A poll of Canadians from earlier this year found that the environment ranks as the third most important issue to us, behind the economy and health care. In fact, Canadians are quite divided in their opinions about the environment and what we ought to be doing to protect natural resources and regulate environmental pollutants.

Some of the strongest voices in Canada advocating for the environment are doctors. However, there are tensions around what the appropriate role is for doctors in environmental advocacy. Who gets to define what the ‘medical needs’ of a community are? And is there a point when a doctor’s role and expertise ought to be limited when it comes to advocacy about the impact of the environment on health?

The Adams Mine controversy: should doctors “stick to what they know best”?

The experience of the Adams Mine, located in northeastern Ontario, provides a clear example of these tensions. The former iron ore mine stretches over 16 km square and has a number of deep, open pits.  The mine closed in 1990, leaving hundreds of local people unemployed.

Almost immediately, provincial and municipal politicians and planners began developing proposals to use the mine as a landfill for garbage shipped from Southern Ontario. For over a decade, proposals around how to transport, treat and manage the landfill were reviewed by various municipal governments, as well as the provincial government. Ultimately, the proposals were defeated and the Ontario provincial government passed an act prohibiting disposal of waste at Adams Mine.

However, the nearly 15 year period when these proposals were being considered created a great deal of tension with members of the surrounding communities advocating strongly for – and against – using the mine as a landfill.

Kirkland Lake – a nearby town of around 9000 was no exception. Brian Hamilton, retired high school teacher and former chair of the Kirkland & District Hospital board describes a decade of tension in the town where “the proposals divided our community.”

The prospects of jobs in waste management at the mine site were appealing to some, while others were concerned about the impact of the waste on the surrounding environment. Many of the strongest voices opposing using the mine as a landfill were from the town’s physicians.

Richard Denton, who was a family doctor in Kirkland Lake at that time and is now assistant professor at the Northern Ontario School of Medicine reflects on his activism in trying to defeat the landfill proposals. Denton describes working in partnership with geologists who believed that waste by-products would seep through cracks in mine walls into the groundwater. He argued that contaminated groundwater would have effects the health of those living in the surrounding communities, and downstream.

“As a doctor I carried quite a bit of weight in speaking out about health issues – my expertise is on how toxins effect bodies and the associated risks” Denton said in an interview with Healthy Debate.

However, some experts, politicians and community members questioned the extent to which doctors spoke out about the issue, and whether they had the authority to do so. Editorials in the local newspaper referred to the doctor advocates as “fear mongering elitists out of touch with the economic realities of the town.”

Hamilton says “there were some rumblings in parts of the community that the doctors should stick to what they know best – looking after the medical needs of the community.”

The Adams mine controversy has been repeated across Canada, where doctors who believe that they are advocating for the health of their communities are criticized as overstepping their role. For example, this criticism has been raised against family doctor John O’Connor in his very public advocacy around potential health impacts on the Fort Chipewyan community of upstream oil sand extraction.

Advocacy is a core competency of practicing medicine

The Royal College of Physicians and Surgeons of Canada is a national body that sets standards for specialty medical education in Canada. Nearly twenty years ago, the College developed a competency framework of seven roles every Canadian doctor should have – one of which is ‘Health Advocate’.  This role is described as the responsible use of a doctor’s “expertise and influence to advance the health and well-being of individual patients, communities, and populations.”

While environmental advocacy has been seen as part of the specialty of doctors who work in Public Health and Preventative Medicine, there are many doctors outside this specialty who engage in environmental advocacy.

“The public says that doctors have unique knowledge and power in society – and the obligation to use that power for good” says Jason Frank, Director of Specialty Education, Strategy and Standards at the College.

Frank describes the Health Advocate role “as the most difficult and controversial” of the competency framework, noting that it is also “the one that medical educators find the most difficult to teach.”

Frank says advocacy is a value-laden term and may conjure up images like marching in protests or launching a legal case.  He acknowledges a spectrum of opinions on what constitutes advocacy, noting that there are “tensions in perspectives that Canada’s doctors have on to what degree they should have an advocacy role.”

The politics of global and local advocacy

This tension is particularly evident when doctors take advocacy positions around the impact of the environment on health. Debates in Canada echo many of the same themes as global debates around the impact of the environment and health – and the role of advocacy.

For example, scientific evidence clearly points to humans influencing climate change by activities increasing the concentration of carbon dioxide and other greenhouse gases in the atmosphere.

In a BMJ article published last month Eric Chivian, Director of the Center for Health and the Global Environment at Harvard Medical School, says that in spite of mounting examples of impact, the public is confused about climate change, and says that scientists are ill equipped to clearly communicate what it means to them as individuals.

Chivian won a Nobel Peace Prize for his efforts to highlight the health implications of nuclear conflict in 1985. He argues that doctors must “help educate people about what is really happening… and there is no more compelling way to do this than by talking about human health.”

He further says “as physicians we can provide people with concrete examples of the medical consequences of climate change and thus help convince them that we have no choice about whether to preserve the global environment.”

Kapil Khatter is a family doctor in Ottawa and former director of the Canadian Association of Physicians for the Environment. Khatter says that if doctors aren’t evidence-based in their advocacy, they risk jeopardizing their credibility. However, he points out that “inevitably the question of what is strong enough evidence to take action is a values decision, not a science decision – and that’s where the politics come in.”

Khatter says, however, that even if the causal mechanism cannot be studied with the highest degree of methodological rigour expected in other areas of health research, it is up to doctors to “raise questions about strong associations.” He argues that there are differences in opinion around “what the threshold of evidence is for taking action.”

Debates around the strength of evidence needed for advocacy

Bob Woollard, Professor in the Department of Family Practice at the University of British Columbia is more definitive.  He says “the evidence is never going to give you the answer, but it may point you in the right direction.”

Woollard says that waiting for evidence of harm is not the right approach, and today’s doctors are too tentative. He argues that doctors ought to push instead for evidence of safety to be present when new technologies or chemicals are being introduced into their communities. This approach to regulation and the environment is described as ‘the precautionary principle‘.

Ray Copes, Chief of Environmental and Occupational Health at Public Health Ontario warns, however, that “there are different formulations of the precautionary principle and following it can be a recipe for gridlock and the status quo and not moving ahead with anything until you’re sure about risks.” Copes says that it can be used, for example, to oppose renewable energy projects such as solar power even though current ways of generating power such as gas and nuclear are associated with demonstrable risks.

Tensions around the role of clinician and advocate

The science and politics associated with advocacy around the environment and health can be complicated. While the CanMEDS Health Advocate role says doctors are required to promote the health of their communities, there can be disagreements about what this means.

Copes highlights that while “most primary care physicians can identify an unusual pattern of illness in their practice, they are not the experts in making a link between exposure to the environment and this pattern of illness.” He says that in these circumstances “the responsible move is to draw attention to the observation and refrain from making claims beyond their area of expertise.”

This was raised as a criticism of the doctors opposing the Adams Mine landfill proposals – but has been seen across Canada when it comes to doctors speaking out about the link between the environment and health.

In 2002, David Swann was chief medical officer of health for the Palliser Health Authority and was fired after making remarks that Alberta should work to meet emission targets set forth in the Kyoto agreement on greenhouse gas. Media reports at the time quoted Health Authority board representatives as saying that Swann’s position conflicted with the economic interests of the region. A letter in support of Swann from the Canadian Public Health Association noted that in the role of advocate, medical officers must have the freedom to speak out on sectors beyond the control of public health.

Robert Woollard observes that “physicians can be working against the public consensus if they work in communities with strong resource based economies” and raise questions about the health impacts of these industries – like mining or oil.

The 2005 CanMEDS framework role of the doctor as Health Advocate “doesn’t deal with the politics of advocacy” says Jason Frank. As part of a commitment to updating and renewing the Framework, the College is currently seeking input from the medical profession and the public. Click here to see various opportunities to contribute to updating the CanMEDS Framework.

A report of the working group tasked with revising the ‘Health Advocate’ role notes that the definition has been refined to reflect that advocacy happens in partnership. It also clarifies that large-scale activism is not an expected role for physicians.

The current, working definition states that “as Health Advocates, physicians responsibly contribute their expertise and influence to improve health working with the patients, communities or populations they serve.”

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