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Commentary
Acting on climate change for a healthier future
Critical role for primary care in Canada
Edward Xie MD MSc CCFP(EM) Courtney Howard MD CCFP(EM) Sandy Buchman MD CCFP(PC) FCFP Fiona A. Miller PhD
I
n 2018, the Declaration of Astana on primary health A number of factors promote resilience to climate
care renewed the principles established more than change in Canada, such as high national income, high
40 years earlier in another Kazakh city, once known levels of public concern and education, and universal
as Alma-Ata. Much of the new vision was familiar, with health coverage. Yet no one is immune, and people liv-
a notable addition: a warning that, without immediate ing with poverty or chronic illness are among those
action, “the health impacts of climate change” will con- most likely to be affected.8,17,22 Many First Nations, Metis,
tinue to end lives prematurely.1 and Inuit experience persistent health disparities and
Despite strong and consistent evidence, measures to intergenerational socioeconomic marginalization.19,23 By
address the links between climate change, health, and virtue of close relationships with the land, Indigenous
health care have not been proportionate to the urgency peoples are often the first to experience health effects
and severity of the problem.2 The Canadian public is of environmental degradation. Taken together, climate
increasingly concerned about the negative consequences.3 change will disproportionately harm people who have
In an address to the 2020 World Health Assembly, the contributed least to, and benefited least from, climate-
World Health Organization director-general announced altering activities.7,22
that we “cannot afford repeated disasters on the scale of
COVID-19 [coronavirus disease 2019], whether they are How does health care
triggered by the next pandemic, or from mounting envi- contribute to climate change?
ronmental damage.”4 To prevent even greater harm from The Canadian health care system is a major contribu-
climate change, a renewed focus on primary care values tor to GHG emissions, rivalling those of large economic
can be a healing shift in practice. sectors such as aviation.24 Medication is the largest pol-
luting category, comprising more than a quarter of all
Health impacts of climate change in Canada health sector GHGs.24 Emissions from pharmaceuticals
Climate change describes deviations of long-term weather may be owing to high consumption, especially for com-
patterns leading to increased frequency, severity, or dura- monly prescribed drugs, or because of potent climate-
tion of extreme events.5 These events interact in complex altering effects in the atmosphere, such as those caused
ways with the physical world and our social systems, con- by drug propellants.25 For example, delivery devices for
tributing to negative health outcomes already evident today inhaled bronchodilators can have dramatically different
and projected to accelerate in the future.6,7 Notwithstanding carbon footprints (Figure 2).25,26
this complexity, the Intergovernmental Panel on Climate Compared with countries with similar health out-
Change, representing global scientific consensus, found comes, Canada’s health care system also has high
that health outcomes will be overwhelmingly negative, with per capita carbon dioxide emissions (Figure 3). 27,28
“very high confidence.”8 Human activities are a major driver Differences are partly explained by electricity sources,
of climate change and also exacerbate the related problem population density, and measurement variations: factors
of air pollution.9 Along with releasing greenhouse gases not directly modifiable by the health sector.27 However,
(GHGs), the combustion of fossil fuels contributed to an esti- some health systems are making concerted efforts
mated 17 574 avoidable deaths in Canada owing to air pol- to reduce emissions within their control.29 Notably,
lution in 2015—more than all causes of injury, accidents, England’s national public health service improves sus-
and trauma combined.10,11 tainability through innovative models of care, technol-
Pathways to the health impacts of climate change are ogy, and behaviour change. Between 2007 and 2017, the
commonly grouped into 3 categories: direct effects from institution reduced carbon dioxide emissions by 18.5%
weather events, indirect effects from natural systems, despite increasing clinical activity.30
and indirect effects mediated through human systems.8 Compared with Canada and the United Kingdom,
Examples in Canada include links to vector-borne dis- many low- and middle-income countries have fewer
ease, disruption of health services, mental illness, pop- resources for adaptation to climate change yet are expe-
ulation migration, and mortality (Figure 1).12-19 Just as riencing some of the strongest impacts. Globally, heat
shutdowns due to COVID-19 have broken medical sup- exposure, food insecurity, and vector-borne diseases
ply chains, the increasing social, economic, and envi- threaten hundreds of millions of people. 12 Climate-
ronmental effects of climate change present major risks related changes in global migration and disease patterns,
to health and care delivery.9,20,21 alongside disruptions to labour productivity, transport,
Vol 67: OCTOBER | OCTOBRE 2021 | Canadian Family Physician | Le Médecin de famille canadien 725
Commentary Acting on climate change for a healthier future
Figure 1. Simplified examples of pathways linking climate change exposures with health outcomes and Canadian
examples: Direct and indirect effects are mediated through natural and human systems.
supply chains, and land use, may also have large-scale Primary care, and the health care system in general,
indirect effects on health and health care in higher- has the capacity to drive action through deep connections
income countries, including Canada.9,12 Examining this to people’s lives, large-market participation in hiring and
unequal access to the full enjoyment of health in the purchasing, and a trusted position of leadership in agenda
context of primary care values can offer insights into setting.7 Although mandates and resources for action from
strategies for change. governing bodies are not yet fully in place, we already pos-
sess the ability to act rapidly through existing structures
Our responsibility to act while advocating for necessary policy solutions and tools.
Social accountability has become a recognized duty of Failing to meaningfully act on climate change threat-
primary care providers and all health professions to meet ens the viability of high-quality health services through
the changing needs and emerging challenges facing economic and infrastructure disruption.12,22 Whether we
people in Canada.31 In conflict with goals of promoting deliberately address these challenges or not, our health
and protecting health, health system GHG emissions are systems are both contributing to the problem of climate
associated with preventable and growing downstream change and are poised to suffer its consequences.
harms.30 Since the environmental side effects of care The complex relationships between climate change
also affect work force, infrastructure, and personal health, and health necessitate a multifaceted and adaptive
managing health care–related pollution serves the full approach. While government actions, including car-
breadth of personal, professional, and societal interests. bon pricing, regulation, and investments in renewable
726 Canadian Family Physician | Le Médecin de famille canadien } Vol 67: OCTOBER | OCTOBRE 2021Acting on climate change for a healthier future Commentary
Figure 2. Estimated GHG emissions from dry-powder inhalers, metered-dose inhalers, and car travel
Figure 3. Comparison of emissions attributed to national health sectors in 2014
energy, can be powerful interventions to limit further resources, or be cost saving. Taking health gains into
warming, they must be complemented by efforts from account, mitigating climate change would likely result in
critical actors, including health institutions and pro- a large net benefit overall.32
fessionals, to alleviate existing and expected harms Primary care, as the largest medical work force, with a
(Figure 4).12,30 Some policies, such as phasing out coal, holistic commitment to the health of patients across the
can have real-time health benefits.12 Depending on the complete life cycle, has a distinctive interest in the pursuit
manner of implementation, these approaches could of health co-benefits, the prevention of harm, and inter-
require additional resources, involve reorienting existing ventions to support well-being beyond medical services.33
Vol 67: OCTOBER | OCTOBRE 2021 | Canadian Family Physician | Le Médecin de famille canadien 727Commentary Acting on climate change for a healthier future
Figure 4. Conceptual model of primary care in health system sustainability
Potential roles of primary care in achieving an impact on Framing climate change in terms of health is known to
climate change can be examined using a “macro, meso, be an effective communication strategy to help patients
micro” framework of social accountability.31 and health professionals conceptualize climate change
as salient to their lives.39 Most people recognize that cli-
Macro: policies to take mate change is a threat but do not appreciate its risks to
advantage of co-benefits their own health; describing health effects can close this
Advocating for health-in-all approaches to public policy psychological gap.40 To that end, medical schools across
can address the interconnected roots of both poor health Canada are beginning to introduce climate change into
and climate change.34 Shifting to prevention or manage- curricula.41 As a next step, family medicine academic pro-
ment earlier in the illness process can lower the inten- grams can integrate concepts into training and continu-
sity of care required to maintain or restore health. For ing development that address sustainability-promoting
example, dietary habits recommended in Canada’s Food practice changes.
Guide or policies to encourage active transport are likely
to prevent chronic disease and premature mortality, while Micro: innovation in quality
also lowering GHG emissions.7,35 Targeting the social and improvement and care delivery
structural determinants of health is necessary to limit the Innovative models of care can respond to unmet
unequal impacts of climate change, including prioritizing needs while also reducing unnecessary resource
the needs of populations at greatest risk, addressing his- use. During the COVID-19 pandemic, a rapid shift to
torical and ongoing injustices, supporting just economic virtual care is expanding a model that can address
transitions, and reducing health inequities.23,36,37 Advocacy challenges with geographic distribution and inequi-
and policy change must be carried out in partnership with ties of access for remote communities.42 Other inter-
groups at highest risk, many of whom already contribute ventions may combine patient-centredness with
critical knowledge and leadership.31 improved integration between clinical and commu-
nity supports. For example, “social prescribing” is an
Meso: emphasize sustainability emerging practice of linking patients with commu-
in education and health promotion nity activities such as volunteering, addiction support
Health professionals, and especially primary care provid- groups, and nature experiences.43,44 Early projects have
ers, are trusted sources of information to their commu- shown promise for improving wellness while shift-
nities and experienced with discussing complex issues.38 ing patients away from higher intensity care, and are
728 Canadian Family Physician | Le Médecin de famille canadien } Vol 67: OCTOBER | OCTOBRE 2021Acting on climate change for a healthier future Commentary
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Dr Edward Xie is Clinical Assistant Professor in the Department of Family and 20. Pharmaceutical industry profile. Ottawa, ON: Government of Canada. Available from:
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at the Toronto General Hospital Research Institute. Dr Courtney Howard is Clinical
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Associate Professor in the Cumming School of Medicine at the University of Calgary
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in Alberta. Dr Sandy Buchman is Associate Professor in the Department of Family
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Palliative Care at North York General Hospital. Dr Fiona A. Miller is Professor of Health
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Policy and Chair in Health Management Strategies in the Institute of Health Policy,
23. Wuttke S, Carter V, Williamson ASR. Factum of the Intervener, the Assembly of First Nations.
Management and Evaluation at the University of Toronto.
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Dr Edward Xie has received financial compensation as Faculty Co-Lead of Climate 24. Eckelman MJ, Sherman JD, MacNeill AJ. Life cycle environmental emissions and
Change and Health in the Department of Family and Community Medicine at the health damages from the Canadian healthcare system: an economic-environmental-
University of Toronto. Dr Courtney Howard is a board director of the Canadian Medical epidemiological analysis. PLoS Med 2018;15(7):e1002623.
Association and the Global Climate and Health Alliance. She has received financial 25. Patient decision aid. Inhalers for asthma. London, UK: National Institute for Health and
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