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General Practitioners’ responses to global climate change - lessons from clinical experience and the… Blashki, Grant; Abelsohn, Alan; Woollard, Robert; Arya, Neil; Parkes, Margot W; Kendal, Paul; Bell, Erica; Bell, R W Aug 8, 2012

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COMMENTARY Open AccessGeneral Practitioners’ responses to global climatechange - lessons from clinical experience and theclinical methodGrant Blashki1*, Alan Abelsohn2, Robert Woollard3, Neil Arya4, Margot W Parkes5, Paul Kendal6, Erica Bell7and R Warren Bell8AbstractBackground: Climate change is a global public health problem that will require complex thinking if meaningfuland effective solutions are to be achieved. In this conceptual paper we argue that GPs have much to bring to theissue of climate change from their wide-ranging clinical experience and from the principles underpinning theirclinical methods. This experience and thinking calls forth particular contributions GPs can and should make todebate and action.Discussion: We contend that the privileged experience and GP way of thinking can make valuable contributionswhen applied to climate change solutions. These include a lifetime of experience, reflection and epistemologicalapplication to first doing no harm, managing uncertainty, the ability to make necessary decisions while possessingincomplete information, an appreciation of complex adaptive systems, maintenance of homeostasis, vigilance forunintended consequences, and an appreciation of the importance of transdisciplinarity and interprofessionalism.Summary: General practitioners have a long history of public health advocacy and in the case of climate changemay bring a way of approaching complex human problems that could be applied to the dilemmas of climatechange.BackgroundThe history of humanity is a story of a species populat-ing the world from its origins in Africa, and survivingclimactic challenges through extraordinary ingenuity andtenacity. It’s clear that Homo Sapiens needed to adapt tomajor climatic changes over tens of thousands of yearsas they sought ways to guarantee their food supply, ini-tially as nomads, and then later through cultivating theland. What is unique about this time in history is thatwe are witnessing human induced pressures on theEarth’s life support systems at a rate and scale that chal-lenges the capacity of even robust ecosystems to adaptquickly enough.The leading scientific academies around the world arein agreement that the average global temperature isrising, and that it is most likely mainly attributable tohuman activities, in particular the emission of green-house gases [1]. While some legitimate debate continuesregarding the extent, rate of human contributions towarming, the most respected journals and scientificinstitutions are confident that climate change is indeedreal and is a serious concern for future generations[2-5].The impacts of climate change are already observablein a range of physical and biological systems [6]. The listincludes; more frequent and severe heatwaves [7],changes in precipitation which results in increasedflooding in some regions and drought in others [1],increases in the rate of sea level rise [1], an increase inthe strength of storms and other extreme weather events[1], an overall pattern of glacial retreat [1], and altera-tions in the distribution of infectious diseases includingwater and vectorborne diseases [8]. A number of plantand animal species are exhibiting changes in their geo-graphical distribution and the changes to the timing of* Correspondence: gblashki@unimelb.edu.au1Nossal Institute for Global Health & The Melbourne Sustainable SocietyInstitute, The University of Melbourne, 161 Barry St, Carlton, Melbourne 3010,AustraliaFull list of author information is available at the end of the article© 2012 Blashki et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Blashki et al. Asia Pacific Family Medicine 2012, 11:6http://www.apfmj.com/content/11/1/6their life cycles are consistent with a global warmingsignal [6].All these changes can have significant impacts on pub-lic health [9]. Some of these effects are direct such asinjuries from extreme weather events [8], or increasedmortality and morbidity related to heatwaves [7]. Thereare other impacts that are less direct such as the effectsof warming on food security [10], clean water [11,12],environmental refugees [13], and the mental [14] andeconomic [15] well-being of communities who are sub-ject to climate change effects. Together, climate changeand its effects are recognised as one of the great threatsto global public health in the coming century [16].DiscussionThe role of General PractitionersGeneral practitioners are first and foremost concernedwith the enormous task of providing competent compas-sionate clinical care of the patient who presents to them[17]. GP training and clinical experience tends to lead toa strong focus on individuals attending for consultations,usually ahead of the public health perspective [17]. It isalso true to say that the traditional general practitioneris not usually a key decision maker when it comes tomaking societal policy decisions that will dramaticallyaffect climate change, for example, the way in which weobtain our energy supply, our foreign trade policies, oreven our societal patterns of consumption.Yet there is much that general practitioners can offer.They have a special role as the generalists of the medicalsystem who bring a broad systems perspective and anunderstanding of their local communities [18]. From apractical perspective there is much that general practi-tioners can do to help encourage mitigation of climatechange [19] and also to assist communities in theiradaptation efforts [20]. A clear example is the provisionof health care in an environmentally responsible manner,for example, programs in Australia and New Zealandwhich assist practices to reduce energy, waste and waterusage [19,21] General practitioners can also use theirrelationships with their patients to encourage lifestylesthat are both good for the patient’s health and also goodfor the environment, for example encouraging activetransport, and eating locally grown fresh food [22]. Add-itionally GPs can play a role in advocacy for strong miti-gation targets within their countries, and this can beachieved individually or through joining a range of advo-cacy groups nationally, or internationally, such as theInternational Society of Doctors for the Environment[23,24], the International Association for Ecology &Health, the environmental working group of WONCA[25] , WHO [26] and other global medical organizations.The regional nature of climate change, which is aboutinteractions between place, community and individualhealth mean that general practitioners have a uniqueperspective about the health impacts of climate changein their local regions that national and international leveldata does not capture so well.All these activities are worthwhile and important con-tributions that general practitioners can make. Howeverthe remainder of this paper is more conceptual, explor-ing how the perspective and culture of general practice,with the immense experience of literally hundreds ofthousands of patient visits over a lifetime, might be ap-plied to the complex problem climate change presents(see Table 1).First do no harmThe medical principle of Primum non nocere arose at atime when the understanding of anatomy and physiologywas rudimentary and physicians were wisely called uponto take no action unless there was a reasonable prospectof improving a patient’s problem. Similar wisdom can beapplied to action on climate change. The principle isself-explanatory but often forgotten in medicine wheretoo often the cure is worse than the disease. GPs wellknow that whenever managing a patient we need toweigh up the risks and benefits of tests and treatmentsagainst the illness itself. Far from a call to therapeutic ni-hilism it is a call to humility in suggesting interventions,Table 1 Application of GP clinical principles to climate change dilemmasGP axiom Clinical application Climate change applicationFirst do no harm Consider potential risks of all clinicalmanagement plansEnsure responses and solutions to climate change don’t do harmManage Uncertainty Utilise probabilistic decision making in relation touncertain diagnosis or managementUndertake major societal decisions in context of scientificuncertainty about climate change predictionsAppreciate ComplexAdaptive SystemsUnderstand the interconnectedness of humanbiological systemsAppreciate the interdependence of geological, atmospheric,water and food systemsMaintain homeostasis Recognise the prominence of balance as acornerstone of human wellbeingRecognise the balance of earth systems as an indispensablerequirement for supporting lifeValue generalism Apply a broad psychosocial approach to maximisepatient wellbeingDon’t lose sight of the “big picture” in regards to climatechange and recognise the need for contributions from multipledisciplinesBlashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 2 of 5http://www.apfmj.com/content/11/1/6considering their ramifications as far as can be deter-mined and taking no irreversible action without consid-ering risks, benefits and who is assuming each. This is aprofoundly complex ethical process that has analogiesin society’s approach to complex challenges in theecosystem.As societies seek solutions to climate change there aremany potentially harmful wrong turns that could betaken. Perhaps the greatest risk is that in addressingclimate change, the vast inequities in the world (withtheir attendant impact on everyone’s health) are furtherexacerbated [27]. Great care is needed so as not to fur-ther economically burden the poorest and most vulner-able people in the world. Choices about new forms ofenergy are also fraught with technical pitfalls. Nuclearenergy may arguably well be less carbon polluting to theatmosphere (at least excluding uranium mining and theuncertain costs of disposal of waste) but the risks of mis-use of nuclear materials is perhaps the only global threatwhich is on par with climate change itself. How nationschoose to adapt to some inevitable impacts of climatechange can also potentially exacerbate the problem–forexample, mass air conditioning powered by carbon pol-luting energy sources to deal with heatwaves andwarmer temperatures may provide some short-term re-lief but clearly is not in our long-term interests. Theprinciple of Primum non nocere is a valuable guide towisdom and safety in this area.Managing uncertaintyGeneral practitioners are no strangers to uncertainty–undifferentiated illness, early presentations and diagnos-tic ambiguity are our stock in trade. So for example, apatient presenting with back pain could mean a widerange of possibilities including a minor strain, a metasta-sis of a cancer, or even psychological distress. Though itis true that managing uncertainty in healthcare is notthe same as uncertainty in climate science, the basicskills are transferable. Interpreting small changes in theaverage global temperature of the planet and the follow-on effects in physical and biological systems requires thesame probabilistic decision-making that GPs are soaccustomed to in interpreting early signs of disease intheir patients. Take for example hypertension, a sign in-visible to the patient but detectable by the clinician andone that heralds potentially catastrophic ramifications inthe future such as a stroke or blindness. Even a raisedtemperature, and its significance for the human body, ismetaphorically and literally analogous to the risingtemperature that climate scientists now detect in ouratmosphere.To make decisions in the context of uncertainty andto properly assess risks and benefits of courses of action(or inaction) is a great strength that the discipline ofgeneral practice can bring to issue of climate change.In their communities general practitioners are ideallyplaced to offer nuanced approaches to uncertainty andrisk management in a context where even scenario mod-elling is likely to have major limitations. For example,consider the management of malaria, which has provedto be a major challenge for regional forecasters, preciselybecause of the way that local contexts (e.g. the presenceof preventative activities and services) can mediatehealth effects [28-30].Appreciation of complex adaptive systemsThe importance of understanding complex adaptivesystems resides in recognising their intrinsic unpredict-ability, a property appreciated by GPs, and one that iscrucial to appreciating our climate system. A complexadaptive system is a dynamic network of interconnectedagents that impact on each other, and which results inemergent properties of the whole system. Emergent prop-erties can best be understood as that point when a sys-tem, such as a sports team, becomes more than the sumof its parts. Such systems, which include most livingthings, are open and non-linear which means smalleffects can have great ramifications for the whole system.This study of complexity has been used to understanddiverse systems such as the workings of the brain, thebehaviour of insects and even the machinations of theeconomy.It can be helpful to differentiate between simple, com-plicated and complex approaches to problem solving[31]. Simple problems can be dealt with by a recipeproperly applied. However the differentiation betweencomplicated and complex problems is a more nuancedyet fundamental difference to understand when consid-ering global warming and the specific skills the GP canbring to the issue. Compare for example a complicatedproblem, (lets say, sending a rocket to the moon), with acomplex problem, (for instance raising a child). In theformer example, current efforts inform future attempts,formulae are essential, high levels of expertise in mul-tiple fields are necessary and rockets are similar incritical ways. However, in the case of raising a child,formulae have a limited application, raising one childprovides experience but not assurance with the next, ex-pertise is necessary but not sufficient for success andevery child is unique and must be understood as anindividual.As general practitioners we have a built-in sense ofthis type of complex thinking, and we see it in action ona daily basis in clinical situations- from the unexpectedside-effects and interactions of medications throughto the psychological reverberations of trauma throughfamilies and communities. Every day we see medicalconditions play out in unpredictable and oftenBlashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 3 of 5http://www.apfmj.com/content/11/1/6unexpected ways as patients, their families and commu-nities adapt (or don’t) to challenges to their health. Anapparently small dysfunction can spiral a patient intohigh levels of distress and disability. And seeminglycatastrophic illness can unexpectedly resolve throughhealing mechanisms not always apparent to us. It is arare day in practice when we are not confronted withboth the fragility and the resilience of human fleshand the human experience.So too the emergent properties of the climate aredriven by processes, which characterise complex adap-tive systems. For example, a slightly warmer atmospherecan drastically increase its capacity to carry moisture,resulting in shifts in the patterns of precipitation–some-times causing floods, sometimes causing droughts. And,as with human physiology, there are tipping pointswhere, the capacity of the system to adapt is over-whelmed. The great risk of climate change is that it maytip the climate system, like a patient going into renalfailure, into an irreversible new state. For instance, cli-mate change could trigger a positive feedback loopwhere melting permafrost releases long trapped methanegases that in turn further warm the planet.In the same spirit of exploration with which the gener-alist physician approaches complex disease, they can setaside the debilitating hopelessness often attending com-plex and large scale change, and thoughtfully seek tobuild interventions and feed-back loops that are charac-teristic of solutions to complex problems. Adaptiveexpertise is the hallmark of general practice and it is alsoa key area where climate change and health research andmedical education, training and practice have much tolearn from each other [32]. The adaptive expertise ofgeneral practitioners stands in contrast to the approachto complicated problems that demands mechanisticinterventions and predictable, reproducible impacts fromexperimental interventions.Maintenance of homeostasisLife is a balancing act, from human physiology throughto the Earth’s physical systems that allow life to flourish.It is clear that the earth, like the human body, has nu-merous regulatory systems, and negative feedback loopswhich like the porridge in the Goldilocks and the ThreeBear’s fairytale is “just right” for life [33]. Our bodieshave evolved complex hormonal and chemical thermo-stats to make sure our temperature, our salts, and ourfluids all stay within a narrow range necessary for life.Every patient encounter and proposed therapy must takethis homeostasis into account. It is the basis for the fra-gility and resilience noted above.Similarly, the Earth’s physical systems maintain theconcentrations of key elements in our oceans and at-mosphere and the lands that allow life to exist and anyapproach to influencing them must humbly take thisinto account. For example, concentrations of carbondioxide in the atmosphere (the natural greenhouse) arecrucial to keeping the Earth within a temperature rangein which human beings can live and even thrive. How-ever, all homoeostatic systems have their limits and wecan see the impacts of excessive carbon dioxide beyondthat which the oceans can absorb, resulting in oceanacidification with catastrophic implications for shell for-mation and the oceans’ food chain [34]. It is not simplythat general practitioners understand homeostasis:through their special relationship with their local com-munities, they have intimate knowledge of the factorsthat shape fragility and resilience in those communities.GeneralismGeneral practitioners are generalists–they are not con-strained by the demographics of their patients, nor thenature of their illnesses [35]. As non specialists GP's playa key role in integrating health care and pulling togetherthe skills of their specialist colleagues, as well as othertypes of knowledge, to improve service for patients andfoster healthier communities [35].The approach to the problem of climate changerequires a similar balance of specialisation and general-ism. What is required is problem solving at multiplelevels, paralleling the role of the GP, to tie together thestrands of knowledge from experts from different fields–from climate scientists to economists to psychologistsjust to name a few professions; and from the values andaspirations of people and communities themselves.SummaryIt is clear from the failures of the world to act on climatechange that scientific knowledge alone is necessary butnot sufficient to create political climate change solutions.Lessons from general practice, which is often the com-mon sense of the health system, could be usefully ap-plied to bringing together society wide transformationsthat effectively address climate change.Competing interestsThe Author declare that they have no competing interest.Author contributionsGB conceptualised the initial manuscript. All authors have contributed to theconceptual development and commented on successive drafts of themanuscript.Author details1Nossal Institute for Global Health & The Melbourne Sustainable SocietyInstitute, The University of Melbourne, 161 Barry St, Carlton, Melbourne 3010,Australia. 2Department of Family and Community Medicine and Dalla LanaSchool of PublicHealth, University of Toronto, 1466 Bathurst Street, #205,Toronto, ON M5R-3S3, Canada. 3Department of Family Practice, University ofBritish Columbia, 320-5950University Blvd, Vancouver, BC V6T 1Z3, Canada.4Director Global Health Office Western University AssistantClinical ProfessorFamily Medicine McMaster University and Adjunct Professor EnvironmentBlashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 4 of 5http://www.apfmj.com/content/11/1/6and Resource Studies University of Waterloo, 200 University Avenue West,Waterloo, ON N2L 3G1, Canada. 5School of Health Sciences, University ofNorthern British Columbia, 3333 University Way, Prince George V2N 4Z9,Canada. 6Rural Coordination Centre of British Columbia, University of BritishColumbia, 300 - 5950 University Blvd, Vancouver, BC V6T 1Z3, Canada.7University Department of Rural Health, University of Tasmania, Elizabeth St,Hobart 7001, Australia. 8Canadian Association of Physicians for theEnvironment Active Staff, Shuswap Lake General Hospital Salmon Arm,Salmon Arm, BC V1E 4S2, Canada.Received: 16 November 2011 Accepted: 18 July 2012Published: 8 August 2012References1. IPCC: Summary for Policymakers. In Climate Change 2007: Impacts,Adaptation and Vulnerability. Contribution of Working Group II to the FourthAssessment Report of the Intergovernmental Panel on Climate Change. 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Davies P: The Goldilocks Enigma- why is the universe just right for life? UnitedKingdom: The Penguin Press; 2008.34. Kerr RA: Ocean acidification unprecedented, unsettling. Science,328(5985):1500–1. Jun 18.35. Parkes MW, Bienen L, Breilh J, Hsu L, McDonald M, Patz JA, et al: All Handson Deck: Transdisciplinary Approaches to Emerging Infectious Disease.Ecohealth 2005, 2:258–72.doi:10.1186/1447-056X-11-6Cite this article as: Blashki et al.: General Practitioners’ responses toglobal climate change - lessons from clinical experience and the clinicalmethod. Asia Pacific Family Medicine 2012 11:6.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitBlashki et al. 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