Opinion
A PIECE OF MY MIND Caroline Wellbery, MD, PhD Department of Family Medicine, Georgetown University Medical Center; American Family Physician, Washington, DC.
Corresponding Author: Caroline Wellbery, MD, PhD (wellberc@georgetown .edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Code Green More than 40 years ago I had a dream: the earth was getting warmer and warmer, and people lay prostrate on the streets, lethargic from thirst and heat. That dream I recite only from memory, but here is another one I recorded in a diary I kept in those days: “I found myself in a house with many people. Suddenly I looked outside and saw that we were surrounded by sea. Huge waves crashed in the distance. The end of the world! Water was seeping through the windows. A girl was using a cup to scoop out the water. ‘Is the house sinking?’ I asked. While we were trying to stay afloat, I was rescued by the alarm clock.” And lest my theme here isn’t yet clear, another dream I wrote down, dated March 7, 1969: “I dreamt there was a huge fire; the flames were everywhere, destroying everything. That is not the first time I have dreamt of fire. Always the hot flames. … ” These dreams suggest how deeply the awareness of the earth’s fragility had already in the 1960s penetrated the collective consciousness, even contributing to the terrors of a 16-year-old girl. Indeed, my diary explicitly refers to the ecological concerns of the day. I had attended an “ecology action meeting” and learned about the environmental impact of the then proposed supersonic transport (SST) plane. My diary lists many of today’s concerns, including threats to climate, wildlife, and agriculture. The SST project largely foundered, but the dire warnings about the fate of our planet have escalated. What concerns me is the current low level of expressed alarm. Among my physician colleagues, a profound silence surrounds this discussion about environmental threat.1 It seems there is no appropriate milieu to bring up this topic. The only settings where such conversations are sanctioned are at on-theme conferences or meetings. What is the cause of our reticence? In matters of religion and politics, most Americans, not just physicians, keep their views close to home. Climate change, alas, has become saturated with our personal values, making it difficult to avoid sounding contentious when addressing this issue in a public space. Our climate change beliefs, admittedly complex, have both political and psychological origins. First, corporate interests’ defeat of cap-and-trade legislation in 2009 negatively impacted public discourse, making even the label climate change a political liability. Climate change has become a problem defined along party lines, with 67% of Americans compared with only 25% of the subset of Tea Party Republicans acknowledging that climate change is real. Second, these political pressures, which the past decade’s economic downturn has reinforced, play into the mechanisms of psychological denial. When we talk about climate change, we draw attention to the probability of enormous upheavals. Of the commonly cited rea-
sons for avoiding discussions about climate change— for example, our unwillingness to change our comfortable way of life, or the hope that somehow we will find a fix for the messes we’ve made, the unintended consequences of many economic improvements—one of the easiest for ideological detractors to manipulate may be the psychological resistance to a threat that feels beyond our control. It may also be that our training makes it difficult to reconcile climate change with medical concerns. This is a legitimate objection, but just as climate change knows no national borders, this global and far-reaching environmental phenomenon does not observe political, economic, biologic, meteorologic, public, and personal health boundaries. Climate change is both global and systemic. The air in Beijing reaches Los Angeles. Heat airlifts toxic pollutants thousands of miles. Warming temperatures increase ice melt, precipitation, forest fires, and drought. As environmental problems continue to proliferate, physicians will be called on to recraft their professional identities and participate in interdisciplinary teams that address the multifactorial dimensions of global change. So, speaking up matters, positioning physicians to give voice both to truth and to hope. Here are four reasons why physicians should break their silence on climate change:
Scientific Evidence Climate change science is far more solid than medical evidence. According to a Cochrane cross-sectional review of 1016 systematic reviews, almost half of these studies concluded that the available evidence could neither support nor refute the practice in question.2 Yet even when good medical evidence isn’t always forthcoming, we soldier on looking for it in order to provide the best possible care to our patients. With a near-universal scientific consensus that human greenhouse gas emissions are changing our atmosphere, the evidence for climate change is much stronger than most of the evidence that informs our day-to-day practice. Therefore, we should respond even more pragmatically to the consistent and ever-mounting evidence for the human contribution to climate change and its consequences. Average global surface temperatures have increased 1.5°F in the last century and in spite of variations are projected to climb even further.3 More important still in terms of imminent threats to human health is greenhouse gas production. A recent report estimates that in 2011, 2.4 million lb (1089 metric tons) of carbon dioxide was released into the air every second. 4 Last year, atmospheric CO 2 reached 400 ppm for the first time in recorded history. Oceans are acidifying. Sea levels are rising. Both climate change and human behavior contributing to
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JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
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Opinion A Piece of My Mind
climate change, such as deforestation, are accelerating the loss of biodiversity. Water is becoming scarce. Weather patterns are changing. On the basis of the best evidence, no disaster threatens as much as environmental change.
Health Matters Quality of life and survival are medically relevant. Access to sustainable food and clean water may seem exclusive to the domains of public health5 and may be complicated by intermediate effects of pollution in the local environment, but when children present with asthma, when heat waves, extreme weather events, and mudslides bring patients into our emergency departments, when malaria reaches Alaska and other pathogens find new vectors and hosts, it becomes difficult to extricate the individual’s experience from the bigger impact of warming temperatures. When people can’t breathe because of polluting particulates, then individual needs, environmentally unsound practices, and carbon emissions intersect in a way that affects our daily practice as physicians.
Physicians Are Trusted Advocates In mainstream America, physicians are trusted individuals.6 Physicians have an unusual power to be heard. We can advocate for reduced carbon emissions and responsible environmental regulations to safeguard the quality of our air and our water. In addition to Additional Contributions: Thanks to Georgetown University’s Environment Initiative Program and to Cindy Parker, MD, for reviewing the facts and figures cited in this essay. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. 1. Fraser S. Do Doctors Have a Responsibility to Lead on Climate Change? BMJ Group Blogs. June 3, 2013. http://blogs.bmj.com/bmj/2013/06/03 /scott-fraser-do-doctors-have-a-responsibility -to-lead-on-climate-change/. Accessed November 24, 2013.
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public health advocacy, we can advocate for the reduction of medical waste, an important contributor to carbon emissions.
Moral Courage Global environmental changes have grave implications. Those who pay attention have good reason for alarm. We have a moral obligation to act. In his film about the arctic melt, Chasing Ice, James Balog says he pursued his photographic project because he didn’t want his daughter to grow up and learn that her father had done nothing to counter climate change. There are many individual choices available to us and our patients, for example, walking or biking instead of driving, eating vegetarian (livestock, especially beef and dairy cattle, accounts for 34.4% of US methane production7), and curtailing our air travel. True, these are individual acts, but they have symbolic value. As a profession, we physicians should consider our collective responsibility to stand up to the threats to both our immediate and our global family. This involves participating in emergency preparedness planning, affecting policy through our professional organizations, monitoring our local communities, maximizing influence through social media, and contributing to collaborative research. We should break the silence by speaking out in every way we can: to our patients, to our colleagues, to the public. We must wake up. It’s not a dream anymore.
2. El Dib RP, Atallah AN, Andriolo RB. Mapping the Cochrane evidence for decision making in health care. J Eval Clin Pract. 2007;13(4):689-692.
5. McMichael AJ. Globalization, climate change, and human health. N Engl J Med. 2013;368(14): 1335-1343.
3. Summary for Policymakers. In: Stocker TF, Qin D, Plattner G-K, et al, eds. Climate Change 2013: The Physical Science Basis. Contribution of Working Group I to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK/New York, NY: Cambridge University Press; 2013:3. http://www .climatechange2013.org/images/report/WG1AR5 _SPM_FINAL.pdf. Accessed August 20, 2014.
6. Gallup. Honesty/Ethics in Professions. Survey report. http://www.gallup.com/poll/1654 /honesty-ethics-professions.aspx. Accessed November 24, 2013. 7. Agriculture. http://www.epa.gov/climatechange /Downloads/ghgemissions/US-GHG-Inventory -2013-Chapter-6-Agriculture.pdf. Accessed November 24, 2013.
4. Peters GP, Andrew RM, Boden T, et al. The challenge to keep global warming below 2 °C. Nature Climate Change. 2013;3:4-6.
JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/12/2015
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A PIECE OF MY MIND Caroline Wellbery, MD, PhD Department of Family Medicine, Georgetown University Medical Center; American Family Physician, Washington, DC.
Corresponding Author: Caroline Wellbery, MD, PhD (wellberc@georgetown .edu). Section Editor: Roxanne K. Young, Associate Senior Editor.
Code Green More than 40 years ago I had a dream: the earth was getting warmer and warmer, and people lay prostrate on the streets, lethargic from thirst and heat. That dream I recite only from memory, but here is another one I recorded in a diary I kept in those days: “I found myself in a house with many people. Suddenly I looked outside and saw that we were surrounded by sea. Huge waves crashed in the distance. The end of the world! Water was seeping through the windows. A girl was using a cup to scoop out the water. ‘Is the house sinking?’ I asked. While we were trying to stay afloat, I was rescued by the alarm clock.” And lest my theme here isn’t yet clear, another dream I wrote down, dated March 7, 1969: “I dreamt there was a huge fire; the flames were everywhere, destroying everything. That is not the first time I have dreamt of fire. Always the hot flames. … ” These dreams suggest how deeply the awareness of the earth’s fragility had already in the 1960s penetrated the collective consciousness, even contributing to the terrors of a 16-year-old girl. Indeed, my diary explicitly refers to the ecological concerns of the day. I had attended an “ecology action meeting” and learned about the environmental impact of the then proposed supersonic transport (SST) plane. My diary lists many of today’s concerns, including threats to climate, wildlife, and agriculture. The SST project largely foundered, but the dire warnings about the fate of our planet have escalated. What concerns me is the current low level of expressed alarm. Among my physician colleagues, a profound silence surrounds this discussion about environmental threat.1 It seems there is no appropriate milieu to bring up this topic. The only settings where such conversations are sanctioned are at on-theme conferences or meetings. What is the cause of our reticence? In matters of religion and politics, most Americans, not just physicians, keep their views close to home. Climate change, alas, has become saturated with our personal values, making it difficult to avoid sounding contentious when addressing this issue in a public space. Our climate change beliefs, admittedly complex, have both political and psychological origins. First, corporate interests’ defeat of cap-and-trade legislation in 2009 negatively impacted public discourse, making even the label climate change a political liability. Climate change has become a problem defined along party lines, with 67% of Americans compared with only 25% of the subset of Tea Party Republicans acknowledging that climate change is real. Second, these political pressures, which the past decade’s economic downturn has reinforced, play into the mechanisms of psychological denial. When we talk about climate change, we draw attention to the probability of enormous upheavals. Of the commonly cited rea-
sons for avoiding discussions about climate change— for example, our unwillingness to change our comfortable way of life, or the hope that somehow we will find a fix for the messes we’ve made, the unintended consequences of many economic improvements—one of the easiest for ideological detractors to manipulate may be the psychological resistance to a threat that feels beyond our control. It may also be that our training makes it difficult to reconcile climate change with medical concerns. This is a legitimate objection, but just as climate change knows no national borders, this global and far-reaching environmental phenomenon does not observe political, economic, biologic, meteorologic, public, and personal health boundaries. Climate change is both global and systemic. The air in Beijing reaches Los Angeles. Heat airlifts toxic pollutants thousands of miles. Warming temperatures increase ice melt, precipitation, forest fires, and drought. As environmental problems continue to proliferate, physicians will be called on to recraft their professional identities and participate in interdisciplinary teams that address the multifactorial dimensions of global change. So, speaking up matters, positioning physicians to give voice both to truth and to hope. Here are four reasons why physicians should break their silence on climate change:
Scientific Evidence Climate change science is far more solid than medical evidence. According to a Cochrane cross-sectional review of 1016 systematic reviews, almost half of these studies concluded that the available evidence could neither support nor refute the practice in question.2 Yet even when good medical evidence isn’t always forthcoming, we soldier on looking for it in order to provide the best possible care to our patients. With a near-universal scientific consensus that human greenhouse gas emissions are changing our atmosphere, the evidence for climate change is much stronger than most of the evidence that informs our day-to-day practice. Therefore, we should respond even more pragmatically to the consistent and ever-mounting evidence for the human contribution to climate change and its consequences. Average global surface temperatures have increased 1.5°F in the last century and in spite of variations are projected to climb even further.3 More important still in terms of imminent threats to human health is greenhouse gas production. A recent report estimates that in 2011, 2.4 million lb (1089 metric tons) of carbon dioxide was released into the air every second. 4 Last year, atmospheric CO 2 reached 400 ppm for the first time in recorded history. Oceans are acidifying. Sea levels are rising. Both climate change and human behavior contributing to
jama.com
JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/12/2015
1201
Opinion A Piece of My Mind
climate change, such as deforestation, are accelerating the loss of biodiversity. Water is becoming scarce. Weather patterns are changing. On the basis of the best evidence, no disaster threatens as much as environmental change.
Health Matters Quality of life and survival are medically relevant. Access to sustainable food and clean water may seem exclusive to the domains of public health5 and may be complicated by intermediate effects of pollution in the local environment, but when children present with asthma, when heat waves, extreme weather events, and mudslides bring patients into our emergency departments, when malaria reaches Alaska and other pathogens find new vectors and hosts, it becomes difficult to extricate the individual’s experience from the bigger impact of warming temperatures. When people can’t breathe because of polluting particulates, then individual needs, environmentally unsound practices, and carbon emissions intersect in a way that affects our daily practice as physicians.
Physicians Are Trusted Advocates In mainstream America, physicians are trusted individuals.6 Physicians have an unusual power to be heard. We can advocate for reduced carbon emissions and responsible environmental regulations to safeguard the quality of our air and our water. In addition to Additional Contributions: Thanks to Georgetown University’s Environment Initiative Program and to Cindy Parker, MD, for reviewing the facts and figures cited in this essay. Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for the Disclosure of Potential Conflicts of Interest and none were reported. 1. Fraser S. Do Doctors Have a Responsibility to Lead on Climate Change? BMJ Group Blogs. June 3, 2013. http://blogs.bmj.com/bmj/2013/06/03 /scott-fraser-do-doctors-have-a-responsibility -to-lead-on-climate-change/. Accessed November 24, 2013.
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public health advocacy, we can advocate for the reduction of medical waste, an important contributor to carbon emissions.
Moral Courage Global environmental changes have grave implications. Those who pay attention have good reason for alarm. We have a moral obligation to act. In his film about the arctic melt, Chasing Ice, James Balog says he pursued his photographic project because he didn’t want his daughter to grow up and learn that her father had done nothing to counter climate change. There are many individual choices available to us and our patients, for example, walking or biking instead of driving, eating vegetarian (livestock, especially beef and dairy cattle, accounts for 34.4% of US methane production7), and curtailing our air travel. True, these are individual acts, but they have symbolic value. As a profession, we physicians should consider our collective responsibility to stand up to the threats to both our immediate and our global family. This involves participating in emergency preparedness planning, affecting policy through our professional organizations, monitoring our local communities, maximizing influence through social media, and contributing to collaborative research. We should break the silence by speaking out in every way we can: to our patients, to our colleagues, to the public. We must wake up. It’s not a dream anymore.
2. El Dib RP, Atallah AN, Andriolo RB. Mapping the Cochrane evidence for decision making in health care. J Eval Clin Pract. 2007;13(4):689-692.
5. McMichael AJ. Globalization, climate change, and human health. N Engl J Med. 2013;368(14): 1335-1343.
3. Summary for Policymakers. In: Stocker TF, Qin D, Plattner G-K, et al, eds. Climate Change 2013: The Physical Science Basis. Contribution of Working Group I to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK/New York, NY: Cambridge University Press; 2013:3. http://www .climatechange2013.org/images/report/WG1AR5 _SPM_FINAL.pdf. Accessed August 20, 2014.
6. Gallup. Honesty/Ethics in Professions. Survey report. http://www.gallup.com/poll/1654 /honesty-ethics-professions.aspx. Accessed November 24, 2013. 7. Agriculture. http://www.epa.gov/climatechange /Downloads/ghgemissions/US-GHG-Inventory -2013-Chapter-6-Agriculture.pdf. Accessed November 24, 2013.
4. Peters GP, Andrew RM, Boden T, et al. The challenge to keep global warming below 2 °C. Nature Climate Change. 2013;3:4-6.
JAMA September 24, 2014 Volume 312, Number 12
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://jama.jamanetwork.com/ by a University of St. Andrews Library User on 05/12/2015
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