
Earlier
this year, I published a series of three posts based upon a commentary
I wrote, entitled "Physicians and the Environment," that was published
in the Journal of the American Medical Association. The commentary was
an invited piece, and reflected some of my thoughts about current
environmental issues and the role of the medical profession in
achieving the education necessary to be able to intelligently respond
to these issues. Recently, the AMA issued a statement supporting many
of the concepts I presented in my commentary. Since that announcement,
I’ve received numerous requests from readers of this blog to combine
the posts into a single offering, which I offer here.
This post
uses parts of my original commentary in JAMA to put this issue into
context for the layperson, and so I am including the references where
appropriate from the original commentary.
There is every reason
for persons involved and interested in wilderness and outdoor medicine
to be advocates for preservation of the environment. The entire concept
of "wilderness medicine" is predicated upon the existence and
improvement of wilderness areas, which are among the most pressured and
rapidly receding parts of planet Earth.
In many circumstances
in the past, the medical profession has responded to adverse situations
of global reach, such as epidemic diseases, genocide, the threat of
nuclear war and natural disasters. As the world’s scientists,
governments, and businesses now confront the state of the environment,
all manner of health care professionals also must be prepared to
respond, because in the final analysis, health matters are integral to
the predicament, predictions and discussion. Beyond being just a
reliable resource, given the magnitude and complexity of issues as they
relate to human health, the medical profession should accept the
challenge of becoming a leader in the discussions and debates.
Despite
our preoccupation with armed conflicts and the economy, the environment
is perhaps today’s most pressing global issue, as it contributes not
only to direct effects, but to other situations of concern, such as
economic decline and civil disobedience. Environmental conditions
contribute to the presence or intensity of many medical conditions,
such as temperature-related morbidity and mortality, health effects of
extreme weather events (e.g., storms, floods, tornadoes, hurricanes,
and precipitation extremes) and their sequelae (e.g., oceanic algae
blooms), ecological change (e.g., the potency of certain harmful
plants, such as poison oak), starvation, allergies, pollution-related
health effects, water- and food-borne diseases, and vector- and
rodent-borne diseases.
1,2As
we learn more, it becomes apparent that the full eventual effects of
global climate change and other environmental issues are not
necessarily easily defined or well predicted. There are multiple views
surrounding every issue. Some of the most important issues that need to
be continuously examined from every angle include global warming,
depletion of stratospheric ozone and increases in ground-level ozone,
destruction of forests, polar melting, deficiencies in water production
and sanitation, and human population growth and dynamics.
There
are and will be significant differences of opinions about what follows
here. My comments are properly interpreted as being "pro-environment"
or "green," leaning toward the perspective that advocates that there
are significant environmental problems and that many of these can be
attributed to the activities of humans. However, I most certainly
acknowledge the rights and responsibilities of others to hold different
viewpoints and opinions, and the value of their being skeptical about
science and conclusions. The most important thing is that we do not
become acrimonious or disengaged, because it will take all of our
skills of observation, analysis, and collaboration to reach consensus
on these matters in a timely fashion and in a way that promotes
improvement, not conflict. The acts of remediation are expensive and
potentially diverting (from other problems), so no significant change
should be taken lightly.
Global Warming.
Atmospheric accumulation of gases (predominately carbon dioxide,
methane, nitrous oxide, and halocarbons) traps heat by the greenhouse
effect.
3 The Intergovernmental
Panel on Climate Change predicted that average global temperature will
continue to increase, and a major concern is the rate of warming.
4
Compared with the century 1906-2005 required to raise the earth’s
average atmospheric temperature by 0.56 degrees Centigrade, some
suggest that only a decade may be needed to raise it another 0.28
degrees C.
5 This rate of
change has been created by burning fossil fuels in power plants and for
transportation, a decline in carbon intensity reductions, and natural
sinks removing a smaller proportion of emissions from the air.
6
Each year, more than 1.2 cubic miles of oil, 3.5 billion metric tons of
coal, and 100 trillion cubic feet of natural gas are burned worldwide,
releasing 30 billion tons of carbon dioxide into the atmosphere.
7 Without
efforts to stabilize or decrease consumption of fossil fuels, the 14.9
billion metric tons of carbon emissions released by the United States,
the European Union, China, and India in 2005 are projected to increase
to 25.6 billion metric tons in 2030.
8
Even if one disputes the precise numbers, we seem to be on an
unsustainable spree of consumption. Is global warming due to rising
carbon dioxide levels, and are these rising levels attributable to the
activities of humans, or are these environmental "facts" part of a
series of coincidences? We need to know the answer. How many barrels of
oil, tons of coal, and cubic feet of natural gas can be extracted from
the earth before we run out? At our current rates of consumption, when
will this occur? We need to know the answers.
Depletion of Stratospheric Ozone.
Chlorofluorocarbons and other ozone-depleting substances released into
the atmosphere are major contributors to the destruction of ozone in
the stratosphere. Depletion of the ozone layer exposes the earth’s
inhabitants to increased amounts of harmful ultraviolet-B radiation.
This contributes to skin cancer, cataract formation, suppression of the
immune system, and damage to certain crops.
9 This is counter-posed by accumulation of ozone at ground level, which contributes to lung disease and other health risks.
Destruction of Forests.
Fires set to clear forests for agriculture and grazing release carbon
dioxide, which is a contributing factor to global warming. According to
the World Bank, approximately 22 million acres of rain forests are
destroyed by intentional fires each year, accounting for approximately
20% of worldwide carbon dioxide emissions.
10 Wildfires, often coinciding with droughts, generate additional atmospheric carbon dioxide.
11 In
preindustrial times, the atmospheric abundance of carbon dioxide was
relatively constant at 280 ppm; in the 1950s, the level was 300 ppm; in
2006, it had attained 381 ppm; and in 2008 it is increasing.
12 At
what rate are these forests being re-planted? Can men and women
continue to remove habitat, plants, animals, and minerals from planet
Earth at current rates and be assured that this does not pose a
catastrophic future for our populations of life forms? We need to know
the answers.
Polar Melting.
Consistent with the increase of global temperature, there is a loss of
snow cover in the Northern Hemisphere, the amount of Arctic and
Antarctic sea ice is diminishing, and glaciers are melting.
13 Predictions
suggest that in the next few centuries, sea levels could rise by as
much as 17.8 cm to 6 m, and the Gulf Stream may be diminished or even
eliminated.
14 In low-lying
coastal areas where populations cannot be protected by natural or
artificial barriers, large numbers of climate refugees may be forced to
migrate to other locations, thereby increasing population crowding.
Global climate change also is predicted to contribute to flooding and
fire risk; increase the intensity of cyclones (hurricanes) and heat
waves; accelerate beach erosion and desertification; hasten species
extinction; and diminish water and food (livestock, fish, and plants)
availability.
15 I have heard
many arguments about animals, such as polar bears, that putatively face
extinction because of hunting, habitat and climate change, loss of food
supply, etc. Are important animal populations declining? Can or should
we intervene in the decline of any species? What does history tell us
about the effects of rising and falling sea level? We need to know the
answers to these questions.
Deficiencies in Water Production and Sanitation. Sachs
16
contends that global climate change will tighten the availability of
water, and force migration of hundreds of millions of individuals over
the course of a few decades. According to the United Nations, more than
5 billion persons on Earth may live under severe water stress by the
year 2025.
17 Currently, 1.1
billion persons lack adequate water worldwide, 2.6 billion lack
adequate sanitation, and 1.8 million children die each year because of
one or both of these deficiencies.
18 The
outdoors can be beautiful, marvelous, and a tonic for the body and
spirit, but it can also be a cruel, terrifying environment of forced
survival. What is the true status of our water supplies, nation by
nation, region by region? We need to know.
Human Population Growth and Dynamics.
The human population is increasing exponentially, which has an
unprecedented global effect on ecology and biodiversity. This effect
takes place through overharvesting, introduction of nonnative species,
pollution, and habitat fragmentation and destruction.
19 As
large, developing countries face increasing energy demands, they will
undoubtedly burn increasing amounts of fossil fuels. The environmental
conditions and climate changes that have been touted as major
influences on health may potentially involve millions of individuals
being injured or killed by floods, tsunamis, and cyclones; tens of
millions afflicted by poorly controlled diseases that might emerge as a
consequence of unchecked vectors (such as mosquitoes); hundreds of
millions malnourished due to desertification, loss of crops, and
insufficient potable drinking water; and ultimately, poor health and
the loss of prosperity as individuals are crowded into a reduced
landmass that may be too small to reasonably support their survival.
20,21
The worldwide growth of the human population dramatically increases the
possibility of loss of life-sustaining resource bases during large
geological and weather events in a manner that limits human survival.
Simply put, the more pins standing behind the lead pin when the bowling
ball strikes, the more that are vulnerable to being struck down and
swept away. We need to be very thoughtful about this, because hunger
and economic deprivation inevitably lead to conflict and even war. So,
basic human needs may trump our desire to divert crops, such as corn,
to alternative fuels. We are already witnessing these effects.
While
there are a wide variety of opinions about the timeline for such
events, the arguments supporting environmental trends are substantiated
by reasonable scientific observations.
2,22
Proponents of accelerating global climate change suggest that given the
rapidity of changes and their unforeseen consequences, successful
adaptation would appear unlikely and unattainable. The most viable
solution is to halt the inexorable assault on the environment as
quickly and effectively as possible. Arguments that do not support
these trends are espoused by dispassionate and intelligent individuals,
who also care very much about their planet, but do not necessarily
agree with the scientific conclusions indicating human-generated
planetary degradation and climate change. Which faction is correct?
Issue by issue, point by point, we need to know. What might be at stake
are the futures of species and resources that cannot be easily
regenerated, if they can be regenerated at all. On the other hand, if
there are better approaches than those currently favored by
environmentalists, then let them be identified and implemented.
It
is increasingly the case that environmental remediation recommendations
are topics of great debate, for many reasons. Some reputable
authorities do not agree with the proposed causation or acuity of
environmental problems. Others astutely observe that some of the
solutions proposed, such as diversion of crops for alternative fuels,
may contribute to hunger and economic consequences that are more
disruptive than expensive fuel, or even the consumption of fossil fuels.
Because
the nature and magnitude of environmental changes have only recently
come to be recognized, it is difficult to predict the attribution of
inevitable to natural cycles, or whether the forces of nature are
becoming unbalanced. Some suggest that while human activities have an
effect on climate, there is not proof that this affects global
temperature. For instance, there may be years during which global
temperature declines. Others acknowledge the inevitability of global
climate change, but recommend adaptation or geoengineering solutions.
23
Opponents of those who predict irreversible global climate change and
warming argue that until the precise nature and rate of these phenomena
can be established, governments and industries should be tentative and
cautious about making expensive policy decisions.
24
Still, others point out that by focusing attention on global warming,
there is a risk of not properly addressing more important environmental
and health issues.
I am increasingly convinced that persons
who argue against the magnitude and timing of global climate change are
not doing so out of personal interests. They truly believe that our
current surge in environmentalism is an over-reaction to a situation
that may not be as dangerous as has been proposed. Wherein lies the
burden of proof? Is it upon the conservationists, or those who demand
data to support initiation of policies and practices with wide-reaching
economic consequences? I think it is a shared responsibility. Beyond
the data, we must certainly act with common sense.
Certain
issues seem to me to be beyond calculated inaction. Developing
alternative sources to substitute for fossil fuel consumption is widely
supported. How can preservation of fossil fuels be bad, unless in the
preservation, man unleashes some greater hardship upon the planet or
its inhabitants? We are probably not yet at the stage where we should
accept starvation in Africa as a consequence of our attempts to promote
ethanol production for automobile fuel, but if we do not find a
solution to pumping oil into our tanks, will be be creating even
greater misery downstream? Despite the fact that there is almost
universal assent and agreement on many issues, politics, economics, and
special interests delay progress.
I cannot speak for everyone,
but I have an opinion about the response needed from the medical
profession. If one believes that there are situations upon which we
should soon act, significant behavioral changes will be needed to begin
to reverse apparent deleterious trends. Achieving global environmental
change requires public and private efforts, led by a massive
educational effort that should include all institutions of higher
learning, including schools of medicine. By virtue of their knowledge
and experience, physicians are rightfully concerned about individual
and population health. However, the germs and disease processes with
which we have become familiar may not pose as great a threat as what
might result from such environmental eventualities as the melting of
the polar caps.
It is my feeling that the time has come to
broaden what the medical profession (and in particular, those with an
interest in wilderness medicine) must learn, expanding awareness by
educating physicians about the best environmental science. Given the
hypothetical and known links of global climate change to human health,
and the increasing concern that this change is accelerating, it is our
duty to become informed.
Accordingly, in response to the
environmental imperatives, an educational action plan is appropriate
for the medical profession. Nelson
25
noted about environmental studies, “ . . . the subject matter is
all-encompassing. It includes . . . the air, water, minerals, soil,
forests, oceans, lakes and rivers, as well as all living things in the
seas and on land, the relationship and influence of each on the others,
plus economics, politics, religion, culture, and philosophy. And,
although we will never know or understand more than a small fraction of
the endless intricacies of nature’s works, we can comprehend and learn
the general principles that should guide our conduct as a society, if
we are to preserve a livable habitat. The proposition is, quite simply,
that we must conduct our activities in such a way as to protect the
integrity of our ecosystems and their resources. . . ”
There are
several potential methods for physicians and other healthcare
professionals to increase awareness and involvement with environmental
issues. First, there should be courses at every level on the
relationship of environmental issues to human health. To cover the
principles of environmental science and related medical issues, these
courses should include information on atmosphere and climate; global
climate change; the relationship of climate change and weather to
disease vectors and transmission; the effect of climate change on the
biology and afflictions of humans, plants, and animals; methods for
assessing climate-related health effects; ecology and the environment;
biodiversity and human health; natural environmental hazards; causes
and effects of environmental contaminants; food and water science; and
the causes and effects of population growth. Courses should be prepared
and reviewed for accuracy and objectivity by authoritative
environmental scientists and educators, in collaboration with medical
professionals.
Medical societies and special interest groups,
specialty organizations, and research institutes should whenever
possible engage experts to summarize the best evidence about the
effects of environmental change on health and medical conditions. This
continuous process should foster exchange of views that takes into
account medical, social, geopolitical, economic, and cultural issues.
It goes without saying that the opinions that emanate from the medical
profession, or any other profession for that matter, should be
science-based to the greatest degree possible. Whenever new evidence
emerges, current views may need to be modified as they relate to both
the environment and health implications. I think it would be terrific
if medical organizations would review their missions, and determine to
what extent they are willing to disseminate environmental education
material to their membership. Medical organizations should encourage
members to become environmentally aware, and consider creating reports
and multimedia presentations on global environmental health for
delivery to medical professionals, students of medicine, business,
government, and the general public.
Persons with special medical
knowledge should investigate environmental organizations and consider
supporting them with their special expertise. When appropriate,
healthcare professionals can develop specific initiatives in
collaboration with environmental professionals. Moreover, medical
professionals should all learn about companies that truly use
environmentally sound practices in their business efforts and consider
supporting them. It may not make a big difference to the environment,
but if for no other reason than to begin to establish a trend,
hospitals and health care practices should make reasonable efforts to
become green in ways that promote effective patient care while limiting
the negative effect on the environment of providing that care.
And
what about the wilderness medicine community? What can a person learn
and do who wants to be healthy in the outdoors? The educational goals
are to be better informed, become inspired, and take action. In the
countless debates that will ensue, physicians and their patients should
be positioned to wisely explain the medical ramifications of
environmental issues. It is time to eliminate complacency and
acknowledge the common “planetary patient” for whom we all share
responsibility. Through education and personal resolve, each of us
should strive to be active advocates for the environment.
image courtesy of
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