Bringing the planet into the generalist practice: a form of preventive care
Authors: Ralph Guggenheim
Journal: The Lancet Planetary Health (2018)

For the patient who presents with a clinical illness at the doctor's office, some questions are an underlying part of every consultation, although the patient rarely asks them explicitly. What caused my problem? What, consequently, can be done about it? What could I have done differently in the past and how can I prevent the problem in the future? Did the environment or society surrounding me provide me with the best chance of avoiding disease? Did my activity or inactivity, components of my nutrition, or air or water contribute to my condition? Implied in all questions is the concern about the role of environmental factors in the pathogenesis of disease. When health maintenance is part of the purpose of the encounter, the principal question posed to the physician, from a patient's perspective, is how to live to maximise one's chances of having a long and healthy life. We have been trained to consider as an integral part of our clinical work the discussion of what is conventionally termed prevention, such as known risk factors for cardiovascular or pulmonary disease and some cancers, and to conclude a consultation with recommendations for lifestyle modifications and established diagnostic tests. Although we know of many truly preventive actions, such as wearing seatbelts and helmets or smoking cessation, few clinically promoted activities deal with the actual prevention of illnesses, with most actions consisting of screening for the early diagnosis of existing problems that have yet to cause clinical symptoms.1United States Preventive Services Task ForceRecommendations.https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendationsDate: 2018Date accessed: March 5, 2018Google Scholar The most thorough preventive actions would consist of avoiding important adverse causative factors or increasing the body's resistance to disease or injury, should exposure occur.2Introduction to preventive medicine.in: Katz DL Wild D Elmore JG Jekel's epidemiology, biostatistics, preventive medicine, and public health. 4th edn. Saunders, Philadelphia2013Google Scholar In reality, many aetiological factors, especially those that can be linked to malignancies, have not been identified, while others are suspected to be causative but cannot be unequivocally proven to be noxious to human beings.3Prüss-Ustün A Wolf J Corvalán C Bos R Neira M Preventing disease through healthy environments: a global assessment of the burden of disease from environmental risks. World Health Organization, Geneva2016Google Scholar Consequently, discussing most preventable causes of disease necessarily involves uncertainty or even speculation. As a clinician, I can only take in statements like the following, from an Oncology text: “Although the causes of many human cancers remain unidentified, cumulative data support the opinion that environmental or dietary agents are the principal cause of human cancers.”4Strickland PT Kensler TW Environmental factors.in: Niederhuber J Armitage J Doroshow J Abeloff's clinical oncology. 5th edn. Saunders, Philadelphia2013Google Scholar The Precautionary Principle is described as taking preventive action in the face of uncertainty5United NationsThe Rio Declaration on environment and development.http://www.unesco.org/education/pdf/RIO_E.PDFDate: 1992Date accessed: March 5, 2018Google Scholar and is widely known since its proposal at the Rio Earth Summit 1992.6Kriebel D Tickner J Epstein P et al.The precautionary principle in environmental science.Environ Health Perspect. 2001; 109: 871-876Crossref PubMed Scopus (385) Google Scholar If we allow this principle to guide our preventive efforts, it can take the concerns of our prevention-minded patients one step further: patients should consider important factors that could improve the prospect of living a long life with an optimal life quality. Planetary health deals with prevention on a large scale. It attempts to include the important factors that determine health for humankind and other living creatures, in both short and long term. Countering planetary-scale threats requires coordinated global action by governmental and international organisations, but political action has been fragile and subject to dissuasion, especially in the past few years, rendering it essential, but not sufficient. Additional approaches are needed. Cooperation by individuals on a large scale could substantially add to efforts to safeguard planetary health. For the actions of individuals to make a difference, greatly increased awareness and motivation to act in their essential interest would be needed. As of now, in most populations, daily worries take precedence over what might happen to the world decades or centuries ahead. Therefore, if we want to facilitate understanding and motivation for planetary priorities, we should attempt to make the concept that personal behaviour contributes substantially to global development transparent to all. In the health-care sector of some countries, appeals have been published calling on health-care professionals to impress on their patients to change wasteful habits and overconsumption and to cut carbon footprints.7Guidotti TL Hancock T Bell W Physicians and environmental change: what is our role and why should anyone listen to us?.Persp in Biol and Medicine. 1998; 41: 591-604Crossref Scopus (4) Google Scholar The need for health-care professionals to acquire operative sustainable health expertise and skills has been pointed out.8Guitton MJ Poitras J Acquiring an operative sustainability expertise for health professionals.Lancet Planet Health. 2017; 1: e299-e300Summary Full Text Full Text PDF PubMed Scopus (3) Google Scholar Directions for the patient who asks about how to live a healthier life and what are the best options for effective prevention can emphasise simple and common sense messages. Next to preventive action that has a clear evidence base—such as cardiovascular or accident prevention—simple, catchy explanations on the need to cut carbon footprints or to minimise exposure to pesticides or air pollution should be widely disseminated and their use encouraged.9The Lancet Planetary HealthOur polluted world: the need for a global pollution strategy.Lancet Planet Health. 2017; 1: e209Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Simple and concise messages, as needed for the busy practitioner, have not yet been formulated. The potential to broadly propagate these universally applicable ideas will depend on keeping them straightforward. Emphasising the common sense of such ideas may contribute to preserving the planet's environment.