Climate Change and Health Louis Reynolds and David Sanders [The second of a 2-part series on the NHI, based on an article written for the One Million Climate Jobs Campaign] Climate change is the largest threat to global health in history. Health systems, on the other hand, exist to promote, protect and improve people’s health, and to prevent and treat disease. As large, resource and energy-intensive organizations that employ many people, health systems produce large amounts of greenhouse gases. Therefore, they contribute to climate change, raising the paradox that, on balance, they may, inadvertently, do people’s health more harm than good in the long term. The impacts of climate change on health The World Health Organisation estimates that global warming and trends in rainfall due to human-induced climate change already claim over 150,000 lives annually. Diseases associated with climate change include heart and lung disease due to heat waves, increased spread of infectious diseases, and malnutrition due to crop failures. Sub-Saharan Africa is one of the most vulnerable regions, especially its sprawling cities where the effects of urbanisation aggravate extreme climatic events. More people die from the effects of climate change in Africa than anywhere else. Humanitarian disasters like the famine in Somalia, where the effects of drought are being compounded by corruption, conflict and political instability, are likely to become more frequent. With refugees pouring into camps in Kenya at the rate of 1500 a day – 80 percent of them women and children – and uncountable deaths, this is emerging as Africa’s worst humanitarian crisis in decades. But the health impacts of climate change extend beyond those directly due to heat waves, floods and droughts to include those due to destroyed livelihoods, altered land use, and food insecurity. These include large-scale migration from affected areas, leading to squalid urbanization, social disruption, conflict, and instability; and increasing the burden on already overburdened health systems. The impact of health systems on climate change Given the devastating and growing impact of climate change on health, it is ironic that health systems themselves contribute substantially to climate change through their enormous greenhouse gas (GHG) emissions. While no data exist for South Africa, it is possible to extrapolate from the United Kingdom (UK), where research by the Sustainable Development Unit (SDU) – a unit within the National Health Service (NHS) established recently in recognition of the urgent need to address the NHS contribution to climate change – shows that in 2004, the carbon footprint of the NHS was 18.61 million tons (MtCO2) per year, representing 25% of England’s public sector emissions. It has since grown to 21 MtCO2 per year, which is larger than some medium-sized countries. This carbon production is made up of an ‘external’ component (coal burning for energy, food processed and transported, transport used by staff) and an ‘'internal’ component – calculated per hospital bed or per outpatient visit. CO2 emissions resulting from a typical hospital admission in the UK are approximately 7 times greater than an outpatient visit. South Africa’s total carbon emissions per capita are remarkably similar to those of the UK. In 2008 for example, the carbon footprint of the UK was 8.5 metric tons of CO2 per capita, while in South Africa it was 8.8. Moreover, in South Africa, to a far greater extent than in the UK, greenhouse gas emissions are disproportionately produced by industries, a corporate sector, and conveniences that predominantly cater to the demands of a small elite. While South Africa has 28 hospital beds per 10000 people overall, the public and private sectors have 22 and 38 beds per 10000 respectively. Our private sector is more hospital-centered than the public sector, and its bed number is almost identical to the UK’s 39 per 10000 people. Thus, we can reasonably assume that both the ‘external’ and the ‘internal’ components of health system emissions in South Africa’s private sector are comparable to those of the UK. Public sector emissions are likely to be lower per capita because of the greater proportion of facilities that serve mainly outpatients (clinics and health centres) with relatively fewer energy-consuming, GHG-producing inpatient beds and technology. Given the above, urgent action is needed to reduce health sector greenhouse gas emissions on a massive scale. Health systems exist to promote and protect the health of populations, and they should not themselves contribute to the causation of disease. Furthermore, health systems must be sustainable into the future. Climate change increases the urgency of health system transformation in South Africa The growing awareness of the interactions between health systems and climate change challenges us to ensure that our new health system not only provides good health care for all now and in the future, but that it also minimizes its impact on the planet and is sustainable. The parallel policy initiatives of the NHI and Re-engineering Primary Health Care’ could, if thoughtfully implemented, address three crises simultaneously: the health crisis, the employment crisis, and the carbon emissions crisis. The common core of these policies would be to move the centre of gravity of the system out of the hospitals and into the community, closer to where people live. This will entail new thinking about human resources for health, with a shift in emphasis from the hospital based, doctor-centered model to a community-based model that incorporates more community and midlevel health workers. With the necessary political will and a participative multi-sectoral approach, massive reductions in GHG emissions can be achieved and simultaneously large numbers of jobs created. Greening the health system is highly likely to save money and to create employment both within the health service itself and in other sectors that are necessary for the process. In the UK the SDU calculates that the NHS can save at least £180 million per year by reducing its carbon emissions. Some of the measures being considered and implemented include: reduction of hospital energy consumption and costs through efficiency and conservation measures; construction and modification of hospitals and facilities to ensure responsiveness to local climate conditions with reduced energy and resource demands; on-site production and consumption of clean, renewable energy; use of alternative fuels for hospital vehicle fleets; encouraging public transport for staff and patients; reducing expensive imported processed foods; providing sustainably-grown local food for staff and patients, ideally procured from small local farmers or produced in hospital grounds by community members; reduction, re-use, recycling and composting; employing alternatives to waste incineration; and conserving water. Implementation of these measures in South Africa would create jobs and expertise in the health, transport, agricultural and other sectors and in the fields of recycling, energy conservation and renewable energy production. In the run-up to COP17 in Durban in late November South Africa, the host, will be expected to demonstrate its own commitments to reducing its carbon footprint. To our knowledge plans to address health sector emissions are at best embryonic. Many of the above measures, researched in the UK, should be urgently explored here. Conclusion: Radical health system transformation and job creation are two key imperatives for South Africa. It is essential that this transformation should address not only the health and employment needs of people in South Africa today, but also those of future generations. The advent of the NHI gives us an historic opportunity to build a sustainable national health system that not only meets the health care needs of all, but that also addresses and minimizes the growing impacts of climate change by reducing its own greenhouse gas emissions; playing a leading role in promoting social justice and equitable socioeconomic development in order to minimize the impacts on the poor and vulnerable; and finally, being prepared and ready to deal with the changing disease patterns that emerge in the wake of climate change. To do all this, we will have to confront powerful groups with vested interests who will resist transformation at many different levels. These must be overcome. Such a transformation of South Africa’s health sector will require strong political will and concerted efforts by all progressive organs of civil society. Associate Professor Louis Reynolds, Health Sciences Faculty University of Cape Town. Emeritus Professor David Sanders, School of Public Health, University of the Western Cape. Both authors are paediatricians and members of the Peoples Health Movement www.phmovement.org