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Planetary health and sustainable primary care: What does this mean for a GP curriculum?

Suchita Shah is the RCGP Curriculum lead for Population and Planetary health. She is also a GP, population & global health specialist, writer, editor, and GP tutor at Oxford University Medical School. She is on Twitter @SuchitaShahUK

 

“Wherever we deliver care, in our hospitals, clinics and communities around the world, we are already responding to the health harms caused by climate change” [The Healthy Climate Letter to Heads of State, 2021]

In January the roses bloomed. In July, smoke billowed from scorched urban grasslands and homes. The global climate emergency—of which the untimely unfurling of flower buds and extreme heat are just two tell-tale signs—has roused a call to action from the global health community.1 It is claimed, though, that doctors have remained relatively inactive in this conversation and that this is linked to gaps in their training, including a “dearth of curricular space”.2,3 For tomorrow’s doctors to be able to successfully navigate climate-related health threats in partnership with their patients, medical curricula must shape teaching and learning now.

To address this need, the Royal College of General Practitioners (RCGP) has collaborated with experts and other stakeholders to develop a curriculum Topic Guide that embeds Planetary Health into UK postgraduate family medicine training.

What is planetary health and why do GPs need to know about it?

The health impacts of climate change on individuals are well documented and include rises in infectious diseases, food insecurity, and the effects of pollution and severe weather.

The health of individuals is deeply interconnected with the health of populations and the planet. Planetary health can be defined as “the health of human civilization and the state of the natural systems on which it depends”.4 As a field, it aims to understand and address the human health impacts of human-caused disruptions to the earth’s natural systems.5 Disruption of these natural systems through, for example, climate change and biodiversity loss, profoundly affects the social and environmental determinants of human health. We harm the planet, which harms our health.

The health impacts of climate change on individuals are well documented and include rises in infectious diseases, food insecurity, and the effects of pollution and severe weather.6 In a landmark ruling in the UK in 2021, air pollution was for the first time listed as a medical cause of death.7 At the same time, healthcare services, including primary care, are a major contributor to environmental damage; addressing this is also part of planetary health.

Simply put, what this means in general practice is understanding how the health of the planet is affecting the health of our patients, how their clinical care is affecting the planet, and what we can do about it.

The global context: lessons from COP26 and COVID-19

The RCGP Population and Planetary Health Curriculum Topic Guide is published in the wake of a global climate conference, the COP26, and a pandemic, both of which have generated political and social imperatives that further drive the case for including planetary health in medical curricula.

The COP26 Health Programme focuses specifically on the link between climate change and health. It supports committed countries to develop climate resilient and low carbon sustainable health systems. In July 2022 the UK National Health Service, whose emissions in England account for 4% of the country’s total carbon footprint, became the first health system to embed net zero into legislation.8 Although there is no requirement to include sustainability in postgraduate medical education, an eco-literate workforce is surely compatible with these aims.

The COVID-19 pandemic has brought to attention some core planetary health concepts. Most of these are not new. Indeed, even if not explicitly couched in planetary health terms, they are often what community-based clinicians, and communities themselves, have for a long time recognised as being necessary for health.

Take, for example, interdependence. COVID-19 has shown us that human health relies on global ecosystems and that individual behaviours, such as getting vaccinated and wearing masks, affect the collective. Many traditional communities have long recognised the interdependence of living things.9 Another concept is complexity. COVID-19 was once a new and unpredictable disease with no evidence base for its management; in dealing with this, GPs managed complexity in a way that is already core to general practice: by recognising that the human body is a complex adaptive system10 and not just a series of predictable working parts. Planetary health approaches build on this by looking at the complex interactions within and between populations and ecosystems. Thirdly, just as we have witnessed the disproportionate impact of COVID-19 on marginalised communities, this is also the case for human-caused harm to the planet, which exacerbates health inequalities.11

Interventions in practice

Planetary health in the everyday clinical encounter can be guided by the principles of sustainable clinical practice: disease prevention and health promotion, patient education and empowerment, lean pathways (minimising low-value activities) and low carbon treatments.12 The RCGP curriculum introduces these concepts, contextualises them using a case study and reflective questions, and links them to the core capabilities of Being a GP.

In this approach we may recognise already familiar concepts, such as the social determinants of health, lifestyle medicine, overdiagnosis, and personalised care, which are about the broader influences on health, prevention, and doing what matters to patients rather than doing too much medicine which may cause harm.

We may also start to think in terms of “health co-benefits” – interventions that benefit both our patients and the planet. For example, a planetary health approach to cardiovascular disease may favour green prescribing, sustainable diets, and walking instead of driving, instead of pharmacological treatments or resource-heavy tertiary care. However, if access to, or outcomes from, such therapies are limited or unfavourable for certain groups, the intervention is unlikely to be effective, and may even cause harm which, in a clinical setting, risks undermining the therapeutic relationship. Planetary health learning objectives therefore need to be implemented with sensitivity and common sense, and as part of a broader agenda to tackle inequalities.

Planetary health and decolonising the curriculum

As an academic field, planetary health has been criticised for being colonial.13 However, the Association for Medical Education in Europe emphasises the importance of an inclusive planetary health approach that welcomes diverse cultural views.14 By incorporating these values into the RCGP curriculum, which looks at attitudes as well as skills and knowledge, we hope to address epistemic injustices such as the exclusion or marginalisation of certain knowledge, world views, health beliefs, or ways of learning.

Training and implementation – getting the right balance

Medicine can sometimes be myopic: we see close-up details but not the bigger picture.

The reasons to include planetary health in medical curricula are compelling, but this doesn’t make the task any less challenging, as there are clear implications for training and assessment. To create informed GPs, rather than overburdened trainees and trainers, the GP curriculum emphasises relevant concepts over very detailed content. For example, in the context of respiratory illness, understanding that air pollution is an important cause is more useful than remembering the green credentials of individual asthma inhalers. Supply chain management will be beyond the remit of most trainees, but avoiding over-prescribing and waste are not. Of the various stakeholders we consulted in the development of the Topic Guide, trainees were one of the most enthusiastic. Partnering with education providers will help deliver the curriculum’s objectives.

Medicine can sometimes be myopic: we see close-up details but not the bigger picture. By situating planetary health in the GP curriculum as a set of professional, rather than clinical, capabilities, we emphasise its role as a view-altering perspective on our everyday clinical encounters—a lens that allows us to see the bigger picture, no matter how intimate the scope of our immediate inquiry—and, in doing so, hope to improve outcomes for patients and the planet.

Acknowledgements: many thanks to Dr Mike Tomson and Professor Steve Walter of the curriculum working group on planetary health.

References 

1. Atwoli L, Baqui AH, Benfield T, Bosurgi R, Godlee F, Hancocks S, et al. Call for emergency action to limit global temperature increases, restore biodiversity, and protect health. Lancet Reg Health – Eur [Internet]. 2021 Oct 1 [cited 2022 Jul 25];9. Available from: https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(21)00197-6/fulltext
2. Chase H, Hampshire K, Tun S. Improving the medical curriculum on planetary health and sustainable healthcare. BMJ. 2022 Jan 25;376:o209.
3. Walpole SC, Barna S, Richardson J, Rother HA. Sustainable healthcare education: integrating planetary health into clinical education. Lancet Planet Health. 2019 Jan 1;3(1):e6–7.
4. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health – The Lancet [Internet]. [cited 2022 Jul 25]. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60901-1/fulltext
5. Planetary Health Alliance. Planetary Health [Internet]. [cited 2022 Jul 25]. Available from: http://www.planetaryhealthalliance.org/planetary-health
6. Climate Effects on Health | CDC [Internet]. 2022 [cited 2022 Jul 25]. Available from: https://www.cdc.gov/climateandhealth/effects/default.htm
7. Ella Kissi-Debrah [Internet]. [cited 2022 Jul 25]. Available from: https://www.judiciary.uk/publications/ella-kissi-debrah/
8. Greener NHS » Delivering a net zero NHS [Internet]. [cited 2022 Jul 25]. Available from: https://www.england.nhs.uk/greenernhs/a-net-zero-nhs/
9. Chapple CK, editor. Jainism and ecology: nonviolence in the web of life. Cambridge, MA: Center for the Study of World Religions, Harvard Divinity School : distributed by Harvard University Press; 2002. 252 p. (Religions of the world and ecology).
10. Sullivan T. Embracing Complexity. Harvard Business Review [Internet]. 2011 Sep 1 [cited 2022 Jul 25]; Available from: https://hbr.org/2011/09/embracing-complexity
11. Health inequalities [Internet]. Greener Practice. [cited 2022 Jul 25]. Available from: https://www.greenerpractice.co.uk/information-and-resources/health-inequalities/
12. Mortimer F. The sustainable physician. Clin Med. 2010 Apr;10(2):110–1.
13. Baquero OS, Benavidez Fernández MN, Acero Aguilar M. From Modern Planetary Health to Decolonial Promotion of One Health of Peripheries. Front Public Health [Internet]. 2021 [cited 2022 Jul 25];9. Available from: https://www.frontiersin.org/articles/10.3389/fpubh.2021.637897
14. Shaw E, Walpole S, McLean M, Alvarez-Nieto C, Barna S, Bazin K, et al. AMEE Consensus Statement: Planetary health and education for sustainable healthcare. Med Teach. 2021 Mar 4;43(3):272–86.

Featured image: photo by Andrew Papanikitas, Oxford 2022

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