Coal Harms Health: Climate Change and Health, Past, Present and Future

Hello everyone. It’s a great pleasure to be speaking (October 16, 2021) at the 20^th anniversary conference of Doctors for the Environment Australia (DEA); I’d like to thank the organisers and to acknowledge the traditional owners, the Kuarna people. I’d also like to congratulate DEA for no longer being a teenager and for having over 2,500 members. I can recall when there were fewer than ten.

The organisers asked me to prepare no slides but with one exception – I am thus calling my talk “Coal harms health”. This photo was taken near Maules Creek coal mine, in 2014. It’s an export mine; from there coal is taken by train, through the air-polluted Hunter Valley, to the coal dust contaminated city of Newcastle, where I studied medicine. This protest was organised by the Australian Religious Response to Climate Change; my support team were devout – even if they look scruffy.

While waiting to be arrested I was holding this book – the first edition of “Climate Change and Global Health”, which had just been published, and which I edited. 

 

At that time I had also just contributed to the health chapter of the 2014 IPCC report, thus I was the first IPCC health contributor to be arrested for what could be called “climate disobedience”.  I take the issue of climate and health seriously, and I also take seriously the issue of climate justice – the main reason I chose arrest was to protest at the immorality of rich Australia profiting from the export of a substance clearly harmful to health, especially future health. I also lament the decline of ethics in science.

If this was not virtual I would ask for a show of hands: who attended the first iDEA conference, in Melbourne in 2009? I did – in person of course. My talk there focussed on the “tertiary” – or catastrophic - health consequences of climate change, including conflict, war and famine. The first editorial on climate change and health – in The Lancet in 1989 – hinted at these issues. However the topic is still vastly under-recognised, despite the implications of Will (and other’s) work. For me, the risk of runaway climate change (or Hothouse Earth) is terrifying, and trying to prevent that has now motivated me for 3 decades. We are making progress but there is enormous work ahead.

Since the early 90s I have used a three-way categorisation of how climate change will impact human health and well-being. In addition to tertiary effects are what is generally called direct and indirect, or “primary” and “secondary”. I based the first and forthcoming editions of my edited book on these categories.

By “primary” health effects Andy Haines and co-authors meant comparatively obvious things, such as heat stroke. Of course, nothing is simple, but I ask you to consider the field at a time when the existence of anthropogenic climate change was challenged by most, and when, for conservative doctors, links between it (as opposed to climate) and health were considered speculative. Thus tertiary health effects were a largely no go area at that time.

Temperatures in the high 40s in Australian cities were unimagineable when I was at medical school, they now seem almost unremarkable. Extreme heat has adverse effects that are pretty well-known; such as heat strain and heat stroke. Their risk is worsened by high humidity; indeed in some parts of the world, in the near future (without emergency climate action), the combination of heat and humidity will be fatal, even without exercise. Thus some areas of the planet will literally be uninhabitable, at least for some times of the year. Heat strain is an incredibly important issue for occupational health, especially for outdoor workers in already hot places and for emergency workers wearing protective clothing in hot conditions. Heat strain may also have a “long tail” of adverse effects, including on some chronic diseases – especially people with pre-existing cardiovascular disease. What happens to people who are vulnerable but who recover? It seem unlikely that they all return to their previous level of function. I believe this question remains under-explored.

An important co-author of that early work on primary, secondary and tertiary effects was the late Tony McMichael. Tony, with David Shearman, were the true founders of DEA. Both were far ahead of their time; with viewpoints best called “ecological.” Tony’s most influential book, published in 1993, was called “Planetary Overload”. Four years later, David’s book “Green or Gone” was published.

Four years after, DEA was born, and now it is 2021.

Some of you will have heard of the UN Conference on the Human Environment, in Stockholm: 1972. More will have heard of the Rio Earth Summit, 20 years later. The main organiser for these meetings was Maurice Strong; he was also founding director of the UN Environment Programme.

His autobiography, “Where on Earth are We Going?” was published in 2001. It starts with a report to the shareholders, from 2031; a world of profound disorder, massive forest fires, including Siberian, and famines, droughts, floods, conflict, refugees, plague and “Virus X”. Global population is below five billion; it is, today, about eight. These risks arise not only from climate change, but as Kerryn Higgs, a co-editor for the 2^nd edition of Climate Change and Global Health, says, endless growth on a finite planet is a collision course.

 

 

Hopefully Strong’s forecast is too pessimistic. However, global life expectancy has fallen due to the pandemic; hunger has risen, and foodprices are at a 10 year high.

There is risk from exaggeration, but also from under-statement. Pessimism paralyses; understatement generates complacency. I believe it is our duty to sound a warning. Prevention is better than cure. Past civilisations have collapsed; ours could too.

But I will end with hope. Activism lifted Greta Thunberg from depression, and is an important antidote to despair; as is fellowship. Getting arrested – even here – is serious; consequences can be unforeseen. I was unable to attend the inaugural planetary health conference in New York because a timely visa was denied.

Protest is necessary, but not sufficient.

Last month, over 230 medical journals jointly published an editorial (includiung in the Medical Journal of Australia) calling for “emergency action to limit global temperature increase, restore biodiversity, and protect health.”

That is progress. So is the growth of DEA and the involvement of so many medical colleagues and colleges in this struggle, globally. The link between the health of our planet and the health of people is now widely accepted. Tough times are ahead, but together we can make a great difference.

Thank you.  

Climate change, heat, and a possible risk to infant and child health

I recently wrote to warn that players and spectators at events such as the Australian Open may unknowingly be placing their future as well as short term health at risk, due to exposure to levels of heat (up to 69 degrees C in the sun on the court enclosed by a vast stadium) which I think are unacceptable, particularly for players engaged in the most strenuous exercise that is imaginable. 

I also warned that some spectators, many of whom are far less fit and most of whom are older than the players, may also be at risk, even if not exercising and even if they are well hydrated.

But I would like to add that there is also a theoretical risk that pregnant women may be putting their unborn babies at risk, both in the womb and after birth, perhaps lifelong.

This hypothesis is plausible if the link between season of conception and foetal deaths is confirmed to be in part due to heat exposure. While that is currently uncertain there are suggestive data in support, such as an econometric paper. This found that additional days above 80°F (26.7°C) causes a "large decline in birth rates approximately 8 to 10 months later". The authors comment that air conditioning could be used to substantially offset the fertility costs of climate change, a suggestion which is unfortunately as yet too expensive for most of the world's people.

Pregnant women watching events such as the Australian Open, especially in very hot days and even more so if they are sitting in the sun, may therefore risk having a miscarriage. 

However, that is not the only risk. If we hypothesise that a certain "dose" of heat, a metric that combines air temperature, humidity, duration of exposure, clothing and exercise can lead to foetal death, then it follows that a lower dose of heat may cause subtle or even gross foetal abnormality, in infants exposed to a lower dose in utero. This would be analogous to my hypothesis, which I first originated in 2012, that frail, elderly and in other ways vulnerable people who do not die of prolonged heat exposure are likely to suffer from other effects, some of which could be long-lasting, especially if they accidentally fall during a period of recovery.

Furthermore, if there is a threshold of a heat "dose" then it is highly unlikely that one size fits all. The dangerous dose is likely to be influenced by many other factors: age, fitness, weight, other indicators of health status, genes, and perhaps, even month of birth. It is also likely that some stages of pregnancy are more vulnerable than others.

It has long been known that being born in autumn confers a higher life expectancy than being born in spring (at least in non-equatorial regions that have distinct seasons). Could heat in the first trimester be an under-recognised factor helping to explain this?

Of course, this is only speculation. It would require a great deal of study to be more sure. But, since 2012, research funds to study this and similar questions have been virtually unavailable in Australia. 

My recommendation to the organisers of the Australian Open is to hold the tournament in a later month. But that suggestion won't be taken seriously for many more years. For spectators who are pregnant or possibly pregnant - I suggest that they sit in the shade and drink lots of water. Wear a hat and bring a fan. Or perhaps consider staying at home if the temperature is too high. Yet, no one knows what temperature is too high. I suggest the risk is likely to be higher with higher temperatures and the relationship is likely to be non-linear, i.e. the additional risk between 43 °C and 42°C is likely to be more than between 21°C and 20°C. And, please, lobby a politician to treat global warming and climate disruption with the seriousness it deserves.

Climate disruption, extreme heat and sport

In recent weeks sportsplayers and health have been in the news. Last month, Suranga Lakmal, a fast-bowling cricketer from Sri Lanka, vomited in New Delhi, on field, due to air pollution and exercise. This month (January 2018), English cricketer Joe Root retired ill, due to diarrhoea and extreme heat. Kato Ottio, a New Guinean rugby player died this month, after falling ill at football training. Cycle races in Adelaide have been truncated or rescheduled due to multiple days with shade temps in the mid-40s.

And this week, at the Australian Open, tennis players and tennis spectators are being exposed to unacceptable levels of heat with surface temperatures, in the sun, on some courts, approaching 70 degrees C. I am no expert in building design, but several factors turn the main stadium into a heat trap. The centre court is enclosed in all directions by ranks of seats, has a roof, and gets zero, or very little ventilation (especially if the roof is closed). The enclosure has enormous thermal mass and the court is laid on concrete. In addition, each spectator is itself a producer of heat (about 100 watts per person, continuously.) (see PS for how to improve this design.)

I am sorry but it is time to reschedule the summer cricket, cycling and tennis to a cooler month, and similarly, time to recognise that dangerous climate change is no longer in the future. Climate disruption is here. Shifting the dates would be a form of adaptation. It would leave a big hole in our summer,'s entertainment, but it is unacceptable to treat athletes as guinea pigs for the pleasure of spectators, watching at home in air conditioned comfort. (That is, if the air conditioning and energy infrastructure can keep up.)

What we know about heat and health

There is a fair bit known about heat, humidity, the wet bulb temperature and that fit young men and women can easily die of heat stress. Dogs pant and elephants flap their ears in extreme heat; humans sweat. When sweat evaporates we lose a little heat, lowering our core temperature. We also have long known that humidity greatly increases the danger of heat, as in humid environments our sweat does not easily evaporate. Thus, sweating when it's humid is not as effective.

If the wet bulb temperature reaches 35 degrees C. then even a fit person will die, probably in just a few hours. Such wet bulb temperatures are still extremely rare, but by treating our atmosphere as an open sewer, as recommended by a legion of politicians, we are on track to make some parts of the world completely uninhabitable if we go outside. If you are not fit, you will probably die even sooner, and at wet bulb temperatures below 35 deg C.

We also know that people with pre-existing illnesses are more vulnerable to acute heat effects, manifesting within minutes, hours or perhaps days. We know that in the 2009 heatwave in Victoria, where 173 people died in bushfires, even more died in Melbourne from simple heat exposure. (See the Victorian Department of Health report.)

Acute (rapid onset) symptoms can be reduced and hopefully prevented by drinking, cooling and stopping exertion. Sports people can drink, apply ice, and maybe even have the roof lowered so there is shade - but they can't stop their exercise without losing.

Heat can, in some locations, especially cities, elevate exposure to troposphericic (low-level) ozone (mainly from traffic), which harms lung function.

We have virtually no idea of the long term effects of excess heat

In contrast to the knowledge on acute exposure to extreme heat, we know next to nothing about the long term effects, other than some data on renal impairment and urinary tract stones due to prolonged dehydration, mainly affecting agricultural workers with inadequate water access. We also know a little about sudden, often mysterious deaths in exploited construction workers, particularly in the Middle East. But we know next to nothing about the life expectancy and other health indicators of those workers who do survive. (And we are not likely to - their employers will not welcome such studies.)

The starting position of those running the Australian Open appears to be that if a player or spectator survives symptomatic heat stress then their future health will be completely unaffected. But this may be wishful thinking. We don't even know that if someone who experiences extreme heat exposure, but is completely without symptoms, will be ok in the long run.

In fact, the converse is more plausible. It is, for example, highly likely that those who are vulnerable to heat (such as the elderly and those with pre-existing conditions, e.g. heart failure, dementia or many other severe chronic diseases) who do not die will have a step-like fall in their function, at least temporarily. Will they recover that full lost step? Over what period? How many will have a mishap, such as a fall, before they fully recover, in the weeks or months after the heat event? In the elderly, falls can be very serious, and often presage death.

It is also well-known that many multiple sclerosis (MS) patients experience a decline in function during heat - heat slows nerve conduction. Could excessive heat tip some people, previously unaffected, into neurological conditions, including migraine? (French tennis player Gael Monfils reported extreme dizziness at the Australian Open). We don't know. We do know that people at higher latitudes have more MS. The dominant explanation is that such people are exposed to more ultraviolet light, but could a factor be that, in part, over long periods of time, such people have sought to live in cooler conditions? Or perhaps that those with MS in very hot areas aren't able to have the same reproductive success?

Extreme heat also has harmful effects on unborn children

Human bodies can be thought of as complex mixtures of chemicals and electrical signals. We have evolved to live in an "envelope" of temperature and humidity, an envelope many people are now exceeding. How do we know that proteins (or any other bodily component) repeatedly exposed to high temperatures will completely recover? Is that plausible?

"The healthy player effect"

Sure, we see champions like Roger Federer appearing to function well, despite the heat. But could there be a "healthy player effect"? That is, might we not learn a lot more about the adverse effects of extreme heat upon sportspeople by studying people who abandoned sport, or perhaps switched to a winter sport, due to their discomfort with heat? My former mentor, Tony McMichael, coined the term "healthy worker effect", recognising that studying the health of long-term factory workers told only a small part of the story.

The NH&MRC's failure to recognise the risk of chronic heat effects

Between 2012 and 2016 I repeatedly proposed research projects to investigate aspects of these questions, but with no success. The National Heath and Medical Research Council has declined to fund at least six large grant applications of relevance. (I was involved with five of them, one of which I led).

Conclusion

It is unconscionable to treat athletes and spectators in hot conditions as guinea pigs. Many emergency workers such as firefighters and military personnel have to endure such heat. We urgently need to better understand the long term risks that those workers face, and, if we find them, then try to work out ways they can be protected. However, until we know, spectators and athletes will be better protected by a change in the date of the Australian Open, cycle races, and in the near future, cricket.

Decades of denial and neglect about climate change, such as by former Australian Prime Minister  Tony Abbott (a keen cyclist), have created this crisis. Let us not compound that negligence. Ignorance is no defence. We have a duty of care to investigate chronic health effects of heat. I have a duty to add my voice about these many concerns.

PS A correspondent has suggested that the stadium could be retrofitted to have water flowing through tubes under the court to extract heat from the slab, and possibly the stands, circulating it for other uses. If the roof were closed and the air conditioning turned on, the mass cooling would possibly use less energy that individuals if they were at home turning on their air conditioners. A greater use of solar panels would lower the greenhouse gas footprint of the stadium, offset the carbon emissions the complex uses from the grid (as Victoria still uses mainly coal-fired power), and create good will.

However, some observers may claim that a cooled stadium would give an unfair advantage to players (especially higher ranked seeds) who are more likely to be chosen to play on that court. 

About the author

Adjunct Professor Colin Butler graduated in medicine in 1987, and has four post-graduate degrees or diplomas in public health, including a PhD in epidemiology and population health from the Australian National University (awarded in 2002). He also has over 10 years of clinical medical experience, mainly with elderly, disadvantaged patients, in the Australian state of Tasmania. He is one of only two living Australian contributors to the health chapter of the most recent IPCC report.

In 2014 he became the first Australian IPCC contributor to be arrested for civil disobedience about climate change, attempting to draw more attention to this crisis. He is sole editor of the book Climate Change and Global Health (CABI, 2014). In 2010 he was awarded a Future Fellowship by the Australian Research Council, allowing 4 years of independent research on topics related to global environmental change and health. He has experienced hate mail and an official complaint to his former university, due to his activism over climate change. His first article on climate change and health was published in the Medical Journal of Australia in 1991.

Climate change and activism: time for protests to rival those against the Vietnam war

In late 2014 I was arrested at the Maules Creek mine, opposing coal exports, becoming the first Australian contributor to the Intergovernmental Panel on Climate Change (IPCC) to be arrested for coal disobedience. I don't regret that (even though it effectively ended my chances to go to the US again), but it has clearly been woefully inadequate.

Even Cory Bernadi should now be able to connect the dots

I originally wrote "Blind Freddy" instead of "Cory Bernadi" (an ultra conservative Australian politician) but it was pointed out me that this discriminates against the blind; apologies for that. The evidence of trouble from adverse environmental change is now overwhelming; but (to use another metaphor) we appear to collectively stand frozen, like a kangaroo in the headlights.

In recent days (continuing as I write at 03.30) there has been another infernal heat wave in much of Australia. In parts this has been compounded by blackouts. It's not only unpleasant, but can be highly dangerous and disabling, including to people with chronic cardiac, renal and neurological illnessses, including dementia, multiple sclerosis and epilepsy. Not to mention to people who are homeless, poor and in other ways vulnerable, including many who work outside, the elderly and some with mental illness. Added to this is the risk of devastating bushfires, including urban.

Note too that urban temperatures are often higher than officially recorded, due to the heat island effect, made worse by the killing of urban trees for cars and trams. Perth in Western Australia had its coldest February day ever, followed by an almost record deluge. That may seem paradoxical, but in fact climate change is not just about heating; it's also about the jetstream deforming (leading to paradoxical cold) and heavier rain, including "rainbombs". Parts of interior Australia have also been affected by significant extreme heat-associated infrastructure failure, including of mobile phones, the internet and the access to electronic cash. 

Australia: shooting itself in the brain

As civilisation gets closer to its apparent end we collectively seem to be functioning with less intelligence; just like a human being with advancing dementia. Part of civilisation is still alive and well - but those who can see the problems most vividly are probably aged between about 15 and 40 - and they lack the power to bring about real change. (Though this age cohort was very effective in ending our involvement in Vietnam.)

A scientific paper in Nature Climate Change has recently lamented the bias (I would say flagrant negligence) by Australia's National Health and Medical Research Council (NH&MRC) against funding research on climate change and health, most plausibly because they don't want to risk their political capital.  (Disclosure: when still an Australian Research Council Future Fellow, in 2014 - before I was arrested at Maules Creek - I led a research bid to establish a "centre of excellence" on global environmental change and health. It was the third NH&MRC climate and health related attempt I was involved with in 3 years, we paid great attention to the feedback from the bid in 2013, yet one review we received in 2014 was almost contemptuous.)

Three of our 15 proposed research projects concerned heat and health, others concerned conflict and climate change and the rest were about biodiversity loss, heat, infectious diseases, disasters and climate change. The Australian Defence Force was a willing partner, something I thought would at least make the NH&MRC take our bid seriously. The Australian Red Cross and two state health departments were also involved, as were the Chief Medical Officer and the Chief Veterinary Officer.

However, Tony Abbott ("coal is good for humanity") was then newly elected as Australian Prime Minister. I don't think it is paranoid to consider that the NH&MRC dared not risk offending "Captain Abbott" when the NH&MRC was itself vulnerable to further funding cuts?

South Australia's investment in renewable energy, which is a courageous step to protect us against extreme weather events, has been perversely blamed for blackouts, which are in fact more to do with climate change exacerbated storms and private enterprise profiteering. Federal ministers have even carried lumps of coal into the Australian parliament, which they seem to worship like icons. Professor Clive Hamilton has resigned from the Climate Change Authority. I don't blame him.

Even Mark Butler, the ALP shadow minister for environment, has failed to endorse the emergency phasing out of coal. We phased out asbestos; coal is even worse.

Do Australian politicians collectively lack leadership and courage, or do they inhabit such a bubble that they do not understand the immense risks the world now faces?  Or, perhaps, both?

In the US, a thoughtful article in the Atlantic, by David Frum, argues that protests, on their own, will shore up Trump's power. (The wilder the US political environment, the more his supporters in rustbucket states will appreciate Trump's autocracy.)

But Australia is a little more democratic. Just watching the world heat up, the weather to turn even wilder, and crops and animals to suffer is not going to do much good. 

Massive civil disobedience is needed - I wish it were more likely

I'm not sure that massive civil disobedience (on the scale of that against the Vietnam war) about coal in Australia will do any good, but just sitting in the frypan is futile. Such disobedience seems unlikely to occur, however, for several reasons:

1. Australians have many other stresses and priorities.

2. This heat wave will pass, and so will memory of it.

3. Globally, we are not like Syria or Yemen; we can afford food price rises, (see my open access chapter about food prices and climate change here) and we are already spending a significant sum deterring asylum seekers. Australians are not among the worst affected by climate change; we are still among the least affected. Here I disagree with some academics who point out our vulnerability - we are vulnerable, but we have the means to protect ourselves from the worst for a few more decades, though large urban bushfires scare me the most in Australia's near future. 

4. As inequality grows, so too does Australian public acceptance of the dreadfully named "harvesting effect" of heat on the vulnerable. 

5. The "eco-social" links between catastrophes such as in Yemen, Syria and South Sudan and adverse environmental change are substantially suppressed. (That is, these causes are ecological as well as social.) Since many academics deny, or fail to understand, such links what chance does the Australian media have of publicising them? Without widespread understanding of these factors, how will enough people be motivated to protest?

6. The Australian Federal and state governments will be increasingly draconian (I was initially threatened by the police with having to pay over $40,000 in compensation to the mine). The situation in Tasmania (where I was also arrested, opposing the Franklin dam) is also draconian, though Bob Brown is courageously challenging this. However the courts will probably be more sympathetic.

7. Finally, the massive (and entirely justified) protests in Australia and elsewhere against our participation in the 2003 invasion of Iraq were completely unsuccessful. That is discouraging.

Trying to end more positively

We truly are behaving like a slowly boiling frog. I wish I could be more positive. We need a new compact, a new economy, new leadership. President Trump may be replaced by Senator Warren. Like so many Australians I once had hope for Malcolm Turnbull, who I met in about 2011 - we talked then for ten minutes then solely about what I call the "tertiary" - civilisation wrecking - effects of climate change, and he seemed to understand. I think he probably still does, but he still feels he cannot dare risk the wrath of the Australian right.

I attended a moving funeral service for the late Professor Basil Hetzel two days ago (in the heat).  Basil was a very important mentor for the late Professor Tony McMichael. Basil devoted himself to public service and medical research, but had some understanding of the peril of the Anthropocene - the modern age. Tony, even more so, appreciated this. Former Australian Prime Minister Bob Hawke attended the funeral, and it was great to see him (at a distance). At the tea and sandwiches I spoke to a pastor who mentioned that Bob Hawke's accord was founded on a less adversarial approach to politics which had evolved in (convict-free) South Australia.

There is certainly something wrong with Federal politics at the moment, and not just here. We need more of what Thich Nhat Hahn calls "deep listening". Could this emerge as the world goes deeper in crisis? I think it might just be possible. In any case, despair does not help. Action to try to bend the world towards more justice is probably despair's best antidote. And, if anyone under 40 does read this, I hope you will contribute to the organisation of massive - but peaceful - protests. That is still a democratic right in Australia. Not everyone needs to get arrested.
--


Colin Butler is an adjunct professor of Public Health at the University of Canberra, Australia, and co-founder of the NGOs BODHI and BODHI Australia. He is founding co-chair of Health Earth and lead author for the section on health in the forthcoming flagship Global Environmental Outlook report of the United Nations Environment Programme, called Healthy Planet, Healthy People.