Profiles in Planetary Health: Courtney Howard

As part of the newly launched Clinicians for Planetary Health initiative, which galvanizes health professionals across the globe to take action on environmental challenges, we are excited to showcase profiles of visionary and impactful leaders from the healthcare community dedicated to planetary health. We hope these interviews and stories provide insight, inspiration, and ideas for ways to incorporate planetary health principles into your own work.

You can listen to the interview here.

Dr. Courtney Howard is an emergency room physician in Yellowknife, Canada, who has dedicated herself to addressing the environmental issues that are deeply impacting the global community. When not in the emergency room, Dr. Howard spends her time working at the intersection of climate change and health, motivated by her experiences working in the Arctic with a majority-Indigenous Northern patient population and in Djibouti working on a pediatric malnutrition project with Médecins Sans Frontières (Doctors Without Borders).

Dr. Howard is the president of the Canadian Association of Physicians for the Environment (CAPE). She has been involved in policy and advocacy work on coal phase-out, active transport, plant-rich diets, integrating health impact assessments into environmental assessments, carbon pricing, and the health impacts of fracking. She has also led the successful campaign to have the Canadian Medical Association create fossil fuel free equity and bond funds for its own use and for Canadian MDs to invest in. With CAPE, she organizes MD-advocacy across Canada. She has researched the respiratory and wellness impacts of the extreme wildfire season of 2014 in Yellowknife. In addition, she led the first randomized controlled trial comparing tampons to reusable menstrual cups.

Dr. Howard is on the steering committee of the Planetary Health Alliance, represents CAPE on the board of the Global Climate and Health Alliance, is the Co-Chair for North America of the WONCA Working Group on the Environment, and sits on the boards of the Canadian Medical Association, Health in Harmony, and her local environmental NGO, Ecology North. Watch her TEDx Talk here.

The following is an edited transcript from an interview that took place on July 31st, led by Hannah Nash, Outreach Manager of the Clinicians for Planetary Health initiative.

Planetary health has become increasingly mainstream in the Canadian medical establishment. What factors have allowed Canada to be a leader in planetary health?

Yes, over the past few years CAPE and the CMA have joined forces to successfully call for a federal commitment to phase out coal-fired power by 2030, to support putting a national price on carbon, and to bolster efforts to implement the most evidence-based food guide in Canada’s history — one which ended up being very consistent with the planetary health diet recommended by the EAT-Lancet Commission. The way all of those different things have come about is through different pathways so I’ll speak to them individually.

Number one, we are a circumpolar nation, so we have people within our country who are some of the most highly impacted people in the world. We have a lot of stories in Canada of patients impacted by climate change, which can really help move the dial. For example, when I went to Canadian Medical Association general council meetings as a young doctor — I’m on their board now — I was able to tell a lot patients’ stories from the position of a clinician. When we look at what works in terms of communication, that kind of storytelling really resonates with people. Numbers numb, but stories stick. It’s not a very intuitive way for scientists and doctors to communicate, because we are raised on graphs and data, but it’s a very effective form of communication. Now, during media interviews, I try to have one stat and one story. I find that’s a way to communicate that moves people’s hearts, and which moves their minds.

You also need to keep showing up. It can be lonely to be that voice in the room. The first time I ever went to a Canadian Medical Association (CMA) general council meeting, I was yelled at in front of 500 people, so much so that it made national headlines. We were talking about the need for local health impact assessments for resource extraction processes, and I just got lambasted. These issues can be very emotional for people: they may have family or friends working in industry — and our politicians and media have portrayed things in such a confrontational and inaccurate way that people can sometimes get really triggered. It’s hard to go back in after something like that, but I had really good support from my local community, the broader medical community, and my local Indigenous leadership — who were present at the meeting. So — I kind of mustered my resources and just kept showing up. As you do that, you realize that personal relationships are really important. The first time you come to an event, you don’t know anyone, but you meet a few folks, get coffee, talk about their kids, and then the next time you come, those contacts are extremely important. I have realized that the wheels of change turn in the presence of trust — and that relationships are key to developing that trust.

Interdisciplinary work has also been a big part of our success in Canada. I’ve worked with economists, energy planners, financial planners, urban transport experts, artists, graphic designers, and movie makers. If I’m in a room and I’m talking to only doctors, I ask myself, “Is this the right room to be in?” Sometimes it is, but the learning and potential for impact is generally much higher when there are people from many disciplines in the room. I think that is what made the Lancet Report on Planetary Health so successful. There were experts from all these different fields working together.

Overall, I think what has worked for us in Canada, is that we’ve been willing to take on new partnerships and we’ve been very strategic about how we’ve chosen our targets. We’ve chosen politically attainable goals that maximize impact on health. We’ve chosen our messengers very carefully, using doctors and nurses as the public face of a lot of multidisciplinary arguments. We are very explicitly non-partisan in everything that we do. The key element of our work on coal phase-out was a partnership with the Pembina Institute, an incredible evidence-based think tank that employs lawyers, economists, energy specialists, communications specialists. So when we produced reports together, we were able to present policymakers with an entire argument: i.e. if you phase out coal and move to X mix of other energy-production, it will save you Y lives, which translates into Z monies. That’s what policymakers need in order to themselves make arguments for change.

It’s all about pulling together for the sake of everyone’s health. At our best, we approach with a real sense of openness in humanity. There is one lovely person on a board I sit on who doesn’t really believe in anthropogenic climate change. I think she’s great, and I think she would say the same about me. We’ve had a ton of conversations and we’ve had to agree to disagree, but we can work productively together on most things. I think we have to recognize that pretty much everybody just wants the best for their kids, and that just looks different depending on who you are and what your job is. In many cases, people don’t know what they don’t know about the impacts of climate change on health and health systems, and once they understand that it’s about more than the polar bears, their motivation completely changes. As a health community, we also haven’t done a good job at connecting the conversation around the ecological determinants of health to the one around the social determinants of health. We need to be at the front of the pack calling for a Just Transition. When we ask that fossil fuel subsidies be eliminated, we can ask that those monies be redirected to supporting workers in transitioning to a clean energy economy. Just trying to see the world through other eyes helps us to understand what the very real barriers are for people to transition to a new way of putting food on the table for their kids. Once we better understand, we can ask for those solutions as well. In general, looking for common ground and communicating in a non-confrontational way is super important.

Can you speak a little about how the new Canadian Food Guide came about?

The key thing to changing the Canadian Food Guide was actually that a female physician got elected to be the Minister of Health. She basically gave Health Canada leave to conduct the entire Food Guide process without closed-door meetings with the industries. So we ended up with a product that was published within weeks of the EAT-Lancet Commission — and which essentially recommended the same thing — because they’d both been working from the evidence base. That was a great example of how important it is to have people of different descriptions around decision making tables. We need more scientists, more people of diverse heritage and backgrounds… and we need more women. I’m often enough now the only woman at a decision-making table, and I know for sure that a lot gets said that wouldn’t be said if I wasn’t there. It’s important to create structures that allow women to be included — child care, and places to breastfeed, or maybe being okay with bringing a child to a meeting. It’s not just about knowing who you want at a table, it’s also about making it possible for those people to be there.

I also think it’s so important to be supportive of colleagues who are taking those slightly scary first steps into new roles and spaces. I’ve had such incredible support from my local medical community here, and that’s partly because we’re just very highly impacted. My emergency department chief told me the other day that because I do what I do he can sleep at night. Because of that support, I can come home and feel like I’m in a really comfortable place.

Not everyone has that kind of support in their local community, and so when they come home, they feel additional stress. So, if you know a colleague writing an op ed, or getting involved in policy, take the time to send them a small personal note that says something like, “Hey thanks for doing that work on behalf of all of us.” That can go a long way towards creating space for people to take new steps into these really novel areas.

As an ER doctor, do you think about planetary health in your conversations during your clinical work or are those two spheres of your life relatively separate? What do you think the role of clinician advocacy is in a clinical setting?

I think planetary health as a way of looking at the world. It’s a frame. If you adopt that frame, you’ll start to see different places where there are opportunities to just apply it in a practical way. It’s everything from prescribing a dry powder inhaler instead of a metered dose inhaler if you have a chance, to trying to get the paper towels you use in the hospital collected for composting. The dry powder inhaler has a much lower carbon footprint than the metered dose inhaler, and there is absolutely no need for paper towels to go into the landfill when they could instead be helping to create soil to enhance the food security of a soil-poor subarctic region. When you look at the carbon footprint health care, there are a lot of changes we can make in our hospitals so that everybody feels good about the contribution that the health sector is making in planetary health.

Sometimes the world just brings environmental impact into your emergency department. In 2014, an extreme wildfire season, we had tremendous amounts of asthma. It’s important to study those instances so they’re logged and can be taken into account in future decision-making — so our local medical community joined forces with our environmental NGO and academics from the South to study the impacts on both health and wellness.

The other thing about working in the emergency department is that exercise is a good treatment for almost everything. It doesn’t matter whether somebody comes in with heart related-issues, diabetes-related issues, or mental health issues. I try not to prescribe long term medications out of the emergency department — I think that’s a decision better made by somebody’s primary care physician — so a lot of the time, I’ll prescribe exercise as part of a treatment plan. Part of that is often talking about how they are going to work activity into their day, and a really reliable way of doing that is through active transport — walking and biking to where you want to go. That’s a conversation I have with people all the time — probably three times a shift. Active transport has also been shown to decrease air pollution and greenhouse gas emissions. I don’t necessarily mention that, but it’s a co-benefit of the clinical intervention that I think is actually the most appropriate one for the patient.

Do you have any advice for clinicians who feel compelled to address planetary health challenges, but just don’t know where to start. How can clinicians become involved in this world and feel like they are making impactful change? What would be your get-started plan for clinicians interested in addressing planetary health challenges?

It’s really helpful to seek out like-minded colleagues either locally or afar. Mentorship is important because at the end of the day, a lot of this work takes courage, and it’s hard to get that from a textbook. I find that being a lonely advocate is a real recipe for burnout, whereas feeling like you’re part of a team leads to increasing energy and momentum — and it can be even just being part of an active listserv — like the PHA Hylo network or the WONCA Listserv. On the WONCA lists, there are people there from the U.K. mentoring people from Brazil who are mentoring people from Germany. Recently there’s been a conversation around the best type of hand-held air pollution monitor. I think those types of platforms can really accelerate change. I’ve watched the level of skill of the people on the WONCA Listserv go up exponentially over the last 18 months, and it’s really exciting.

Reaching out is really important. If you’re currently feeling lonely with this, and I think a lot of people do initially, getting in touch with the Planetary Health Alliance and networking on the Hylo platform, or figuring out which local group or specialty group to join is a really good first step.

I like to learn about what other people have done. I heard that the British Medical Association had voted to divest, and that was exactly why I started looking into trying to get the Canadian Medical Association to divest. There’s that Marshall quote: “You can make a difference.” Once you realize that credible solutions have already seen the light of day in other places, you can see that people like you can make a difference. I think that learning the actual material, accessing mentorship and teammates, and looking for stories of change that you can emulate are three really concrete ways to get started.

Are there any planetary health initiatives or activities in the coming year that you are particularly excited about? What trends and changes have you been witnessing?

I see a very significant worldwide mobilization of the health voice being organized in association with the Friday for Future protest on September 20 and 27. I think that that’s a really important demonstration of allyship of the world’s health professionals with the world’s youth. I would love to see Twitter, Instagram, and Facebook just ablaze with #medicsforfuture, #doctorsforfuture. I think that when the voice of health stands beside children, that is a really powerful train that can help motivate populations to pull together towards a healthy response to climate change. So I’m really excited about that.

I’m also really excited about a new initiative I’m part of called CODA Change. It’s growing out of an Australian education phenomenon called SMACC (Social Media And Critical Care). SMACC really took medical education to the next level in terms of compelling speakers, community engagement on social media platforms, and reaching an international audience. They sell out 2000-person conferences in hours, and their website gets up to twenty million views a month. SMACC realized that, in the process of teaching people about ICU and emergency medicine, they had built this community with a lot of expertise and skill. They asked themselves: “What do we do with this community?” They surveyed the community, and since they wanted to focus on solving urgent health challenges around the world, they chose climate as their first initiative.

We’re in the process now of convening working groups with some of the smartest people in the space from many different organizations to come up with a really focused, short list of high-impact action items to help people who have recently become activated by the IPCC 1.5C report and Greta Thunberg and the worldwide mobilizations she has sparked. These are people who are like: “I’m interested. I have 20 minutes to dedicate to this. What can I do that is most-worth my time and effort?” We want to have discreet actions that they can easily take in their lives, local hospital environment, and local community, and we will offer support and tools from afar. Then we’ll ask people to log those actions on the website so we can keep track of the community of the change that we’re making. The S.M.A.C.C. community is at 25,000 and has a really high degree of engagement and mutual trust — and it’s now growing beyond critical care to include all health workers. If many health professionals worldwide take the same actions, it can start to impact capital flows and signal a defined direction of travel to the medical establishment as a whole — and to markets and decision-makers. We’re at a world tipping point. We want to help it tip — towards a healthy response to climate change.

So yeah I’m really excited about that. The website just launched: https://codachange.org. Check it out, and join us. So many people are doing such excellent work — it’s an incredibly exciting time.

Key takeaways and points of action:

We’d like to give a big thank you to Dr. Howard for being so generous with her time. Below, we’ve highlighted some key suggestions for clinicians looking to address planetary health challenges:

  • Reach out to like-minded colleagues, either locally or afar. Being a lonely advocate can be a recipe for burnout, and relationship-building is essential for turning ideas into action. There are amazing people all over the world working on planetary health issues. Try getting involved with CODA Change, joining the WONCA listerv or the PHA’s Hylo platform, engaging in local initiatives, or finding a specialty group to join.

We hope that regularly highlighting health professionals who have successfully made positive impacts on planetary health challenges will help provide you with inspiration and support. Thank you for your engagement in Clinicians for Planetary Health!

Listen to the interview here.

Generating better understanding of the links between accelerating global environmental change and human health to support policy making and public education