Making a Planetary Health Case for Whole Person Health

Abstract

Whole person health care offers a number of potential benefits including better health outcomes for patients, decreased health care utilization, and lower overall costs of care. With its emphasis on health promotion and disease prevention, whole person health also has great potential to help align health care with planetary health by decreasing both direct and indirect environmental impacts associated with conventional medicine. In addition, by emphasizing plant-based and plant-forward nutrition, active transportation, mindfulness, and nature connection, whole person care is poised to contribute to the societal transformation needed to overcome the planetary health challenges we face. This essay, in response to the recent article Making the Case for Whole Person Health, provides an overview of the bi-directional connections between health care and planetary health, and emphasizes how whole person care offers a pathway forward for the health care industry that is better for both people and the planet.

Introduction

Whole person health is defined as an approach to health care that “focuses on restoring health, promoting resilience, and preventing disease across a lifespan,” ¹ and “empowers and equips people to take charge of their health and well-being and live their life to the fullest.” ² In their article, Making a Case for Whole Person Health, authors Herman, Pitcher, and Langevin offer a compelling argument for transforming health care from a conventional disease-centric approach to a whole person model through a comparative analysis of health outcomes, health care utilization, and total health care cost of the two approaches. ³ The article highlights how implementing a whole person health care approach for a hypothetical female patient beginning at age 40 fosters patient empowerment, contributes to a higher quality of life and greater independence in later years, and offers substantial health benefits and cost savings in comparison to simply continuing conventional care. The purpose of this essay is to highlight how, in addition to the benefits described above, whole person care—with its emphasis on promoting health through nutrition, physical activity, and stress management, and addressing the root causes of disease—also has great potential for promoting planetary health.

Before exploring the interconnections between whole person health and planetary health, a few interrelated terms are useful for setting the stage. In addition to the definition above, whole person health moves beyond the reductionist approach to medicine that considers individual symptoms, organs, and body systems in isolation, and instead expands our understanding of health by recognizing interactions between the “interconnected biological, behavioral, social, and environmental” factors that determine a person’s location on the health-disease continuum at any given time. ¹ Similarly, the term “whole health” is defined as “physical, behavioral, spiritual, and socioeconomic wellbeing as defined by individuals, families, and communities,” and is anchored in an interprofessional, team-based, long-term relationship building approach to care that focuses on “what matters to you, rather than what is the matter with you.” ⁴ Both whole person health and whole health are related to “integrative health” which seeks to treat the whole person rather than separate organ systems, while also coordinating—or integrating—all available evidence-based conventional and complementary treatment options to care for the whole person. ¹

Planetary Health: A Primer for Health Professionals

The basic tenet of planetary health is quite simple: human health and the health of the planet are intrinsically linked through a bi-directional relationship. ⁵ When natural systems are healthy, they support both our physical health (through ecosystem services that provide clean air, clean water, and nutritious foods grown in healthy soils and pollinated by an array of biodiverse species ⁶ ), and our mental health (through several mechanisms that provide stress reduction, attention restoration, ⁷ and moments of awe ⁸ ). In this way, human activities that promote flourishing natural systems in turn promote human flourishing.

In comparison, when human activities disrupt natural systems, human health suffers. Changes to the global climate system caused by human activities that release greenhouse gases are leading to increased incidence of several human health impacts including heat illness, injury from extreme weather events, vector-borne disease, respiratory illness from exposure to wildfire smoke and extended allergy seasons, climate anxiety and mental health disorders, among others. ⁹ Air polluted by human activities that release particulate matter, sulfur dioxide, nitrogen oxides, ozone, heavy metals, and other substances cause a range of acute and chronic diseases including asthma, heart disease, lung cancer, and other illnesses that contribute up to an estimated 8 million deaths each year globally. ¹⁰ Water contaminated with pathogens causes over one million global deaths annually, primarily from diarrheal disease. ¹¹ Likewise, water contaminated with toxic metals (eg, lead), persistent organic chemicals (eg, per- and polyfluoroalkyl substances), microplastics, pharmaceuticals, and other hazards contribute to a variety of illnesses including neurologic and metabolic disorders.^12,13 Soils depleted of nutrients from unsustainable agricultural practices lead to both lower crop yields and decreased essential nutrients and minerals in fruits, vegetables, and grains, thereby contributing to food insecurity and malnutrition. ¹⁴ Habitat destruction and fragmentation caused by deforestation, mining, wetland drainage, and other land use practices decrease biodiversity, increase the emergence of infectious pathogens, and alter human interactions with wildlife, leading to the emergence of new diseases such as avian influenza. ¹⁵ Furthermore, in urban areas a lack of exposure to healthy greenspaces is associated with higher rates of several psychiatric disorders and suicide. ¹⁶

Each of the examples above follows the same pattern: unsustainable human activities lead to seemingly localized negative health outcomes. When considered collectively, these activities combine to disrupt the Earth’s life support systems on a global scale. Environmental scientists have identified nine critical “planetary boundaries” that pose irreversible, existential threats to life on Earth if we continue to transgress their “safe operating limits”.^17,18 The nine planetary boundaries include climate change, biodiversity loss, novel entities (chemical pollution), biogeochemical flows (nitrogen and phosphorus cycles), land system change (conversion of natural ecosystems to agricultural and urban areas), freshwater consumption, ocean acidification, stratospheric ozone depletion, and atmospheric aerosol loading (emissions of particulate matter into the atmosphere).

The root cause of our societal transgression of these boundaries is the idea of “human exceptionalism”—the belief that humans are separate from and dominant over nature. ¹⁹ To overcome the challenges we face, we must acknowledge that we are a part of nature and reenvision our connection to the world through reciprocity and stewardship—a belief that is central to many Indigenous cultures ²⁰ and Eastern wisdom traditions.^21,22

This understanding has gained increasing interest in the scientific literature over the past decade. In 2015, The Rockefeller Foundation-Lancet Commission on Planetary Health published a seminal report highlighting the urgent need for transformative action built on the knowledge that “human health and human civilisation depend on flourishing natural systems and the wise stewardship of those natural systems.” ²³ Since then many thought leaders have recognized the role that health care must play in this transition away from human exceptionalism and toward interconnection.^24-26

The Role of Health Care in Planetary Health

Health care plays a critical, bi-directional role in planetary health. In one direction, health care systems must build resilience to be able to provide high-quality care during extreme weather events, while also preparing to respond to the increasing burden of health conditions related to global environmental change.^27,28 When assessing patients, it will become increasingly critical to understand environmental exposures in order to minimize risks through preventive care and effective treatment. ²⁹ The integration of climate-related health needs into clinical practice is in line with growing demand from students in medical, nursing, and other health professional programs who are increasingly requesting training on planetary health, as exemplified by the Planetary Health Report Card—an international metrics-based tool to assess and grade programs on their alignment with student demand for training on these critical topics. ³⁰ A whole person approach is poised to promote the integration of planetary health into clinical practice through its recognition of the importance of interconnected environmental factors in shaping health. ³¹

In the opposite direction, health care systems must acknowledge their role in the societal transformation needed to overcome the planetary health challenges we collectively face. Health care systems themselves must mitigate both their direct and indirect impacts on the health of the planet, which in turn contribute to the global burden of disease. ³² Globally, the health care sector is responsible for about 5% of climate forcing greenhouse gas (GHG) emissions. ³³ The United States contributes about one quarter of these emissions—the largest per capita. ³⁴ Approximately 80% of these emissions result from supply chains—the manufacturing, packaging, transportation, and waste disposal of medical products and devices—and prescription drugs alone account for 10% of the sector’s GHG emissions. ³⁵ One of the few studies to compare the environmental outcomes of different types of care found that conventional inpatient care for terminally ill cancer patients utilized up to 33 times more common medical supplies per patient per day, dispensed up to three times more pharmaceuticals, and produced twice as much municipal waste and 100 times more infectious waste than acute inpatient hospice care, a form of whole person care. ³⁶ The study noted that the majority of environmental impacts of conventional care result from the medical supply chains associated with diagnostics, surgical procedures, various treatment options, and other resource-intensive aspects of care, along with infrastructure such as facilities, transportation, laundry, and food systems. With its emphasis on health promotion and disease prevention across the lifespan, ¹ whole person care has the potential to drastically reduce the carbon footprint of the health care sector simply by keeping people healthy, thereby decreasing health care utilization. ³⁷

Pharmaceuticals, in addition to the impacts noted above on climate change, ³⁵ are major contributors to water pollution. Active pharmaceutical ingredients (API) have been detected in more than 50% of rivers tested across all continents. ³⁸ In the U.S., API have been detected in 80% of tested surface waters (lakes, rivers, and streams), ³⁹ 81% of tested groundwater, ⁴⁰ and 100% of municipal drinking water samples collected from 25 drinking-water treatment plants across the U.S., with a maximum of 20 different pharmaceutical compounds detected in a single sample of treated drinking water. ⁴¹ Pharmaceuticals in the environment are considered “chemicals of emerging concern” because of their pseudo-persistence and bioaccumulation in aquatic environments, their potential to cause antimicrobial resistance, and because as biologically active compounds they elicit a range of behavioral, physiological, reproductive, and neurotoxic responses in non-target species across aquatic food webs. ⁴² Our cultural reliance on pharmaceuticals to treat symptoms is exacting a toll on the planet, and again we see the role that whole person care can play in mitigating this harm both through health promotion and by expanding beyond pharmaceuticals to integrate all evidence-based therapeutic options into preventive care and disease treatment. ⁴³

While the examples noted above offer insight into the ways that whole person health can decrease the environmental effects of health care systems, whole health also offers a tremendous opportunity to help decrease the environmental impacts associated with individual behaviors and lifestyle factors. By incorporating a salutogenic approach to care that promotes the factors that make people healthy, ⁴⁴ as opposed to the conventional pathogenic approach concerned with the factors that make people sick, whole person care could contribute to the societal transformation needed to overcome the planetary health challenges we face. Imagine the ripple effects if whole person care provided patients with not just nutrition support, but support for transitioning to the EAT-Lancet Planetary Health Diet which provides dietary guidelines for optimizing both human health and environmental sustainability—widespread adoption of this plant-forward diet would lead to a decrease in rates of cardiovascular disease, metabolic disorders, cancers, and obesity while also drastically reducing the harms associated with the industrial production of animal products. ⁴⁵ Whole person care, with its emphasis on physical activity, could promote active modes of transportation, making it easier for people to incorporate healthy movement into their daily routines while also shifting away from carbon-intensive car-centric planning and toward people-centered community design. ⁴⁶ A whole person approach that incorporates mindfulness training can improve both physical and mental health outcomes among patients and clinicians, ⁴⁷ while also nurturing pro-social behavior and non-materialistic values which are a cornerstone of sustainable consumption and key factors in the societal transformation needed to remain within the safe operating space of planetary boundaries. ⁴⁸ By employing therapeutic nature prescriptions, whole person care could emphasize the importance of nature connection in human well-being, and encourage reconnection and reciprocity with the natural world in ways that help overcome the idea of human exceptionalism. ²⁴ In these and many other ways, whole person care offers a clear pathway forward that is better for both people and the planet.

Whole Person Health as a Pathway to Planetary Health

Several existing initiatives are working to integrate planetary health into health care, including efforts to transform medical education,^49,50 incorporate climate change communication in patient counseling, ⁵¹ and advocate for decarbonization within local and national economies, ⁵² among others. Whole person care offers yet another opportunity to bring health care systems back within planetary boundaries. At the very minimum, this model of care has the potential to curtail the environmental impacts of conventional care simply by decreasing health care utilization, as exemplified in the patient scenario presented in Making the Case for Whole Person Health. ³ In the article a typical female patient, Mrs. M., presents at age 40 with hypertension, knee osteoarthritis, insomnia, heartburn, and weight gain. The analysis compares the outcomes of care under both conventional and whole person models of care over the following 40-year period. Under the conventional model, each symptom is treated separately and by the time the patient is 80 years old, her care has accrued a total cumulative cost of $353,155, and has included two medical procedures (upper endoscopy at age 45, and treatment for gastrointestinal bleed from erosive gastritis related to prolonged use of nonsteroidal anti-inflammatory drugs at age ^∼65), a total of eight days of hospitalization, eventual nursing home care, and a total of nine pharmaceutical prescriptions (ibuprofen, acetaminophen, hydrochlorothiazide, lisinopril, metformin, omeprazole, temazepam, trazodone, and oxycodone). Six of these medications are prescribed beginning when the patient is 40–45 years of age and continue through age 80, the remaining three begin around age 65.

The case is instructive regarding the unintended planetary health impacts resulting from conventional care. Conventional care relies heavily on medical supply chains in the diagnosis and treatment associated with disease-centric care, as exemplified in a quote from a conventional physician in a recent ethnographic study: “Conventional care means more imaging, more blood tests…and scans, and X-rays, and catheters, and IVs…and there are just more interventions with conventional care; so more interventions means more of everything else.” ⁵³ Each intervention utilizes medical supplies that range from disposable materials like nitrile exam gloves, to hospital gowns that must be laundered, to durable supplies such as metal IV poles that require frequent sterilization. ³⁷ Each of these materials contributes to climate change, biodiversity loss, and pollution across its life-cycle from the harvesting and mining of natural resources, to the production, packaging, and transport of finished goods, to eventual disposal via incineration or landfill. Similarly, every pharmaceutical prescribed contributes to climate change, as described above, primarily because of strict temperature and humidity requirements throughout manufacturing, packaging, transportation, and distribution, ⁵⁴ and each poses risks to aquatic environments when they enter the wastewater system upon excretion from the patient’s body. ⁵⁵

In comparison, the whole person approach presented in the article utilized a coordinated approach to identify the underlying causes of illness and to teach the patients skills and behavioral changes she could make to restore her health. The whole person scenario employed health coaching, physical therapy, nutrition counseling by a dietician, social work support to set-up home food delivery to access fresh fruits and vegetables, and a prescription for just one medication (hydrochlorothiazide) over the same 40-year period, with a total cost of $52,425. These costs primarily resulted from behavioral and lifestyle interventions that provided the patient with skills she could utilize throughout her lifetime, and which allowed her to remain active and maintain independence late into life.

This comparative analysis strongly suggests that if a whole person approach were adopted throughout the health care system, the resulting decrease in health care utilization and shift away from reliance on pharmaceuticals could have a major impact on mitigating the unintended impacts of the sector on planetary health. Two statistics in particular highlight this potential. First, according to the most recent U.S. Census estimates, 11.88 million 40-year old women currently live in the U.S. Imagine the transformative change we could see if each of them was provided with whole person care, let alone the change that would result from all 347 million U.S. residents. Second, while one patient’s prescriptions may seem a minor concern, collectively, 5.4 billion prescription medications are currently dispensed each year in the U.S., and are a major contributor to the health sectors’ climate impact and pollution. ⁵⁶

Now imagine the further benefits that could result if whole person care promoted the EAT-Lancet Planetary Health Diet, physical activity through active transportation, pro-environmental mindfulness practices, and reciprocity through nature prescriptions, as outlined above (Figure 1). Collectively, we would enjoy the co-benefits of better health with minimal planetary impact while also sparking the societal need for a shift in consciousness that acknowledges our place within the world. ²⁵ Whether simply reducing the harms associated with the current conventional model of care or becoming a leader in the transition to a flourishing future, whole person care offers a pathway for aligning health care with the health of the planet. Strategies for integrating planetary health into whole person health range from individual actions to collective advocacy for transforming health care systems. Changes in medical education and clinical training, communication that engages and empowers individuals and communities, technological advancements that reduce health care’s environmental impacts, and advocacy for policy change at institutional, state, and national levels are all necessary for overcoming the planetary health challenges that we face. ⁵⁷ Much work has been done to develop frameworks and principles to guide this work,^58-61 and multiple resources are available for people who are ready to take action, in particular from the Planetary Health Alliance—an international organization founded as a result of the 2015 Rockefeller Foundation-Lancet Commission on planetary health. ⁵ Advancing planetary health through whole person health has the potential to serve as a model for improving patient outcomes through both preventive and therapeutic care, reduce costs by reducing healthcare utilization, and enhance the well-being of the health care team, all while bringing health care systems back into alignment with planetary boundaries. ⁶¹

Figure 1.

Overview of Planetary Health Outcomes Associated With Three Care Trajectories: Conventional Care (Bottom), Whole Person Care (Middle), and Whole Person Care that Integrates Care for the Planet (Top). While Whole Person Care Substantially Decreases the Unintended Planetary Costs of Care, Whole Person Care that Intentionally Integrates Planetary Health has the Potential to be a Leader in Societal Transformation and a Flourishing Future.

Conclusion

Adopting whole person health as the new standard of care offers a holistic solution that benefits both individual health and planetary health. By reducing the unintended impacts of health care on the environment, whole person health contributes to broader societal sustainability goals, while incorporating plant-based diets, active transportation, mindfulness practices, and nature connection has the capacity to elevate the role that the health care sector can play in the societal transition needed to chart a way forward where all life on Earth may flourish. It is imperative that health care systems and policymakers recognize the interconnectedness of human and planetary health, and prioritize whole person health strategies to create a healthier future for all.