In a current editorial, Fiona Godlee, editor of the British Medical Journal, writes: ‘The greatest risk to human health is neither communicable nor non-communicable disease, it is climate change'.1 Earlier, the World Health Organization (WHO) had estimated that by 2002 global warming and trends in rainfall due to human-induced climate change already claimed over 150 000 lives annually as a result of extreme weather conditions, changing transmission patterns for water-related diseases such as diarrhoea, vector-borne infections including malaria, and increased malnutrition from the impacts of changing weather patterns on food production.2

But, as Richard Smith, previous BMJ editor, points out on his blog, the health effects of climate change go beyond the consequences of altered weather: ‘Until comparatively recently we talked mostly about infections like malaria, dengue fever, and schistosomiasis extending their range and high death rates during heat waves. Now we realise that much more death and suffering will come from hunger, drought, flooding, mass migration, and war.’3

Given these wide-ranging and devastating impacts of climate change on health, it is ironic that health systems contribute substantially to climate change through their own large greenhouse gas (GHG) emissions. This negates the very reasons they exist – to promote, protect and improve people’s health – and is perhaps the supreme example of cultural iatrogenesis. Globally, it vindicates Ivan Illich’s famous 1975 indictment that ‘The medical establishment has become a major threat to health’.4 Furthermore, unless it can be mitigated, it renders health systems fundamentally unsustainable.

This article looks at how health systems contribute to GHG emissions and how this can be addressed in South Africa. It argues that recent initiatives by the National Department of Health provide unique opportunities to reduce GHG emissions.

Health system greenhouse gas emissions in England, the USA and Australia

In 2008 the National Health Service (NHS) in England established the Sustainable Development Unit (SDU) to ensure that NHS development is sustainable – that it meets the healthcare needs of today without compromising those of tomorrow.5 Research by the SDU showed that in 2004 the carbon footprint of the NHS was 18.61 million tons of CO2 equivalent (MtCO2e) per year, representing 25% of England’s public sector emissions and 3.2% of England’s total emissions. It has since grown to 21 MtCO2e per year, which is larger than that of some medium-sized countries.6

This carbon footprint comes from a wide range of health system activities including heating; cooling and lighting buildings; powering equipment; procuring goods and commissioning services; sending waste to landfill; and patient, staff and visitor travel. The major components of the NHS carbon footprint in 2004 were procurement (60% of the total); energy for heating, hot water, electricity consumption and cooling (22%); and travel (18%).6 (Fig. 1.)

Emissions from the manufacture and transport of pharmaceuticals and medical equipment accounted for half of the procurement emissions – pharmaceutical emissions alone were equivalent to either building energy or transport emissions.7

Hospital admissions result in far greater GHG emissions than outpatient appointments. Table 1 shows that a typical hospital admission in the UK leads to CO2 emissions that are approximately seven times greater than those of an outpatient visit.

Studies in other high-income countries show similar massive health sector GHG emissions. In the USA, Chung and colleagues estimated that in 2007 the healthcare sector contributed an estimated total of 546 MtCO2e, equivalent to 7% of total USA CO2 emissions. As in the UK, the largest contributors were the hospital and prescription drug sectors (39% and 14%, respectively).8 In Australia, health facilities account for 53% of the total New South Wales government building energy usage.9 It is clear that where data exist, health systems are major contributors to climate change, and there is an urgent need to reduce GHG.

While there are no systematic data on the GHG emissions of the South African health sector, they are likely to be at least of the order of those of the UK, particularly in the private sector. South Africa ranks among the top 30 GHG emitters in the world, and relies on coal for 70% of its energy requirements. Its total carbon emissions per capita are remarkably similar to those of the UK. In 2008, for example, the carbon footprint of the UK was 8.5 metric tons of CO2 per capita, while in South Africa it was 8.8. 10

South Africa’s health sector has 28 hospital beds per 10 000 people. The private sector however, which is more hospital-centred than the public health system, has 38 beds per 10 000, almost identical to the UK’s 39 per 10 000 people. Therefore, in the absence of data it is reasonable to assume that, conservatively, health system emissions in South Africa are comparable in scale with those of the UK, particularly in the private sector. Public sector per capita emissions are likely to be far lower because of the greater proportion of facilities that serve mainly outpatients (clinics and health centres) with relatively fewer energy-consuming, GHG-producing inpatient beds and technology.

Climate change increases the urgency of health sector transformation in South Africa

The extreme vulnerability of sub-Saharan Africa to the effects of climate change has major implications for health in South Africa and increases the urgency of health system transformation.

Fig. 2 shows the global distribution of deaths from climate change for 2002 as estimated by the WHO.2 Already more people die from the effects of climate change in Africa than anywhere else, particularly in sprawling cities where the effects of urbanisation aggravate extreme climatic events.11 Therefore, the very people who already have the highest disease burden and depend on poorly functioning, overburdened health systems are the most vulnerable.

This is highly pertinent for South Africa, given that climate change leads to mass migration, national insecurity, conflict and war. Humanitarian disasters like the current famine in Somalia, due to a deadly combination of drought, conflict and political instability, are likely to become more frequent. With refugees pouring into refugee camps in Kenya at the rate of 1 500 a day – 80% of them women and children – and hundreds of thousands of deaths, this is Africa’s worst humanitarian crisis in decades.12 Such droughts will increase with climate change, and we should anticipate increasing migrations from the region and other parts of sub-Saharan Africa. This will increase the burden on our already crisis-stricken public and private health systems.

We cannot allow our health sector to lag behind these complex challenges; it must respond to the consequences of climate change as an integral part of its proposed transformation.

Tackling health sector emissions in the context of the National Health Insurance

The challenge is to ensure that our new health system not only provides good health care for all, now and in the future, but that it minimises its impact on the planet and is sustainable. The initiative around the government’s National Health Insurance (NHI) proposal provides opportunities that will make this possible.

Addressing climate change and its consequences requires action in three broad areas.

• Firstly, the health sector has to reduce its current GHG emissions and ensure that the transformed health system has low emissions.

• Secondly, it has to take on a more prominent leadership role in reducing people’s vulnerability to climate change. This vulnerability is rooted in social and economic inequality, implying a need to address the social determinants of health more proactively, and for more powerful advocacy for social justice and equality not only in the country, but throughout Africa and the world.

• Finally, it must prepare itself to deal with the changing patterns of disease and disease burdens that inevitably arise from climate change.

Fortunately, the guiding principles contained in the NHI green paper embody values that align closely with these imperatives. Among these are social solidarity, a commitment to equity, and the right to health, access and affordability. The re-engineering of primary health care based on the principles of the 1978 Declaration of Alma Ata provides a strategic way forward with its strong emphasis on community-based services.13

It is essential to build excellence in all three primary health care streams: the district clinical specialist teams, the school health promotion services and the municipal ward-based primary health care teams. This will move the centre of gravity of the system out of the hospitals and into the community, closer to where people live. It entails a shift in emphasis in human resources from the hospital-based, doctor-centred model to a community-based model that incorporates more community and mid-level health workers.

These processes will require political will and a participative multisectoral approach, and an acceptance by professional bodies of the necessity to work in collegial, non-hierarchical health-worker teams in community settings. The potential benefits are immense, better and more accessible health services and a healthier nation, and significant reductions in GHG emissions.

Panel 1 lists a number of practical suggestions for reducing the carbon footprint of hospitals and health facilities. Many of the above measures have been researched by the SDU in the UK, and they should be urgently explored here.

The SDU estimates that the NHS can save at least £180 million per year by reducing its carbon emissions. Thus, greening the health system is also likely to save money.

It is also likely to lead to technical innovations in building, alternative energy generation and energy conservation, local food production and urban farming. This will lead to employment opportunities not only in the health sector, but also in agriculture, transport and science and technology.

Low GHG emissions should be an overriding concern in the development of the health system. Yet neither the NHI Green Paper nor the 10-point plan mentions the impacts of climate change on health, or the need for the sector to reduce GHG emissions. A possible way forward is to consider including low carbon emissions in the requirements for the accreditation of service providers under the NHI.

Another concern is the limitation of the right of access to South Africans, legal permanent residents, refugees and asylum seekers. This excludes people who migrate because of the impacts of climate change, since they are unlikely to fall within these categories. Furthermore, there is no accepted legal definition of climate change refugees, nor any legal instrument for their protection.14

Conclusions

The advent of the NHI gives us a historic opportunity to build a sustainable national health system that not only meets the health care needs of all, but that also addresses and minimises the growing impacts of climate change by reducing its own GHG emissions; playing a leading role in promoting social justice and equitable socio-economic development in order to minimise the impacts on the poor and vulnerable; and finally, being prepared and ready to deal with the inevitable changes in disease patterns that emerge in the wake of climate change.

References

1. Godlee F. How on earth do we combat climate change? BMJ 2011;343:d6789. doi: 10.1136/bmj.d6789. Available at: http://www.bmj.com/content/343/bmj.d6789.full

2. WHO. Climate Change. Health and Environment Linkages Initiative - HELI. Undated. Available at: http://www.who.int/heli/risks/climate/climatechange/en/

3. Smith R. Climate change, torturers, Nero, and me. BMJ Group Blogs, 21 October 2011. Available at: http://blogs.bmj.com/bmj/2011/10/21/richard-smith-climate-change-torturers-nero-and-/?utm_campaign=181101&utm_content=372318265&utm_medium=email&utm_source=Emailvision

4. Illich I. Limits to Medicine: Medical Nemesis – the Appropriation of Health. London: Marion Boyars, 1995.

5. NHS Sustainable Development Unit. About us. Available at: http://www.sdu.nhs.uk/about-us/

6. NHS Sustainable Development Unit, 2009. NHS England Carbon Emissions: Carbon Footprint Modelling to 2020. Available at: http://www.sdu.nhs.uk/documents/publications/1232983829_VbmQ_nhs_england_carbon_emissions_carbon_footprint_mode.pdf

7. Eastern Region Public Health Observatory and the NHS Sustainable Development Unit. Briefing No. 23. Available at: www.erpho.org.uk

8. Chung JW, Meltzer DO. Estimate of the carbon footprint of the US health care sector. JAMA 2009;302(18):1970-1972. doi:10.1001/jama.2009.1610

9. Pencheon D. Health sector leadership in mitigating climate change: experience from the UK and NSW. NSW Public Health Bulletin 2009;20(11-12).

10. Wikipedia. List of countries by carbon dioxide emissions per capita. Available at: http://en.wikipedia.org/wiki/List_of_countries_by_carbon_dioxide_emissions_per_capita

11. Patz JA, Campbell-Lendrum D, et al. Impact of regional climate change on human health. Nature 2005;438:310-317. doi:10.1038/nature04188

12. BBC News Africa. 5 September 2011. Somalia famine: UN warns of 750,000 deaths. Available at: http://www.bbc.co.uk/news/world-africa-14785304

13. Department of Health, Republic of South Africa. National Health Insurance in South Africa: Policy Paper. 12 August 2011.

14. Docherty, B & Giannini, T. (2009) Confronting a Rising Tide: A Proposal for a Convention on Climate Change Refugees. 33 Harv Envtl L Rev 349.

IN A NUTSHELL

• Climate change is a major threat to health and to the sustainability of health systems. Sub-Saharan Africa is the most vulnerable region of the world.

• Health systems and organisations are a major contributor to climate change through their own GHG emissions.

• The three most important GHG emitting areas are procurement of supplies and resources, building energy and travel.

• Inpatient hospital admissions have seven times the carbon footprint of outpatient visits.

• Health system transformation in South Africa should include a commitment to reducing the health sector’s carbon footprint.

• A number of practical suggestions for GP practices, health centres and hospitals are made.