Introduction
Throughout the history of the Earth, its climate has ebbed and flowed. Because of our growth and utilization of resources, greenhouse gas emissions are at their highest levels in 2 million years. (1) As a result, our planet is now about 1.1°C warmer compared to the late 1800s. (1,2) We have already observed some of the effects of this rise in temperature such as wildfires, droughts, worsening tropical storms and multiple other extreme weather events. (3) As it stands, climate change is currently the most significant threat to human health with lower income and disadvantaged communities and countries at particular risk, due to weaker health infrastructure and a lack of financial resources. (4) This places South Africa and the rest of the African continent at risk.
As multiple climatic hazards intensify, there will also be an effect on human pathogenic diseases. (5,6) Additionally, South Africa is still plagued by high rates of HIV (Human Immunodeficiency Virus) and tuberculosis with the latter being the leading cause of death among HIV infected individuals in South Africa. (7) Climate-induced human migration due to droughts and extreme weather events have been associated with increased prevalence of HIV. (8) Additionally, poorer control of the HIV epidemic related to progressive overcrowding, undernutrition and poverty as a result of climate change will likely increase the susceptibility of individuals to tuberculosis. (8,9)
Healthcare workers and healthcare facilities have a duty, not only to deal with these health-related impacts as they arise, but also to make significant efforts to reduce carbon emissions, and thereby reduce the effect climate change will have on human health. Many doctors and other healthcare professionals are not as well versed about the effects of climate change and its impact on human health compared to other public health matters such as smoking/tobacco use. (10) There is therefore a need to assess and address the knowledge gap of healthcare workers regarding climate change. If healthcare workers become more aware of the potential impact of climate change on health, they are more likely to become policy advocates and additional ambassadors in combatting climate change. (11)
Several international studies have attempted to assess this knowledge. (12,13) These studies have a strong bias towards the views of healthcare workers from developed nations, particularly the United States of America (USA) and Europe. Lastly, few studies have assessed how healthcare facilities are planning to reduce their carbon footprint or preparing for the additional health burden of climate change. (12–14)
Because South Africa, as well as the rest of Africa, is at significant risk for climate change related health issues, it is important to assess South African healthcare professionals’ knowledge and perspectives on climate change. To our knowledge there is no previous study that has assessed this specifically in South Africa. It is our belief that only after assessing the South African healthcare professionals’ knowledge and perspectives on climate change, can efforts be made to fill the knowledge gaps, thereby helping to initiate appropriate actions that will help mitigate the impact of the effects of climate change.
Methods
We designed a questionnaire (Supplement 1) for our survey which was conducted online, using Google Forms. Included in the questionnaire were health professionals’ demographics, views on climate change, perceptions on climate change and its impact on diseases as well as preparedness of healthcare systems for climate change. Participation was voluntary and confidential. Ethical clearance for the survey was obtained from the University of Witwatersrand Ethics Committee. The questionnaire was shared via two broad national platforms - amongst hospital/clinical social media groups as well as email lists. Healthcare professionals from public and private hospitals were targeted. The questionnaire was conducted in August 2022. Fisher's exact test was used to assess if there was an association between demographic information such as healthcare worker's age, profession or sector of employment and their perspectives on climate change and its effects on healthcare.
Results
We had 235 participants attempt the survey with 234 participants completing the survey. Unfortunately, due to the wide range of platforms the survey was shared upon, the average participation rate is unknown.
Of the 234 participants, 132 (56%) were in the 18-30 year age group. Of the remainder, 62 (26%) respondents were between 31-50 years and 40 (17%) respondents were older than 50 years (Figure 1).
The majority, 203 (87%) of the survey participants were doctors; 16 (7%) were allied professionals; 5 (2%) were medical students; 1 (0.4%) was a nurse and 9 (4%) were from other professions (Figure 2). Although most participants of the survey were doctors, there was no significant association between the different healthcare professions and their views on aspects of climate change. (Supplement Table 1)
With regards to general views on climate change, most of the survey participants, 226 (97%), believed that climate change was a reality; 5 (2%) respondents disagreed and 3 (1%) were unsure. Of note, 178 (76%) participants viewed climate change as being a man-made phenomenon, whilst 36 (15%) disagreed and 20 (9%) were unsure. 214 participants (91%) believed that we have the ability to reduce the negative effects of climate change, 10 disagreed (4%) and 10 were unsure (4%). Most participants, 217 (93%), believed that climate change will negatively affect them, their communities and their patients with 8 (3%) disagreeing and 9 (4%) being unsure. (Supplement Table 2) There was no significant association between age groups, healthcare profession or sector of employment and broad views on climate change.
Regarding the perceptions of climate change and health, almost two-thirds of respondents felt that waterborne diseases and malnutrition/food borne diseases would be severely affected by climate change; 60% and 62% respectively. Only 35% of respondents believed that respiratory illnesses, zoonotic infections, vector-borne diseases and mental health would be severely affected by climate change. Only 17% of respondents felt that non-communicable diseases would be severely affected by climate change (Figure 3).
Healthcare workers perspective on climate change as a negative contributor to different aspects of health
Of interest was that we found that the stance on the adverse effects of climate change on respiratory illness and non-communicable diseases was dependent on age, with the younger age group (18-30 years) feeling more concerned about respiratory illnesses than their older counterparts (p < 0.05) and the inverse being true with regard to non-communicable diseases, with the age group 50 years and older being more concerned about the impact of climate change on non-communicable diseases (p < 0.02). Views on other health related issues were independent of age.
With regards to views on their broad stance on climate change and health, there was no difference between public and private healthcare doctors. However, the stance on the adverse effect of climate change on non-communicable diseases was dependent in which health sector the health worker was employed. Those in the private sector were of the view that non-communicable diseases will be more severely affected by climate change (p < 0.05). All other opinions on the effects of climate change were not dependent on the type of health sector employment.
Most participants, 190 (81%), were not aware if or how their facility was adapting or changing to climate change, whereas only 27 (12%) were aware and 17 were unsure (7%). There was no significant association with age or healthcare profession, but public sector workers were significantly less likely to be aware as compared to healthcare workers in the private sector (p < 0.001). (Supplement Table 3). Given this, 184 of our participants (79%) believed that their facilities should be doing more in response to climate change, while 21 participants (9%) believed that their facilities should not be doing more, and 29 were unsure (12%).
Discussion
In concert with studies in the USA and Europe (12,13) and other multinational studies (14,15), South African healthcare workers demonstrate a similar level of understanding regarding their broad beliefs on climate change. A global multinational survey in 2021 found that 95% of healthcare workers believed that climate change is occurring while a lesser number (81%) believed climate change is entirely or mostly caused by humans (14), which mirrors data from our study.
In the current survey, although most respondents believe that climate change will adversely affect our communities, they also felt that there are changes we can make to mitigate against climate change. Our survey findings are similar to the views of climate specialists. (16) This serves as further evidence that South African healthcare workers are aware of climate change and its possible dangers.
Despite this there is still space for growth regarding education regarding climate change and health amongst healthcare workers. With greater knowledge, healthcare workers will be better prepared to tackle these threats as they arise in clinical practice, and many believe that climate change and environmental health education should be included in the medical curriculum. (17,18)
Climate change has the potential to affect many health-related issues. (4) The three health categories about which participants felt the most concern included malnutrition/foodborne diseases, waterborne diseases/other water related health concerns and morbidity and mortality related to extreme weather events. Although similar studies in developed nations also demonstrated a significant concern for harm from extreme weather events, there was less concern that food/waterborne diseases were a major health problem of climate change. (12–15) This is probably due to the high prevalence of these issues in South Africa and its potential to worsen with the effects of climate change. An example of this is the 2017 epidemic of Listeria monocytogenes in South Africa, which appeared to have a strong link to rising temperatures and water scarcity. (19,20)
Some of the health areas of lower concern amongst participants in our survey included non-communicable diseases and mental health. This finding was surprising as South Africa has some of the highest levels of mental illness internationally, likely related to high levels of gender-based and other forms of violence, poverty, crime, inequality, HIV and political turmoil. (19) Additionally, the rates of non-communicable diseases such as cardiovascular disease, renal disease and cancers have the potential to worsen with climate change. (21,22) This lack of concern is possibly due to a lack of knowledge and awareness regarding the link between climate change and these diseases.
Only one-third of respondents felt that zoonotic and vector infections would be severely affected by climate change. This is despite the world still recovering from the COVID-19 pandemic, a zoonotic pandemic. Climate and environmental changes, such as habitat disruptions, have accelerated the rate of emergence of zoonotic diseases worldwide. (5,23) Therefore, there is scope for better awareness in this area.
Although our data did demonstrate some differences in responses related to age groups, the majority of responses was not dependent on age. Some climate commentators believe that the younger generation are more concerned with climate action and protection, a view made more prominent with the prominence of climate activists such as Greta Thunberg. (24) In spite of this, a meta-analysis analyzing the environmental views of almost ninety thousand individuals indicated a negligible relationship with age. (25)
The United States contributes more than 10% of global carbon emissions, and one-tenth of emissions arise from their healthcare sector. (26) Healthcare workers, therefore, have a responsibility to make significant efforts to reduce carbon emissions within their own institutions. In our survey, 78% of respondents felt that their health facility should be doing more to mitigate against climate change but only 12% were aware of how their facility was adapting to climate change. Additionally, we found a disparity between those in the public and private healthcare sectors, with those in the private sector significantly more aware of the ways their facility was adapting to climate change. This is likely attributable to the greater financial resources in the private sector. Last year, a new R470 million Cintocare Hospital in Tshwane was unveiled as the first certified “green” hospital on the continent, and the fifth in the world. (27) Also, many of the major public health facilities are older with struggling infrastructure and inadequate resources. To our knowledge, very few public sector facilities in South Africa have made significant efforts to achieve energy neutrality.
Limitations
Unfortunately, due to the wide range of platforms used to reach maximal participant numbers, we were unable to measure the participation rate. We expected a higher response rate to the survey, but the length of the survey (only one month) may have influenced the overall participation rate. Although we set out to involve many healthcare professionals including nursing staff, allied medical staff and medical students, most of the respondents were doctors and thus this survey largely reflects the views of doctors. The study also involved several facilities, in which certain views and concerns may predominate.
Conclusion
Based on our survey, South African healthcare workers demonstrate reasonable knowledge regarding climate change and the effects it will have on healthcare. This knowledge base is very similar to that found in many other developed and high-income countries. However, there is still room to expand this knowledge. Through improvements in climate change and environmental health education, as well as increasing awareness and understanding amongst healthcare workers, there will be greater advocacy and transformation of our healthcare systems. Hopefully, we can then initiate and accelerate appropriate actions that will help mitigate the impact that climate change will have in various health settings in South Africa.