Health informaticians have a role in contributing to climate justice

Health informatics and its subspecialty nursing informatics play a substantial role in supporting healthcare processes towards achieving optimal patient outcomes and safe patient care. During COVID-19, health informaticians helped oversee a rapid deployment of many digital health technology information systems that have transformed how we have managed the public response to COVID-19 pandemic. ^{1, 2} Undoubtedly, these interventions represent an opportunity to permanently transform healthcare. However, while we transform healthcare on a digital level, there is another transformation that is urgently needed. This transformation will help determine the fate of this planet and it depends on the effective implementation of the interventions aiming to reduce the impact of healthcare on climate change.

The United Nations Framework Convention on Climate Change (UNFCCC), Article 1, defines climate change as ‘a change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable time periods.’³ This definitions makes a distinction between human-made activities that contribute to climate change and the natural variability in climate change observed as a result of geological processes and time. The human activity-driven changes stem primarily from use of fossil fuels and to a lesser extent, deforestation and agriculture.⁴ To address the challenges of climate change impact on planetary health, two strategies are proposed: the mitigation and adaptation.⁵ The mitigation strategies involve reducing sources of greenhouse gases that lead to atmospheric warming, for example stopping the use of fossil fuels, whereas the adaptation strategies involve adapting to new ways of living in a changing climate.⁶

It may not be commonly known that if all the healthcare were a country, global healthcare would be the 5^th largest polluter on the planet, accounting for about 4.4% of global greenhouse gas net emissions.⁷ In more relatable terms, this translates to the healthcare’s annual global carbon footprint of annual emission from 514 coal-fired power stations.⁸ In Australia, the carbon footprint attributed to healthcare is approximately 7% of Australia’s total contribution to greenhouse gas emissions.⁹ On a personal level, this is a horrifying statistic as it forces me to confront a realisation that while my life’s work has been devoted to helping people live healthier lives, simultaneously, my work also contributes to making all living organisms on this planet sick through my environmental footprint as measured in carbon currency. In the context of digital health technologies and related interventions, the environmental impacts include: production and disposal of wearable technologies, robotics and devices (such as laptops, computers, smartphones and tablets) used to facilitate health interventions, impact of collection and storage of health data, and the impact of digital health infrastructures that facilitate digital health, such as telehealth call centres.¹⁰ Two years ago, I made a conscious decision and redirected my life’s work to find ways to address the substantial contribution of healthcare to global green gas emissions. However, my effort alone is not enough. Our planet needs every person to engage and act both individually and collectively to help reduce the carbon footprint at home and at work, to help our health systems move towards net zero carbon emissions.

For nursing and midwifery, examples of such actions range from advocating switching energy supplies to renewable sources, innovation in reducing medical waste, making better choices when ordering single-use clinical products, to better management of medical recycling programs and advocating for vulnerable populations.^{11, 12} For health informaticians in general, I would argue that this extends to rethinking processes of how we deploy and run digital technology solutions; when we participate in the decision-making process to think about how we choose digital health technologies required for the development, testing and deployment within the context-specific digital health technology solutions; to think about the end user (for example, can our solutions work for our community during natural disasters or extreme heatwaves or when the electricity power is frequently lost); and creating digital solutions that help others in our organisation make environmentally sound decisions. We also need to ask ourselves; how do we capitalise on the potential of digital health technologies to help with mitigation and adaptation strategies to climate change to reduce vulnerability to climate change as suggested for telehealth, whilst not creating greater carbon footprint?¹³

The relationship between climate change and nursing/midwifery informatics rests in our transferable informatics skills and our core value of addressing social inequities and social justice.^{12, 14} Social inequity in health arises from disparities in health status within the context of social determinants of health that may disadvantage an individual and/or the entire populations.¹⁵ It also arises from structural inequities in the health system serving those populations.¹⁶ When thinking about inequity, the starting point is to ask why is there an absence of equal opportunities for individuals or group of peoples to be healthy and to benefit from available resources and how should these resources be distributed in a just and fair way so that all people have a chance to achieve good health outcomes for themselves and their families?¹⁵ Braveman and Gruskin state that ‘Equity means social justice or fairness; it is an ethical concept, grounded in principles of distributive justice’ and further add that how social justice is interpreted depends on many attributes, including cultural values and beliefs.¹⁵ How climate change increases impact on global social justice must be layered into this discussion.

The World Health Organization (WHO) estimates that between 2030 and 2050, climate change is expected to cause approximately 250 000 additional deaths per year from causes such as heat stress, malnutrition, malaria and diarrhoea.¹⁷ This estimate does not account for the devastation of climate-change related natural disasters or pollutants in the environment. Climate change-associated weather patterns have seen destructive megafires, floods, droughts, famine, sea-level rise, ecosystem loss and increasing link to negative health and wellbeing outcomes for our planet. Many of the human health effects are direct impacts of extreme weather events, increasing impact on environmental and social determinants of health including air quality, water safety, food security and quality nutrition, secure housing and affected livelihoods, such as farming. Climate change refugees are now common and humanitarian disasters due to climate-change driven events such as droughts and floods are increasing.⁵

The distribution of the climate-caused suffering is not equally distributed with the poorer nations bearing the brunt of the cost. This different kind of social inequity and injustice, known as climate justice, requires global efforts to address. Climate justice is defined as justice that ‘links human rights and development to achieve a human-centred approach, safeguarding the rights of the most vulnerable people and sharing the burdens and benefits of climate change and its impacts equitably and fairly.’⁽¹⁸⁾ The reality is that climate injustice disproportionately affects vulnerable populations, who are least responsible for the events leading to climate change. Examples of most vulnerable groups include children and elderly, world’s poor people and many Indigenous communities. Climate-change related natural disasters further expose racism, racial disparities^{19, 20} and threats to Indigenous ways of living and knowing.²¹

Women and girls are particularly vulnerable to climate change because they represent almost 70% of the world’s poor and are proportionally more dependent on threatened natural resources.²² Furthermore, social, economic and cultural factors, encompassing different roles between women and men in some societies, different responsibilities, different levels of participation in the decision-making , land ownership, access to natural resources and access to education and training, threaten women’s and girls’ capacity to adapt to climate change thus further deepening gendered health inequities.²³ Alarmingly, women and children are increasingly at the threat of human trafficking and sex slavery, also linked to climate change.²²

The nexus between nursing/midwifery informatics and climate justice may not at first be evident as many of us are not aware of the environmental impact our decisions can make. For example, did you know that every decision you make in the context of a new information system implementation also carries a carbon footprint that would then contribute to the formation of greenhouse gases and to climate change? Many of the information technology components (known as e-waste), once they reach their use-by date, are often shipped (sometimes illegally), treated, recycled and destroyed in developing and impoverished nations.²⁴ In many countries, the waste disposal and labour are dirt cheap, people work in appalling conditions and in many places, the overall recycling process is also poorly managed from the environmental point of view.²⁵ Incineration of plastics used to make technology lead to increased local pollutions and toxin release, impacting the health of those who are also ready vulnerable.²⁴ What happens in the countries where child labour is common in many impoverished countries where children would be exposed to toxic e-waste chemicals, many of which are linked to negative health outcomes, including cancer.²⁶ Similarly, ageing, and obsolete medical equipment, including digital technologies, are often shipped to poorer nations as a gesture of solidarity and good will to help improve health services in that country. However, we need to think about what happens when that equipment is no longer usable, and that country has no means of processing the waste generated by that technology. Does it contribute to landfills in those countries where it can leak more toxins and pose health threats to those already vulnerable? Do we have a moral responsibility to discuss this possibility with our colleagues in poorer nations to find a solution to this problem as part of our help to improve healthcare in poorer nations in this way?

Every time a new digital health technology and the related information systems are implemented, informaticians have an opportunity to consider the downstream effects of this decision on the environment and to refine these decisions with planetary health in mind. COVID-19 has shown that nurses and midwives are creative, resilient, determined, and innovative and find solutions to most challenging circumstances.²⁷ We can transfer these attributes to go beyond creating digital health technologies and related computational infrastructures and towards more sustainable outcomes that would minimise the impact of our choices on developing nations. This includes integrating climate justice into our decisions and championing women and girls’ rights as the best means to adaptation to climate change. Advocating for racial justice and for the rights of Indigenous peoples, diversity and inclusion of vulnerable groups in climate justice discussions at national and local level is the key to more successful and sustainable mitigation and adaptation strategies to address the challenges of climate threats to health.²⁸ Conscious thinking about these issues as part of the decision-making process leads to a meaningful, sustainable contribution to global climate change resilience and adaptation strategies.

As we embark on what may be a never-ending journey of addressing the health impacts of climate change, let us do this with mindfulness. Let us challenge ourselves to not fall once again into the trap of helping one group of humans and their ecosystems to lead optimal lives only to harm another somewhere else in the world. Instead, the next time we design a digital health solution, let us ask ourselves: Is our solution environmentally sustainable and will it improve the health of our planet?

#ThereisnoplanetB

A/Prof Zerina Tomkins, February 2022