What if the earth had a fatal heart attack?
Authors: Atul Nakhasi, Daniel M Croymans, Jonathan E Fielding
Journal: The Lancet Planetary Health (2019)

Now in her 60s, Mrs PE hauls around a metal oxygen tank. She is the victim of a slow, debilitating process that began decades earlier with fast food consumption, physical inactivity, and cigarette smoking. Although she felt fine, over time she steadily gained weight and her cholesterol levels crept up. By the time these subtle warning signs became apparent, the damage to her vital organs was irreversible. This woman might help save our planet. That is because Mrs PE is actually a metaphor for Mrs Patient Earth—our plastic-clogged waterways are her cholesterol build-up, our global warming crisis is her silent rise in blood pressure, and our coal overdependence is her food overconsumption. These are the chronic stressors on Earth's vital organs. Metaphors like the aforementioned one are perhaps our most precious currency in this crusade for a sustainable planet, because the modern technological era now demands more than ever that effective risk communication be relatable, memorable, and succinct. Indeed, this ongoing failure in risk communication is the most serious threat to the environmental movement. Dr John Sterman, a leading scientist on climate change from Massachusetts Institute of Technology, highlights that “strong scientific consensus on the causes and risks of climate change stands in stark contrast to widespread confusion and complacency among the public”,1Sterman JD Risk communication on climate: mental models and mass balance.Science. 2008; 322: 532-533Crossref PubMed Scopus (244) Google Scholar and ineffective risk communication is now the “major bottleneck preventing science from playing an appropriate role in climate policy.”2Sterman JD Communicating climate change risks in a skeptical world.Clim Change. 2011; 108: 811Crossref Scopus (140) Google Scholar Researchers are now actively working on this pressing communication problem, including at the University of California Climate Lab, the Yale Climate Change Communication programme, and the Climate Outreach programme. Yet, more work needs to be done. So, if the science is clear yet the communication unclear, how do we save Patient Earth? As doctors, we learn how to communicate risk throughout our careers. Every day we are charged with the responsibility to explain complex and preventable conditions with distant consequences, much akin to environmental risks, such that patients can immediately understand their situation and make actionable changes themselves. First, we've learned that risk communication is a trainable skill. In fact, a major study showed that communication training for doctors improves patient adherence by more than 10% for treatments such as medications, diet improvements, increased exercise, and cancer screening—behaviours with high stakes yet distant outcomes.3Zolnierek KBH DiMatteo MR Physician communication and patient adherence to treatment: a meta-analysis.Med Care. 2009; 47: 826Crossref PubMed Scopus (1458) Google Scholar Indeed, in medical school, the practice of working with hired patient actors and then reviewing our interactions with clinical mentors is considered an essential training tool. We quickly learn which risk communication techniques motivate behaviour change and which do not. For example, in trying to connect today's sugar-loaded diet to an increased risk of diabetes, the vividness of a surgical limb amputation resonates more powerfully than the vague future risk of diabetes itself. This skill is both teachable and fundamental to the work of both doctors and environmental scientists alike. Second, we have realised the striking effect of risk communication during moments of crisis. One large longitudinal survey found that patients with a new diagnosis of stroke, cancer, lung disease, heart disease, or diabetes were three times more likely to quit smoking than the average smoker.4Keenan PS Smoking and weight change after new health diagnoses in older adults.Arch Intern Med. 2009; 169: 237-242Crossref PubMed Scopus (84) Google Scholar Numerous studies since then have confirmed that new diagnoses, especially of serious medical conditions, represent teachable moments for risk-factor modification. Perhaps, environmentalists too could initiate timely, highly-focused campaigns surrounding important natural disasters. For example, this strategy might have substantially magnified risk communication (and perhaps even changed human behaviour) following the destructive California wildfires that cost more than US$3·5 billion or the record-setting US mid-west freeze that killed 21 people. Third, we tap into the power of figurative language to shed light on risk and complexity and motivate crucial behaviors. One of us faced this dilemma on a medical trip to Malawi, Africa—how do you get a 7-year-old boy with HIV to take life-saving medications every day of his life? By sharing with him that taking his (antiretroviral) medications gives the soldiers in his body the vitamins they need to fight disease and keep him strong. A study substantiated our personal experience, showing that when explaining cancer treatments, patients appreciated the use of metaphors such as traffic jam and bus driver, instead of exon specificity and driver mutation.5Pinheiro AP Pocock RH Dixon MD Shaib WL Ramalingam SS Pentz RD Using metaphors to explain molecular testing to cancer patients.Oncologist. 2017; 22: 445-449Crossref PubMed Scopus (6) Google Scholar By creating simplified mental models (such as in the case of Patient Earth), metaphors might represent a potent cure to the problem of risk communication. We live in a time when the battle is often over tweets and truth, in which human attention span is measured in milliseconds, and in which viral and instafamous are status symbols. This reality is ours. Thus, our tactics should be tailored to the 280 character limit of our lives. In a world in which our greatest enemy is the mischaracterisation of truth by a single tweet, the metaphor further lends itself to battle in this medium. After nearly 50 years of policy advancement since the first Earth Day in 1970, our planet is now under unprecedented assault. Although US policies are not the only contributor, we are far from leading the charge in the right direction. In just the past 2 years alone, our nation has withdrawn from the Paris Agreement, proposed reversal in fuel efficiency standards, and recommended budget cuts to renewable energy research and climate change initiatives.6Greshko M Parker L Howard BC A running list of how trump is changing the environment.https://news.nationalgeographic.com/2017/03/how-trump-is-changing-science-environmentDate accessed: April 8, 2019Google Scholar Progressive causes have long struggled with their inability to overcome academic tendencies and abstract policy prescriptions, failing to galvanise widespread public action. This is especially true for issues with far-removed consequences, such as climate change and chronic disease risks. Current events remind us all of our shared purpose to protect and preserve the health of our planet. We should reflect, refine, and reclaim the techniques and tactics we use to serve this purpose. Ultimately, Earth's health might depend on a simple metaphor. We declare no competing interests.