The COP26 health agenda must revitalize Primary Health Care

As COP26 continues, we bring an overview of the intersection of health and climate change at the summit. Health systems can contribute to decreasing carbon emissions by promoting the Primary Health Care approach

November 04, 2021 by Louis Reynolds
Scottish doctors protest demanding action at the COP26 summit.

“The greatest risk to human health is neither communicable nor noncommunicable disease — it is climate change,” wrote Fiona Godlee, editor-in-chief of the British Medical Journal (BMJ), in 2011. This took courage — putting climate change at the top of the list of things to worry about seemed hard. A decade later, human and planetary health are at the center of the global climate agenda. The BMJ and more than 200 health journals have jointly published an editorial calling for emergency action to limit global temperature increases, restore biodiversity, and protect health.

In the October 23 issue of The Lancet, Talha Burki summarizes the COP26 health agenda. He quotes Ian Hamilton, professor of energy, environment, and health at University College London: “If the nationally determined contributions (NDCs) align themselves to the Paris Agreement, then the benefits to health would be pretty substantial.” Kristie Ebi at the Center for Health and the Global Environment, University of Washington, called for the representation from ministries of health. Professor Matthew Neidell, from Columbia, argues that health professionals should join the fight against climate change. Arguably, they should be represented in the talks too.

Burki goes on to raise a more fundamental issue: health systems themselves are major greenhouse gas (GHG) emitters. As Ivan Illich predicted in his controversial 1974 book Medical Nemesis, “the medical establishment has become a major threat to health” through its enormous GHG emissions.

For example, research by the Sustainable Development Unit (SDU) in the National Health Service (NHS) found that between 2004 and 2012, the carbon footprint of the NHS grew from 18.61 million tons of CO2 equivalent (MtCO2e) per year to 21 MtCO2e per year, larger than that of some medium-sized countries. These emissions came from heating, cooling and lighting buildings; procuring goods and commissioning services; powering equipment; sending waste to landfill; and patient, staff and visitor travel.

Hospital admissions resulted in substantially greater GHG emissions than outpatient appointments. A typical hospital admission resulted in CO2 emissions approximately seven times greater than an outpatient visit. All current health systems based on the hospital-centered biomedical model of health care are almost certain to follow this pattern.

The importance of Comprehensive Primary Health Care

This calls on us to advocate more strongly for the revitalization of Comprehensive Primary Health Care (CPHC) with its focus on health promotion, disease prevention, curative care, rehabilitation of the sick, and palliative care. Revitalizing CPHC will mitigate the burden of ill health, reduce the transport needs of the health system, cut hospital admissions and their waste, and thus eliminate a large proportion of health system GHG emissions. Access to good health care should be readily and universally accessible within the community and close to home. Well-trained and equipped community health workers (CHWs) with decent working conditions, remuneration and support systems are essential for such systems and should provide much of the care in the household. CHWs recruited from local communities can facilitate meaningful community participation in matters concerning health — a fundamental requirement of CPHC.

But making health systems greener will not fully address the complex health challenges associated with the global ecological crisis. Deep structural inequalities — inequalities of income and wealth, of vulnerability to risk, of gender and race, and of political power — underpin it. Large sections of the world’s people lack access to the goods, services, and environmental conditions that are essential for good health. These are known as the social determinants of health (SDH), but in reality they are also economic and political. Inequitable access to the SDH underlies the causes, and the causes of the causes, of ill health. For COP26 to have a meaningful impact on people’s health, it must address these inequalities in a meaningful way.

Delegates must stand up to vested interests

To do so, health delegates must confront powerful vested interests in a context where power is massively unequal. Fundamentally, at the core our profound ecologic crisis — from climate change to COVID-19, interpersonal violence and the pandemic of non-communicable disease — is global neoliberal capitalism and its extractive and exploitative paradigm of infinite growth.

The 1978 Declaration of Alma-Ata, which put forward Comprehensive Primary Health Care as the means of achieving Health for All, emphasized a transformative developmental approach to health.  It supported the call from the Non-aligned Movement for a just New International Economic Order (NIEO) to allow “developing” countries to achieve the economic equivalent of their newly-acquired political independence. This threatened the prevailing status quo, which was seen as biased in favor of industrialized countries. Instead of a more just global economic system, the NIEO that came to prominence in the 1980s was based on extractive neoliberalism with its devastating impact on society and the ecosystem.

Recently two new ideas about political economy have emerged: degrowth — “socialism without growth”, and Doughnut Economics. Jason Hickel explains degrowth as “a planned reduction of energy and resource use designed to bring the economy back into balance with the living world in a way that reduces inequality and improves human well-being”. He makes it clear that degrowth focuses primarily on rich countries, while many poor countries in fact need to increase resource and energy use in order to meet human needs. In Doughnut Economics, Kate Raworth points out that human well being depends on planetary health. She depicts the social and ecological boundaries of well-being as a doughnut.

These new approaches offer political-economy alternatives to the infinite growth model, but they must explicitly prioritize socioeconomic justice and equity from the start. Whether COP26 will adequately address the questions raised by these key new ideas remains to be seen.

Burki’s piece lacks a critique of the idea of the “net zero” concept. Some scientists warn that it may turn out to be a dangerous trap. The idea that emerging technologies for removing GHGs are capable of balancing ongoing emissions has licensed a reckless “burn now, pay later” approach, allowing GHG carbon emissions to continue escalating, continuing deforestation and threatening further devastation. No matter how seductive, assuming that technical solutions are able to solve complex social and political problems is both lazy and dangerous. COP26 must avoid this trap.

Whatever emerges from COP26, further climate-related catastrophes are inevitable. We must deal with these in solidarity and in line with human rights.

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Louis Reynolds is a health activist in the People’s Health Movement, South Africa.