2Environmental change and human health
9.The past 150 years have seen huge improvements in human health and wellbeing. We live longer, healthier lives as a result of advances in food production, public health and access to medicines.26 But the systems that support human life rely on a healthy global natural environment. Human activity has caused unsustainable global pressures on natural resources and the life support systems which support us.27
10.Professor Sir Andy Haines, LSHTM, summarises the main concerns:
Human health has advanced tremendously in recent decades… but that has all come at a considerable environmental cost.
Global average temperature has increased by 1 °C since preindustrial times, and based on the commitments that were made in the run up to the COP21 Paris, the increase could amount to around 2.7 °C or more by the end of the century in absence of further actions. There are many other changes as well, including dramatic loss of tropical forests, one of the factors that is driving the loss of biodiversity that is occurring at rates 100-fold greater than [in] pre-human times.
Freshwater resources are in decline in many parts of the world and about three billion people live in locations that are subject to varying degrees of water stress, partly because of depletion of aquifers, which cannot be replenished in human lifetimes. Carbon dioxide is dissolving in the ocean leading to increasing acidification with probable major impacts on marine ecosystems.
A single species, Homo sapiens, is now dominating the global environment, which has led an increasing number of scientists to call our epoch the Anthropocene, in recognition of the dominant role played by humanity.28
11.The Rockefeller Foundation Economic Council on Planetary Health set out its concerns on planetary health:
Improvements to health have come from advancements in public health and medicine as well as from agriculture and industry. However, this progress often comes at a cost. Human activities have caused global environmental change—not only do we pollute the air we breathe and the water we drink directly, but greenhouse gas emissions are changing the world’s climate. This has knock-on effects for our health and society. The World Health Organization estimates that 25 per cent of death and disease globally, and nearly 35 per cent in regions such as sub-Saharan Africa, is linked to environmental hazards.29
12.The Rockefeller Foundation-Lancet Commission on planetary health, published a series of graphs comparing data on human progress and resource usage (including population increase, water consumption etc), with graphs showing the detrimental impacts to the environment (including tropical forest loss, and carbon dioxide emissions). Figure 2 shows that human progress has been accompanied by an increase in environmental damage.
Figure 2: Characteristics of the Anthropocene epoch - global trends (Years 1800 to 2000) in population, consumption, health and the environment30
13.The Millennium Ecosystem Assessment, a major assessment of the human impact on the environment conducted by the UN, divided the threats to human health from environmental change into three categories, direct health effects, ecosystem-mediated health effects, and indirect, deferred and displaced health effects.
Figure 3: Mechanisms by which the harmful effects of ecosystem change can affect human health31
Indirect health effects
14.Our witnesses emphasised indirect health effects of a degraded environment and the importance of ecosystem-mediated health effects including:
a)Non-communicable diseases (NCDs), such as obesity and cardiovascular disease: Much of the food system is focused on agricultural yields and not directly on healthy and sustainable food. Witnesses emphasised how current agricultural practices, marketing and consumer behaviours are leading to an increased burden of non-communicable diseases such as obesity and diabetes. Professor Tim Benton, University of Leeds, told us that a: “few crops are produced in enormous quantities and are associated with increasing global dietary convergence, over-consumption of calories and production of food waste (partly driven by reduced food prices)”.32 In a recent review article the importance of non-staple crops was also emphasised, “climate and other environmental changes also reduce the yield of vegetables and legumes overall, which has important implications for the prevention of noncommunicable diseases”.33
b)Mental health impacts: Professor Lora Fleming, University of Exeter Medical School outlined the impacts that environmental change might have on mental health:
“Both climate and other environmental changes… have been shown to directly impact on mental health potentially negatively, things like wars, poverty, extreme weather and so on. […] In the UK, we have data that shows that the more you interact with natural environments, particularly coastal and blue environments, the better for your physical and mental health”.34
Eco-anxiety, has emerged as a psychological disorder afflicting an increasing number of people concerned about the environmental crisis and suffering a sense of grief or loss. Eco-anxiety has been described by the American Psychological Association as “chronic fear of environmental doom”.35
c)Infectious diseases: Professor Sir Andy Haines, LSHTM, told us about the role of environmental and climate change on infectious diseases:
“There are also the effects on infectious diseases through natural systems; for example, vector-borne diseases like malaria and dengue. The distribution of those is changing as a result of climate and other environmental changes. Water-related diseases, of course, increase risks of diarrhoeal and other diseases related to water. Cholera as well can be influenced by climatic factors”.36
NHS and planetary health
15.The NHS is one of the largest employers in the world, with up to 1.5 million employees, and is the largest public sector carbon emitter in the UK. Its annual budget, £110 billion in 2017/18, is roughly the same size as the GDP of Croatia and Sri Lanka combined.37
Adapting to change
16.Witnesses expressed concern that the NHS is not ready for a rise in health problems as a result of environmental damage. Dr Richard Horton, the Lancet, expressed his frustration at the lack of NHS preparedness for emerging health problems:
We do not have enough doctors in the NHS to address liver mortality. We do not have enough liver specialists. We do not have a public health strategy that is working on obesity. We do not have a public health strategy that is working on alcohol. Unless we address the health system components and the public health components together then many of these environmental-determined or influenced diseases we will not be able to contain or control.38
17.Dr Horton was particularly critical of Public Health England’s (PHE) failure to see the big picture, noting that during a discussion with a senior official at PHE, “their vision” was limited to just two targets: incentives for smoking cessation and for reducing alcohol consumption. He explained that this narrow focus was driven by funding cuts, which were leading to a “struggle to deliver services in the NHS”.39 He went on to say:
… We are talking about planetary health, we are talking about the environment and we are talking about these broader determinants. They [Public Health England] are nowhere, and they will admit they are nowhere when you ask them about that. That limited vision is a huge constraint on the future of public health in our country. Until they lift their gaze and embrace that broader vision, we are nowhere.40
18.That Public Health England “does not own these broader determinants of health”, Dr Horton stated, “is a catastrophic failure in our health system”.41
19.We note that the Government recently published a 10-year plan for the NHS.42 Professor Chris Whitty, Chief Scientific Adviser at the Department of Health and Social Care (DHSC), told us that it had been “developed with multiple different people feeding in, including me and scientists from Public Health England and other areas”.43 He noted that parts of the 10-year plan “explicitly” took account of climate change.44 Jonathan Marron, Director General of Community and Social Care at the Department of Health and Social Care, also emphasised that the 10-year plan had “a much broader focus than previous NHS documents in tackling environment sustainability as well as basic healthcare”.45
20.However, there was also a recognition that tough decisions would need to be made, to ensure that the NHS was contributing sufficiently to climate change mitigation actions, reducing its own emissions and adapting to the future impacts of a changing climate. Professor Whitty reflected that there would need to be a “political decision as to where you trade off the different speeds and the costs”.46
21.Without rapid action to curb greenhouse gas emissions and efforts to safeguard the environment we risk causing irreversible damage to the planet. This is already having a significant and growing impact on human health, with impacts set to become more severe.
22.We are concerned that the NHS and the pharmaceutical industry is not sufficiently resourced to deal with these projected changes. Non-communicable diseases (NCDs) kill 41 million people each year, equivalent to 71 per cent of all deaths globally. We note that more people now die from non-communicable diseases than communicable diseases.47 We also note the recent stalling in life expectancy in the UK as a result of lifestyle changes with increased pressure for NHS resources.48 Public Health England should broaden its key performance indicators to include climate resilience and adaptation measures to tackle emerging diseases. These should include guidance to general practitioners and the pharmaceutical industry on Lyme disease, malaria, the zika virus and other emerging tropical diseases. We repeat our recommendation from our toxic chemicals report that Public Health England should introduce a comprehensive UK wide human and wildlife bio-monitoring scheme to measure the effects of toxic chemicals.49 A focus on lifestyle change means that it does not prioritise the impacts that wider economic and ecological changes will have on human health. Secondly, Public Health England must work across Government to advise local Government on the impacts of heat stress and protecting vulnerable communities, particularly the elderly, people living in care homes and those with kidney failure.
Climate change mitigation by the NHS
23.The NHS is on the frontline of dealing with the impacts of environmental change on human health. However, as an organisation, it too has a responsibility for stewardship of the environment. The NHS employs 1.5 million people and is one of the largest consumers of water, energy and raw materials in the U.K. It has an annual water usage of 2.32bn m³ (similar to that of Estonia), generates almost 600,000 tonnes in waste and accounts for 6.3 per cent of all carbon emissions in England.50
24.The NHS Sustainable Development Unit, established in April 2008 supports the NHS in England, public health and social care, to embed sustainable development into their operating practices.51 The Unit is jointly funded by, and accountable to, NHS England and Public Health England.
25.NHS England published its Long-Term Plan in January 2019.52 The Plan restated its commitment to the carbon targets in the UK Climate Change Act (2008): reducing carbon emissions (from a 1990 baseline), by 34 per cent by 2020 and by 51 per cent by 2025.53
26.As of 2018 the NHS54 has achieved an 18.5 per cent reduction on carbon emissions against a 2007 baseline. Whilst this is progress, the NHS Sustainable Development Unit note that “this is still behind the trajectory needed to achieve the Climate Change Act 2020 target of 34 per cent, highlighting the need to redouble and accelerate efforts going forward”.55
27.The Sustainable Development Unit’s actions to reduce emissions include improving energy efficiency through widespread use of LED lighting and smart energy management, and by modernising the ambulance fleet to reduce emissions and improve air quality.56
28.Professor Sir Andy Haines, LSHTM, noted that the Long-Term Plan:
Does not capitalise sufficiently, in my view, on the potential for the NHS to be involved in thinking about these broader issues around how we sustain and promote health. I would like to see that given a much higher priority in future plans.57
29.In a letter to our Committee in May 2019, Sonia Roschnik, Director of the NHS Sustainable Development Unit, told us that 35 per cent of double crewed ambulances have low emission engines (Euro VI diesel engines) against a target of 66 per cent by 2028.58 She also stated that of 1,458 rapid response vehicles, in operation in England, just 0.3 per cent of these (44 vehicles) are ultra-low emission.59 She also stated that the NHS [in England] has committed to “phasing out primary heating from coal (by 2023/24) and oil (by 2028/29) in NHS sites”.60
30.Our report in 2018, UK Progress on reducing F-gas Emissions, highlighted that fluorinated gases, used in refrigerators, foams and inhalers, are a major contribution to global heating.61 We note that the Sustainable Development Unit has removed nearly 1 million tonnes of CO₂e per year from Metered Dose Inhaler (MDI) use. However, the use of MDIs continues to produce over 3 per cent of the health and social care sector’s annual carbon emissions, greater than its emissions from the sector’s construction and only slightly less than the sector’s freight transport emissions.62
31.The NHS has shown some progress in reducing carbon emissions by 18.5 per cent since 2007. It is deeply disappointing that it will miss its Climate Change Act target of a reduction in emissions of 34 per cent by 2020. As the largest employer, and one of the largest consumers of goods and services in the UK, the NHS should bring forward its targets to end the use of coal (2023/24) and oil (2028/29) for primary heating on NHS sites. This target should now be revised to reflect the Government’s commitment to achieve net zero greenhouse gas emissions by 2050 at the very latest. A new pathway for carbon reduction should be developed by April 2020 and communicated to all stakeholders. The NHS’ carbon footprint should be clearly communicated to staff, patients and suppliers, with messages on how they can contribute.
32.Fluorinated gases remain a major problem, with inhalers contributing to over 3 per cent of total annual emissions from the NHS. We reiterate our recommendation that Government should work with medical professionals, pharmacists, the pharmaceutical industry and patients to significantly improve the recycling of Metered Dose Inhalers (MDIs); this makes both environmental and economic sense. We encourage the Government to investigate all the means of removing the barriers to the safe re-use of those valuable quota-restricted gases. The Government should also ensure that by 2020, at least 50 per cent of MDIs are recycled. It should also set out how it will reduce medical waste, such as MDIs, in its waste strategy.
Net Zero in the NHS
33.The Committee on Climate Change’s (CCC) report, “Net Zero: The UK’s contribution to stopping global warming”, set out actions that should be taken by the Government to contribute to the UK’s net zero goal. The CCC recommended that: “Ideally, ultra-low emission vehicles would reach 100 per cent of sales of cars, vans and motorbikes by 2030 or soon after, but must certainly do so by 2035”.63 The CCC also recommended that:
If possible, an earlier end to sales of petrol and diesel vehicles would be preferable (e.g. by 2030 if feasible), as this will have lower financial costs, lower cumulative CO₂ emissions and lead to better air quality. This means a rapid ramping up of the market share of [Electronic Vehicles] EVs, from around 2 per cent today, during the 2020s.64
34.We are concerned that, at current rates of progress, the NHS will fall far short of the Committee on Climate Change’s recommendation of 100 per cent of low emission vehicles by 2035 at the latest. The current target of 66 per cent of vehicles being low emission by 2028 is not ambitious enough. The NHS should be taking the lead in the mitigation of climate change, given its size, budget and workforce, particularly when a major impact of climate change is likely to be a deterioration of several measures of population health. The Committee on Climate Change is clear that early uptake of electronic vehicles (EVs) brings co-benefits from reductions in air pollution. NHS direct fleet procurement and “Grey fleet” purchased through tax schemes should prioritise EVs. We recommend that the NHS aligns its plans with the Committee on Climate Change’s cost-efficient path for electric vehicle uptake to benefit from the financial savings and co-benefits (e.g. reduction in air pollution) of earlier EV uptake.
26 The Rockefeller Foundation Economic Council on Planetary Health, What is planetary health (Accessed 8 August 2019)
27 Will Steffen et al., The trajectory of the Anthropocene: The Great Acceleration, SAGE Journals, Vol. 2 (2015), pp.81–98
28 Andy Haines, Addressing challenges to human health in the Anthropocene epoch—an overview of the findings of the Rockefeller/Lancet Commission on Planetary Health, International Health, Vol. 9 (2017), p.269
29 The Rockefeller Foundation Economic Council on Planetary Health, What is planetary health (Accessed 8 August 2019)
30 Source: Sarah Whitmee et al., ‘Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health’, The Lancet, Vol. 386 (2015), pp.1973–2028
31 Source: Millennium Ecosystem Assessment, reproduced in: Sarah Whitmee et al., ‘Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health’, The Lancet, Vol. 386 (2015), pp.1973–2028
33 Andy Haines and Kristie Ebi, The Imperative for Climate Action to Protect Health, The New England Journal of Health. Vol. 380 (2019), pp.263–273
35 Susan Clayton Whitmore-Williams, et al., Mental Health and Our Changing Climate: Impacts, Implications, and Guidance. American Psychological Association (2017), p.68
37 Employee data from Lucina Rolewicz and Billy Palmer, The NHS workforce in numbers [date accessed 06/08/2019], Nuffield Trust (2018); annual budget data from NHS England, Annual Report and Accounts 2017/18, (2018); and GDP data for Croatia and Sri Lanka from World Bank, GDP (current US$), (2018)
42 NHS England, NHS Long Term Plan, (2019)
44 Ibid.
47 World Health Organization, Noncommunicable diseases (June 2018)
48 Raleigh, British Medical Journal, Stalling life expectancy in the UK 2018; 362:k4050
49 Environmental Audit Committee, Twentieth Report of Session 2017–19,Toxic Chemicals in Everyday Life, HC 1805, paragraph 36
50 NHS Sustainable Development Unit Reducing the use of natural resources in health and social care, (2018), p.3
51 NHS Sustainable Development Unit, Who We Are [Accessed 01 July 2019]
52 NHS (2019) NHS Long Term Plan, (2019), p.120
53 Ibid.
54 Referring to Health and social care
55 NHS Sustainable Development Unit Reducing the use of natural resources in health and social care, (2018), p.8
56 NHS Sustainable Development Unit, Key sustainability actions in NHS Long Term Plan [Accessed 01 July 2019]
58 Sonia Roschnik, Letter from NHS England to the EAC Chair on Planetary Health, (03 May 2019)
61 Environmental Audit Committee, Fifth Report of Session 2017–19, UK Progress on reducing F-gas Emissions, HC 469, paragraph 1
62 NHS Sustainable Development Unit, Reducing the use of natural resources in health and social care, (2018), p.11
63 Committee on Climate Change, Net Zero: The UK’s Contribution to Stopping Global Warming, (2019), p.198
64 Committee on Climate Change, Net Zero: The UK’s Contribution to Stopping Global Warming, (2019), p.178
Published: 17 September 2019