Existing health system creates difficulties in creating change for planetary health

Participants noted that the existing health system creates difficulties in creating change for planetary health. Many participants mentioned engrained organisational structures and processes in the NWT health system, including cultural barriers, and barriers from management, which make change difficult. One participant noted regarding the barriers of improving access to Telehealth that

…despite years of trying to convince the Government and people in positions of authority about the value of this, it was exceedingly hard to seemingly get peoples’ attention and sell this notion. It was shocking in a way because usually, quite apart from the climatological benefits and so forth, you would think cost would be compelling. Often for governments and health authorities, cost is something that would interest them but despite that, it seemed impossible to move that agenda [ID 1.6].

There were repeated comments on the structures and operations of the government bureaucracy. More specifically, that many bureaucratic actors in the north do not have the “same amount of investment in the long-term vision and future of the north” [ID 2.4] with many coming to work in the NWT for short periods of time before moving back south. This lack of longer term vision was said to be compounded by both electoral cycles of changing mandates, as well as by health systems that are often in “this reactive process…trying to fix the fires that are burning and it’s perhaps an apt climatological analogy, putting out fires, that’s exactly what they’re running around doing” [ID 1.6].

Health system management-level challenges were highlighted specifically regarding the delivery of care. Physicians who reported trying to make changes in the system towards planetary health said they have had a noted lack of support.

…I was doing an endometrial biopsy and it kills me because you open these trays and they’re meant to be disposable but there’s nothing disposable about them…they’re fully metal…Some of my colleagues have gotten in such trouble for trying to transport equipment…to reduce the need for people to fly [yet] it was shut down because of infection prevention and control, even though it was being done in a really reasonable way…there’s very, very little interest [from the health system] in compromising at all [ID 2.1].

The seeming lack of interest from the system to make planetary health-motivated changes was amplified by physicians acknowledging that they may have power with patients, but not as much control and power systemically to make change within the system.

I certainly think that we can play a role… I guess I’m a little burnt out from trying administratively to get things done, and so I feel the voice of the physician is not that powerful; I certainly don’t think it is here [ID 1.2].

Outside of talking about things and pushing, we have very little power to actually implement anything…So I feel we’re pretty powerless. Outside of again talking and insisting on some measure to be taken, we’ve not been able to make any impact to anyone [ID 2.6].

One participant noted that there is often little room for discussion, and that it is disheartening to work in a system where “no one listens”. Additionally, despite there being a sense of physicians not having flexibility within their employment contracts, generally, many did believe that high-level government involvement and decisions would be needed to make change in the NWT healthcare system

To get a health system to do that [focus on planetary health] is going to require, frankly, a Premier that is going to say this must be done, and probably that Premier is also going to need to be pressured by a Prime Minister who’s going to say, this needs to be a countrywide thing, or some middle people along the way with an enormous amount of vision and a lot of courage, who can do this without necessarily having that pan-governmental support [ID 2.2].

There was an acknowledgement of the current siloed approach within healthcare delivery not being conducive to systemic change within the health system. Given this, there were repeated mentions of the need to involve pharmacists and other health professionals, plus multiple other stakeholders inside and outside the healthcare system to enable change. It was additionally noted that the pandemic triggered changes within healthcare delivery quickly, but climate change has not.

…we just didn’t do it until Covid happened and then within weeks we were doing everything virtually which goes to show we were capable of doing this. There just seemed to be either a lack of desire, a lack of imagination, lack of organizational capacity, lack of governance wherewithal within the healthcare sector to transform itself in any meaningful way, in a manner that would be beneficial to all Canadians. And so, it’s quite fascinating. So suddenly all these perceived obstacles, oh we can’t do that, just vanished in literally weeks [ID 1.6].

Ultimately, there was a recognition that with complicated interjurisdictional relationships existing between the NWT and other regions; that there is a tendency for performative actions with no real embedded accountability; that there is high levels of institutional risk aversion; that continued top-down approaches are implemented without actual implementation support; and that change in the NWT often relies on a few champions working really hard—and this is not sustainable or feasible for lasting change.

Resource and capacity barriers prevent movement forward for planetary health

Participants noted that resource and capacity barriers have prevented movement forward for planetary health within the NWT. The NWT specifically was stated to have a stark lack of human resources and capacity at multiple levels of the health system, although this was platformed on a lack of movement in considering creative and practical options for benefiting patients and the planet.

…[H]uman resourcing in the territory is a huge issue as it is but I don’t think there’s been enough talk around actually balancing the cost of ongoing status quo medivacs, high reliance on medical travel, high reliance on short-term contracts of people being here for short periods of time and then high turnover and all the inherent costs of that, versus getting really high quality healthcare in communities through other strategies of aggressive training programs, trying to focus on upstream determinants like good-quality primary education in the north, getting people into health careers, getting people back, recruiting them back to the north (ID 2.4).

With high turnover and a lack of permanent long-term staff, there was a noted lack of continuity of care affecting the ability to provide planetary health-based healthcare. For example, one participant noted that it is difficult to adjust prescribing in a transient workforce due to the time needed to develop trusting relationships with patients, with another participant noting similar challenges with seeing non-patients for prescription changes due to a lack of established relationship (eg, on-call, locums, fill-ins, etc). A lack of continuity of care was amplified with the standard time limitations for medical visits that were perceived to make addressing planetary health difficult in addition to regular care.

Issues with improving the availability of more advanced technology that could reduce medical travel were also highlighted by some of the participants. For example, “having a CT scan, a CT scanner does not operate itself. Although you’d reduce travel, you’d need to have a proper trained technician to be able to make the machine work” (ID 2.7). With the lack of human resources noted, there is also the high cost for technology infrastructure to take into consideration with one participant noting that physicians often need to balance patient recommendations with resource utilisation considerations independent of planetary health considerations. For example, the balance of needing to ship somebody out on medical travel for an MRI needs to be considered with the high financial cost of this travel to the system which can be independent to the high greenhouse gas contribution of medical travel itself.

Planetary health-related care delivery is not part of our common dialogue, culture or training as physicians

Participants noted that planetary health–related care delivery is not part of their common dialogue, culture or training as physicians. One participant stated, “I would say it’s probably not something that’s really talked about, at least to me or by me” (ID 2.5), with another participant stating, “I don’t think that is a big part…I don’t even think it’s a small part of most health discussions” (ID 3.2). Another participant stated that

I’ve not been in a conventional medical learning environment where this even comes up…environment or nature has not even come up as a topic and as something to consider… we have not had any formal education on the subject (ID 2.6).

It was therefore stated that people need more knowledge, training, and resources to move this work forward. Underlying the lack of dialogue and knowledge on the topic, most participants noted, however, that there is a tricky balance between patients being the priority and including planetary health considerations with many factors to consider. Perspectives varied with one participant noting that

My patient is my primary responsibility but I’m also having to balance the health of the healthcare system when we look at resource utilisation. So, balancing the health of the planet I think is again one of those factors, along with lots of other things that I take into consideration but it’s not going to be primary when my patient is sitting in front of me (ID 4.1).

Participants saw the need for a balanced perspective with a need for “making sure that there’s the right balance between the benefits of the individual and the benefit to the environment” (ID 2.7). With varied perspectives on the degree to which the planet should be the focus within the clinical environment, there was also clearly an anticipation of a mixed or unclear response from patients towards planetary health-informed care. Some participants confidently expected patients would be very receptive towards patient-planetary-informed care with the right context and communication approach, with others citing direct experience already engaging patients on the topic.

I suppose in the individual interactions, if you were to explain your choices of I’m prescribing this medication to you because it’s been shown to be better for the environment, the middle of the road people would probably just appreciate that and say that’s great, thank you…(ID 2.5).

Others, however, were not so confident with a positive patient response: “I think, to be honest, most people would completely dismiss it, or I’d probably even get some eyerolls” (ID 3.2). There were also some participants who were less clear on what the patient response might be to these discussions: “Maybe in my soul, everybody cares a lot. They would care a lot and maybe they don’t or maybe I think no, it probably wouldn’t be a priority here…So, the answer is I don’t know” (ID 2.7). Regardless, there was a clear note specific to prescribing that patients might be nervous about change, but also for the physician to be attuned to “…patient choice and what people value” (ID 4.1) when thinking about discussing planetary health-informed choices within clinical practice. Although there is “some” knowledge and progress being made on patient-planetary co-benefit understandings by physicians, it was highlighted that in many circumstances changing individual physician prescribing and practise habits can be difficult and take time.

Currently, overburdened physicians and the healthcare system do not prioritise the planet

Participants were very clear in that currently overburdened physicians and the healthcare system overall are not prioritising the planet. There was a sense of day-to-day burden with regular care that makes thinking about planetary health an extra weight of responsibility. Yet, despite the work burden, many wanted to be advocates to better ensure the planet is considered in the care provided.

…[T]hings are so stressed now that it is a very challenging to effect long-term change, visionary change in a system which is struggling to sustain itself on a day-to-day basis. That’s the difficulty. So, the airspace is limited and yet not addressing it will just make the sustainability worse and this is what’s happened with climate change in all domains or biodiversity, all these planetary threats. We’ve backed ourselves into a corner (ID 1.6).

I feel right now we’re just in this total crisis of it’s hard to imagine that that’s going to happen any time soon [i.e., integrating planetary health], when how are we going to fill our labor and delivery shift Thursday? It doesn’t feel like there’s a lot of capacity for that type of engagement right now, which is depressing and frustrating (ID 4.7).

A participant added that “…the responsibility just seems really heavy” for planetary health while a personal pet peeve is that “…[e]verything is on us. I’m like, oh this is a problem, I need to fix it. We’re not going to look at the system. I need to fix it, individually patient by patient” (ID 4.1). This responsibility for the planet put onto the shoulders of physicians was also amplified through a different lens with another participant noting that when the health system does not take action for planetary health that this can cause stress for physicians who understand the environmental imprint of their existing clinical practice: “I think we underestimate the amount of moral injury that healthcare workers experience as a result of the emissions that we know that our work is associated with” (ID 3.7).

Participants did note, however, that physicians should be advocates and leaders, and lead by example despite the sense of overburden often felt. One participant stated that, “I think it should be the responsibility of everyone, including physicians” (ID 2.6), with another one stating more firmly that, “…it’s not just my opinion that it’s the responsibility of physicians, it is becoming the professional norm that it’s going to be the responsibility of physicians” (ID 2.7). Physicians were noted to play a role in “being advocates for the planet and climate change” (ID 4.7). However, this leadership and advocacy were noted to be dependent on accepting the notion “that the health of the planet is contiguous with our own health, and the health and wellbeing of individuals and populations is the job and the accountability and the purpose of physicians” (ID 1.6). “You can’t soil the sandbox…kids get unwell and we get unwell in our sandbox [the planet]…what’s the point of ignoring the fact it’s littered with shit and everyone’s getting sick…pretending that working on them and ignoring what’s happening makes no sense” (ID 1.6).

Unique health system considerations in the north

Ultimately, participants were very cognizant that there are very unique health system considerations in the north when it comes to thinking about P-PH. Participants were clear, regardless of their perspectives on other elements of the topic that global environmental changes are affecting or could affect patient health and the delivery of care in the NWT. For example, participants mentioned lung-related conditions and exacerbations from wildfires, and changes in food availability either happening or anticipated to happen in the north among other things.

…[W]e could easily have an entire summer where it’s just smoke the whole summer basically and people who have pre-existing medical issues, respiratory issues, that would basically mean they wouldn’t be able to be outside of a controlled ventilated setting, like a house with HEPA filters or a well-ventilated facility where they’re not exposed to the smoke…otherwise if they are, they would have an exacerbation of their pre-existing medical condition and have to be in hospital (ID 2.4).

Participants also referenced the loss of caribou as a food source and the health impacts this has on Indigenous communities in the area in addition to the impact of changing landscapes on local communities. They have awareness or have increasingly managed within their clinical practices mental health-related issues given the increasing number of climate-related events in the region with patients presenting with

…[f]eelings of vulnerability, fear, of a lot of worries about the future, frankly of just PTSD from some of those types of situations [i.e., climate change events], and a feeling of fragility that comes from living in these communities, but also just about your life in general. You want to establish your life, you want to establish your kids, you want to do all these things in the north, and have your families here, and then suddenly there’s this question, is living in the north going to be a sustainable choice, are we going to be actually able to do this, when is the next fire going to come? (ID 2.2).

Participants highlighted in different ways that the NWT health system has a role to play given the high per capita contribution to greenhouse gas emissions and impact on GEC. This was noted specifically regarding the high amount of medical travel that occurs in the region and the high cost associated with this, as well as the high amount of medical waste produced without effective plans or management in place to reduce waste and pollution.

I think it’s a huge topic that probably hasn’t received the attention it deserves in the territory. I don’t know the exact numbers, but I think per capita, the territory probably has some of the highest greenhouse gas emissions or just sheer amount of waste by-product of healthcare of any place in Canada. Just given our remote setting, just bringing up any medical devices, it’s a large expense on the road (ID 2.4).

Yet, it was noted that the global impacts of the NWT health system in terms of reducing its ecological footprint, “globally speaking, would not even be measurable because it’s such a small jurisdiction” (ID 2.2). With this, there was a clear note from participants that there are planetary health implementation challenges in rural and remote areas that need to be considered. The acute care hospital service, for example, was noted to be entirely staffed by southern-based locums. “So, this drives huge cost and consumes a lot of fuel and just energy, moving people back and forth…” (ID 1.6). Additionally, “…just patient movement itself in terms of the medivacs and medical travel, that’s a huge expense to the system but also environmentally, when you think that, at any given moment, there’s planes in the air transporting patients and whether that’s transporting an individual patient on a medivac plane, like a small plane for medivac, or whether it’s a patient going down for services they can’t obtain in Yellowknife or other small communities going on a scheduled flight” (ID 2.4). To improve access to telehealth, however, available broadband access was a large issue in the rural and remote NWT landscape.

They [physicians] need to be able to hear them [patients] and not have this kind of really terrible internet connection where it’s all crackly and you can’t hear each other, and that’s what a lot of our telemedicine appointments have been like, from having been involved in a number of these. So better internet to have better telemedicine would be great, so that we don’t have to fly people around so much, because we have huge distances and really old, very environmentally unfriendly planes (ID 1.5).

Given the unique landscapes and majority Indigenous population in the region, it was also highlighted that any planetary health-informed health system changes need to be done in a culturally safe manner given the continued colonial, inequitable, and paternalistic system for Indigenous Peoples limiting progress in the region.

Sovereignty is attached to self-determination and power…and right now I think we’re still stuck in the consultative process [with Indigenous Peoples in the region]…like we’re asking Indigenous Peoples their perspective about care without actually having a pipeline that leads to [them having] power [in the health system] and them actually being able to create frameworks that work for their communities (ID 2.7).

Patient-planetary health opportunities in the NWT

Despite the unique context apparent in the NWT, there were many P-PH opportunities in the NWT highlighted by participants. Participants noted through varied perspectives that the NWT could be an innovative model for change for other health systems given the smaller size of the jurisdiction and being on the front lines of climate change. These changes were often noted to be dependent, however, on having “…set staff in the NWT and…a compelling leader who can say we really need to do this…” (ID 1.6).

We need to be more creative and bolder in our approaches (ID 2.7).

To start the process of initiating change, the NWT was said to need better baseline climate-related health system assessments and monitoring (eg, life-cycle assessments), and the leveraging of technology for efficient change. There was also repeated emphasis that system changes should be enabled and promoted to support physicians’ changing their prescribing and practice behaviours instead of relying on the individual level. System change could be focused on leveraging existing programmes and processes. “…[I]n fact we could piggyback off Choosing Wisely because it already has a brand, it already has international spread” (ID 2.1). Additionally, participants stated that clinical guidelines and policies should be developed and implemented in the north to facilitate more efficient change.

I don’t think that there’s any policy or guideline barriers, I just don’t think that there are policies or guidelines to support it (ID 2.5).

But many, many people use guidelines as instruction and so they [guidelines] have a huge impact on how people prescribe because lots of people, especially new clinicians, will just follow those [guidelines] like a recipe (ID 2.1).

Participants highlighted the opportunity for building up local capacity for care close to home to reduce travel. This was most often noted through better access to telehealth/virtual services that gained an increasing level of comfort throughout the pandemic.

It’s sort of a win-win thing. It [telehealth] reduces system cost. It reduces displacement of people who may at times not want to be displaced from their family or whatever and it reduces consumption of fossil fuels…and it usually shortens time to care, so you can, rather than having to move people, see them virtually (ID 1.6).

Lastly, participants additionally noted both challenges and opportunities around drug formularies and stock (ie, whether a more planetary health-friendly drug was listed on formularies and/or available in stock); the use of planetary health-based prescribing statistics (eg, monitoring the amount of metered-dose inhalers [MDI inhalers] being prescribed vs dry power inhalers); and insurance coverage considerations for adjusting medical care to support planetary health (see box 1). Participants specifically noted that insurance coverage including the non-insured health benefits programme for Indigenous Peoples was an important variable for possible changes in drug prescribing practices that consider planetary health.

But one thing that comes to mind is that a lot of our patients have NIHB [non-insured health benefits program]. So, if a certain medication that’s less environmentally friendly is covered, but the more environmentally friendly medication is not covered, then unfortunately you’re going to have to make that decision. For NIHB patients, usually they’re not going to pay money for things, because a lot of them can’t (ID 1.5).

Ultimately, despite the many opportunities that were highlighted, one participant stated that they “would only be on-board…if it was coming from within a community…and I’d be happy to jump on-board…but I wouldn’t be wanting to invoke something…that wasn’t coming from within the community, that wasn’t something they’d decided was a priority for their community memberss” (ID 1.2). Given this, the consideration or implementation of planetary health-informed changes was often emphasised to require co-design considerations with patients and other health system stakeholders involved in the process. Regardless, there was some hope for progress.

I do hope we can adopt…that we can make that [planetary health] a priority of the health authority…we’ve been so impacted, as so many people across the globe have been impacted, by environmental impacts. The time is now, for sure, to be doing that. So, I’d hope that we could have that as one of the priorities of the health authority, going forward, that we always apply that lens in whatever discussion we’re having when it comes to policy and resource applications, that that’s always kind of a consideration every time we’re making those decisions. When you keep it at the forefront and you have that as a priority, then you can make change (ID 1.2).