Art & science
If you would like to contribute to the Art & science section, email [email protected] or @NSclinicalEd
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Climate change and ecological public health Goodman B (2015) Climate change and ecological public health. Nursing Standard. 29, 24, 37-41. Date of submission: October 8 2014; date of acceptance: November 6 2014.
Abstract Climate change has been identified as a serious threat to human health, associated with the sustainability of current practices and lifestyles. Nurses should expand their health promotion role to address current and emerging threats to health from climate change and to address ecological public health. This article briefly outlines climate change and the concept of ecological public health, and discusses a 2012 review of the role of the nurse in health promotion.
Author Benny Goodman Lecturer in adult nursing and sustainability education developer, Faculty of Health and Human Science, Plymouth University, Cornwall, England. Correspondence to: [email protected]
Keywords Climate change, ecological public health, health promotion, nursing, public health
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
NURSES HAVE A HISTORY of engaging in health promotion and public health. Both roles are reflected in the Nursing and Midwifery Council (NMC) Standards for Education (NMC 2010). However, trends such as population growth, new technologies and climate change suggest that nurses’ understanding needs to develop to adapt to a very different future. It is argued that nurses should move beyond adopting individualistic and behaviour-changing perspectives (Kemppainen et al 2012) to adopting an ethico-socio-political role (Falk-Raphael 2006) in health promotion, based on a wider understanding of what health promotion means. This article reflects on climate change, outlines the concept of ecological public health and discusses Kemppainen et al’s (2012) integrative review of the nurse’s role in health promotion.
Climate change Despite the requirement to curb greenhouse gas emissions to prevent catastrophic climate change (Costello et al 2009, Roberts and Stott 2011, McCoy et al 2014), the world is experiencing a continuing rise in anthropogenic (arising from human activity) greenhouse gases (Intergovernmental Panel on Climate Change (IPCC) 2014). This emissions increase is expected to persist as a result of population growth and economic activity, resulting in global mean surface temperature rises of 3.7°C to 4.8°C by 2100 if there is no further mitigation (IPCC 2014). This means that the average temperature on the surface of the earth may increase by that amount, compared with the average temperature in 1990. This rise is in excess of the 2°C safety threshold (Peters et al 2013, Marshall 2014, McCoy et al 2014), beyond which there may not be a safe operating space
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Art & science public health for humanity (Rockström et al 2009). In other words, it is recognised that the earth is warming up and to prevent severe consequences, such as sea level rises, extreme weather events and Arctic ice sheets melting, it is necessary to ensure that there is no more than a 2°C rise in average temperatures compared with those in 1990. McKie (2014) suggests that global evidence supports the assertion that climate change is already happening and is resulting in floods, melting permafrost, rising sea levels and lack of snow in the Alps. He states: ‘In its latest report, the Intergovernmental Panel on Climate Change estimates that up to 139 million people could face food shortages at least once a decade by 2070.’ According to Marshall (2014), heat waves and the extinction of animal species will be routinely experienced by the end of this century. Feeding 10 billion people will become more difficult, the loss of glaciers and ice sheets will result in two thirds of major cities being under water, and ocean acidification will adversely affect more than two thirds of the ecosystem surface (Marshall 2014). According to Climate Central (2014), record flooding in Washington DC this century is almost guaranteed. This influences thinking about where it will be safer to live in the United States. Alaska, the Mid West and the Pacific North West will fare much better than California and the South East if, as Mora et al (2013) state, unprecedented high temperatures become the norm by 2047. Mora et al (2013) go on to argue that Washington DC will reach its tipping point in 2047, Los Angeles in 2048, San Francisco in 2049 and Chicago in 2052. The tipping point will occur when extreme high temperatures become the new norm, rather than occasional, infrequent events. In other words, some scientists have accepted that increases in temperature and sea level will severely affect cities in the next few decades, requiring major adaptations around population migration and land and flood defences and major structural changes in economics and society. This is in line with the National Climate Assessment’s (2014) third report, which outlines the increases in temperature, making it clear that these adverse effects will occur in decades, not centuries. The effect of climate change on health has been documented elsewhere (World Health Organization (WHO) 2014a) and this is partly based on the social and environmental determinants of health (Barton and Grant 2006, WHO 2008). Barna et al (2012) have also set out what nurses should know about climate change, but the urgency of addressing this issue is increasing, as outlined by the NHS Sustainable Development Unit (2014) in Fit for the
Future: Scenarios for Low-Carbon Healthcare 2030. All of the above raises the question of what the health promotion role of the nurse might be in this context.
Ecological and planetary public health Horton et al (2014) call for a new social movement to support collective action on public health. They introduce the concept of planetary public health, rather than public health. As in Lang and Rayner’s (2012) discussion of ecological public health, Horton et al (2014) focus on the unsustainable nature of current consumption, linking it with poorer health outcomes. Horton et al (2014)’s concept of planetary public health relates to Barton and Grant’s (2006) ‘health map’, a circular diagram illustrating determinants of health. Climate stability, biodiversity and ecosystems are in the outer ring of the diagram, indicating that these are foundational determinants of health, without which no one can survive. The planet includes the climate system, biodiversity and ecosystems, so Horton et al (2014) are in accord with Barton and Grant (2006) in describing this foundation for human health. Horton et al (2014) also make an overtly political statement: ‘We have created an unjust global economic system that favours a small wealthy elite over the many who have so little.’ They call for urgent transformation of values and practices, based on recognising human interdependence and interconnectedness with a finite planet, and a new vision of democratic action and co-operation. A principle of ‘planetism’ is invoked, which requires the conservation and sustenance of the ecosystems on which humans rely. Finally, they suggest that public health and medicine can be independent voices of conscience, which, along with empowered communities, can confront entrenched interests. In the same vein, Ottersen et al (2014) are explicitly political regarding the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’. The tone of their report makes clear a need to address global governance and undertake an analysis of power. Such an analysis would highlight the fossil fuel industry as a major contributor to carbon emissions (Heede 2014) and, therefore, a direct threat to public health. Lang and Rayner (2012) point out that proponents of public health (and therefore, by implication, I would add public health nurses) have allowed their roles to develop around the language of individualism and choice, and such
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positioning leads to behaviour-change models and theories of rational action. These theories focus on changing the behaviour of individuals and are often based on a belief that, given enough education and information, people can make rational choices to change. However, they say that public health is about bigger social (and political) issues that might threaten vested interests, for example, the interests of the fossil fuel industry (Lang and Rayner 2012). They reviewed public health developments from the 19th century onwards and suggested a rethink is in order. They outlined four current models of public health, but suggested that they are anthropocentric, meaning that the health of the living, natural and physical world – the ecosystem – is marginalised. Climate change challenges those models, since it is fundamentally about ecosystem damage and the concomitant threats to health on a global scale. Ecological public health has two focuses on interactions, one on the biological world, for example biodiversity, and the other on material issues such as industrial pollution, energy use and toxicity. Ecological public health is based on systems thinking and complexity in understanding health. It has material, biological, cultural and social dimensions. It goes beyond simplistic behaviour-change models, which do not deal with socio-political contexts. ‘Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so…is insulting and even futile’ (Lang and Rayner 2012). Telling families to eat less red meat, fly less and to stop consuming, without addressing the actions of global corporations is, arguably, similarly insulting and possibly futile in trying to curb carbon emissions (Klein 2014). The domains of public health, medicine and nursing may be insufficiently politically aware of the scale of the issues that affect human health. This may be because, until now, education of professionals has been ahistorical and apolitical, resulting in a lack of a sociological or political imagination driven by critical analysis of the link between current unsustainable lifestyles, political economies and public health. However, adopting the perspective of ecological public health, or seeing the world through a ‘sustainability lens’ (Goodman and East 2014), might encourage more healthcare practitioners and policy makers to critique and take action regarding current economic and political structures that create health inequities and, if some are to be believed, threaten civilisation (Costello et al 2009, Hamilton 2010, Klein 2014, Marshall 2014, Oreskes and Conway 2014). There are countervailing voices, which do not express the same level of threat and
even deny climate change is occurring (Goklany 2007, 2009a,b,c, Ben-Ami 2010, Delingpole 2013, Lehmann 2014), but many health groups, including the WHO (2008, 2014b,c), Faculty of Public Health (2014) and International Council of Nurses (2008), do not share these views.
Nurses’ role in health promotion practice Kemppainen et al’s (2012) integrative review on the nurses’ role in health promotion is based on an analysis of research papers from 1998 to 2011. Although it therefore does not include research published in the past few years, some of the conclusions still resonate today. Kemppainen et al (2012) argue that studies suggest nurses have adopted an individualistic and behaviour-changing perspective to health promotion, which is underpinned by nurses working from a holistic and/or patient-centred theoretical basis, or a chronic disease and/or medical-oriented approach. Neither of these theoretical groundings equips nurses with the knowledge or attitudes to address the emerging public health concept of planetary health, as outlined above. Although a common defining concept of health promotion found in the studies, along with the individual perspective and empowerment, was social and health policy, they state that ‘…nurses were not familiar with social and health policy documents [and] did not apply them to their nursing practice’. If this is still true, the policy initiatives such as the WHO’s 2008 social determinants of health and Horton et al’s (2014) manifesto for planetary and public health will not be found in nurses’ concepts of health promotion. Nurses’ health promotion expertise has historically focused on general health promotion, patient-focused health promotion and project management health promotion. Commonly this involved health education. The competencies outlined were based on multidisciplinary knowledge, skill-related competence and competence related to attitudes and personal characteristics (Kemppainen et al 2012). Nurses were expected to be aware of economic, social and cultural issues and their influence on lifestyle and health behaviour. Whether this included knowledge of climate change or other ecological issues is not clear and is not mentioned in Kemppainen et al’s (2012) review. The review highlighted the need to clarify the concept of health promotion and clearly stated that ‘health policies have little impact on nursing practice’ (Kemppainen et al 2012). Therefore, health policies directed at future trends, such as
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Art & science public health the ecological changes indicated above, will gain little support in practice unless changes are made. Indeed, Kemppainen et al (2012) noted that knowledge of future trends affecting population health was not identified as being part of nurses’ health promotion competencies. The review concludes: ‘It appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities… their health promotion activities (are) based on knowledge and giving information to patients.’ Lang and Rayner (2012) argue that public health must address complexity and dare to confront power. This understanding ought then to be part of the language of health promotion used by nurses. In the UK, nursing students are introduced to the social determinants of health approach as outlined by the WHO (2008) and the Rio declaration (WHO 2011). The NMC’s Standards for Education (2010) states: ‘All nurses must understand public health principles, priorities and practice, in order to recognise and respond to the major causes and social determinants of health,
illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion.’ This introduces an ethical imperative and a socio-political role for nursing (Falk-Rafael 2006), since the NMC explicitly states that nurses are to work to improve health. If health has social determinants based on the distribution of money, power and resources, then nurses are required to understand what that means. Indeed public health principles are now embracing concepts such as the social determinants of health and going further in the ecological public health approach (Lang and Rayner 2012). Climate change and threats to ecosystems are real health concerns for individuals, communities and populations both at present and in the medium- to long-term future. The long term, in this instance, is defined as the 21st century. The scientific community agrees that we are moving towards a warmer world. The wider
References Barna S, Goodman B, Mortimer F (2012) The health effects of climate change; what does a nurse need to know? Nurse Education Today. 32, 7, 765-771. Barton H, Grant M (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health. 126, 6, 252-261. Ben-Ami D (2010) Ferraris for All: In Defence of Economic Progress. The Policy Press, University of Bristol, Bristol. Climate Central (2014) Risk Finder: Washington, DC. Surging Seas. http://sealevel. climatecentral.org/ssrf/dc (Last accessed: December 12 2014.) Costello A, Abbas M, Allen A et al (2009) Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. The Lancet. 373, 9676, 1693-1733.
Delingpole J (2013) Global Warming Believers are Feeling the Heat. http://blogs.telegraph.co.uk/news/ jamesdelingpole/100238047/ global-warming-believers-arefeeling-the-heat/ (Last accessed: December 12 2014.) Faculty of Public Health (2014) Sustaining a Healthy Future: Taking Action on Climate Change. www.fph.org.uk/uploads/r_ sustaining_a_healthy_ future.pdf (Last accessed: December 12 2014.) Falk-Rafael A (2006) Globalization and global health: toward nursing praxis in the global community. Advances in Nursing Science. 29, 1, 2-14. Goklany I (2007) Is a richer-but-warmer world better than poorer-but-cooler world? Energy & Environment. 18, 7/8, 1023-1048. Goklany I (2009a) Is climate change the ‘defining challenge of our age’? Energy & Environment. 20, 3, 279-302.
Goklany I (2009b) Climate change is not the biggest global health threat. The Lancet. 374, 9694, 973-974. Goklany I (2009c) Global health threats: global warming in perspective. Journal of American Physicians and Surgeons. 14, 3, 69-75. Goodman B, East L (2014) The ‘sustainability lens’: a framework for nurse education that is ‘fit for the future’. Nurse Education Today. 34, 1, 100-103. Hamilton C (2010) Requiem for a Species: Why We Resist the Truth about Climate Change. Earthscan, Oxford. Heede R (2014) Tracing anthropogenic carbon dioxide and methane emissions to fossil fuel and cement producers, 1854–2010. Climatic Change. 122, 1–2, 229-241. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S (2014) From public health to planetary health: a manifesto. The Lancet. 383, 9920, 847.
Intergovernmental Panel on Climate Change (2014) Summary for policymakers. In: Climate Change 2014. Mitigation of Climate Change. Contribution of Working Group III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. http://report.mitigation2014. org/spm/ipcc_wg3_ar5_ summary-for-policymakers_ approved.pdf (Last accessed: December 12 2014.) International Council of Nurses (2008) Nurses, Climate Change and Health. www.icn.ch/images/ stories/documents/publications/ position_statements/E08_Nurses_ Climate_Change_Health.pdf (Last accessed: December 12 2014.) Kemppainen V, Tossavainen K, Turunen H (2012) Nurses’ roles in health promotion practice: an integrative review. Health Promotion. 28, 4, 490-501. Klein N (2014) This Changes Everything: Capitalism vs. the Climate. Simon and Schuster, New York NY.
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health community and some nursing organisations are aware of the issues and are advocating for changes to practice and education. There are many who disagree either on the phenomenon of climate change itself, or on what to do about it. There is distrust of politicians based on fears of the introduction of global governance and state interference (Klein 2014, Marshall 2014), and many distrust the scientists themselves. Nurses already have a health promotion role, but it has been defined in particular ways that result in an inability to grapple with the new challenges that climate change and ecosystem damage are bringing. Thus, there is an urgent need to address the emerging paradigm of ecological or planetary public health in nurses’ health promotion definitions and competencies, to confront entrenched interests through individual and community empowerment. As Falk-Raphael (2006) argued: ‘Nursing’s fundamental responsibilities to promote health, prevent disease and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national and
Lang T, Rayner G (2012) Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geoff Rayner. British Medical Journal. 345, e5466. doi:10.1136/bmj.e5466. Lehmann E (2014) Heartland Institute Says More CO2 is Good for the Planet. www. midwestenergynews.com/2014/ 03/31/heartland-institute-says-moreco2-is-good-for-the-planet/ (Last accessed: December 12 2014.) Marshall G (2014) Don’t Even Think About It: Why Our Brains Are Wired to Ignore Climate Change. Bloosmbury, New York NY. McCoy D, Montgomery H, Arulkumuran S, Godlee F (2014) Climate change and human survival. British Medical Journal. 348, g2351. doi:10.1136/bmj.g2351. McKie R (2014) Floods, Fires, Expanding Deserts: The Future has Arrived. www.theguardian. com/environment/2014/sep/28/
international levels to bring about reforms of the current global economic order.’
Conclusion It is becoming ever clearer that the global climate is changing, that human activity is causing most of this change and the consequences for people, population health and the diversity of plants and animals will be wide-ranging and in many cases severe. The timescale for action seems to be just a few decades if the temperature rise is to be kept around a ‘safe’ 2°C. Healthcare professionals are in a position to know what the effects of increased global temperature on human health might be and have been called to act. New concepts about public health and health promotion are emerging, requiring new understanding that goes beyond a focus on individual behaviour change through education. The health promotion role of the nurse will have to adapt to meet these challenges and new ways of thinking. This means understanding and applying an ecological public health model and a socio-political role NS
climate-change-has-arrivedglobal-warming-icecaps-deserts (Last accessed: December 12 2014.) Mora C, Frazier A, Longman R et al (2013) The projected timing of climate departure from recent variability. Nature. 502, 7470, 183-187. National Climate Assessment (2014) Climate Change Impacts in the United States: The Third National Climate Assessment. http://globalchange.gov/browse/ reports/climate-change-impactsunited-states-third-nationalclimate-assessment-0 (Last accessed December 12 2014.) NHS Sustainable Development Unit (2014) Fit for the Future. Scenarios for Low-Carbon Healthcare 2030. www. forumforthefuture.org/sites/ default/files/project/downloads/ fitforthefuturenhssept09.pdf (Last accessed: December 12 2014.) Nursing and Midwifery Council (2010) Standards for Education. www.nmc-uk.org/Educators/
Standards-for-education (Last accessed: December 12 2014.) Oreskes N, Conway E (2014) The Collapse of Western Civilisation: A View From the Future. Columbia University Press, New York NY. Ottersen O, Dasgupta J, Blouin C et al (2014) The Lancet-University of Oslo Commission on Global Governance for Health. The political origins of health inequity: prospects for change. The Lancet. 383, 9917, 630-667. Peters G, Andrew R, Boden T et al (2013) The challenge to keep global warming below 2°C. Nature Climate Change. 3, 4-6. doi:10.1038/nclimate1783. Roberts I, Stott R (2011) Doctors and climate change. The International Journal of Occupational and Environmental Medicine. 2, 1, 8-10. Rockström J, Steffen W, Noone K et al (2009) Planetary boundaries: exploring the safe operating space for humanity. Ecology and Society. 14, 2, 32.
World Health Organization (2008) Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health. www.who.int/social_determinants/ thecommission/finalreport/en/ (Last accessed: December 12 2014.) World Health Organization (2011) Rio Political Declaration on Social Determinants of Health. www.who.int/sdhconference/ declaration/en/ (Last accessed: December 12 2014.) World Health Organization (2014a) Climate Change and Human Health. www.who.int/globalchange/en (Last accessed: December 12 2014.) World Health Organization (2014b) Health Topics. Climate Change. www.who.int/topics/ climate/en (Last accessed: December 12 2014.) World Health Organization (2014c) Climate Change and Health. Fact sheet No. 266. www. who.int/mediacentre/factsheets/ fs266/en/ (Last accessed: December 12 2014.)
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If you would like to contribute to the Art & science section, email [email protected] or @NSclinicalEd
The synthesis of art and science is lived by the nurse in the nursing act
Josephine G Paterson
Climate change and ecological public health Goodman B (2015) Climate change and ecological public health. Nursing Standard. 29, 24, 37-41. Date of submission: October 8 2014; date of acceptance: November 6 2014.
Abstract Climate change has been identified as a serious threat to human health, associated with the sustainability of current practices and lifestyles. Nurses should expand their health promotion role to address current and emerging threats to health from climate change and to address ecological public health. This article briefly outlines climate change and the concept of ecological public health, and discusses a 2012 review of the role of the nurse in health promotion.
Author Benny Goodman Lecturer in adult nursing and sustainability education developer, Faculty of Health and Human Science, Plymouth University, Cornwall, England. Correspondence to: [email protected]
Keywords Climate change, ecological public health, health promotion, nursing, public health
Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software.
Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: rcnpublishing.com/r/author-guidelines
NURSES HAVE A HISTORY of engaging in health promotion and public health. Both roles are reflected in the Nursing and Midwifery Council (NMC) Standards for Education (NMC 2010). However, trends such as population growth, new technologies and climate change suggest that nurses’ understanding needs to develop to adapt to a very different future. It is argued that nurses should move beyond adopting individualistic and behaviour-changing perspectives (Kemppainen et al 2012) to adopting an ethico-socio-political role (Falk-Raphael 2006) in health promotion, based on a wider understanding of what health promotion means. This article reflects on climate change, outlines the concept of ecological public health and discusses Kemppainen et al’s (2012) integrative review of the nurse’s role in health promotion.
Climate change Despite the requirement to curb greenhouse gas emissions to prevent catastrophic climate change (Costello et al 2009, Roberts and Stott 2011, McCoy et al 2014), the world is experiencing a continuing rise in anthropogenic (arising from human activity) greenhouse gases (Intergovernmental Panel on Climate Change (IPCC) 2014). This emissions increase is expected to persist as a result of population growth and economic activity, resulting in global mean surface temperature rises of 3.7°C to 4.8°C by 2100 if there is no further mitigation (IPCC 2014). This means that the average temperature on the surface of the earth may increase by that amount, compared with the average temperature in 1990. This rise is in excess of the 2°C safety threshold (Peters et al 2013, Marshall 2014, McCoy et al 2014), beyond which there may not be a safe operating space
©Downloaded NURSINGfrom STANDARD RCN PUBLISHING 11 other :: vol uses 29 no 24 :: permission. 2015 37 RCNi.com/ by ${individualUser.displayName} on Nov 23, 2015. For personal february use only. No without Copyright © 2015 RCNi Ltd. All rights reserved.
Art & science public health for humanity (Rockström et al 2009). In other words, it is recognised that the earth is warming up and to prevent severe consequences, such as sea level rises, extreme weather events and Arctic ice sheets melting, it is necessary to ensure that there is no more than a 2°C rise in average temperatures compared with those in 1990. McKie (2014) suggests that global evidence supports the assertion that climate change is already happening and is resulting in floods, melting permafrost, rising sea levels and lack of snow in the Alps. He states: ‘In its latest report, the Intergovernmental Panel on Climate Change estimates that up to 139 million people could face food shortages at least once a decade by 2070.’ According to Marshall (2014), heat waves and the extinction of animal species will be routinely experienced by the end of this century. Feeding 10 billion people will become more difficult, the loss of glaciers and ice sheets will result in two thirds of major cities being under water, and ocean acidification will adversely affect more than two thirds of the ecosystem surface (Marshall 2014). According to Climate Central (2014), record flooding in Washington DC this century is almost guaranteed. This influences thinking about where it will be safer to live in the United States. Alaska, the Mid West and the Pacific North West will fare much better than California and the South East if, as Mora et al (2013) state, unprecedented high temperatures become the norm by 2047. Mora et al (2013) go on to argue that Washington DC will reach its tipping point in 2047, Los Angeles in 2048, San Francisco in 2049 and Chicago in 2052. The tipping point will occur when extreme high temperatures become the new norm, rather than occasional, infrequent events. In other words, some scientists have accepted that increases in temperature and sea level will severely affect cities in the next few decades, requiring major adaptations around population migration and land and flood defences and major structural changes in economics and society. This is in line with the National Climate Assessment’s (2014) third report, which outlines the increases in temperature, making it clear that these adverse effects will occur in decades, not centuries. The effect of climate change on health has been documented elsewhere (World Health Organization (WHO) 2014a) and this is partly based on the social and environmental determinants of health (Barton and Grant 2006, WHO 2008). Barna et al (2012) have also set out what nurses should know about climate change, but the urgency of addressing this issue is increasing, as outlined by the NHS Sustainable Development Unit (2014) in Fit for the
Future: Scenarios for Low-Carbon Healthcare 2030. All of the above raises the question of what the health promotion role of the nurse might be in this context.
Ecological and planetary public health Horton et al (2014) call for a new social movement to support collective action on public health. They introduce the concept of planetary public health, rather than public health. As in Lang and Rayner’s (2012) discussion of ecological public health, Horton et al (2014) focus on the unsustainable nature of current consumption, linking it with poorer health outcomes. Horton et al (2014)’s concept of planetary public health relates to Barton and Grant’s (2006) ‘health map’, a circular diagram illustrating determinants of health. Climate stability, biodiversity and ecosystems are in the outer ring of the diagram, indicating that these are foundational determinants of health, without which no one can survive. The planet includes the climate system, biodiversity and ecosystems, so Horton et al (2014) are in accord with Barton and Grant (2006) in describing this foundation for human health. Horton et al (2014) also make an overtly political statement: ‘We have created an unjust global economic system that favours a small wealthy elite over the many who have so little.’ They call for urgent transformation of values and practices, based on recognising human interdependence and interconnectedness with a finite planet, and a new vision of democratic action and co-operation. A principle of ‘planetism’ is invoked, which requires the conservation and sustenance of the ecosystems on which humans rely. Finally, they suggest that public health and medicine can be independent voices of conscience, which, along with empowered communities, can confront entrenched interests. In the same vein, Ottersen et al (2014) are explicitly political regarding the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’. The tone of their report makes clear a need to address global governance and undertake an analysis of power. Such an analysis would highlight the fossil fuel industry as a major contributor to carbon emissions (Heede 2014) and, therefore, a direct threat to public health. Lang and Rayner (2012) point out that proponents of public health (and therefore, by implication, I would add public health nurses) have allowed their roles to develop around the language of individualism and choice, and such
38 february 11 ::from vol RCNi.com 29 no 24 by :: 2015 NURSING STANDARD / RCN Downloaded ${individualUser.displayName} on Nov 23, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
positioning leads to behaviour-change models and theories of rational action. These theories focus on changing the behaviour of individuals and are often based on a belief that, given enough education and information, people can make rational choices to change. However, they say that public health is about bigger social (and political) issues that might threaten vested interests, for example, the interests of the fossil fuel industry (Lang and Rayner 2012). They reviewed public health developments from the 19th century onwards and suggested a rethink is in order. They outlined four current models of public health, but suggested that they are anthropocentric, meaning that the health of the living, natural and physical world – the ecosystem – is marginalised. Climate change challenges those models, since it is fundamentally about ecosystem damage and the concomitant threats to health on a global scale. Ecological public health has two focuses on interactions, one on the biological world, for example biodiversity, and the other on material issues such as industrial pollution, energy use and toxicity. Ecological public health is based on systems thinking and complexity in understanding health. It has material, biological, cultural and social dimensions. It goes beyond simplistic behaviour-change models, which do not deal with socio-political contexts. ‘Telling families who live in poverty that they should make healthy choices ignores the conditions that prevent them doing so…is insulting and even futile’ (Lang and Rayner 2012). Telling families to eat less red meat, fly less and to stop consuming, without addressing the actions of global corporations is, arguably, similarly insulting and possibly futile in trying to curb carbon emissions (Klein 2014). The domains of public health, medicine and nursing may be insufficiently politically aware of the scale of the issues that affect human health. This may be because, until now, education of professionals has been ahistorical and apolitical, resulting in a lack of a sociological or political imagination driven by critical analysis of the link between current unsustainable lifestyles, political economies and public health. However, adopting the perspective of ecological public health, or seeing the world through a ‘sustainability lens’ (Goodman and East 2014), might encourage more healthcare practitioners and policy makers to critique and take action regarding current economic and political structures that create health inequities and, if some are to be believed, threaten civilisation (Costello et al 2009, Hamilton 2010, Klein 2014, Marshall 2014, Oreskes and Conway 2014). There are countervailing voices, which do not express the same level of threat and
even deny climate change is occurring (Goklany 2007, 2009a,b,c, Ben-Ami 2010, Delingpole 2013, Lehmann 2014), but many health groups, including the WHO (2008, 2014b,c), Faculty of Public Health (2014) and International Council of Nurses (2008), do not share these views.
Nurses’ role in health promotion practice Kemppainen et al’s (2012) integrative review on the nurses’ role in health promotion is based on an analysis of research papers from 1998 to 2011. Although it therefore does not include research published in the past few years, some of the conclusions still resonate today. Kemppainen et al (2012) argue that studies suggest nurses have adopted an individualistic and behaviour-changing perspective to health promotion, which is underpinned by nurses working from a holistic and/or patient-centred theoretical basis, or a chronic disease and/or medical-oriented approach. Neither of these theoretical groundings equips nurses with the knowledge or attitudes to address the emerging public health concept of planetary health, as outlined above. Although a common defining concept of health promotion found in the studies, along with the individual perspective and empowerment, was social and health policy, they state that ‘…nurses were not familiar with social and health policy documents [and] did not apply them to their nursing practice’. If this is still true, the policy initiatives such as the WHO’s 2008 social determinants of health and Horton et al’s (2014) manifesto for planetary and public health will not be found in nurses’ concepts of health promotion. Nurses’ health promotion expertise has historically focused on general health promotion, patient-focused health promotion and project management health promotion. Commonly this involved health education. The competencies outlined were based on multidisciplinary knowledge, skill-related competence and competence related to attitudes and personal characteristics (Kemppainen et al 2012). Nurses were expected to be aware of economic, social and cultural issues and their influence on lifestyle and health behaviour. Whether this included knowledge of climate change or other ecological issues is not clear and is not mentioned in Kemppainen et al’s (2012) review. The review highlighted the need to clarify the concept of health promotion and clearly stated that ‘health policies have little impact on nursing practice’ (Kemppainen et al 2012). Therefore, health policies directed at future trends, such as
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Art & science public health the ecological changes indicated above, will gain little support in practice unless changes are made. Indeed, Kemppainen et al (2012) noted that knowledge of future trends affecting population health was not identified as being part of nurses’ health promotion competencies. The review concludes: ‘It appears that nurses have not yet demonstrated a clear and obvious political role in implementing health promotion activities… their health promotion activities (are) based on knowledge and giving information to patients.’ Lang and Rayner (2012) argue that public health must address complexity and dare to confront power. This understanding ought then to be part of the language of health promotion used by nurses. In the UK, nursing students are introduced to the social determinants of health approach as outlined by the WHO (2008) and the Rio declaration (WHO 2011). The NMC’s Standards for Education (2010) states: ‘All nurses must understand public health principles, priorities and practice, in order to recognise and respond to the major causes and social determinants of health,
illness and health inequalities. They must use a range of information and data to assess the needs of people, groups, communities and populations and work to improve health, wellbeing and experiences of healthcare; secure equal access to health screening, health promotion and healthcare; and promote social inclusion.’ This introduces an ethical imperative and a socio-political role for nursing (Falk-Rafael 2006), since the NMC explicitly states that nurses are to work to improve health. If health has social determinants based on the distribution of money, power and resources, then nurses are required to understand what that means. Indeed public health principles are now embracing concepts such as the social determinants of health and going further in the ecological public health approach (Lang and Rayner 2012). Climate change and threats to ecosystems are real health concerns for individuals, communities and populations both at present and in the medium- to long-term future. The long term, in this instance, is defined as the 21st century. The scientific community agrees that we are moving towards a warmer world. The wider
References Barna S, Goodman B, Mortimer F (2012) The health effects of climate change; what does a nurse need to know? Nurse Education Today. 32, 7, 765-771. Barton H, Grant M (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health. 126, 6, 252-261. Ben-Ami D (2010) Ferraris for All: In Defence of Economic Progress. The Policy Press, University of Bristol, Bristol. Climate Central (2014) Risk Finder: Washington, DC. Surging Seas. http://sealevel. climatecentral.org/ssrf/dc (Last accessed: December 12 2014.) Costello A, Abbas M, Allen A et al (2009) Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. The Lancet. 373, 9676, 1693-1733.
Delingpole J (2013) Global Warming Believers are Feeling the Heat. http://blogs.telegraph.co.uk/news/ jamesdelingpole/100238047/ global-warming-believers-arefeeling-the-heat/ (Last accessed: December 12 2014.) Faculty of Public Health (2014) Sustaining a Healthy Future: Taking Action on Climate Change. www.fph.org.uk/uploads/r_ sustaining_a_healthy_ future.pdf (Last accessed: December 12 2014.) Falk-Rafael A (2006) Globalization and global health: toward nursing praxis in the global community. Advances in Nursing Science. 29, 1, 2-14. Goklany I (2007) Is a richer-but-warmer world better than poorer-but-cooler world? Energy & Environment. 18, 7/8, 1023-1048. Goklany I (2009a) Is climate change the ‘defining challenge of our age’? Energy & Environment. 20, 3, 279-302.
Goklany I (2009b) Climate change is not the biggest global health threat. The Lancet. 374, 9694, 973-974. Goklany I (2009c) Global health threats: global warming in perspective. Journal of American Physicians and Surgeons. 14, 3, 69-75. Goodman B, East L (2014) The ‘sustainability lens’: a framework for nurse education that is ‘fit for the future’. Nurse Education Today. 34, 1, 100-103. Hamilton C (2010) Requiem for a Species: Why We Resist the Truth about Climate Change. Earthscan, Oxford. Heede R (2014) Tracing anthropogenic carbon dioxide and methane emissions to fossil fuel and cement producers, 1854–2010. Climatic Change. 122, 1–2, 229-241. Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S (2014) From public health to planetary health: a manifesto. The Lancet. 383, 9920, 847.
Intergovernmental Panel on Climate Change (2014) Summary for policymakers. In: Climate Change 2014. Mitigation of Climate Change. Contribution of Working Group III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change. http://report.mitigation2014. org/spm/ipcc_wg3_ar5_ summary-for-policymakers_ approved.pdf (Last accessed: December 12 2014.) International Council of Nurses (2008) Nurses, Climate Change and Health. www.icn.ch/images/ stories/documents/publications/ position_statements/E08_Nurses_ Climate_Change_Health.pdf (Last accessed: December 12 2014.) Kemppainen V, Tossavainen K, Turunen H (2012) Nurses’ roles in health promotion practice: an integrative review. Health Promotion. 28, 4, 490-501. Klein N (2014) This Changes Everything: Capitalism vs. the Climate. Simon and Schuster, New York NY.
40 february 11 from :: vol RCNi.com 29 no 24 by :: 2015 NURSING STANDARD / RCN Downloaded ${individualUser.displayName} on Nov 23, 2015.©For personal use only. No other usesPUBLISHING without permission. Copyright © 2015 RCNi Ltd. All rights reserved.
health community and some nursing organisations are aware of the issues and are advocating for changes to practice and education. There are many who disagree either on the phenomenon of climate change itself, or on what to do about it. There is distrust of politicians based on fears of the introduction of global governance and state interference (Klein 2014, Marshall 2014), and many distrust the scientists themselves. Nurses already have a health promotion role, but it has been defined in particular ways that result in an inability to grapple with the new challenges that climate change and ecosystem damage are bringing. Thus, there is an urgent need to address the emerging paradigm of ecological or planetary public health in nurses’ health promotion definitions and competencies, to confront entrenched interests through individual and community empowerment. As Falk-Raphael (2006) argued: ‘Nursing’s fundamental responsibilities to promote health, prevent disease and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national and
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international levels to bring about reforms of the current global economic order.’
Conclusion It is becoming ever clearer that the global climate is changing, that human activity is causing most of this change and the consequences for people, population health and the diversity of plants and animals will be wide-ranging and in many cases severe. The timescale for action seems to be just a few decades if the temperature rise is to be kept around a ‘safe’ 2°C. Healthcare professionals are in a position to know what the effects of increased global temperature on human health might be and have been called to act. New concepts about public health and health promotion are emerging, requiring new understanding that goes beyond a focus on individual behaviour change through education. The health promotion role of the nurse will have to adapt to meet these challenges and new ways of thinking. This means understanding and applying an ecological public health model and a socio-political role NS
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