Download Climate Change Strategy-NPHS response

30 September 2009
MDS/HB/MLM
Claire Bennett
Director of Climate Change and Water Division
Welsh Assembly Government
Cathays Park
Cardiff
CF10 3NQ
Dear Claire
Climate Change Strategy – Programme of Action consultation
The National Public Health Service for Wales welcomes the opportunity to respond to
the Welsh Assembly Government’s Climate Change Strategy – Programme of Action
consultation document and I have sought the views of Huw Brunt, Consultant in
Environmental Health Protection and Carolyn Lester, Lead for Health Inequality and
Equity.
We recognise that, whilst climate change is a global phenomenon, many of its
associated effects have the potential to impact on the population of Wales. It is
therefore of paramount importance that we work collaboratively to develop coordinated plans that set out sustainable, achievable and tangible mitigation and
adaptation-related actions to tackle these effects.
In public health terms, the anticipated impacts of climate change could be significant.
Some of these impacts may be a direct result of climate change effects, such as
temperature and extreme weather-related morbidity and mortality. Other impacts,
however, may be indirect (e.g. water, food, vector and rodent-borne diseases, air
pollution-related health effects, effects of food and water shortages, allergic diseases
and ancillary health benefits). In addition, there are likely to be wider public health
impacts that are influenced by impacts on planning and the built environment,
vulnerable population groups, environmental and health inequalities, energy and
transport, food and agriculture and insurance.
With these potential public health impacts in mind, provided below are some
comments that I hope will support the Welsh Assembly Government’s consultation
process around the document and inform the development of the final Climate
Change Strategy for Wales. Since many of the questions posed in the consultation
document were not public health specific, I have attempted to pull together
comments under general headings.
GENERAL

Temple of Peace & Health, Cathays Park, Cardiff CF10 3NW
Teml Heddwch ac Iechyd, Parc Cathays, Caerdydd CF10 3NW
DX 6070101 Cardiff 90 CF
Tel/Ffôn 029 2040 2530 Fax/Ffacs 029 2040 2529
Although acknowledging that a brief description of the work of the Climate
Change and Health Working Group is contained in section 5.6 of the consultation
document, I am concerned that, considering the potential for the effects of climate

change to impact significantly on public health, there is no ‘health-specific’
chapter as there are for other sectors e.g. waste, agriculture/land and business. I
hope that the comments provided in this consultation response highlight the
importance of health considerations in terms of climate change impacts and
demonstrate that NHS agencies, and public health professionals in particular,
have a key role to play in facilitating collective action to mitigate against, and
adapt to, such impacts;
Page 7 of the strategy sets out a vision for 2050. Long term targets can diminish
the perceived urgency for action, with the risk that sectors may fail to act now in
the hope that they can ‘catch up’ later. Targets should avoid being too modest at
the outset and emphasise the need for immediate action.
MITIGATION

Making the links with public health
Climate change is an important public health issue and all carbon reduction
strategies and action plans should, therefore, have health protection and
improvement as core values. For example:
- Physical activity: Physical activity can improve physical and mental health and
active travel can reduce car use. After cycling or walking home, further carbon
reduction could be achieved as it is feasible that a lower domestic temperature
would be required for maybe the first 30 minutes after return.
- Healthy eating: Home-cooked low fat meals with plenty of fruit and vegetables
are healthier than ready meals. A family meal is socially beneficial and can
potentially use less power than several individuals cooking separately. When
the family is sharing a meal in one room, heating can be reduced in other parts
of the home.
- Mortality: Warmer winters are likely to result in lower excess winter mortality in
the elderly and it is unlikely that this will be matched by the possibility of
increased mortality during heat waves. There is, therefore, likely to be a net
increase in the elderly population.
- Morbidity: The predicted increase in the elderly population will result in greater
demands on health and social services and there is also a possibility that new
diseases will occur in the UK due to global warming. This could be exacerbated
by ‘climate change migration’ if people from hotter countries attempt to move to
more temperate zones.

Behaviour change issues
The document rightly identifies behaviour change as an essential component in
reaching carbon reduction goals. There will, therefore, be a significant and
continuing requirement for public education and it is clear that, for maximum
impact, this will need to take place at both a national and local level. Programmes
which target school children would have the twin benefits of educating future
consumers and applying pressure on parents to live more sustainably.
Experience from health promotion, however, demonstrates that providing
information can raise awareness but does not necessarily change behaviour.
Changing entrenched behaviour is a complex matter and seldom achieved by
appeals to altruism, so information regarding the undesirable impacts of climate
change on future generations or on African or Asian populations may not be
effective.
Theories and models of behaviour change can provide a useful framework upon
which to base a carbon reduction campaign. These include the Theory of
Planned Behaviour, Social Cognitive Learning Theory, Diffusion of Innovations,
and the Stages of Change Model.
Weinreich (1999) provides a useful synthesis of the main behaviour change
theories in which he lists conditions that need to exist in the target group:
-
Belief in the risk and severity of the problem
Belief that the proposed behaviour will lower or prevent the risk
Belief that benefits of the behaviour outweigh costs
Intention to perform the behaviour
-
Skills to perform the behaviour
Self efficacy
Belief in consistency of behaviour performance with self image
Perception of consistency with social norms
Experience fewer barriers to perform than not to perform.
Diffusion of Innovations theory as discussed in Malcolm Gladwell’s The Tipping
Point (2000), describes how a behaviour gains momentum via dissemination by
opinion leaders and peer to peer networks until it reaches a point where it is
perceived as desirable and adopted by a high proportion of the target population.
Similarly, ‘buzz marketing’ has been used to promote ideas, services and
products in a wide range of social and commercial settings (Holdford 2004).
Incorporating the methods described above, social marketing is the systematic
application of marketing concepts and techniques to achieve ‘social good’ via
tangible and measurable behavioural goals. Whilst one of the primary focuses of
social marketing is improving health and reducing health inequalities, it is also
used to bring about positive change in areas such as recycling, modes of
transport and compliance with legislation.
Social marketing is just one of a number of intervention options which can be
used to promote a desired behaviour. One of its major contributions is to provide
‘customer insight’ to inform policy and strategy and improve the development of
interventions aimed at different groups. As such it can be used in conjunction
with, for example, legislation, fiscal measures and community development.
Achieving behavioural goals can be extremely complex so, to justify its cost,
social marketing must demonstrate evidence of sustained positive change in
difficult to reach groups. Social marketing aims to achieve this by understanding
and working with three facilitators of change:
- Insight - the lived reality of the target audience, avoiding professional
assumptions about what they might want or think;
- Exchange – what may be lost during behaviour change and balance this with
what will be gained (loss of pleasure and convenience versus avoiding extreme
climate change);
- Competition – what is competing for allegiance to different ways of living,
balancing this against what can be gained.
This requires the development of a shared understanding by seeing the individual
in his/her social context and understanding that patterns of behaviour may be
ingrained over several generations but also subject to variation according to time
and context. Patterns of behaviour are framed by attitudes, values, beliefs,
wishes and other motivators, sometimes resulting from habit rather than
conscious decision. Behaviour does not always result from cognitive decision
making and social marketers advise that the following should be considered:
-
Product – what’s on offer?
Price – what will it cost the consumer?
Place – where does the relevant behaviour happen?
Promotion – what incentives can be used that will be valued by the target
audience?
These are applied by segmenting the audience by their potential to respond to
differing approaches. Segmentation could be by social class, age, gender, ethnic
origin, area of residence or any other grouping relevant to the behaviour in
question.

Health and social inequalities
- Vulnerability: As stated in the document (6.1), people who are already
disadvantaged will be more vulnerable to the impacts of climate change.
Carbon reduction plans should be subjected to impact assessment, with a
strong emphasis on human health and reducing inequalities (Health Inequalities
Impact Assessment). Whilst WAG must be primarily concerned with impacts
within Wales, consideration should also be given to the severe effects that are
likely to occur in areas such Sub-Saharan Africa.
- Social Justice: The overall aim should be for the social, economic and
environmental impacts of climate change to be more evenly distributed both
within Wales and internationally. Polluting or undesirable processes, such as
those associated with recycling, have often been sited in less prosperous areas
and, though such industries may provide employment, this can be at the
expense of the local environment. Skilled, more highly paid workers are often
brought in from other areas, whilst low paid jobs go to local people. It is
recognised that being in work is generally better for health than being
unemployed, but there are exceptions and wider effects on community health
and wellbeing should be considered.
- Community energy schemes (p 43) Due to lack of expertise and/or
awareness, disadvantaged communities may be less able than the more
affluent to initiate community energy schemes and there is a risk that areas with
more middle class residents may benefit disproportionately.

Public sector organisations
Public sector administration produces vast quantities of waste, often through lack
of thought: for example, large quantities of food waste are sometimes produced
when catering for meetings. Those responsible for procurement should be made
aware of the waste implications of, for example, renewing useable equipment just
because it is the end of the financial year. This could be addressed to some
extent by revising public sector financial rules which encourage this behaviour. It
would also be helpful if the Assembly could develop over-arching policies and
guidance for public sector organisations, for example regarding use of recycled
paper, printing, catering for meetings, procurement and travel.
WAG must ensure that all public sector organisations are fully engaged in
maximising carbon reduction opportunities. It is unlikely that comprehensive
carbon reduction schemes exist in all NHS facilities across Wales, and the
formation of the new Health Boards and of Public Health Wales provides the
opportunity for a new level of commitment.
Meetings should be held at public transport friendly venues or replaced by
tele/audio conferencing. Page 86 states that the Assembly Government has
linked with the UK Government campaign to reduce transport emissions. It
should, therefore, lead by example by organising meetings at public transport
friendly venues and by reducing the use of private cars and air travel for internal
UK flights.
The tendency to over-cater for meetings, producing large amounts of waste
should be better controlled and the use of bottled water and disposable
cups/beakers should be discontinued.
Policy on lighting public buildings when not in use should be reviewed,
considering possibility of using a partial or movement sensitive system. Public
buildings should not be over heated or over cooled, and this includes hospitals,
which are often uncomfortably hot for patients and visitors.
Innovative thinking is necessary in the provision of services, for example, less
carbon is produced if a consultant travels to hold a satellite clinic, rather than
requiring many people to travel long distances to a central location.
All printers should be set to double-sided as the default position.

Agriculture
- Biomass crops: Agricultural land should primarily be considered for food
production and proponents of biomass should be aware of potential risks to
food supply and pricing.
- Meat production: It is now widely accepted that meat consumption should be
reduced considerably, both for health reasons and to free up land for arable
use. WAG can lead by example by in-house catering and by advice to school
meals and hospital food providers and to all public sector organisations. It
would be possible to move closer to consuming a fairer share of the world’s
resources in Wales by making meat free days the norm. Page 101 mentions
intensive poultry and pig farming. and there appears to be an opportunity here
to encourage more environmentally and animal friendly production methods.
- Fish farming: Support for the expansion of eco-friendly fish farming should be
considered.

Transport
Public transport use should be encouraged throughout all strata of society: a
service for the poor is often a poor service. Carbon reduction can only be
achieved if public transport is universally perceived as affordable, reliable and
safe. If the aim is to reduce emissions, rather than just to alleviate congestion,
then weekend and evening public transport services must improve. For example,
one bus an hour to fairly densely populated residential areas is not sufficient to
deter people from using a private car or taxi. Urging greater use of public
transport is likely to encounter capacity problems at peak times and it may be
necessary to consider restricting concessionary travel for the over 60s to
weekends and on weekdays from 9.30 am – 4.30 pm and after 6.30 pm. This
would have the added benefited of ceasing to subsidise commuting for those over
60 who are still working, many in highly paid jobs.
Improved rail services need to be accompanied by improvements to linking bus
services. For example the increase in train services to and from Merthyr Tydfil is
quoted in the document but there has been little or no corresponding
improvement in bus connections from the town centre to outlying communities.
(Personal communication: NPHS staff).
Larger firms and public sector organisations should be encouraged to promote
the use of public transport for official business and to provide car and cycle pools
if necessary. This would overcome the excuse for daily commuting by car as
necessary to facilitate travel during the working day.
Though the growth in air travel has slowed, the aim should be trend reversal,
especially for internal flights. The public sector can contribute by using the train
when travel in unavoidable and by increased used of tele/audio conferencing.
There is a tendency to advocate low carbon transport for others and a risk that
internal air travel has become a status symbol in some public sector
organisations.
Park and ride facilities should include provision for safe storage of bicycles.
Increased use of waterways and coastal transport should be considered for the
movement of passengers and freight.

Planning
New developments such as retail, business, public service and leisure, should be
avoided where access is difficult except by private car. (The exceptions would be
high risk industrial developments or those with the potential to pollute by
emissions, noise, etc.) Energy efficiency design requirements for buildings are
becoming more rigorous but this must be linked with requirements regarding
location and public transport links.
The power for schools to change their hours to make transport more sustainable
should be used with caution and only after consultation to ensure that it does not
have a detrimental effect on working families.

Waste
It may be useful to develop incentives for participation in carbon reduction
strategies to reduce all forms of waste both at home and at work, together with
awards for achievement.
Incinerators: The HPA has stated that modern incinerators do not constitute a
significant risk to public health, as they produce only 1% of UK particulate
emissions, compared with 50% produced by transport. Due to EU regulations on
landfill, the use of incineration, and therefore its proportional contribution to total
pollution is likely to increase. The comparison with emissions from transport does
not seem valid, as pollution from waste incineration is concentrated over a much
smaller area when compared with total UK transport emissions. Such facilities
should, therefore be sited at an acceptable distance from residential areas.
Anaerobic digestion: Care will be needed in selecting sites for these facilities,
with consideration given to transport implications, risk of explosion and exposure
to digestate. Digestate is reduced in the open air and there is a risk of pollution
by odours, spores and particulates. The facility is also likely to be unattractive and
may affect the sense of wellbeing locally. Decisions on waste disposal facilities
should be subject to health (inequality) impact assessment.
ADAPTATION

Prioritising adaptation action
It will be essential for the Welsh Assembly Government to continue to interpret
the findings and predicted impacts from the work of UK Climate Projections
(UKCP09). This information will be required to prioritise adaptation action and
inform multi-agency action planning and resource allocation.
It will be equally important for the Welsh Assembly Government, when developing
adaptation action plans and allocating resources, to ensure that achievable and
tangible outcomes are considered. In order to assess impacts and determine the
effectiveness of adaptation activity undertaken, continuous progress monitoring
will be required. Involving all stakeholders in outcome generation and agreement
will support the process and ensure it is inclusive.

Role of public health professionals
Public health professionals in Wales have an important role to play in planning
and adaptation action implementation, which I feel the consultation document
fails to capture. Not only do public health practitioners have formal links with a
broad range of cross-sector stakeholders, but are also able to provide specialist
public health information, advice and support. Amongst other things, this may be
through:
The public health workforce therefore presents an extremely valuable resource
through which climate change and health-related messages can be
communicated. More emphasis should therefore be given to recognising the key
role public health professionals have to play in assessing public health risk (which
could involve the climate change risk assessment tool referred to in the
consultation document and encouraging its use amongst other NHS agencies)
and influencing policy and facilitating subsequent mitigation and adaptation
action. Public health professionals would also be able to provide information,
advice and support in respect of facilitating behaviour change, managing
surveillance programmes, communicating public health risks and conducting
epidemiological investigations.
Public health professionals could also help develop the climate change research
and development agenda in Wales. Assistance could be provided in the form of
reviewing available evidence, evaluating interventions and disseminating
information about best practice. Whilst it will be important for activity in these
areas to have a local and regional focus, it will be equally important to ensure that
links are made with national and international priorities, research and work
programmes. Funding such research projects will also need to be given careful
consideration as will the need to subject any research and general adaptation
action to health and inequality impact assessment.

Adaptation work already undertaken
The consultation document makes reference to the work undertaken by the
Welsh Assembly Government-led Climate Change and Health Working Group.
This group has been instrumental in developing Tackling the Health Effects of
Climate Change - a multi-agency plan to support collaborative adaptation action
implementation. In turn, this has led to key proposals being agreed to support the
‘health’ contribution to the Climate Change Strategy – Programme of Actions.
In addition to the above, stakeholders have not only contributed to the
development of the Heatwave Plan for Wales (as outlined in the consultation
document), but also to climate change-related work in respect of the SunSmart
campaign, public health flooding advice, food poisoning surveillance, drinking
water quality and availability, bathing water quality, air quality, new infectious
disease threats. This work, whilst is not reflected the consultation document.

Links with emergency planning
Many of the potential acute effects of climate change e.g. heatwaves, floods, food
and water-borne infectious diseases have the potential to escalate into large
scale incidents. Greater focus should therefore be given by the Welsh Assembly
Government to ensuring that appropriate and necessary links are made between
the climate change and emergency planning agendas. The consultation
document does not cover this in any great detail.
There appear to be two significant areas where these links must be made:
emergency response, assessing risks and communicating appropriate public
health messages effectively AND longer-term business planning and resilience
and increasing capacity within organisations

Flooding
Although the document states (p 66) that summer rainfall is decreasing, it has not
happened this year. It is important to appreciate that we are entering a period of
climate chaos where weather events are unpredictable rather than following a
steady pattern.
Combined sewer overflow pipes (CSO) which are used in periods of heavy
rainfall, allow discharge of sewage into bathing water. Use of CSOs is increasing
with more frequent heavy rainfall (BBC Panorama). The quality of bathing water
is also adversely affected by increased amounts of run-off from agricultural land.
It is believed that the current testing regime does not take CSO into account
systematically when assessing water quality. Surfers Against Sewage have
recently reported instances of raw sewage in bathing water and it is suspected
that some lakes have been adversely affected by agricultural run-off. It is unlikely
that the tendency to increased incidents of heavy rainfall can be reversed, even if
carbon reduction measures are pursued vigorously and it is imperative that these
issues are dealt with effectively to minimise risks to public health. It is also likely
that an increase in pollution incidents will damage the aspiration for Wales to
develop as an area of green tourism.
The NPHS has been working with colleagues at WAG and HPA to develop
comprehensive public health (flood-related) information and advice for members
of the public and healthcare professionals.
Yours sincerely
Dr Mike Simmons
Director of Health Protection
References
Ajzen I. The Theory of Planned Behaviour, Organizational Behaviour and Human Decision
Processes 1991; 50: 179-211.
Bandura A. Social Foundations of Thought and Action: a Social Cognitive Theory. Eaglewood
Cliffs, Prentice Hall, 1986.
BBC.Panorama. http://news.bbc.co.uk/panorama/hiu/front_page/newsid_82366995.stm
(website accessed 07/09/09, programme broadcast 8.30 pm, Monday 7 th September, BBC2)
Gladwell M. The Tipping Point. Abacus. 2000.
Holdford, DA. Using buzz marketing to promote ideas, services, and products. Journal of the
American Pharmacists Association: 2004; 44(3):387-95.
Prochaska JO, DiClemente CC. Transtheoretical Therapy: Towards a more integrative model
of change. Psychotherapy: Theory, Research and Practice 1983; 19:276-88.
Weinreich NK. Hands on Social Marketing. Sage Publishers, 1999.