Editorial Issue 1 2009
A comprehensive primary health care perspective on climate change

The Australian Journal of Primary Health receives papers in two ways. The first is proffered papers that are submitted to us on the initiative of authors. The second is papers that we invite or otherwise let it be known are in an area in which we wish to publish.

It has been argued that climate change is the most important issue faced by 21st century communities. If we accept that argument then we must consider how we are to understand climate change in a comprehensive primary health care framework and what it is that researchers and services need to be doing. In this editorial I will explore one approach to thinking about a relationship between comprehensive primary health care and climate change. I would welcome contributions to the AJPH, either as papers or letters, that explore this issue further.

We can use the international framework for primary health care to begin to think about a relationship between comprehensive primary health care and climate change.

In 2008, in his address to the 61st World Health Assembly, Dr Halfdan Mahler, former Director General of the World Health Organization (WHO) and one of the great advocates for primary health care, reflected on its recent origins.

Let me then repeat with awe and admiration the consensus concept of primary health care as contained in the Declaration of Alma Ata 1978:

Primary Health Care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part, both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community (Declaration of Alma Ata cited in Mahler 2008).

Alongside the consensus concept of primary health care is a set of values that should inform the choices we make in regard to the development of primary health care institutions. They include equity and social justice, a focus on the needs of system users and on securing healthier communities by linking primary health care to public health. WHO argue that the reforms required to implement comprehensive primary health care, informed by its core values, are 4-fold. They are reforms to:

• achieve universal access for all members of communities,

• focus service delivery on service users’ needs and expectations in environments where these are changing,

• create healthier communities by linking primary health care to public health, and

• create leadership arrangements that are inclusive of, and responsive to, communities (WHO 2008: xvi).

We can apply this framework to the example of global warming (climate change) that is changing the environment in which people live. In what ways is climate change relevant to comprehensive primary health care?

In the first instance we recognise that there are two major drivers of change. There is climate change itself, which alters, for example, temperature, rainfall, vegetation and habitat, the foundations of life and of civilisation. There are also the adaptation/mitigation strategies the society chooses to implement to adjust to the imperatives of climate change, for example carbon trading schemes (Chapman and Boston 2007). Both climate change itself and the adaptation/mitigation actions create physical, biological and social changes. We need to be alert to the differential impacts of climate change effects on population groups, for example the effect of high temperatures on the very young and very old, and the geographic variation in effects that require different responses in different locations. We also need to be alert to the differential effects of adaption and mitigation initiatives on the poorest segments of the population. An example is the possible effects of market-based initiatives such as a carbon trading scheme on the prices of utilities and the pre-requisites for health such as food and housing. The principal of universality would focus the attention of primary health care on the population groups most affected, and most in need, whether they be defined by age, socioeconomic status or location.

In the second instance we would focus on the changing needs and expectation of communities as they come to terms with the physical and social changes that follow from climate change. Not only do we need to attend to the changing health needs of people as temperatures rise (heat waves) and water availability changes (floods and water shortages), but also to the ways that communities change in response to these stressors. Berkes and Jolly (2001) report on the complex changes taking place in a Canadian Arctic community as their environment is modified by rising temperatures. Some social changes were described as short-term coping in an altered environment, for example familiar changes in subsistence activities, such as hunting and fishing. Some social changes were longer term and can be viewed as adaptive. The community had available to it a range of adaptive strategies that had been used to deal with variability in the past. Some of these remained available to communities but others did not, meaning that communities had to create new institutions and practices. In Australia our communities are also reinvigorating old practices such as water capture and reuse and inventing new ones such as electronic communications as substitutes for face-to-face communications. Are we alert to the effects of these kinds of practices on the physical, mental and social health of our communities?

In the third instance we need to consider the chain of effects of climate change and its implications for public health and primary health care services. An example is depicted in the storyline in Table 1.

Table 1.  Rising cost of carbon (Garnaut 2008): potential effects and service responses

In general we know the probable effects of climate change (see for example Goodwin 2008; Horton et al. 2008; McMichael et al. 2008). For most of those effects, taken in isolation, we know the likely responses required of comprehensive primary health care services. However, putting the two together is a new challenge (for example Parkes and Horwitz 2009).

Finally, inclusive leadership models are a means of negotiating changing community needs and expectations (for example see Douglas 2007). Is the primary health care system and its constituent services taking into account the geographic variability in the effects of climate change and the different adaptive capacities of the communities they serve? Do they take into account the stresses experienced in communities undergoing the necessary change? Is the negotiation of climate change-induced community change appropriately understood?

In this editorial I have tried to explore the issue of climate change using the fundamental principles of comprehensive primary health care. I would welcome letters or papers from our readers that take this important discussion further.

Rae Walker

Co-editor-in-chief