Friday, 3 July 2020

Cancer treatment and climate change

Dr Richard Dean - art exhibition in Stroud (2008)
In an earlier blog I looked at fear and hope and how, for me, there are similarities between cancer and climate change (i): “...climate change and cancer - both are a direct result of our lifestyle. Furthermore the progression of climate change and the delayed effects of our emissions give us a sense of unreality - this is so like a cancer diagnosis before we see debilitating symptoms. It seems to me all this is a huge opportunity to bring changes to the way we live that enhance, not just in our own health but also that of the planet."

In this blog I start to explore what is beginning to be done in terms of thinking about climate and health - and cancer in particular. It is a bit of a hotch potch but some disturbing, fascinating and hopeful facts are revealed here.
There have been a fair few big conferences with titles like "Reframing food, health and communities through the lens of sustainability” and some health authorities like Manchester and Newcastle have recognised the Climate Emergency (ii). Indeed the NHS was one of the first national health systems to produce a carbon reduction strategy 10 years ago and started measuring emissions in 2007. It is estimated the NHS produces 5.4% of the UK’s greenhouse gases (iii). 

I want to note up front that this blog barely skims the surface of this huge topic; so much impacts on our health. Indeed it was one of the areas that led me to support Green Party policies and then to become a District councillor for 8 years. It seemed to me other parties had policies that worked against health whereas Greens looked at how each policy interacted on another. So health isn’t just about medical services it is about public spaces, 20mph in all towns to reducing casualties, cutting pesticide use, a precautionary principle, more walking and cycling and so much more. 

Nothing like what is needed is being done. But here I will cover some of the exciting ways forward in our health services - starting with the Royal College of General Practioners (RCGP) - but please if someone reading this knows about other actions I would welcome links. 

General Practices going green

In September 2019 the RCGP Governing Council acknowledged the climate crisis and the catastrophic effect on human health of not acting decisively and urgently. They accepted a duty to provide leadership, and urgently escalate its action at local, regional, and national level to decarbonise and promote environmental sustainability. Before then, work had started with others and they were a founder member of the UK Health Alliance on Climate Change. This Alliance has developed the Green Impact for Health toolkit (iv) to help every general practice improve their sustainability and environmental impact. Terry Kemple, the former RCGP president and sustainability lead comments: “We want to promote actions in our practices for ourselves and our patients that are good for youthem and good for the planet.”

Frome Medical Practice has been leading the way - in conjunction with the RCGP England Severn Faculty and with the support of Ecotricity and Pukka, they hosted a Green Impact for Health Conference (v) - the first of it's kind in the country this last February. The aim of the Conference was to inspire and share ideas and support other practices who have already signed up to undertake the NUS / RCGP Green Impact Toolkit or who are considering doing so. It was indeed inspiring to see these pioneers. The presentations are shared online (vi) and you can see a short intro film here:

How we can make a difference?

They identified several key areas to consider:
  • Show how health outcomes will be badly affected
  • Use hard to refute facts to show the need for action
  • Use a real life story to cut-through apathy
  • Be clear about the behaviours that need to change
  • Show that any reduction has an impact on health outcomes
  • Show that small actions can have an impact on reduction
  • Give people simple actions, relevant to daily life, ideally with measurable results to maintain belief in positive impact on health outcomes
  • Have local, achievable goals
  • Show the efforts of Government and other authorities to change

Local artist Russ
Tackling energy use?

Well one of the obvious areas being considered is ‘Green’ electricity. Stroud-based Ecotricity started the first green electricity company in the UK around the mid-1990s. They could see that conventional electricity is responsible for 30% of Britain’s carbon emissions; our biggest single source as a nation, and therefore the biggest single thing we can change. Exciting news is they plan to have 1400 GP practices signed up by end of the year. Energy and energy conservation are critical.

Healthy food for a healthy planet?

This is another obvious area to consider re health. Rob Verkerk of the Alliance for Natural Health writes: "Food production has become a central issue as we consider how to tackle climate change along with associated environmental degradations and damage”. In an article from last year (vii) he goes onto look at what might be a healthy diet for a healthy planet; lots about more traditional diets, local food and organic farming that regenerates the soil and sequesters carbon. This is not the blog to go into this topic in any depth but the issue of food has been a constant challenge for me - so many varying opinions as well as recognising the impossibility of a one diet fits all approach. 

I also wanted to note that many of the 'cancer diets’ recommended rely on foods that are carbon-heavy; often travelling many miles or using particular farming techniques. Can we really expect organic blueberries every day all year? Having said that, a healthy diet is usually one with low or no meat and that is usually better for the environment. Then there’s a whole question about how in parts of our society those with more money can afford to live a more healthy lifestyle…..

Preventing illness

Oh my, I hardly want to cover this in this blog as it is another big, big area; there is so much to say about our current lifestyles. Take for example exercise - some have said it might be the single best thing we can do for our health (viii). However as I’ve covered in previous blogs we are not always supported to know what exercise might be good for us (ix). Crazily, despite the outcomes for many cancers being so good if you exercise a certain amount, many of us living with cancer were never given that information. I thought I was doing enough exercise but it was many months later that I discovered what I should be doing to impact most on my health. 
So one of the things I’m doing with others is to see if we can get every medical person in the cancer world aware of the importance of exercise and have more opportunities for people to learn about what exercise they can do (x).

Graph from The Spirit Level
One point under this heading I do want to make, as it is not heard enough and is key in preventing chronic illness. The book ‘The Spirit Level: Why Equality is Better for Everyone' (2009) by Kate Pickett and Richard Wilkinson, points out the "pernicious effects that inequality has on societies: eroding trust, increasing anxiety and illness, (and) encouraging excessive consumption". It shows that for each of eleven different health and social problems: physical health, mental health, drug abuse, education, imprisonment, obesity, social mobility, trust and community life, violence, teenage pregnancies, and child well-being, outcomes are significantly worse in more unequal rich countries. You can see a lot of their info on their website at:
Take the example of obesity - which has been so linked to cancer and rapidly rising to scary proportions - it is fine to talk about support and programmes to help people lose weight but a much deeper issue needs addressing. In the UK, two-thirds of adults are overweight and more than a fifth are obese with childhood obesity also on the rise. The book shows how obesity among men and women (see graph), as well as calorie intake and deaths from diabetes, are related to income inequality in rich countries (xi).

Deprescribing - Opiod project in Frome

I was astonished to learn from the Frome presentations that prescribing is estimated to be 20%—40% and perhaps up to 75% of a practice’s carbon footprint! Other estimates at the Frome conference suggest that 16% of the entire NHS, public health and social care system carbon footprint relates to pharmaceutical products. And of this 16% almost two thirds are due to just 20 medications–Includes atorvastatin, simvastatin and 'sip feeds' as well as most analgesics. Also of this 16% one fifth are due to just one thing – metered dose inhalers (xii).

Opioids are considered good analgesics for acute pain and end of life. Yet amazingly there is little evidence to support their role in chronic pain (xii), there is also no guidance from
the National Institute for Health and Care Excellence (NICE) to suggest that opioids are effective for chronic pain and the Royal College of Anaesthetists clearly highlight the harm they can cause. NHS England have published their proposals for structured medication reviews on all patients taking “high numbers” of addictive pain killers’ AND ‘reduce inappropriate prescribing of drugs known to cause dependency’.

The Frome Medical Practice set up a small project that was able to reduce these prescriptions by 16% and acknowledge there is scope for more. They are considering looking at other medications like Pregabalin, Gabapentin, Morphine, Oxycodone, Fentanyl, Codeine and are looking at inhalers. 

A Guardian article last September highlighted the environmental and financial cost of inhalers (xiii). Frome has started to promote inhaler recycling and switching to more sustainable inhalers. In this country up to 70% of inhalers prescribed by the NHS use metered dose inhalers, which use hydrofluorocarbons to propel the medicine into the airways. These gases are much more potent than CO2. NICE wants doctors to instead follow the Swedish example where 90% of inhalers are 'dry-powder' providing the same medicines without the greenhouse gas emissions. This could reduce total emissions by 4% (xiv).

It seems to me that this whole are of prescribing needs some serious attention, but guess it won’t be easy knowing the power and influence of pharmaceutical companies. In this next paragraph I turn to end of life treatment.

Rethinking end of life?

I recently finished reading the International bestseller ‘Being Mortal’ by Atul Gawande that came out in 2014. In this book he explores the modern experience of mortality and how modern medicine has changed this. The system is often failing us and he shares how, so often we are kept alive for a few more weeks but at a cost to our health and wellbeing that is very significant.

Another example of drugs we could rethink is the research by Professor Swanton; he reviewed 71 new drugs launched in the last 12 years up to 2016. He found that on average they extended life by just 2.1 months (xv). The Academy of Royal Colleges had concluded back in 2014 that palliative drugs were a waste of money which could be better spent on good nursing. Gawande in his book gives many examples of different approaches to end of life including a great story of how a doctor introduced dogs, cats and a 100 birds into a Nursing home and found increases in wellbeing and significant drops in drug use.

One story from Gawande stuck in my mind. Nelene Fox had metastatic breast cancer in 1991 and was terminal.Doctors offered her a radical new treatment of high-dose chemo and bone marrow transplantations. Her health insurance refused to fund the experimental treatment. Fox raised the $212,000 to pay for the treatment herself but it was delayed and she died 8 months after the treatment. Her husband sued the insurers and the jury awarded $89 million and the executives were branded killers. Research ultimately showed the treatment to have no benefit for breast cancer patients and actually worsens their lives.

In contrast another insurer, Gawande tells us, introduced a hospice option where they did not have to forego treatment. A two year study found the number of patients opting for this jumped from 26% to 70%. The surprise to the company, but perhaps not to readers here, was that they visited the emergency room half as often as the control patients and use of ICUs and hospitals dropped by more than two-thirds. Costs fell by a quarter. The conclusions were that people who were able to talk through options with someone experienced and knowledgeable were far more likely to die at peace and in control of their situation.

What is interesting in these examples is that the alternatives often have far less impact on the environment but are also healthy and better for us.

Russ cartoon
Rethinking services

End of life is not the only area that needs attention. Hilary Cottam in her book ‘Radical Help’ about the reimagining of the Welfare State for the 21st Century, has some good examples. One of the deeply disturbing parts of her book is to read her chapter on experiments in the NHS. Some of these were wonderfully successful liek the one mentioned above, saving money and delivering better care, yet commissioners repeatedly failed to find the funding. GP Dr Andy Knox in a great article. 'Reimagining Health and Care – An Apocalyptic Moment?’ (xvi) poses some useful questions like: 'How do we design a system that starts with the good life, enhances community well-being, enables better collaborative care within and from communities themselves, whilst being able to respond to real need?’ Certainly in any rethinking sustainability needs to be at the centre.

As someone who is fortunate to work for a charity that is helping build more welcoming communities I recognise the huge value of people coming together to share their interests and passions. Indeed it is more connected and resilient communities that seem to be fairing better in Covid-19 and will fair better in coming impacts of climate change. Building more welcoming inclusive communities is a big big part of the answer to tackling the impact of climate change - it is also when communities come together they can make the changes that are needed.A blog coming soon on this...

In recent years research has shown us the huge impact loneliness has on our health(xvii). We know about the benefits of coming together; one of the key determinants of health is about our connection to family, friends and out community (xviii). Anecdotally just this week some of the members of the Wigwam Cancer Support Groups I am helping to establish with the charity Yes to Life, have said how the group has been a key part of their healing (xix). 

Social Prescribing
See blog
I’ve blogged before on social prescribing (xx) but I want to mention it again here as it is part of the Green Impact Toolkit. It can have a part to play in linking people to others and to activities that can improve health outcomes. In many areas this has proven to be positive but in my blog I did note some warnings that to some, some schemes have been likened to 'anti-social prescribing’! 
In Frome it looks great from the presentations and they now have 400 local groups, over 1,400 connectors signposting folk to groups and more and 198 Talking Cafes each year where people can signpost to support and make friends. Measuring the impact on carbon will no doubt be very difficult but certainly reducing medication and reliance on health services has got to be good.

Lastly it is worth seeing this short film made by Stroud-based Ecotricity. It is about Frome Medical Practice’s work and includes mention of other practices they are doing to reduce their carbon footprint like recycling:

So come on Gloucestershire what can we do?


(iv) Green Impact for Health Toolkit:
(viii) See video:
(xii) “WHO analgesic ladder: a good concept gone astray” Ballantyneet al., 2016) From 1998-2018 opioid prescribing has more than doubled in the UK (Curtis et al., 2018) and NHS reports:

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