The AMA, despite its superficial support for action on warming, is a climate wolf in sheep’s clothing.
The Australian Medical Association represents slightly less than 30% of Australia’s doctors but is still our most prominent and influential medical group.
In 2019, the AMA released a position statement on Environmental Sustainability and Health Care which was an unambiguously positive contribution to the climate change debate. This month, Doctors for the Environment Australia (DEA) released a similar position statement entitled “Net Zero” which had some important upgrades on the AMA 2019 statement, and it is worth comparing the two policies, revisiting what the AMA included:
| AMA 2019 | DEA 2021 | |
| Declaration of climate emergency | Yes | Yes |
| Advising that Australia should establish a National Sustainable Development Unit (SDU) similar to that developed within England’s National Health Service | Yes | Yes |
| Recognition that Healthcare is responsible for up to 7% of Australia’s emissions | Yes | Yes |
| Advocate reductions of physical waste in the healthcare sector | Yes | Yes |
| Advising that healthcare providers (including hospitals) should shift to renewable energy for power | Yes | Yes |
| Recognition that climate change adversely impacts the health of the population (e.g. that a worsening climate leads to increased bushfires which impact on human health directly and indirectly via poor air quality) | Yes | Yes |
| Advising that Australia should spend more on health prevention and promotion to reduce the need for healthcare due to a healthier population | Yes | Yes |
| Healthcare sector should aim for net zero emissions by 2040 | No* | Yes |
| Healthcare sector should aim for 80% reduction in emissions by 2030 | No* | Yes |
| Recognition that certain areas of healthcare are responsible for disproportionately high emissions, and that these areas require the most urgent reform | No | Yes |
| Reduction of overall demand in healthcare sector by providing fewer actual services, particularly in emissions-heavy parts of the sector (hospitals, procedures, pharmaceuticals) | No | Yes |
The DEA policy certainly spells out far more explicitly that the healthcare sector must reduce emissions in what it refers to as Scope 1 (emissions that healthcare is directly responsible for). The AMA policy has far more of a focus on what the DEA policy calls Scope 2 and Scope 3 (e.g. asking for important reforms of, say, electricity providers upstream from health facilities).
The most telling and stark difference between the policies, as written, is that DEA now advocates an 80% reduction in healthcare emissions by 2030, albeit on March 18 this year the AMA agreed in a joint press release with DEA that a 80% reduction in health care emissions was required. Both the AMA and DEA have declared a climate emergency, but it is worth critical analysis of whether the AMA is actually treating the situation as an emergency. To get to an 80% reduction by 2030, radical reform of the healthcare sector is required immediately and on an ongoing basis. Upon further examination, the track record of the AMA on some of the necessary reforms is poor.
The lowest hanging fruit is easy to illustrate. A long-standing medical aphorism is that “only 50% of medical care is actually helpful, but we have to do it all because we don’t know what the 50% is”. Research over the last two decades has been very helpful at defining the extent of healthcare that is unhelpful (ineffective) or even harmful1. This is the healthcare that we immediately need to reduce/eliminate, particularly when a medical treatment is both ineffective/harmful and emissions-heavy.
An increasing number of emissions-heavy procedures have failed to show benefits over placebo in randomised control trials2-5. Some of the most prominent of these include knee arthroscopy6 7, shoulder arthroscopy/rotator cuff surgery 8 9, angioplasty for stable angina 10 11 and spinal fusion5. Yet all of these procedures are still generously funded by both Medicare and private health insurance in Australia, and all of these procedures continue to be widely performed.
The AMA has taken a general view of arguing against the majority of Medicare review reforms12, particularly those which might decrease funding support for (ineffective) procedures 13. All of the emissions-heavy and, now, discredited procedures are still supported by the AMA (as evidenced by still being referenced in their recommended list of fees) and wherever there has been attempts at reducing health system support for ineffective procedures, the AMA has always lobbied on behalf of the proceduralists who wish to continue the ineffective treatments. There are also many pharmaceuticals which are ineffective with the most blatant being the prescription of opiates for chronic non-cancer pain; a further area where the AMA has been slow to advocate for reform.
One of the flawed defences for retaining funding for ineffective treatments is that patients continue to want these treatments and there is nothing to replace them with. There is however another low hanging fruit as a replacement medical treatment that is both effective and carbon neutral: exercise prescription14. Exercise has been shown to be an effective treatment for almost all of Australia’s National Health Priority Areas, including cardiovascular disease, cancer, arthritis and back pain, depression, osteoporosis and diabetes15. Australia is lucky enough to have a (35-year-old) specialist college dedicated to exercise prescription within medical care: the Australasian College of Sport and Exercise physicians (ACSEP). But the AMA stubbornly refuses to officially recognise sport and exercise medicine (SEM) as a specialty, despite its official college status and government recognition for more than a decade in Australia. The AMA has actively lobbied to prevent SEM physicians from obtaining equitable Medicare rebates to other non-procedural physicians16, which was recommended by the SCPCCC of the MBS review17.
If ineffective medical treatments are analogous to coal, then exercise prescription by doctors is analogous to renewable energy sources. And sadly the AMA (by its actions rather than its words) is analogous to the reactionary politicians who support coal as an energy source but not renewables.
The governance of the AMA and its skewed membership is perhaps responsible for the AMA rejecting reforms which would both improve healthcare outcomes and reduce carbon emissions in the healthcare sector. The Federal Council of the AMA offers neither proportional representation nor a pure college-based representation. The AMA recognises only 11 of the 15 specialist colleges and then offers de facto college representation to the two biggest subspecialty groups – orthopaedic surgeons and paediatricians.
There are therefore 13 “specialty” groups given equal voting representation within the AMA, with only one specialty vote for general practice with the remaining votes for almost-exclusively hospital-based specialists. Sport and exercise medicine may have its own college, but it has no standing nor voting rights within the AMA; the standing of general practice within the AMA is dwarfed by the surrounding hospital/procedural specialists which are represented as the AMA’s core constituency. In defending ineffective emissions-heavy procedures and rejecting divestments from these areas into exercise prescription and primary care, the AMA is doing the bidding in looking after the finances of its core constituency. But in doing so, there is no chance of an 80% reduction in emissions by the healthcare sector by 2030.
The reforms suggested as essential by DEA will struggle to take place without the full support of the AMA in its specific lobbying, because the latter still retains its position as the most influential health lobby group 12. The AMA does contain champions of further action on climate change within its ranks, such as Nick Talley (Editor of the MJA) and Steve Robson (@DrSteveRobson) and has now stated that the health sector needs to radically reduce emissions. However, the resistance of the AMA to reform of the health sector away from emissions heavy and ineffective, but profitable, procedures and pharmaceuticals, remains a huge stumbling block to healthcare reform. The AMA, despite its superficial support for climate change action, can be characterised as a climate wolf in sheep’s clothing. To date, the AMA is talking the talk but not walking the walk on climate change. For the sake of the health of both the population and the planet, it needs to urgently change.
Dr John W. Orchard is an adjunct professor in the University of Sydney’s School of Public Health and a sports and exercise medicine physician.
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