Tim Hoff: Welcome to Ethics Talk, the American Medical Association Journal of Ethics podcast on ethics in health and health care. I'm your host, Tim Hoff. This episode is an audio version of a video interview conducted by the Journal's editor in chief, Dr Audiey Kao, with Dr Andrew Jameton. Dr Jameton is a Professor in the Department of Health Promotion, Social and Behavioral Health at the University of Nebraska. He joined us to talk about the global health threat posed by the COVID-19 pandemic and its intersection with the climate crisis. To watch the full video interview, head to our site, JournalOfEthics.org, or visit our YouTube channel.
Dr Audiey Kao: Professor Jameton, welcome to Ethics Talk. [music fades out]
Dr Andrew Jameton: Thanks. Thanks for having me here in this virtual space. And pleased to see you, Audiey, and to work with the Journal of Ethics.
Kao: Well, we're glad you're here today. So, as you know, this past April, the world heralded the 50th anniversary of Earth Day. While most events marking this milestone were forced online by the pandemic, the novel coronavirus has also shown that individual behaviors in the aggregate can dramatically reduce carbon emissions as seen in photos of clear blue skies across the world's most polluted cities. That said, people don't want to feel guilty about driving, flying, or eating out: many activities that increase greenhouse gas emissions but have been curtailed during this pandemic. While climate change can't be solved without infrastructure shifts away from fossil fuels, what do these past several months say about the responsibilities of all of us as consumers in addressing the global climate crisis?
Jameton: Well, I think your point about the importance of infrastructure is right on target. Because if we're talking about individual responsibilities and the collective effects, a lot of what individuals cause by way of carbon emissions are first, not intended and second, are only part of the overall emissions. So, if you go and lead a simple life and cut down on your consumption, which I think we should, those of us who are using a lot of consumer goods, that's only part of the story. So, it's really important to go out and work with others on changing the infrastructural problem and cutting back on the use of fossil fuels. And I think the COVID experience is a bit of a rehearsal for what needs to be done under climate change.
Jameton: And also, doing our bit gives us some authenticity in our voice when we do promote these other changes.
By the way, although I'm in ethics and big on talking with people about their intended actions, a lot of the important things that happen with this now are sort of the indirect environmental effects of other things. So, the unintended effects of our actions are really important. And I think the response to that is more around shame than guilt. So, I don't want to make people get mad because I'm telling them they should feel guilty. But I think we should all feel, to some degree, ashamed.
Kao: Yeah. That's an interesting, affective point that you're raising here. I'm wondering which of those are affective motivators are more powerful in terms of changing both individual and collective behaviors?
Jameton: I don't know. My work in ethics consultation in clinical areas was mostly I seldom very directly said anything about ethics or what people ought to do. Mostly it was a series of queries that drew people out and helped people reach consensus. And generally, we're talking about facts that have important ethics implications. But you don't have to tell people that they're ethically important, especially in clinical areas. People know it quite well.
Kao: Right. So, climate change and the coronavirus pandemic are obviously both global phenomenon, reflecting the interconnectedness of all species on this planet. So, for example, habitat destruction and deforestation are increasing the contact between humans and other species. This may increase the likelihood of zoonotic transmission of disease from animal hosts to humans. Given that, how should climate scientists and public health experts work together to combat these global threats? And more specifically, how should they respond to denials of and attacks on the scientific basis for COVID-19 and climate change by elected officials and those who put them in office?
Jameton: I've been impressed with regard to climate change and the health sciences. If you go to the IPCC reports, the Intergovernmental Panel on Climate Change, there's a lot of stuff on there in health. And there are thousands and thousands of articles on health conditions, tens of thousands on climate and health issues. And I think the public health people in particular pay a lot of attention to the science. So, that part, I think, is going well. I understand, of course, that it's tempting to sort of soften some of these messages and perhaps politically proper or useful. But I think we all need, insofar as possible, to tell the truth about what we're seeing, and that isn't happening as much as I would like.
It's becoming pretty clear that the world is not going to make its 2015 climate goal of a 1.5 degree limit to global warming. We're going to blow by that certainly by 2050 and probably 20 years earlier. And by 2050, we could be well above two degrees and even more. And I think for the most part, I'm not hearing that loud and clear from the health professions. Probably what happens with that is that the health problems in mid-century will be quite immense, as well as the disruptions to supply chain, hospitals, transportation to hospitals, on and on and on, that will make it very difficult to deliver good health care in this situation. And I'm hearing a lot about public health, but nowhere near enough about the role and effects of health care itself.
And COVID has been somewhat of a message about the instability and defects, shall we say, of the American health care system, where it still suffers problems of high and unpredictable costs, disconnections, lack of preparation for general basic health problems, overemphasis on high-cost care and so on, high-tech, high-cost care, these kinds of things. And these have been made more transparent and will have to be dealt with, with regard to climate change, as well as with COVID.
Kao: Right. Reflecting on what you just said, one further point of connection potentially between COVID-19 and climate change is air pollution, a leading environmental cause of death worldwide. A study recently published in the Proceedings of the National Academy of Sciences found that minoritized communities are acutely vulnerable to air pollution because of the neighborhoods in which they live. The analysis found that White people are disproportionately responsible for consumption of goods and services generating fine particulate matter that gets lodged in the lungs, causing inflammation that triggers diseases such as heart attacks and strokes. The study concludes that White people enjoy a so-called pollution advantage, bearing the burden of 17 percent less air pollution than is generated by their own consumption. Black and Latinx people, on the other hand, experience a pollution burden. They face 56 and 63 percent more exposure, respectively, than is caused by their consumption. How should health professionals consider and respond to these latest findings of environmental health inequities?
Jameton: Well, I think health professionals should do so and speak to these issues, as you are now. And I think it should be clear that the problems posed in particular about air pollution are all part of a family in which the people who use the most consumer goods and produce the most carbon dioxide are causing most of the damage in the world. Oxfam figures there's a 10 percent of the global population that emits about 50 percent of the carbon dioxide, and many climate scientists, Kevin Anderson was very vocal about this, are focusing on not so much on paying attention to people who are poor, but paying attention to people who are well off and seeing if there are ways of many of these, shall we say, health habits bad for other people can be dealt with?
I think one of the important things that people in health care can do right now is that people are anxious to get back to work and to business and rebuild the economies around the world. And there's a host of people who want to put it back the way it was and rebuild roads and airlines and get back to using more fossil fuels. And indeed, just in The Times today, there was a nice article—it wasn't today, a few days ago, anyway—a nice graph showing that the 17 percent dip in carbon dioxide emissions has practically been erased by now, and we're up close to maybe just a five percent dip. And, of course, what will be needed to get to 1.5 degrees, much less 2 degrees is something like a 10 to 15 percent drop in fossil fuel use every year for the next 15 years or so in the First World and developed world. And I don't think anyone's ready to do that. So, I think a vocal health professional voice that says, “We don't think we should go back to normal here. This is not going to work. We need to think about a more modest consumer world technology to serve that rather than the expansive notion of sustainable development. We need to think in terms of growing limits under climate change.”
Kao: Yeah, I think those are well-made made points. And I think, as I'm thinking about your last comments, I think you've alluded to it already: the global health care industry is responsible for about two gigatons of carbon dioxide each year, or about 4.4 percent of worldwide net emissions. And that's the equivalent of 514 or so coal-fired power plants. And if the global health care sector were a country on its own, it would be the world's fifth largest emitter of greenhouse gases. So, given that, and obviously, the health care industry's mission is to promote health, how should clinics, laboratories, and hospitals respond to the climate crisis, given their large carbon footprint?
Jameton: Well, I think it's a question of balance. Clearly, even if we make tremendous achievements in public health to mitigate the damage to health of climate change, there will still be a great need around the world for acute care, health care, hospitals, clinics, treating individuals, and so on. You might think of this is the high cost of the whole public health built environment health picture. And of course, it has to be somewhat high-cost. The question is how high a cost and how high in ratio to other things? And here's where I think we can say something nice and something not so nice about what's going on. Health Care Without Harm, Practice Greenhealth, and many others have been building up, and some hospital groups and so on, really been building up the greening of their institutions and trying to cut down on carbon dioxide emissions and generally on toxic waste and waste volume and a bunch of things like that that are very nice and also promoting health efforts in their neighborhoods around them. And that's great. However, they're very small percent of the U.S. health care system as a whole.
And we're in this funny position where we know everything about what needs to be done, and everything is being done except what is necessary: which is scaling up all that work to cover all of health care and then to look at the design of medicine itself, that is what we provide in the clinical armamentarium and technology that is environmentally problematic and really too large. The earth is going down. And we've talked a bit about justice, but in the long run, it looks like we're experiencing, in climate change, an existential long-term event. And that's a nice line from a philosopher that says, “An acceptable system of ethics is contingent on its ability to preserve the ecosystems which sustain it.” And we're not doing such a good job there. So, in some way, we're all in the wrong.
And I think that environmental element—which by the way, has been utterly absent for the most part in the history of bioethics itself, health care ethics—needs to be really combined with it. And there's a kind of tragedy that environmental ethics and health care ethics have become separate specialties and aren't talking to each other enough.
Kao: Yeah, I think that's a good point. I also have wondered, given this pandemic, there's been a need to find creative ways to reuse health care supplies that, in the past, during quote-unquote “normal times” we would use once and dispose of.
Kao: And obviously, I'm not suggesting that once we get back to quote-unquote “normal” that we reuse PPE. But I wonder if that spirit of creativity that the coronavirus has brought on can be applied post-pandemic so that many of the things that the health care sector uses that are used once and then disposed of can be reimagined. But I guess time will tell.
Jameton: Well, yeah, that's a good point. Although it's been one that's been being made quite strongly for 20, 30 years, something like that. This will, of course, to put more pressure on it. I think there's a lot of wonderful stuff going on. And I should've worn some of the nice masks that my wife made that look very nice and are the good informal kind. But single-use items, plastic disposal sharps and the red bag waste, you go to that literature, that's been well studied. And I think part of the problem is the group purchasing organizations are playing a game of sort of maximizing profit, minimizing cost at fractions of a cent. When actually, that's the bulk of environmental costs that need to be considered, and these are virtually never considered in all of these financial kinds of things.
Jameton: So, until we can some way index the environmental costs of all this stuff—and by the way, using less is more powerful than just switching from single-use to reuse in many cases—that we're not going to solve this problem as long as we keep it within this financing perspective. It has to be an environmental perspective. And we're not doing it, and it'll be hard to do.
Kao: Yeah. Yeah, no. I think you make a good point because I think the cost benefit analyses often don't take into account the environmental cost. Because—
Jameton: No, it's almost always finance—
Kao: —it's a negative externality that the hospital or clinic doesn't have to worry about.
Kao: I've also thought that, as opposed to a slow motion crisis like the climate change crisis, the pandemic is more a regular speed or fast motion crisis.
Kao: And to the extent that that mobilizes and concentrates the mind in terms of creativity and focus, I just wonder if any of that will carry on post the pandemic to address other global health threats like the climate [inaudible; cross-talk] that we confront.
Jameton: Well, it'll be interesting to see how that plays out. Because in this case, the lack of supplies and reusable supplies has been quite hazardous for health professionals and workers of all kinds at all levels and in addition to patients. And I don't know what will happen, but certainly, there will be some important discussion about these things as the pandemic sort of slides down over the years.
Kao: Yeah. So, as we near the end of our conversation today, in December 2017, you authored an article in the AMA Journal of Ethics as part of a group of articles on the theme issue of climate change. And according to the National Oceanic and Atmospheric Administration, the amount of carbon dioxide in the air just last month hit an average of more than 417 parts per million. And that's the highest monthly recording ever made. So, can you share, in lot of the article that you authored in our journal, can you share with our audience some of the key points that you raised in your article about physicians' climate advocacy responsibilities in the exam room and in the public square?
Jameton: Yeah, there's good people who've addressed it in the exam room, and they've been teaching in some of our classes. And I don't think I'm qualified to do that, nor did I address it in the article. It was mostly about physicians and their role in fighting the denial that you asked about further, the political denial. And by and large, medical professional organizations are scientific organizations and have done a nice job of speaking to the issues and being straightforward. And I certainly endorse that. So, we're kind of talking about the public message. However, I do have regrets about the article. I don't think, you know, a thing happens when you write papers in ethics and look for references and so on, you sound all grown up and mature. And I wasn't urgent enough about this. This is very important material that's highly hazardous, not just to poor people around the world, but to everyone. And as Mona Sarfaty said and quoted in one of your AMA items, most medical groups see climate change as a health emergency that we have to address as quickly as possible to avoid far more catastrophic impacts. And, by the way, impacts more varied and stronger than the pandemic itself even.
And what I regretted was I like the journal. I liked talking with the AMA. I don't think it's helpful to be rude, but AMA's made a couple statements, and I checked the last few days. I'm still not finding anything that says, “Oh, yes. We have a staff of six in our sustainability division who are working on nothing but climate change and adapting health care to it and the professional positions on it.” And I look at the statements, and it says, oh, we're the ones to lead. Why should physicians lead? They're too rich by and large, although the banks own most of them. But you can't lead by example if you're very well off, because this is a question of justice and poverty and the increasing impoverishment of the world. And then I look at the statements. The AMA has hedged. As I recall, the sustainability division's all about income maintenance and happiness, which is great. All it needs to do is take on what would need to be a fairly serious staff well led by climate scientists and public health people to figure out how physicians' jobs can survive in the 20, 30-year frame of climate change. And I'm not betting it's going to do that. So, I'm kind of upset about it all in that I didn't say that more clearly in the article.
Kao: Yeah. Well, I appreciate your candor, because I do think that the global public health threat that climate change poses is something that we need to take with greater urgency than we have been. And maybe some of the lived experiences and lessons from this pandemic will apply to the climate change-public health threat as well. And even though you didn't have a chance to say that in your article back in 2019—
Jameton: Oh, I had a chance. I chose not to. It was [inaudible; cross-talk].
Kao: —you've gotten another bite at the apple. And so, I think that I appreciate your candor. And I think that the AMA Journal of Ethics welcomes discussions on difficult issues. And I think that—
Jameton: I know you do. I think you guys are great, and you're doing a great job. But I did look at your publication schedule for topics in the next few months. It's a great time to connect COVID rather heavily with climate change, and I don't see climate change mentioned in any of the up and coming things. So, if I were you, I would take this more seriously and actually work on the journal schedule, and be talking with people you report to about how they're going to build their climate change response division at the AMA.
Kao: Yeah. Yeah, well, I think your point's well made. Hopefully, this interview will be one indication of that going forward. So, I want to thank Professor Andrew Jameton for sharing his targeted and candid expertise and deep insights with our audience today. Professor Jameton, thank you for being a guest on Ethics Talk.
Jameton: Hey, thanks, Audiey. Appreciate it.
Kao: Finally, I want to encourage everyone to continue wearing face masks, especially in larger gatherings. These actions will not only protect you, but your fellow human beings, and will hopefully hasten the pandemic's end. On the other hand, the climate crisis will not end unless we also act as a global community with urgency. Thank you for joining us today. We'll see you next time on Ethics Talk. [bright theme music plays]
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