Planetary health cases

Persistent coughing is a sign of poorly controlled asthma. Coughing all the time should indicate a review of the current treatment. This would include checking her inhaler technique and understanding of how she uses her inhalers. As she is 14 this might include offering a change from a pressurised metered dose inhaler (pMDI) to a Dry powder inhaler.

Persistent coughing is a sign of poorly controlled asthma. Coughing all the time should indicate a review of the current treatment. This would include checking her inhaler technique and understanding of how she uses her inhalers. As she is 14 this might include offering a change from a pressurised metered dose inhaler (pMDI) to a Dry powder inhaler.

Air pollution is a well established exacerbator of asthma (as well as being associated with COPD, Lung Cancer, Ischaemic Heart Disease and strokes, Diabetes, Dementia, etc.) The closer to the road the bigger the effect. Royal College of Physician data suggests that 36,000 people per year die from air pollution in UK. 

She is using more SABA inhalers than is appropriate (using more than 3 per year should trigger a review of her asthma). She is not receiving/requesting enough Clenil to act as a treatment / preventer for her asthma. It might be appropriate to consider a MART inhaler so that she receives both LABA and ICS with each dose.

UK asthma outcomes are poor compared to equivalent countries. The UK Asthma Death study demonstrated that most asthma deaths were preventable with better care. The national review of asthma deaths: what did we learn and what needs to change?.  The UK is also an outlier for use of pMDI using this type of inhaler much more (70%) than Sweden Denmark and Norway (13-40%)  which have better health outcomes.

Cough syrup is a black triangle medicine i.e. one that is established as having little clinical value in changing outcomes. Prescribing medications which do not work is wasteful and consumes resources so this is an example of overprescribing enlarging healthcare’s excessive carbon footprint.

The best fit is probably Dengue fever, though other possibilities include malaria and zika. It is also appropriate to consider non vector illnesses (flu and covid for instance). This scenario suggests that in the same way as clinicians have adapted to include Lyme’s disease as ticks have become endemic in UK (rather than isolated to the New Forest) climate change is bringing us new diseases which will have to be part of the differential diagnosis.

Aedes Aegypti is the main mosquito associated with Dengue (also with Zika). Anopheles is the group associated with Malaria.

Warmer temperatures are associated with an enlargement of the distribution of mosquitoes. So Aedes mosquitoes (not necessarily A Aegyptii) have developed a wider distribution over the last years. The latest data suggests it is introduced but not established in Kent and neighbouring areas in the UK and established in much of France and almost all of Germany. Data from 3-4 years earlier had a much smaller European distribution.

As many people getting dengue are asymptomatic it is likely that once Aedes is established Dengue will follow.

Malaria is not currently (2024) endemic in UK (though cases have been identified in people living close to major airports from mosquitoes imported in aircraft. There are reports of endemic malaria from France and Greece.

Virus carrying mosquitoes (Culex which is associated with West Nile virus) have been found as far north as Finland. 

In warmer climates mosquitoes have a faster rate of reproduction/shorter intergenerational period. The mosquitoes will also bite more actively in hotter weather (NB only female mosquitoes bite).

Her story suggests that she is experiencing Eco distress. This is not a mental health disorder but a rational response to the crisis we are in. (Some people use the term eco-anxiety which can be seen as a medicalisation of her issues and makes it easier to then reach for tablets as a “solution”). Eco-distress can encompass a wide range of emotions including anxiety, grief, despair, anger, hopelessness and feelings of overwhelm. It is important to validate rather than seeking to minimise or dismiss the feelings of those with this challenging situation.

It is common and getting more common. 59% extremely worried about climate and 84% at least moderately worried.

There are several resources available to guide management these difficult emotions. Most contain 4 core elements:

1.Take action – Doing something positive helps us not to drown in despair. 

Living and acting according to our values is empowering and energising.

In this strange world where people around us seem oblivious to the threat we face, being aware of the crisis can feel isolating. Joining with others to work towards a shared positive vision of the future and take part in collective action nurtures hope, helps to validate your feelings and builds support around you.

2. Self-care

Pacing ourselves and accepting the limits of what we, as individuals, can achieve. Taking time for regeneration when we are struggling.

Accepting help from others and not feeling we must do everything ourselves.

Paying attention to our physical and mental wellbeing by making sure we are getting enough sleep, eating healthy diets, getting enough physical activity and making time to connect with the people, activities and places that nurture and recharge us. Re-connecting with nature has been found to be particularly beneficial (nature connectedness engagement with nature (green prescription) or water (blue prescription). Practising gratitude for ourselves, the people around us and the natural world that sustains us.

3. Nurture hope

Make time to read about hope-based, solutions-focused visions of the future, not just negative information.

4. Allow space to process distress and times to shut off from it

We often try to push away difficult feelings, but this can prevent us processing them so that they become disabling. Rather than try to avoid or ease these emotions, climate psychologists advise that we make time and space to accept and experience them without avoidance, denial or intellectualisation. This is best done in a safe space with a supportive group of trusted people. Equally it is important to make times not to think about it and to focus on people and activities we enjoy and renew us. Spending time in nature can help many people. 

Discussing her involvement with a group working with the environment is likely to be important, she may benefit from a different type of group. In addition The Resilience Project  works specifically with youth activists struggling with eco distress and burnout.

Other resources might include the Climate Psychology Alliance; Climate Cafes – Ultimate resource for green and sustainable living | Speak your #ClimateTruth and The Royal College of Psychiatrists has produced a podcast and fact sheets for children and young people and for parents, carers, teachers and other adults who support young people.

If there is such severity that treatment with drugs needs to be considered this  should include full discussion of the carbon footprint of the treatment and comparison with non pharmacological options. 

Mammals respond to heat by vasodilation of the vessels, if there is prolonged significant vasodilation then the heart has to work harder to maintain blood flow around the body. This leads to an increased risk of heart attacks and strokes. This is a direct effect of heat, dehydration and renal impairment will be additional factors. 

Diuretics will add to the dehydration and Calcium channel blockers will increase the vasodilation, both exacerbating stress on the heart. There is currently (2024) little established advice in UK or internationally on drug holidays and heat though there is some guidance here. 

Off guidance possibilities might include patients taking their own blood pressure during hot spells and reducing specified BP treatments if the blood pressure is low. 

Deprived neighbourhoods are associated with much higher levels of air pollution and most UK (and European) cities have significantly higher air pollution than WHO guidelines. Air pollution is linked to higher risks of many diseases from cardiovascular disease to diabetes and dementia. 

Air pollution will act as an irritant triggering more asthma or rhinitis but small particulate matter (PM2.5) will become intracellular and this changes cell behaviour triggering a wider spread of diseases.

Air pollution will build up in cars (unless using specialist filters) so that the average levels of pollution exposure are higher for a commute by car than for the same journey by bike or walking. 

Heat and it’s impacts are still not widely talked about in the consulting room. Clinicians are all taught to ask about tobacco use (which accounts for 8 million deaths every year) and alcohol (3 million every year) but air pollution is estimated to contribute to 6.7 million deaths per year 5.7 of these due to non communicable disease.

NB the UK death rate attributed to the cold is 13400 (12.21 to 3.22) compared to the spring and autumn periods.  Heat related deaths are significantly lower at 4,500 for 2022 .

It is unlikely that this is a dignified way to die but opinions on this will vary and hers/those with power of attorney are essential. There is a real risk that these admissions are causing her more harm from overdiagnosis, overtreatment, painful interventions, risk of delirium, falls, hospital acquired infections, deconditioning from lying in hospitals etc. This is a high carbon end of life where it is possible to argue that resources could be used more effectively for patients who are more likely to benefit from them.

Involving family, holistic and advance care planning can be valuable. RESPECT forms can help with this and are good practice in addition to DNACPR . Admissions avoidance. Think about comfort and dignity rather than prolonging life at all costs, especially when quality of life may be very poor. 

It is likely that some of her 14 meds are not necessary or positively dangerous e.g. statins as preventive drugs are unlikely to be appropriate. Drugs with an anticholinergic effect are likely to increase risk of falls and death so considering the anticholinergic burden is appropriate to improve her quality of life.  There are risks that some medication has been started to manage the effects of earlier treatments ( ‘cascade prescribing’ ) so looking to simplicity can be helpful.

10% of the total NHS costs are spent in the last year of life, and this is broadly similar in other developed countries. Almost 25% of costs are incurred in the last 3 years of life in UK suggesting that the costs relate to chronically ill people rather than last ditch attempts to save lives. The challenge is to work with patients and families to identify what is justified and important, and what is futile and harmful. 

Many of his meds are not formulary first choices, There is little evidence for codeine for chronic pain. Cimetidine can be bought OTC which may make it popular with some prescribers. Some patients are worried by the total removal of acidity with PPIs. Paroxetine is commonly used, though not first choice of the SSRIs generally. Chlorpheniramine is quite sedating. These over prescribing issues cause planetary health harm and contribute to the 60% of primary care’s carbon footprint coming from medication. 

Cascade prescribing describes the reality of meds being added to manage the side effects of earlier meds. Possibly his weight may have impacated his joint pain. The codeine given for pain relief made him less energetic (and less active) reducing his social life and leading to the Paroxetine, which is known to exacerbate acid reflux and so the cimetidine is added. At any point along the line his skin became itchier and so the chlorphenamine was added.

Anticholinergic burden (ACB)

(codeine =1, paroxetine 3, cimetidine 2, chlorphenamine 3, metformin 1) https://www.acbcalc.com/medicines

The higher the ACB score the higher the risk of mortality and effects on cognitive function. Clinicians prescribe more to those who are older and lower social class.

There is evidence for the effectiveness of green (outside in contact with the natural world) or blue (involving water) therapies as part of social prescribing to manage mild to moderate depression. 

Working with him to look at diet options which might help him to reduce his weight is also appropriate (as weight is potentially a cause of his issues).

NB there are financial issues with ideal diets like EAT Lancet diet as the proportion of disposable income involved means this is unaffordable in its entirety for many poorer people in UK.