Peak petroleum and public health

Health-care systems' resource footprints and their access and quality in 49 regions between 1995 and 2015: an input-output analysis

BACKGROUND

Strategies to reduce the environmental impact of health care are often limited to greenhouse gas emissions. To broaden their scope, our aim was to determine the evolution of the resource footprints, dependency, and efficiency of health-care systems and to determine the relationship between this evolution and their Healthcare Access and Quality (HAQ) index.

METHODS

We carried out an input-output analysis of 49 health-care systems from 1995 to 2015. We harmonised the EXIOBASE v3.8.2 database-providing data for 49 world regions-to the World Health Organization Health Expenditures Database. We then performed a panel data analysis to understand the relationship between Healthcare Access and Quality index and energy footprint per capita of health-care systems. EXIOBASE3 does not provide measurement errors so it was not possible to propagate the uncertainties as can be done with other input-output databases.

FINDINGS

Health-care systems' footprint increased over the past two decades, reaching 7% of global non-metallic minerals footprint, 4% of global metal ores footprint, and 5% of global fossil fuels footprint in 2013. This increase was mostly due to China, rising from 7% of the non-metallic minerals footprint in 1995 to 45% in 2013. 80% of the health-care systems studied were dependent at more than 50% on fossil fuel imports. The energy footprint per capita was correlated exponentially with the HAQ index but some countries performed much better than others at a given energy footprint. Health-care systems have not become more efficient between 2002 and 2015.

INTERPRETATION

Health-care systems' resources footprint are exponentially linked to their HAQ. Both prevention and efficiency measures will be needed to change this relationship. If it is not enough, high-income countries will have to choose between further reducing the resource consumption of their health-care systems or shifting the efforts to other sectors, health being considered an incompressible need. We call for the creation of a HAQE (health-care access, quality, and efficiency) index that would add resource efficiency to access and quality when ranking health-care systems.

FUNDING

The Shift Project.

Trends in Automobile Travel, Motor Vehicle Fatalities, and Physical Activity: 2003-2015

INTRODUCTION

Annual per-capita automobile travel declined by 600 miles from 2003 to 2014 with decreases greatest among young adults. This article tests whether the decline has been accompanied by public health co-benefits of increased physical activity and decreased motor vehicle fatalities.

METHODS

Minutes of auto travel and physical activity derived from active travel, sports, and exercise were obtained from the American Time Use Survey. Fatalities were measured using the Fatality Analysis Reporting System. Longitudinal change was assessed for adults aged 20-59 years by age group and sex. Significance of changes was assessed by absolute differences and unadjusted and adjusted linear trends. Analyses were conducted in 2016.

RESULTS

Daily auto travel decreased by 9.2 minutes from 2003 to 2014 for all ages (p<0.001) with the largest decrease among men aged 20-29 years (Δ= -21.7, p<0.001). No significant changes were observed in total minutes of physical activity. Motor vehicle occupant fatalities per 100,000 population showed significant declines for all ages (Δ=-5.8, p<0.001) with the largest for young men (Δ= -15.3, p<0.001). Fatalities per million minutes of auto travel showed only modest declines across age groups and, for men aged 20-29 years, varied from 10.9 (95% CI=10.0, 11.7) in 2003 to 9.7 (95% CI=8.7, 10.8) in 2014.

CONCLUSIONS

Reduced motor vehicle fatalities are a public health co-benefit of decreased driving, especially for male millennials. Despite suggestions to the contrary, individuals did not switch from cars to active modes nor spend more time in sports and exercise. Maintenance of the safety benefits requires additional attention to road safety efforts, particularly as auto travel increases.

Food System Policy, Public Health, and Human Rights in the United States

The US food system functions within a complex nexus of social, political, economic, cultural, and ecological factors. Among them are many dynamic pressures such as population growth, urbanization, socioeconomic inequities, climate disruption, and the increasing demand for resource-intensive foods that place immense strains on public health and the environment. This review focuses on the role that policy plays in defining the food system, particularly with regard to agriculture. It further examines the challenges of making the food supply safe, nutritious, and sustainable, while respecting the rights of all people to have access to adequate food and to attain the highest standard of health. We conclude that the present US food system is largely unhealthy, inequitable, environmentally damaging, and insufficiently resilient to endure the impacts of climate change, resource depletion, and population increases, and is therefore unsustainable. Thus, it is imperative that the US embraces policy reforms to transform the food system into one that supports public health and reflects the principles of human rights and agroecology for the benefit of current and future generations.

Sustainable emergency medical service systems: how much energy do we need?

OBJECTIVE

Modern emergency medical service (EMS) systems are vulnerable to both rising energy prices and potential energy shortages. Ensuring the sustainability of EMS systems requires an empirical understanding of the total energy requirements of EMS operations. This study was undertaken to determine the life cycle energy requirements of US EMS systems.

METHODS

Input-output-based energy requirement multipliers for the US economy were applied to the annual budgets for a random sample of 19 metropolitan or county-wide EMS systems. Calculated per capita energy requirements of the EMS systems were used to estimate nationwide EMS energy requirements, and the leading energy sinks of the EMS supply chain were determined.

RESULTS

Total US EMS-related energy requirements are estimated at 30 to 60 petajoules (10(15) J) annually. Direct ("scope 1") energy consumption, primarily in the form of vehicle fuels but also in the form of natural gas and heating oil, accounts for 49% of all EMS-related energy requirements. The energy supply chain-including system electricity consumption ("scope 2") as well as the upstream ("scope 3") energy required to generate and distribute liquid fuels and natural gas-accounts for 18% of EMS energy requirements. Scope 3 energy consumption in the materials supply chain accounts for 33% of EMS energy requirements. Vehicle purchases, leases, maintenance, and repair are the most energy-intense components of the non-energy EMS supply chain (23%), followed by medical supplies and equipment (21%).

CONCLUSION

Although less energy intense than other aspects of the US healthcare system, ground EMS systems require substantial amounts of energy each year.

Higher energy prices are associated with diminished resources, performance and safety in Australian ambulance systems

OBJECTIVE

To evaluate the impact of changing energy prices on Australian ambulance systems.

METHODS

Generalised estimating equations were used to analyse contemporaneous and lagged relationships between changes in energy prices and ambulance system performance measures in all Australian State/Territory ambulance systems for the years 2000-2010. Measures included: expenditures per response; labour-to-total expenditure ratio; full-time equivalent employees (FTE) per 10,000 responses; average salary; median and 90th percentile response time; and injury compensation claims. Energy price data included State average diesel price, State average electricity price, and world crude oil price.

RESULTS

Changes in diesel prices were inversely associated with changes in salaries, and positively associated with changes in ambulance response times; changes in oil prices were also inversely associated with changes in salaries, as well with staffing levels and expenditures per ambulance response. Changes in electricity prices were positively associated with changes in expenditures per response and changes in salaries; they were also positively associated with changes in injury compensation claims per 100 FTE.

CONCLUSION

Changes in energy prices are associated with changes in Australian ambulance systems' resource, performance and safety characteristics in ways that could affect both patients and personnel. Further research is needed to explore the mechanisms of, and strategies for mitigating, these impacts. The impacts of energy prices on other aspects of the health system should also be investigated.

The energy burden and environmental impact of health services

OBJECTIVES

We reviewed the English-language literature on the energy burden and environmental impact of health services.

METHODS

We searched all years of the PubMed, CINAHL, and ScienceDirect databases for publications reporting energy consumption, greenhouse gas emissions, or the environmental impact of health-related activities. We extracted and tabulated data to enable cross-comparisons among different activities and services; where possible, we calculated per patient or per event emissions.

RESULTS

We identified 38 relevant publications. Per patient or per event, health-related energy consumption and greenhouse gas emissions are quite modest; in the aggregate, however, they are considerable. In England and the United States, health-related emissions account for 3% and 8% of total national emissions, respectively.

CONCLUSIONS

Although reducing health-related energy consumption and emissions alone will not resolve all of the problems of energy scarcity and climate change, it could make a meaningful contribution.

Securing 'supportive environments' for health in the face of ecosystem collapse: meeting the triple threat with a sociology of creative transformation

In this paper, we reflect on and explore what remains to be done to make the concept of supportive environments--one of the Ottawa Charter's five core action areas--a reality in the context of growing uncertainty about the future and accelerated pace of change. We pay particular attention to the physical environment, while underscoring the inextricable links between physical and social environments, and particularly the need to link social and environmental justice. The paper begins with a brief orientation to three emerging threats to health equity, namely ecological degradation, climate change, and peak oil, and their connection to economic instability, food security, energy security and other key determinants of health. We then present three contrasting perspectives on the nature of social change and how change is catalyzed, arguing for an examination of the conditions under which cultural change on the scale required to realize the vision of 'supportive environments for all' might be catalyzed, and the contribution that health promotion as a field could play in this process. Drawing on sociological theory, and specifically practice theory and the work of Pierre Bourdieu, we advocate rethinking education for social change by attending more adequately to the social conditions of transformative learning and cultural change. We conclude with an explication of three key implications for health promotion practice: a more explicit alignment with those seeking to curtail environmental destruction and promote environmental justice, strengthening engagement with local or settings-focused 'communities of practice' (such as the Transition Town movement), and finding new ways to creatively 'engage emergence', a significant departure from the current dominant focus on 'risk management'.

Fuel use in a large, dynamically deployed emergency medical services system

INTRODUCTION

Emergency medical services (EMS) systems are a central component of the healthcare system, particularly for older patients. As currently configured, EMS transport is fundamentally petroleum dependent. Petroleum scarcity is an emerging public health concern, particularly for patient transport. Little is known regarding EMS fuel use, potential impacts of scarcity on operations, or strategies to minimize these impacts.

OBJECTIVE

The objective of this study was to characterize the fuel use of a large, urban, hospital-based, dynamically-deployed EMS system, and to identify broad optimization categories to minimize EMS's petroleum dependence.

METHODS

Fuel use was reviewed retrospectively using fuel purchasing and maintenance data from January 2007 through September 2008. Data on unit-hours, call volume, and patient transports also were collected. Data were processed using descriptive statistics.

RESULTS

During the study period, a fleet of 35 diesel ambulances operated for 277,849 unit-hours and traveled 1,902,710 miles. Detailed mileage data were available for 66,527 unit-hours, 23.9% of the sample. Overall, vehicles averaged 6.6.89 (6.71, 7.08) miles per gallon (mpg), 11.5 (10.4, 12.6) miles were travelled per call, and 16.2 (14.8, 17.6) miles per transport; 2.7 (2.4, 2.9) gallons of fuel were used per transport.

CONCLUSIONS

In this EMS system, operations are fundamentally dependent on petroleum. Mileage estimates can serve as a baseline to evaluate interventions for reducing petroleum dependence and in contingency planning. As cost pressures increase and these interventions become more common, systematic evaluations will be important.

Framing peak petroleum as a public health problem: audience research and participatory engagement in the United States

Between December 2009 and January 2010, we conducted a nationally representative telephone survey of US adults (n = 1001; completion rate = 52.9%) to explore perceptions of risks associated with peak petroleum. We asked respondents to assess the likelihood that oil prices would triple over the next 5 years and then to estimate the economic and health consequences of that event. Nearly half (48%) indicated that oil prices were likely to triple, causing harm to human health; an additional 16% said dramatic price increases were unlikely but would harm health if they did occur. A large minority (44%) said sharp increases in oil prices would be "very harmful" to health. Respondents who self-identified as very conservative and those who were strongly dismissive of climate change were the respondents most likely to perceive very harmful health consequences.

Petroleum and health care: evaluating and managing health care's vulnerability to petroleum supply shifts

Petroleum is used widely in health care-primarily as a transport fuel and feedstock for pharmaceuticals, plastics, and medical supplies-and few substitutes for it are available. This dependence theoretically makes health care vulnerable to petroleum supply shifts, but this vulnerability has not been empirically assessed. We quantify key aspects of petroleum use in health care and explore historical associations between petroleum supply shocks and health care prices. These analyses confirm that petroleum products are intrinsic to modern health care and that petroleum supply shifts can affect health care prices. In anticipation of future supply contractions lasting longer than previous shifts and potentially disrupting health care delivery, we propose an adaptive management approach and outline its application to the example of emergency medical services.

Public health and medicine in an age of energy scarcity: the case of petroleum

Petroleum supplies have heretofore been abundant and inexpensive, but the world petroleum production peak is imminent, and we are entering an unprecedented era of petroleum scarcity. This fact has had little impact on policies related to climate, energy, the built environment, transportation, food, health care, public health, and global health. Rising prices are likely to spur research and drive efficiency improvements, but such innovations may be unable to address an increasing gap between supply and demand. The resulting implications for health and the environment are explored in the articles we have selected as additional contributions in this special issue. Uncertainty about the timing of the peak, the shape of the production curve, and decline rates should not delay action. The time for quick, decisive, comprehensive action is now.

Food systems change and the environment: local and global connections

Making changes to the way food is produced, distributed, and processed is one strategy for addressing global climate change. In this case study, we examine the "forming" stage of an emergent and locally-based coalition that is both participatory and focused on promoting food security by creating food systems change. Social network analysis is used to compare network density, centrality, and centralization among coalition partners before the formation of the coalition and at its one-year anniversary. Findings reveal that the coalition facilitated information seeking, assistance seeking, and collaborative efforts related to food security among a group of organizational stakeholders that were relatively disconnected pre-coalition. Results also illuminate tensions related to increased centralization of the network, coalition efficiency, and the goals of democratic decision-making. This study highlights the utility of social network analysis as a tool for evaluating the aims and trajectory of locally-based coalitions focused on global concerns.

Health, Climate Change and Sustainability: A systematic Review and Thematic Analysis of the Literature

BACKGROUND

Evidence of climate change and its impact continues to be accumulated, and it is argued that the consequences of climate change are likely to result in an increased demand on health services. It has been claimed that climate change presents new challenges for health services and that strategies should be adopted to address these challenges.

AIM

The aim of this systematic review was to map published literature on health, climate change and sustainability by categorising papers according to their focus on effects, strategy and actions, and to provide a thematic analysis of their content.

METHODS

Systematic searches were conducted via a range of healthcare related databases i.e. Pubmed, Medline, CINAHL, AMED, ASSIA, IBSS and ISI Web of Knowledge. Searches focussed upon papers published in English between 1998 and 2008. Retrieved papers were studied by the authors in order to inform the thematic analysis of their content.

RESULTS

A total of 114 publications were retrieved, of which 36 met the inclusion criteria for the systematic review. These 36 publications were categorised and are discussed according to their focus on: effects/impacts, strategy/policy, action/examples.

CONCLUSIONS

A number of papers report the potential health effects of climate change while others report policies and strategies to tackle these effects. However there is an urgent need to identify and report on the implementation of strategies to mitigate and adapt to these challenges and to publish real examples of actions. Actions that are taken need to be evidence/policy based, and implementations monitored, evaluated and published.

Climate change and emergency medicine: impacts and opportunities

There is scientific consensus that the climate is changing, that human activity plays a major role, and that the changes will continue through this century. Expert consensus holds that significant health effects are very likely. Public health and health care systems must understand these impacts to properly pursue preparedness and prevention activities. All of medicine will very likely be affected, and certain medical specialties are likely to be more significantly burdened based on their clinical activity, ease of public access, public health roles, and energy use profiles. These specialties have been called on to consider the likely impacts on their patients and practice and to prepare their practitioners. Emergency medicine (EM), with its focus on urgent and emergent ambulatory care, role as a safety-net provider, urban concentration, and broad-based clinical mission, will very likely experience a significant rise in demand for its services over and above current annual increases. Clinically, EM will see amplification of weather-related disease patterns and shifts in disease distribution. In EM's prehospital care and disaster response activities, both emergency medical services (EMS) activity and disaster medical assistance team (DMAT) deployment activities will likely increase. EM's public health roles, including disaster preparedness, emergency department (ED)-based surveillance, and safety-net care, are likely to face increasing demands, along with pressures to improve fuel efficiency and reduce greenhouse gas emissions. Finally, EM's roles in ED and hospital management, particularly related to building and purchasing, are likely to be impacted by efforts to reduce greenhouse gas emissions and enhance energy efficiency. Climate change thus presents multiple clinical and public health challenges to EM, but also creates numerous opportunities for research, education, and leadership on an emerging health issue of global scope.

Health, climate change and energy vulnerability: a retrospective assessment of strategic health authority policy and practice in England

BACKGROUND

A number of policy documents suggest that health services should be taking climate change and sustainability seriously and recommendations have been made to mitigate and adapt to the challenges health care providers will face. Actions include, for example, moving towards locally sourced food supplies, reducing waste, energy consumption and travel, and including sustainability in policies and strategies. A Strategic Health Authority (SHA) is part of the National Health Service (NHS) in England. They are responsible for developing strategies for the local health services and ensuring high-quality performance. They manage the NHS locally and are a key link between the U.K. Department of Health and the NHS. They also ensure that national priorities are integrated into local plans. Thus they are in a key position to influence policies and practices to mitigate and adapt to the impact of climate change and promote sustainability.

AIM

The aim of this study was to review publicly available documents produced by Strategic Health Authorities (SHA) to assess the extent to which current activity and planning locally takes into consideration climate change and energy vulnerability.

METHODS

A retrospective thematic content analysis of publicly available materials was undertaken by two researchers over a six month period in 2008. These materials were obtained from the websites of the 10 SHAs in England. Materials included annual reports, plans, policies and strategy documents.

RESULTS

Of the 10 SHAs searched, 4 were found to have an absence of content related to climate change and sustainability. Of the remaining 6 SHAs that did include content related to climate change and energy vulnerability on their websites consistent themes were seen to emerge. These included commitment to a regional sustainability framework in collaboration with other agencies in the pursuit and promotion of sustainable development. Results indicate that many SHAs in England have yet to embrace sustainability, or to integrate preparations for climate change and energy vulnerability within their organisational strategies. Evidence also suggests that SHAs that have recognised the importance of sustainability within their documentation and policies have yet to fully demonstrate this in practice through the implementation of these policies.

CONCLUSIONS

Further research is required to investigate means by which SHAs (U.K.) and agencies responsible for health service policy in other countries may be enabled to include a greater consideration of sustainability and climate change within their policies, and to find effective ways of implementing these policies within daily working practice.

Climate change: impacts on and implications for global health

The most severe consequences of climate change will accrue to the poorest people in the poorest countries, despite their own negligible contribution to greenhouse gas emissions. In recent years, global health efforts in those same countries have grown dramatically. However, the emerging scientific consensus about climate change has not yet had much influence on the routine practice and strategies of global health. We review here the anticipated types and global distribution of health impacts of climate change, discuss relevant aspects of current global interventions for health in low-income countries, and consider potential elements of a framework for appropriately and efficiently mainstreaming global climate change-mitigation and -adaptation strategies into the ongoing enterprise of global health. We propose a collaborative learning initiative involving four areas: (1) increased awareness among current global health practitioners of climate change and its potential impacts for the most disadvantaged, (2) strengthening of the evidence base, (3) incorporation now of climate change-mitigation and -adaptation concerns into design of ongoing global health programs, and (4) alignment of current global health program targets and methods with larger frameworks for climate change and sustainable development. The great vulnerability to climate change of populations reached by current global health efforts should prompt all concerned with global health to take a leading role in advocating for climate change mitigation in their own countries.

A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers

OBJECTIVE

Household energy security has not been measured empirically or related to child health and development but is an emerging concern for clinicians and researchers as energy costs increase. The objectives of this study were to develop a clinical indicator of household energy security and assess associations with food security, health, and developmental risk in children <36 months of age.

METHODS

A cross-sectional study that used household survey and surveillance data was conducted. Caregivers were interviewed in emergency departments and primary care clinics form January 2001 through December 2006 on demographics, public assistance, food security, experience with heating/cooling and utilities, Parents Evaluation of Developmental Status, and child health. The household energy security indicator includes energy-secure, no energy problems; moderate energy insecurity, utility shutoff threatened in past year; and severe energy insecurity, heated with cooking stove, utility shutoff, or >or=1 day without heat/cooling in past year. The main outcome measures were household and child food security, child reported health status, Parents Evaluation of Developmental Status concerns, and hospitalizations.

RESULTS

Of 9721 children, 11% (n = 1043) and 23% (n = 2293) experienced moderate and severe energy insecurity, respectively. Versus children with energy security, children with moderate energy insecurity had greater odds of household food insecurity, child food insecurity, hospitalization since birth, and caregiver report of child fair/poor health, adjusted for research site and mother, child, and household characteristics. Children with severe energy insecurity had greater adjusted odds of household food insecurity, child food insecurity, caregivers reporting significant developmental concerns on the Parents Evaluation of Developmental Status scale, and report of child fair/poor health. No significant association was found between energy security and child weight for age or weight for length.

CONCLUSIONS

As household energy insecurity increases, infants and toddlers experienced increased odds of household and child food insecurity and of reported poor health, hospitalizations, and developmental risks.