Ryan A. Crowley, BSJ; for the Health and Public Policy Committee of the American College of Physicians (*)
Financial Support: Financial support for the development of this guideline comes exclusively from the ACP operating budget.
Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M15-2766.
Requests for Single Reprints: Ryan A. Crowley, BSJ, American College of Physicians, 25 Massachusetts Avenue NW, Suite 700, Washington, DC 20001; e-mail, RCrowley@mail.acp online.org.
Author Contributions: Conception and design: R.A. Crowley, D.V. Moyer, D.M. DeLong, S.S. Bornstein, R.M. Lohr, F. Syed.
Analysis and interpretation of the data: R.A. Crowley, J.F. Bush, S.U. Rehman.
Drafting of the article: R.A. Crowley, D.V. Moyer, F. Syed.
Critical revision of the article for important intellectual content: R.A. Crowley, D.M. DeLong, G.A. Hood, G.C. Kane, R.M. Lohr, K.E. Olive, S.U. Rehman, M. Beachy, M. Biermann, F. Syed.
Final approval of the article: R.A. Crowley, D.V. Moyer, D.M. DeLong, S.S. Bornstein, J.F. Bush, G.A. Hood, C.A. Horwitch, G.C. Kane, R.M. Lohr, K.E. Olive, S.U. Rehman, M. Beachy, M. Biermann, F. Syed.
Administrative, technical, or logistic support: R.A. Crowley, G.A. Hood, G.C. Kane.
Collection and assembly of data: R.A. Crowley, G.A. Hood.
Crowley RA, for the Health and Public Policy Committee of the American College of Physicians. Climate Change and Health: A Position Paper of the American College of Physicians. Ann Intern Med. 2016;164:608-610. doi: 10.7326/M15-2766
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Published: Ann Intern Med. 2016;164(9):608-610.
Published at www.annals.org on 19 April 2016
Climate change could have a devastating effect on human and environmental health. Potential effects of climate change on human health include higher rates of respiratory and heat-related illness, increased prevalence of vector-borne and waterborne diseases, food and water insecurity, and malnutrition. Persons who are elderly, sick, or poor are especially vulnerable to these potential consequences. Addressing climate change could have substantial benefits to human health. In this position paper, the American College of Physicians (ACP) recommends that physicians and the broader health care community throughout the world engage in environmentally sustainable practices that reduce carbon emissions; support efforts to mitigate and adapt to the effects of climate change; and educate the public, their colleagues, their community, and lawmakers about the health risks posed by climate change. Tackling climate change is an opportunity to dramatically improve human health and avert dire environmental outcomes, and ACP believes that physicians can play a role in achieving this goal.
Polar Regions (Arctic and Antarctica): Risks for ecosystems, human health and well-being, unprecedented challenges especially from rate of change.
Europe: Increased damage from river and coastal floods, increased water restrictions, increased damages from extreme heat events and wildfires.
Asia: Increased flood damage to infrastructure, livelihoods, and settlements; heat-related human mortality; increased drought-related water and food shortage.
Australasia: Increased flood damage to infrastructure and settlements, increased risks to coastal infrastructure and low-lying ecosystems.
Small Islands: Loss of livelihoods, settlements, infrastructure, ecosystems, services, and economic instability; risks for low-lying coastal areas.
Africa: Compounded stress on water resources, reduced crop productivity, vector- and water-borne diseases.
Central and South America: Reduced water availability and increased flooding and landslides; reduced food production and quality, spread of vector-borne diseases.
•Climate change is real and human-caused.
•Climate change is bad for us and our community in a number of ways.
•We need to start taking action now to protect the health of our community's most vulnerable members—including our children, our seniors, people with chronic illnesses, and the poor—because our climate is already changing and people are already being harmed. [Our top priorities for protecting people's health from our changing climate are (list your organization's top three priorities here).]
•Taking action creates a “win-win” situation for us because, in addition to dealing with climate change, most of these actions will benefit our health too.
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Erik Mondrow MD, FACP
Flatiron Internal Medicine, Louisville, CO
April 19, 2016
A concern regarding the ACP position on climate change
I read with dismay the ACP position paper calling for “urgent action” on climate change. With egregious overreach, the ACP abandoned our expertise in medicine to preach about atmospheric science. This should strike physicians with the same incredulity that we would feel if NOAA were to issue a policy on best practices for managing diabetes. This ACP policy tarnishes our College’s distinguished reputation with the appearance of promoting a biased political agenda.
As soon as I read “ninety-seven percent of climate scientists agree that humans are largely causing global warming”, I knew the authors were influenced by sensationalism over science. The authors, who reference Cook with this “97%” canard, should know it is a discredited statistic. Cook reviewed 12,000 relevant abstracts, but found only 34 percent even expressed an opinion about man-made climate change. Thirty-three percent appeared to support it. He divided 33 by 34 to get 97%. If the ACPs’ Annals were to receive a research submission with such shoddy methodology as Cook’s, it would be summarily rejected.
If the authors seek consensus, consider Linzen’s (lightly edited) assertions of points of agreement between skeptical and alarmist atmospheric scientists:
“1) The climate is always changing. 2) CO2 is a greenhouse gas without which life on earth is not possible, but adding it to the atmosphere should lead to some warming. 3) Atmospheric CO2 has been increasing since the end of the Little Ice Age in the 19th century. 4) Over this period, the global mean temperature has increased slightly and erratically by about one degree Celsius; but only since the 1960’s have man’s greenhouse emissions been sufficient to play a role. 5) Given the complexity of climate, no confident prediction about future global mean temperature or its impact can be made. The IPCC, acknowledged in its own 2007 report that ‘The long-term prediction of future climate states is not possible.’”
The authors demand “urgent action” with reckless disregard for the consequential cost, the negligible reward, the prospect that warming actually has some benefits , and any evidence contrary to their conclusions, not to mention, Occam's Razor and the null hypothesis . Thus, they abandon our vital adage to “first, do no harm.”
As a physician, I turn to the ACP for insight on the practice of medicine. Please do not strain the credibility of the ACP by advocating policy that is politically biased and outside the ACP's area of expertise.
1. Tuttle, Ian. "The 97 Percent Solution." National Review Online. National Review, 8 Aug. 2015. Web. 27 Apr. 2016.
2. Lindzen, Richard. "Climate Change: What Do Scientists Say?" PragerU. Prager University, 17 Apr. 2016. Web. 27 Apr. 2016.
3. Lomborg, B. (2016), Impact of Current Climate Proposals. Global Policy, 7: 109–118. doi: 10.1111/1758-5899.12295
4. Zhu, Z. (2016), Greening of the Earth and its drivers. Nature Climate Change doi:10.1038/nclimate3004 Published online 25 April 2016
5. Giever, Ivar. "Video - Ivar Giaever (2015) : Global Warming Revisited." Video - Ivar Giaever (2015) : Global Warming Revisited. Council for the Lindau Nobel Laureate Meetings/Foundation Lindau Nobel Laureate Meetings, n.d. Web. 27 Apr. 2016.
MD BROCKMAN MD
COX HEALTH CENTERS
May 4, 2016
It's hard to believe a panel of trained internists supports the concept of anthropogenic climate change much less the ridiculous claim it is causing human health hazards.
Eric J. Reines
Element Care PACE
May 8, 2016
Animal products, climate change, and human health
The burning of fossil fuel is not the only cause of climate change, as noted in the introductory statement on "Climate Change and Health: A Position Paper of the American College of Physicians". However, the statement that "...deforestation, ...agriculture and food production ...all release carbon dioxide and other greenhouse gases..." omits an important distinction. While the production of food is necessary for human life, the raising of food animals, especially beef cattle, contributes to deforestation and green house gas emissions far more than does the growing of plants for human consumption. Moreover, the Scientific Report of the 2015 Dietary Guidelines Advisory Committee recommends that Americans reduce their intake of beef and other animal products for two reasons: First, such a diet is healthier than the current standard American diet; and second, continuing animal production at current rates is unsustainable and harmful to the environment. This advice was removed from the final guidelines for political reasons. Our College should include a statement in the Position Paper on Climate Change and Health urging doctors to advise a diet lower in animal products and higher in whole plant products as a way to both improve the health of their patients and of their environment. Crowley RA; Health and Public Policy Committee of the American College of Physicians. Climate Change and Health: A Position Paper of the American College of Physicians. Ann Intern Med. 2016 May 3; 164(9):608-610. Eshel G, Shepon A, Makov T, Milo R. Land, irrigation water, greenhouse gas, and reactive nitrogen burdens of meat, eggs, and dairy production in the United States. Proc Natl Acad Sci U S A. 2014 Aug 19:111(33):11996-12001. Scientific Report of the Dietary Guidelines Advisory Committee [Internet]. Washington. 2015 Feb [cited 2016 May 8]. Available from: http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf Dietary Guidelines for Americans 2015-2020 [Internet]. Washington. 2016 Jan [cited 2016 May 8]. Available from: http://health.gov/dietaryguidelines/2015/guidelines/ Scudellari M. Nutrition experts criticize new federal dietary guidelines [Internet]. The Boston Globe. 2016 Jan 12 [cited 2016 May8]. Available from: https://www.bostonglobe.com/lifestyle/food-dining/2016/01/12/nutritionists-criticize-new-federal-dietary-guidelines/bx7b9lU5jAQ7thec97h52L/story.html
Daniel S. Berman, MD
Montefiore Medical Center
Response to Climate Change and Health
Crowley, in a position paper on climate and health, recommends that physicians "advocate for climate change adaptation and mitigation policies." As an internist and Infectious-Disease specialist, I find this recommendation difficult to follow. Such advocacy might also compromise my ability to influence patients in other areas of healthcare.As a physician, it is my responsibility to analyze data provided in the medical literature and not just accept blindly conclusions that are stated, even by prestigious medical societies. My education and training allow me to review data and come to conclusions about the reliability and significance of medical data. However, I do not possess the tools to analyze data from scientific areas outside of medicine, such as climate change, to form opinions. I respect the integrity and knowledge of the "Intergovernmental Panel on Climate Change," which states that "human influence on the climate system is clear." However, without my own understanding of the science, I am uncomfortable advocating for "climate change adaptation and medication policies," especially when I might be challenged by individuals with more educational background in this area. As a physician I am often confronted with patients' opinions, which are contrary to the medical literature. Some examples include vaccine hesitancy; insistence on antibiotics to "knock out a cold," demand for long-term antibiotics for "chronic Lyme disease," and reluctance to use statins when indicated. In these areas I can confidently present my position to patients, often succeeding in convincing them to reevaluate their positions. Fighting for "climate change adaptation and mitigation policies," is a position I can only defend based on belief in the recommendations made by others, and not through independent analysis of data. Fighting for such policies may compromise my ability to convince patients in areas where I do have the background and training to understand and present the data. Patients may interpret my advocacy in areas that I have limited knowledges as an indication of biased recommendations, not based on facts. Understanding the impacts of climate change on human and environmental health is important for management of patients. This knowledge is based on medical data that I can interpret independently. Advocating for “climate change adaptation and mitigation,” without understanding the facts, is challenging and may compromise my ability to properly care for patients
James J Fulmer, MD, FACP
May 16, 2016
I read the position paper from ACP on global warming as well as the accompanying editorial with interest. It occurred to me that public buy in would be much more robust if we stopped calling the issue "climate change" and started calling for steps to contain "air pollution" or perhaps simply, "pollution". Pollution is a much more personal and meaningful phrase to most people than the more ephemeral and highly politicized "climate change" or the just as politicized "global warming". People can more easily understand pollution and its link to health and well being. Therefore in order to advocate for public health, my thought is for physicians to focus on steps to reduce pollution, many of which will also reduce global warming.
Ryan A. Crowley,Darilyn V. Moyer, MD, Douglas M. DeLong, MD
American College of Physicians
July 8, 2016
We respectfully disagree with Eric Mondrow’s claim that ACP’s policy paper on climate change and health is an “egregious overreach” that is outside the College’s mission. ACP became involved in analyzing the health impacts of climate change and developing our policy paper at the request of our Board of Governors—elected leaders of our state and international chapters. The Board of Governors’ resolution asked the Board of Regents to support efforts to educate and respond to the medical consequences of climate change affecting or potentially affecting patients. The Board of Regents adopted the resolution in November 2014.As requested by the Board of Governors, our Health and Public Policy Committee, made up of practicing internist-members, reviewed the evidence on the impact of climate change on human health and concluded that climate change poses an immediate and longer-term threat to individual and population health. The committee’s draft position paper was reviewed and commented upon by our Board of Governors, comprised of the leaders of our state chapters elected by the membership, and by ACP’s councils of student members, young physicians, residents, and subspecialties, and by independent experts in the science of climate change and its impact on health, before being adopted as policy by ACP’s Board of Regents. This process, involving review of the draft by hundreds of ACP members, ensured that the full and diverse range of views within our membership was considered. As atmospheric science does not fall within the College’s usual purview, the College relied on the work of trusted, objective experts—including the National Academies of Sciences and the Royal College, the National Aeronautics and Space Administration, and the Intergovernmental Panel on Climate Change— to reach its conclusion that the warming of climate is definite and that climate change is largely caused by human activity. These organizations do have the relevant data review expertise, and their consensus on anthropogenic climate change is clear. Dr. Mondrow’s claim that the statement “Ninety-seven percent of climate scientists agree that humans are largely causing global warming” has been discredited is also unfounded. While it is true that some critics of taking action to address climate change have questioned the accuracy of the Cook et al. study, this study was recently bolstered in the peer-reviewed scientific journal Environmental Research Letters, in which the authors concluded “The consensus that humans are causing recent global warming is shared by 90%–100% of publishing climate scientists according to six independent studies by co-authors of this paper” and “that the finding of 97% consensus in published climate research is robust and consistent with other surveys of climate scientists and peer-reviewed studies.”(1) Like other ACP position papers, we believe the College’s paper objectively describes how climate change has impacted, is impacting, and will continue to impact human health, from exacerbating respiratory disease to increasing the risk of heat-related illness. Climate change is an individual and public health issue and because it affects the patients that are treated by our members, the College believes it is imperative that our members work to become educated about climate change and health, reduce the greenhouse gas footprint of their own practices, and advocate for policies to adapt to and mitigate climate change. Daniel S. Berman expresses concern about Recommendation 3 of the position paper, which says “Physicians, both individually and collectively, are encouraged to advocate for climate change adaptation and mitigation policies and communicate about the health cobenefits of addressing climate change in objective, simple language to their community and policymakers.” Dr. Berman states that physicians may lack the expertise to independently analyze climate change research, making it difficult to effectively discuss climate change adaptation and mitigation policies with their patients. We clarify that the intent of the recommendation is call on physicians and other health care professionals, both individually and collectively, to advocate for action to address climate change to members of their community and policymakers. To assist our members in this charge, ACP has developed a Climate Change Action Plan. The toolkit includes talking points and presentation slides that can be used for chapter presentations, Grand Rounds, and other educational opportunities. Because the health care – particularly hospitals – is among the most energy intensive commercial sectors, the toolkit includes a collection of “Greening the Health Care Sector” documents to help guide physicians and their colleagues to make their practices and facilities more environmentally sustainable by addressing energy management, transportation, waste and food, and the built environment. For physicians who are comfortable providing such information to their patients, the toolkit includes a Patient FACTS education document developed by ACP's Center for Patient Partnership in Healthcare. Part of ACP’s patient-tested educational series designed to help patients increase their understanding of health issues, Patient FACTS also list relevant questions that patients can ask to facilitate communication with their doctor.We agree with Eric J. Reines’ comment that agriculture and food production are major sources of greenhouse gas emissions and that reductions in meat protein consumption could help mitigate climate change. According to the Intergovernmental Panel on Climate Change, the Agriculture, Forestry, and Other Land Use sector is responsible for about 25% of anthropogenic greenhouse gas emissions.(2) Under the rationale for position 1, which recommends the development and implementation of strategies to adapt to and mitigate climate change, the policy paper states “The agricultural sector is a major source of global greenhouse gas emissions, such as methane from livestock. By reducing demand for greenhouse gas–intensive meat in high-income countries and shifting to healthier diets rich in legumes, fruits, and vegetables, environmental and health cobenefits could be realized.” The aforementioned ACP Climate Change Action plan includes a document summarizing how the health care sector can reduce its greenhouse gas footprint by eliminating waste and encouraging consumption of healthy, local foods. Sincerely, Ryan A. Crowley; Senior Associate, Health Policy; American College of PhysiciansDarilyn V. Moyer, MD, FACP; Immediate Past Chair, American College of Physicians Health and Public Policy Committee; Executive Vice President and Chief Executive Officer Designee, American College of PhysiciansDouglas M. DeLong, MD, FACP; Immediate Past Vice Chair, American College of Physicians Health and Public Policy Committee; Chair, Board of Governors, American College of Physicians(1) Cook J, Oreskes N, Doran PT, Anderegg WRL, Verheggen B, Maibach et al. Consensus on consensus ;a synthesis of consensus estimates on human-caused global warming. Environ Res. Lett. 2016;11(4): 11 048002. Accessed at http://iopscience.iop.org/article/10.1088/1748-9326/11/4/048002/pdf on April 28, 2016.(2) IPCC, 2014: Climate Change 2014: Mitigation of Climate Change. Contribution of Working Group III to the Fifth Assessment Report of the Intergovernmental Panel on Climate Change [Edenhofer, O., R. Pichs-Madruga, Y. Sokona, E. Farahani, S. Kadner, K. Seyboth, A. Adler, I. Baum, S. Brunner, P. Eickemeier, B. Kriemann, J. Savolainen, S. Schlömer, C. von Stechow, T. Zwickel and J.C. Minx (eds.)]. Cambridge University Press, Cambridge, United Kingdom and New York, NY, USA http://www.ipcc.ch/pdf/assessment-report/ar5/wg3/ipcc_wg3_ar5_full.pdf
Linda Karl MD, Cynthia MahoneyMD
Linda Karl MD, member ACP
July 9, 2016
Thank you for confronting this urgent issue
To the Editor:
We want to thank the ACP for their recent position paper on climate change and health.(1) They provided an excellent overview and call to action on the most existential issue of our lives. Although the efforts of individual physicians and medical institutions to green themselves, to adapt and to foster resilience are all necessary and laudable, they are insufficient to the urgency and scale of the problem. We need a concerted national effort to prevent accelerated climate change: a policy to mitigate the problem. Unfortunately the ACP paper omitted any discussion of the most powerful mitigation policy available to address this "catastrophic risk" that warrants "urgency". That is like educating physicians about severe uncontrolled diabetes without telling them there is a treatment called insulin. 90% of economists agree that carbon pricing is the best mitigation policy because it harnesses the entire economy to reduce greenhouse gas emissions. The most effective, equitable, cost-efficient and transparent way to put a price on carbon and one that could actually gain the support of both progressives and conservatives is carbon fee and dividend. By putting a steadily increasing price on carbon emissions at the source and then returning all funds to each household we can achieve the needed CO2 reductions while creating 2.8 million jobs and saving hundreds of thousands of lives here in United States, not to mention the millions of lives that would be saved worldwide. The medical community should use its substantial individual and joint influence to encourage Congress to pass carbon fee and dividend ASAP.
(1) Crowley, RA for the Health and Public Policy Committee of the American Society of Physicians. Climate Change and Health: A Position Paper of the American college of Physicians. Ann Intern Med. 2016; 164:608-610. doi:10.7326/M15-2766
Cynthia Mahoney MD
Contra Costa Chapter, Citizens Climate Lobby
Linda Karl, MD
Tucson Chapter, Citizens Climate Lobby
Emergency Medicine, Infectious Disease, Pulmonary/Critical Care, Asthma.
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