Ásthildur Árnadóttir - Sustainability in practice

Transcript

Please note that the following transcript is AI generated an may contain errors.

Thank you.

Dear colleagues and friends, thank you for the invitation to be here.

I'll make sure you have a little break before the next session.

But yeah, my name is Austildur, I'm from Iceland, living in Denmark.

And I am a general practitioner working in Nysted, Laarland, rural Denmark, and a researcher at the research unit for general practice with the easy name Sleilsikø, København.

I have nothing to declare.

And I wouldn't be standing here today if it wasn't for my great colleagues and friends whom I wish to thank dearly for all the conversation feedback and supports.

My interest in sustainability did not come suddenly and it's based on my own observations and experiences as a young doctor working at different departments at hospitals and healthcare.

and I found myself ordering and doing investigations without consequences for the patients and without the knowledge to resist the demands.

And I looked around at my colleagues and half of them were either returning or entering sick leave because of stress and burnout.

Living in the era of climate crisis, with this paradox of modern healthcare that while treating patients or actions have a huge environmental impact with a global carbon footprint from healthcare being as large as the fifth largest country in the world, none of this was making sense to me.

So I shifted paths from internal medicine to general practice and the research field from paraclinical PhD to a broad focus on sustainability.

And I still wonder sometimes if it's the right path, and mainly because of the dire readings and facts, but don't tell it to my boss.

However, participating in a conference like this is where the scientific committee has chosen sustainability as the overall theme, makes me hopeful and grateful.

So thank you for that.

And this focus is necessary.

for knowledge, awareness, and to begin the conversation for a sustainable tomorrow.

And some may say that definitions are not always needed.

However, some kind of an agreement or what we talk about when we talked sustainability promotes understanding.

And therefore, I refer to the definition of sustainability from the United Nations.

where they define sustainable development as development that meets the needs of the presence without compromising the ability of future generations to meet their own needs.

But sustainability still has many perspectives and more than 300 different definitions and numerous aspects.

And many of those are nicely covered in the program.

So I will narrow my focus to environmental sustainability of healthcare.

primary care, which also has been defined by the World Health Organization as being a health system that improves, maintains or restores health while minimizing negative impacts on the environment and leveraging opportunities to restore and improve it to the benefit of the health and well-being of current and future generations.

And this is the nine planetary boundaries.

The green circle in the middle is a safe operating space for humanity.

Seven of the planetary boundary are overshooting.

One we talk most about is climate change or carbon dioxide concentration.

And then there are novel entities.

There is also microplastic in the environment.

Biosphere integrity, including biodiversity loss.

land system change from forests to agricultural land, freshwater change, chemical pollution, and the seventh planetary boundary that got overshot last year, ocean acidification.

And the planet is not going off the cliff right now, but it's in a risk zone for developing serious lifestyle diseases.

And adapting and mitigating to these changes are necessary for future environmental robust healthcare system.

And to do that, we need to address different challenges and act on different levels simultaneously.

We need reduce the need for healthcare through structural prevention.

Make sure that the patient that needs healthcare gets high-value care and avoids unnecessary care.

And every investigation ordered and every medication prescribed has a financial cost, a treatment burden for the patient and environmental impact that we need to quantify.

And how do we do that?

Firstly, we really need research on this area.

And I'm looking forward too soon to some published results from Sweden on environmental impact from general practice.

But what we know so far is that the average GP consultation in Switzerland has a carbon footprint of 4.8 kilo.

It's the same impact as two pieces of 200 grams red meat.

And is there a lot?

The average GDP consultation England has the carbon foot print that is 15 times higher And that's the same impact as six new t-shirts.

And is that a lot?

And what about time in these consultations?

Does it change anything if we add time?

The consultation in Switzerland is 15 minutes and in England it's nine.

And however, these two numbers cannot really be compared fairly, because only one of them includes pharmaceuticals in the analysis.

And when measuring environmental impact, it is important to reflect on that, that not everything that counts can be measured, and that everything can't be measure counts.

And I don't think that we all should go and measure carbon on Monday from our practices, but we need help with the measurements and we an understanding of these numbers to interpret and understand.

And the numbers are dependent on both context, like the size of the clinic, is it a rural or urban area, and the system boundaries of their analysis, seen with the example of pharmaceutical.

And the impact from general practice is roughly divided between non-clinical activities and clinical activities.

The non clinical are like commuting to work, the patient transportation, buildings, heat and electricity.

And clinical activity are all the investigations.

We start pharmaceutical treatment and referrals.

But carbon footprint is only one of the measurements.

We also need to be aware of chemical and plastic pollution, biodiversity degradation and freshwater use.

And by the way, all the numbers were before AI was used in healthcare.

And there are good intentions for decarbonizing primary care with both clinical and non-clinical perspectives.

However, this area is under explored and with limited evidence right now on how the implementations are reducing carbon footprint.

The second challenge is ensuring that the patients that need health care receive high value care.

And we heard the numbers yesterday, 60, 30, 10, with 30% of all clinical activities being of low value, care and 10% being harmful.

Luckily, most of our clinical, activities are still high-value care, and I must say in my clinical practice I find it quite challenging to single out the activities that might be unnecessary.

And the Danish doctors and patients were asked by choosing wisely if they found our treatment problematic in healthcare.

And surprise, surprise they were not, they did not agree on that.

With 79% of the doctors finding it problematic and only 35% percent of patients.

And last year we did a non-scientific audit in Danish College of General Practice to evaluate the clinical relevance of the contact to general practice office.

Or with other words, might the patient best be held aside the GP office?

And the GPs evaluated that almost 20% of all contacts might be better helped at home in a rehabilitation center and social services or at hospital ambulatory.

But is 20% a small or a large number?

I don't know, and maybe we should expect some kind of excess clinical contact in GP But we need to also prioritize in our contact.

But what about inside the GP office?

There is a 50% chance you will get a blood drawn as a patient.

And this makes it one of the medical activities with the highest volume.

We rely on blood tests in many clinical situations from diagnosis and monitoring.

And we are really good at ordering those and we say the patient population is getting better, now bigger and older.

But there are some results saying that it doesn't count for all the increase in blood tests.

And there might be inappropriate monitoring going on.

And 12 to 15 percent of patients receive at least one low-value care practice a year.

And this is only the tip of the iceberg with these examples I've shown here.

And they are all between medication, imaging, screening and diagnostic tests.

And focus on the value of these tests is important and we've seen that the atheroscopy is going down while other invasive diagnostic test like gastroscopy is rising.

And the determinants of low-value care are really many and related to the patient.

Like the patients' expectations to contact the doctor.

The patient's health condition, the socioeconomic status, age, and also expectations from relatives.

There's also determinants related to the doctors.

Knowledge of low-value care is important to do less of it.

But the drivers are like fear of missing a diagnosis, or fear for litigation, and lack of time and pressure.

And there is inner context.

determinants for low-value care, and that's the structural and social environment of the clinic or healthcare center.

And that can be lack of care continuity, the staff composition or missing staff, organizational structure and the interaction between professionals.

And the outer context relates to the social, political and geographical context of healthcare.

And this is like, where is the clinical located?

The economic incentives and high healthcare consumption and a high specialist to primary care ratio are some of the drivers for low value care.

We know that the treatments in healthcare are getting more advanced, and we have never had so many opportunities in health care as now.

This was also a likewise showed with Stefan here left on yesterday.

that despite all our good intentions, we are not getting better health for the excess spending in healthcare.

And this graph shows the increased spending on the x-axis and the healthy life years on y-axes.

And this is a dilemma in modern medicine, especially for us in the high-income countries, that the higher levels of spending, economic and material resources, is not yielding gains in health outcomes and it's counterproductive waste and overconsumption.

And this overconsumption is not solely seen in healthcare and it is a product of our modern society.

And the structure is maintained through economic growth, cultural acceleration and technological innovation.

And Victor Montari mentioned it yesterday that we need unhurried consultations.

And I am also convinced that one of the answers for sustainable health care and better well-being in society is slowing down.

This is here where I need your help.

because we need to take back control of our time and stand up for our values of family medicine, doing care that can't easily be measured or technologically innovated.

And last but not least, we needs to reduce the needs for healthcare through structural prevention.

And what I like about sustainability is the holistic approach.

It challenges our normal way of thinking, and it includes and emphasizes the interconnectedness between sectors and culture, as well as individuals and society.

I think both as a doctor and a healthcare worker, looking at sustainability through the lens of health is meaningful and useful.

The health threats from the overshooting of the planetary boundaries is not distant.

And like mentioned before, we do have very close health risks.

They are present.

We also have found microplastics in placenta and arteriaries.

And air pollution is linked to dementia and diabetes.

And with chemical pollution of drinking water and soil, we have a lot we can prevent by doing so.

The recurrent heat waves with a striking excess mortality.

And this is in fact threatening our human rights to clean and healthy environments.

And I think a great example of the connectedness sustainability makes visible between health and society is antibiotics.

And we are actually doing good here in Scandinavia in prescribing antibiotics rationally.

We can always do better And if we want to be able to prescribe antibiotics to our patients now in the future, we can't oversee the link to food systems.

And this is because 62% of all prescribed antibiotics in The European Union go to the food industry.

and who is better than us to be advocates for our patients now and in the future.

And while argumenting for the less extensive use of antibiotics in the food industry, we can add that globally it is responsible for 30% of all greenhouse gas emissions and 70% percent of our fresh water use.

And it's the main cause of biodiversity loss globally.

And there are numerous co-benefits for human well-being, planetary health and sustainable health care through structural prevention, making it easier and safer to choose sustainable ways of living and limit access to those things that we know harm our health.

And We heard Margaret McCarthy talk a little bit about the aggression in advertising for health.

longevity and optimizing, but we have also internalized this aggression and it distances us from a natural look and optimising our health and health performances.

And it also has externalized in aggression towards the planet as well.

And I think the antidote for that is kindness in resonance, both towards us, each other and the planet.

And caring is human and it's one of the most powerful feelings and actions we contain.

With that, I believe we can find meaning in sustainability.

We already possess the scientific, economic and practical tools for sustainable change.

And heat accelerates many things, and these climate stripes visualize rising temperature.

With that, I hope for accelerated motivation for a sustainable tomorrow.

Thank you.