How challenging climate change will have profound benefits for public health

Gretchen Miller: Hi there, and welcome to Prevention Works, the podcast of The Australian Prevention Partnership Centre. I am Gretchen Miller, and on this episode, I have with me, Dr Nick Watts, whose work right now is more relevant than ever. As I did my research listeners, I found things he had been saying over the past years in relation to his work on The Lancet Countdown that felt deeply prescient in this strange time of COVID-19.

This conversation is one of the many we need, to raise public consciousness. We are in a climate and a health emergency and the Prevention Centre needs and wants to be at the forefront of evidence-based solutions around chronic disease and sustainable development.

So, let me introduce Dr Watts properly as he joins us online from the UK. He’s been Executive Director of The Lancet Countdown since 2012 and he has just been appointed Chair of the Greening the National Health Service Advisory Board. He is a medical doctor from Western Australia with training in population health and public policy and has over a decade of experience in health and climate change. We are so grateful Nick can be with us. So let’s get started.

Nick, The Lancet Countdown. Tell us a little about its history. What got it going?

Nick Watts: Sure. Our work really begins with a series of studies in The Lancet. It is one of the world’s most recognizable medical journals, and they said, I think really very simple things, obviously underpinned by a mountain of evidence, but two simple things.

One, climate change presents this enormous threat – to public health, to global health, and to the broader determinants of health, with the potential to undermine the last 50 years of gains that we as health professionals have made. And that is a huge problem. The other study came out in 2015 and it was really the foundational work for the Countdown, the response to climate change.

If we do this right, the response to climate change could be the biggest global health opportunity of the 21st century. And that’s because, almost everything you want to do to respond to climate change, it has these profound benefits for public health, whether we are talking about cleaner air, whether we are talking about healthier diets, safer cities, or more liveable cities.

And so, at The Lancet Countdown we do a really simple thing. Once a year we put a finger on the pulse of the planet and we try to track countries, track populations moving from climate change as a threat to human health, to the response to climate change as an opportunity for public health.

Gretchen Miller: Okay. So how does that manifest for you in terms of making that comparison?

Nick Watts: With great difficulty, we are a collaboration of some 35 academic institutions, UN agencies, scattered across every continent. We include engineers, climatologists, hydrologists, environmental economists, transport, food, and building experts and philosophers. Unfortunately, and I think I can say this because I am medically trained, unfortunately, we also include doctors who are often the hardest to get along with. It takes the form of about 41 indicators, and these 41 indicators come out every single year just before the UN Climate Summit, towards the end of the year, and track progress across every single country.

We track anything from mortality, from extremes of heat through to the deaths that we’re seeing from air pollution, from coal fired power, through to, and this is a new indicator for 2020, the mortality that we are seeing as a result of unhealthy diets, and also unsustainable diets.

Gretchen Miller: This is really interesting, are you seeing any of those indicators improving, dare I ask?

Nick Watts: You may not want to, broadly we know, when we take a step back and look at The Lancet Countdown as a whole, what we can see is very clear. Climate change is affecting the health of populations, not in 2100, not in 2050, but today. It is affecting the health of populations today, everywhere, and no individual, no country is immune. It affects the United Kingdom in varied ways and different ways to how it might affect Australia, in different ways to how it might affect Peru, or Brazil, or a small island state. Each of us face different challenges depending on our geography and population health profile, and our unique vulnerabilities.

In terms of the response, broadly we have known that climate change and health are intertwined for the last three decades. And at the very, very broadest level, we have done very little about that. We have held the carbon intensity of the global energy system flat. So, we haven’t improved it. We have more or less just kept it stable since 1990, which is, for something that should be a low hanging fruit is quite disappointing.

But there are some positive signs and it is really important that we remember these, that we repeat these, that we hold onto these. And I think the exciting thing for this podcast is that those positive signs are in the areas of where the health profession has either already acted, or where we have the most ability to take that sort of positive beginning and accelerate it.

And so, we see increases in adaptation capacity. We see increases in spending for health system adaptation. We see improvements in air pollution around the world. We know that just in a 12-month period, the European Union reduced air pollution to roughly a health bill of 5.2 billion euro every year. An annual health bill of 5.2 billion euro. That is an enormous reduction from a very high baseline, so it’s a modest improvement but it’s also only over that 12-month time-period. It is roughly just over one-hundred billion every year.

Gretchen Miller: You have just done a plenary session remotely at the Public Health Association of Australia’s Preventive Health Conference. You were prevented from coming in person because of COVID-19 and the global travel restrictions. And when I was doing my background research, it felt really odd to be reading and listening to your words spoken prior to this incredible force, which has had such a powerful impact. So much of what you spoke about and wrote about was kind of prescient. And I have to ask you, how researchers and NGOs and businesses and governments around the world, and the milieu you’re moving in, are making the connections between this virus and climate issues?

Nick Watts: Let me take the broader question and then the specific question, in reversed order. Broadly, I think at the moment it depends on the country you are in, but across the board, I don’t think we’re seeing quite the evidence we would like to see that governments and countries are coming together to make the links between climate change and human health. And yet there are exceptions.

There are exceptions when you see the United Kingdom turn around and commit two billion pound to active transport infrastructure, because it knows in the same way as Milan knows, it isn’t the same way as Amsterdam knows, that as they rebuild their transport sector, as they restart the economy there, they don’t want to do it in the same way. They want to invest in local communities. They want to invest in active transport and cycle lanes. And so those sorts of changes I think are positive.

Equally, in England we are seeing the NHS (National Health Service) as it starts to think hard about what the long-term recovery from this pandemic looks like. This is at the same time as trying to think about how it builds its existing commitments to climate change because it knows that if it’s going to have a sustainable recovery, it has to be one that is green as well. And it also knows that it really isn’t a good idea to combat one health crisis by exacerbating another health crisis. And so, I think we do see some positive signs of governments making those connections.

The one thing I would say, we had our high-level advisory board meeting for The Lancet Countdown late last night, because we span too many times zones – Costa Rica, Kenya, New Zealand. We had quite a few names there, but a couple of people that I think we would agree know what they are talking about, Helen Clark, the former Prime Minister from New Zealand; and Christiana Figueres, who championed and pushed through the Paris Agreement within the UN Framework Convention on Climate Change, and many others. The advice we had from this board who was giving us some strategic input was that this is going to be the defining challenge of the next decade. COVID-19 and the response are going to shape how the world thinks, looks and feels over the next 10 years. And so, we do not have a choice, no longer are the nationally determined contributions the biggest game in town.

In fact, those COVID recovery packages are the biggest game town, and if we want to have any chance at making a dent over the next 10 years in this long-term crisis, we have to make sure that we marry up and synergize our responses with the short-term process.

Gretchen Miller: So, you have been involved for climate and public health for quite some time, working for example with WHO, with the NHS Sustainable Development Unit, you are the first author on all The Lancet Countdown global reports and you set up and ran the UK Health Alliance on Climate Change. Did these past few months, with all your history and background surprise you at all?

Nick Watts: Yes, the past few months, I think have surprised everyone.

Gretchen Miller: We’ve been expecting some nasty viruses for a while, haven’t we?

Nick Watts: When you speak to pandemic preparedness experts whose entire job is to do this, and you say, well, were you surprised? And they laugh and they say, yeah, we were, it is one thing to be expecting it, it is another thing to be faced with the reality.

We know, we know that there are strong and powerful links between climate change and a variety of infectious diseases, vector-born diseases like dengue fever and Chikungunya virus carried by Aedes aegypti and Aedes albopictus, links between climate change and malaria carried by the Anopheles mosquito.

Indeed, we were seeing emerging evidence linking Zika virus and climate change, although I have to stress that it’s an emerging field because it’s a very, very new virus. Anywhere that you know that a pathogen is interacting with a climate and that climate used to be stable, we know that we will expect to see change as a result of climate change. It doesn’t necessarily always mean more, but often more doesn’t have to be all you need to disrupt health systems. Health systems were built with the understanding that the climate was stable. We trained health professionals, doctors, nurses, allied health professionals, public health professionals with the understanding that the climate was stable. And when you yank that out from underneath them and you create some shifting sands, it’s actually quite easy as we’ve seen to disrupt a health service.

Gretchen Miller: So, what are the key illnesses we know that as contributors to lifestyle-related chronic disease that are adversely affected by climate change?

Nick Watts: So, for climate change and, and heart disease, we see that in indeed kidney disease, we see that in the form of extremes of heat. We know that there are hundreds of millions of additional exposure events to vulnerable people from extremes of heat all around the world every single year. Who are those vulnerable people? They are people over the age of 65? They are people living in highly urbanized conditions where they struggle to get out of the heat.

But, most importantly, they are people living with chronic disease. It’s the exacerbations of heart failure, the acute kidney injury – diabetes is a strong risk factor for the negative sequelae of heatwaves. And so, we see some powerful links there. And indeed, Europe is one of the most vulnerable parts of the world to these extremes of heat in large part, because it has an unhealthy population there, those links, I think are everywhere you look.

Gretchen Miller: And how does that work? I mean, why would somebody who has diabetes or heart disease be affected?

Nick Watts: Yeah, we have a problem, I think in public health communications where whenever there’s a heat wave that comes along the image you see on the news is of children playing in a fountain, along with some messaging about how you must drink water and you must stay in the shade and probably shouldn’t engage in too much physical activity for work.

Heatwaves are silent killers, we shouldn’t be showing those sorts of pictures. In terms of heart disease, what we’re really talking about is not one day or two days or three days. It’s sort of four or five-days worth of heat waves to the two to three standard deviations above the norm of what we might normally expect. And there you start to see that hearts have to pump faster, they pump faster, they pump harder, they get sort of pushed again and again, and over a longer period of time, they get overwhelmed, they get tired, and so you get this exacerbation of congestive heart failure. There is an underlying illness and the environment pulls the trigger in this case. It is kind of the opposite to what we were taught in medical school.

When it comes to kidney injury, it’s really quite interesting. They discovered this in a couple of studies that found these very strange spikes in AKIs (acute kidney injury) across the United States, and across South America. And everyone was wondering what was going on until they looked closer. And there’s now quite a healthy body of evidence emerging here, to see that actually it was outdoor agricultural workers and manufacturing workers who were becoming dehydrated because they were being forced to continue to work in order to maintain livelihood, in temperatures that were simply too hot, were far too hot for them to be working in day after day, and it was resulting in the short-term and then eventually long-term kidney disease.

Gretchen Miller: Super interesting. And, I’m thinking too now about mental health, which is also, affected by climate change.  And, how when we have extreme weather, when we have, drought, heat waves, but also the bushfires we just experienced over the summer. Long periods of time where you have to stay inside, where you can’t get outside, you can’t do the exercise, which boosts your mental health, but also boosts your physical health. What’s happening with mental health and climate change?

Nick Watts: I’m so glad we get to talk about this because I think the mental health impacts of climate change are among the most insidious, and they are among the most concerning. We don’t hear about them enough. We don’t talk about them enough. We have enormous problems in mental health in general. When you then add an overlay, sort of a complex changing climate changing environment, it becomes kind of tricky. But we do have some good evidence, and in fact this has been led by a number of experts in Australia talking to us about the impacts of a flood or the impact of an extreme event. Not one day, or two days, or three days after the event has occurred, but three months or six months, or coming back after 12 months and saying, Hey, how’s your mental health doing? Are you feeling yourself? You see spikes in anxiety related disorders. You see spikes in effective depressive disorders. You actually also see spikes and it depends on the kind of flood and on the kind of disruption, but you see spikes in thought disorders as well, so schizophrenia.

Now that connection is most likely a disruption to health services kind of pathway that we are looking down. But those are really concerning. You touched on it and I think it’s important that we also highlight chronic disease is a major risk factor for mental health. To the extent that something like a wildfire exacerbates COPD or exacerbates asthma, to the extent that heat waves do the same, to the extent that some of the malnutrition we’re seeing around the world has long-term lifestyle implications. In some ways, every single part of climate change and human health interacts with mental health, which is what makes it so important, and also what makes it so difficult to track and cover.

Gretchen Miller: Incredibly difficult because if you don’t have good mental health, it’s extremely hard just to keep up with maintaining physical health, just in eating sensibly and getting out and exercising, you know, really simple factors like that. What I wanted to talk about next was the long-term impacts of climate change on chronic disease at a population level. What are we looking at? You know, numbers of heatwave exposures, elderly people exposed, that kind of thing, crop growth even…

Nick Watts: Sure. So, at present day, globally, we see somewhere between a 2–4% reduction in global yield potential for spring and winter wheat for maize, for rice. That’s for present day. Now, if we go forward to 2050, our projections from the London School suggest somewhere between 7 to 9 million additional kids under the age of five stunted as a result of malnutrition that has happened from climate change just in sub-Saharan Africa and in South East Asia, for each of those, that’s a pretty enormous spike. We see somewhere between an additional 100 to 200 million exposure events happening to vulnerable populations for the heat wave.

So, it varies depending on how hot the year is, but we are seeing a big increase compared to us climatologically stable baseline back in the eighties up to present day. Going forward, we are not talking in the hundreds of millions anymore. We start talking in the billions. We start talking about large, large parts of the population globally experiencing one, two, three heat waves every single year. And again, they are not just children playing in a fountain, they are really quite concerning things. In 2003, there were over 70,000 excess deaths from a five-day period across Western Europe alone.

Gretchen Miller: Five days!?

Nick Watts: Yeah, that’s right. And those deaths, they lasted over about two weeks. But the heat wave itself that caused that was just there, that’s an enormous spike if you consider even with what the world is going through at the moment with COVID-19.

Gretchen Miller: So, the health sector is really good at talking about the problems and we’ve talked a lot about the problems and the issues there. What kind of conversations around solutions are happening, particularly whole of system solutions? What are the priorities there and how can the health sector contribute to that?

Nick Watts: It’s really important that we keep laser focused on the solutions. We know what the problem is. You can see the effects of climate change and the fingerprints of climate change on extreme weather all around the world. We have some really good detection and attribution studies to help us assign probabilistic causality to these events now.

We have to stay focused on the solutions and I think there’s a lot of good news there that we should really hold onto. And a lot of good news if you are interested in preventative health, if you’re interested in chronic disease, it turns out if you go and grab a hydrologist, the climatologist, and engineer and economist, a transport expert and energy expert, and you sit them all in a room and you say, Hey, climate change is an enormous global health threat, help us figure out how to respond to that.

They will devise you a plan and they will tell you, you have to keep global average temperature rise to somewhere between 1.5 and 2 degrees above pre-industrial levels. And they will tell you, you’ve got to try to do that at the global level by at least 2050. Anything later, and it gets pretty dangerous.

And you will sit down, if you work in public health, and you will look at that and you will say, well, that’s not a climate intervention plan, that’s a public health intervention plan. Because you’ve told me I need to phase out coal rapidly and early, but I as a public health professional can tell you that that will save just over one million lives every single year from reductions in air pollution. And those lives are people that otherwise would have been dying from stroke, from heart attack, from lung cancer and chronic respiratory diseases. They will also tell you that if you are a child born in France, or if you’re a child born in many, many countries across the world you should no longer be living in a world where you would buy a fossil fuel car, where you buy a petrol or diesel car, because they would be phased out because we don’t need cars anymore because we have designed better alternatives for mobility. We now have more place-based solutions for communities but where we do have cars, they’re electric, they’re clean. And so, there’s better physical activity that comes from that. And there’s reduced air pollution. And then finally they would tell you, Hey, agriculture is a big problem in climate change, we have to do something to decrease our emissions.

And you’d ask what? And they said, well, one of the big problems is an over-consumption in meat from ruminants, red meat and another big problem is an over consumption in processed meat, processed foods that comes from a long, long way away. And so, the solution from a public health professional perspective for a healthier diet is a reduction in red meat consumption. It is an increase in seasonable vegetables and fruits. And it turns out that when you look at all of those different things that a climatologist and an engineer and an economist might want you to do, they are just common sense, no regrets, public health interventions.

Gretchen Miller: How important is whole of government? How important is that phrase in your toolkit of addressing the issues? Is there real consideration and action globally around the co-benefits of working with other sectors, transport, education, and the environment? How is that being sold by policy makers and practitioners who already know this? How has it been sold to governments?

Nick Watts: A whole of government response is essential for exactly the reason you outlined in your question there It is only by linking up the department in your government responsible for climate change and the environment, with the department responsible for health, with the department responsible for transport, and energy, and special infrastructure of buildings, and agriculture, it is only by linking all of those sectors up that we are going to be able to secure those public health benefits.

Gretchen Miller: Is that happening though in any government around the world?

Nick Watts: It really depends. My understanding is that it probably is happening in certain parts of Australia. I think South Australia for a very long time has been held up as doing quite an impressive job of responding to some of these issues and linking up some of those concepts. Equally, they were held up early on in the health-in-all-policies movement, so it is no surprise.

In Western Australia, the Ministry of Health has just finished a climate change and health inquiry. If you read through some of the drafts, one of the things you will see is an understanding and embracing of the fact that multiple sectors are needed as part of the solution and health must be a central part of that. Indeed, it must lead some of that change, but it can’t do that alone.

I think we are seeing that, but I think we are also seeing the same problems that we see in chronic disease that we see in poverty reduction and in broader issues. Siloed thinking remains an enormous problem that keeps getting in the way.

Gretchen Miller: But what’s interesting, as you point out, is that health puts a human face on what can seem to be a distant threat to the wicked problem that is climate change. I wonder how you are using health to put a positive spin, because positivity is what we all crave as individuals and as governments and as policy makers, how challenging it is at times to approach all this with, with that positive spin and with a human focus on the wicked problem that is climate change?

Nick Watts: If you just talk about climate change, you risk talking about time periods around 2100. You risk talking about populations that are geographically a long, long way away from us and you risk talking about something that, I don’t know if people really understand, something like parts per million of Co2 equivalents or something like a petajoule, which is, an amount of energy so enormous that it’s sort of impossible to understand what it even is.

It is by bringing in that human face that we get to start to talk about the impact of health. Not in 2100, but in 2020, that we get to start talking about those effects. Not on a continental, long, long way away important, as essential though that the health there is as well, but a child with asthma, a child in our community standing right next to us and we get to talk about the positives. And those positives I think are really important.

We know from public health behavioural science literature, fear motivates in the short term. If you really want to inspire someone, to bring them with you in the long term, you need positive messaging. And we’ve just done some conjoint experiments in public opinion polling across the world, trying to test this exact thing out. And I think, the preliminary results we were just looking at back that up. People like the positive messaging because they like to believe that there’s a future that we could all go to that we think will be a nice place to live.

Gretchen Miller: How do you propose the conversations be had in countries where governments struggle with the reality of climate change or just pay lip to it because the economic arguments, the logical arguments, and the health arguments seem to fall short? There is a great deal of ideology involved. We know that. How do you have that conversation when we know that it’s the law, logic and economics aren’t cracking it?

Nick Watts: I think at the global level, yes. But also in a few countries, the United States, and Australia, one of the biggest mistakes we have ever made is allowing climate change to become politicized. It is not a political issue.

There are legitimate discussions to be had about this pace of change required and about the cost and the ways to deliver that, but the existence of that science, that’s not a political issue, although it has become one in a select number of countries. In part, I think that’s because we’ve had the wrong message and the wrong messenger. I think we have allowed climate change to be seen as only an environmental issue, a long way away, both in space and time. One of the things that I think is going to be crucial going forward is trying to build in the understanding of the climate change, yes there’s an environmental component there, but this is also about being able to do good business. As a friend of mine says, there is no business on a dead planet. It’s also about, bringing in faith communities. It’s about bringing in local communities that are place-based solutions.

It’s about bringing in people from a whole range of different parts of society, including the health profession. We have seen that the health profession often do a good job of de-politicizing something. And they’re saying, Hey, I’m here not because I care about one political party or the other, I’m here because I care about my patients’ health. I care about public health. And I think when we start to break it down and understand it’s something that affects local communities and health, we start to sort of wear away at some of those, quite honestly, unfounded questions.

Gretchen Miller: What are some of the practical solutions for health departments around the world that you’re suggesting?

Nick Watts: Well, and it depends on the country you’re in, right? The world’s a big place and climate change is everywhere, and carbon is everywhere as well. Number one, by far and away the easiest first thing that every country must look at, is to phase out coal fired power. It is an outdated, it is an old form of energy. Health departments have a really important role to play here. In Canada, which is committed to phasing out all of its coal fire power. And in the United Kingdom, which will do the same and maybe one year, maybe two years from now. The departments for health and public health bodies have essentially been making that case. In saying, the reason we need to do this, yes, it’s because of climate change, but it’s also because of human health, because of the air pollution cost. It’s really notable that when the former president of the United States, when he announced the clean power plan, he didn’t do so standing outside a wind farm and he didn’t do so standing in the White House. He went to the asthma ward of a children’s hospital and said, we need to phase out coal fire power, and these kids behind me demonstrate why we need to do that.

And so that’s the first really, really concrete thing. It kills over a million people every year. It’s a big challenge for Australia. Australia is responsible for 7% of the world’s emissions, largely because of its coal exports. It exports about a third of the world’s coal.

Another really concrete thing that we think health systems can start to look at – they’ve got to start to adapt and mitigate. We are powerful advocates for more rapidly progressing change, but there are also things we can do to clean up our own backyard. Around the world, the health system is responsible for an enormous amount of emissions, somewhere between
4-7%, depending on the country you’re in.

There’s a lot that the health system can do to reduce it to emissions profile. Again, and this sounds like a lot of good news, but again, when you look at it, and when we take some examples from across North America, from across South America, and from the United Kingdom, we see that every time a hospital or a clinic has tried to reduce its emissions. It has done so by saving money, it has done so with improved patient outcomes, and it has done so by investing in public health. It turns out that a lot of this is saying, Hey, do we really need that really intensive health care? Or, is there a better way to do this that is actually cheaper and better for outcomes?

In the United Kingdom, the NHS has managed to decrease its emissions by 18% since the Climate Change Act came into force about 10 years ago. That’s a huge, huge reduction. But they did it while they were saving money and they did it while improving patient care.

Gretchen Miller: Nick, on this appropriately positive note. We should leave it there. It has been a fascinating conversation. Thank you for your generosity and your time, and your work. This has been Prevention Works. Listeners, you will find show notes on our website and your podcast provider. If you use Apple iTunes, go on, leave us a review. We will love you for it.

Send us a message. We’d like to hear from you. I’m Gretchen Miller and I’ll see you next time.