Speaking on Global Climate Change and Health – American College of Preventive Medicine 2012

I’m expanding my repertoire a bit by representing Kaiser Permanente at Global Climate Change & Health , a free conference convened by American College of Preventive Medicine as part of their annual meeting in Orlando, Florida, on February 22, 2012.

Some details:

The conference will enable preventive medicine physicians and other healthcare providers to come together to hear about the issues facing local and national leaders and to make a commitment to mobilize and actively participate in advocacy efforts targeting global climate change in their communities. This conference will include interactive working group sessions to develop communication messages and concrete plans for each participant to take back to their own community and work setting. The conference is free but you must register. See below for details.*

Featured speakers include:

·         Cindy Parker, MD, MPH, ACPM Environmental Health Committee Chair and Associate Director of the Johns Hopkins Environment, Energy, Sustainability, and Health Institute;
·         George Luber, MA, PhD, Associate Director for Climate Change of the National Center for Environmental Health, Centers for Disease Control & Prevention;
·         Edward Maibach, MPH, PhD, Director of the Center for Climate Change Communication Distinguished University Professor, Department of Communication George Mason University; and 
·         A panel of experts to discuss greening your practice, tools and resources, and science-based advocacy

I am not in the class of experts featured above; instead, I am coming to discuss the Kaiser Permanente experience and commitment to make the “link between the health of our members, our community and our planet.”

It’s a pretty big (dare I say huge) commitment to the environment (that you can read about on the History of Total Health blog) that I first learned about during my work to understand the future of technology in integrated care when I first came to KP. The idea of a health care system being as responsive to the environment around it as it is to the patients and families it cares for was not taught to me in medical school, residency, and not integrated into my practice before I came to work here. I was immediately drawn to it.

It turns out that the green movement in health care has a lot of similarities to the patient empowerment movement from my review of things. If we disrespect our patients, their diversity, or the environment around them, we waste their time, our time, their lives, our lives. I *almost* chose preventive medicine as my medical specialty, but decided to train in family medicine instead, because of my interest in making things easier for people earlier rather than later in their health journey. It’s all related…

So here I am, taking this as a great opportunity to continue my learning, and learning a lot about what an individual health professional and a health system can do to make a difference. My short presentation will lead into great resource developed by Todd Sack, MD for the Florida Medical Association called My Green Doctor. I really like it because it breaks down all the things a system can do to make a difference into the things a medical practice can do, and it all adds up. This is what I hope to show.

How you can help me

I am a fan of crowdsourcing presentations before I give them, especially for new content, and would love ideas on what’s most important to share.

You can take a look at the Green Resource Center at the Kaiser Permanente web site and My Green Doctor at the Florida Medical Association web site.  Feel free to let me know what jumps out at you for the medical practice and patients who are wondering the “why?” and “how” of delivering care that’s healthy for people, healthy for communities.

This can be everything from the impact of electronic health records on the environment (KP published a study on this), to the challenges you see in medical practice to being green, or your reflections as a patient about a practice that works at being green. Just post in the comments.

And if you’re in Orlando, stop in, you can register at http://www.acpm.org/?ClimateChangeConf


The real problem here is that global climate change has zero effect on health. No individual human or animal experiences changes in the average global temperature statistic – what matters is local weather conditions, which are actually experienced.

Unfortunately, in a chaotic system like our planet’s weather system, no modeling can give us any sort of long term insight into what regional weather conditions will be. The utility of a global average temperature statistic simply doesn’t exist in the real world.

Put another way, if you’re going to be asserting that this is all science based, what is your falsifiable hypothesis? What observations would convince you that your base assumptions (about what is/isn’t green, or what links do/do not exist)?

My fear here is that instead of focusing on health issues that have real impact on our members (say, the chronic toxic effect of elevated insulin levels caused by carbohydrate intake), we’re buying into a Green religion, and wasting valuable resources and energy that could be better applied to real results. While some parts of the “Green” mantra make sense (energy efficiency, for example), others cripple our ability to provide affordable services (expensive alternative energy), and others are downright damaging to the health of humanity (diets with minimal fat content, and lots of starchy grains).

Dere Jere,

Thanks for taking a look and for your comment. I am not planning to get into the science behind climate change in the 15 minutes I have. I wouldn’t have the credibility compared to the other speakers anyway.

What I think is useful for practicing physicians to learn from our experience is related to the thinking that comes from looking at CO2 emissions. We are all interested (or obsessed) with efficiency and eliminating waste, and CO2 equivalents may be as good a measure as any we use today of that. And maybe even better than money or health care cost because it includes patient/family/society expense to stay/become healthy.

By that yardstick, diets that are wasteful to produce and cause or contribute to chronic illness will result in increased CO2 production. Put another way, if we want to reduce green house gas emissions in health care, we have to work to reduce obesogenic lifestyles as well as reduce electricity use. There’s some good modeling around this that I can share.

What do you think, and since you also work at Kaiser Permanente, which aspects of our environmental commitment would you showcase?

This is helping me formulate my comments, I appreciate it, Jere,


@tedeytan Well, the problem here is the entire concept of “waste”. That is, it can be used in two, diametrically opposed ways.

Let’s take agricultural output as a proxy similar to CO2, that is a relatively decent measure of human industrial and economic activity. In once sense of “efficiency”, we’re looking to have less output per human (that is, if we’re really efficient, we can have a human survive on 1/2 their current diet – compare this to having humans survive with 1/2 their current power needs). In another sense of “efficiency”, we’re looking to have *more* output per human (that is, if we’re really efficient, we can support the natural human growth of population).

Now, of course, we *could* do both (have people eat only half the food, *and* increase agricultural output per person), and at the upper limits of arable land and population, that might very well be what we get to. However, the metrics there are contradictory – sort of like how you can have high house prices, or affordable housing, but not both 🙂

My personal take is that it’s a basic human right to reproduce as they choose, so I’m firmly in the *more* output per human camp to sustain human population growth (which, by my estimation, eventually tapers off on its own). Insofar as what “environmental” commitment I think Kaiser should have, I’d argue the following:

1) the cheapest energy possible. That means supporting petroleum exploration, nuclear, coal, fracking, and any other method of spending the *least* amount of money on the *most* amount of energy. Human quality of life varies in direct proportion to the amount of energy available to the individual, which means reducing energy costs yields a higher quality of life. We waste our resources when we spend them on expensive energy like solar or wind.

2) the least obesogenic diet possible – that means less starches and sugars, and more animal fats and proteins. The medical profession is an odd one, in that success in preserving health is detrimental to the profitability of the profession – if we didn’t have sick people, we wouldn’t need doctors, and in their hearts most doctors are trying to stop people from getting sick, even though it is contrary to their own financial best interest. Any medical care is an economic waste, so focusing on interventions that decrease the per capita amount of medical care is important in getting rid of waste.

3) the most *efficient* electricity use possible – that means that while per capita electricity use may increase, individuals should get *more* per watt. That is to say, if a person currently uses 100kWh per month, and gets to heat and light a small studio apartment, if they can double the size of their apartment, and only increase their electricity use by half, we’ve succeeded in improving quality of life, and that individual has become more efficient as well. So if Kaiser improves electrical efficiency such that they can afford to build more hospitals, or run more equipment to serve more people, that’s a good thing.

My problem is that except for #3, Kaiser Permanente has actually done the opposite of what I think we should be doing. It’s embarrassing to think that as a health care organization, we’re not leaders in reducing chronically elevated insulin levels through carbohydrate restriction, and that we actually waste money on expensive energy sources, which mean that our care becomes less and less affordable to our members.

In the end, CO2 emissions are a measure of the energy available to humanity for the most part, and if anything, we should be *increasing* them in order to lift the world out of poverty. While some of those CO2 emissions are “wasteful” (that is, the activity being driven by them is medical care that would be unnecessary if humans eschewed carbohydrates), most of those CO2 emissions are directly beneficial to human prosperity and health.

So while I know that the powers that be still hold onto the catastrophic anthropogenic global warming trope, and the low-fat diet/exercise trope, I guess if anything, I’d skip over those two bits, and focus on energy efficiency. LED lights and decent thermal insulation materials are no brainers, no matter what you may think about CO2 or carbs 🙂

@Jere Krischel Dear Jere,

Thanks for the advice, it’s in line with where I see the majority of KPs efforts on measurement and action currently happening. As I mentioned above, the discussion is not about global CO2 reduction, it’s about CO2 reduction in health care, which we want to be minimized, or maximally applied to people’s achievement of their life goals, which usually do not include being a patient in the health care system.

There are some pretty sweeping generalizations about health care, physicians, and the profession, in just a few sentences – not consistent with my knowledge of life experience. Those will not be a part of my talk :).

I’ll post the slides here when I’m done. Thanks again, and open to any others’ thoughts on this and the above,


@tedeytan Yeah, the only caveat I’d make is that it must be CO2 reduction with *cost* reduction – CO2 reduction that *costs* more (say, solar power, wind power) is harmful to our goal of affordable health care. As a reducto ad absurdum, you can imagine the cost of 100% carbon capture devices at every hospital, building and other facility in KP, and see how that enormous cost would give us no benefit (since it would artificially lower CO2 emissions without actually intervening in health). On the other hand, imagine if you could replace all the computers/lights/elevators/mechanical equipment with equipment that has comparable costs, but use only 1/4 of the energy to achieve their work – that’s a CO2 reduction *per capita* that can be used to increase capacity. Or imagine an intervention that meant that our hospitals simply didn’t have enough sick people to fill them up, and we could shut down entire buildings for days or weeks at a time – *that* would be an absolute reduction of CO2 and costs (even though it might be detrimental to those workers we employ since they’d have forced furlough days).

Anyway, good luck with the presentation!

@Jere Krischel Jere,

You crack me up – I would just add that costs in a system like ours are not just direct, now costs, they include long term, societal costs, and benefits and sometimes the investment in innovation is justified, in a calculated risk kind of way. In a growing system, it may be about building less new buildings than shutting down existing ones, which is also what’s happening.

Which is why there will always be plenty of work to do in health care, whether or not it is in big hospitals….

This has been good, it’s helping me to target the sweet spot of engagement for 15 minutes of air time. Thanks for the thought provoke,


@tedeytan You’re absolutely right – long term societal costs and benefits need to be taken into account, it’s just that we’re not very good at quantifying them. For example, over the 20th century, the global average temperature probably rose by 0.8C. Just taking a look at something as basic as agricultural output, this 0.8C rise was a net benefit – we, as a planet, sustained more people at a higher quality of living in 2000 than 1900. Now, one could make the assertion that we would have done even *better* if that 0.8C rise didn’t happen, but that’s a tenuous argument to make, since we can take a look at other 100 year periods where temperatures dropped, and humanity suffered (Maunder minimum, Dalton minimum, Little Ice Age).

I also agree that there will always be plenty of work to do in health care, but unlike other industries which *want* to increase their markets, I’d love it if the world got so healthy that our health care system had to shrink by 90% per capita 🙂 Imagine a world with no heart disease, no cancer, no diabetes and no obesity!

@Jere Krischel Jere, Same page re your last paragraph. It’s why I went into family medicine, and how you and I have arrived at this conversation in non-violent agreement :),


Ted Eytan, MD