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.

June 2013: Uncertainties, knowledge gaps and research priorities

“Imagine a world in which the scientists who were pioneering new understanding of earth system processes were also those who were most active in embedding that new knowledge in the delivery of social or economic value” Dr Tim Daley (i)

In the recent years, researchers are increasingly challenged not only participate in creating knowledge but to take a more active role in translating this knowledge into policy and practice. Researchers along with research organisations, funding agencies and charities make decisions every day what topics would be conducted as a research project. These research projects shape the available knowledge that policy makers, practitioners, managers and the public use to inform their decision making. However, there are few studies done evaluating systematically how decisions on selecting certain research questions affect the scope of the knowledge that is available to policy makers and the public (ii). For example a study engaging with patients with osteoarthritis of knee demonstrated a mismatch between the uncertainties that patients and clinicians face (effectiveness of physiotherapy and surgery, and assessment of educational and coping strategies) and the research that was conducted (research predominately evaluated drugs) (iii). Consequently, we need to ask ourselves (a) “are we, as researchers, doing enough to fill the knowledge gaps that policy makers and the public face in every day decision making” (b) can an earlier dialogue between the researchers and the public, practitioners and policy makers on shaping identifying, shaping and prioritisation of research questions increases the relevance and acceptability of our research”. As part of an international community called Cochrane Agenda and Priority Setting Methods Group (http://capsmg.cochrane.org), we attempt to answer these and other methodological questions to develop an evidence base for methods to prioritise research and set a research agenda. (Photograph by Roland Gehrels from the Climate Science Group with Plymouth University).

Our ongoing quest to identify and prioritise key uncertainties for dental research has identified uncertainties on strategies to achieve and maintain environmental sustainability in the dental care. This was identified as part of a research priority setting project with the Shirley Glasstone Hughes Trust and British Dental Association (BDA). The BDA hosts an online forum called curious about (http://www.bda.org/dentists/education/sgh/). Dentists are encouraged to join the online forum and submit burning question to problems they have encountered in their day to day dental practice. Once a month, they are given the opportunity to vote for the questions. The fund would commission a rapid evidence review on the most voted question; this review will be subsequently published in the British Dental Journal. The rapid evidence review intends to demonstrate whether (a) the question is already answered with research but there is a gap in translating the research to practice or (b) there is a genuine uncertainty and the question still remains unanswered. Every year, the trustees come together and make a decision informed by the rapid evidence reviews which of the prioritised topics are in more urgent need for new research to fill the knowledge gap. The selected topic (or topics) would be part of a commissioned funding call. The fund goes a step further in ensuring the relevance of its commissioned research to its final targeted audience (general dental practitioners); it requires that each grant proposal be led by a general dental practitioner in collaboration with academic researchers.

In 2012, one of the questions that was raised and prioritised was “can plastics used in dentistry act as an environmental pollutant? Can we avoid the use of plastics in dental practice?”. The rapid evidence review identified a narrative review on environmental legislations that are relevant to dental care environment. The narrative review suggested that dentists should consider using environmental audit as part of their daily practice. However, there were no studies identified evaluating the feasibility, applicability and impact of environmental audit in dental practices (iv). Further explorative searches (as part of the rapid evidence review) identified a randomised controlled trial (RCT) comparing two impression materials in a general dental practice. Unlike most RCTs which evaluate patient and biomedical outcomes, this one evaluated an environmental outcome, the relative wastage of the materials (v). The rapid evidence review has shown that despite a number of studies discussing and exploring the issue of environmental sustainability in dental care environment, there are no studies identified directly answering the prioritised question. We are currently working together with researchers in Institute for Sustainability Solutions Research on developing research proposals and applying for research grants to make the first step in filling up this knowledge gap. Finally, I do like to encourage you to “Imagine a world in which the scientists engage in a dialogue with policy makers, practitioners, managers and the public to understand their day to day problems, questions and uncertainties and reflect on strategies that facilitates making collective decisions on what research topics are most worth answering through research”.



Note: If you are interested in research priority setting methods, we developed a collection of publications and other resources on (http://capsmg.cochrane.org). You could also join us on our next two events in the Cochrane Colloquium in Quebec City, Canada (www.colloquium.info) in Sep 2013. We are organising workshop on planning and conducting a research priority setting exercise and also a special session on responsive evidence development.










(i) Daley T. Institute for Sustainability Solutions Research JanuaryBlog. http://www1.plymouth.ac.uk/research/issr/Documents/ISSR%20Blog%20January%202012.pdf

(ii) Nasser M, Welch V, Ueffing E, Crowe S, Oliver S, Carlo R. Evidence in agenda setting: new directions for the Cochrane Collaboration. J Clin Epidemiol. 2013 May;66(5):469-71. doi: 10.1016/j.jclinepi.2012.08.006. Epub 2013 Jan 9. PubMed PMID: 23312393.

(iii) Tallon D, Chard J, Dieppe P. Exploring the priorities of patients with osteoarthritis of the knee. Arthritis Care Res. 2000 Oct;13(5):312-9. PubMed PMID: 14635301.

(iv) Nasser M. Evidence summary: can plastics used in dentistry act as an environmental pollutant? Can we avoid the use of plastics in dental practice? Br Dent J. 2012 Jan 27;212(2):89-91. doi: 10.1038/sj.bdj.2012.72. Review. PubMed PMID: 22281636.

(v) Wilson N H, Cowan A J, Crisp R J, Wilson M A. Wastage of a silicone impression material in a general practice setting: a comparison between hand and automixing methods. SADJ 2001;56: 233–236.

Dr Mona Nasser is a Clinical Lecturer in Evidence Based Dentistry

December 2012: But Will Xi Jinping Save the Planet?

As the world waited with bated breath for the re-election of President Barack Obama and the transfer of leadership from Hu Jintao to Xi Jinping in the People’s Republic of China, events in both countries served to emphasise the urgency of strong political leadership on environmental policy - East and West.

The return of Obama to the White House following the devastation of Hurricane Sandy was interpreted by some as a small vote for action on climate change. With his subway still partially under water, Mayor of New York Michael Bloomberg endorsed Obama just five days before the election asserting the President’s environmental credentials.

And whether or not ordinary Americans linked Hurricane Sandy to anthropogenic climate change, they have given Obama a second chance. In his acceptance speech the President affirmed “We want our children to live in an America that isn't burdened by debt, that isn't weakened by inequality, that isn't threatened by the destructive power of a warming planet.”

While it is indeed welcome that the largest economy in the world (for now) is run by a President who appears determined to address the domestic risks of climate change, it was in Beijing that more decisive policies were being fashioned. For it is in China, not in the US, that rapid economic growth creates the most spectacular environmental risks and perhaps the greatest opportunities for innovation in sustainable energy, transportation and agriculture.

In the run-up to the 18th National Congress of the Communist Party of China there was clear recognition of the momentous environmental challenges the world is facing, and the increasing responsibility of the world’s second largest economy to address those challenges.

According the English language China Daily, official Party commentary acknowledged that “Problems have emerged in the country's economic development, including unreasonable energy consumption and environmental pollution, causing some to doubt whether the world can survive a China living an American lifestyle.”

Popular unrest over environmental pollution continues to grow in China, with street protests successfully halting the $8.8bn expansion of a Sinopec petrochemical plant in Ningbo in October. Warnings are issued on a regular basis by state environmental protection agencies concerned about water, soil and air quality issues. Persistent photochemical smog remains a serious environmental health issue in many of China’s largest cities. And Chinese scholars have estimated that the Chinese economy is incurring environmental costs as high as 8.9% of Gross National Income, compared to just 0.5% in Germany.

But things are changing fast. In China’s new Energy Policy 2012, released in late October, the State Council announced that China wants to cut CO2 emissions per unit of GDP by up to 45% by 2020 (compared to 2005 levels). The Chinese Government promises strong support for hydroelectricity, biomass, wind and solar energy generation. And – doubtless spotting a massive export opportunity for Chinese technology - China has signalled the resumption of its domestic nuclear power generation programme as part of a commitment to reach 15% non-fossil fuel electricity generation by 2020.

In pursuing such a radical transformation in its energy mix, China is taking to heart the advice of business experts that supporting domestic markets for clean energy will enable China to compete globally in the development, sale and deployment of 21st century energy technology.

In a report for WWF released in June 2012: Clean Economy, Living Planet – The Race to the Top of the Global Cleantech Market, authors Arnoud van der Slot and Ward van den Berg of strategy consultants Roland Berger noted that by 2015, the ‘cleantech’ sector could be as large as €290 bn - up from €200 bn in 2011. Fastest growing suppliers to the global cleantech market in 2010/11 were Taiwan (+36% on the 2009/2010) and China (+29%). India and South Korea were tied at +19%.

But most telling of all is that China’s absolute sales of cleantech equipment (€57 bn in 2011), are now greater than both the EU (€47 bn) and the US (€37 bn). As a proportion of clean tech sales to GDP, at 1.7%, China is well placed between Denmark (1st) and Germany (3rd) in the ranking of economies focused on green manufacturing. Around half of these sales are wind and solar technology.

According to the WWF report, in 2011 seven of the world’s top 10 public flotations in cleantech industries were Chinese companies. And loan guarantees of more than $40bn were provided to seven Chinese companies in the solar energy business in the same year.

Given the continuing weakness of the European and US economies, and the massive investments in cleantech R&D being made by Chinese and South Korean businesses, there can hardly be any doubt that it will be East Asian businesses, and not European or American firms that will be dominating many cleantech growth opportunities in coming decades.

As long ago as 1995, strategy guru Michael Porter wrote in the Harvard Business Review: “Successful environmentalists, regulatory agencies and companies will reject old trade offs and build on the underlying economic logic that links the environment, resource productivity, innovation and competitiveness.”

It appears the Chinese were listening. They may have some way to go on resource efficiency and pollution control, and sponsoring the global proliferation of nuclear power may make many environmentalists squeamish, but which other country is promising 5 million electric and plug in hybrid vehicles on the road by 2020? With Bloomberg estimating his family wealth in excess of $1bn, Xi even might want to finance some of that personally.

David Wheeler is Pro Vice-Chancellor (Sustainability) at Plymouth University and Dean of the Plymouth Business School (At time of writing).

This article will appear in Croner’s Environment Magazine 50, 22

October 2012: I’m Mandy, Fly Me

When David Cameron announced his Cabinet reshuffle in September, there was a shudder amongst environmentalists reacting to the appointment of (fox hunting, badger culling, climate denying) Owen Paterson at DEFRA and the replacement of (scourge of the airport expanders) Justine Greening at Transport. Green Tories like ‘honest’ Zac Goldsmith and ‘bicycling’ Boris Johnson were quick to give their ecological sabres a public rattling, with Goldsmith threatening to force a by-election in his Richmond Park constituency if the Conservatives did a U turn on the third runway at Heathrow.

The replacement of (popular and knowledgeable) Charles Hendry by (wind farm opposing) John Hayes at DECC was seen as further evidence that Mr Cameron had finally given up on his ‘greenest government ever’ aspirations, even if (beleaguered eco-enthusiast) Greg Barker was left in place as Climate Change Minister for the time being. All of these changes appeared to confirm that George Osborne was winning the argument for killing off any prospect of financing a green economic recovery via the Treasury.

One of the most intriguing observations in the aftermath of the reshuffle was the fact that new Transport Minister Patrick McLoughlin has a fear of flying.

I was reminded of the 10CC’s 1976 hit I’m Mandy Fly Me, with its juxtaposition of a fear of flying with the seduction of an airline poster girl who gets us to buy a ticket anyway. Like Mr Cameron, Mandy overcomes our fears “with a smile as bright as sunshine” and we are welcomed aboard. As Mr McLoughlin joined DfT no doubt he managed to control any irrational fears – even as the HS2 decision loomed and Virgin’s objection to the West Coast Main Line decision was being filed. Facing the combined ire of the Tory shires and Sir Richard Branson might spook many ambitious politicians, but evidently not Mr McLoughlin.

Although many Croner Environment readers may not have been born when 10CC were in the UK charts with Mandy (Zac Goldsmith would have been in nappies), those of my generation will recall that the opening lines of the song also carried a warning: “oh no you’ll never get me up in one of those again; because what goes up, goes up, must come down, down, down….”

And so if we continue weaving the narrative of the fading green credentials of Mr Cameron’s government with the lyrics of Mandy, we might ask at what point the Coalition turns into an environmental plane wreck.

The first clear signal that Liberal Democrat queasiness with their role in the Coalition might take a nasty turn came in the run up to their annual Party Conference in Brighton; with the lack of Tory support for green investment as the chosen battleground.

In an interview with the Guardian on the eve of the conference, Coalition super-loyalist Danny Alexander, chief secretary to the Treasury complained that Tories were waging a "constant war of attrition" on green issues ….claiming they were “endangering billions in green investment, as well as the whole government growth strategy”.

Former Energy Secretary Chris Huhne crossed swords with the Chancellor on these topics many times before he resigned from the Cabinet to fight his prosecution for perverting the course of justice. But the fact that Alexander was directly challenging his boss at the Treasury signalled the seriousness of this new attack, raising the spectre of open warfare over prospects for a green economy.

If such a war does break out, many of the battle lines are likely to be drawn on the energy economyenvironment axis, with the Lib Dems challenging George Osborne and the right wing of the Conservative party on how the economy gets decarbonised – with or without fracking, and with or without nuclear power. As the Telegraph noted on 22nd September “the row over energy has now become a major fault-line in the Coalition that is set to define the next few years.”

Before everyone prepares too gleefully for the disintegration of the Coalition over its developing environmental schizophrenia, perhaps we might enter a note of caution. Canada had a minority Conservative government between 2006 and 2011 and the absence of absolute control meant that the environmental scepticism of successive administrations was kept broadly in check. But since winning an outright victory in 2011, Prime Minister Stephen Harper’s Conservatives have abolished the National Round Table on Environment and the Economy, cancelled several thousand Federal environmental reviews, and confirmed themselves as unrestrained cheerleaders for the continued expansion of tar sands in Alberta.

If a majority Tory Government is elected in 2015 on the back of a Lib Dem meltdown, some on the hard right may see that as a mandate for ditching all green pretentions – perhaps with George Osborne as PM in waiting. In which case we may wish to keep our fingers crossed that life jackets will be found under our seats…..

David Wheeler, Pro Vice-Chancellor (Sustainability) at Plymouth University and Dean of the Plymouth Business School (At time of writing) 

This article will appear later in the year in Croner’s Environment Magazine 49, 22