When I was planning my elective (Bangalore 1990) the only issue around flights was how to pay for them. But unfairly, unfortunately and undeniably, a new factor has crept into decision-making around long-haul travel – the annoying spectre of climate change. The medical student community, bound by ethical codes to “do no harm”, finds itself on the horns of a dilemma.
Debates are always better if we have some skin in the game. If we respect international scientific consensus, we’ll believe that climate change is real and a really bad thing for human health. We’ll be against the rapid expansion in coal-fired electricity generation in China, India and Africa. We’ll be concerned about the Amazon rainforest going up in smoke. But we may not, on balance, want to cramp our education and recreation by choosing not to fly.
Our recent year one debate defined the dilemma in sharp terms. We heard an F2 doctor describe the awesome experiences she had clocked up in forest communities, state-of-the-art hospitals and on the tourist trail. Seasoned international development medic, Dr Matt Ellis, iterated the multiple benefits of visiting low- and middle-income countries for our sense of the world and of ourselves. Long-haul flights, for Matt, are a necessary compromise, because “we can’t put aeroplanes back in the box”.
Kieran Tate, a fourth-year engineering student, refreshed proceedings with some data. News to me was the contrail effect, a.k.a. “Aviation Induced Cloudiness” (AIC). When aeronautical fuels combust, CO2 and other climate-forcing gases are released. But aviation’s biggest contribution to global warming is water vapour that condenses to form high-altitude clouds that trap heat with twice the efficiency of conventional GHGs.
Kieran was able to quantify the climate impact of last year’s elective programme using destination data from the medical school. In 2018, 177 Bristol students went overseas on elective to 38 countries. The average student’s emissions were 3800Kg of eCO2 (the “e” bit accounts for AIC). That is around annual per capita eCO2 emissions of middle-income countries such as Mexico, Romania and Lebanon. You could barter that consumption by not driving (average UK mileage) for 1.3 years or not eating meat (average UK consumption) for 3.7 years.
So we have climate change, and the 3.5% of this attributable to aviation. But whether this can respectably be called an emergency is a matter of definition. I see a child with a petechial rash and a fever but who is playing normally. The rash is likely not due to septicaemia but, if it were, she might die and I might be out of a job. So, I reach for the benzyl-penicillin. Similarly, we are not sure that global temperatures are rising out of control but, if they are, the consequences for humanity are dire. Hence, so the argument goes, strenuous and immediate action is indicated. This is the precautionary principle – defining urgency not on what something is but on what it might become.
It fell to me to set out these future (and current) impacts of climate change on global health, something I am mildly qualified to do as co-author of Sustainable Healthcare by BMJ Books. I’ll spare you the details, but the headlines include drought, flood, storm, water insecurity, food insecurity and mass migration of a scale we can’t imagine. A veritable apocalypse.
So how’s your moral arithmetic? How do we balance the self-evident benefits of far flung travel with the equally evident harms of aviation? On debate day we benefitted from some moral coaching from Dr Jonathan Ives from Bristol’s Centre for Ethics in Medicine. He got us considering the difference between needs and wants (do we need or just desire an elective in Nepal?) and the idea of moral sainthood (do we need to be saints or is it OK to be just “good enough”?). I was tickled by this cartoon raised in response to the “planes will still fly even if I am not in them” argument.
The motion “This house believes that in this age of climate emergency it is a moral wrong for medical students to fly long-haul on elective” was defeated with 31% in favour and 69% against. From the floor came the understandable question “why should we be denied a long-haul elective when you (meaning all previous generations of medics) had that opportunity?”. I wouldn’t draw from this vote the conclusion that the majority of students are denying the health impacts of climate change. There may be moral wrongs about flight, but these are overcome by the benefits. Others may simply have voted, fatalistically, with what they will actually most likely do.
Are there mitigations, things we could do to reduce the overall carbon impact of the Bristol elective programme? Electives in the UK have the major educational advantage of preparing us for life in the system in which most of us are destined to work. Other slightly less far-flung places can be reached by short-haul (one of my mentees did hers with the Norwegian Air Ambulance Service) or even train (possible to the likes of Morocco). European electives provide a great opportunity to consolidate a useful language (and the language barrier is a significant draw-back of going distant). Another option, controversial to some, is to offset the carbon costs of a flight by paying someone to sequester carbon on your behalf.
The medical elective is under threat from other sources – the GMC is concerned about the duration of medical training and is questioning the relevance of electives to the creation of NHS foot-soldiers. Personally, I think the idea of a period of truly “elective” study is brilliant. It is a tough degree, we need a few perks. But I do think climate change thing is going to catch up with us, maybe not in your time, but soon. And if soon, could we as a medical school get ahead of the game, pour encourager les autres? Could we, for instance, agree an average, per student, carbon allocation. Then those with their hearts set on the Cook Islands could trade with those settling on hearts at the Hammersmith. Meantime, hardcore sustainistas can sign up for www.2020doctorsdontfly.com – seeking 2020 medical practitioners and students to pledge not to fly at all in 2020.