November 2013: Planetary Health: starting in Devonport!

What have sustainability, global health and health inequalities in Plymouth got in common, and why should they be part of medical education?

The link is of course that the ultimate source of human health is our shared home, the earth. As we overstep what Johan Rockström has usefully described as planetary boundaries – not only for greenhouse gases, but many other critical things such as water use and chemical pollution, it will inevitably impact on health.

Here is the link with inequalities though; it will often be other people’s health that we affect. More precisely, most of the consequences, at least to start with of rich lifestyles will be felt by the poor.  This is health inequalities on a global scale: early death is the ultimate social exclusion!

Within medicine, voices have been calling pretty much in the wilderness for doctors to think seriously about climate change. Organisations like Medact (http://www.medact.org/), a pioneering group that grew out of the former International Physicians for the prevention of nuclear war have led the way. Its former chairman, Dr Robin Stott now leads the climate and health council (http://www.climateandhealth.org/). The “campaign for greener healthcare” was founded in 2008. Now called the Centre for Sustainable Healthcare (http://sustainablehealthcare.org.uk/).

Over the last year though everything has changed, doctors leaders have listened to their scientific colleagues and most of the major medical journals have run articles on global health and anthropogenic climate change.

Map of the City of Plymouth and differences in life expectancy

The city of Plymouth demonstrates the problem of inequalities in heath as starkly as anywhere in England. The map below shows that if one were to catch a bus from Widewell in the north to Devonport in the south, there would be on average 2 years of life expectancy less for every mile travelled.

Why is health so unequal? There are probably 2 main underlying factors. One has been underlined very eloquently by Sir Michael Marmot who now leads the Institute for Health Equity at UCL in London. His research (most accessibly presented in his book “Status Syndrome”) demonstrates that health is to a great extent socially constructed. That is, it depends on the conditions in which people are born, live and work. Put simply, being poor is very bad for your health. This does not only apply to absolute poverty but also to relative poverty. There is a social gradient in health that is not fixed but depends on how we organise our society.

Another book, by social epidemiologists Richard Wilkinson and Katie Pickett called “The Spirit Level” shows that more unequal societies (and we are increasingly one of those) do worse not only on health, but on many other measures.

So, to answer my original question, the thread that links all this is that the way that we all live our lives and organise our societies will largely determine future health –and there is a win- win here. Most of the ways that we can respond to planetary threats like climate change will improve global and individual health too and reduce inequalities. Using cars less, walking and cycling more, eating less meat and processed food, producing clean energy, living in efficient homes – all will improve health.

This positive message drives what is now often known as “ecological public health” and it forms the basis for a curriculum in sustainable healthcare that has just been agreed across most of UK medical schools following a “Delphi” consultation conducted by the Centre for Sustainable Healthcare mentioned above.

The full curriculum can be found at http://sustainablehealthcare.org.uk/sustainable-healthcare-education/expanded-learning-outcomes. It is based around 3 main headings.

1. Describe how the environment and human health interact at different levels.
2. Demonstrate the knowledge and skills needed to improve the environmental sustainability of health systems.
3. Discuss how the duty of a doctor to protect and promote health is shaped by the dependence of human health on the local and global environment.

At Plymouth University Peninsula Schools of Medicine and Dentistry we are now looking at extending sustainability teaching to include these outcomes. Perhaps more importantly, the new school has included “making a difference” firmly in its ethos.

The most practical outworking of this opened in February of this year. The new Devonport Academic Health Centre is a joint venture between the University of Plymouth and Plymouth Community Health Care, who provide primary care and community services in the city. Clinical academic staff both provide care and teach in the new centre. Medical students, together with dental, nursing and other healthcare students now divide their time between the safety of the medical school buildings and the more edgy environment of Devonport, a neighbourhood having one of the highest index of multiple deprivation scores and worst health outcomes in England.

Children in a Devonport primary school

Children in a Devonport primary school eating sausages and  “turkey twizzlers” produced in a welsh food factory (this situation has fortunately improved following the “Jamie Oliver” school lunch campaign)

Our aim is that puPSMD will truly be a socially accountable medical school, where students not only learn from a global and sustainable perspective, but are encouraged to make a difference themselves. I call this the “locally global” curriculum!

 Dr Richard Ayres, Lead for Population Health at Plymouth University Peninsula Schools of Medicine and Dentistry and GP Cumberland Surgery, Devonport.