MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast about the culture of medicine. I’m Mic Cavazzini for the Royal Australasian College of Physicians. If you didn’t know what La Niña was before this summer, you definitely know by now. It’s the climate system that brought us Australia’s wettest November on record, followed this year by Sydney’s wettest ever first quarter by a big margin too. Tragically for the residents of Lismore in the Northern Rivers, it also brought the worst of 29 floods they’ve had since records began in 1870.
La Niña is a colloquial way of describing one phase of a climate system known as the Southern Oscillation. In the current phase we have warm coastal waters and cloudy skies, since every degree the air temperature increases allows 7% more humidity.
In the alternate phase called El Niño, the ocean is cool and the air is dry. The record heat of Australia’s 2019-2020 summer was an El Niño event compounded by another climate oscillation called the Indian Ocean Dipole. The result was 17 million hectares of forest burnt, including normally wet rainforests of Queensland and Tasmania. A fire complex in the Blue Mountains of NSW set the record for the longest burning in Australian history.
Later in this podcast I’ll explain how global warming is increasing the frequency of extreme weather events in parts of the developing world as well, that are ill equipped to respond. And we’ll hear about the commitment the College is seeking from the major parties contesting our federal election this May. I’ll take it as understood that global warming is happening and it’s due to the vast volumes of carbon dioxide, methane and other greenhouse gases that humanity has dumped into the atmosphere since the industrial revolution.
The globe has already warmed by about one degree above pre-industrial levels and you might remember it was the Paris Agreement of 2015 where a call was made to try and limit this rise to 1.5 degrees. Two degrees Celsius was the absolute ‘guardrail’ we were warned not to overshoot, but the Special Report released in April by the Intergovernmental Panel on Climate Change shows that that horse has bolted already.
We may well land closer to three degrees by the end of the century, unless declared commitments to reducing carbon pollution are implemented immediately. Real emission volumes need to peak within the next three years and then be reduced by a quarter or more by the year 2030. Worryingly, the globe Iast year set a new record for gross volume of carbon emissions, bouncing back with vigour from a pandemic-induced dip.
The political resistance to reducing emissions is the fear of adding dollar costs to industrial output, but there’s an astounding cost to inaction too. Auditors from Deloitte concluded that natural disasters already cost the Australian economy $38 billion a year, and by 2060 that figure would reach $73 billion. That factors in damage to property, reduced agricultural output, resourcing of emergency services, but also health and social costs where they could be estimated.
The IPCCS’s recent impact Assessment along with the Lancet Countdown series mapped out some of the health impacts of a warmer climate, and identified Australia as one of the developed countries that are most vulnerable. The RACP has explored these in a review titled Climate Change and Australia's Healthcare Systems, along with collaborators at the Monash Sustainable Development Institute, the Uni of Melbourne and the Climate and Health Alliance. I’ll give you a summary of the report before we hear from its lead author, Professor Lynne Madden.
So what were the consequences of this torrential eastern summer on human health? Between Lismore, Brisbane and surrounding areas there were about 30,000 people whose homes were swamped because of the quickly rising floodwaters. Around Sydney evacuation orders affected another 30,000 though there were fears it could reach ten times that number. Warnings were issued to residents to avoid floodwaters for fear of gastrointestinal disease and skin infections.
But warm wet conditions are also a fertile breeding ground for other infectious diseases, or rather their mosquito vectors. In a shock to public health observers, cases of Japanese encephalitis cropped up in New South Wales, Victoria and South Australia. The JE virus had previously been confined to the Torres Strait with a brief incursion to Cape York in 2004. Now it appears to have found a reservoir in piggeries all the way down the east coast, from where it can jump via mosquitos into the human population. While most cases are asymptomatic or cause chronic fatigue-like symptoms, this outbreak put a handful of people in ICU, one of whom did not survive.
This summer South Australian health authorities also detected higher than average case numbers of Ross River fever and Murray Valley encephalitis and infectious disease experts are concerned about the expanding range of the Aedes aegypti mosquito. This is the main vector for dengue fever which until now had been confined to arrivals of people infected overseas. But as the globe warms, the mosquito will encroach south of its current boundary at Rockhampton and start to take in bigger population hubs.
If we cast our minds back to the Black Summer of 2019-2020, the plumes of bushfire smoke were visible from space and it was respiratory problems that came up on the health radar. While the fires killed 34 people directly, it’s estimated that another 430 people died from smoke-related health effects. Add to that about 1500 excess attendances at ED for asthma and over 3000 hospital admissions for respiratory or cardiovascular causes.
According to the most recent impact reports from the IPCC, we’re in for a 30% increase in the frequency of severe fire weather days by the middle of the century, meaning there will be a much greater need for respiratory medicine specialists. In the RACP review there are a number of case studies from the Black Summer fires that reflect the human face of this. In Canberra, the concentration of most damaging aerosol particles peaked at more than 26 times the hazardous level or 200 times the ‘safe’ level. So much so that at Canberra Hospital the air filtration system was unable to cope even in the “the inner sancta” such as birth wards, surgical theatres and neonatal ICU. Medical equipment in pathology and imagining suites failed and sterilised equipment became contaminated.
In a recent ABC article a woman on the New South Wales south coast who inhaled bushfire smoke for five weeks while pregnant was later told she had the placenta of a heavy smoker. While her baby turned out healthy, the pregnancy was defined by her constant anxiety for its wellbeing. The mental health impacts of such biblical scale catastrophes are hard to quantify though we are becoming more aware of them.
During the three years of drought leading up to 2020, one of most deeply scarred towns was Stanthorpe in regional Queensland. Local doctor Jane Brundell told Melbourne researchers that, “it got to the point where every single general practice consult I did started with a mental health check to make sure I didn’t have someone suicidal sitting there.” The suicide rate in rural Australia is twice as high as it is in major cities in part because farming communities are so financially exposed to the elements. But the social isolation and poor availability of services just makes things worse. Greater funding for mental health services in the regions is the type of resilience-building that will be required as we move into a more volatile climate.
And it wasn’t just Stanthorpe’s farmers who were affected by the drought either. With the town’s water supply exhausted, it became reliant on daily truckloads of drinking water for 18 long months, leading to problems with sanitation. And in remote Northern Territory townships, water shortages meant that mobile dialysis could no longer be provided to indigenous patients.
However on January 4th 2020 the hottest place on Earth was not in the dusty red centre, but Penrith in Sydney’s Western suburbs. It clocked a reading of 48.9˚C, and half the summer days reached 35 degrees or more. This most recent summer Perth experienced a record 13 days above 40 degrees, which is a warning that urban design also needs to adapt to a warmer climate. One of the IPCC’s predictions for the cities of Sydney, Melbourne and Brisbane was that mortality related to heat stress would reach 300 deaths per year which is about double what it is now. And that’s in the optimistic scenario where the global average doesn’t exceed a 2 degree increase. For Australians, this will actually translate to increases of 3 to 6 degrees, depending on how far inland they live.
To put this into perspective, 2019, our hottest year on record, was just 1.5 degrees over Australia’s long-term average. In an MJA collaboration with the Lancet Countdown series it was estimated that the number of work hours lost due to heat stress that year was about twice what it had been in 1990, and the same trend was observed recreational activities like outdoor sport. And in a survey of communities in Western Sydney called Sweltering Cities, 11% of the almost 700 people surveyed that summer said that they’d sought medical care because the heat had made them unwell.
Regional physician Dr Simon Quilty described a dramatic episode to the SMH in which a patient in the Northern Territory had an epileptic fit likely triggered by the extreme temperatures. After falling to the ground he suffered third degree burns from the bitumen yet none of the medical records mentioned heat a contributing factor. With Thomas Longden of the ANU, Dr Quilty published a paper in the Lancet Planetary Health suggesting that heat-related mortality may be 50 times higher than records would indicate.
I’ve given you just a glimpse of how everyday health will be impacted by the foreseeable rise in global temperatures over the next generation. That’s if the commitments made by 31 countries at the recent UN Conference in Glasgow are kept. The RACP along with nine other major medical Colleges have just made a request to Australian political leaders for a “a healthcare system that is both climate ready and climate friendly.” The country is only weeks away from a Federal election, and the Colleges want an urgent commitment of leadership and funding to respond to this problem. To explain the details of the Healthy Climate Future campaign I spoke to Professor Lynne Madden who chaired the RACP report I’ve described for you.
LYNNE MADDEN: My name is Lynne Madden, I chaired the climate change and health research project advisory committee for the RACP. I am a public health physician, and I am Professor of Population and Planetary health at the National Medical School at the University of Notre Dame, Australia.
MIC CAVAZZINI: So, the RACP recently published an open letter, along with 10 of the major colleges. The first ask that the colleges had of the candidates going forward towards the election is to “Create and fund a National Climate Change and health strategy. So that would involve vulnerability assessments for the healthcare system” in some of the areas I've touched on already. Can you give us some examples of what improved resilience for the healthcare system would look like in these fields of medicine?
LYNNE MADDEN: What do we mean by a climate resilient healthcare system? As we have seen, the compounding natural disasters that we've seen in recent years, a lot of people come to the health care system seeking support and care. So that's the first thing; we need to be ready for the increased demand. And sometimes people forget that during events like this things happen that actually take those hospital and primary care and various health care structures out of play out of the system. So, for example, during the bush fires people were cut off from hospitals, people were cut off from pharmacies, they couldn't reach care. The same thing in floods in America, we saw the whole hospitals flooded during their various hurricanes. I mean, a classic case is that once upon a time, everyone put the generators for a hospital in the basement. What's the first part of a building that gets flooded? The basement. So basically, we just have to rethink the whole way we actually build our infrastructure. And then we also need to recognize that during these events our own staff, our own workforce, is actually being impacted upon in the same way that the communities that they serve are being impacted upon. And so we need ways to actually support our staff during those sorts of events.
MIC CAVAZZINI: Some of those infrastructure and planning issues would fill another podcast again, but thinking specifically about the medicine workforce, where do you see the biggest gaps or the biggest room to improve the training or numbers of certain types of specialists and so on?
LYNNE MADDEN: For example, one of the groups who is most involved in planning and policy and as you saw throughout COVID, is public health physicians. And yet public health physicians don't have a nationally-funded training program. So climate change does need to inform national health workforce strategy and planning. Speaking from someone who works in the tertiary education sector, essentially what we need to look at very comprehensively is the way that we prepare medical students and our trainees for current practice. Current practice means that people need to be aware of the threats of climate change, they need to be understanding about how this will present in patterns of illness and also how they themselves can help to drive down the carbon footprint of the health care that we currently provide.
MIC CAVAZZINI: So of course, rural and remote communities are particularly exposed to extreme weather events. And there's a gap in servicing that we've known about for years, even without the added pressure of climate warming. Do you think the long-term structural solutions are going to come from within Health alone? Or do we see other branches of government waking up now that climate impacts are so big and so costly?
LYNNE MADDEN: Well, there's no doubt that rural communities are on the frontline when it comes to climate change. I mean, essentially, climate change is a health issue but it affects all aspects of society. This requires a whole of government response. And there are many fine examples from around the world, in particular from the UK, where they created a Climate Act in 2008. And Tony Blair organized a whole of government response to that. All government departments in England are responsible for reporting on climate change related targets. That's what needs to happen in Australia.
MIC CAVAZZINI: And beyond the longer-term adaptation, there will be need, at least during natural disasters for “Establishment of a surge health and medical workforce for deployment in response to extreme weather events.” Do we know yet what that might look like? Are we are we talking about city physicians who would act as reservists for emergency deployments to Lismore and so on when there is flooding?
LYNNE MADDEN: Well, a good example is the New South Wales Public Health Officer training program, which actually prepares multidisciplinary specialists in public health. So that's a group of people who are in training who can be moved around the state in response to sudden and an increased need. We've also seen how the system surges within itself during COVID. So, essentially, lots and lots of people became involved in the public health containment response, whose everyday responsibility is not working in core public health—they’re usually people working on wards receiving patients in active patient care. But the whole focus during COVID was initially to contain the disease so that we could protect the health care system so it didn't become overburdened. So there's great examples of how the system can surge. For example, the system also used medical students for the first time that medical students went in to partially paid positions and supported, you know, the exhausted health profession staff. And so there's a variety of ways in which a surge capacity can be managed.
MIC CAVAZZINI: Yeah, the pandemic was an incredible—I don't want to say real life experiment, but there were solutions coming thick and fast. There were nurses coming out of retirement. There were supply chain issues that to an extent were dealt with, but I'm sure we have a better grasp of the vulnerabilities now. One difference, I suppose is that we have all of these jurisdictions with different health systems, you know, public health orders, and policing are done at a state level. The Defence Force is Federal. The health system is state, of course, but the vaccines were bought and distributed by the Feds. So after the pandemic do we have a better sense of how these bodies could be unified to provide a prompter response?
LYNNE MADDEN: Well, look, one of the things that the research report that the RACP commissioned, one aspect of that was a policy and institutional analysis of how the jurisdictions—Commonwealth and the jurisdictions—are responding to climate change. And essentially what was described, was excellent work was being done within some jurisdictions, like in New South Wales, excellent work being done by some local health districts, excellent work being done by some primary health care networks. So there is real leadership emerging from and established within the healthcare system in various parts.
What we lack is a coherent overall plan, something that creates an illustrated vision or direction; an overall guidance that can take us forward at a national level. We have lots of national strategies for important diseases. We have a national diabetes strategy. But as we’ve said, health doesn’t feature in our national response to climate change. And we really do desperately need to have research funds directed at the health effects of climate change and how healthcare systems can actually rapidly decarbonise. Part of the reason why there isn't a lot of work in this area is that this is an unfunded area of research.
MIC CAVAZZINI: And I think that that was on one of the scorecards published by the Lancet Countdown series and also by the Global Climate and Health Alliance, where they ranked countries on their preparedness for the climate impacts on health. Sure, we have the Australian Research Council, and the NH&MRC. But we need to dedicate a specific pool of funding to this kind of this problem. There was a review in last year's Lancet Countdown collaboration with the MJA titled, "Australia increasingly out on a limb" and the author has made this observation. “The continued absence of a national health and climate change adaptation plan is a glaring gap in Australia's preparedness, and continues to put the health and lives of Australians at risk. There is a stark contrast between Australia's world-leading COVID-19 response, and its world-lagging Climate Change Response.” Do you think there's a difference in the nature of the threat and people's existential response to it. Climate change is still seen as such a distant problem?
LYNNE MADDEN: Well, then the COVID threat was extremely proximal, and it threatened to kill—I mean, It did kill—I think the latest numbers 18 million people died around the world. So what COVID demonstrated to us was that we are capable of directing all of our resources to answering very difficult questions. Coming back to the research, I mean, the development of COVID vaccines within the window that it took was unprecedented in medical history. And that was because we mobilized as nations around the world. Whether it had been so equally good about a rolling those vaccines, once produced, out is a completely different matter.
But another thing that happened that supported all that was the open publication of research. So as fast as the research was being produced, it was being shared, it was being shared openly. So everybody had access. And that got you away from the whole sort of difficult space of where, essentially, the wealthy countries have access to information, less wealthy countries don't have access to information. So there are many great examples of how we can mobilize and unite and collaborate to achieve great health outcomes with without a doubt.
MIC CAVAZZINI: There's also an acknowledgment in the RACP letter about reducing the carbon footprint of the health system itself. We don't have time to go into all the examples, but what are some of the big ticket items, and you've referred to the NHS as a good model?
LYNNE MADDEN: Well Yeah, so basically, it's not only be about being climate ready, but it's also about being climate friendly. And as I mentioned before, the Australian healthcare system has a carbon footprint of about 7% of national carbon emissions.
MIC CAVAZZINI: I think, globally, all the health systems in the world, together would be the fifth biggest emitter—the fifth biggest country as an emitter.
LYNNE MADDEN: Yeah, globally, was responsible for about 5% of all carbon emissions. So where is that carbon coming from? Well, pharmaceuticals, have a very big carbon footprint, that's a big contributor. So does energy within the infrastructure. And so does travel associated with seeking health care. But the interesting thing is the carbon footprint of pharmaceuticals, and we know that a lot of pharmaceuticals are wasted. And it comes back to the provision of wiser health care, you know, prescribing less, but better is better for your patient, and it's better for the climate.
And if you want to see a lot of waste, have a look at what comes out of an operating theatre. And that's been well described by Australian researchers who are informing the process of change within theatre practice, but also within anaesthetics. So some anaesthetics have a very large carbon footprint, very environmentally unfriendly, and a lot of our carbon comes from the things that we've purchased into healthcare systems.
MIC CAVAZZINI: So to be clear, you're talking about shipping all these things into our country that's…
LYNNE MADDEN: Purchasing any services, whether it's IT, purchasing pharmaceuticals, purchasing linen services. Whatever you purchasing into your healthcare system, you're also purchasing in carbon. The NHS is actually—one of its really innovative things is it's working with all their providers, and they're actually asking their providers to sign up to the same carbon commitments that the NHS is. And not only that, that if those companies won't, then they will no longer purchase from them. So we're talking about some of the biggest pharmaceutical companies in the world here signing on to join the NHS, on helping the NHS become carbon neutral by 2040. And they have well-established plans in place to actually achieve that. Their sustainability unit has now been absorbed into a much larger “Greening the NHS” initiative and there is a lot that we can learn by simply exchanging with colleagues and following their examples, we do not need to make all this up from first principles. There are some fabulous examples out there, but particularly in the NHS.
MIC CAVAZZINI: Finally, all of this doom and gloom may seem detached from the daily grind in the clinic, and much too big for any health professional to feel like they can contribute to it. But leave us with a message of how listeners could respond to this today's message. How can they help, whether it be by writing letters or signing up to a campaign?
LYNNE MADDEN: As we've talked about, governments control the policy decisions and the purse strings that actually drive action. Making your representatives responsible to you and responsible for the health implications of climate change is one of the things that we can do as health advocates. So in conjunction with the campaign for a healthy climate future, there are resources available that will help fellows from across the colleges to take action, giving them the information to email their local federal member about their support for the healthy climate future campaign. There's fact sheets you can download, you can leave them at various places around your workplaces.
So there's a whole range of things that which we really strongly encourage fellows and trainees to engage with, but that can feel very isolated and alone. And the other thing to remember is the value of acting together. And once again, I bring us back to the research project that's generated this, this letter that was done in conjunction with 10 other colleges. It was a tremendous experience. We enjoyed coming together we enjoyed supporting and informing that research journey. So by responding together across colleges, we demonstrate how we can build off each other's resources, and we can build off each other's energy. But it's urgent, and basically, every fraction of a degree of heating that we can prevent will have immense health care benefits.
MIC CAVAZZINI: You’ll find a link to the Healthy Climate Future campaign and attached resources on the landing page of the RACP website. Before leaving you though, I want to zoom out to capture the global picture not just the Australian one. And if the picture is gloomy for us here in one of the richest countries in the world, just consider the predicament of the developing world despite its negligible contribution to carbon emissions until now.
Long before scientists had formally described the link between ocean currents and atmospheric conditions, fishermen in Peru and Ecuador noticed that poor anchovy hauls would predict heavy drawn-out rainfall. Since this occurred around Christmas time it was named after the baby Jesus, El Niño.
For a given phase of the Southern Oscillation, the Pacific coast of the Americas experiences the opposite weather conditions that Australia’s eastern states do. So while La Niña means a wet summer for us, they’re going into a third year of drought. 2020 was California’s worst wildfire season in history and fire services are bracing for more catastrophic conditions this year.
I only just learned that the Southern Oscillation is also the main driver of rainfall in East Africa and Central Asia. Those regions are currently in their second year of failed rains, leading close to 30 million people between Ethiopia, Kenya, Somalia and Afghanistan to face critical food insecurity from poor harvests.
The Southern Oscillation cycles from El Niño to La Niña and back again about every four years. But the exact timing and intensity of these events varies quite a bit. An dramatic swing from El Niño to La Niña events between 1997 and 1999 was described as “the climate event of the twentieth century”. More than half of Bangladesh was flooded, and in China 200 million people were displaced by flooding. One of the strongest and deadliest hurricanes hit the region of Honduras and Nicaragua, and landslides in Venezuela killed over 25,000 people.
Now it’s nonsensical to say that any given natural disaster, even a record-breaking one, is clear evidence of climate change. Only by collecting records for another hundred years or so could we be certain that disasters had become more frequent, but that would be far too late to turn things round. Climate modelling is a necessary predictive tool, despite the uncertainties in it that opponents to decarbonisation make a big deal about.
The most extreme La Niña events are normally separated by around 23 years, but several climate models predict an increase in the frequency of the Southern Oscillation as the climate warms. CSIRO researcher Wenju Cai reviewed these in a Nature paper from last year, including a rather pessimistic forecast from his own research team. This suggested that an increase of 2 degrees Celsius in global average temperatures would bring the recurrence of extreme La Niña events down to 13 years. Another study showed that the pendulum of the Indian Ocean Dipole would also swing more wildly.
I haven’t even mentioned today the spectre of rising sea levels. This is caused not just melting of polar ice sheetsbut also thermal expansion of water and it’s expected that average sea level will rise by at least 50 centimetres by the end of the century [using realistic assumptions about the RCP4.5 global emissions trajectory]. This would put many Pacific Islands, parts of Indonesia and a tenth of Bangladesh’s land mass under water right off the bat. But the additional risk from storm surges and salinification of aquifers could impact directly on the lives of a billion people by the year 2050. The humanitarian and geopolitical consequences of this will be impossible for us to ignore.
I’ll leave you with a passionate appeal made by UN Secretary General Antonio Guterres at the launch of the IPCC report in February. “Today’s IPCC report is an atlas of human suffering and a damning indictment of failed climate leadership ... With fact upon fact, this report reveals hope people and the planet are being clobbered by climate change. Nearly half of humanity is living in the danger zone now… Unchecked carbon pollution is forcing the world's most vulnerable on a frog march to destruction now. The facts are undeniable. This abdication of leadership is criminal.”
Many thanks to Lynne Madden for contributing to this episode of Pomegranate Health. The theme of health system responses to climate change will be picked up at again at the RACP Congress in mid-May, this year occurring in Melbourne with digital feeds available on New Zealand time. There will also be workshops for on every clinical speciality, on presentation skills, on dealing with the media, on challenging consultations and much more.
For a full transcript of this episode with references please go to racp.edu.au/podcast. There are also more readings on climate and health in the curated collections at elearning.racp.edu.au. Please share this episode with friends and colleagues to build the momentum for a healthy climate future. I’m Mic Cavazzini, and this podcast was recorded on Gadigal country. I pay my respects to the storytellers who came long before me.