Beyond adaptation and resilience: A call for health-care transformation

The COP28 UAE Climate and Health Declaration is largely focused on adaptation of the health sector to climate change and on “climate resilience,” although one of the three common objectives in the declaration is directed specifically at reducing the climate impact of the health system. The other two address the need for the system to prepare for and respond to climate-sensitive disease and health risks and, more broadly, to be ready to address issues such as “mental health and psychosocial wellbeing, loss of traditional medicinal knowledge, loss of livelihoods and culture, and climate-induced displacement and migration.”

It is important to consider what is meant by climate adaptation and resilience. These two terms were defined by the Intergovernmental Panel on Climate Change in 2014 and they are not quite the same thing. For me, adaptation has a passive quality – accepting, accommodating to and coping with the changes that are coming while maintaining the current system.

Adaptation. The process of adjustment to actual or expected climate and its effects. In human systems, adaptation seeks to moderate or avoid harm, or exploit beneficial opportunities.

Resilience. The capacity of social, economic, and environmental systems to cope with a hazardous event, trend, or disturbance, responding or reorganizing in ways that maintain systems’ essential function, identity, and structure while also maintaining the capacity for adaptation, learning, and transformation (IPCC 2014).

Resilience, on the other hand, is of two sorts: “bouncing back” and “bouncing forward.” And it is only one of those that we should be focusing on.

Most commonly, resilience means “bouncing back” – being able to return to, or close to, the initial condition after being impacted by some event. It’s what we want if we have an injury or illness; what we want our health system or community to do after, let’s say, being hit by a tornado. In that sense, it’s more like adaptation.

But bouncing back is not always such a good idea. If we have built our homes (or our health-care systems) on a delta or floodplain, does it really make sense to go back and build again in the same place? Or would it be smarter – not to mention cheaper and less traumatic in the long run – to rebuild someplace else?

“Bouncing forward,” on the other hand, is about going to a better situation, rather than back to a bad situation. Going from business as usual to transforming the system, be it the health-care system, the community or society as a whole.

Adaptation

Adaptation is the focus of the Canadian government’s work in the health sector, as the joint statement from the Ministers of Health, of Environment and Climate Change and of Indigenous Services make clear. Canada’s National Adaptation Strategy, launched in June 2023, “allows Health Canada to work with partners to renew and expand the HealthADAPT program to support actions to build climate-resilient health systems and protect the population from extreme heat – a growing and urgent health risk.”

The Canadian Coalition for Green Health Care has a Resiliency section on its website and as far back as 2015 created The Health Care Facility Climate Change Resiliency Toolkit and an associated Checklist. These help facilities assess their resilience to climate change in areas such as emergency management, facilities management, health care services and supply chain management.

CASCADES also has resources for climate-resilient health systems.

The HealthADAPT program “helps the health sector prepare for and respond to the impacts of climate change.” The commitment in the joint statement to renew and expand the program is welcome since program funding ran out in March 2022. By then, Health Canada had invested a mere $3.5 million – not exactly a major commitment. In addition, the program had created two resources: A Guide and a Workbook for the Canadian health sector on climate change and health vulnerability and adaptation assessments.

However, adaptation is largely a responsibility of the provinces and territories since they run Canada’s health-care system. That is why, in a joint letter to Canada’s Ministers of Health and of Environment and Climate Change, a number of leading health organizations have called on Health Canada and each of the provinces to establish and fund a climate change and health secretariat, and for climate-resilient and sustainable health systems to be on the agenda for the next meeting of health ministers.

Resilience as transformation

It is, of course, important to adapt to oncoming changes, and to maintain a form of “business as usual” to some extent, both as a health-care system and as a society.

But focusing on adaptation and resilience in the form of “bouncing back” does not work when the current system is the problem; in that case, maintaining business as usual becomes the problem, not the solution.

Not only has our modern industrial society taken us close to crossing the 1.5 C boundary for global temperature increase that we are trying to avoid (we seem headed to between 2.5 and 2.9 C change by 2100), it has also resulted in us crossing six of nine key Earth system or planetary boundaries. The ecological and societal situations we face between now and 2100 will be anything but usual.

Clearly, then, the current system cannot – and should not – be maintained.

There are really only two options: Either we continue to work to maintain the societal and economic systems as they are, in which case ecosystems and the societies embedded within them will decline or collapse, or we will undertake a quite radical transformation to a more sustainable, equitable and healthy society.

There are profound implications here for the health care system. The most important implication stems from the fact that the health care system of the future will reflect the society of which it is a part, and not the other way around, a point I often made in my work as a health futurist.

Obviously, if society declines and collapses, so too will the health- care system. But if we take a more hopeful approach, and assume that in the face of massive global ecological changes, communities and societies respond in a transformative way, what sort of society would we bounce forward to, and what would the health-care system look like in such a society?

While this is not the place to explore in depth the transformative society we need to create, in a nutshell, it would be the Well-being Society that the World Health Organization has been calling for; societies that are “committed to achieving equitable health now and for future generations without breaching ecological limits.”

More than 40 years ago, I drew an analogy between the hard-tech nuclear energy system that was mainstream thinking back then and the hard-tech hospital-based health system, contrasting them with what Amory Lovins had called the “soft energy path” of decentralized, green, renewable energy systems and what I called the “soft health path.” I suggested this soft health path would include “self-care and mutual self-help groups; ‘barefoot doctors’ and the World Health Organization’s primary health-care strategy; the move toward nurse-practitioners’ providing care; the holistic health movement; the interest in alternative healing modalities; and the renaissance of the public health movement.”

Soft technologies: According to Lovins, soft technologies are flexible, benign, sustainable and resilient, and have five characteristics: they are renewable, diverse, flexible and relatively easy to use (and therefore accessible to the general population), matched in both scale and distribution to end-use needs, and also matched in quality to these needs. (Hancock, 1982)

Much has changed since 1982, but Lovin’s vision of the soft energy path remains important, and we are probably closer to it now than we were then. We need to continue to move that way. I am not sure we are closer to my transformative vision of the soft health path than we were then, but the current failings in primary and community care suggest we might be a lot better off if we were.

The World Wide Fund for Nature (WWF) noted some years ago that “ecosystems sustain societies that create economies. It does not happen the other way round.” Substitute “health-care system” for “economies” and there you have it.

So, a key challenge we face is to envision a health-care system that is compatible with a future society that is in turn compatible with the Earth’s limited biocapacity and resources. That would be a resilient health-care system.