opposed to the prevalent and cheaper dry drilling which creates a lot of dust).

This dust contains crystals of silica which lodge themselves in the lungs and accumulate over time. The initial symptoms are irritation and inflammation of lung tissue which then progresses to fibrosis (scarring) of the lung tissue. The effects of silicosis are the collapse of alveoli (air sacs) in the lung, emphysema and a weakened resistance to secondary lung diseases such as tuberculosis. Silicosis limits life-expectancy by an average 15 years and cause early death through respiratory failure and heart disease.

The problem with linking silicosis and climate change is that it is not as easily correlated as - for example - a rise in communicable diseases (such as diarrheal diseases) during flooding.  The causal link between the two is more complex and runs through many events such as crop failure and migratory patterns. Furthermore, the variability of employer responsibility regarding healthy and safe practices complicates any direct causal link. If the employer took the legal responsibility for mineworkers’ health, it would go a long way to mitigate the effects of Silicosis.

However, currently this protection is not happening; therefore, after years of failed rainfall, farmers become forced environmental refugees who are economically disempowered.  They are living a life of subsistence exacerbated by environmental problems. Therefore, they do not have the economic independence to demand better working conditions or the opportunity of alternative employment. They are working for the continued survival of themselves and their families.

The other issue which causes a difficulty in creating a link between climate change and many deaths, such as those arising from Occupational Lung Diseases, is that they occur over a much longer time period. Therefore, unlike many casualties of climate change, the impacts are not as easily and directly demonstrable.  The effects of climate change take place within a slow time-frame, unlike the rapid human impacts of environmental changes seen in disasters such as flooding.

Climate change is the most fundamental issue facing this planet, economy and people – particularly the world’s poor – and it is time that global society recognises the full extent of its effects.

These are not just the direct and immediate costs – those easily viewable and provable – but also about making the link between the complex and gradual impacts which are just as catastrophic.  In this sense, the loss of 370,000 lives reported by the WMO is just the tip of the iceberg: we need to reach deeper into the complexities of the human cost of climate change in order to protect the poorest people on the planet.

Grace Remmington is currently volunteering with GRAVIS working on documentation and research.  Following her graduation from the University of Southampton, she has spent this year working overseas in India and in working rural development in Nicaragua. She is planning to study Water Science and Policy in 2014, and will be part of the HP Support and Comms team during COP19.  Follow her here: @graceremmington