Tag: sustainability

Developing the Concept of Sustainability in Nursing

“NOTICE: this is the author’s version of a work that has been submitted for publication in Nursing Philopsohy. If accepted, changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication.

 

Developing the concept of sustainability in nursing.

 

Abstract

 

Sustainability, and the related concept of climate change, is an emerging domain within nursing and nurse education.  Climate change has been posited as a serious global health threat requiring action by health professionals and action at international level. Anåker & Elf undertook a concept analysis of sustainability in nursing based on Walker and Avant’s framework. Their main conclusions seem to be that while defining attributes and cases can be established, there is not enough research into sustainability in the nursing literature. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing and grey literature and, for example, the literature in the developing web based ‘paraversity’. Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability and its suggested links with social and health inequalities and the dynamics underpinning unsustainable neoliberalist political economy. This understanding is based on the social and political determinants of health approach  and the emerging domain of planetary health.  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice.


 

Introduction

 

Sustainability, and the related concept climate change, is an emerging domain within nursing (Adlong & Dietsch, 2015; Allen, 2015; Aronsson, 2013; Goodman, 2011; Hunt, 2006; Polivka, Chaudry & Mac Crawford, 2012; Sattler, 2011) and nursing education (Goodman, 2008; Goodman, 2011; Goodman & East, 2013; Goodman & Richardson, 2009; Johnston et al., 2005; Richardson et al., 2013). Climate change has been posited as a serious health threat (Costello, Grant & Horton, 2008; IPCC, 2014; McMichael, Montgomery & Costello, 2012)  requiring action by health professionals (Costello et al., 2011; Gulland, 2008; Harding, 2014; Patton, 2008; Reale, 2009; Thomas, 2014) and action at international level (Durban Declaration on Climate and Health, 2011; WHO (2016) . The status of climate change as health threat has however been contested (Goklany, 2009a; Goklany, 2009b; Goklany, 2012; Goodman, 2014), but it remains an important determinant of health (Barton & Grant, 2006; Griffiths, 2009). In this context, Anåker & Elf (2014) undertook a concept analysis (Walker & Avant, 1982)  of sustainability in nursing. This paper seeks to develop their argument to argue that sustainability in nursing can be better understood by accessing non nursing literature, to address the socio-political context in more depth. This should include going beyond accepted peer reviewed nursing journals and include literature such as that written by Wendell Berry (Berry, 1995) who writes eloquently on human health and our relationship to the natural environment.  There is also a growing body of work online and of an academic standard to qualify for what might be called the ‘Paraversity’ (Goodman, 2015a; Rolfe, 2013). Without this understanding, and application in nursing scholarship, nurses will have a rather narrow understanding of sustainability. There is a need to link social and health inequalities (Dorling, 2013; Marmot, 2015) and the dynamics underpinning unsustainable neoliberalist political economy (Harvey, 2005; Harvey, 2014; Sayer, 2015) with the concept of sustainability. Climate change is just one aspect, albeit a very important aspect, of that linkage. This understanding is based on the social (Davidson, 2015; Raphael, 2004; WHO, 2013) political (Ottersen, Frenk & Horton, 2011) and ecological (Goodman, 2014; Goodman, 2015b; Lang & Rayner, 2012; Lang & Rayner, 2015; Rayner & Lang, 2012) determinants of health (Barton & Grant, 2006).  However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge, a reflection which might reject this as irrelevant to much of nursing practice. Before addressing the definition of sustainability in nursing, the socio-political ‘pattern of knowing’ will be outlined to form the justification for the ensuing discussion.

 

The fifth ‘Pattern of knowing’ in Nursing

Jill White (White, 1995) added a fifth pattern of knowing in nursing to Barbara Carper’s four (Carper, 1978): the ‘Socio-Political’. White argued the other four patterns provided answers to the ‘who, how and the what’ of nursing practice but not the ‘wherein’, the context. This, White argued, is the pattern of knowing essential to an understanding of all the other four. Socio-political knowing that is gained from a fuller understanding of the ‘sustainability literature’, might lift the ‘gaze’ from introspective nurse patient relationships at the bedside and requires the situating of that relationship within the wider socio-political context. This may result in challenging the taken for granted assumptions about practice, health, the profession and wider health policy. To that could be added the raising of questions about political economy and engaging in philosophical enquiry about such concepts such as ‘non duality’ (Loy, 1988), a concept Wendell Berry implies in his essay ‘health is membership’ (Berry, 1995).

White quoted Chopoorian who suggested:  “nursing ideas lack an archaeology of the social, political and economic worlds that influence both client states and nursing roles’ (White 1995 p84). This ‘archaeology of ideas’ still seems relatively poorly uncovered. Davies argued that ‘some of our concepts are missing’ in a critique of the Sociology of Health and Illness (Davies, 2003).  By that is meant that there had been a lack of a ‘sociology’ of organizations in the sociology of health and illness, a sociology which is able to reveal concepts such as discourses of managerialism (Gilbert, 2005; Traynor, 1996; Traynor, 1999; Traynor, Boland & Buus, 2010), or to reveal patterns of power and accountability for policy and its consequences (Freudenberg, 2014; Scambler, 2012; Schrecker & Bambra, 2015). Davies argued that

“sociology needed to take seriously the politics of NHS modernisation” (p183)

It is suggested here that many nurses also don’t have such a set of critical concepts to give them a more critical discourse upon which to base critical action or ‘praxis’ (Cox & Nilsen, 2014). There are a few papers addressing political activism in nursing, providing critical theories and concepts (Antrobus, Masterson & Bailey, 2004; Hewison, 1994; Phillips, 2012; Racine, 2009; Shariff, 2014) and other papers which discuss politics and nursing (Davies, 2004; Masterson & Maslin-Prothero, 1999; Salmon, 2012; Traynor, 2013).  These works suggest an interest in the interplay of the socio-political context and nursing practice and provide some evidence of relevance of this ‘pattern of knowing’.  White argued that nurses must “explore and expose alternative constructions of health and health care, find means of enabling all concerned to have a voice in care provision and develop processes of shared governance for the future” (p85). Exploring sustainability, climate change and health assists in that work. Indeed a focus on global governance for health in the context of climate change and environmental challenges is a key theme of recent reports  (Ottersen, Dasgupta & Blouin, 2014; Ottersen, Frenk & Horton, 2011) in non-nursing literature. This leads us onto consider how nurses are to understand what sustainability means.

 

Defining Sustainability in Nursing

 

Anåker & Elf (2014) argue that the “term is not clearly defined and is poorly researched in nursing” (p382). This applies not only in nursing.  Sustainability has diverse and contested meanings in many disciplines (Thompson, 2011; Williams & Millington, 2004). The quest to tie down the concept is possibly futile, as Anåker and Elf themselves suggest that: “a concept analysis is never a finished product” (p388). They provide a definition which is a helpful contribution to the discussion, and their model and contrary case illustrate for clinical nurses the value of trying to understand sustainability in practice. Throughout the paper they provide attributes and definitions from various sources and refer to, but do not foreground, social and health inequalities arising from wider determinants of health including political economy, which also underpins understandings of sustainability and climate change (Goodman & Richardson, 2009; Sayer, 2015).

The defining attributes identified in Anaker and Elf’s concept analysis were:  ecology, environment, the future, globalism, holism and maintenance. The attribute ‘globalism’ indicates that they are getting close to discussing and emphasising political economy underpinning such issues as climate change, ocean acidification and soil erosion which are three of the nine planetary boundaries which, it is argued, delineate a ‘safe operating space for humanity’ (Rockstrom et al., 2009; Steffen et al., 2015) . Nonetheless, the analysis misses something important, i.e. the neoliberal (Freudenberg, 2014; Harvey, 2005) and environmental, socio-political context of health (Barton & Grant, 2006; Ottersen, Frenk & Horton, 2011; Sayer, 2015; Scambler, 2012; WHO 2015) characterised by social and health inequalities (Dorling, 2013). This is the link between capitalism, climate change and sustainability (Goodman, 2014; Griffiths, 2009; Klein, 2014; Sayer, 2015). Various writers (Hamilton, 2010; Jackson, 2009; Marshall, 2014; Sayer, 2015; Urry, 2011) suggest or imply, that it is our political orientations (Douglas & Wildavsky, 1992), moral intuitions (Haidt, 2012) and our social and economic relationship with carbon which are foundations upon which we as communities and individuals assess environmental issues and our reactions to them.

Urry particularly on this point, (2011) coins the term, ‘high carbon economy-society’ to describe capitalism. He argues that the starting point for an analysis of why society engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist. Thus, community behaviours are implicitly locked into high carbon systems that are taken for granted aspects of our lifeworld. Urry suggests that much of social science has been carbon blind and has analysed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. It is these social practices that provide the structure within which our agency operates.

most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).

 

These social practices arise out of our ‘lifeworld’ (Husserl 1936, Habermas 1981), i.e. our internal subjective viewpoints as well as the external viewpoints of the social and political ‘system’.  A high carbon economy society thus provides the backdrop for values, assumptions and social practices that are taken for granted in everyday life. Defining sustainability therefore requires acknowledgment of such lifeworlds and the socio-political systems in which they ‘operate’.

 

Nursing, sustainability and acontextual Concept Analysis?

 

The wider body of literature, including that in the social and political sciences and philosophy, may give nurses tools and concepts to further develop their understanding of sustainability and its relationship to human health. Importantly this could include an understanding of the political economy of capitalism (Harvey, 2011) and its link with growth, climate change and sustainability (Hamilton, 2003; Jackson, 2009; Johnson, Simms & Chowla, 2010; Sayer, 2015). Without this understanding, and application in nursing scholarship, nurses may miss the arguments linking the growth dynamics underpinning the neoliberalist capitalist political economy (Chomsky, 1997; Harvey, 2005; Sayer, 2015), climate change (Klein, 2014; Sayer, 2015) and unsustainable lifestyles (Hamilton, 2010). This sits within the social and political determinants of health approach (Barton & Grant, 2006; Davidson, 2015; Ottersen, Frenk & Horton, 2011; Scambler, 2012) and the emerging domain of planetary health (Lang & Rayner, 2012; Lang & Rayner, 2015).  This paper argues that to fully develop the concept in nursing, an analysis or at the least an understanding, of the political economy of neoliberal capitalism could be a component of nurses’ understanding of sustainability and health. This is because political economy relates to both health and social inequalities (Dorling, 2013; Dorling, 2014; Marmot, 2015; Schrecker & Bambra, 2015; Stiglitz, 2012; Wilkinson, 2005; Wilkinson & Pickett, 2009)  and to issues around sustainability and climate change. However, this is a major challenge as it requires a critical reflection on what counts as nursing knowledge (White, 1995), a reflection which might reject this as irrelevant to much of nursing practice.

 

Anåker & Elf’s (2014) inference that nursing misses foregrounding political economy and society might be a result of the method employed to search the literature, as well as their acknowledged lack of discussion in the nursing literature of political economy. Of course there might be very little reason currently for nursing literature to discuss political economy, based as it is on knowledge (biosciences, biomedicine) that may well be largely antithetical to critical social and political science. Adult nurses in particular might face a real challenge in accepting this idea in practice as Ion and Lauder argue:

 

“For very good reason, adult nursing remains committed to a biomedical vision of illness which, while cognisant of the importance of a holism, is tied to a physical approach to care” (Ion & Lauder, 2015).

 

In addition, Walker and Avant’s method was originally published (1982) before the development of academic blogs and websites such as academia.edu and therefore may not be explicit in its direction to search beyond accepted channels. This emerging literature, which may contribute to the construction of the ‘paraversity’ (Goodman 2014, Rolfe 2014), will therefore be missed as source of information and discussion on topics such as linking sustainability, health, climate change and capitalism.

 

There are several key papers discussing the link between human health, political economy and the environment. Goodman and Richardson (2009) explicitly link Sustainability, Climate Change and Health conceptualizing them as three sides of a triad. To fully understand one requires an understanding of the other two. The three, in this conception, are indivisible. Further, the link involves political economy and socio-economic behavior as crucial underpinnings for climate change and sustainability issues. Barton and Grant’s (2006) health map discusses key determinants for health including Biodiversity, Global Ecosystems and Climate change. Each one of those of course involves human activity and disruption to create what some are calling a new geological era, the ‘Anthropocene’ (Zalasiewicz et al., 2010). Lang and Rayner (2012) discuss the concept of ‘Ecological Public Health’, while the Canadian Public Health Association (2015) has just published its own report on ‘Global Change and Public Health: Addressing the ecological determinants of health’ which on page 1 argues:

“…changes in the earth’s ecological systems are driven principally by our social and economic systems, and by the collective values and institutions that support them”.

This echoes the World Health Organisation’s definition of the social determinants of health which explicitly mentions distributions of resources, money and power (WHO 2015). The report does not name, or analyses, in any more depth what that economic system is, as it seems to take for granted that it is capitalism. Ottersen et al emphasize the political determinants of health (Ottersen, Dasgupta & Blouin, 2014) which, alongside the WHO’s (2008) social determinants of health approach, acknowledges the role of powerful global actors and the lack of global governance for health. Health equity and social determinants are now a crucial component of the post 2015 sustainable development goals (WHO 2015).

For example, powerful global actors, i.e. the Fossil Fuel Industry, may be acting in a way to either downplay the risks to human health from rising atmospheric carbon dioxide, or engaged in protecting their assets’ (coal oil and gas) value for the short term over and above longer term risks to climate. Exxon Mobil have argued that world climate policies are highly unlikely to stop the production and selling of fossil fuels (Exxon Mobil shrugs off climate change risk to profit – BBC News, 2014) while Shell have been accused (Macalister, 2015) of accepting a 4 degree rise in global mean temperatures. This is in the context of a reported $5 trillion annual subsidy in fossil fuel subsidies (Coady et al., 2015)  while the Bank of England considers a ‘carbon bubble’ (Carrington, 2014)  i.e. the drop in value of assets if fossil fuels are kept in the ground through the imposition of any global governance regimes to curb carbon emissions. This is an aspect of the political economy of capitalism that must be understood as a driver underpinning human health. At the time of writing, world leaders and delegates are meeting in Paris for COP 21. At this meeting there will be another meeting of the The Sustainable Innovation Forum (SIF15) which is a business focused event held during the annual Conference of Parties (COP). The two day Forum will convene  participants from business, Government, finance, the United nations, Non-governmental organisations, and civil society to “create an unparalleled opportunity to bolster business innovation and bring scale to the emerging green economy” (COP21 Paris 2015). This forum operates within the paradigm of capitalism rather than seeking radical reform. However, it illustrates the complexity of players dealing with sustainability issues.

 

Scambler (2012) outlines ‘The Greedy Bastards Hypothesis’ to describe how the Capitalist Class Executive can ‘command’ the Political Power Elite to enact policies in their favour, with the unintended consequences of exacerbating health inequalities. Evidence that corporate activities impacts on political decision making is provided by the delays to air pollution standards, Euro 6 (Archer, 2015; Neslen, 2015).  Volkswagen’s use of software to cheat emissions testing in the United States (Topham, 2015) indicates the lengths corporates will go (Freudenberg, 2014; Oreskes & Conway, 2011) to avoid externality costs resulting in the externality of for example, increased air pollution. Therefore any concept of sustainability in nursing that does not understand political economy misses something important in understanding both the concept of sustainability and of health.

 

Anaker and Elf’s definition of sustainability:

“…a core of knowledge in which ecology, global and holistic comprise the foundation. The use of the concept of sustainability includes environmental considerations at all levels. The implementation of sustainability will contribute to a development that maintains an environment that does not harm current and future generation’s opportunities for good health”. In this it echoes the Brundtland commission’s definition of sustainable development (WCED1987) which has been critiqued for being uncritical of business and growth based capitalism (Sinclair 2009).

 

This definition is a good start but requires development. Nurses, particular nursing scholars interested in health and public health, need to consider the argument already suggested around the dynamics of capitalism as a major driver for both carbon emissions and unsustainable practices. It is perfectly possible to begin the study of sustainability and environmental health within taken for granted paradigms, but what is required is a cultural critique of the values and systems that support environmental damage (Martusewicz 2014) and a better understanding how the economy and sustainability issues such as climate change, interact (Better Growth, Better Climate, 2015). Nurses, if they stick to nursing journals and literature, will not find a large amount of material that discusses this. For example the Royal Society of Arts has a wealth of papers, presentations and works streams addressing climate change (Hahnel, 2015; Rowson, 2015)  which address causes, behaviour changes, political economy and culture change.

 

Conclusion

 

Anåker & Elf (2014) argue that there is a need for theoretical and empirical studies of sustainability in Nursing. This could include accessing literature unknown to most nurses.  Writers such as Aldo Leopold, Wendell Berry, Paul Hawken, Mike Hulme, John Urry all provide insights into human wellbeing, health and the social context. Related concepts include ecojustice education, education for sustainability, dualism, anthropocentrism, anthropocene, neoliberalism, modernity and capitalism. A problem for nursing scholars is that these related concepts are not readily seen as relevant to nursing and thus there may be a reticence of nursing journals to publish them, and a reticence in nurse education to discuss them. There may be a need to resort to both non nursing peer reviewed journals but also to web based materials open to all. Anaker and Elf acknowledge in their limitations (p387) ‘the lack of research literature available for review in which sustainability was the major topic and in which sustainability was not linked to other concepts’. This paper goes further in trying to make those wider links for nurses. A problem however for nurses, is the sheer scale of literature and concepts that are involved. The task for nursing scholars is to consider just what is feasible, useful and relevant as part of their scholarly development and curriculum work.

 

 

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Reale, E. (2009) ‘ANF joins union climate change campaign’. Australian Nursing Journal, 17 (4). pp 9-9.

 

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Rockstrom, J., Steffen, W., Noone, K., Persson, A., Chapin, F. S., III, Lambin, E. F., Lenton, T. M., Scheffer, M., Folke, C., Schellnhuber, H. J., Nykvist, B., de Wit, C. A., Hughes, T., van der Leeuw, S., Rodhe, H., Sorlin, S., Snyder, P. K., Costanza, R., Svedin, U., Falkenmark, M., Karlberg, L., Corell, R. W., Fabry, V. J., Hansen, J., Walker, B., Liverman, D., Richardson, K., Crutzen, P. & Foley, J. A. (2009) ‘A safe operating space for humanity: identifying and quantifying planetary boundaries that must not be transgressed could help prevent human activities from causing unacceptable environmental change, argue Johan Rockstrom and colleagues’. Nature, 461 (7263). pp 472.

 

Rolfe, G. (2013) The University in Dissent; Scholarship in the Corporate University. London: Routledge.

 

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Salmon, M. (2012) ‘Policy and Politics in Nursing and Health Care, 6th ed (book review) JAMA307(1):94-95.

 

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Schrecker, T. and Bambra, C. (2015) How politics makes us sick: neoliberal epidemics Basingstoke.Palgrave Macmillan.

 

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Sustainability – what can a nurse do?

Sustainability – what can a nurse do?

 

This appears to be a common question, perhaps indicating that the debate has moved on from questioning the scientific basis for both climate change and the data around environmental damage caused by human activities such as ocean acidification. These are of course global issues which can make one feel powerless. This need not be so.

 

In June 2015, The Lancet argued:

 

“tackling climate change could be the greatest health opportunity of the 21st century”

 

If this is so, then nurses could play an important role in both climate change and health.

 

This report followed on from Pope Francis’s encyclical ‘Laudato Si  – care for our common home’.

The National Health Service Sustainable Development Unit (NHS SDU) welcomed the Lancet’s publication and argued that:

 

“The health sector can play a real role in making sure that its activities promote lower carbon and a more resilient infrastructure. This holds true in relation to every part of the sector including travel and transport systems, in relation to building infrastructure and through the procurement of products and services”.

 

Stefi Barna et al (2012) set out what nurses need to know about climate change and elsewhere I (Goodman 2013) challenge nurses in the NHS to act on climate change and suggests ways of thinking to do so. The NHS SDU is a great resource to support clinicians in their attempts to make the NHS responsive to sustainability and climate change issues.

 

This sets the context for nurses, but what can the nurse actually do. First of all we could consider those sectors of the health service in which that the SDU outline action can take place and ask what roles nurses can play, if at all in each.

 

A start for the nurse would be to consider what level they can work at:

 

 

 

  1. On a personal level:

 

  • Understand the facts: for example, learn what ‘carbon footprint’ means and what your personal footprint is. Access the resources published by The Lancet and the National Health Service Sustainable Development Unit. Access the literature on the subject. Understand the social political and ecological determinants of health.
  • Reflect on your values and assumptions about what the good life means on this planet. Consider the effects of consumerism, materialism and individualism on the quality of human relationships and our relationship to nature. Consider if modern culture is sustainable in its current form.
  • Eat better: e.g. reduce your intake of red meats; perhaps try to cut out/down on processed/packaged foods; shop for locally and seasonally produced foods.
  • Drink better: Consider your use of bottled water. See the ‘Story of Stuff’
  • Move better: g. use public transport walk more, reduce your use of the car, buy a bicycle (called ‘active transport’).
  • Communicate better: make full use of digital technologies.

 

  1. On an organisational level:
  • Consider the core aspects of energy, travel, food, gases and drugs, waste, and medical devices .

 

  • Energy: Between 2007/08 and 2013/14the NHS carbon footprint in relation to building energy use dropped by 3.5% despite increases in activity of 13%. The decrease represents around £50m of energy costs for the NHS in England in 2013/14. Nurse action: is there a plan for your clinical area to address energy consumption? Are you involved in innovations to reduce carbon emissions and increase renewables?   Work with your organisation’s carbon reduction team (if it has one) or consider getting a carbon reduction team developed if it does not.

 

  • NHS Derbyshire Community Health Services saved more than 3,000 hours of staff travel time, 20 tonnes of carbon, and over £100,000 by using teleconferencing services. Nurse action: consider how patients and staff travel to and from services and whether it is always necessary.

 

  • Nottingham University Hospitals NHS Trust shows how part of the health system can lead sustainable food systems.  It serves fresh, healthy meals made with local, seasonal and organic ingredients.  Nurse Action: find out where your food comes from and what it is? Discuss nutrition and food choices with your patients.

 

  • Gases and medicines. The use of anaesthetic gases represents 5% of acute hospital CO2e emissions. These could be reduced with lower flow rates or substituted for instance moving away from nitrous oxide. Inhalers which represent 4.3% of the English health and care sector’s footprint could be replaced by a pulverised form as in Scandinavian countries. New meter dose inhalers without high environmental impact propellants could save nearly 7 million tCO2e over five years. Medicines are often a cornerstone of our health response be this through immunisations, diagnostics or therapeutic drugs. It is however sometimes more effective to prescribe physical activity, dietary changes or talking therapies.  The pharmaceutical industry is similarly keen to help reduce environmental impacts involved in the production, use and disposal of medicines so are already important partners in this journey. Nurse action: Find out about these practices if they apply to you, work with colleagues to address these issues.

 

  • Contaminated waste. The health sector produces waste in vast quantities, some of which is contaminated and needs to be separated and disposed of effectively. We hold the key to doing this effectively and  safely as well as reducing environmental impacts. Nurse action: review waste management practices in your clinical area, search the literature for new approaches to waste. Find out what the waste process is and what it costs and how it is segregated.

 

  • Medical devices. The use of multi-use or single use items, balancing the ethical sourcing and material use with decontamination and/or recycling approaches needs to be fully understood and effectively implemented to minimise both visible and hidden costs and environmental impacts.  Work with organisations such as the Infection Prevention Society on issues such as single use.

 

  • The SDU argues “The very nature of our business which is now considered unsustainable economically, environmentally and socially means that we need to focus on improving health and reduce our reliance on acute settings. The NHS Five Year Forward View is addressing some of these through the development of Vanguard sites and it would be exemplary to be able to demonstrate the benefits in environmental and social terms too”.


  1. On a national/international level:

Nurses may wish to see this as a menu of choices for tackling climate and health, but remembering always climate change and carbon emissions are only one aspect of sustainable healthcare. We have to consider the economic, social and other environmental aspects of sustainability as well. This is because social and political inequalities adversely affect the health of individuals, communities and populations.

We need to consider whether the global economic system is fair, just, equitable and is not a cause of environmental damage. There are concerns over social inequalities leading to health inequalities adversely affecting those lower down on the socio-economic scale. This takes nurses away from clinical considerations and into socio-political debates about how global governance affects human health and well being. Another Lancet commission report questions whether the current system is fit for that purpose.

 

Selby’s 10 propositions.

 

David Selby, in 2007, produced 10 propositions for education that might be useful as another framework for action:

 

  1. Confront denial (of climate change, health crises) by challenging our own base assumptions, knowledge and responses. We need to feel unease at the current situation. Nurses should reflect on the potential a very different world in which current cultural assumptions will not hold up to be true. For example, a belief in progress, that our children will have a better standard of living may not happen.

 

  1. Given the threat to human health, nurses need to address personal issues of despair, grief, loss. Once some of the facts are known, we may have to make a personal journey through challenging long cherished world views, hopes and dreams. Our perspectives may have to shift to embrace wider loss and grief issues that flow from climate change.

 

  • Shift to a holistic dynamic understanding of the relationship between humans and nature is an end in itself not a means to an end. Nurses may already have a holistic understanding of human health and approaches to care, but this goes beyond the individual to embrace the social and the natural. Health is too often reductive, i.e. it is reduced to body parts and systems existing as separate entities from other bodies and the physical environment. It is also thus individualistic, being located within a single individual’s body. Within this reductive individualised view of health people can still view themselves as healthy in a

 

 “disintegrating family, community or a destroyed or poisoned ecosystem” (Wendell Berry p89).

 

  1. Cultivate a poetic understanding alongside a rational understanding – we need to develop awe, celebration, enchantment, reverence as well as classification, prediction, evaluation and exploitation of nature. This mirrors the ongoing debate within nursing education concerning the art/science dichotomy and would provide another useful lens to address the need for scientific competence and artistic appreciation and application in nursing praxis. There needs to be space to allow this and perhaps even academic credit?

 

  1. Marginalised ‘educations’ will be important, e.g. the field of non –violence. Rather more challenging for some fields of health care such as acute hospital care but may well be core to therapeutic approaches within mental health.

 

  1. Given the heating – sustainable and emergency education need to come together. Social dislocation, hunger, environmental disaster, tribalism necessitates nursing action that can respond, e.g. global citizenship, peace education, conflict resolution, anti-discriminatory education. Health care staff may well be key professionals in dealing with emergencies and disaster management and thus education and training that explicitly addresses these skills may well be valued and developed.

 

  1. Alternative ideas of what ‘the good life’ means need exploring: Again this could be core to philosophy especially within the contexts of mental health and palliative care and living with long term or life limiting conditions.

 

  1. Rethinking notions of democracy, citizenship and sustainability could be part of the professional responsibilities of health care staff. ‘Global citizenship’ could be a core feature.

 

  1. Shift from atomistic/reductionist thinking to holistic ways of mediating reality. This means that nurses change their paradigms, their world views away from focusing on the individual as the core unit of being, to understanding that the individual cannot exist with community and nature. They are indivisible.

 

  1. Finally Selby asks: “Everyone has to understand and come to terms with the fact that we are threatening our own existence. To confront this requires a Copernican revolution in aims, structures, processes of education and perhaps in the loci of learning ... as the heating happens, education and educational institutions ... will be deeply disrupted and if unresponsive to the need for transformation, will disintegrate as people find other more relevant loci for learning what they have to learn”. Although this is written for education in general it is a challenge to nurse education. If nurse education is too focused on developing professional competencies based in a biomedical paradigm, then it is an education that will have failed the future nursing workforce, who will be passive recipients of policies and climate change rather than active in prevention and adaptation to the changes.

 

 

So what can a nurse do?

Nursing is an ethical practice and nurses are asked to address the health not just of individuals but of communities and populations. Health education, promotion and public health are core to nursing practice. Nursing organisations have accepted both environmental issues and climate change as a health threat. All health services need to save money and use resources better. Population health would improve through adopting low carbon lifestyles. Clinical leaders can assist in the transition from unsustainable health care delivery and lifestyles towards sustainable health care as they are on the ground  and would be able to see where innovations and changes could be made.

 

  • Read – widely, inform yourself.
  • Reflect – on your personal values, assumptions and beliefs.
  • Revise – current ways of working.
  • Renew – yourself, your workplace, your community.
  • Reconnect – to your family, community, your social and political networks.
  • Remember- this will not be easy.

 

 

 

Suggested reading

 

Barna, S, Goodman, B. and Mortimer, F. (2012) The health effects of climate change; what does a nurse need to know? Nurse Education Today. 32(7) pp 765-71

Goodman, B. (2013) The Role of the nurse in addressing the health effects of climate change. Nursing Standard. 27 (35) pp 49-56

 

Griffiths, J. et al (2009) The Health Practitioner’s Guide to Climate Change. Earthscan. London.

 

Lang T and Rayner G (2012) Ecological public health: the 21st century’s big idea? British Medical Journal 345:e5466 doi 10.1136/bmj.e5466

Climate Change, Health and Capitalism

Climate Change, Health and Capitalism The debate on climate change and health in the context of Ecological public health: A necessary corrective to Costello et al’s ‘biggest global health threat’, or co-opted apologists for the neoliberal hegemony?

Abstract

The threat posed to global health by climate change has been widely discussed internationally. The United Kingdom public health community seem to have accepted this as fact and have called for urgent action on climate change, often through state interventionist mitigation strategies and the adoption of a risk discourse. Putting aside the climate change deniers’ arguments, there are critics of this position who seem to accept climate change as a fact but argue that the market and/or economic development should address the issue. Their view is that carbon reduction (mitigation) is a distraction, may be costly and is ineffective. They argue that what is required is more economic development and progress even if that means a warmer world. Both positions however accept the fact of growth based capitalism and thus fail to critique neoliberal market driven capitalism or posit an alternative political economy that eschews growth. Ecological public health, however, appears to be a way forward in addressing not only social determinants of health but also the political and ecological determinants. This might allow us to consider not just public health but also planetary health and health threats that arise from growth based capitalism.

 

Keywords Ecological Public health, climate change; risk discourse; capitalism; neoliberalism;

The health impacts of climate change have been much discussed internationally1,2,3,4  however there is some disagreement about the magnitude of those effects, when they will occur and what the right course of action is. Underpinning those disagreements is a tacit and sometimes uncritical acceptance of the fundamental structure of the political economy of growth capitalism – neoliberalism5 , with the differences being around whether climate change requires more immediate public policy and health professionalintervention6 or whether capitalism will address the health issues though economic development. In other words, both use the frame of reference of capitalism to argue for either more market freedom or statist intervention based in a risk discourse. This paper seeks to outline the arguments over the health effects of climate change while rooting that discourse within wider often background taken for granted political economy. Two writers, Indur Goklany and Daniel Ben Ami will be used to represent the critical camp in riposte to Costello et al’s 2009 UCL-Lancet paper on climate change and health. While the focus is on climate change, other factors such as biodiversity loss, chemical pollution, ozone depletion, ocean acidification, all threaten the ecological systems we depend on7. These issues are also associated with our current growth based economic structures.  The ecological public health discourse will not be discussed at length here, but might provide a newer perspective linking global political structures, critiques of growth based capitalism and public health.

The Climate change ‘debate’

 

The Intergovernmental Panel on Climate Change 5th Assessment Report (AR5)8 argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s9,10 . Despite this, there is continuing doubt, denial and a focus on uncertainty,11,12,13,14,15   that Climate Change is human induced and that it requires radical shifts in public policy.   This doubt sits in opposition to many in the medical16and public health domain17. The World Health Organisation18,19  accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public healthwhile previously ranking it very low down in a table of health threats20,21. In the United Kingdom, Costello22 et al argue that climate change is a major potential public health threat that does require major changes such as action on carbon emissions. In addition, Barton and Grant’s health map23 has in its outer ring ‘Climate Stability, Biodiversity and Global Ecosystems’ as key determinants of health and supports the WHO view that alongside the social determinants of health, health threats arise from large scale environmental hazards such as climate change, stratospheric ozone depletion, biodiversity losses, changes in water systems, land degradation, urbanisation and pressures on food production. WHO24  argues:   “Appreciation of this scale and type of influence on human health requires a new perspective which focuses on ecosystems and on the recognition that the foundations of long-term good health in populations rely in great part on the continued stability and functioning of the biosphere’s life-supporting systems”.

 

It is this call for a ‘new perspective on ecosystems’ that indicates why there is a backlash, one that underpins critiques of the link between climate change, environmental issues and human health. Many of those critical are libertarian, anti-state conservatives defending the neoliberal hegemony of free market dogma which ‘new perspectives’ may threaten.  For example, Stakaityte25 argues:   “Free market proponents are quick to point out that the whole climate change issue has been used to stifle freedom and to expand the nanny state – and they are right. If the climate is changing, and if humans really are responsible, the market will adapt”.

 

The WHO call for a ‘new perspective’ however is not a radical critique of neoliberal capitalism or a call for its replacement by other political economies. It sits within an overarching acceptance that growth25 capitalism is the only economic model, and that only its particular current form requires changing, for example by investments in green technologies.   Critical discourse over such an important issue is crucial. Argument should proceed over matters of empirical facts, within discourses of risk and an understanding of scientific uncertainty27 .  Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony28,29 attempts to build and maintain a sceptical view30,31  in the media on climate change and on alternative, including no growth, economic models32,33,34  because neoliberalism is antithetical to ‘nanny state’ intervention implicit in public health ‘upstream’ analysis.

 

Health Impacts of climate change and the policy response.

Indur Goklany and Daniel Ben Ami respectively are noted writers on the topic and both are in the sceptical camp regarding what to do about climate change. Both however appear to accept the fact of climate change, they just don’t agree with the focus on carbon reduction targets.   For the health community that makes decisions on what the main threats to health are, there is a need to carefully weigh up the evidence for threats to population health in the short, medium and long term, or what Goklany calls the ‘foreseeable future’ defined as 2085-2100. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Ami’s argument on progress. For Goklany the health threats this century are not from climate change, nor will they be. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.   In this there is some support from the latest IPCC report 35 (p3)  which states   “the present worldwide burden of ill health from climate change is relatively small compared with other stressors and is not well quantified”.   The report also states that rapid economic development will reduce health impacts on the poorest and least healthy groups, with further falls in mortality rates.  In addition, they argue36 (p4), alongside poverty alleviation and disaster preparedness, the most effective adaptation measures are:   “basic public health measures such as the provision of clean water, sanitation and essential healthcare”.   A key point is that climate change and extreme weather events affects the poor disproportionally and that37 (p3)   “until mid century climate change will act mainly by exacerbating health problems that already exist”   So there is an emphasis on economic development and poverty alleviation by the IPCC, thereby accepting the basic tenets of growth capitalism, alongside mitigation and adaptation, to deliver them.   However, McCoy38  et al points out that by 2100,  ‘business usual’ emissions growth will see increases in levels of CO2 in the atmosphere giving a 50:50 chance that global mean temperatures will rise by more than 4 degrees, which they argue  is   “incompatible with an organised global community”.   However, they stop short of a critique of the political economy of growth capitalism that drives C02 emissions39,40,41.   Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth on a finite planet, and may be over confident that limits have been correctly identified or can be overcome. Goklany might turn out to be empirically correct that in the ‘foreseeable future’, climate change will not be the major threat to public health, however this line of reasoning might support the denial of climate change in particular and obscures the requirement of addressing the sustainability of current economic structures. It also sidesteps addressing the language and discourse of risk42,43 which includes considering that human action should not be based on total certainty but on the assessment of the probabilities of high and low impact events. However, the position taken by both writers is that humanity needs more capitalist economic and technological development even if that results in a warmer world.   Goklany44 argues that humanity, in developing and using fossil fuels, both freed itself from the vagaries of nature’s provision and also has saved nature from humanity’s need to turn more of it into cropland. The inference from this argument is that we ought to continue to use fossil fuels to further human progress and to save nature from ourselves. Increasing global GDP, i.e. a wealthier world, would also be better equipped to deal with future global warming issues45.   Daniel Ben-Ami46 forwards this argument. He points out that we are living longer and healthier lives than ever before thanks to economic development and growth. Therefore, inductively, we need more growth. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.   Those who suggest climate change is a health threat do not address this economic and development argument head on.  There may be implicit acceptance of the current economic models of development. Instead there is a focus on the magnitude of climate change per se as a health threat rather than the economic structures which may drive climate change and other unsustainable practices such as deforestation.       Costello v Goklany.   In 2009 Costello et al 47(p1693)  argued that ‘climate change is the biggest global health threat of the 21st century’ . Goklany48,49 in the same year replied and argued that climate change is not the number one threat to humanity, and questioned whether it is the defining challenge of our age. Goklany50  pointed out that climate change was ranked only 21st out of 24 global health threats. Goklany’s rebuttal data comes from the World Health Organisation51 ‘World Health Report 2002’ and the Comparative Quantification of Health Risks 200452and he used results from “Fast Track Assessments” (FTAs) of the global impacts of global warming53,54 .   Costello, Maslin and Montgomery 55  in reply to Goklany argued that     “The ranking of climate change at 21st out of 24 risk factors was made at a time when global temperature rise was only 0·74°C, and when the effects of climate change on the other risk factors was unclear”   …and they claimed that there has since been substantial changes in our understanding of climate change risks. They cite two papersshowing that about 1 trillion tonnes56 is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit57, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider58 who raised the prospect of worst case scenarios: warming at 3°C gives a 90% probability that Greenland will melt, raising sea levels by many metres, and that on present evidence and trends there is a 5—17% chance that temperatures will go up by 6·4°C by 2100. They argue that this a risk threshold, way beyond which people would buy insurance.   Goklany59  in 2012,  argued Costello et al made their claim about climate change in 2009 without a comparative analysis of the magnitude, severity and manageability of a range of health threats at that time and therefore ranking it as the No 1 threat is untenable.  His position in 2012 is that the 2 degree target is irrelevant in any case and he seems happy to accept a 4 degree rise.   The 2013 IPCC report AR560, while accepting a pause in warming over recent years, argues that climate change is a continuing very serious issue and now post dates this difference in Goklany and Costello’s arguments which are based on data from 1999 to 2009. The report makes it clear that even if greenhouse gas emissions are stopped right now climate change will persists for many centuries, much of it will be irreversible characterised by impacts such as sea level rises and argues that the last time the world was 2 degrees warmer, sea levels were 5 -10 metres higher.   On what to do, Goklany61 (p69)  argued in 2009 that   “Societal resources devoted to curb carbon dioxide and other greenhouse gas emissions will be unavailable for other…more urgent tasks including vector control, developing safer water supplies or installing sanitation facilities in developing countries….”   However this sets up a false dichotomy. The decision to spend on carbon reduction is not an either/or one. There are myriad spending decisions being made, and those choices are made from a raft of competing priorities. One could equally argue that resources devoted to nuclear armaments and other military spending is unavailable also for these other urgent tasks. So to focus on emissions reduction as the spending that diverts funds away from addressing other pressing health issues is a biased view. Goklany could argue for an end to subsidies for the fossil fuel and nuclear industries, reductions in military spending, changing the international tax regimes to access wealth deposited in offshore accounts, or the introduction of a Tobin tax on financial transactions. These are admittedly biased positions and may be seen to be too left wing, and ideologically incompatible with current growth capitalism and neoliberal hegemony62.   Whether funding spent on carbon reduction actually works in terms of human welfare and is less expensive than alternatives, is a valid question but has to be seen in a wider political discourse about spending decisions. His points regarding the need for poverty reduction via sustainable economic development and advancing our adaptive capacity would possibly bring broad agreement. In any case some63 consider that it is too late for mitigation and that adaptation to a warmer world is now needed. Goklany64  uses the term ‘focused adaptation’ meaning taking advantage of the positive benefits of warming. If sea levels are to rise by 5-10 metres this is beyond the foreseeable future and so we should focus on economic growth and development to adapt to those future scenarios rather than wasting time resources and energy on emission curbs. However, this seems somewhat an anthropocentric view taking in little regard for biodiversity loss and ocean acidification, both of which are also threats to human health.   Ben Ami and Goklany put faith instead in ‘secular technological change’. This believes that   1) Existing technologies will become cheaper or more cost effective. 2) New technologies that are even more cost effective will become available.   They may well be correct. They argue the potential health threats may be addressed through human ingenuity based on economic progress and economic progress is best served by accepting the IPCC worse case scenario which would result in greater per capita GDP and thus release capital for adaptation (figure 1).   Goklany argues that if humanity has a choice, it ought to strive for the developmental path corresponding to the richest IPCC scenario (A1FI  – 4 degrees C above 1990 by 2085), notwithstanding any associated global warming, because this increases adaptive capacity and poverty would be eliminated. Other health risks that rank higher than global warming are also associated with poverty and would thus also be eliminated. Poverty related diseases contribute to mortality and morbidity 70 to 80% more than warming. Mitigative capacity would be increased, therefore health improves with economic and technological development, and development encourages the ‘environmental transition’.   This is a very risky strategy which future generations will have to judge the merits of. There is gathering evidence beyond climate change suggesting that humanity is already transgressing other environmental limits65, transgressions which will not support a ‘safe operating space’ in the new era, the ‘anthropocene66,67 .   Risk Discourse.   Goklany68 argued in 2012   “This paper does not address hypothesized low-probability but potentially high consequence outcomes such as a shutdown of the thermohaline circulation or the melting of the Greenland and Antarctica Ice Sheets, which have been deemed unlikely to occur in the foreseeable future by both the IPCC and the US Global Change Research Program, among others”,   …although the IPCC69(p22) has since written that it is     “very unlikely that the Atlantic Meridional Overturning Circulation (part of the global thermohaline) will undergo abrupt transition or collapse…however, a collapse beyond the 21st century…cannot be excluded”.   Goklany, in not addressing these risks, appears to dismiss the need for ‘risk discourse’ to frame public debate relying on ‘kicking into the long grass’ serious future consequences of climate change.   ‘Risk’ is already an essential part of everyone’s experience, including in the world of insurance, health and investment. It is not uncommon for people to insure against low probability but high impact events, e.g. house fires, and for the long term, e.g. pensions. It is thus arguable that the thermohaline shutdown and ice sheets melts may well be just the sort of low probability but high impact events that humanity ought to be insuring against and taking measures to prevent through carbon emissions reductions. Painter70 suggests therefore that elements of risk discourse would provide a better frame for debate than disaster and uncertainty frames, which are both more prevalent in news media.   Space precludes an examination of the concept of exponential growth and the requirement to produce resources to meet the needs of potentially 9-10 billion people by 2050. Costello et al’s position seems to be that climate change will stress ecosystems before we have time to adapt and that both direct and indirect affects will adversely impact on global health. They are not so sanguine about our ability to live within our limits.         Goklany is correct to point out that currently health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach and the IPCC AR5 WGII71.  Costello et al have not dismissed this and public health experts would probably accept a similar position. A focus on the social determinants of health and the political determinants of health72 needs to run alongside mitigation or else the good work could be undone by a low probability, according to Goklany,  but high impact event such as the melting of the Arctic Ice. They differ on when climate change will be a health threat and importantly on how to address it. Goklany and Ben Ami appear to be on the market driven economic development model as the answer whereas Costello et al argue for more immediate state and public intervention in addressing climate change. All however do not critique the fundamental neoliberal growth economic model or call for alternative economic ‘no growth’ or circular models73,74. There is little doubt that we are running an experiment with the climate, there is agreement that this will impact on global health but the dominant discourse of political economy seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.There are voices, now however, pointing public health in another direction. Horton et al75 call for a new social movement in a ‘manifesto from public to planetary health’, to support collective action on Public Health, introducing the concept of ‘planetary’, rather than just ‘public’ health.  As with Lang and Rayner’s76  discussion of Ecological public health, there is a strong focus on the unsustainability of current consumption. Interestingly,  an overt political statement is introduced in the ‘manifesto’: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”77 p847. They attack the idea of progress, and thus implicitly growth based neoliberalism, for deepening this ecological crisis and for being socially unjust. The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, and a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests. In the same vein, Ottersen et al78 are explicitly political on the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’ and while they do not use the term ‘growth based capitalism’ or ‘neoliberalism’, the tone of the report makes it quite clear that there is a need to address global governance and an analysis of power. The domains of Public Health, Medicine and Nursing may be insufficiently politically aware of the scale of the issues, and the sheer force and dynamics of capitalism79, that impacts on human health. This might be due to the (necessary?) ‘ahistoric’ and ‘apolitical’ education of health care professionals, resulting in a lack of a sociological or political imagination underpinned by a critical theory of capitalism. However, adopting the perspective of Ecological Public Health or seeing the world through a ‘sustainability lens’80 might move more health practitioners and policy makers into critique and action on current economic and political structures that result in health inequities, and indeed, if some are to be believed, that threaten western civilisation81,82.

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Figure 1: net GDP per capita, 1990-2200 for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C)       Author’s statement

Funding: none

Competing Interests: None declared

Ethical approval: Not required. This is a review paper.

 

“NOTICE: this is the author’s version of a work that was accepted for publication in Public Health. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in PUBLICATION, [VOL#, ISSUE#, (DATE)] DOI

The BBC and The IPCC working group 2 report on Climate Change

The BBC and The IPCC working group 2 report on Climate Change.  30th March 2014.

 

As part of its periodical Assessment Reports, the Intergovernmental Panel on Climate Change (IPCC) has just published working group 2’s (WGII): Climate Change 2014: Impacts, Adaptation and Vulnerability’. Before I get onto the content, the spin, has inevitably begun but sadly on the BBC radio 4 today programme. The chair of WGII was interviewed by Justin Webb who is gaining a reputation as a climate change sceptic. As part of the interview Webb focused on the economist Dr. Richard Tol’s withdrawal of his name from the report on the grounds that the report was not positive enough on the benefits of extra carbon dioxide. The report, Tol said, was too alarmist. His disagreement is how science actually works, but Webb’s focus on this point supports those who think the science is not settled enough.  The report itself was a result of a team of 70 scientists working on revisions so it is not surprising that at least one will disagree with the final report and will wish to remove their own name.

Tol’s argument appears to centre on farmer’s ability to adapt to new circumstances and that carbon dioxide is actually good for plants, a point accepted by WGII. The IPCC, in their video,  state that yields would not have improved without climate change which is neither alarmist or underplayed. It is a fact.  Adaptation is now clearly on the stage as well as mitigation, they are complimentary according to WGII. Adaption will bring benefits to some sectors and populations, but clearly mitigation (reducing emissions) has to run alongside adaptive responses. If we don’t try to mitigate, we run the risk of the climate overpowering adaptive systems. Low probability but high impacts events like the melting of the Greenland Ice sheets should lead us to consider insuring against that risk and trying to prevent it.

We might ask if the media is responsible for supporting scepticism on climate science; Does the media, in the interests of ‘balance’ give too much time to climate change sceptics?

Alistair Burnett , editor of the World tonight argued in 2009 “From the BBC’s perspective, the answer to this question is that our journalistic role is not to campaign for anything. Impartiality means not taking sides in a debate, while accurately representing the balance of argument. So, in the case of climate change we need proportionately to reflect the sceptical view but also, for example, reflect the debate among climate scientists about the most effective way of dealing with global warming”.

The word here is ‘proportionate’.  So 1 scientist in 70 wants his name removed from the final report. Perhaps Webb could have mentioned this and moved on the explore the more substantial discussion regarding adaption and mitigation.

More recently, February 2014, the BBC responded to complaints regarding the inclusion of Lord Lawson on the Today programme: “We believe there has to be space in the BBC’s coverage where scientific consensus meets reasonable argument about the policy implications of that consensus view. That said we do accept that we could have offered a clearer description of the sceptical position taken by Lord Lawson and the Global Warming Policy Foundation in the introduction. That would have clarified in the audience’s minds the ideological background to the arguments”.

 

There are very real debates to be had on this issue and the adaptation and mitigation angle is very pertinent. The good news is that, at last apart from a very few,  most accept the fact of climate change. It is what we do about it that is causing the heat. The BBC can help by reflecting the science, and ensuring we know what the ideological positions of prominent, and financially supported, sceptics are.

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

Why social change for sustainability may be ‘difficult’. 2014

Why social change for sustainability may be ‘difficult’.

 

Many people accept that ‘we live in interesting times’, and for example that liberal democracy in the west is facing both internal and external threats.  An internal threat is the democratic deficit in which people are beginning to feel the pointlessness of voting in the face of growing disparities of income and wealth. China’s economic success challenges notions of free market, politically liberal capitalism while at the same time the so called Arab Spring shows signs of disintegration. The IPCC’s 2013 fifth report on ‘Climate change, the physical science basis’ has not yet radically altered our dependence on fossil fuels. In contrast, investment in fracking and Canadian tar sands continue unabated while carbon reaches towards 400 parts per million, a figure last noted over 415,000 years ago (planet for life). In the UK the debate over energy is characterised by its cost and fuel poverty rather than production, efficiency or reduction in use. Sustainability solutions are being developed, but social change lags behind the unceasing rise in carbon emissions, ocean acidification and deforestation. This paper addresses the questions about our social responses and suggests that our ‘lock in’ to high carbon economies are related to unreformed, and possibly unreformable, consumer and finance capitalism.

 

When considering social change we need to think about who are the ‘communities’ who will be involved. The Transition Towns ‘movement’ is an example of a community who are already committed to some differing vision of the future based on building resilience to issues around peak oil. Grid-group culture theory, and the locking in of communities to ‘high carbon systems’, both suggest that top down education and clearer explanations do not work. Another perspective is that of Baumann’s (2001) idea of ‘liquid modernity’ in which society is characterised by atomism, individualism, fragmented social bonds and consumerism. If Baumann is right about ‘liquid modern’ society, if the ‘lock in’ is correct, and if there are competing cultural world views as suggested by grid group theory, then the future is indeed bleak for humanity because each suggests change towards a sustainable future faces major challenges.

What follows is a brief discussion around consumer and neoliberal capitalism, high carbon systems and the social ‘lock in’ (Urry 2011), and grid-group culture theory. We need to understand that human behaviour change around sustainability means accepting that that this is a ‘wicked problem’ (Rittel and Webber 1973) requiring ‘fuzzy’ solutions. This is not therefore a positive narrative with easy solutions. Baumann’s liquid modern society needs to be discussed elsewhere.

 

The high carbon economy-society.

Sociologically, we can make the following observations about our current ‘high carbon economy-society’ (Urry 2011):

The starting point for an analysis of why a society, and hence communities within that society, engages in particular practices and habits is the observation that energy is the base commodity upon which all other commodities exist (Urry 2011). We need to consider ‘commodity’ as a starting point because it is the fundamental analytical unit for understanding capitalism and capitalism is the base process that drives social forms. Commodity production, distribution and exchange forms the basis for the current ‘economy-society’, it is the infrastructure upon which the socio-cultural superstructure is based. The economics of commodity production, distribution and exchange has been dominated in western countries by neo-liberal economic theory, and the process of globalization, since about the 1980’s. Social relationship within capitalism are played out within commodity production, distribution and exchange through markets. The kind of commodities societies develop, or have access to, underpin much of social life.

 

 

Consider a society that does not have or has never had access to coal, gas or oil. All they have is the wind and water for energy. You don’t have to imagine it, those societies have been well documented and some still exist. Their habits and social practices are then based on the energy form that water and wind gives them. This is not to say that the energy commodity determines the social forms they create otherwise they would all look the same.

At the risk of being too marxist-determinist about this, any understanding of why we do what we do has to take the mode of production, e.g. capitalism, and the energy forms that underpin it, into account. Since the discovery of steam power based on coal, and then power based on oil and gas, our western societies were able to develop in particular ways until we designed a society that needs this form of energy. Thus, our community behaviours are implicitly locked into various high carbon systems that are taken for granted: 1) Energy system: coal, gas, oil which support the 2) Transport system 3) the high carbon military-industrial complex 4) Urban housing and domestic technology system, 5) Tourism, e.g. airlines and 6) food, supermarkets, agribusiness system.

These are all high carbon systems with which we have become enchanted, entranced and encapsulated, made manifest in and by our everyday attitudes and behaviours. Some of these have become very fashionable and have become embedded into everyday practice. The material physical world, its energy source, and our relationship to it, is therefore the basis for analysis here.

However we have had a problem with economics as a discipline in telling this narrative. Orthodox economics has forgotten is ‘political economy’ roots – it is as if Marx, Smith, Ricardo, Keynes, Veblen, Galbraith, to name a few, have been forgotten. However, there are signs that there is a growing realisation that this is a deficit in mainstream economics courses. Economics undergraduates at the University of Manchester have formed the Post-Crash Economics Society in an attempt to critique the ‘free market ideology’ of neoliberal capitalism taught in many Universities.

‘Free market’ Economics tries to explain human behaviour using overly ‘instrumentally orientated, rational planning, utility maximizing’ model of human behaviour, populated by ‘homo economicus’. John Urry critiques this for failing to address the fundamental relationship between people and the material physical world:

most of the time people do not behave as individually rational separate economic consumers maximising their individual utility from the basket of goods and services they purchase and use given fixed unchanging preferences…(we are) creatures of social routine and habit…fashion and fad…(we are) locked into and reproduce different social practices and institutions, including families, households, social classes, genders, work groups, schools, ethnicities, generations, nations…. (Urry 2011 p4).

The material conditions of economic life that we are locked into and so dominate our thoughts and actions are carbon based. For example, how we move physically in our locality is now almost exclusively by the use of the motorcar. We simply do not walk, much. It is as if cars have taken on a quasi-spiritual ‘Top Gear’ meaning for us, moving beyond simply a means to a travelling end. Being asked to give up the car is like being asked to give up sex. Unthinkable. So the social practices of meeting up together, employment, going shopping, sport and entertainments, are very often mediated through the use of the motorcar.

 

 

To date we have to accept that much of social science has been ‘carbon blind’ and has analyzed social practices without regard to the resource base and energy production that we now know are crucial in forming particular social practices. We have to now realize that social practices are in a dialectal relationship with the high carbon economy-society and that individuals within it have internalized this economy-society so that it becomes who they are. This explains persistence of behaviours within certain economies.

 

Social and Individual behaviour change within high carbon economy-societies.

Social change results from myriad, often competing factors such as class struggles, for example between labour and capital;  from ideological struggles, for example over Austerity economics; the technological, for example the ‘washing machine (Chang 2010), and from the pragmatic availability of material resources at hand. The task facing us is assisting in some small way the unlocking of communities from some aspects of these high carbon systems and of ideological commitments to forms of economy that trash the planet and also encourages inequalities in income and wealth that are socio-politically damaging (Wilkinson and Pickett 2009).

So, we live in societies that are locked into high carbon systems. We are also being asked to change our behaviour to adopt low or zero carbon habits, fashions and social practices. “Deep greens” ask us to fundamentally change everything about how we live. This rejects all high carbon systems, and that means rejecting totally consumer capitalism. ‘Mainstream’ sustainability adopts a less radical approach including the idea that capitalism can be reformed. The focus in the latter is not on complete system overhaul but on incremental individual behaviour change while encouraging and being encouraged, or ‘nudged’ by governments and corporations to do the right thing.

A technology of behaviour change is the UK’s ‘Pro-environmental Behaviours Framework’. Social conduct can be divided up into segments, e.g. our travel behaviours, which are then amenable to intervention. We can re-engineer choices step by step. Behaviour forms under certain conditions which then can be manipulated using social marketing techniques. Concepts include: ‘Behavioural entry points’, ‘wedge behaviours’, ‘behavioural levers’, ‘choice editing’. There is a set of 12 headline behaviour goals categorised within 3 areas of consumption: 1) personal transport 2) homes and 3) Eco-products.  This is the ‘change the lighbulbs approach’ to climate change and sits within a taken for granted neoliberal paradigm which sees the citizen consumer exercising their freedoms within deregulated markets. This is a technical-rational approach that assumes that there is no contradiction between greening our lifestyles and the capitalist system’s need for growth and consumption to increase.  This focus on changing the individual’s behaviour also obscures questions of collective social responsibility and power. Thus we have the project of the ‘carbon calculating’ consumer who may be nudged to do the right thing, to exercise choice within frameworks of governance that does not challenge the fundamentals of consumer capitalism chasing GDP growth.

 

Neo-liberal consumer capitalism

The paradigm within which all of this sits is that of neoliberal consumer capitalism. This requires, or rather has to have, 3% growth on capital accumulation (Harvey 2010), deregulated markets and accelerating consumption. GDP growth is the central goal of economic policy. This form of capitalism also externalises costs, has cycles of crises due to the surplus capital accumulation problem (Harvey 2010) and relies on technological solutions (Ben-Ami 2010). It also wishes to rely on individual responsibility for health, welfare and social problems, e.g. Big Society solutions. Baumann calls it “a parasitic form of social arrangement which may stop its parasitic action only when the host organism is sucked dry of its life juices” (1993:215). The contradictions between consumer capitalism and sustainability are obscured, power and collective responsibility issues are marginalised. It produces two main approaches to carbon reduction:

1. Macro economics: e.g. cap and trade systems, e.g. the EU’s Emission Trading System.

2. Micro economic techniques designed to encourage pro environment consumer choice.

It does not however look to itself to change.

What this seems to imply is that consumer capitalist societies will not address carbon reduction other than within this paradigm. If we are locked into clusters of high carbon systems, and given the limits to growth (Meadows, Randers and Meadows 2004), the crossing of ‘planetary boundaries’ (Rockstrom et al 2009) and ecological devastation,  then we will need to focus more and more on disaster management. David Selby made this point in 2007 in ‘as the heating happens’.  Behaviour change technologies such as the pro-environment behaviours change framework cannot address the fundamental driver of carbon emissions in anything like the time frame required because neoliberal capitalism will always outrun sustainability due to its need for growth and consumption. Its very mechanism is antithetical to sustainable living.

 

Resistance to Change.

Webb (2012) suggests citizen consumer knowledge on climate change is patchy at best. Short term concerns over the practicalities, convenience and cost of domestic and social life unsurprisingly dominates longer term concerns. Surveys demonstrate that we on the one hand identify with the need to adopt a low carbon future but on the other hand adopt high carbon choices. This ‘value-action gap’ is seen by government as a non reflexive fact about self interest, we don’t think about the contradictions in our answers, which is then seen as a barrier to change. In other words, self interest is supposed to drive behaviour but from a governments point of view we are not seeing our self interest as lying towards a low carbon future. We are paradoxically acting against our self interest. We value a low carbon future but we act as if we don’t because we are not reflecting on the connections.

However, surveys do not pick up the ‘situatedness’ of our response and the meaning we give to questions about low carbon living; cultural perspectives, social institutions and political values mediate the responses to attitudinal surveys and interpretations of climate science (Leiserowitz et al 2010). Therefore survey responses cannot be taken to be any true account of our actual preferences because our actual social practices are bounded by the material life we live in, the sorts of houses we have, the cars we drive, the products we buy.

 

Despite ‘sustainability’ seeming to be mainstream, vis the Climate Change Act 2008 and various initiatives and policies such as those of the NHS Sustainable Development Unit, the continuing existence of and adherence to the high carbon systems are implicated in the lack of progress towards a low carbon future. This will not change until enough individuals and organisations can free themselves. To do this we will need to encourage the development of perceptions that do not encourage social threat. For sustainability to become fashionable it has to be non-threatening or else change will be resisted.

Knowing the science, knowing the role of carbon in social practices is not enough. A personal commitment to a more sustainable lifestyle requires dealing with the direct threat this imposes to current values and behaviours that are experienced socially. If one’s family is not similarly committed, if one’s job or career is threatened by behaviour change such as reducing hours worked or changing to a more sustainable but lesser paid job, then the personal price may be too high to pay even for those who who ‘buy in’ to the sustainability agenda.

For those who do not yet accept or know that there is an issue, appealing to rationality, explaining the science, does not work because we are not rational and we have different ways of understanding the world. Individuals, with varying emotional drivers, vested interests and differing ways to rationalize behaviour, will collect together perhaps virtually as well as physically, and form groups that support their interests and knowledge. Social groups thus form around their various orientations to social cohesion and how they consider what are solutions to social problems. This brings forth various forms of resistance to change as outlined in ‘Grid-Group Theory’.

Grid-Group Culture Theory

‘Grid-Group’ Culture Theory (Douglas 1992) describes individual perceptions of societal dangers and then the response to them. Individuals tend to associate societal harms with conduct that transgresses societal norms. Sustainability practices may seem to many to be just such a transgression of norms. For example, the social norm of, say car ownership in a rural community, is transgressed by those advocating active transport, e.g. walking, cycling. Regardless of the actuality, public transport in rural areas is seen as non existent and current lifestyles demand a car – walking is just not an option. So, a social harm caused by giving up the car may be perceived to be the lack of communication with needed services in the countryside that is poorly served by public transport. This tendency to equate social harm, Douglas argued, plays an indispensable role in promoting certain social structures, both by imbuing a society’s members with aversions to subversive behavior such as ‘Transition Town Behaviour’ or selling the family car, and by focusing resentment and blame on those, e.g. sustainability advocates, who defy such institutions such as the petrol/steel/car  privatized Transport system.

The second important feature of Douglas’s work is a particular account of the forms that competing structures of social organization assume. Douglas maintained that cultural ways of life and affiliated outlooks can be characterized within and across all societies at all times along two dimensions, which she called “group” and “grid”. A “high group” way of life exhibits a high degree of collective control, whereas a “low group” one exhibits a much lower one and a resulting emphasis on individual self-sufficiency. A “high grid” way of life is characterized by conspicuous and durable forms of stratification in roles and authority, whereas a “low grid” one reflects a more egalitarian ordering.

 

 

It might then be suggested that Conservatives are low ‘group’ advocates putting faith in individual action and freedoms and would therefore seek sustainability solutions in free markets and freedom from government diktat. Socialists tend towards high ‘group’ orientations seeking solutions in such things as international binding treaties and government action on climate change. Indeed some claim that climate sceptics are more likely to be conspiracy theorists and free market advocates.

Douglas and Wildavsky (1982) previously had focused largely on political conflict over air pollution and nuclear power in the United States. They attributed political conflict over environmental and technological risks to a struggle between adherents of competing ways of life associated with the group-grid scheme: an egalitarian, collectivist (“low grid,” “high group”) one, which gravitates toward fear of environmental disaster as a justification for restricting commercial behavior productive of inequality; and individualistic (“low group”) and hierarchical (“high grid”) ones, which resist claims of environmental risk in order to shield private orderings from interference, and to defend established commercial and governmental elites from subversive rebuke.

Later works in Cultural Theory suggested that group-grid gives rise to either four or five discrete ways of life, or ways of thinking and rationalising about life, each of which is associated with a view of nature: as robust, as fragile, as capricious, that is congenial to its advancement in competition with the others:

 

  • The Collectivist.
  • The Individualist.
  • The Egalitarianist.
  • The Fatalist.

 

There may be a fifth: The Hermit – those who withdraw from social life as completely as possible.

The model is a two-by-two table, though it must be emphasized that the lines are arbitrary — the two dimensions are spectra, not binary divisions.

 

Let’s be realistic, in communities where cultural shifts are being forced through on the back of austerity programmes, many are locked into clusters of high carbon systems that will be almost impossible to break out of. This may lead to feelings of Fatalism. The fatalist culture considers there are many differences, and only limited bonding, between groups people within society. A result of this is that those ‘who have’ feel little obligation towards the ‘have nots’. Individuals are left to their own fates, which may be positive or negative for them. They thus may become apathetic, neither helping others nor themselves. Those that succeed, however, feel they have done so on their own merits and effectively need those who are less successful as a contrast that proves this point.

Neoliberalism encourages low group (individualised) low grid (no external constraints) cultural forms, manifest in the perversity of the unemployed blaming themselves for being out of work during a time of austerity and recession! In an individualistic culture, people are relatively similar yet have little obligation to one another. People enjoy their differences more than their similarities and seek to avoid central authority. Self-regulation is a critical principle here and in the arena of health, self control and personal responsibility are emphasized. If one person, or an ‘elite’ takes advantage of others then power differences arise and a fatalistic culture could develop. Individualistic cultures favour market solutions, accepting competition, laissez faire, pragmatic materialism as answers to social and economic issues.

We are at a point in history where the struggle between these cultural forms are being played out within a Neoliberal hegemony. Western media and politics are dominated by those who proffer free market solutions to social issues. They are distrusting and accusatory of international solutions, fearing they are on the ‘road to serfdom’. These voices are low group, low grid cultural forms. Countervailing voices are denounced as socialist and communist responsible for the economic woes of western democracies. This is despite the fact that the financial crash of 2008 was precipitated not by social democratic policies but by the deregulation of financial markets and the encouragement of personal and sovereign debt. The result is that many people are now concerned not about ocean acidification or other potentially devastating environmental issues but by the immediate problems of job losses, low incomes and high personal and public debt. This is only to be expected whereby the immediate economics underpinning social relations bring forth certain cultural forms, behaviours and attitudes. It still is “the economy, stupid”.

One light is Paul Hawken’s idea of the ‘Blessed Unrest’.  Hawken describes a worldwide movement for environmental and social change; a movement largely unrecognized by the mainstream media and politics, but nonetheless are countervailing voices. This movement has no leader, no overarching organisation, no one constitution but it is coming from ordinary citizens and groups who share a different vision for the world based on social and environmental justice. Hawken calls this movement ‘unstoppable’.

Conclusion.

The four rationalities expressed with grid-group culture theory explain why change is difficult. The issues are contested and even if agreed upon, the solutions will be very different. What will then be required is the development of cultural forms and politics that encourage all forms of rationality and solutions so as to harness the variances in people’s social orientations. However, a politics dominated by neoliberalism allows denial and individualism to trump necessary collectivist and egalitarian solutions to global problems. Ultimately though, grid group theory takes us only so far. It is an examination of political economy, such as that of neoliberalism and other variants of capitalism, that require analysis and social change. The challenge now is whether individuals and societies can adapt and develop fast enough to break out of high carbon systems before the full effects of climate change become potentially catastrophic.

 

Benny Goodman 2014

 

 

 

 

 

 

 

 

 

Refs:

Baumann, Z. (2000) Liquid Modernity. Cambridge. Polity

Ben-Ami, D (2010) Ferrari’s for all. Polity Bristol

Chang. Ha-Joon. (2010) 23 Things they don’t tell you about capitalism. Bloosmbury New York.

Douglas, M., Wildavsky, A.B. (1982) Risk and Culture: An Essay on the Selection of Technical and Environmental Dangers. Berkley, University of California Press.

Douglas, M. (1992). Risk and Blame: Essays in Cultural Theory. London: New York: Routledge

Leiserowitz, A., Maibach, E., Roser-Renouf, C., Smith, N. and Dawson, E. (2010) Climategate, public opinion and the loss of trust. Yale Project on Climate Communication. July. [online] http://environment.yale.edu/climate/publications/climategate-public-opinion-and-the-loss-of-trust/

Meadows, D., Randers, J., and Meadows, D. (2004). Limits to growth: the 30 year update. Earthscan. London.

Harvey, D. (2010) The Enigma of capital and the crises of capitalism. Polity. Cambridge

Urry, J. (2011) Climate Change and Society. Cambridge. Polity Press.

Rittel, H, and Webber, M. (1973) Dilemmas in a General Theory of Planning  pp. 155–169, Policy Sciences, Vol. 4, Elsevier Scientific Publishing Company, Inc., Amsterdam [Reprinted in N. Cross (ed.), Developments in Design Methodology, J. Wiley & Sons, Chichester, 1984, pp. 135–144

Rockström, J. Steffen, W., Noone, K. et al (2009) A safe operating space for humanity. Nature. 461. Pp 472-475. 24th September.  http://www.nature.com/nature/journal/v461/n7263/full/461472a.html accessed 8th January 2011

Selby, D. (2007) ‘As the heating happens: Education for sustainable development or education for sustainable contraction? Discourse, Power, Resistance Conference, Talking Truth to power’, http://www.esri.mmu.ac.uk/dpr_07/abstracts_07/index.php accessed 25th March 2009

Webb J (2012) Climate change and society: The chimera of behaviour change technologies. Sociology. 46(1): 109-125.

Wilkinson, R and Pickett, K. (2009) The Spirit level. Why equality is better for everyone. Penguin. London.

 

Indur Goklany and Daniel Ben-Ami on health, climate change and progress: A necessary corrective to Costello et al’s climate change health ‘propaganda’, or co-opted apologists for the neoliberal hegemony?

Introduction

 

The health impacts of climate change have been much discussed internationally, however there is some disagreement about the magnitude of those effects, when they will occur and what the right course of action is. Underpinning those disagreements is a joint uncritical acceptance of the fundamental structure of the political economy of late modern capitalism (neoliberalism), with the differences being around whether climate change requires more immediate public policy intervention or whether capitalism will address the health issues though economic development. In other words, both use the frame of reference of capitalism to argue for more market freedom v statist intervention. This paper seeks to outline the arguments over the health effects of climate change while rooting that discourse within wider often background taken for granted political economy. Two writers, Indur Goklany and Daniel Ben Ami will be used to represent the critical camp in riposte to Costello et al’s 2009 Lancet paper on climate change and health.

 

Climate change ‘debate’

 

The Intergovernmental Panel on Climate Change 5th Assessment Report (IPCC 2013) argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s (McGrath 2013). Thomas Stocker, IPCC co-chair stated:  “…in order to limit climate change, it will require substantial and sustained reduction of greenhouse gas emission…” (BBC 2013). Despite this, there is continuing doubt, denial and a focus on uncertainty in many countries, especially in news media, that Climate Change is human induced and that it requires radical shifts in public policy. See for example Delingpole (2013) in the United Kingdom and particularly in the United States and Australia (Painter 2013). The UK’s Owen Paterson, secretary of state for environment, food and rural affairs, told the 2013 Conservative party conference not to worry about global warming. “I think we should just accept that the climate has been changing for centuries.” (Syal 2013). Previously on BBC television’s ‘Any Questions’, he repeated ten discredited claims about climate change (Mason 2013).

 

This sits in opposition to many in the medical and public health domain. The World Health Organisation accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public health (WHO 2013 a,b), while previously ranking it very low down in a table of health threats (WHO 2009). In the United Kingdom, Costello et al (2009) argue that climate change is a major potential public health threat that does require major changes such as action on carbon emissions. In addition, Barton and Grant’s health map (2006) has in its outer ring ‘Climate Change, Biodiversity and Global Ecosystems’ as key determinants of health and supports the WHO view that alongside the social determinants of health, health threats arise from large scale environmental hazards such as climate change, stratospheric ozone depletion, biodiversity losses, changes in water systems, land degradation, urbanisation and pressures on food production. WHO (2013c) argues:

 

“Appreciation of this scale and type of influence on human health requires a new perspective which focuses on ecosystems and on the recognition that the foundations of long-term good health in populations rely in great part on the continued stability and functioning of the biosphere’s life-supporting systems”.

 

It is this call for a ‘new perspective on ecosystems’ that indicates why there is a backlash that underpin long standing critiques of the link between climate change, environmental issues and human health. Many of those critical are libertarian, anti state conservatives defending the neoliberal hegemony of free market dogma which ‘new perspectives’ may threaten.  For example, Stakaityte (2013) argues:

 

“Free market proponents are quick to point out that the whole climate change issue has been used to stifle freedom and to expand the nanny state – and they are right. If the climate is changing, and if humans really are responsible, the market will adapt”.

 

The WHO call for a ‘new perspective’ however is not a radical critique of neoliberal capitalism or a call for its replacement by other political economies. It sits within an overarching acceptance that capitalism is the only economic model, and that only its particular current form requires changing, for example by investments in green technologies.

 

Critical discourse over such an important issue is crucial. Argument should proceed over matters of empirical facts, within discourses of risk and an understanding of scientific uncertainty (see Painter 2013). Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony (Crouch 2011, Plehwe et al 2006) attempts to build and maintain a sceptical view in the media on climate change and on alternative, including no growth, economic models (Jackson 2009) because it is antithetical to ‘nanny state’ intervention implicit in public health ‘upstream’ analysis.

 

Health Impacts of climate change and the policy response

 

Indur Goklany and Daniel Ben Ami respectively are noted writers on the topic and both are in the sceptical camp regarding what to do about climate change. Both however appear to accept the fact of climate change, they just don’t agree with the focus on carbon reduction targets. They are both far more nuanced in their arguments than other commentators such as the UK’s James Delingpole; Andrew Bolt of Australia’s Herald Sun and Steve Molloy of the United States’ Fox News. However, Goklany is associated with the Heartland Institute, but care should be taken not to debunk his thesis merely because he publishes at that anti climate change organisation.

 

For the health community that makes decisions on what the main threats to health are, there is a need to carefully weigh up the evidence for threats to population health in the short, medium and long term, or what Goklany calls the ‘foreseeable future’. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Amis’ argument on progress. For Goklany the health threats are not from climate change, nor will they be for the foreseeable future. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.

 

Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth, and may be over confident that limits have been correctly identified or can be overcome. Goklany might turn out to be empirically correct that in the ‘foreseeable future’, defined as 2085-2100, climate change will not be the major threat to public health, however this line of reasoning gives support to the denial of climate change in particular and obscures the requirement of addressing the sustainability of current economic structures. It also sidesteps addressing the language and discourse of risk (Haggett 2010, Painter 2013) which includes considering that human action should not be based on total certainty but on the assessment of the probabilities of high and low impact events. However, the position taken by both writers is that humanity needs more capitalist economic and technological development even if that results in a warmer world.

 

Goklany (2012) argues that humanity, in developing and using fossil fuels, both freed itself from the vagaries of nature’s provision and also has saved nature from humanity’s need to turn more of it into cropland. The inference from this argument is that we ought to continue to use fossil fuels to further human progress and to save nature from ourselves. Increasing global GDP, i.e. a wealthier world, would also be better equipped to deal with future global warming issues (Goklany 2007). This is inductive in that it assumes that this past pattern of innovation will be repeated in the future.

 

Daniel Ben-Ami (2010) also forwards this argument in ‘Ferrari’s for all –a defence of economic progress’. He points out that we are living longer and healthier lives than ever before thanks to economic development and growth. Therefore, inductively, we need more growth. The book is also based on the idea that humanity is apart from nature – human exceptualism – and is capable of enormous technical, cultural and progressive ingenuity. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.

 

It is a counter to what he terms ‘growth scepticism’, i.e. the “tendency to undermine economic progress by indirect means” (p3). If populations are to be in better health and free from poverty then the only answer is more of the same. Those who suggest climate change is a health threat do not address this economic and development argument head on, there may be implicit acceptance of the current economic models of development. Instead there is a focus on the magnitude of climate change per se as a health threat rather than the economic structures which may drive climate change and other unsustainable practices such as deforestation.

 

Costello v Goklany

 

So, Costello et al (2009a) argued that climate change is the biggest global health threat of the 21st century’ (p1693). Goklany in the same year replied and argued that climate change is not the number one threat to humanity and questioned whether it is “the defining challenge of our age” (Goklany 2009a). Costello replied to Goklany’s riposte again in 2009, but Goklany in 2012 further rebutted that claim.

 

Goklany argued Costello et al made their claim about climate change in 2009 without a comparative analysis of the magnitude, severity and manageability of a range of health threats at that time and therefore ranking it as the No 1 threat is untenable. Goklany (2009c) argued that climate change was ranked 21st out of 24th global health threats. Goklany’s rebuttal data comes from a World Health Organisation World Health Report 2002 and Comparative Quantification of Health Risks 2004 and he uses results from “Fast Track Assessments” (FTAs) of the global impacts of global warming (Arnell et al 2002, Parry 2004). In his 2012 article he also cites Parry (1999) and the World Health Organisation’s 2009 Global Health Risks.

 

Costello et al (2009b) in reply to Goklany argued that “The ranking of climate change at 21st out of 26 risk factors was made at a time when global temperature rise was only 0·74°C, and when the effects of climate change on the other risk factors was unclear” and they claimed that there has since been substantial changes in our understanding of climate change risks. They cite two papers showing that about 1 trillion tonnes is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider (2009) who raised the prospect of worst case scenarios: warming at 3°C gives a 90% probability that Greenland will melt, raising sea levels by many metres, and that on present evidence and trends there is a 5—17% chance that temperatures will go up by 6·4°C by 2100, “a risk way above the threshold at which people would usually buy insurance”.  Goklany’s position (2012) is that the 2 degree target is irrelevant in any case and he seems happy to accept a 4 degree rise.

 

The 2013 IPCC report AR5, while accepting a pause in warming over recent years, argues that climate change is a continuing very serious issue and now post dates this difference in Goklany and Costello’s arguments which are based on data from 1999 to 2009. This will need constant revision as more scientific data is published. The IPCC WGII contribution on ‘impacts adaptation and vulnerability’ is due to be reported in March 2014. The report makes it clear that even if greenhouse gas emissions are stopped right now climate change will persists for many centuries, much of it will be irreversible characterised by impacts such as sea level rises. The last time the world was 2 degrees warmer , sea levels were 5 -10 metres higher.

 

On what to do, Goklany (2009c) argues that ’Societal resources devoted to curb carbon dioxide and other greenhouse gas emissions will be unavailable for other…more urgent tasks including vector control, developing safer water supplies or installing sanitation facilities in developing countries….’ (p69). However this sets up a false dichotomy. The decision to spend on carbon reduction is not an either/or one. There are myriad spending decisions being made, and those choices are made from a raft of competing priorities. One could equally argue that resources devoted to nuclear armaments and other military spending is unavailable also for these other urgent tasks. So to focus on emissions reduction as the spending that diverts funds away from addressing other pressing health issues is a biased view. Goklany could argue for an end to subsidies for the fossil fuel and nuclear industries, reductions in military spending, changing the international tax regimes to access wealth deposited in offshore accounts, or the introduction of a Tobin tax on financial transactions. These are admittedly biased positions and may be seen to be too left wing, and ideologically incompatible with current the neoliberal hegemony (Crouch 2011).

 

Whether funding spent on carbon reduction actually works in terms of human welfare and is less expensive than alternatives, is a valid question but has to be seen in a wider political discourse about spending decisions. His points regarding the need for poverty reduction via sustainable economic development and advancing our adaptive capacity would possibly bring broad agreement. In any case some consider that it is too late (Peters et al 2013) for mitigation and that adaptation to a warmer world is now needed. Goklany (2009b) uses the term ‘focused adaptation’ meaning taking advantage of the positive benefits of warming. If sea levels are to rise by 5-10 metres this is beyond the foreseeable future and so we should focus on economic growth and development to adapt to those future scenarios rather than wasting time resources and energy on emission curbs. However, this seems somewhat an anthropocentric view taking in little regard for biodiversity loss and ocean acidification. Both of which are also threats to human health

 

Ben Ami and Goklany put faith instead in ‘secular technological change’. This believes that

 

1) Existing technologies will become cheaper or more cost effective.

2) New technologies that are even more cost effective will become available.

 

They may well be correct. They argue the potential health threats may be addressed through human ingenuity based on economic progress and economic progress is best served by accepting the IPCC worse case scenario which would result in greater per capita GDP and thus release capital for adaptation (figure 1).

 

 

 

 

Figure 1: net GDP per capita, 1990-2200, after accounting for upper bound estimates of losses due to global warming for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C) (source Goklany 2012)

 

 

Figure 1, therefore, indicates that if humanity has a choice, it ought to strive for the developmental path corresponding to the richest IPCC scenario (A1FI  – 4 degrees C above 1990 by 2085) notwithstanding any associated global warming. Because this increases adaptive capacity and poverty would be eliminated. Other health risks that rank higher than global warming are also associated with poverty and would thus also be eliminated. Poverty related diseases contribute to mortality and morbidity 70-80% more than warming. Mitigative capacity would be increased, therefore health improves with economic and technological development, and development encourages the ‘environmental transition’.

 

This is a very risky strategy which future generations will have to judge the merits of. There is gathering evidence beyond climate change suggesting that humanity is already transgressing other environmental limits, transgressions which will not support a ‘safe operating space’ as we enter a new era, the ‘anthropocene’. (Rockstrom et al 2009).

 

Risk Discourse

 

Goklany (2012) further argued “This paper does not address hypothesized low-probability but potentially high consequence outcomes such as a shutdown of the thermohaline circulation or the melting of the Greenland and Antarctica Ice Sheets, which have been deemed unlikely to occur in the foreseeable future by both the IPCC and the US Global Change Research Program, among others”, although the IPCC has since (2013) stated that it is “very unlikely that the Atlantic Meridional Overturning Circulation (part of the global thermohaline) will undergo abrupt transition or collapse…however, a collapse beyond the 21st century…cannot be excluded” (IPCC 2013 SPM-17).

Goklany, in not addressing these risks, appears to dismiss the need for ‘risk discourse’ to frame public debate relying on ‘kicking into the long grass’ serious consequences of climate change.

 

‘Risk’ is already an essential part of everyone’s experience, including in the world of insurance, health and investment. It is not uncommon for people to insure against low probability but high impact events such as house fire, or critical illness. People also invest for the long term, for example in a pension that might take over 40 years to pay off. It is thus arguable that the thermohaline shutdown and ice sheets melts may well be just the sort of low probability but high impact events that humanity ought to be insuring against and taking measures to prevent through carbon emissions reductions. Painter (2013) suggests therefore that elements of risk discourse would provide a better frame for debate than disaster and uncertainty frames, which are both more prevalent in news media.

 

Space precludes an examination of the concept of exponential growth and the requirement to produce resources to meet the needs of potentially 9-10 billion people by 2050. Costello et al’s position seems to be that climate change will stress ecosystems before we have time to adapt and that both direct and indirect affects will adversely impact on global health. They are not so sanguine about our ability to live within our limits.

 

 

Conclusion

 

Goklany is correct to point out that currently that health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach. Costello et al have not dismissed this and as public health experts would probably accept a similar position. A focus on the social determinants of health to address poverty needs to run alongside carbon reductions or else the good work could be undone by a low probability but high impact event such as the melting of the Arctic Ice. They differ on when climate change will be a health threat and importantly on how to address it. Goklany and Ben Ami appear to be on the market driven economic development model as the answer whereas Costello et al argue for more immediate state and public intervention in addressing climate change. All however do not critique the fundamental neoliberal economic model or call for alternative economic ‘no growth’ models (Jackson 2009).  There is little doubt that we are running an experiment with the climate, there is agreement that this will impact on global health but the answer seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

References

 

 

Allen MR, Frame DJ, Huntingford C, et al. (2009) Warming caused by cumulative carbon emissions towards the trillionth tonne. Nature pp 458: 1163-1166

 

Arnell N.W, et al. (2002) The consequences of CO2 stabilization

for the impacts of climate change. Climatic Change 53 pp 413-446.

 

BBC (2013) Climate change threatens our planet, our only home.http://www.bbc.co.uk/news/science-environment-24292615 accessed 1st October 2013

 

Ben-Ami, D. (2010) Ferrari’s for All – In defence of economic progress.  Policy Press. University of Bristol.

 

Costello, A., et al (2009a) ‘Managing the health effects of climate change’, The Lancet, 373, pp. 1693 – 1733.

 

Costello, A., Maslin, M., and Montgomery, H. (2009b) Climate change is not the biggest global health threat  – author’s reply. The Lancet. 374 9694 pp 974-975

 

Crouch, C. (2011) The strange non death of neoliberalism. Polity Press Bristol.

 

Delingpole, J. (2013) Global warming believers are feeling the heat. The Telegraph. http://blogs.telegraph.co.uk/news/jamesdelingpole/100238047/global-warming-believers-are-feeling-the-heat/

 

Goklany I. (2007) Is a Richer-but-warmer World Better than Poorer-but-cooler Worlds? Energy & Environment, 18 (7 and 8) pp1023–1048

 

Goklany I. (2009a) Is climate change the “defining challenge of our age”? Energy Environment, 20 pp 279-302

 

Goklany, I. (2009b) Climate change is not the biggest global health threat. The Lancet, 374 9694 pp 973 – 974.

 

Goklany, I. (2009c) Global Health Threats: Global Warming in Perspective. Journal of American Physicians and Surgeons 14 (3) pp 69-75 available at http://www.jpands.org/vol14no3/goklany.pdf

 

Goklany, I. (2012) Is climate change the number one threat to humanity? October 17th, available at http://wattsupwiththat.com/2012/10/17/is-climate-change-the-number-one-threat-to-humanity/

 

Goklany, I. (2012) Humanity Unbound: How Fossil Fuels Saved Humanity from Nature and Nature from Humanity. December 19th Policy Analysis, No. 715, Cato Institute, Washington, DC. Available at SSRN: http://ssrn.com/abstract=2194659

 

Haggett, C. (2010) Discourses of Risk: the construction of responsibility and blame: using discourse analysis to understand contested risks and the management of blame and accountability. Lambert Academic Publishing.

 

Intergovernmental Panel on Climate change (2013) Summary for policy makers. WG1 AR5 September 27th. IPCC

 

Jackson, T. (2009) Prosperity without growth. The transition to a sustainable economy. Sustainable Development Commission. http://www.sd-commission.org.uk/data/files/publications/prosperity_without_growth_report.pdf

 

Mason, J. (2013) UK secretary of state reveals his depth of knowledge of climate change (not!). Skeptical Science. http://www.skepticalscience.com/paterson-on-climate.html

 

Meinshausen M, Meinshausen N, Hare W, et al. (2009) Greenhouse-gas emission targets for limiting global warming to 2°C. Nature pp 458: 1158-1162

 

McGrath, M. (2013) IPCC climate report: humans ‘dominant cause’ of warming. 27th September. http://www.bbc.co.uk/news/science-environment-24292615 accessed 1st october 2013

 

Painter, J. (2013) Climate change in the media. Reporting risk and uncertainty. I.B. Tauris and Co. Reuters Institute for the Study of Journalism, University of Oxford.

 

Parry M.L. and Livermore M., eds. (1999) A new assessment of the global effects of climate change. Global Environmental Change 1999, 9 S1–S107

 

Parry M.L, ed. (2004) Special issue: an assessment of the global effects of climate change under SRES emissions and socio-economic scenarios. Global Environmental Change.14 pp1-99.

 

Parry M, Palutikof J, Hanson C, Lowe J. (2008) Squaring up to reality. http://www.nature.com/climate/2008/0806/full/climate.2008.50.html

 

Peters, G., Andrew, R., Boden, T., Canadell, J., Ciais, P., Le Quere, C., Marland, G., Raupach, M. and Wilson, C. (2013) The Challenge to keep global warming below 2 degrees C. Nature Climate Change. 3, 4-6 doi:10.1038/nclimate1783

 

Plehwe, D., Walpen, B. and Neunhoffer (2006) Neoliberal Hegemony. A global critique. Routledge. London.

 

Rockström, J et al. (2009) Planetary boundaries: Exploring the safe operating space for humanity. Ecology and Society [online] 14, 32. www.ecologyandsociety.org/vol14/iss2/art32

 

Schneider S. The worst case scenario. Nature 2009; 458: 1104-1105

 

Syal, R. (2013) Global warming can have a positive side, says Owen Paterson. 30th September. The Guardian  http://www.theguardian.com/environment/2013/sep/30/owen-paterson-minister-climate-change-advantages

 

Stakaityte, G. (2013) Libertarianism and (climate) science denial. The Libertarian. http://the-libertarian.co.uk/libertarianism-and-climate-science-denial/

 

World Health Organization. (2002) World Health Report 2002—Statistical Annex. Available at: http://www.who.int/whr/2002/annex/en/index.html

 

World Health Organization. (2004) Comparative Quantification of Health Risks. Geneva: World Health Organization; Available at: www.who.int/healthinfo/global_burden_disease/cra/en/index.html

 

World Health Organization (2009). Global Health Risks. Geneva: WHO. http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html

 

World Health Organization (2013a) Climate change and human health. http://www.who.int/globalchange/en/index.html

 

World Health Organization (2013b) Health topics. Climate Change. http://www.who.int/topics/climate/en/

 

World Health Organisation (2013c) Global environmental change. http://www.who.int/globalchange/environment/en/index.html

 

Sustainability, Health and Cycling ‘on yer bike’

Sustainability, Health and Cycling.

 

Following the success of cycling at the London Olympics, which has propelled Chris Hoy and Victoria Pendleton into the limelight, and two successive Tour de France wins by British based Chris Froome and Bradley Wiggins, the Great British public are getting back on their bikes and not just to find work. At the mass cycling event ‘Ride 100’ held in London this summer,  even London Mayor Boris Johnson (17 stone) took part, commenting that he was no “chiselled whippet”. Boris is of course also known for the introduction of the Boris bike in the capital. He stated: “The truth is it’s not that hard, and I’m here to prove it. I am 17 stone, I’m by no means fit, and I got myself round that (100 mile) course in a perfectly respectable time. Not supersonic, but perfectly respectable…The message we’re trying to get over is this is for everybody”.

The Department of Transport has produced figures on walking and cycling by local area based on a survey in 2010/11. The key findings include 10% of adults cycle at least once per week but this varies a great deal by area (from over 50% to less than 5%), 11% of adults cycle for at least half an hour at least once per month but again with huge variations (35%-4%). Perhaps unsurprisingly, Cambridge  reports 52% cycling at least once per week and the highest rates are reported in cities and boroughs within cities. Why do we cycle? The survey suggests that 16% do so for utility purposes and 77% for recreation. The Cycling Touring Club (CTC) reports cycling is up by 20% in the last 12 years from 4 billion kms in 1998 to 5 billion kms in 2011.

So this is good news. For society, a shift from cars to cycling may bring about reduced air pollution, reduced greenhouse gas emissions and increased physical activity. For the individual there is an increase in exposure to air pollution and risk of road accidents. The health benefits of cycling are well understood. According to the NHS choices website these include helping you to lose weight, reducing stress and improving fitness. The example of calorie burning is given: someone weighing 80kgs (12st 9lbs) will burn more than 650 calories in an hour’s riding. As a keen road cyclist I can burn 1500 calories on a weekend ride. Of course there are concerns about death and injury on the roads, even Bradley Wiggins has been involved in a collision back in the UK after winning the Tour de France. Department of Transport figures for 2011 indicate that 107 cyclists were killed, but this figure is declining from 2004. However, combined figures for deaths and injuries show these steadily rising to 19,215 in 2011. What of course we really need to know is the relative risk of cycling compared to say horse riding, other forms of motor transport or any other activities. We need to know how many deaths per 100,000 kms of cycling and then to ask, whatever the number is, is cycling beneficial despite the risk?  Depending on who you ask, the health benefits of cycling do seem to outweigh the risks. Hartog et al in their study (2010) argue “on average the estimated health benefits of cycling were substantially larger relative to car driving for individuals shifting their mode of transport”.

Cycling is not just an individual issue, it is a social issue and perhaps a political issue as well. Both Denmark and the Netherlands have higher rates of cycling than the UK. This might be obvious given the geography, but the story is not as simple as the relative lack of hills, it is also down to political and urban planning decisions taken and active policy decisions by politicians over decades to make the countries cycle friendly, to get people back on their bikes.

In ’The Energy glut – the politics of fatness in an overheating world’ Roberts and Edwards (2010) argue that fossil fuels are making whole populations fat/obese. We have replaced food with fossil fuels as our main energy source while at the same time we are eating, if not less than we did, then certainly no more. We have become sedentary, replacing walking and cycling as active transport with mechanical modes of transport, mainly the motor car. Whole societies are using the energy oil has given us to replace physical labour. The upside is the construction of advanced civilizations and huge increases in food production, and the ability to buy stuff, the downside is that as countries develop and begin to increase their car use, whole populations get fat, and experience death and injury on the roads that make cycling injury statistics seem small. Did I mention the contribution to climate change?

Cycling as active transport is a positive sustainability issue, but it is also complicated in that in achieving positive health gains and reducing carbon emissions on the one hand, we have to also consider the carbon footprint of cycling. This includes the manufacture of cycles and  their transporting around the world. Raleigh manufactures in the Far East and my own Bike, a ‘Merida’, was shipped to the UK from overseas. Then of course there are the clothes and accessories and the taking part in weekend ‘sportives’ which may involve driving to events across the country. I have not calculated the carbon footprint of my own cycling interests nor have I calculated yet how many car miles I have not done as a result of cycling. I have to confess that I am one of the 77% who cycle for recreation, having not yet bitten the bullet on commuting. My only excuse is a 20 mile round trip to work on an A road in West Cornwall at , yes even in Cornwall, ‘rush hour’ where far too many drivers seem not have yet woken up and speed by far too closely.

My value system approves of cycling, I believe it has health benefits as well as risk but the risks could be far better managed if UK policy makers went even further in their plans for cycling. Am I about to sell the car though….?

 

 

 

The medics get it – sustainable literacy in education

Sustainability, health and education – Priority Learning Outcomes for health professionals.

 

 

Although some scientists and commentators such as Indur Goklany, have disputed claims about the precise impacts of climate change and human health, it is nonetheless accepted that wider environmental factors can and do impact severely upon health. Climate change, as has been pointed out before, is only one aspect of the relationship between the environment and health and focusing on it may not always be helpful. Instead, many medical and other organisations in the UK have clearly accepted that our relationship with the environment is a foundation upon which health is based. This relationship is also part of our socio-political relationships and forms the matrix of connections and systems that life on earth depend on. Oil and its production, distribution and exchange is a fact of that socio-political and environmental relationship – what John Urry calls the carbon based economy-society.

 

At this point the connection between health and social analysis might begin to seem tenuous, especially to those steeped in a biomedical frame of reference. However, within health education there are two perspectives that bring issues around sustainability, whether they be political, social and/or environmental, back into focus. The Social Determinants of Health and the Inequalities in Health literature raise issues about our relationship both to the environment and to each other and the impact this has on individual, community and population health. Both of these perspectives on health may well be addressed in undergraduate medical and nursing education, but the extent to which they are, is not currently mapped. Although these two perspective do not always explicitly discuss the environment they do focus attention beyond the individual and biology. A great example is Barton and Grant’s (2006) ‘health map’ which clearly models determinants of health. Their paper, and model for health, would or should be a foundational read in undergraduate health education emphasising as it does biodiversity, climate change and the global ecosystem as key determinants of health.

 

This has now been explicitly accepted by some in the medical profession following the publication of three specific priority learning outcomes for the education of ‘Tomorrow’s Doctors’. This publication follows calls for medical graduates to be sustainability literate and is based on a General Medical Council’s request for learning outcomes for environmental sustainability in medical education. A call for nursing in general, and the Nursing and Midwifery Council (NMC) in particular, for nursing to be more explicit on sustainability and environmental health in its educational standards for undergraduate nursing education has not resulted in a similar request by the NMC for learning outcomes of this nature. The NMC prefer to see this subsumed under general public health.

 

The priority learning outcomes just published on the Sustainable Healthcare Education network are:

 

1. Describe how the environment and human health interact at different levels.

2. Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems.

3. Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment.

 

The site helpfully expands on these outcomes.

 

An important point is that although sustainability literacy may involve explicit new curricular content for doctors, for example critical reflection on the philosophy of dualism and anthropocentrism, it is also about developing a perspective on health, a lens through which we see anew the relationship between human health and the environment. Medical schools may already address models of healthcare delivery that go beyond the biomedical to embrace and examine biopsychosocial, salutogenic and complementary approaches. The European Centre for Environment and Human Health based in Truro, Cornwall,  is an example of a research centre specifically and explicitly addressing sustainability and environmental issues.

 

Thus we have the medical profession very clearly stating that sustainability and environmental health should be explicit in the education of our doctors of the future. This of course follows on from other clear statements such as the first University College London and the Lancet Commission on managing the health effects of climate change report.

 

These learning outcomes have been called ‘priority’ learning outcomes and this perhaps reflects the seriousness with which the issues are taken. A counter is that of course Public Health is a core component of both medical and nursing education, so why the need to make sustainability specific? Why indeed have ‘priority’ learning outcomes if this is being covered already within public health education. The answer may be that ‘Public Health’ itself is a multi perspectival subject in which it is possible that biomedical and epidemiological approaches could dominate while downplaying the environmental and social determinants of health. It is certainly possible to address public health without critically examining and understanding sustainability. The General Medical Council seem to have accepted this,  and hence their call for these learning outcomes. The Nursing and Midwifery Council have considered that their own standards that inform education practice are broad enough so that sustainability can be incorporated into undergraduate programmes within Public Health teaching. This might be a mistake, because if educators do not have a sustainability perspective, or lens, then they may well miss a vital aspect of health education.

 

The publication of the medical priority learning outcomes on the other hand gives a very clear message to those developing educational experiences for doctors. The message is that to fully understand human health one has to address environmental, social and political determinants of health. This understanding then feeds into strategies and actions  to address inequities in health and the environmental health crises that may severely impact on individuals, communities and populations. Other health professions might learn from this approach taken by the GMC.

Changing our mindset for health and sustainability

Changing our mindset for health and sustainability

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (David Loy 1988 p 302).

This is also on the 2 degrees site

As I have previously suggested, health care professionals are becoming more alert to the issue of climate change and how this might affect the health of populations in the future. Climate change is only one aspect of sustainability, others of course relate to issues such as food production, distribution and security. The solutions put forward to address the myriad issues appear to be based in two different, but not necessarily mutually exclusive, approaches: 1) the technico-rational and 2) philosophical. If health care professionals are to put forward plans of action then they need to consider some of their philosophical and ideological assumptions that underpin those solutions.  I would suggest that a little more philosophical enquiry into the nature of society and our relationship to ‘nature’ just might prompt a rethink of our reliance on technical solutions.

 

The first, technico- rational, approach implicitly accepts dominant modes of thinking, which could be called ‘modernist’.  It is often based upon various philosophical traditions without explicitly critiquing them. These traditions, such as rationalism, empiricism and dualism, can be traced back to the Enlightenment and the dawn of western science. These ideas of course underpin much of modern capitalism which is another taken for granted economic model underpinned by philosophical assumptions about how the social world works.

 

A modern exponent of this is Daniel Ben Ami who, in ‘Ferraris for All’, argues that what is required is more economic development and growth, i.e. much, much more of the same, in order that humanity can better control nature and to come up with scientific and technical solutions to such issues as ocean acidification, climate change and soil erosion. Capitalism, rationalism, empiricism and dualism are implicit in this way of thinking. In short, this accepts the current economic growth based model and an understanding of how we relate to nature through extraction and development of natural resources for human use. The answer for sustainability and human health is improved technologies. I think there are flaws in this approach, one of which is that it relies too much on assuming what brought us success in the past, i.e. capitalism and technological development, will continue to do so in the future. That is to say it is based on inductive logic and its flaw; past patterns might predict the future but cannot guarantee it. As Nicolas Naseem Taleb reminded us, there might be a black swan to confound the ‘all swans are white’ logic.

 

David Loy’s comment leads us to the second approach, the philosophical, in that we might want to examine some of the assumptions that underpin the technico-rational, and especially ‘dualism’ – the separation between man and nature, mind and body. Loy contrasts Eastern non dualist philosophical traditions, with mainly Western dualism in that  “….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings” (p140). This then is a non dualist viewpoint in which ‘us’ includes the biosphere; we are indivisible as human beings from all life forms and all matter.

 

In Cartesian dualism, the Platonic tradition and the Judeo-Christian religious tradition, the self is separate from nature and is understood to be the source of awareness, meaning and value. This results in a devaluing of the physical world in which the human self is separate and superior.  The human ‘subject’ is separate from the natural ‘object’, and so what we do to ‘it’ is not part of ‘us’. Dumping toxins into the oceans is acceptable because the ocean is not part of us – it is a waste sink, we are doing something to a separate ‘it’. The human subject then becomes capable of confronting an objective world, a world which is there for our use.  The idea of human exceptualism (Catton and Dunlap 1978) – that man is special and apart from nature – takes root in this discourse.

 

This sentiment harks back to Francis Bacon, who argued in 1620 “The world is made for man, not man for the world”. In ‘The New Atlantis’ , Bacon thought that by and through the application of scientific and technological dominion over nature, men would usher in a new age of abundance and comfort.  This has echoes in Sigmund Freud’s (1927) assertion: ‘The principal task of civilization, its actual raison d’etre, is to defend us against nature’.

 

The call to have dominion over, to conquer, to harness, control or subjugate nature is predicated upon this idea of separateness from it. This control is thus predicated upon the self in opposition to nature which Yagelski (2011) calls  ‘the problem of the self ‘:  “My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”. Shabecoff (2001) suggested that concerns expressed in critiques by environmentalists of this dualist interpretation resulted in the ‘Heidelberg Appeal’ , a document signed by many scientists,  which reasserted that progress by man always involved harnessing nature to man’s needs.

However, we know that human health is inextricably bound with the physical and natural environment and what Charles Eisenstein calls ‘separation’, i.e. dualist thinking, results in practices that are injurious to us. In this regard Chivian and Bernstein (2010) argue the biodiversity is crucial to human health and I suggest that we might do better to consider ourselves part of nature not separate from it. Is it a philosophical step too far to consider that the clearing of Amazon rainforest is therefore as injurious to my health as contracting a virus?  Changing low energy light bulbs is a technical solution, perhaps I also need to change the way I think.

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