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AMEE Consensus Statement: Planetary health andeducation for sustainable healthcare
Emily Shaw , Sarah Walpole , Michelle McLean , Carmen Alvarez-Nieto ,Stefi Barna , Kate Bazin , Georgia Behrens , Hannah Chase , Brett Duane ,Omnia El Omrani , Marie Elf , Carlos A. Faerron Guzmán , Enrique Falcetode Barros , Trevor J. Gibbs , Jonny Groome , Finola Hackett , Jeni Harden ,Eleanor J. Hothersall , Maca Hourihane , Norma May Huss , Moses Ikiugu ,Easter Joury , Kathleen Leedham-Green , Kristin MacKenzie-Shalders , DianaLynne Madden , Judy McKimm , Patricia Nayna Schwerdtle , Sarah Peters ,Nicole Redvers , Perry Sheffield , Judith Singleton , SanYuMay Tun & RobertWoollard
To cite this article: Emily Shaw , Sarah Walpole , Michelle McLean , Carmen Alvarez-Nieto ,Stefi Barna , Kate Bazin , Georgia Behrens , Hannah Chase , Brett Duane , Omnia El Omrani ,Marie Elf , Carlos A. Faerron Guzmán , Enrique Falceto de Barros , Trevor J. Gibbs , JonnyGroome , Finola Hackett , Jeni Harden , Eleanor J. Hothersall , Maca Hourihane , Norma MayHuss , Moses Ikiugu , Easter Joury , Kathleen Leedham-Green , Kristin MacKenzie-Shalders ,Diana Lynne Madden , Judy McKimm , Patricia Nayna Schwerdtle , Sarah Peters , Nicole Redvers ,Perry Sheffield , Judith Singleton , SanYuMay Tun & Robert Woollard (2021): AMEE ConsensusStatement: Planetary health and education for sustainable healthcare, Medical Teacher, DOI:10.1080/0142159X.2020.1860207
To link to this article: https://doi.org/10.1080/0142159X.2020.1860207
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AMEE Consensus Statement: Planetary health and education forsustainable healthcare
Emily Shawa, Sarah Walpolea,b,c , Michelle McLeand , Carmen Alvarez-Nietoe , Stefi Barnac, Kate Bazinf,Georgia Behrensg, Hannah Chaseh, Brett Duanei, Omnia El Omranij , Marie Elfk ,Carlos A. Faerron Guzm�anl, Enrique Falceto de Barrosm, Trevor J. Gibbsn, Jonny Groomeo, Finola Hackettp,Jeni Hardenq, Eleanor J. Hothersallr, Maca Hourihanes, Norma May Husst , Moses Ikiuguu ,Easter Jouryv , Kathleen Leedham-Greenw, Kristin MacKenzie-Shaldersd , Diana Lynne Maddeng ,Judy McKimmx , Patricia Nayna Schwerdtley, Sarah Petersh, Nicole Redversz , Perry Sheffieldaa ,Judith Singletonab, SanYuMay Tunac and Robert Woollardad
aNewcastle University, Newcastle Upon Tyne, UK; bNewcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK;cCentre for Sustainable Healthcare, Oxford, UK; dFaculty of Health Sciences & Medicine, Bond University, Gold Coast, Australia; eNursing,Universidad de Ja�en Campus de las Lagunillas, Jaen, Spain; fDepartment of Physiotherapy, King’s College London, London, UK; gSchoolof Medicine Sydney, The University of Notre Dame Australia, Sydney, Australia; hUniversity of Oxford, Oxford, UK; iSchool of Dentistry,Trinity College Dublin, Dublin, Ireland; jInternational Federation of Medical Students’ Associations, Copenhagen, Denmark; kSchool ofEducation, Health and Social Studies, Department of Nursing, Dalarna University, Falun, Sweden; lPlanetary Health Alliance, HarvardUniversity T H Chan School of Public Health, Boston, MA, USA; mUniversidade de Caxias do Sul, Caxias do Sul, Brazil; nAMEE, Dundee,UK; oGreener Anaesthesia & Sustainability Project, Great Ormond Street Hospital for Children, London, UK; pUniversity of Calgary, CFMSHealth and Environment, Lethbridge, Alberta, Canada; qUniversity of Edinburgh Usher Institute of Population Health Sciences andInformatics, Edinburgh, UK; rMedical School, University of Dundee, Dundee, UK; sIrish Society of Chartered Physiotherapists SpecialInterest Group for Healthcare Professionals in International Health and Development and Irish Red Cross Society, Dublin, Ireland;tHochschule Esslingen, Esslingen, Germany; uOccupational Therapy, University of South Dakota School of Health Sciences, Vermillion,SD, USA; vInstitute of Dentistry, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London,UK; wMedical Education Research Unit, Imperial College London Faculty of Medicine, London, UK; xMedical School, Swansea University,Swansea, UK; yHeidelberg Institute of Global Health, Heidelberg, Germany; zDepartment of Family & Community Medicine, University ofNorth Dakota School of Medicine & Health Sciences, Grand Forks, ND, USA; aaDepartments of Environmental Medicine and PublicHealth and Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA; abPharmacy, School of Clinical Sciences, Faculty ofHealth, Queensland University of Technology, Brisbane, Australia; acImperial College London Centre for Environmental Policy, London,UK; adFamily Practice, The University of British Columbia, Vancouver, Canada
ABSTRACTThe purpose of this Consensus Statement is to provide a global, collaborative, representative andinclusive vision for educating an interprofessional healthcare workforce that can deliver sustainablehealthcare and promote planetary health. It is intended to inform national and global accreditationstandards, planning and action at the institutional level as well as highlight the role of individualsin transforming health professions education. Many countries have agreed to ‘rapid, far-reachingand unprecedented changes’ to reduce greenhouse gas emissions by 45% within 10 years andachieve carbon neutrality by 2050, including in healthcare. Currently, however, health professionsgraduates are not prepared for their roles in achieving these changes. Thus, to reduce emissionsand meet the 2030 Sustainable Development Goals (SDGs), health professions education must equipundergraduates, and those already qualified, with the knowledge, skills, values, competence andconfidence they need to sustainably promote the health, human rights and well-being of currentand future generations, while protecting the health of the planet.The current imperative for action on environmental issues such as climate change requires healthprofessionals to mobilize politically as they have before, becoming strong advocates for majorenvironmental, social and economic change. A truly ethical relationship with people and the planetthat we inhabit so precariously, and to guarantee a future for the generations which follow,demands nothing less of all health professionals.This Consensus Statement outlines the changes required in health professions education, approachesto achieve these changes and a timeline for action linked to the internationally agreed SDGs. It repre-sents the collective vision of health professionals, educators and students from various health profes-sions, geographic locations and cultures. ‘Consensus’ implies broad agreement amongst all individualsengaged in discussion on a specific issue, which in this instance, is agreement by all signatories of thisStatement developed under the auspices of the Association for Medical Education in Europe (AMEE).To ensure a shared understanding and to accurately convey information, we outline key terms in aglossary which accompanies this Consensus Statement (Supplementary Appendix 1). We acknowledge,however, that terms evolve and that different terms resonate variably depending on factors such as set-ting and audience. We define education for sustainable healthcare as the process of equipping current andfuture health professionals with the knowledge, values, confidence and capacity to provide environmentallysustainable services through health professions education. We define a health professional as a person who
KEYWORDSEcological crisis; humanrights; planetary health;health professionseducation; sustainablehealthcare
CONTACT Sarah C. Walpole [email protected] Department of Infectious Diseases, Royal Victoria Infirmary, Queen Victoria Road,Newcastle, NE1 4LP, UK
Supplemental data for this article can be accessed here.Institutions at which research conducted: Home institutions of the authorsþ online collaboration� 2021 Informa UK Limited, trading as Taylor & Francis Group
MEDICAL TEACHERhttps://doi.org/10.1080/0142159X.2020.1860207
has gained a professional qualification for work in the health system, whether in healthcare delivery, publichealth or a management or supporting role and education as ‘the system comprising structures, curricula,faculty and activities contributing to a learning process’. This Statement is relevant to the full continuumof training – from undergraduate to postgraduate and continuing professional development.
Introduction
For millions of years, the Earth has sustained a diversity oflife on land and sea. Since the industrial revolution, humandevelopment has harnessed the power of fossil fuels andother natural resources and rapidly reshaped environmentsto meet our needs. The scale of urbanization, industrialagriculture and anthropogenic carbon emissions has, how-ever, led to a range of global environmental changes,including deforestation, biodiversity loss, ocean acidifica-tion and air, water and soil pollution and climate change(Frumkin and Haines 2019; Barna et al. 2020) – collectivelyreferred to in this Statement as ecological crisis.
Industrialization was generally enabled by Westernnations exploiting the Global South, in the form of colon-ization, mass enslavement and even genocide (Lewis andMaslin 2015). Present-day ecological crises that underminethe health of people across the globe are rooted in thepractices of colonialism and capitalism, in particular the six-teenth century colonization of the Americas, where thetrans-Atlantic enslavement of people and the homogeniza-tion of agriculture gave birth to plantation economies andglobal trade (Sealey-Huggins 2017). Over the past four cen-turies, the beliefs justifying the superiority of some humansover others also justified the exploitation of the planet’snatural systems. This violence lies at the foundations ofcontemporary global society and at the root of healthinequality. As such, the global ecological crisis we face hasits roots in, and perpetuates, deep ecological and socialinjustice. Furthermore, the ecological crisis will dispropor-tionately impact vulnerable groups such as those in theGlobal South, Indigenous Peoples and people of color(Thomas et al. 2019). Thus, the ecological crisis is deeplyintertwined with issues of inequity and human rights.
Humanity now faces an ecological crisis that threatensthe ecosystems on which we rely. The human population isexpected to increase to 8.6 billion people by 2030 andnearly 10 billion by 2050 (United Nations 2017), with con-comitant social and economic development increasingdemand on natural resources. We have been ‘mortgagingthe health of future generations’ (Whitmee et al. 2015;p.1973), expending resources at a far greater rate than theycan be replenished in nature, bringing us to a presentwhich has been termed the Anthropocene (Lewis andMaslin 2015; Weidmann et al. 2020).
To limit global warming to 1.5 �C, as per the ParisAgreement (United Nations General Assembly 2015), green-house gas emissions must be reduced by 45% (from 2010levels) by 2030 and to net zero by 2050 (IntergovernmentalPanel on Climate Change 2018). A 0.5 �C of warming (i.e.,from 1.5 �C to 2.0 �C) is expected to result in increased risksto health, food security, water supply, human security andlivelihoods. Climate change can increase the frequency offlooding, heat waves and natural disasters, all of which causeinjury and disease and may directly impact healthcare facili-ties. For H€ohne and colleagues (2020), a wasted decade has
shortened the timeframe to act: ‘In 2010, the world thoughtthat it had 30 years to halve global emissions of greenhousegases. Today, we know that this must happen in ten years tominimize the effects of climate change’ (p. 25).
Health systems are responsible for about 4.4% of theworld’s greenhouse gas emissions (Health Care WithoutHarm 2019). Healthcare is also responsible for a broaderenvironmental impact of between 1% and 5% of the totalglobal impact and more than 5% for some national impacts(Lenzen et al. 2020). Healthcare thus contributes to ill-health through emissions, which cause climate change andother environmental impacts including air pollution (e.g.through waste incineration) and water pollution (e.g.,through pharmaceutical waste) (Eckelman and Sherman2018; Health Care Without Harm 2019; Lenzen et al. 2020).The health professions therefore have a moral obligation totake action to reduce the environmental impacts of health-care provision. As well as working to mitigate further envir-onmental degradation, health professionals will need todevelop climate resilient healthcare facilities (WHO 2020) –equipped to anticipate, respond to and adapt to climateimpacts already underway such as altered patterns of dis-ease, threats to infrastructure due to changing weatherpatterns and psychological impacts. These will requireambitious and clear plans, with flexibility to monitor pro-gress and adapt as circumstances change.
Planetary health solutions
There are many cultural models for living in harmony withthe Earth, whilst also meeting humanity’s needs.Indigenous People across the world have long acted ascustodians of the environment, recognizing the interconnect-edness of all living things, including the impact of all ele-ments of the planet on well-being, health and spirituality.
Practice points� Health professionals must be prepared to deliver
system-wide changes to mitigate and adapt tothe ecological crisis.
� Education for sustainable healthcare (ESH)includes mainstreaming planetary health as atransversal curricular theme.
� Faculty development, eco-ethical leadership andtransdisciplinary and interdisciplinary planetaryhealth action are urgently needed.
� ESH guidance plus ESH learning and assessmentresources are already available.
� ESH accreditation standards, indicators and pro-gress monitoring are required.
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Western medical practice, often focused on the biomedicalmodel, has neglected this traditional Indigenous wisdom, wis-dom which can enhance our ability to promote planetaryhealth and ability to deliver education for sustainable health-care. Planetary health pertains to the interdependent vitalityof human and earth systems, both biological and sociallyconstructed. Education for sustainable healthcare necessarilyincorporates planetary health principles. Indigenous popula-tions have long held conceptions of planetary health(Indigenous traditional knowledge) and the interconnectednessof all beings on the planet (Redvers et al. 2020). Planetaryhealth is inclusive of all species and environments andemphasizes equally ‘all that is known about the world aroundus and how to apply that knowledge in relation to thosebeings that share the world’ (Bennett et al. 2014, p. 301).
Whilst each country has a unique context with regard toIndigenous Peoples and colonialist history, an increasedfocus on the interdependence of all life on Earth has appli-cation to health professionals across the world. This focusensures a health workforce that is informed about theinterdependence of ecosystems and health, prepared totackle social and ecological injustice and inequities andpossesses the skills, values and capabilities to respond.
Recognizing that development must protect andpromote human rights and be equitable and environmen-tally sustainable, the United Nation’s 2030 SustainableDevelopment Goals (SDGs) provide a framework for action atall levels – global, national, institutional and individual. Asthe ‘Accelerating Education for the SDGs’ Report describes,universities play a vital role in helping society to meet the2030 targets (Sustainable Development Solutions Network2020; UN 2020). Universities can facilitate ‘Education for theSDGs’ by equipping students with the knowledge, skills andmotivation necessary to tackle complex problems that weface as a society, such as the ecological crisis. They can alsomotivate learners to become active agents in workingtowards a sustainable future (Box 1).
To ensure a sustainable existence, we must addressinequalities, respect human rights and become stewards ofour planet’s limited resources. Raworth’s (2017) ‘Doughnutmodel’ is useful for depicting the social and ecological
boundaries that encompass human well-being which needto be preserved to promote ‘a safe and just space forhumanity’ (Figure 1). This requires us to challenge existingpower structures that often perpetuate overuse of resour-ces and exacerbate inequalities. For health professionalsspecifically, the values enshrined in the human rights dis-course have the potential to lead the way within the socialfoundation necessary for the health of our planet.
Role of health professionals
There is a growing recognition among health professionalsthat the current ecological crisis poses a major threat tohuman health and well-being. Many health professionalbodies have responded by declaring a climate crisis oremergency (e.g. WONCA World Organization of FamilyDoctors and International Council of Nurses) and callingfor environmental sustainability and resource stewardshipin healthcare (e.g. the World Medical Association,Environmental Physiotherapy Association and theAustralian Medical Association). Many health professionalsand their organizations are calling for action, includingdeveloping the evidence base on the interactions betweenenvironmental change and health, reducing negative envir-onmental and health impacts of health systems, educatingprofessionals, educating the public, lobbying policymakersand preparing health systems to manage the directimpacts of the ecological crisis (e.g. the WHO 2020Guidance for Climate Resilient and EnvironmentallySustainable Health Care Facilities document).
Health professionals can drive social and policy change(Haines and Ebi 2019) as they are generally highly trusted(Gallup poll 2019) and have influence at all levels of society.With trust comes responsibility to influence wisely and leadeffectively, which requires collaborative engagementbeyond individual actions, thus ‘Health professionals will becalled on to engage as humble, informed, and trusted part-ners in the collective, boundary-crossing effort of transform-ing practices and structures to better sustain the health and
Box 1. Targets and indicators for the three SDGs that include an education target, ratified by the UN General Assembly, July 2017.
Goal 4. Ensure inclusive and equitable quality education and promote lifelong learning opportunities for allTarget 4.7By 2030, ensure that all learners acquire the knowledge and skills needed
to promote sustainable development, including, among others, througheducation for sustainable development and sustainable lifestyles, humanrights, gender equality, promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and ofculture’s contribution to sustainable development
Indicator 4.7.1Extent to which (i) global citizenship education and (ii) education for
sustainable development are mainstreamed in:(a) national education policies(b) curricula(c) teacher education(d) student assessment
Goal 12. Ensure sustainable consumption and production patterns Indicator 12.8.1Target 12.8By 2030, ensure that people everywhere have the relevant information and
awareness for sustainable development and lifestyles in harmonywith nature
Extent to which (i) global citizenship education and (ii) education forsustainable development are mainstreamed in:
(a) curricula(b) national education policies(c) student assessment(d) teacher education
Goal 13. Take urgent action to combat climate change and its impacts Indicator 13.3.1Target 13.3Improve education, awareness-raising and human and institutional capacity
on climate change mitigation, adaptation, impact reduction andearly warning
Extent to which (i) global citizenship education and (ii) education forsustainable development are mainstreamed in:
(a) national education policies(b) curricula(c) teacher education(d) student assessment
MEDICAL TEACHER 3
well-being of all life, including our own’ (Parkes et al. 2020;p. 4).
Education has been identified as having an essential role inattaining the SDGs and stabilizing the Earth’s climate by 2050(Otto et al. 2020). Consequently, we must rapidly mobilizehealth professions educators to deliver education for sustain-able healthcare. Setting targets, developing indicators, andmeasuring and monitoring progress can help achieve changeacross the sector (Box 1).
This Consensus Statement explores how the health pro-fessions can and must prepare the health workforce, includ-ing healthcare leaders, to deliver on this agenda. In a recentsurvey of the inclusion of climate change and air pollution inthe medical curricula in more than 100 countries, only 15%of medical schools had included climate change and evenfewer had incorporated air pollution (El Omrani et al. 2020).These omissions further highlight the urgency as educationis considered one of the important tipping points for action(Otto et al 2020; McLean et al. 2020).
Vision for education for sustainable healthcare
The “responsibility for planetary health requires us to relinquishconventional professional, societal, and cultural partitions and todevelop contextual coalitions based both on science and broadercultural narratives” (Prescott and Logan 2019; p. 3).
The overarching education for sustainable healthcare visionis one in which positive changes to education, healthcare,public health and planetary health are achieved throughcollective, collaborative, non-hierarchical and inclusive
commitment and action. Our vision for education for sus-tainable healthcare emphasizes ecological accountabilitythrough environmental stewardship – (caretaking) of theliving planet – by health professionals and health and edu-cation institutions. It respects Indigenous knowledge interms of the link between people and the planet.Education for sustainable healthcare needs to ensure ahealth workforce that is informed about the interdepend-ence of the ecosystems and health, possesses the skills, val-ues and capabilities to drive change and is mobilized andmotivated to foster change.
In this Consensus Statement, we affirm the duty of allhealth professionals to protect and promote the health ofboth the planet and all of its inhabitants in the context ofhumanity’s complete dependence on the ecosystemswithin which we live (Prescott et al. 2018). We supportlearning that equips health professionals to meet this duty.We acknowledge that Indigenous People across the worldhave long acted as custodians of the environment, recog-nizing the interconnectedness of all living things, includingthe impact of all elements of the planet on spirituality,well-being and health. In line with this approach, healthprofessions educators need to highlight the complex chal-lenges related to the ecological crisis and how human livesand well-being are directly dependent upon the nat-ural world.
Education for sustainable healthcare practices are syner-gistic with promoting planetary health (Prescott et al.2018). Shared, evidence-informed practices can advancehealth and environmental sustainability, reduce healthinequalities, minimize the environmental footprint of health
Figure 1. Raworth’s (2017) Doughnut model of a regenerative and distributive economy within social and planetary boundaries (with permission).
4 E. SHAW ET AL.
systems and strengthen populations’ resilience to environ-mental change, thereby contributing to overall wellness forour communities while ensuring the continued existence ofall living organisms. For practitioners to be cognizant ofand responsive to planetary health requires not only rele-vant knowledge and skills, but also values. Education forsustainable healthcare engenders these values, such as pri-oritization of health equity, human rights and respect forlife and ecosystems. Figure 2 depicts the vision for educa-tion for sustainable healthcare in which knowledge andvalues guide practice, informed by Indigenous perspectivesand part of a wider planetary health paradigm.
This vision and Consensus Statement are guided byIndigenous traditional wisdom and connection to nature,informed by evidence on the safe operating space forhumanity and Raworth’s doughnut (Figure 1) and shaped
to align with the internationally agreed SDGs (Box 1). Thisdeveloping education for sustainable healthcare vision ispart of a growing positive response to the ecological crisisthat we are currently experiencing. It outlines some import-ant directions for healthcare institutions. We have anincreasing need for professionals, citizens and leaders—healers, if you will—who are able to adapt and movequickly to educate both existing and emerging practi-tioners to address our collective future and the well-beingof our shared home.
Enacting the vision
Our vision for education for sustainable healthcaredemands a shift from rhetoric to action. Action requiresunderstanding, acceptance and strategies for leading a
*Indigenous Peoples have incorporated this knowledge & these values for centuries; these points are informed by Indigenous perspectives, which can guide our understanding & our practiceSDG 4.7 – Ensure that all learners acquire the knowledge and skills to promote sustainable development, including through education for sustainable lifestyles, human rights, gender equality,
promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and of culture’s contribution to sustainable development.SDG 12.8 - Ensure that people everywhere have the relevant information and awareness for sustainable development and lifestyles in harmony with nature.
SDG 13.3 - Improve education, awareness-raising and human and institutional capacity on climate change mitigation, adaptation, impact reduction and early warning.
Practice principles & transferable skillsSystems thinking; Transdisciplinary collaboration; Indigenous place-based perspectives*Acting in harmony with nature* (SDG 12.8); Reflective practiceCollaborative planning & action to mitigate & adapt to the ecological crisis (SDG 13.3)
Evidenced-based practice; Integration of varied forms of knowledge; Dealing with complexity & uncertainty;Good governance; Accountability (SDG 4.7)
Skills for planetary health Epidemiology (disease, population size, ecology) – Building evidence base; Communicating knowledgePromoting healthy lifestyles (SDG 12.8) – Health promotion; Advocacy; Informing policySupporting pathways to net zero healthcare (SDG 13.3) – Sustainability literacy; Ecological & ethical allocation & use of resources; Sustainable quality improvement; Communication with colleagues & patientsEco-ethical leadership (SDG 4.7) – Promoting collaboration, Supporting emotional responses, Inspiring positive action
ValuesHarmony with nature* (SDG 12.8)
Respect for human rights & dignity* (SDG 4.7)
Equity & social justice*Responsibility for ethical resource use (SDG 12.8)
Challenging inequity & misuse of powerProfessional duty to protect health
Planetary Health
Education for Sustainable Healthcare
KnowledgeInterconnection of human & earth systems* Anthropocene & ecological crisis (SDG 13.3)
Urgency & scale (SDG 13.3)
Differential impacts of ecological changeNeed for mitigation & adaptationComplexity & unintended consequences
Figure 2. The relationship between planetary health, Indigenous perspectives and the knowledge, values and practices which are incorporated into educationfor sustainable healthcare.
MEDICAL TEACHER 5
major culture change – from the glorification of consump-tion and economic growth to working towards health andsustainability for all. Education for sustainable healthcareleaders require understanding of organizational behaviorand politics in the real world. Education for sustainablehealthcare encompasses environmental accountability asdefined by Pearson et al. (2015), the obligation to ensurethat education and research contribute to active develop-ment, promotion and protection of environmentally andecologically sustainable solutions (Boelen et al. 2016). Italso aligns with social accountability, the responsibility ofhealth education institutions to focus their considerableresources and capacity on the priority health concerns ofthe societies which they serve (Woollard 2006; Woollardand Boelen 2012; Boelen et al. 2016).
Health professions educators must aspire to facilitatelearning in a very different way and to incorporate environ-mental and ecological sustainability into curricula (Walpoleet al. 2017). Educators must also nurture transdisciplinaryproblem-solving to bring disciplines together to design cur-ricula to promote the best possible outcomes for patients,communities and the planet (Schwerdtle et al. 2020).Nurturing knowledge, skill development and values canmove learners and educators beyond despair to engage-ment (Walpole et al. 2016). Today’s health professionalsmust be equipped to respond to local and global environ-mental changes as urgent threats and address wide-ranginghealth, healthcare and sustainability challenges (Sterling2015; UNESCO 2014a). In such an emergency, eco-ethicalleadership is required (McKimm and McLean 2020; McKimmet al. 2020).
Leadership in a complex world
Health professionals work in multiple, overlapping, dynamicbiological, social and ecological VUCA (Volatile, Uncertain,Complex and Ambiguous) systems (Mack et al. 2015), withina nested hierarchy of domains, ranging from the personalto the family, community and national and internationallevels. In many Indigenous communities, the responsibilityto act as stewards for the planet is central (Greenleaf 2008)to pass it on in the best shape to generations who follow(McKimm and O’Sullivan 2016). This responsibility is notnew, but the current ecological crisis makes it urgent.
To achieve the education for sustainable healthcarevision, an ‘eco-ethical’ leadership approach, integratedaround environmental and ecological sustainability, val-ues, collaboration, justice, advocacy and activism,designed to address issues in complex systems must beapplied by health professions educators and incorporatedin learning (McKimm and McLean 2020). Eco-ethical lead-ership facilitates meaningful and sustainable changethrough understanding how people and systems workand interact to create change. Addressing sustainabilityissues can cause strong or overwhelming reactions instaff or students, which need to be recognized anddirected to appropriate sources of support (Tun 2019).Eco-ethical leadership enables translation of policy andstrategy into meaningful action and working with para-dox, uncertainty and ambiguity whilst retaining moralpurpose (Obolensky 2017).
Eco-ethical leadership must embrace an inclusiveapproach that welcomes diverse cultural views. From anIndigenous perspective, education for sustainable health-care can be seen as being rooted in the land as a medicineplace, i.e. a place that brings healing and greater overallwell-being (Redvers 2018). Health professions educationinformed by Indigenous knowledge systems recognizes theinterconnectivity of all life on the planet. This calls forinclusive leadership skills which cross existing boundariesand domains to foster innovation, effective engagementpractices and inclusiveness, while utilizing the strengths ofcollective intelligence (Kuenkel 2016).
Engaging facultyTo enact this vision, faculty engagement is essential. Facultymust recognize that addressing environmental and eco-logical issues is a matter of utmost urgency and should be acore priority for the health service as well as the duty of allhealth professionals. Sustainability literacy is essential if fac-ulty are to educate for sustainable healthcare, yet environ-mental concepts may not be familiar to all health professionseducators (Walpole and Mortimer 2017). Faculty develop-ment can help prepare and support faculty in assuming theirnew roles as sustainability educators. Key concepts in sus-tainability include causes of the ecological crisis, the healthimpacts and the ethical dimensions, sustainable healthcaredelivery and clinical practice (Tun et al. 2020).
Health professional students may already be familiar withenvironmental issues through knowledge acquired in theirsecondary school curriculum or the school Climate ChangeStrikes. Thus, they are ideally placed to partner with academ-ics not only by helping to integrate sustainability conceptsinto curricula but also by contributing to faculty develop-ment. To this end, student organizations have created resour-ces that can be used for curriculum planning and facultydevelopment, such as the International Federation of MedicalStudents’ Associations’ climate change short course and theCanadian Federation of Medical Students’ planetary healthcompetencies. In addition, Tun and colleagues’ (2020) MedicalTeacher Special Issue article provides case studies of studentcontributions to faculty development in planetary health andsustainable healthcare.
Institutional support is also essential. This can includeoffering continuing professional development and awardsfor innovation to incentivize progress. Those who developbest practice activities can be involved in training others.Institutions need to ‘walk the sustainability talk’ and, wherepossible, promote practices such as virtual and distancelearning to reduce the environmental footprint of travel.
Developing a curriculum that incorporates planetaryhealth and sustainable healthcare on campus, in thecommunity and in healthcare settings can enhance facultysatisfaction and self-efficacy (Brand et al. 2020; Tun et al.2020). Faculty development fosters in-depth learning and asense of meaningful interaction with others, both of whichmay improve personal and professional well-being in theface of our climate emergency.
Next, the Consensus Statement explores how healthprofessions education can be adapted to address theurgency of the ecological crisis we are currently facing.It outlines key knowledge, skills and values that healthprofessionals will need to be able practice sustainable
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healthcare and suggests pedagogies and assessment strat-egies. We acknowledge, however, that the knowledge, skillsand values required to practice sustainable healthcare willvary across the world and by profession.
Sustainability literacy, skills and valuesDrawing on the education for sustainable healthcare vision,this section describes what health professionals need tolearn, be able to do and what values they should espouse.While we need to collaborate across health disciplines inline with clinical practice (Schwerdtle et al. 2020), weacknowledge that one size does not fit all and each institu-tion needs to tailor the integration depending on its localneeds – ‘think globally, act locally’. The learning outcomesin Table 1 have been adapted from the Centre forSustainable Healthcare to include skills and values. Higherorder activities, such as ‘apply’ and ‘evaluate’ are essentialto ensure learners are prepared to make a difference in thereal world (Adams 2015). While it is important for healthprofessionals to acquire and apply knowledge and learnskills and appropriate professional behaviors, it is equallyimportant that educators consider the role of values andemotions. Values-based education helps prepare healthprofessionals to work towards the SDGs. The affective(emotion-based) components of learning and responses tolearning (including eco-anxiety) must be supported(Burford et al. 2016; Huss et al. 2020). As the field is con-stantly evolving, professionals need to actively engage incontinuing professional development to ensure life-longlearning (Field 2010). Equity and human rights must becentral to this framework. There must be an awareness ofhow the ecological crisis disproportionately affects certainpopulations, including Indigenous groups, communities ofcolor, the elderly and the young, rural communities, peopleliving with long-term conditions and disabilities and withlow incomes.
In Table 1, we offer suggestions and examples of curricu-lum planning and delivery of education interventions thatcan be adapted for local contexts. Sustainability should beintegrated across all years of the curriculum rather thanbeing a series of stand-alone or add-on elements. A firststep to integration is to identify core education for sustain-able healthcare learning outcomes and map these to localcurricula, professional competencies or other relevantframeworks (NurSus Interim Report 2015; Lopez-Medinaet al. 2019, Tun 2019; Table 1). Introducing practical learn-ing experiences in sustainable healthcare early in trainingemphasizes these concepts and principles as core compo-nents of professional identity (Prescott et al. 2018). Giventhe complexity of the ecological crisis, a transdisciplinaryapproach to learning is essential (Schwerdtle et al. 2020).This transdisciplinary focus bridges traditional dividesbetween disciplines to ensure collective vision, problem-solving and action.
We thus advocate experiential, transdisciplinary learningthat engages individuals in activities that require criticalthinking, communication, leadership and change manage-ment (Table 2). At its best, education for sustainablehealthcare will draw on personal experiences, stimulate dis-covery, encourage problem-solving and be relevant tolearners’ future health professional roles. Learning activitiesassist with progressing from understanding how the eco-logical crisis impacts health to creatively addressing prob-lems, including local and global interventions that not onlyinvolve adaptation and development of resilience, but alsoreduce the environmental impact of healthcare throughresource stewardship and education of patients on topicssuch as the co-benefits of exercise and plant-based diets.
AssessmentAssessment can motivate students to learn (Miller 1990).Thus, to ensure that health professionals gain the essential
Table 1. Learning outcomes and objectives for environmentally sustainable healthcare and associated domains of learning, adapted from the Centre forSustainable Healthcare (Thompson et al. 2014) and the 2020 Sustainable Development Solutions Network Guide.
Learning outcomes Learning domain Examples of specific learning objectives
Describe how the environmentand human health interactat different levels.
Knowledge � Discuss how local and global ecological crises impacts on individual patients andcommunities.
� Describe the interaction between local and global ecological crises and the socialdeterminants of health.
� Discuss how the promotion of environmental sustainability generally and in healthcarecan support progress on social determinants of health, health equity and respect forcultural diversity, including Indigenous traditional knowledge.
Demonstrate the knowledgeand capabilities needed toimprove the environmentalsustainability of healthsystems, using systemsthinking (see Glossary inSupplementary Appendix 1)
Knowledge, Application � Evaluate the environmental impacts of a patient pathway and identify ways to enhanceenvironmental sustainability.
� Describe how changes in disease burden due to environmental change may be identified,characterised and quantified and how such information can inform planning and practiceto address health needs.
� Apply key policies and frameworks related to sustainable development including theSDGs to evaluate a population health challenge.
� Apply critical thinking, problem-solving and systems thinking to sustainablehealthcare challenges.
� Communicate clearly with health professional colleagues when responding to anecological challenge or opportunity in healthcare.
Discuss how the duty of healthprofessionals to protect andpromote health is impactedby the interdependence ofhealth and ecosystems andimplications for healthprofessionals’ personal andprofessional lives.
Knowledge, Values,Mindset and Agency
� Discuss the role of health professionals in mitigation, adaptation, advocacy and activismin terms of sustainable development, planetary health and environmental stewardship.
� Demonstrate the ability to advocate for planetary health and the SDGs.� Demonstrate how to motivate behaviour change to promote environmental sustainability
at an individual, professional and community level.� Discuss examples of eco-ethical leadership.� Identify how Indigenous traditional knowledge and voice can inform healthcare practice
and promotion of planetary health and sustainable development in your local context.� Apply an ethical, compassionate, non-hierarchical and holistic approach to addressing the
ecological and social determinants of health.
MEDICAL TEACHER 7
Table2.
Exam
ples
oflearning
activities,o
pportunitiesandpo
ssible
assessmentapproaches
that
prom
otetransdisciplinary,actio
n-basedlearning
andtheinvolvem
entof
multip
lestakeholders
(SDSN
2020).
Learning
activity
Exam
ples
Opp
ortunities
Possible
form
ativeandsummativeassessments
Rubricsforalla
ssessm
entscanbe
developed
basedon
intended
learning
outcom
esand
enhancevalidity
ofassessment.
Activitieswithaclinical
focus
Environm
entalh
istory
incommun
ication
skillstraining
Inarole
play,takeahistoryfrom
apatient
who
hasbeen
affected
bybu
shfire
smokeor
hasdiarrhea
asaresultof
limitedor
noaccess
tocleanwater.
�Prom
oteattentionto
ecolog
ical
andsocial
determ
inants
ofhealth.
�Practisesensitive
enqu
iryabou
triskfactors.
�Integratesustainabilitywith
historytaking
skills.
�Ad
dressSD
G3(promotionof
health
andwell-b
eing
forall).
Form
ative–ob
served
role
play
Summative–OSCEhistorystation;
MCQ
s&
SAQsregardingenvironm
entalriskfactors
Lifecycleanalysisof
common
medical
resources
Investigateusingpeer
review
edliteratureand/or
grey
literature(e.g.p
rodu
ctinform
ation,
health
system
data)thesocial,enviro
nmentaland
financial
costsof
equipm
entandmedications
common
lyused
inhealthcare.D
iscuss
theimplications
ofthesecostsforhealthcare
planning
and
healthcare
practice.
�Create
awarenessof
theecolog
ical
footprintof
medical
equipm
entfrom
manufacture
todisposal.
�Raisediscussion
abou
tethicalissuesrelatedto
consum
ption,
e.g.
miningformetals/elem
ents
anddism
antling
ofmedicaldevices
oftenhapp
ensin
low
andlow-m
iddleincomecoun
tries.
�Ad
dressSD
Gs12
(sustainable
consum
ptionandprod
uctio
n),1
4(life
below
water)and15
(land
andbiod
iversity
protectio
n).
Form
ative–ob
servationof
grou
pactivity,o
ral
assign
ment,discussion
inclinical
practice
Summative–writtenor
oral
assign
ment,
MCQ
sor
SAQsabou
tmeasurement
metho
dsor
relativecosts.
Conceptmapping
exercise,ind
ividualo
rgrou
p,may
betransdisciplinary
Research
theenvironm
entalimpactsof
care
provided
with
inon
ehealthcare
specialty.U
segraphicaltoolsto
demon
strate
where
environm
entalchang
emay
alterdiseasebu
rden
andhealthcare
seekingandwhere
healthcare
may
impact
onecosystems.Co
nsider
how
causes
andeffectsinteract
andvaried
driversof
costssuch
asgreenh
ouse
gasem
ission
sandnegativeimpactson
patients’em
ploymentor
social
supp
ort.
�Prom
oteun
derstand
ingof
ecolog
icalandsocial
determ
inants
ofhealth
�Ap
plysystem
sthinking
.�
Creativeactivity
engageslearnersandfacilitates
activelearning
.�
AddressSD
Gs3,
12,1
3(clim
ateactio
n),1
4and15.
Form
ative–assessmentof
process,reflections,
ortheconceptmap
prod
uced.
Summative–assessmentof
theconceptmap
prod
uced
usingarubricbasedon
key
learning
outcom
es.
Practicing
commun
icatingwith
patientsabou
tenvironm
ental
sustainabilityand
health
prom
otionin
commun
ication
skillstraining
Inarole
play,d
iscuss
with
apatient
amoreenvironm
entally
sustainable
interventio
nthat
canprovideequivalent
(orgreater)health
benefitsthan
thealternative,e.g.:
�Options
with
lower
environm
entalimpact,e.g.d
rypo
wderinhalersover
metered
dose
inhalers
(asthm
apu
mps)
�Lifestylechangesandtheco-benefits,i.e.reducingenvironm
entalfootprin
tandimprovehealth,e
.g.redu
cing
meatintake
andincreasing
grainand
vegetableintake;w
alking
orcyclingrather
than
driving.
�Facilitatelearning
abou
thealth
co-benefits� o
fsustainable
lifestyles,e.g.
sustainablediets,increasedexercise.
�Facilitatelearning
abou
tenvironm
entalimpactsof
healthcare
interventio
ns.
�Develop
motivationalinterview
ingskills.
�Ad
dressSD
Gs3and12.
Form
ative–Direct
observationof
role
play.
Summative–OSCEcommun
icationskills
station;
MCQ
s&SA
Qsabou
trelevant
evidence,e.g.h
ealth
co-benefits,carbo
nimpactsof
healthcare
interventio
ns,and
/or
relatedethicalissues.
Health
care
pathway
analysisactivity
Exploreon
epatient
pathway
(e.g.thattakenby
apatient
presentin
gto
primarycare
with
abdo
minal
pain
andreferred
tosecond
arycare),and
consider
how
toapplyprinciples
ofsustainablehealthcare,including
:�
Avoiding
investigations
that
dono
taddvalue,(e.g.imagingno
trecommendedforlow
back
pain
unless
neurolog
ical
damageissuspected)
�Avoiding
interventio
nswhere
aconservativeapproach
isbeneficialo
requivalent
andlower
financial
orsocial
cost
(e.g.w
atch
andwaitapproach
forherniascanbe
preferable)
�Ch
oosing
lower
carbon
optio
nswhich
areequivalent
inhealth
benefits,e.g.
anaesthetic
gaseswith
less
glob
alwarmingpo
tential
�Calculate(orapplycalculations
of)thefin
ancial,sociala
ndenvironm
entalcosts
ofhealthcare
provision
�Und
erstandtheintegration(orlack
ofintegration)
ofdiffe
rent
healthcare
services.
�Co
nsider
patient’sexperiences
ofaccessinghealthcare
andtake
thisinto
accoun
twhenevaluatin
gahealthcare
pathway.
�Identifystrategies
toachievebo
thsustainabilitygainsand
improvem
ents
inhealthcare.
�Ad
dressSD
Gs12,1
3,14
and15.
Form
ative–Observedgrou
pwork,grou
ppresentatio
n,individu
alreflectivepractice
assign
ment
Summative–grou
ppresentatio
n,written
assign
ment(group
orindividu
al)
Qualityimprovem
ent
projects
inprimaryor
second
aryor
high
erlevelsof
care
ApplytheSusQI(Sustainabilityin
QualityImprovem
ent)fram
ework(M
ortim
eret
al.2
018)
toplan
anddeliver
aproject,e.g.
abou
tmedicines
waste.
�SusQIframew
orkcanbe
appliedin
diffe
rent
contexts
tofocuson
localn
eeds
andresources.
�Clearly
linkenvironm
entaltop
icsto
clinicalpractice.
�Integrateenvironm
ental,social,cultural,fin
ancialandethical
perspectives.
�May
addressanyor
allS
DGs.
Form
ative–supervisor’srepo
rt,learner’s
reflectiverepo
rt.
Summative–repo
rt,p
oster,oralor
other
presentatio
n.
(continued)
8 E. SHAW ET AL.
Table2.
Continued.
Learning
activity
Exam
ples
Opp
ortunities
Possible
form
ativeandsummativeassessments
Rubricsforalla
ssessm
entscanbe
developed
basedon
intended
learning
outcom
esand
enhancevalidity
ofassessment.
Activitieswhich
may
have
aclinical,p
ublic
health
orwider
sustaina
bilityfocus
Literature-based
individu
alor
grou
presearch
projectand
presentatio
n
Research
andcommun
icatebest
evidence
onaplanetaryhealth
topic.The
SDGsofferauseful
fram
eworkwhich
couldinform
thechoice
oftopicor
approach
toaddressing
it.Learners
may
choose
toprod
uceavideoto
commun
icateon
theirtopicor
useanotherform
at.
�Practiseanddemon
strate
effectivecommun
icationwith
colleaguesor
thepu
blicabou
tplanetaryhealth.
�Learners
may
choose
atopicof
person
alinterest.
�Ifvideopresentatio
nisused,learnersmay
developdigital
techno
logy
skills.
�May
addressanyor
allo
ftheSD
Gs.
Form
ativeor
summative–Assessmentof
the
presentatio
nmay
becarriedou
tusinga
rubricbasedon
keylearning
outcom
es.
Writtenassign
ment,
inform
edby
aliteraturereview
Designan
assign
mentqu
estio
nor
select
from
alistof
questio
nsaddressing
anyplanetaryhealth
topic.Co
nstructawrittenargu
mentin
respon
seto
thequ
estio
n.
�Develop
skillsforevidence
basedpractice,includ
ingcritical
appraisala
ndsynthesizing
complex
and/or
diverseinform
ation.
�Dem
onstrate
effectivewrittencommun
icationabou
taplanetary
health
topic.
�In-depth
learning
onachosen
planetaryhealth
topic.
Form
ativeor
summative–Arubricfor
marking
assign
ments
may
includ
eun
derstand
ingof
topic,developm
entof
argu
mentandwrittencommun
ication.
This
assessmentmay,h
owever,b
etim
e-consum
ingwith
largecoho
rts.
Research
assign
ment
involvinglocalo
rglob
alcommun
ities,
preferably
transdisciplinary
Ascenario
orchalleng
ethat
allowslearnersto
exploretherelatio
nship
betweenon
eor
moreecolog
icalcrises,sociald
eterminants
ofhealth
and
inequality,e.g.
exploringho
wmarginalized
Indigeno
uscommun
ities
experiencetheseissues,o
rinvestigatinggend
erinequality.
Participatoryresearch
(with
notaboutcommun
ities)wou
ldbe
anidealw
ayto
achievedeeper
learning
iftim
eandstructures
tosupp
ortethicalresearch
arein
place.
�Develop
qualitativeresearch
skills.
�Participatoryresearch
may
prom
oteem
pathyandadvocacy.
�Learners
may
focuson
anarea
ofperson
alinterest.
�Learners
may
form
lastingconn
ectio
nswith
stud
ents
from
other
disciplines;theymay
mutually
supp
orteach
otherto
implem
ent
positivechange.
�Mirrorsteam
workin
clinicalpractice.
�Learnermay
exploreseveralS
DGs,e.g.
1(alleviationof
poverty),5
(genderequality)
and13
(clim
ateactio
n).
Form
ative–ob
servationof
team
working
,learnersprovidefeedback
onother
presentatio
ns,w
rittenreflections
onlearning
.Summative–research
projectwrite-up
asconference
presentatio
nor
journala
rticle.
Debate,preferably
transdisciplinary
Preparean
argu
mentanddebate
amotion,
which
couldbe
abou
t:�
-profession
aldu
ty–therole
ofhealth
profession
alsin
advancing
sustainabledevelopm
entthroug
hresource
stew
ardship,
�-an
ecolog
ical
justiceissuesuch
astheimpact
ofrisingsealevelson
Small
Island
Nations
�-respon
ding
toasustainabilitychalleng
e,e.g.
thelinkbetweenpand
emics
andenvironm
entalfactors.
�-an
ethicalissue,e.g.single-useitemsin
health
care,o
rtheglob
albu
rden
ofdiseasecaused
bythehealth
sector
emission
s.
�Practicedeveloping
anevidence-based
view
point.
�Engaging
form
atto
encourageengagement.
�Prom
otes
commun
icatingeffectivelywith
colleaguesfrom
diffe
rent
health
profession
sandaddressing
resistance
orconflict.
�Allowsengagementwith
emotionally
challeng
ing,
ethicala
nd/or
politicalissues.
�Learners
may
form
lastingconn
ectio
nswith
stud
ents
from
other
disciplines;theymay
mutually
supp
orteach
otherto
implem
ent
positivechange.
�May
addressvario
usSD
Gsdepend
ingon
debate
topic.
Form
ative–ob
servationof
team
working
inpreparationor
durin
gdebate.
Summative–ob
servationof
debate
presentatio
nsandcontrib
utions
using
assessmentrubric,e
ssay
arou
ndthedebate
questio
n,MCQ
sor
SAQson
the
debate
topics.
Smallg
roup
public
health
learning
scenario,p
referably
interprofessionalo
rtransdisciplinary
Use
system
sthinking
todesign
apu
blichealth
strategy
forascenario
(individu
alpatient
orcommun
ity)addressing
anecolog
icaleventor
crisis
andits
impactson
health
and/or
healthcare
facilities,e.g.:
�Respiratory
diseaselinkedto
locala
irpo
llutio
n�
Forced
migratio
ndu
eto
sealevelrise
�Bu
shfirecausingdestructionof
alocalh
ealth
post
�Climate-indu
ceddrou
ghtandfood
insecurity
�Ecolog
ical
crisiscausingeco-anxiety�,g
rief,depression
andsuicide,
particularlyam
ongyouth
�Stimulates
discussion
abou
thealth
profession
als’rolesin,e.g.
redu
cing
healthcare’senvironm
entalfootprin
tandadvocacy.
�Scenarioscanbe
design
edbasedon
locale
cologicala
ndpu
blic
health
challeng
esto
prom
oteengagement.
�System
sthinking
explores
interactions
betweendiffe
rent
partsof
asystem
andpo
tentialu
nintendedconsequences
ofagiven
respon
se.Learnerscanthen
applyitto
othersettings
andchalleng
es.
�Opp
ortunity
toprom
otetransdisciplinarycollabo
ratio
n.
Form
ative–ob
servationof
discussion
orpresentatio
nby
smallg
roup
.Summative–usingrubricto
assess
small
grou
pworkor
agrou
ppresentatio
nof
discussion
andsolutio
nsidentified,
written
repo
rtof
learning
.
Reflectiveassign
ment
Exploreperson
al,p
rofessionala
nd/orethicalchalleng
es,e.g.single-useplastic
equipm
entin
term
sof
sustainablelifestylesandglob
alcitizenship
orin
relatio
nto
healthcare
practice.Read
relevant
articles,consider
how
the
issues
arefacedin
your
dayto
daylifeandmay
affect
currentor
future
choices.Writean
essayor
collectionof
shortreflections
onthisprocess.
�Facilitateengagementwith
person
alvalues,feelings
and
attitud
es,w
hich
may
lead
tomindset
andbehaviou
ralchang
es.
�Identifyandexploretensions
which
may
enhanceability
toun
derstand
diverseperspectives
�Practicewrittencommun
icationregardingchalleng
ingand
sensitive
issues
�May
addressanyor
allS
DGs.
Form
ative–po
rtfolio
entries
Summative–po
rtfolio
entriesor
essayto
meetparticular
domainrequ
irements,e.g.
profession
al,advocacy.
� See
Supp
lementary
Append
ix1(Glossary).
Abbreviatio
ns:ESH
:edu
catio
nforsustainablehealthcare;M
CQs:multip
lechoice
questio
ns;O
SCE:ob
jectivestructured
clinical
exam
ination;
SAQs:shortansw
erqu
estio
ns,SDGs:SustainableDevelop
mentGoals.
MEDICAL TEACHER 9
knowledge and develop the appropriate skills and valuesto advance sustainable healthcare, assessment must notonly be constructively aligned with education for sustain-able healthcare learning outcomes, but must be authentic(Gulikers et al. 2004), acceptable, fair and cost-effective(Norcini et al. 2018).
Assessment must test competence in understanding andapplying broad and complex planetary health concepts ata global and a local level. Competence in the cognitive(i.e., knowledge) and psychomotor (i.e. manual skills)domains can generally be ‘measured’ using standardizedassessment instruments such as multiple-choice questionsor Objective Structured Clinical Examinations (OSCEs).Assessment of the complex concepts and the affectivedomain is more difficult and is generally considered moresubjective (Smith et al. 2007). As the global communityincreasingly faces complex problems that impact on ourhealth and well-being, e.g., ecosystem disruption, climatechange, pollution and pandemics such as COVID-19, assess-ment of competency needs to accommodate creative solu-tions to these complex problems and differences in valuesor perspectives.
Thus, to educate fit-for-practice health professionals,assessment not only tests acquisition of knowledge butalso its application. Learning is not only about knowingbut also about ways of ‘being’. If the aim of assessment isto drive the appropriate learning, then reliability is onlycritical in ‘high stakes’ scenarios where there are progres-sion implications. Assessment can be more developmentalthan judgmental (i.e. for, rather than of, learning). Todevelop skills and values to mitigate and address planetaryhealth challenges, we need more authentic approachesthat allow multiple views of a learner’s progress and alsoprovide opportunities for individual creativity (Feltovichet al. 1993) while fostering the appropriate values (e.g.empathy and advocacy) and behavior (e.g. activism).Finally, assessment communicates what is valued by a pro-fession (Boud 2000).
Professional bodies should include assessment of educa-tion for sustainable healthcare learning outcomes. Table 2provides a range of assessment approaches with sugges-tions for ensuring students achieve the required competen-cies in education for sustainable healthcare.
Practical recommendations for implementing andevaluating education for sustainable healthcare
This section presents specific recommendations to enact theeducation for sustainable healthcare vision, including indica-tors to monitor progress and a road map for implementation,including specific, time-bound recommendations (UNESCO2014b). Further resources to support implementation areavailable in Supplementary Appendix 2.
Proposed indicators for education forsustainable healthcare
Few targets and indicators for the inclusion of educationfor sustainable healthcare exist (Madden et al. 2020). ThreeSDGs include a target and a linked indicator relevant toeducation for sustainability (Box 1). An international med-ical student initiative has recently produced a set of
indicators to assess the progress of medical schools inincorporating planetary health (https://phreportcard.org/our-metrics/). Other examples of indicators address onlyone aspect (e.g., climate change) of many environmentalchanges that impact health and well-being. For example, inAustralia, the MJA Lancet Countdown recently added a newindicator to monitor The inclusion of health and climatechange in medical curricula (Beggs et al. 2019). Annualreporting will commence in 2021.
How can targets and indicators help? By measuring andmonitoring what we do, we can identify whether strat-egies and interventions to create change are effective.Well-constructed indicators also provide a tool for commu-nication about progress and can inform change. Indicators,where they exist, can also inform us whether institutionsare meeting accreditation requirements for education forsustainable healthcare. Targets and indicators are bestrefined in consultation with the community of practice(Navi et al. 2017). There is thus a need for engagement ofthe health professional community to use existing indica-tors but also develop new robust indicators to measureand monitor progress.
Proposed targets for education forsustainable healthcare
Table 3 provides recommended targets for educators, healtheducation institutions, health professions regulators andhealth professional organisations. For example, accreditationstandards for the regulated health professions should reflectthe environment and climate change as determinants ofhealth and the responsibility of health professionals to prac-tice environmentally sustainable healthcare. Health profes-sional organizations, from trade unions to internationalorganizations such as AMEE, can play a role. Organizations’scope, skills and mandate vary greatly and some or all of therecommendations may be applicable. When organizationsdevelop and enact a plan to reduce the environmentalimpacts of healthcare, this models good practice and can bean aspect of eco-ethical leadership. ‘Eco-ethical’ leadershipalso involves embracing and welcoming diverse culturalviews, advocacy and role modelling (McKimm andMcLean 2020).
Concluding commentsOver the year-long development of this ConsensusStatement, there has been wide and inclusive consultationacross health professions, representing many countries, andreflecting the insights of Indigenous Peoples whose trad-itional knowledge and voices have largely been marginal-ized. This Consensus Statement reflects the currentsituation and is by no means exhaustive. Its primary purposeis to create an awareness of the important role of health pro-fessions educators and health professional institutions inadvancing environmental accountability and to offer somedirection for those who are new to this space. While thisConsensus Statement focuses on education for sustainablehealthcare, the broader lens of planetary health is particularlyrelevant to health professionals, to ensure an inclusive,respectful, collaborative, transdisciplinary response to address
10 E. SHAW ET AL.
Table3.
Prop
osed
road
map
andrecommendedtargetsforeducationforsustainablehealthcare
(ESH
).
Focusarea
Educator
College/school
Health
profession
alaccreditatio
nbo
dyNationalor
internationalh
ealth
profession
alorganizatio
n
Eco-ethicalleadershipinclud
esenvironm
ental
accoun
tability,mod
elling
good
practiceand
supp
ortin
geco-ethical
leadership
developm
ent
�Identifywhether
your
institu
tionhasa
sustainabilitystrategy
andan
ESHplan.
�Co
ntactthedirector
ofyour
institu
tion
oranotherapprop
riate
colleague
toprop
oseho
wyoucouldcontrib
uteto
existin
gplan
ordevelopaplan
forESH.
�Co
ntrib
uteto
developm
entof
acommun
ityof
practiceforESH.
�Allow
spaceforand/or
open
discussion
swith
colleaguesand
stud
ents
todiscussem
otional
respon
sesto
planetary
health
challeng
es.
�Prop
osethat
your
institu
tionsign
sup
totheSD
Gsifithasno
talready.
Early
2021:State
acommitm
entto
ESH,e
.g.Schoolo
fNurses’commitm
entto
ClimateCh
alleng
e(sup
plem
entary
Append
ix2)
2021:D
evelop
aplan
tointegrateplanetaryhealth
across
curriculaandyour
institu
tion,
inlinewith
SDGs4,
12and13.
�Involvediverseexpertsandstakeholders,including
Indigeno
usPeop
lesandotherpo
pulatio
nsdispropo
rtionatelyaffected
bytheecolog
icalcrisis,in
theinitiation,
developm
entanddeliveryof
ESH.
�Facilitatethedevelopm
entof
acommun
ityof
practiceto
supp
ortESHdevelopm
ent.
�Providespace(in
clud
ingph
ysical
space&curriculum
space)
tosupp
ortthedevelopm
entof
emotionalresilience.
�Workwith
localp
artnersto
prom
oteenvironm
ental
accoun
tability(Box
1),p
rogresstowards
theSD
Gs
andplanetaryhealth.
�Use
virtual/d
istance/remotelearning
toredu
cetravel
where
approp
riate.
2021:P
ublishaform
alstatem
ent
supp
ortin
gactio
non
planetaryhealth
byhealth
profession
alsin
training
,health
profession
alsandhealth
profession
alorganizatio
ns.
2021:D
evelop
asustainabilityplan
foryour
ownorganizatio
n,includ
ingastrategy
andtim
elineto
reachnet
zero
emission
s.
2021:P
ublishaform
alstatem
entcalling
for
urgent
integrationof
sustainabilityand/
orplanetaryhealth
into
allh
ealth
profession
alcurriculaacross
the
spectrum
oftraining
,from
undergradu
ateto
continuing
profession
aldevelopm
ent.
2021:M
easure
theenvironm
entalfootprin
tof
your
organizatio
nanddevelopand
publishaplan
toreachnetzero.
�As
ahealth
leader,advocateforpo
licies
andpractices
that
supp
orttheSD
Gs
andprom
oteplanetaryhealth.
Contrib
uteto
faculty
developm
ent
�Read
keyreferences
toadvanceow
nknow
ledg
e(sup
plem
entary
Append
ix2)
�Initiateconversatio
nsabou
tESHwith
colleagueswho
youhave
notdiscussed
sustainabilitywith
before
–on
ewith
inyour
field
andon
ewith
inanother
profession
/department.
2021:P
rovide
initialfaculty
education.
2022:P
rovide
guidance,trainingandresourcesso
that
all
faculty
mem
bersun
derstand
how
sustainabilityrelates
totheoverallcou
rse,includ
ingassessment.
2024:LinkESHto
prog
ress
markers,awards,con
tinuing
profession
aldevelopm
entandcareer
recogn
ition
by�
Supp
ortin
gfaculty
todevelopsustainabilityliteracy
�Engaging
health
profession
alswho
developand
deliver
sustainablehealthcare
inpractice
2021:R
ecog
nize
sustainabilityas
acore
competency(e.g.G
MCOutcomes
for
Gradu
ates
2018).
2022:R
ecom
mendESHbe
addressedwith
insupervision,
appraisala
ndrevalidationof
health
profession
alsin
training
and
health
profession
alsandprovide
guidance
onho
wto
achievethis.
�Offe
rincentives
todriveinno
vatio
n,such
asaplanetaryhealth
essayprize
forstud
ents
andprizes
forfaculty
who
cham
pion
ESH.
�Provideresourcesto
educateeducators
abou
tplanetaryhealth.
�Provideaplatform
foreducatorsto
shareandaccess
ESHresources.
Identifywhere
sustainability
andplanetaryhealth
canbe
incorporated
into
your
curriculum
�Identifyon
eothercoun
tryor
region
alcontactwho
isalreadyengagedin
ESH
andcontactthem
toshareresources.
�Plan
toincorporateaplanetaryhealth
perspectivewith
inasessionor
mod
ule
which
youdeliver.
2021:Seekstud
entinpu
tto
ESHdevelopm
ent.2021:
Briefly
map
sustainability/planetaryhealth
across
the
curriculum
,including
across
assessment,andidentify
oppo
rtun
ities
forintegration.
2022:D
evelop
aplan
andstrategy
forintegratingESH
by2025.
2024
orearlier:Integrate
sustainabilityat
thenext
publicationof
profession
alstandardsin
multip
ledo
mains
toinclud
eknow
ledg
e,skillsandvalues.
�HostSpecialInterestGroup
sandevents
where
educatorscancollabo
rate
todevelopnew
ESHresources
�Mon
itorprog
ress
locally,regionally
and
internationally
anddissem
inate
exam
ples
ofbest
practice.
Trialn
ewactivities
and
assessmentto
drivelearning
�Designandtrialo
nenew
sustainability
learning
oppo
rtun
ity,w
hether
core
orop
tional.
�Designandimplem
entan
approp
riate
form
ativeor
summativeassessment
2021:Incorpo
rate
ESHin
atleaston
ecore
curriculum
elem
ent,e.g.
ethics.Seekfeedback
from
staffand
stud
ents
anddissem
inateprog
ress
andevaluatio
nfin
ding
sto
faculty.
2022:B
uild
onprevious
experienceandaddressplanetary
health
topics
inadiffe
rent
mod
ule/year
ofthecurriculum
.
2021:C
allfor
ESHto
beinclud
edin
assessmentforhealth
profession
altraining
courses.
2024
orearlier:A
ddress
ESHwith
inprofession
alexam
sandother
prog
ressionstepsforhealth
profession
als.
HostSpecialInterestGroup
sandevents
where
educatorscannetworkand
discussanddevelopassessmentforESH.
Integratesustainabilityand
planetaryhealth
across
curriculaand
educationalp
ractice
�Workwith
your
institu
tionto
integrate
sustainabilityacross
curriculalocally
�Co
llabo
rate
natio
nally
orinternationally
todevelopeffectiveESH.
2023:Incorpo
ratio
nof
sustainabilityandplanetaryhealth
across
atleaston
eclinicalandon
epu
blichealth
mod
ulein
allh
ealth
profession
alcurricula.
2025:Incorpo
rate
sustainabilityas
across-cutting
curriculum
them
eacross
allh
ealth
profession
seducation.
2024
orearlier:D
evelop
indicators
foruse
atnatio
nala
ndinternationallevelsto
measure
prog
ress
byeducational
institu
tions
onESH(in
clud
ingbu
tno
tlim
itedto
integratingplanetaryhealth
across
curriculaandassessment).
Provideaplatform
foreducatorsand
stud
ents
toshareresourcesto
supp
ort
integrationof
planetaryhealth
into
curricula,from
assessmentrubricsto
approaches
totoolsformapping
planetaryhealth
across
curriculato
tips
(continued)
MEDICAL TEACHER 11
Table3.
Continued.
Focusarea
Educator
College/school
Health
profession
alaccreditatio
nbo
dyNationalor
internationalh
ealth
profession
alorganizatio
n
�Ad
aptESHlearning
outcom
esand
approaches
foryour
setting,
learners
andresources.
�Co
nstructivelyalignassessmentwith
learning
outcom
es.
�Use
arang
eof
assessmentapproaches.
Reliabilityin
assessments
canbe
achieved
byinclud
ingmultip
leview
sof
alearner’s
prog
ress.
�Supp
ortextra-curricular
activities,e.g.student-led
initiatives,informal
learning
oppo
rtun
ities.
�Ad
aptESHob
jectives
andapproaches
relevant
toyour
setting,
learnersandresources
�Provideauthentic
learning
experiences,e.g.involve
clinicians
todemon
strate
practical
applications
�Incorporateinterprofessionallearningto
prom
ote
collectiverespon
sesandmirror
clinicalteam
work.
�Use
arang
eof
authentic
assessmentapproaches
�Co
nstructivelyalignassessmentwith
learning
outcom
es
foraddressing
planetaryin
hidd
encurricula.
Ong
oing
collabo
ratio
n,developm
entandevaluatio
n�
Workandlearncollabo
rativelywith
colleaguesfrom
diffe
rent
disciplines.
�Learnfrom
bestpracticein
other
institu
tions
andbenefit
from
collabo
ratio
nandresource
sharing
across
institu
tions,d
isciplines
and
borders,includ
ingviaon
lineplatform
s,e.g.
Centre
forSustainableHealth
care,
GlobalC
onsortium
onClimateand
Health
Education,
PlanetaryHealth
Alliance&NurSU
S.
Review
theseactio
nson
anannu
albasis:
�Evaluate
prog
ress
towards
integrationof
planetary
health
across
entirecurriculum
.�
Canvas
health
profession
seducatorsandstud
ents
for
theirview
son
institu
tionalp
rogresson
ESH.
�Encouragefaculty
tojoin
networks
ofeducatorsand
contrib
uteto
movem
ent-bu
ildingandadvocacy
for
policyactio
nwith
inandexternalto
the
educationalsph
ere.
Collabo
rate
with
health
profession
alaccreditatio
nbo
dies
internationally
tosupp
ortESH.
2021:P
rovide
aplatform
foreducatorsfrom
diffe
rent
institu
tions
todiscussESH
prog
ress,challeng
es,app
roaches
andleadership.
12 E. SHAW ET AL.
the ecological crisis currently impacting on our health andwell-being as well as that of our planet.
Our health and well-being are dependent on a healthyplanet. The window of opportunity to protect our ecosys-tems is fast disappearing, so urgent, collective, transdiscipli-nary action is required. The 2020s can be the decade inwhich we step up action on pressing issues such as achanging climate. While COVID-19 stopped us in our tracks,it has also been a wake-up call. Our relationship with natureis broken and with an increasing but unequal affluence overthe past 50 years and our unsustainable impact on the plan-et’s ecosystems, not only our health but also survival is atstake. Given the dependence of human health on ecosys-tems, there is a need for eco-ethical leaders who can inspirecurrent and future generations of healthcare professionals tobecome environmental stewards who strive towards a safeand just space for humanity and all of Earth’s inhabitants.
Acknowledgements
We would like to thank Teddie Potter, Arianne Teherani and CarolineWellbery who have kindly shared their expertise and their time asexpert reviewers.
Disclosure statement
Trevor Gibbs is President of AMEE. All other authors have no conflictsof interest to declare.
Notes on contributors
Emily Shaw, MBBS, DipMedEd, Newcastle University.
Sarah Walpole, BSc, MBChB, MRCP, DipTM&H, MSc(Res), NewcastleUpon Tyne Hospitals NHS Foundation Trust, and Newcastle University,Newcastle, UK; and Centre for Sustainable Healthcare, Oxford, UK.
Michelle McLean, PhD, M.Ed., FAMEE, Professor, Faculty of HealthSciences & Medicine, Bond University, Gold Coast, Australia.
Carmen Alvarez-Nieto, PhD, BSc, RN, PGCE. Faculty of Health Sciences,University of Jaen, Spain.
Stefi Barna, MPH, Centre for Sustainable Healthcare, Oxford, UK.
Kate Bazin, MSc, FHEA, MCSP, King’s College London Faculty of LifeSciences and Medicine, Department of Physiotherapy, London, UK.
Georgia Behrens, BA(Hons), School of Medicine, Sydney, The Universityof Notre Dame Australia, Sydney, Australia.
Hannah Chase, BA VetMB, Medical Sciences Division, University ofOxford, UK.
Brett Duane, BDS, MAM(Health), GCertDent, MPH, PhD, Trinity CollegeDublin, School of Dentistry, Dublin, Ireland.
Omnia El Omrani, International Federation of Medical Students’Associations, and Faculty of Medicine, Ain Shams University, Egypt.
Marie Elf, RN, PhD, MSc, Professor, School of Education, Health andsocial studies, Department of Nursing, Dalarna University,Falun, Sweden.
Carlos A. Faerron Guzm�an, MD, MSc, Planetary Health Alliance,Harvard University T H Chan School of Public Health, Boston MA, USA.
Enrique Falceto de Barros, MD, Masters in Science Education,Universidade de Caxias do Sul, Brazil; and Working Party on theEnvironment Chair, World Organization of Family Doctors.
Trevor J. Gibbs, MD, DA, FRCGP, SFHEA, FAcadMed. FAMEE.Association for Medical Education in Europe (AMEE), Dundee,Scotland, UK.
Jonny Groome, MBBS, BSc, FRCA, Greener Anaesthesia & SustainabilityProject (GASP), Great Ormond Street Hospital for Children,London, UK.
Finola Hackett, MD, BA&Sc, University of Calgary, CFMS Health andEnvironment; Adaptive Response Task Force. Lethbridge, Alberta, Canada.
Jeni Harden, PhD, MPhil, MA (Hons), University of Edinburgh UsherInstitute of Population Health Sciences and Informatics, Edinburgh, UK.
Eleanor J. Hothersall, BSc, MBChB, MPH, MMEd, MD, University ofDundee, Medical School, Dundee, UK.
Maca Hourihane, MISCP, PGD (Obs. & Gyn. for Physios), PGD(Advanced Resp. Studies for Physios), IDHA, EMA, LLM. ISCP ResearchOfficer for CPIHD and Regional Volunteer Coordinator MigrationProgramme for Irish Red Cross Society, Galway, Ireland.
Norma May Huss, MN, Dr Rer Med, Dip N, RGN, Faculty of Social Work,Health and Nursing, Hochschule Esslingen, Esslingen, Germany.
Moses Ikiugu, PhD, MA, BA, University of South Dakota School ofHealth Sciences, Occupational Therapy, Vermillion, SD, USA.
Easter Joury, DDS, DOrth, MSc, PhD, MFDS RCPS, FHEA, Institute ofDentistry, Barts and The London School of Medicine and Dentistry,Queen Mary University of London, London, UK.
Kathleen Leedham-Green, BSc, MBBS, CDipAPHE, PGCert Med Ed, AFHEA, Imperial College London Faculty of Medicine, Medical EducationResearch Unit, London, UK.
Kristin MacKenzie-Shalders, PhD, APD, Bond University, Nutrition andDietetics Research Group, Faculty of Health Sciences and Medicine,Gold Coast, Australia.
Diana Lynne Madden, BSc(Med)Hons1, MBBS, MPH, MSc, FFPH(UK),FAFPHM, FPHAA School of Medicine, Sydney, The University of NotreDame Australia, Sydney, Australia.
Judy McKimm, MBA, MA(Ed), FAMEE, SFHEA, FAcadMed, SwanseaUniversity Medical School, Swansea, UK.
Patricia Nayna Schwerdtle, MPH, PGD-Crit Care, PGD-HPE, Bach. HealthPromotion, BN RN, Heidelberg Institute of Global Health,Heidelberg, Germany.
Sarah Peters, Medical Sciences Division, University of Oxford, UK.
Nicole Redvers, ND, MPH, Department of Family & CommunityMedicine-INMED, University of North Dakota School of Medicine &Health Sciences, Grand Forks, ND, USA; and, Arctic IndigenousWellness Foundation, Yellowknife, NT, Canada.
Perry Sheffield, MD, MPH, Icahn School of Medicine at Mount Sinai,Departments of Environmental Medicine and Public Health andPediatrics, New York City, NY, USA.
Judith Singleton, BPharm, MBA (Hons), PhD, GradCert AcadPrac, Schoolof Clinical Sciences (Pharmacy), Faculty of Health, QueenslandUniversity of Technology, Brisbane, Australia.
SanYuMay Tun, MB BS, MSc, DIC, FHEA, Centre for EnvironmentalPolicy, Imperial College London, London, UK.
Robert Woollard, MD, CCFP, FCFP, LM, Professor, Dept of FamilyPractice, Faculty of Medicine, The University of British Columbia, andAssociate Director Rural Coordination Centre of BC, BritishColombia, Canada.
ORCID
Sarah Walpole http://orcid.org/0000-0003-2600-0386Michelle McLean http://orcid.org/0000-0002-9912-2483
MEDICAL TEACHER 13
Carmen Alvarez-Nieto http://orcid.org/0000-0002-0913-7893Omnia El Omrani http://orcid.org/0000-0002-1655-1195Marie Elf http://orcid.org/0000-0001-7044-8896Norma May Huss http://orcid.org/0000-0001-6098-3385Moses Ikiugu http://orcid.org/0000-0002-6341-8813Easter Joury http://orcid.org/0000-0002-2983-0679Kristin MacKenzie-Shalders http://orcid.org/0000-0003-4938-5362Diana Lynne Madden http://orcid.org/0000-0003-2829-7195Judy McKimm http://orcid.org/0000-0002-8949-5067Nicole Redvers http://orcid.org/0000-0001-8521-2130Perry Sheffield http://orcid.org/0000-0001-9156-1193SanYuMay Tun http://orcid.org/0000-0003-0071-5666
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