More on the rationale underpinning the Environmental Physiotherapy Agenda 2023

This is a critical time in healthcare. Large-scale environmental degradation, including climate change, biodiversity loss, land-system change, and other closely related issues, are now widely recognised as the largest current threats to human health and flourishing around the world (Steffen et al., 2015). From the Paris Climate Agreement, the IPCC special report on Global Warming, the UN Agenda 2030 SDGs and the recent 2019 Report to the Lancet Countdown on climate change and health, it is established that immediate action and the ‘mobilisation of all available resources’, as well as ‘participation of all countries, all stakeholders and all people’ is required to ensure the health and wellbeing of current and future generations in light of these challenges (UN, 2015). There are only ten years left to achieve the SDGs, so there are high hopes for this decade becoming a ‘decade of action’, with its beginning year being a particularly critical marker ‘for establishing ambition’ (Horton, 2020; Guterres, 2020 UN, 2020). In recognition of our current environmental crises amounting to the largest health crisis of our time, the essential role of the healthcare professions has become ever more evident. As stated in the recently published 2019 Lancet Countdown report, it consists in com­municating the health risks of present environmental issues and ‘driving the implementation of a robust response which will improve human health and wellbeing’ (Watts et al., 2019).

The EPT Agenda 2023 seeks to take up the imperative health needs and responsibilities highlighted in all of these calls by energising and supporting the integration of environmental and sustainability perspectives into the entry-level programmes of an entire healthcare profession around the world. We believe that changing education is the single most effective action with the longest-lasting effect that we can take as a profession at this point to ensure the health of future generations and support the transition to a more sustainable and environmentally responsible future (Hackett et al., 2020). Physiotherapy has not yet taken a clear stand with regard to our current health and environmental crises at a larger scale. We are sure that supporting entire generations of upcoming colleagues to be knowledgeable, skilled and conscious concerning the inseparable relationship between human health and our planetary environment will turn this tide and send a clear message with regard to our professions’ commitment to global health and flourishing in light of today’s most pressing health challenges.

To provide more context, the identified major environmental issues of our time encompass climate change, biodiversity loss, air pollution, tropical and other forest loss, land-system change, resource depletion, changes in biogeochemical flows, and ocean acidification (Steffen et al., 2015). These, in turn, have already been identified as having and driving a range of rapidly increasing impacts on human health and function across the globe, including a rise in non-communicable diseases, malnutrition, obesity, infectious and vector-borne disease, trauma and injury, climate migration, displacement and conflict, and associated mental health problems (Myers, 2017; Rice, Thurston, Balmes, & Pinkerton, 2014; Watts et al., 2019). Apart from this being a striking indication that more people will need more treatment going forward, one of the core insights from all of these health impacts is precisely their underscoring of the inseparable link between and dependence of human health and functioning on our planetary environment. In simple terms, human health can no longer be considered and addressed, without simultaneously understanding and attending to environmental determinants. Failing to do so, not only means failing to prepare for increasing burdens on healthcare provision (as an adaptation strategy), but also failing to protect the health and safety of people around the globe via effective and combined preventative health and environmental action (as a mitigation strategy).

Key international strategies and ‘existing policy processes for sustainable development (i.e., the SDGs), health (i.e., the WHO Global Strategy on Health, Environment and Climate Change and WHO Health Emergency and Disaster Risk Management Framework), environment (the United Nations [UN] Environmental Assembly resolutions on environment, health, and pollution issues), climate change (i.e., The Paris Agreement), disasters (i.e., The Sendai Framework for Disaster Risk Reduction), biodiversity (i.e., the post-2020 global biodiversity framework)’ and others already fundamentally build on the recognition of this inseparable link between human health, society, and environment (Pongsiri, et al., 2019). As strategies ‘for people, planet and prosperity’ they seek to comprehensively and conjointly address global poverty and hunger, health and wellbeing for all, promote sustainability and combat environmental issues (UN, 2015).

Across the healthcare professions, recognition of the inextricable link between the environment and human health has also led to the rise of several closely corresponding fields of research, practice and education, including planetary health, sustainable healthcare, environmental medicine, One Health and others (Myers, 2017; Pongsiri, 2019; Walpole, Barna, Richardson, & Rother, 2019). Approaching the issue from a variety of angles, all of these efforts resonate with ‘the pursuit of the highest attainable standard of health, wellbeing, and equity worldwide’ (WONCA, 2017) while addressing ‘the health of human civilization and the state of the natural systems on which it depends’ at the same time (Watts et al., 2015).

Efforts in sustainable healthcare education are increasingly introducing the research and evidence across these fields into healthcare curricula around the world (Musaeus et al., 2018; Walpole et al., 2019). Notable endeavours also include the development of relevant learning outcomes that ‘include environmental considerations in clinical ethical reasoning’, the first effective changes to health professional curricula, and even the modelling of sustainable clinical specialities like sustainable primary care and many more (Walpole et al., 2019). Thus far, sustainable healthcare education is increasingly adopted in a growing number of professional education programmes in medicine, nursing, midwifery, occupational therapy, and psychology, and where this is not yet happening, resounding calls for doing so are voiced clearly and loudly by healthcare professionals and students alike (Hackett et al., 2020; IFMSA, 2018; Legar, Green, Tucker, & van Daalen, 2019; NMC, 2019; RCOT, 2019).

The EPT Agenda 2023 aligns with these calls and aims at education as the most effective means to help the physiotherapy profession as a whole transition into a more sustainable and environmentally responsible future and, therewith, further support the health and wellbeing of future generations. We recognise that much needs to be done in the way of research and development to better understand this burgeoning field and how we might contribute most effectively in practice. Yet, these are also urgent times that require us to commence taking action across education, research and practice immediately, in parallel, and together. We hope to have succeeded in setting out the EPT Agenda 2023 in a way that reflects this urgency and generates space for all of these efforts to develop in partnership.

Physiotherapy has a rich history of existing ties to the environment and environmental issues, not least in its use of natural and low-carbon means like movement, touch and communication in the rehabilitation of a wide swath of acute and chronic conditions. Side-by-side with colleagues in other healthcare professions, physiotherapists have also long been involved in occupational health and ergonomics, helping people return to meaningful, healthy and safe occupational environments (Boucaut & McPhee, 2013; IFPTOHE, 2019; Stigmar, Ekdahl, Borgquist, & Grahn, 2014). A considerable number of physiotherapists around the world also do therapeutic work with and for animals, either implementing and further developing animal-assisted approaches improving human health, or working for the health and wellbeing of horses, dogs, and other species through animal physiotherapy (Benda, McGibbon, & Grant, 2004; IAPTAP, 2020; Sudmann, 2018).

Though still underrepresented, at least in some countries indigenous worldviews and approaches to health and wellbeing are already included in physiotherapy curricula and nearly always encompass an explicit link between land, water, and animal life and people’s health. Many physiotherapy education institutions around the world are beginning to integrate the SDGs and other green initiatives into their operations and education programmes. Finally, there are also a growing number of clinics and clinicians working to make their workplace more environmentally friendly and responsible (Thomas, 2020). We wish to amplify, encourage and support the sharing of all of these existing efforts such that they can help others refine and develop their own approaches and enrich our efforts.

Being in a good place to build on what we have, we should invest in reframing what we are already doing to make the link between physiotherapy, the environment and environmental stewardship more explicit. We should also invest in refining and advancing this link, and develop corresponding efforts as we take on more environmental responsibility (Foo, 2016; Jones, 2009a, 2009b; Maric & Nicholls, 2019). In doing so, we should also build on the work of our colleagues in other healthcare professions that are already deeply involved in enhancing greater environmental responsibility and stewardship in healthcare and beyond, and collaborate with them, as well as governments and policymakers to maximise our combined impact (e.g. UN, 2015; EC, 2019; Myers, 2017; Spencer & Gee, 2009; WFOT, 2012; and many more). To support this process, we are actively building strong partnerships across the healthcare professions and beyond, and endeavour to continue growing the list of links, resources, references provided in this document and the EPT Agenda 2023 website as the Agenda takes effect. We are confident that collaboration and building upon what we already have within physiotherapy is imperative and cannot fail to support our combined efforts for long-lasting planetary health and wellbeing.

Because ‘environmental physiotherapy’ is a relatively young idea or field of engagement within our profession in this explicit manner, we also believe that it presents us with a great opportunity and responsibility to take to it with care, criticality, and creativity. We hope that the broadly defined primary aim of the EPT Agenda 2023 will support this, beyond just making it achievable for all physiotherapy education institutions. That is, we hope that it will foster diverse novel understandings of how, e.g. the SDGs, planetary health, and sustainable healthcare apply to physiotherapy specifically and what our professions’ unique contribution to these interdisciplinary, global efforts might be. In our discussion of various aspects of this Agenda, we have sought to point to different directions that this care, nuance, criticality and creativity might take us. We do not consider these to be exhaustive and hope that our outlining of them will not be a limitation to creative ingenuity, but a support of it.

Engaging care and criticality was also crucial in the development and formulation of the EPT Agenda 2023 and the challenges that doing so presented. Far from being resolved, we actively continue to wrestle with terms like environment, sustainability, climate change, environmental sustainability, environmental responsibility, stewardship, and sustainable development. We are aware that none of these terms are without contention and problems of their own and so retain an open and eager-to-learn attitude to all of them.

Concerning the terms sustainability and environment, for example, our final choice of naming this the ‘Environmental Physiotherapy Agenda 2023’ is meant to be more reflective of these difficulties than an expression of a final verdict on them. As highlighted by Jean-Paul Moatti, one of the 15 scientists selected to draft the 2019 report on the SDGs, for example, we are not only off-track on most of the SDGs, but even backtracking on many of them. This includes the critical goals of ‘reduction of inequalities (SDG10), limitation and adaptation to climate change (SDG13) and reduction of the environmental and ecological footprint of our modes of production and consumption (SDG 12)’ (Deighton, 2019). It has also repeatedly been highlighted that this is, at least partially, due to the unsustainability of our economic growth and development models, as well as our production and consumption patterns (Deighton, 2019; UN, 2019). From our perspective, this does not mean that we should not strive for sustainability or the achievement of the SDGs. Quite the contrary. But it highlights that to do so also requires that we carefully and critically consider each aspect of the social - environmental - economic triad to avoid perpetuating any element of them that has contributed to our current predicament.

In addition to this, we also believe it relatively safe to assume that the Earth’s natural systems must be thought of as the foundation of health, sustainability and sustainable development. All growth, development and advancement, therefore, have to consider and remain within the planetary boundaries provided by the Earth’s natural systems (Oluwatoyin Onabola, 2019; Pongsiri, 2019, Steffen, et al., 2015; WONCA, 2017). Putting the term ‘environment’ first in the title of the EPT Agenda 2023 is thus also meant to reflect the recognition of the planetary boundaries in which live and on which we depend for our health, wellbeing and flourishing, first and foremost.

It has been pointed out that modern-day health gains have been made in parallel with unsustainably generated wealth associated with degradation and pollution of ecosystems, and thus also at the cost of the health of future generations (Gill & Benatar, 2019; Pradyumna, 2019; Whitmee, Haines, Beyrer, et al., 2015). Recent studies have also shown the considerable contribution of healthcare systems to greenhouse gas emission and other environmental issues (Eckelmann & Sherman, 2016; Karliner et al., 2019). As argued by Oluwatoyin Onabola (2019), we thus concur that we need to emphasise ‘the established interdependencies of human health and natural ecosystems’ as a framework to guide ‘appropriate conduct and stewardship of economic, environmental, political, social, and cultural processes’ such that the health of present and future generations can be ensured.

Even if our understanding and assessment of these complex issues and relationships change over time, the key points remain that our naming of the EPT Agenda 2023 was decided in the hope to: firstly, invite, foster, and support diversity, care, nuance, criticality, and creativity to be brought to the environmental and health issues at hand; and secondly, use terminology that might speak more directly to upcoming physiotherapists and thus draw out the further development and specific application of the SDGs, planetary health and sustainable healthcare, and other relevant fields, to physiotherapy research, education, and practice.

Young people, as well as upcoming and practising healthcare professionals around the world are clearly and loudly calling for more action on the conjoint issues of environment, health and equity (see also Clinicians for Planetary Health; Psychologists for Social Change Manifesto 2019; Practitioner psychologists and the trauma of climate change. An open letter demanding immediate and effective action; US Call to action on climate, health, and equity: a policy action agenda). As pointed out by Hackett and colleagues (2020), it is now up to us to heed their call, and ‘recognise and address this opportunity by tapping into the strong movement to change’ and equipping future generations of healthcare professionals to understand and ‘manage the effects of ecological change on health and health systems’ (Hackett et al., 2020). It is our hope the EPT Agenda 2023 will help us to join forces with the younger generations and collaboratively build our knowledge and skills to respond to pressing novel healthcare needs and responsibilities.