A new guide aims to educate doctors on how to reduce environmental impacts of the care they provide.

In recent years, Canadians have experienced the health impacts of extreme heat, poor air quality from wildfires and harmful algae blooms caused by excess nutrients and pollution, all of which are exacerbated by climate change. Though the climate crisis strains the Canadian health-care system, the sector itself also contributes to the problem, accounting for five per cent of Canada’s total greenhouse gas emissions.

Dr. Ilona Hale, a Kimberley, B.C.-based family physician and author of Planetary Health for Primary Care, hopes her work can help change that statistic. The guide is based on four principles of sustainable health care: reducing unnecessary care, empowering patients, environmental alternatives and health promotion.

“[Climate change] is having direct effects on the health of our communities and our people,” said Hale. “We're realizing that we're not separate from the environment and the ecosystems around us, but we're really a part of the ecosystem. In order to preserve and protect human health, we need to be protecting the environment as well.”

Until recently, it was thought the best way to reduce emissions from the health-care sector was to make buildings more energy efficient and reduce physical waste, according to Hale. However, a 2021 U.K. study revealed the majority of emissions from the health-care sector are from waste generated in the supply chain. According to the study, 80 per cent of emissions from the health-care sector come from producing materials needed for lab tests, medications, surgeries and hospitalizations.

“That [study] sort of shifted the control of the impact on the environment from people in operations towards us as clinicians,” said Hale. “The ones who order the tests and the treatments and prescribe medications have a lot of control over 80 per cent of that impact.”

Environmentally friendly alternatives

A key aspect of Hale’s guide is reducing unnecessary care, or care that provides few to no benefits when considering its harms, alternatives and patient preferences. Hale explained all health-care practitioners want to do what is best for their patients, but factors such as traditions, habits, outdated practices and a fear of missing something can compel them to provide unnecessary care. A 2017 report from the Canadian Institute for Health Information found about 30 per cent of tests, procedures and treatments in the Canadian health-care system were potentially unnecessary.

Unnecessary care is a “popular phenomenon,” said Dr. Melissa Lem, a Vancouver-based family doctor, president of the Canadian Association of Physicians for the Environment and director of PaRx, Canada’s national nature prescription program.

“The recommendations in the guide actually lead to better patient outcomes and shorter wait times, reduce physician and provider workload and save money. So it's actually a win-win situation and it's not pitting environment versus patient care."

“There is definitely a temptation to over-investigate because you're worried you'll miss something,” said Lem. “If you don't take a lot of time to think about the diagnosis or do a proper exam history, it can be easy, especially when you're strapped for time.

One of the most effective ways to reduce unnecessary care is to look for alternatives to prescribing pharmaceuticals, said Hale. Prescriptions account for 60 to 65 per cent of the primary care sector’s carbon footprint, according to the Planetary Health for Primary Care guide. Instead of immediately prescribing medications, Hale suggests doctors consider other “tools in their toolkit.”

For Hale, this could mean referring someone with mild depression symptoms to a mental health professional instead of prescribing antidepressants or choosing to give patients a nature, exercise or social prescription instead of medication. Nature prescriptions reduce the emissions associated with unnecessary medications and encourage patients to stay connected with the natural environment.

“I really like working on nature prescriptions because there are co-benefits that go along with it,” said Lem. “There's evidence showing that people who spend more time outside are more physically active, have better blood pressure, better cholesterol and lower rates of anxiety and depression. Research also tells us that people who spend more time outdoors are more connected to nature and more likely to protect it.”

Dr. Melissa Lem is a Vancouver-based family physician, director of PaRx and president of the Canadian Association of Physicians for the Environment. Photo provided by Melissa Lem

The guidance outlined in Planetary Health for Primary Care does not sacrifice patients’ care; rather, it improves their experience while also reducing the environmental impact of their treatment. “The recommendations in the guide actually lead to better patient outcomes and shorter wait times, reduce physician and provider workload and save money,” said Hale. “So it's actually a win-win situation and it's not pitting environment versus patient care.”

Hale hopes the guide encourages patients to take a more active role in their medical care. “Patients tend to overestimate the benefit of medications and testing and underestimate the risks,” said Hale. “As providers, we could be doing a better job of explaining these things.”

Hale explained that while the benefits of a medication might make sense for one patient’s lifestyle and priorities, the same medication might not be worth taking for another patient with the same condition. That’s why it is important for both doctors and patients to be aware of the benefits and negative side-effects of a medication and the alternatives that exist.

For example, traditional, L-shaped asthma inhalers have significant negative environmental effects. One of these traditional inhalers is estimated to produce the same emissions as driving up to 290 kilometres in a car, according to Hale. However, there are alternatives, such as inhalers that use a powder and produce the same emissions as driving five to seven kilometres in a car, said Hale. She would like to see a nationwide policy that reduces their use.

Both Hale and Lem feel it is their responsibility as health-care professionals to be leaders in sustainability by reducing their own impact on the environment and advocating for climate action.

“The physician's voice is important, and many people trust what we say,” said Hale. “Our mandate is to support and protect health. It just makes sense that we should be starting to think about doing everything we can within our own sphere to minimize our impact.”

“The truth is that only 20 per cent of patients' health outcomes come from what we do in the health-care system,” said Lem. “The other 80 per cent comes from factors outside our direct control as clinicians."It's important for us to not only decarbonize our own practices but also step beyond and advocate for those social determinants of health, too, like access to green spaces in cities, access to healthy food, guaranteed livable income and housing.”

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