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Background: Climate change is a global public health problem that will require complex thinking if meaningful and effective solutions are to be achieved. In this conceptual paper we argue that GPs have much to bring to the issue of climate change from their wide-ranging clinical experience and from the principles underpinning their clinical methods. This experience and thinking calls forth particular contributions GPs can and should make to debate and action. Discussion: We contend that the privileged experience and GP way of thinking can make valuable contributions when applied to climate change solutions. These include a lifetime of experience, reflection and epistemological application to first doing no harm, managing uncertainty, the ability to make necessary decisions while possessing incomplete information, an appreciation of complex adaptive systems, maintenance of homeostasis, vigilance for unintended 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 change may bring a way of approaching complex human problems that could be applied to the dilemmas of climate change. Background rising, and that it is most likely mainly attributable to The history of humanity is a story of a species populat- human activities, in particular the emission of green- ing the world from its origins in Africa, and surviving house gases . While some legitimate debate continues climactic challenges through extraordinary ingenuity and regarding the extent, rate of human contributions to tenacity. It’s clear that Homo Sapiens needed to adapt to warming, the most respected journals and scientific major climatic changes over tens of thousands of years institutions are confident that climate change is indeed as they sought ways to guarantee their food supply, ini- real and is a serious concern for future generations tially as nomads, and then later through cultivating the [2-5]. land. What is unique about this time in history is that The impacts of climate change are already observable we are witnessing human induced pressures on the in a range of physical and biological systems . The list Earth’s life support systems at a rate and scale that chal- includes; more frequent and severe heatwaves , lenges the capacity of even robust ecosystems to adapt changes in precipitation which results in increased quickly enough. flooding in some regions and drought in others , The leading scientific academies around the world are increases in the rate of sea level rise , an increase in in agreement that the average global temperature is the strength of storms and other extreme weather events , an overall pattern of glacial retreat , and altera- tions in the distribution of infectious diseases including * Correspondence: firstname.lastname@example.org water and vectorborne diseases . A number of plant Nossal Institute for Global Health & The Melbourne Sustainable Society Institute, The University of Melbourne, 161 Barry St, Carlton, Melbourne 3010, and animal species are exhibiting changes in their geo- Australia graphical distribution and the changes to the timing of Full 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 Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Blashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 2 of 5 http://www.apfmj.com/content/11/1/6 their life cycles are consistent with a global warming relationships with their patients to encourage lifestyles signal . that are both good for the patient’s health and also good All these changes can have significant impacts on pub- for the environment, for example encouraging active lic health . Some of these effects are direct such as transport, and eating locally grown fresh food . Add- injuries from extreme weather events , or increased itionally GPs can play a role in advocacy for strong miti- mortality and morbidity related to heatwaves . There gation targets within their countries, and this can be are other impacts that are less direct such as the effects achieved individually or through joining a range of advo- of warming on food security , clean water [11,12], cacy groups nationally, or internationally, such as the environmental refugees , and the mental  and International Society of Doctors for the Environment economic  well-being of communities who are sub- [23,24], the International Association for Ecology & ject to climate change effects. Together, climate change Health, the environmental working group of WONCA and its effects are recognised as one of the great threats  , WHO  and other global medical organizations. to global public health in the coming century . The regional nature of climate change, which is about interactions between place, community and individual Discussion health mean that general practitioners have a unique The role of General Practitioners perspective about the health impacts of climate change General practitioners are first and foremost concerned in their local regions that national and international level with the enormous task of providing competent compas- data does not capture so well. sionate clinical care of the patient who presents to them All these activities are worthwhile and important con- . GP training and clinical experience tends to lead to tributions that general practitioners can make. However a strong focus on individuals attending for consultations, the remainder of this paper is more conceptual, explor- usually ahead of the public health perspective . It is ing how the perspective and culture of general practice, also true to say that the traditional general practitioner with the immense experience of literally hundreds of is not usually a key decision maker when it comes to thousands of patient visits over a lifetime, might be ap- making societal policy decisions that will dramatically plied to the complex problem climate change presents affect climate change, for example, the way in which we (see Table 1). obtain our energy supply, our foreign trade policies, or even our societal patterns of consumption. First do no harm Yet there is much that general practitioners can offer. The medical principle of Primum non nocere arose at a They have a special role as the generalists of the medical time when the understanding of anatomy and physiology system who bring a broad systems perspective and an was rudimentary and physicians were wisely called upon understanding of their local communities . From a to take no action unless there was a reasonable prospect practical perspective there is much that general practi- of improving a patient’s problem. Similar wisdom can be tioners can do to help encourage mitigation of climate applied to action on climate change. The principle is change  and also to assist communities in their self-explanatory but often forgotten in medicine where adaptation efforts . A clear example is the provision too often the cure is worse than the disease. GPs well of health care in an environmentally responsible manner, know that whenever managing a patient we need to for example, programs in Australia and New Zealand weigh up the risks and benefits of tests and treatments which assist practices to reduce energy, waste and water against the illness itself. Far from a call to therapeutic ni- usage [19,21] General practitioners can also use their hilism it is a call to humility in suggesting interventions, Table 1 Application of GP clinical principles to climate change dilemmas GP axiom Clinical application Climate change application First do no harm Consider potential risks of all clinical Ensure responses and solutions to climate change don’t do harm management plans Manage Uncertainty Utilise probabilistic decision making in relation to Undertake major societal decisions in context of scientific uncertain diagnosis or management uncertainty about climate change predictions Appreciate Complex Understand the interconnectedness of human Appreciate the interdependence of geological, atmospheric, Adaptive Systems biological systems water and food systems Maintain homeostasis Recognise the prominence of balance as a Recognise the balance of earth systems as an indispensable cornerstone of human wellbeing requirement for supporting life Value generalism Apply a broad psychosocial approach to maximise Don’t lose sight of the “big picture” in regards to climate patient wellbeing change and recognise the need for contributions from multiple disciplines Blashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 3 of 5 http://www.apfmj.com/content/11/1/6 considering their ramifications as far as can be deter- general practice can bring to issue of climate change. mined and taking no irreversible action without consid- In their communities general practitioners are ideally ering risks, benefits and who is assuming each. This is a placed to offer nuanced approaches to uncertainty and profoundly complex ethical process that has analogies risk management in a context where even scenario mod- in society’s approach to complex challenges in the elling is likely to have major limitations. For example, ecosystem. consider the management of malaria, which has proved As societies seek solutions to climate change there are to be a major challenge for regional forecasters, precisely many potentially harmful wrong turns that could be because of the way that local contexts (e.g. the presence taken. Perhaps the greatest risk is that in addressing of preventative activities and services) can mediate climate change, the vast inequities in the world (with health effects [28-30]. their attendant impact on everyone’s health) are further exacerbated . Great care is needed so as not to fur- Appreciation of complex adaptive systems ther economically burden the poorest and most vulner- The importance of understanding complex adaptive able people in the world. Choices about new forms of systems resides in recognising their intrinsic unpredict- energy are also fraught with technical pitfalls. Nuclear ability, a property appreciated by GPs, and one that is energy may arguably well be less carbon polluting to the crucial to appreciating our climate system. A complex atmosphere (at least excluding uranium mining and the adaptive system is a dynamic network of interconnected uncertain costs of disposal of waste) but the risks of mis- agents that impact on each other, and which results in use of nuclear materials is perhaps the only global threat emergent properties of the whole system. Emergent prop- which is on par with climate change itself. How nations erties can best be understood as that point when a sys- choose to adapt to some inevitable impacts of climate tem, such as a sports team, becomes more than the sum change can also potentially exacerbate the problem–for of its parts. Such systems, which include most living example, mass air conditioning powered by carbon pol- things, are open and non-linear which means small luting energy sources to deal with heatwaves and effects can have great ramifications for the whole system. warmer temperatures may provide some short-term re- This study of complexity has been used to understand lief but clearly is not in our long-term interests. The diverse systems such as the workings of the brain, the principle of Primum non nocere is a valuable guide to behaviour of insects and even the machinations of the wisdom and safety in this area. economy. It can be helpful to differentiate between simple, com- Managing uncertainty plicated and complex approaches to problem solving General practitioners are no strangers to uncertainty– . Simple problems can be dealt with by a recipe undifferentiated illness, early presentations and diagnos- properly applied. However the differentiation between tic ambiguity are our stock in trade. So for example, a complicated and complex problems is a more nuanced patient presenting with back pain could mean a wide yet fundamental difference to understand when consid- range of possibilities including a minor strain, a metasta- ering global warming and the specific skills the GP can sis of a cancer, or even psychological distress. Though it bring to the issue. Compare for example a complicated is true that managing uncertainty in healthcare is not problem, (lets say, sending a rocket to the moon), with a the same as uncertainty in climate science, the basic complex problem, (for instance raising a child). In the skills are transferable. Interpreting small changes in the former example, current efforts inform future attempts, average global temperature of the planet and the follow- formulae are essential, high levels of expertise in mul- on effects in physical and biological systems requires the tiple fields are necessary and rockets are similar in same probabilistic decision-making that GPs are so critical ways. However, in the case of raising a child, accustomed to in interpreting early signs of disease in formulae have a limited application, raising one child their patients. Take for example hypertension, a sign in- provides experience but not assurance with the next, ex- visible to the patient but detectable by the clinician and pertise is necessary but not sufficient for success and one that heralds potentially catastrophic ramifications in every child is unique and must be understood as an the future such as a stroke or blindness. Even a raised individual. temperature, and its significance for the human body, is As general practitioners we have a built-in sense of metaphorically and literally analogous to the rising this type of complex thinking, and we see it in action on temperature that climate scientists now detect in our a daily basis in clinical situations- from the unexpected atmosphere. side-effects and interactions of medications through To make decisions in the context of uncertainty and to the psychological reverberations of trauma through to properly assess risks and benefits of courses of action families and communities. Every day we see medical (or inaction) is a great strength that the discipline of conditions play out in unpredictable and often Blashki et al. Asia Pacific Family Medicine 2012, 11:6 Page 4 of 5 http://www.apfmj.com/content/11/1/6 unexpected ways as patients, their families and commu- approach to influencing them must humbly take this nities adapt (or don’t) to challenges to their health. An into account. For example, concentrations of carbon apparently small dysfunction can spiral a patient into dioxide in the atmosphere (the natural greenhouse) are high levels of distress and disability. And seemingly crucial to keeping the Earth within a temperature range catastrophic illness can unexpectedly resolve through in which human beings can live and even thrive. How- healing mechanisms not always apparent to us. It is a ever, all homoeostatic systems have their limits and we rare day in practice when we are not confronted with can see the impacts of excessive carbon dioxide beyond both thefragilityand theresilience of human flesh that which the oceans can absorb, resulting in ocean and the human experience. acidification with catastrophic implications for shell for- So too the emergent properties of the climate are mation and the oceans’ food chain . It is not simply driven by processes, which characterise complex adap- that general practitioners understand homeostasis: tive systems. For example, a slightly warmer atmosphere through their special relationship with their local com- can drastically increase its capacity to carry moisture, munities, they have intimate knowledge of the factors resulting in shifts in the patterns of precipitation–some- that shape fragility and resilience in those communities. times causing floods, sometimes causing droughts. And, as with human physiology, there are tipping points Generalism where, the capacity of the system to adapt is over- General practitioners are generalists–they are not con- whelmed. The great risk of climate change is that it may strained by the demographics of their patients, nor the tip the climate system, like a patient going into renal nature of their illnesses . As non specialists GP's play failure, into an irreversible new state. For instance, cli- a key role in integrating health care and pulling together mate change could trigger a positive feedback loop the skills of their specialist colleagues, as well as other where melting permafrost releases long trapped methane types of knowledge, to improve service for patients and gases that in turn further warm the planet. foster healthier communities . In the same spirit of exploration with which the gener- The approach to the problem of climate change alist physician approaches complex disease, they can set requires a similar balance of specialisation and general- aside the debilitating hopelessness often attending com- ism. What is required is problem solving at multiple plex and large scale change, and thoughtfully seek to levels, paralleling the role of the GP, to tie together the build interventions and feed-back loops that are charac- strands of knowledge from experts from different fields teristic of solutions to complex problems. Adaptive –from climate scientists to economists to psychologists expertise is the hallmark of general practice and it is also just to name a few professions; and from the values and a key area where climate change and health research and aspirations of people and communities themselves. medical education, training and practice have much to learn from each other . The adaptive expertise of Summary general practitioners stands in contrast to the approach It is clear from the failures of the world to act on climate to complicated problems that demands mechanistic change that scientific knowledge alone is necessary but interventions and predictable, reproducible impacts from not sufficient to create political climate change solutions. experimental interventions. Lessons from general practice, which is often the com- mon sense of the health system, could be usefully ap- Maintenance of homeostasis plied to bringing together society wide transformations Life is a balancing act, from human physiology through that effectively address climate change. to the Earth’s physical systems that allow life to flourish. Competing interests It is clear that the earth, like the human body, has nu- The Author declare that they have no competing interest. merous regulatory systems, and negative feedback loops which like the porridge in the Goldilocks and the Three Author contributions Bear’s fairytale is “just right” for life . Our bodies GB conceptualised the initial manuscript. All authors have contributed to the conceptual development and commented on successive drafts of the have evolved complex hormonal and chemical thermo- manuscript. stats to make sure our temperature, our salts, and our fluids all stay within a narrow range necessary for life. Author details Nossal Institute for Global Health & The Melbourne Sustainable Society Every patient encounter and proposed therapy must take Institute, The University of Melbourne, 161 Barry St, Carlton, Melbourne 3010, this homeostasis into account. It is the basis for the fra- Australia. 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Asia Pacific Family Medicine – Springer Journals
Published: Aug 8, 2012
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