Learning to treat the climate emergency together: social tipping ... - The Lancet
Learning to treat the climate emergency together: social tipping interventions by the health community - The Lancet Planetary Health
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If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password Cumming School of Medicine, University of Calgary, Calgary, AB, CanadaDahdaleh Institute for Global Health Research, York University, Toronto, CanadaBlavatnik School of Government, University of Oxford, Oxford, UK School of Population and Public Health, University of British Columbia, Vancouver, BC, CanadaYale School of Public Health, Yale University, New Haven, CT, USADepartment of Economics, University of Southern California, Los Angeles, CA, USA Accelerating the decarbonisation of local and national economies is a profound public health imperative. As trusted voices within communities around the world, health professionals and health organisations have enormous potential to influence the social and policy landscape in support of decarbonisation. We assembled a multidisciplinary, gender-balanced group of experts from six continents to develop a framework for maximising the social and policy influence of the health community on decarbonisation at the micro levels, meso levels, and macro levels of society. We identify practical, learning-by-doing approaches and networks to implement this strategic framework. Collectively, the actions of health-care workers can shift practice, finance, and power in ways that can transform the public narrative and influence investment, activate socioeconomic tipping points, and catalyse the rapid decarbonisation needed to protect health and health systems.
Introduction
The foundations of human health and health systems are being destabilised by climate change. Climate disruption directly undermines health through increasing extreme weather events and wildfires, reducing food security, and spreading infectious diseases, and it indirectly undermines health through effects such as sea-level rise, mass migration, and conflict.
It affects health systems by increasing demand for services, threatening infrastructure and supply chains, and endangering the health workforce via hazardous and strained personal and professional circumstances.
The focus of this Personal View is climate mitigation. The health community has enormous potential to influence the social and policy decarbonisation landscape. Every fraction of a degree of warming averted reduces the risk of self-perpetuating atmospheric heating and of reaching dangerous tipping points (eg, changes in ocean circulation or rate of ice melt).
the oath enhances a sense of shared social identity, which is the single most important motivation for collective action and the key to generating the feeling of collective efficacy that also motivates participation;
North America 13·4, Europe 7·5, and Africa and Middle East 1·7
Actions that decrease fossil fuel use reduced contributions to the 8·7 million global premature deaths in 2018 attributed to fossil fuel-related air pollution (approximately 18% of total excess deaths)
Information feedback in the form of the availability of greenhouse gas emissions for most products has been identified as a social tipping element with the time to trigger a tipping point estimated at only a few years
active transport increases physical activity, social contact, and the ability to interact with the natural environment; reduces the risk of cardiovascular disease, type 2 diabetes, colon and breast cancer, and depression
Transportation mode choices are influenced by past habit, perceptions about the difficulty of non-car travel, contextual factors (eg, distance and quality of infrastructure), beliefs about effect on social status, and presence or absence of pro-environmental norms
Lead initiatives to divest from fossil fuels, and reinvest in low-carbon solutions
Direct via reduction of resources for extraction and increase in resources for low-carbon options; indirect via removal of social licence from fossil fuel industry and effect on other investors and decision makers
it is important to support income and occupational health through a transition to stable employment in low-carbon industries, where jobs outnumbered those in fossil fuel industries in 2020 (more than 12 million employees directly and indirectly employed in renewable energy, exceeding those directly employed in fossil fuel extraction)
Divestment and financial disclosure have previously been identified as potential social tipping interventions, which, by influencing the profitability of fossil fuel exploitation, could trigger tipping within hours at scale
Work to enhance nature-based solutions in your community: protect forests, support Indigenous land tenure, offer nature prescriptions, and encourage sustainable plant-rich local food systems
Globally, reduced or sequestered emissions (in Gt CO2e) from 2020 to 2050: restoration of tropical forests (54·45–85·14); restoration of temperate forests (19·42–27·85); Indigenous Peoples' forest tenure (8·69–12·93); protection of forests (5·52–8·75)
increased nature exposure is associated with improved self-reported wellbeing, positive mood, and aspects of cognitive function, and decreased mental illness, salivary cortisol, heart rate, diastolic blood pressure, risk of preterm birth, type 2 diabetes, stroke, hypertension, and asthma, as well as reduced cardiovascular and all-cause mortality;
100% renewable institutional electricity and low emission health-care-related transport Lead initiatives to transition your institutions to 100% renewable electricity and use this to help power low and zero emissions health-care-related transport
In National Health Service England, 10% of emissions come from staff, patient, and visitor travel; onsite renewables were estimated to ensure faster greenhouse gas reduction than a reliance on a gradual decarbonisation of the electrical grid
solar photovoltaic and wind power are at or near the tipping point where they are competitive with fossil fuels; focused investment could change political priorities and create economies of scale leading to rapid, investment-driven cost declines to outcompete incumbents
switching from metered-dose inhalers to dry powder inhalers in a two-dose per day combination corticosteroid and long-acting β-2 agonist plus salbutamol regimen is similar to carbon reductions per person obtained by switching from a meat-based diet to a plant-based diet or from a fossil-fuelled car to a hybrid vehicle
Advocate for institutional and national commitments to net zero emissions health care as soon as possible (by 2045 at the latest) and for progressive procurement policies that require equivalent mitigation ambition by suppliers by 2030
Reduce the 5·2% of global greenhouse gases attributable to health care
large-scale demonstrations of carbon-neutral buildings can be a social tipping intervention with respect to human settlements, with an estimated time needed to trigger tipping of approximately 10 years
Ambitious nationally determined contributions to the Paris Agreement Advocate for ambitious nationally determined contributions to the Paris Agreement and enhanced climate finance from redirected fossil fuel subsidies, with health co-benefits costed and included in budgeting
For nationally determined contributions evaluated by the Global Climate and Health Alliance and healthy nationally determined contribution scorecard, only Costa Rica, Morocco, the UK, Kenya, and Nepal are aligned with keeping warming within the 2°C upper bound of the Paris Agreement target 2°C, and none were aligned with 1·5°C;
Compared with a current pathway scenario, implementing health-focused policies consistent with the goal of the Paris Agreement for nine countries accounting for over 70% of global emissions could result in an annual reduction of approximately 1 645 000 air pollution-related deaths, 6 436 000 diet-related deaths, and 2 088 000 deaths due to physical inactivity
current context for UN climate governance has been evaluated as being more favourable than at any point since the turn of the millennium; challenges exist in the form of fossil fuel dependence in key countries and risk of authoritarian populist movements;
Social tipping interventions—actions with the potential to accelerate so-called contagious spread of new behaviours, social norms, and structural reorganisations—are more likely to create transformative change if a large group coordinates efforts.
Mutually reinforcing positive feedback cycles have been shown at micro levels (ie, individual), meso levels (ie, institutional and community), and macro levels (ie, subnational, national, and international),
creating the possibility of accelerated impact from networked action across scales. At the micro level, individual pro-climate behavioural change sends a signal to others, shifting social norms, and encouraging learning by doing.
Once a critical mass is reached, policy change to reduce adoption costs becomes more likely, which, in turn, deploys increased technology, bringing with it economies of scale and positive feedback cycles.
Modelling in a coupled climate–social system shows the potential for non-linearities and tipping points associated with connections at individual, community, national, and global scales to be decisive in achieving policy and emissions outcomes.
The foundations of human health and health systems are being destabilised by climate change• Health professionals are trusted, and health sector purchasing power is immense: it allocates over 10% of gross world product
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Many measures that decrease greenhouse gas emissions also enhance wellbeing
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Only a minority of medical curricula incorporate planetary health and climate change, leaving many in the health community motivated to help but unsure of how to respond
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Modelling in a coupled climate–social system shows the potential for non-linearities and tipping points associated with connections at individual, community, national, and global scales to be decisive in achieving policy and emissions outcomes
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We assembled a multidisciplinary, gender-balanced group of experts from six continents to develop a framework for maximising the social and policy influence of the health community on decarbonisation, focusing on measures that have co-benefits for health
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To aid in rapid mobilisation, we provide practical strategies to implement the recommended actions, focusing on strategic target selection, effective communications, compassionate teamwork, and the use of existing and new networks to accelerate movement building
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A coordinated global approach by the health community has the potential to create healthier communities and transform health facilities into anchor institutions of sustainability, leading to shifts in social norms, policy, and investment that activate socioeconomic tipping points and catalyse the rapid decarbonisation needed to protect health and health systems
The potential of health networks to focus work on identified social tipping interventions has not been looked at in detail. Social tipping interventions proposed for stabilising Earth's climate include eliminating fossil fuel subsidies, incentivising low-carbon energy generation, building carbon-neutral cities, divesting from fossil fuels, revealing the moral implications of fossil fuels, strengthening climate education, and disclosing information on greenhouse gases.
A similar concept, sensitive intervention points, includes the financial disclosure of risks related to a low-carbon transition and climate impacts, investment in solar photovoltaics and wind, and mobilisation of a silent or non-vocal pro-climate majority.
Related work on sustainability leverage points emphasises presenting low-carbon visions of a good life, reducing consumption and waste, enhancing latent values of responsibility, and attending to inequalities, justice, externalities from trade, responsible technology, innovation and investment, education, and knowledge generation.
This Personal View seeks to guide health community action on climate mitigation at this moment of high potential. CODA Change, an educational charity centred around an international cohort of emergency and critical care professionals, most of whom are new to working in planetary health, was tasked by its community with developing an approach that harnesses the power of the collective health community to decrease greenhouse gas emissions and improve health. Leaders of practice and of existing networks, including of the Global Climate and Health Alliance (117 global organisational members) were invited to consider how to best channel this energy. To facilitate a rapid transition from education on health and health system impacts of climate change to effective work in service of a healthy climate, we provide practical strategies to support a learning-by-doing approach focused on strategic target selection, effective communications, compassionate teamwork, and network building.
Overall approach to treating the climate emergency: target-based change making
When a patient requires care, clinicians do not simply describe the steps involved—they mobilise people and resources to ensure treatment is carried out. Similarly, treating the climate emergency requires moving beyond telling people things (an information-deficit model of change making) to leading change through methods supported by evidence in the health sciences, behavioural change, communications, movement-building, and policy making.
Marshall Ganz's head, heart, hands method emphasises teaching leadership through practice with an emphasis on analysis to assist heads in choosing goals, storytelling to motivate hearts, and practical instruction to train the dexterous hands required to shape outcomes.
Global networks make possible a meta level of influence in which international goals are developed collaboratively, and supports are offered to community-centred initiatives with the goal of creating a wave of change that influences norms, policies, and markets.
This target-based model is expanded in figure 3 to encompass the learning and movement-building process. Each element of this change-making model will be addressed to illustrate how the health sector can move together to decrease greenhouse gases.
Figure 3Leading change together through target-based change making
and data from community consultation. Contextual elements include market forces, policy processes, and timing of decision-making moments. The social, political, financial, and human resources available to the team direct ambition.
To strategise a list of high-impact targets that could, if applied globally, generate a meta level of influence on sociopolitical tipping points of relevance to the climate system, we assembled an expert group based on previous work. A survey solicited potential action items in the areas of health care, energy, transport, food, and nature-based solutions. Results were considered at a 2-day in-person workshop by a subset of the initial group selected to ensure gender balance; representation from six continents; and diverse competencies across economics, education, communications, policy, advocacy, public health, nursing, medicine, dentistry, health system logistics, planetary health research, and systems change at local to global levels. Actions were excluded if a case of successful accomplishment of the action by the health sector could not be substantiated.
Actions were considered in terms of effect on greenhouse gas emissions, potential for near-term co-benefits to health and cost savings to health systems, alignment with tipping point and behavioural change literature, and ability to be amplified by existing networks. A ladder of engagement was designed to prioritise health co-benefits, establish new social norms, and create policy feedback loops through both resource effects that decrease structural barriers, and interpretive effects that reflect the fact that policies themselves are new sources of information with the potential to shift understanding and create new norms around our response to climate change (figure 4).
Practitioners can measure baseline gender representation in leadership at their institution and set targets for gender equity, including gender-diverse individuals. Practitioners can work at all levels to support gender equity in leadership and ensure universal access to education and sexual and reproductive health services.
Examples of these actions: (1) in 2018, 18 editorial advisory boards in Lancet journals were comprised of only 30% women. As of 2020, Lancet editorial advisory boards were comprised of 51% women.
(2) A population, health, and environment approach was taken in Ugandan Lake Victoria communities to improve health services and access to contraceptive use alongside interventions to facilitate women's income generation. Their outcome of annual couple-years of protection with contraception more than doubled and women's power within the family increased.
Profiting from fossil fuel investments is inconsistent with the ethics of health-oriented organisations; an estimated 18% of global premature deaths in 2018 were linked to fossil fuel-related air pollution.
Climate-related financial risks are grossly underestimated by financial markets, with groups such as the Task Force for Climate-related Financial Disclosures working to align financial flows with low greenhouse gas pathways.
A Fossil Fuel Non-Proliferation Treaty has been proposed to promote leaving fossil fuels in the ground. Support can be indicated via sign-on at the individual, organisational, or jurisdictional levels.
The non-proliferation pillar requires the creation of a global public register to map fossil fuel reserves and regular analysis to identify whether aggregate production phase-down policies align with a 1·5°C scenario.
A just transition pillar requires money from redirected fossil fuel subsidies or a global carbon tax to be distributed through a new Global Transition Fund to support the massive expansion of clean energy technology in low-income and middle-income countries.
Work to enhance nature-based solutions in your community: protect forests, support Indigenous land tenure, offer nature prescriptions, and encourage sustainable plant-rich local food systems
Protecting forests, planting trees, and optimising land use through plant-rich diets decreases CO2 levels while supporting habitat and biodiversity, and reducing unsustainable flows of nitrogen and phosphorus.
Nature prescriptions involve health-care providers writing recommendations for meaningful contact with nature, often in 20 min increments adding up to at least 2 h per week in alignment with evidence that this dose is associated with improved self-reported wellbeing.
(2) A non-profit project in Borneo carried out in partnership with Indigenous communities provides health-care, training in organic agriculture, and small business financing to reduce logging. Results after 10 years show 0·59 Tg of carbon loss avoided, a 90% decline in illegal logging households, habitat protection for 3000 orangutans, and a 67% decline in infant mortality and a 54% decline in births per mother in the local population.
Participation in on-site or community renewable energy installations can ensure adequate capacity to meet power demand, increase resilience to severe weather, and align with hospital and university mandates to serve as anchor institutions that model healthy practices.
Solar panel installation appears catching—ie, the more concentrated the solar photovoltaic in a region, the greater the likelihood of additional installations.
(2) National Health Service (NHS) England ensured that all leased or purchased vehicles have low or ultra-low emissions in 2020–21 with a plan for 90% of the fleet to be low, ultra-low, or zero emission by 2028.
Lead initiatives to rapidly reduce super-pollutants in your institutions starting with inhaled anaesthetics, metered-dose inhalers, refrigerants, and natural gas
The term super-pollutant refers to materials with high global warming potential (GWP) measured relative to CO2 equivalents (CO2e) including black carbon (ie, soot), methane (the dominant component of natural gas), hydrofluorocarbon propellants in metered-dose inhalers, and some inhaled anaesthetics.
Examples of this action: (1) NHS England has launched a primary care incentive scheme to support a shift away from high-carbon inhalers to reduce emissions (currently making up 3% of NHS England's total emissions).
(2) Desflurane (GWP100 2540 CO2e) was eliminated from the Yale New Haven Health System (New Haven, CT, USA) formulary in 2013, saving an estimated US$1·2 million and 1·6 million kg CO2e (the equivalent of 360 passenger vehicles) annually from the flagship hospital alone.
Advocate for institutional and national commitments to net zero emissions health care and for progressive procurement policies for suppliers
Institutional and national bodies should aim to reach net zero emissions health care as soon as possible—by 2045 at the latest. Given that delivering on this target requires decarbonising the supply chain, progressive procurement policies should require equivalent mitigation ambition by suppliers by 2030. The health sector is responsible for 5·2% of global greenhouse gas emissions,
Work at this scale can shape policy and market forces. Suppliers were advised that by 2023 they will need carbon reduction plans to qualify for NHS contracts valued at over £5 million, and that by 2025 they will be contractually required to show alignment with a 2045 net zero target.
Advocate for exclusive use of 100% renewable electricity as soon as possible in your nation: prioritise transitioning from coal-fired power directly to wind, water, solar, and energy storage
Phasing out coal-fired power is a priority given its climate impact and high associated morbidity and mortality. An estimated 561 000 global deaths were associated with related particulate matter emissions in 2020.
Natural gas is not a transition fuel; if the leak rate of methane during extraction and transport equals or exceeds 3%, a given amount of electricity produced from natural gas causes more global heating than coal over a 20-year timeframe.
Examples of this action: (1) Health workers in the UK and Canada centred narratives on reducing air pollution-related asthma, stroke, heart disease, cancer, and chronic lower respiratory disease in successful efforts to persuade policy makers to phase out coal-fired power.
Advocate for ambitious nationally determined contributions (NDCs) to the Paris Agreement and enhanced climate finance from redirected fossil fuel subsidies, with health co-benefits costed and included in budgeting
NDCs outline countries' commitments under the Paris Agreement and can serve as national frameworks to ensure integration of health considerations.
Story—communicating climate change and health effectively
Being able to communicate why people should support a given initiative at a particular time is essential to creating relationships, motivating teams, and seeing change targets realised. Stories can transform values into the emotions needed to drive change, with anger helping overcome apathy, hope conquering fear, solidarity alleviating isolation, and inspiration found in stories of successful change making, which yield the sense that individuals can make a difference.
Did your patients have asthma exacerbations due to wildfire smoke? Were older patients harmed by heat?
An awareness of the emerging climate and health communications evidence base is essential. Mention of measures that decrease greenhouse gas emissions and entail health co-benefits help health professionals understand how they can contribute to sustainability,
Community engagement and message testing in specific contexts help identify shared values and narratives based on respect for different perspectives. Climate Visuals provides a free bank of evidence-aligned images that can be combined with work by artists for compelling communications.
Working in isolation on the climate emergency can feel like providing bystander cardiopulmonary resuscitation in the field—lonely and uncertain. Despite these feelings, it can deliver invaluable results, and motivate others to contribute. If you feel alone, reach out to local networks, and if these do not yet exist, request assistance from the global community. A lack of faculty familiarity with the topic makes co-developed initiatives emphasising student and faculty partnership key.
It will require the work of every profession that makes up the health sector—eg, pharmacists, administrators, architects, engineers, economists, artists, medical device suppliers, pharmaceutical companies, and decision makers—to achieve optimal outcomes. As outlined in the São Paulo Declaration on Planetary Health, “We invite you to consider yourself a partner in planetary healing.”
To facilitate interdisciplinary and intercultural work, avoid jargon and acronyms, be generous in attributing good intent, and agree upon group norms around confidentiality, reporting structures, and mechanisms for norm-correction at the outset of work.
The climate crisis is one in which each of us is both a patient and a potential healer. Ecological grief, eco-anxiety, and ecological anger are normal responses that can affect our mental health as well as our likelihood to take action.
Learning to treat the climate emergency provides an avenue to agency that can align values with action and reduce moral injury-related drivers of burnout. However, unrelenting work worsens both wellbeing and performance. Sleep, nutritious food, exercise and time in nature and with loved ones must be supported as contributory to the transformative work required for both planet and people to thrive.
As in clinical work, sharing stories of the advantages and pitfalls of adventures in advocacy can provide comfort while enhancing group learning.
It is helpful to envision coaching roles within teams (figure 3). Members can transition from coach to coached and vice versa depending on expertise to provide strategic advice, skill-set instruction, and emotional support during moments of perceived failure or personal attack.
Pushback from powerful bodies must be anticipated, and is an additional reason for individuals to reach out to networks, as collectives are better placed to provide legal and emotional support. Teams can help individuals choose roles aligned with their risk threshold and life circumstances. Community helps foster courage.
The nurturing of teams, organisations, and networks requires stewardship and resources. Financial and organisational support for secretariats and coordinating networks is required to catalyse a rapid health sector-led shift.
Tactics
Tactics are the activities that make your strategy materialise and should be chosen in such a way as to move you closer to accomplishing your target.
For instance, work to reach a commitment to phase out coal-fired power might use the release of an evidence-based report detailing the projected lives saved through a transition to renewables as a tactic to generate media interest before a crucial decision point.
Commissioning a poll, bringing forth a motion at a meeting, organising a day to lobby decision makers, and launching a communications campaign are all tactics that require resources and skill and best sit within an overarching strategy.
Clinical teaching emphasises the rehearsal of high-risk skills in simulated situations. Planetary health educators can adopt a similar approach to intimidating situations such as media interviews and lobbying.
Wins
The nature of networked efforts is that progress is the result of the work of many people. Attribution of wins to any one group or action is difficult. That said, it is important to celebrate progress and to acknowledge contributions, as these provide inspiration. The approach outlined in this Personal View was finalised in January, 2022. Presentations have been given to thousands of participants in multiple countries, and downloadable PowerPoint slides based on the figures and content of this Personal View are available in the appendix to facilitate work at the micro level and meso level. The Global Climate and Health Alliance, best able to coordinate work at the macro level in association with its network of international and in-country partners, has joined the Powering Past Coal Alliance to amplify the health voice in coal phase-out efforts and led an international campaign that saw 250 health organisations, including WHO and thousands of health professionals, endorse the call for a Fossil Fuel Non-Proliferation Treaty. Shortly after WHO support was announced, Vanuatu became the first nation-state to call for such a treaty. Tuvalu soon followed, and the EU parliament adopted a resolution in support.
Conclusion
The stewardship of networks, strategic target selection, adoption of communications best practices, and development of compassionate team environments can help the health community learn to treat the climate crisis together. A coordinated approach has the potential to shift practice, finance, and power to transform the public narrative and influence investment, activating socioeconomic tipping points and catalysing the rapid decarbonisation needed to protect health and health systems. Contributors CH led the project, reviewed the literature, wrote the first draft, and coordinated edits. AJM led the health systems group, contributed to the project design, and helped draft and edit. FH led the energy group, contributed to the project design, and helped draft and edit. LA, KC, RdA, RH, BJ, EM, LM, FM, JM, MN, DP, SR, JDS, JV, and HY contributed content and network knowledge, and helped draft and edit. HM provided oversight of the project, and helped draft and edit.
Declaration of interests
We declare no competing interests. Acknowledgments The authors would like to acknowledge Isobel Braithwaite, Alice McGushin, Jessica Beagley, and William Gagnon for their feedback and contributions to the development of the infographics; Sarah West for providing images; Nick Watts and Verena Rossa-Roccor for their suggestions on the manuscript; Marshall Ganz for his contributions to this Personal View; and the broader planetary health community for the many conversations and contributions that informed this work. CODA Change charity contributed funds to the convening of the authorship group as well as financial support for CH's work on the project.