The science is unambiguous. The planet is on course for around 3 degrees Celsius of warming by 2100. The issues at stake are unparalleled and existential. Doing nothing, or ignoring the problem is not an option. Equally, assuming we’re all doomed isn't helpful, either on a personal, or societal basis. We still have choices. We can choose how we react. We actually already have all the answers.
Understandably, many in healthcare are reluctant to engage with issues that are not clearly within their remit. But as soon as we leave the clinic or ward, we, our partners, and children are all part of the same societies that are facing these uncertainties. I would contend that if we genuinely commit to an ethical code through our medical training, then environmental matters, like any other public health issue, are now part of our work.
The future of healthcare is likely to be far more inhospitable than any of us imagine. The majority of doctors and nurses are trained in institutions, usually with countless resources to hand. Similarly, most paramedics rarely stray far from their vehicles. Managing patients in austere conditions, for potentially prolonged periods with limited resources is likely to become a reality in this future. This can be trained for. A niche that those with knowledge and experience in wilderness medicine can fill.
And what’s in a name? “Austere medicine”. “Expedition medicine”. “Extreme” medicine. “Mountain medicine”. “Wilderness medicine”. Yes, expert practitioners might regard these titles as subtly distinct, but they all share features in common. Namely, forms of pre-hospital medical practice that involve providing the best care, usually with limited resources, in a remote or challenging setting, and often involving a significant delay in reaching definitive care. Furthermore, practitioners commonly practice a high degree of self-care often within a dynamic environment, so as not to become a casualty themselves.
Unique Environmental Challenges - The New Zealand Context
Perched in one corner of the South Pacific, the Kiwi population of just over 5 million is mainly found in a few large centers, split between the North and South Islands. Long before colonization, the indigenous Māori, or tangata whenua (people of the land), knew Aotearoa was a place of violent earthquakes and volcanic eruptions.
At 650 kilometres long, and so large it can easily be seen from outer space, the Alpine Fault forms the backbone of the Southern Alps in New Zealand’s South Island. Evidence suggests there is a 75 percent chance of an Alpine Fault earthquake in the next 50 years, with a four out of five chance it would be magnitude 8 or greater. An event like this will disrupt infrastructure and power to tens of thousands (including tourists), isolating multiple areas due to associated landslides and tsunamis. A worst case scenario might happen in daytime, midwinter, with avalanches triggered by the event affecting 1000’s of skiers too.
While such monstrous events lie in wait, there has been no shortage of “smaller” rumblings. The 2011 Christchurch earthquake killed 185 people and devastated large parts of the city center, and Eastern suburbs. Reconstruction work has taken the best part of a decade to complete. In December 2019, Whakaari / White Island, just off the Bay of Plenty, underwent an explosive eruption. Of the 47 visitors on the island at the time, 22 of them died from the explosion or severe burns.
The “Shaky Isles” are also increasingly prone to weather events made worse by climate pollution. January 2023 saw Aotearoa’s biggest city, Auckland, inundated by a tropical “atmospheric river”, (dumping 200-300mm of rain) bringing the city to a standstill, and causing 4 deaths. Two weeks later in February 2023, Cyclone Gabrielle became New Zealand’s costliest natural disaster. Over 140,000 landslides were recorded, 200,000 homes lost power, hundreds of properties were left uninhabitable, many buried under meters of silt and debris. In total, 11 lives were lost and over 1700 injuries were registered. As with many natural disasters, like the Christchurch earthquake, the mental health consequences of these floods will be playing out for years to come.
The Unfolding Climate and Health Emergency
Part of my own lived experience of this emergency began while working as a General Practitioner in the remote South Westland area of New Zealand. For more than a century, tourists have flocked to the glaciers that used to descend almost to sea level in the Franz Josef and Fox valleys.
Sadly, glacial ice in New Zealand is disappearing at anything but a glacial pace. More than 1/3 of glacial mass has disappeared since records began, much of it over the last 20 years. In 2013, the terminus of the Franz Josef Glacier receded so much it became unstable and was closed to guided groups. In 2014 the Fox Glacier terminus was closed for the same reason. Guiding companies then began to use helicopters to ferry paying tourists to the safer middle part of the glaciers. Franz Josef now has over 60 chopper flights a day, making it the busiest heliport in the Southern hemisphere, (without a control tower). Fox Glacier similarly has around 50 chopper flights a day. The constant noise, set against the frame of once massive glaciers receding back up their crumbling valleys, chased by dozens of helicopters burning ever more fossil fuel is one of the most haunting, and visceral depictions of the mess that we are in.
Past debate, mankind's addiction to fossil fuel and its heat trapping pollution is leading to irreversible damage of multiple planetary boundaries. That damage is causing a progressive and pervasive global health crisis. “Time to treat the climate and nature crisis as one indivisible global health emergency” - was the call from 200 of the world’s leading health journals (Oct 2023). The World Health Organization describes it as the “single biggest health threat facing humanity in the 21st Century”.
Personally, nothing sharpens one’s appreciation of the unfolding emergency than managing a small rural hospital during with one of these weather events, with a full ward and emergency department. Learning that the roads are “out”, it dawns on you that no matter how sick patients get, air retrieval of acutely ill patients is not happening for another 12 to 24 hours until the weather clears.
Rural communities in New Zealand, and especially the indigenous people who predominantly live there, already suffer poorer outcomes in most health metrics. The threat to health from a changing climate, much like the threat from pandemics is magnified by inequity, wherever it is found. The triple inequality that defines the climate-health emergency bears spelling out:
- The disparity in responsibility for producing the problem;
- The disparity in experiencing the impacts of the climate crisis;
- And the disparity in the available resources for mitigation and adaptation.
>Like lessons learned from the response to the Covid-19 pandemic, managing the climate-health response will be most effective done collectively. Hence, understanding the magnitude of the threats, offering effective public messaging, and devising actionable and attainable goals is essential if we want peoples’ behavior to change, (in transition to net zero emissions). For example, solar panels are increasingly popular for domestic electricity – not just because it’s better for the environment, but because in many places it’s now the CHEAPEST option!
A New Future for Wilderness Medicine?
As the mountains and our wilderness areas become more impacted by warming and biodiversity loss, the traditional roles for doctors in “adventure tourism” look increasingly ethically questionable. The wilderness medical community is facing a reckoning, which it has yet to fully grapple with. Its clinicians need to own the fact that many of the activities they associated with and lend support to are extremely carbon heavy, commonly transactional, and not sustainable.
And where better to learn about the rapid changes to our environment, than embedded in the places where the effects are being most keenly felt? Who better to teach self-care and pre-hospital methods than practitioners who understand this combination intimately? Thus, “pivoting” wilderness medical practice away from supporting “adventure tourism”, to become an important part of the adaptation and mitigation process seems like a pragmatic and logical response to an increasingly uncertain future.
Kiwi vernacular contains frequent references to the idiom, "number 8 wire". A gauge of fencing material found in abundance, and adapted for a multitude of utilitarian purposes. It’s also a byword for ingenuity and resourcefulness using what one has on hand. Wilderness medicine may just be the "number 8 wire" of the medical world, ripe for repurposing in an increasingly uncertain future.