The objective of the Social Accountability as the Framework for Engagement (SAFE) for Health Institutions project (https://safeforhealthinstitutions.org) is to develop a tool kit that can accelerate the adoption of social accountability strategies in health care. The tool kit includes a social accountability evaluation tool with a framework of 253 institutionally comprehensive “top-down” standards and rapid evidence narratives that identify practical means of implementing knowledge linked to these standards.1Social accountability refers to the obligation to be accountable to society for its health and, unsurprisingly, environmental accountability has been referenced by Xie et al2 and others as being important for social accountability strategies.3-5 Environmental accountability is also frequently referenced throughout the SAFE for Health Institutions project’s evaluation tool and was identified as a key topic for a rapid evidence narrative (Appendix A, available from CFPlus*).

The inclusion of environmental accountability in social accountability strategies reflects the global impact of environmental degradation on all patients and communities, along with the recognition of environmental determinants of health, the right to environmental justice, and climate change as a driver of inequity.6-9 Knowing how to deliver health care with minimal harm to the environment is crucial for current and aspiring physicians and their obligations to the health of the communities they serve.3,4,8

This is the third article to be published in Canadian Family Physician based on rapid evidence narratives from the SAFE for Health Institutions project that addresses key social accountability topics across micro (patient-provider interactions), meso (health care and community environments), and macro (political and policy contexts) levels of care tailored to family medicine.10,11

Providing context

While a central tenet in health care is to do no harm, there is irony in the fact that health care, as an industry, is harming the environment in many ways.8,12,13 The health care sector in Canada accounts for 4.6% of net greenhouse gas emissions.12 In comparison with other industries, this is a sizable environmental footprint.2,8,12 Health care’s carbon footprint is produced by the energy needs for the continuous provision of care, the provision of care itself, and the manufacturing, transportation, and disposal of health care products.12,14,15 It is an industry that struggles to adopt zero- or low-waste circular economy principles and operates predominantly in a high-consumption, high-waste culture.7,16-18 Medical waste, such as pharmaceutical or biological waste, raises additional concerns about the contamination of water, land, and air.14,19 What further impedes seeing the bigger picture of environmental harms is the lack of a consistent, authentic, unified voice on environmental justice from health institutions. Family physicians make up approximately half of the physician health workforce in Canada and therefore have an important role to play in improving environmentally sustainable practices in health care.20

Health consequences of environmental degradation across micro, meso, and macro levels

Considering the health effects of environmental degradation across the micro, meso, and macro levels helps us understand why environmental accountability should be prioritized in social accountability strategies. Environmental degradation from rising temperatures, air pollution, and environmental poisoning influences morbidity and mortality at a micro (patient) level. For example, 619 people lost their lives to heat-related illnesses during a 1-week heat dome in British Columbia (BC) in 2021 that saw temperatures reach 49.6°C (in Lytton, BC).21,22 Air pollution is considered a leading cause of cancer, respiratory disease, cardiovascular disease, and environmentally mediated morbidity and mortality linked to 15,300 premature deaths per year in Canada.23,24 Environmental poisoning is another catastrophic example of a health impact at the micro level as experienced by the people of the Asubpeeschoseewagong First Nation in northern Ontario (also known as Grassy Narrows First Nation), where the disposal of mercury in the English–Wabigoon river system has caused toxicity,25,26 premature mortality,27 and congenital birth defects.25

Environmental degradation can also affect the health of entire communities at a meso level. Contaminating the Asubpeeschoseewagong First Nation’s water and food sources with mercury assaulted crucial dimensions of an entire Indigenous community’s health and well-being.21,25-28 Extreme weather events have also had a meso-level impact by threatening fragile local health systems and destroying public health infrastructure.6,8 This was experienced at the peak of the 2021 heat dome event in BC, during which 911 call volume doubled, lengthening response times to calls and reducing the availability of emergency medical services.21

At a macro level, politics, laws, and legislation open doors to large-scale environmental degradation.6,14 The physical environment in isolation is a social determinant of health,9 but degrading the environment also affects other determinants. Food security can be threatened by loss of agricultural land due to climate change.6,8 Environmental racism is also upheld at the macro level as in the case of the Asubpeeschoseewagong First Nation, with government officials having downplayed effects of mercury toxicity in the past despite evidence to the contrary.25 Overall, the health consequences of environmental degradation drive inequity and unjustly affect Indigenous people, older adults, people who are racially marginalized, children, people with chronic illnesses, and people living in inadequate housing (Box 1).6,7,21

Box 1. Summary of key points

The importance of environmental accountability for social accountability strategies is highlighted by the need for environmental justice, recognition of the environmental determinants of health, and recognition of climate change–driven inequity and how environmental degradation affects patients and communities globally

Currently, delivering health care harms the environment in many ways and consequentially harms the patients and communities that family physicians serve

Environmental degradation causes increased morbidity and mortality for patients, leads to increased pressure on and collapse of local health systems, and has widespread impacts on the social determinants of health

Environmental accountability is the obligation of providers to anticipate how their activities impact the environment while prioritizing environmentally protective solutions that reduce emissions, consumption, and medical waste and that promote zero- or low-waste circular economy principles

Family physicians can choose a pathway to environmental accountability acting across micro (patient-provider interactions), meso (health system and community environments), and macro (political and policy contexts) levels of care, either from the bottom up or top down, and can actively contribute to a healthier planet for all

Pathway to environmental accountability

Although family physicians and the health care sector are not solely responsible for the health impacts of environmental degradation across the micro, meso, and macro levels, they can play a meaningful role in lessening health care’s harm to the environment. By fostering community environmental health and a green economy, family physicians can have a number of positive effects that will also translate to improved health equity for those disproportionately affected by the consequences of environmental degradation.8

In family medicine, environmental accountability can be understood as the obligation for all providers to anticipate how their activities impact the environment while prioritizing environmentally protective and sustainable solutions.2,4 While a few practical examples of how to improve environmental accountability in primary care are presented in this article, more can be found in resources from the Canadian Coalition for Green Health Care (https://greenhealthcare.ca), the Canadian Association of Physicians for the Environment (https://cape.ca), and CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis) (https://cascadescanada.ca/action-areas/primary-and-community-care).

A pathway to environmental accountability in primary care (Figure 1) can be approached from the bottom up or from the top down, mapping action across micro, meso, and macro levels of care in settings where family physicians can have a direct influence and impact.15 A bottom-up approach starts at the micro level and appraises medical activities, practice patterns, and products around provider-patient interactions, connecting those activities to meso-level policy, process, and structural reforms that target environmental harm.15 A top-down approach begins at the macro level and considers the political and policy contexts that affect environmental justice and the environmental determinants of health. A top-down approach also includes an overview of an entire family practice or an interdisciplinary care team that family physicians are part of to identify “hot-spot” targets for policy, process, and structural reforms that connect to environmentally sustainable health care at the micro level.15 Both approaches identify changes that can reduce emissions, consumption, and medical waste and that promote zero- or low-waste circular economy principles15,17,19; they also require measurable targets and continuous monitoring8,16,29 and look to address macro-level drivers across political and policy contexts.15

Figure 1.

Pathway to environmental accountability for social accountability strategies: The examples provided are just a few of the actions family physicians can pursue on their paths to environmental accountability as part of a social accountability strategy. Please consult the Canadian Association of Physicians for the Environment (https://cape.ca), the Canadian Coalition for Green Health Care (https://greenhealthcare.ca), and the sustainable primary and community care resources from CASCADES (https://cascadescanada.ca/action-areas/primary-and-community-care) for more information.

At a micro level, family physicians need to understand the relationship among the environment, health, and the health sector.4,29 With this knowledge, family physicians can take a number of steps in their patient interactions to improve environmentally sustainable practices in health care. Choosing treatments wisely,30 reducing unnecessary tests, and consuming fewer health care resources can have a global impact.15,19 Deprescribing, reducing polypharmacy, and switching from metered-dose inhalers to dry-powder inhalers targets the pharmaceutical industry, which accounts for as much as 25% of health care’s emissions.31,32 Virtual care can reduce transportation needs and emissions.33 Promotion of environmentally sustainable lifestyle choices for patients and preventive care efforts, such as adoption of plant-rich diets, is an approach that can indirectly reduce animal agriculture emissions and have additional health benefits.19 Family physicians can choose products for their workplaces that support a zero- or low-waste circular economy.16-18 Family physicians can also lead by example and make a number of environmentally sustainable lifestyle choices, such as minimizing transportation needs.34

Meso-level action needs to support sustained, environmentally accountable medicine at the micro level.7,8 An environmental accountability task force, with membership that includes leaders and front-line family physicians, can lead policy, process, and structural reforms for entire practices and interdisciplinary care teams.7,8 Quality improvement projects targeting medical interventions, such as deprescribing or identifying patients to switch from metered-dose inhalers to dry-powder inhalers across an entire practice population, are methods for higher-level change.30,32 Virtual meetings and education sessions reduce emissions by eliminating travel.35 A zero- or low-waste circular economy15,18 can be encouraged for an entire clinic by asking distributors to offer supplies with less or no packaging; interchanging disposable medical products for sterilizable, reusable ones18; and by selecting reusable personal protective equipment.36 The Canada Green Building Council (https://www.cagbc.org) can also help guide the “greening” of primary care facilities, which can be responsible for 10% to 30% of primary care’s emissions.15,37,38

At a macro level, family physicians can embrace their power, privilege, and the social platform afforded them in their diverse roles and with the College of Family Physicians of Canada through advocacy.2,7,8 Family physicians can draw attention to and demand environmental justice for communities such as Asubpeeschoseewagong First Nation.25-27 As part of their social accountability strategies, family physicians and the College can also lead initiatives for and work toward environmental accountability with the Canadian Coalition for Green Health Care, the Canadian Association of Physicians for the Environment, and CASCADES, as they have done previously in supporting the phasing-out of coal-fired electricity and a campaign to ban fossil fuel advertising.39,40

Conclusion

The health care sector, inclusive of family physicians, must acknowledge how health care contributes to environmental degradation and its well-known health consequences. Inaction will see family physicians have to further adapt their practices to the consequences of extreme heat events, extreme weather events, hazardous air quality, and the collapse of already-fragile health systems, with poor outcomes for patients and communities. The need for achieving environmental justice, understanding climate change as a driver of inequity, and understanding the widespread impacts across entire patient populations and communities cement environmental accountability as an important piece of social accountability strategies. Family physicians acting across micro, meso, and macro levels, with either a bottom-up or top-down approach, can actively be part of the solution and choose a pathway to environmental accountability that leads the way to a healthier planet for all.

Footnotes

↵* Appendix A is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.

Competing interests

None declared

The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

This article is eligible for Mainpro+ certified Self-Learning credits. To earn credits, go to https://www.cfp.ca and click on the Mainpro+ link.

This article has been peer reviewed.

Cet article se trouve aussi en français à la page 239.

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