I will be still working (I hope) in 2030, but maybe I won’t. But I know that there will be younger pelvic health physios carrying the baton for conservative management of pelvic floor dysfunction. Some will be private, but some will be in the public sector. I would like to present you with a future scenario.

A woman presents with stress incontinence to a public hospital physiotherapy department in May,2030. A chronic cough from air pollution and allergies has made her symptoms of urinary incontinence worse. Obesity is a major issue for this patient, but fresh fruit and vegetables are unaffordable. She can’t get out to exercise because of the heat and the bushfire smoke that’s been hanging around. The economic strain of a series of natural disasters, and their effects on the tourism and agricultural industries, has led to an economic downturn. The smoke and the ongoing heatwaves and another new infectious disease epidemic mean that emergency departments are again overflowing with acute presentations. There’s not much money left over for chronic (and unglamorous) conditions like incontinence. There’s no longer any public funding for physiotherapy and the waiting list for surgery is over 5 years. At the end of the clinic, the young physio puts on her mask and drives home.

She wonders if something different could have been done back in 2021.

Today I am aghast.

Today I woke to the news that the Morrison government has confirmed it will spend up to $600m to build a new gas-fired power plant in New South Wales’ Hunter Valley despite experts warning the fossil fuel investment makes little commercial sense. (Interestingly, the announcement comes four days before a NSW state by-election in the Upper Hunter region. Tony Wood, energy program director with the Grattan Institute, said the Kurri Kurri plant was “just not necessary”. “It’s not necessary for prices, it’s not necessary for reliability and it’s not necessary to bring down emissions,” he said. (The Guardian, May 19th 2021).

So today I am pledging to devote more hours of my (precious, already hard-to-come-by) time and more money to supporting Climate Change initiatives. Can anything I do possibly make a difference?  A young woman called Greta has been a constant source of inspiration for me for a couple of years now and as she says: ‘The moment we decide to fulfill something, we can do anything. Right here, right now is where we draw the line’.

I know we are still facing the dramas of a global pandemic. But as I watch my grandchildren grow up, I despair at our Australian Government’s inability to embrace the concept that a much bigger catastrophe is staring us right in the face.

Climate change is all around us.

Most of the people I know are individually trying to do bits and pieces – no more plastic wrap, composting, some have bought hybrids or electric cars, many have solar electricity. But our National leaders are pussy footing around – the Liberal/Nationals and Labor parties are both repugnantly hopeless on facing this giant issue. And as I approach 65 I am getting sick of ‘behaving’ (which amounts to staying silent) and not speaking out. I am getting worried……genuinely terrified of what we are leaving for our children, grandchildren and their children.

I can’t glue myself to the road and block traffic like the protesters from Extinction Rebellion. As annoying as it may be when patients are late caught in the traffic mayhem the protesters create, I hugely respect the effort they go to – to try and wake us up from our complacency slumber.

But I can stop being mostly silent  so as not to rock the boat. (Whilst I currently do Facebook posts, Instagram stories and chatting to anyone who’ll listen, it is always in a quiet, pleasant sort of way. But there is no time to be pleasant anymore. We are running out of time.)

As Greta Thunberg has said: “We can’t save the world by playing by the rules, because the rules have to be changed. Everything needs to change – and it has to start today.” 

We actually just don’t have the time to ignore the magnitude of this issue. The clock is ticking and basically the world is stuffed if we, the old sedate people, do not make a loud noise and let our elected leaders know: Climate Change Matters!!

We just had a gigantic spend in the 2021 Budget and there was barely a mention of spending on climate change inititatives. We had a Budget reply from the Opposition and there was no emphasis on the importance of Climate Change spend and initiatives. I get that they are scared because of the last election results, but we as a nation, and a Government and as the prospective Government have to be brave and bring the message home to the people. That is your responsibility if you want to govern.

That is your job- sell the hard messages to the people. 

When I was 18, I was in first year university. I dressed up in fancy dress to attend a combined Med and Physio social night. Life was full of parties, tennis, fun and some serious study to become a physio. Greta Thunberg at 18, took a gap year from school and travelled the world to look at some of the major catastrophic climate events that are happening right now around the world. She has become an iconic figure in climate change activism – and admired by the most profoundly eminent man I know – Sir David Attenborough.

She is little in stature, but a giant in courage as she addressed the Climate Change conferences and told the adults off in the room:

“My message is that we’ll be watching you. This is all wrong. I shouldn’t be up here. I should be back in school on the other side of the ocean. Yet you all come to us young people for hope. How dare you. You have stolen my dreams and my childhood with your empty words. Yet I am one of the lucky ones. People are suffering.”

Greta’s gap year in 2019 was presented in a fabulous series on the ABC – here is the link. It was inspiring, it was scary and I felt protective towards her because she is so tiny, so slight – she looks weak, but she is a towering strength on climate policy and awareness and she is truly rocking the boat despite being so physically small. As Greta herself says: ‘I have learned you are never too small to make a difference’.

Last year, I was Co-Chair of NCOI (National Conference on Incontinence) with Dr Peta Higgs, a Sunshine Coast Urogynaecologist. We are both passionate about climate change and we pushed the Continence Foundation of Australia to include a talk on Climate Change and its impact on pelvic floor dysfunction. To their credit they allowed the topic to make the congested programme and Dr David King, a GP who is very active on climate issues – in a very proactive way – gave a fabulous talk.

He worked with Dr Kristine Barden, an Obstetrician and Gynaecologist in Tasmania to come up with a draft proposal for the content to present to CFA to help them make their decision regarding the talk being on our programme. I have been sitting on this document for a while now itching to publish it in its entirety on my blog as the information is fabulous (but scary as hell).

Here is the article from Kristine.

Humanity has never before faced a problem like climate change. Our collective failure to act has been attributed to our inability to grasp how our everyday activities can cause the world to heat, and from our failure to appreciate how a heating planet will materially affect our own lives.

The climate has always changed but in human history change has never been this fast or this extreme. We are seeing more frequent and more severe extreme weather events, worsening pollution of air and water, a reversal of gains in public health, food and water insecurity, increasing global conflict, and an exacerbation of inequality.

Women’s Health and Climate Change – background information

1. The health impacts of climate change affect everyone. In many cases, women are particularly vulnerable, either due to physiological factors, or due to existing health and socio-economic inequities,^{[1] [2]}which are in turn likely to be exacerbated by the economic impacts of climate change. Predicted health impacts of climate change include:

• more frequent and intense heat waves resulting in more heart attacks, strokes, accidents, heat exhaustion and death
• more frequent or intense extreme weather events—particularly storms, floods and cyclones— resulting in more injuries, deaths and post-traumatic stress
• more fires increasing the number of cases of smoke-induced asthma attacks, burns and death
• more exposure to some air pollutants and air-borne allergens, such as pollens and moulds, exacerbating respiratory illnesses, such as asthma, hay fever and longer-term heart and lung diseases
• changed rainfall patterns and hotter temperatures increasing the spread and activity of disease- transmitting mosquitoes and increasing the chances of food-borne infections
• a higher prevalence of mental health problems and lower morale, especially in rural communities
• changed rainfall patterns and hotter temperatures leading to reduced supply and increased prices of some foods, resulting in reduced nutrition
• displacement of people from within and outside of Australia and community-wide negative effects on social and economic wellbeing
• increased pressure on health systems and emergency responses delaying effective delivery of health care ^[3]
• Exposure to high ambient temperatures in pregnancy has a dose response effect on rates of both preterm birth and stillbirth. For example:
  • A study published in December 2019 looking at 56 million births in the USA between 1969 and 1988  found about 5% more children are born on unpredictably hot 90 degree-plus Fahrenheit  (32°C) days than would be expected. The average loss due to heat was about six days of gestation, but the losses were potentially as large as two weeks for some births.^[4]
  • A US group found a 10% change in the risk of stillbirth^[5] and an 8.6% increase in preterm birth^[6] for every 10°F (5.6°C) rise in apparent temperature.
  • A Canadian study found that the odds of stillbirth after 37 weeks gestation were 16% higher at 28°C compared to 20°C, and stillbirths attributed to maternal complications were 46% higher for the same temperature difference.^[7]
  • An Australian study looking at windows of exposure to heat found relationships between preterm birth and heat wave exposure in all months of pregnancy. Earlier gestational months seemed to be key exposure windows for heat-wave–affected stillbirth.^[8]

1. A number of studies have linked heat exposure to low birth weight for gestational age. For example, the chance of LBW at term was found to be 2.5x higher when average temperatures during the second and/or third trimesters were above the 95th percentile.^[9]
2. Pregnant women have impaired thermoregulation and an impaired physiological response to heat stress, and as such are vulnerable to all potential medical complications of heat exposure. A US study looking at the effects of exposure of extreme heat (temperature >3SD above the monthly average) found that for every day spent in extreme heat there was an additional 4.8% risk of hospitalisation for second trimester exposure, and 3% increased risk for third trimester exposure.^[10]
3. The stagnant conditions associated with heatwaves tend to boost air pollution. Exposure to air pollution in pregnancy has been linked to increased rates of miscarriage, preterm birth, fetal growth restriction, hypertensive disorder of pregnancy and gestational diabetes. Exposure to air pollution in utero and in infancy has also been linked to increased infant mortality, poor lung development, adverse neurodevelopmental outcomes, and childhood cancer.^[11] Women and children are generally more susceptible to the harmful effects of environmental toxins and pollutants. ^[12] Air pollution affects the body through direct toxicity, often due to chemical elements attached to the fine particles, or by causing inflammation that can affect organs throughout the body. Concerning for pregnancy, air pollution can damage or alter DNA. ^[13] Air pollution particles have been found on the fetal side of the placenta. ^[14]
4. Bushire smoke is likely to be similar to other forms of air pollution in its effects, although it has been less comprehensively studied. A Colorado study of over 500,000 exposed pregnancies found an increased risk of preterm birth, particularly for second trimester exposure. For a woman whose second trimester coincided with the peak wildfire season, and with average levels of exposure to smoke, the odds of preterm birth were increased by 7%. First trimester exposure was associated with low birth weight, gestational diabetes, and gestational hypertension.^[15]
5. Studies on the effects of heat and air pollution on pregnancy have looked at each in isolation, controlling for other variables. Population studies have been unable to assess the degree to which access to air-conditioning protects from hot conditions and dilutes the magnitude of the heat effect. In reality, extreme levels of heat and air pollution (whether bushfire smoke or generated by fossil fuel use) tend to occur together. Women who are most likely to be exposed to extreme levels of heat and air pollution are those who are already socio-economically disadvantaged, and already with numerous other risk factors for adverse pregnancy outcome.
6. Globally, women are more likely than men to be affected by extreme weather events. The more extreme the event, and the greater the level of socio-economic inequality, the greater the gender disparity. Women and children are 14 times more likely than men to die during a disaster, and women make up upwards of 80% of climate refugees.¹⁶
7. Human trafficking, and levels of sexual and gendered violence, increase during and after natural disasters. In Australia, rates of domestic violence have been shown to rise sharply in the aftermath of natural disasters.^[16]
8. Health and economic co-benefits of climate mitigation—the benefits achieved through reductions in levels of air pollution and pollution-related disease—significantly outweigh the costs of mitigation.^[17]
9. The promotion of women’s and girls’ education, health and reproductive rights has environmental co-benefits. Environmental benefits mainly derive from slowed population growth, ^[18] but studies show that women are more likely than men to accept climate change science, be more willing to make sacrifices to reduce emissions, and are more likely to exhibit environmentally sustainable behaviour. ¹⁵ Indigenous women are at the forefront of local and global efforts to protect and defend the socio-ecological diversity of their lands, and hold unique and invaluable traditional ecological knowledge, as well as spiritual and philosophical understandings critical to healing and maintenance of the Earth’s climate and cycles.¹⁶
10. Every day, we care for women whose health is severely impacted by smoking, physical inactivity, poor nutrition and poor mental health. Bushfire smoke in Sydney this summer has seen air pollution levels to the equivalent of smoking 34 cigarettes per day, with levels even higher for people closer to the fires.^[19] Outdoor exercise is unhealthy in times of high heat and air pollution. Climate change is predicted to have significant impacts on food production, and fresh food will become increasingly expensive. The effects of climate change on mental health are likely to be significant.^[20] It seems futile for health professionals to counsel women on the risks of “lifestyle behaviours” without addressing underlying systemic and climate factors.
11. Advancing women’s rights and the leadership roles of women can help resolve the global climate and environmental crisis. In the words of Mary Robinson, ex-Irish President and UN Special Envoy on climate change, “climate change is a man-made problem with a feminist solution”.^[21] Taking a leading role in lobbying for action on climate change is in perfect alignment with RANZCOG’s role in advocating for women’s health, reproductive rights, and leadership.
12. Obstetricians can lead in the following ways:
    • By educating women about the dangers posed to pregnancy by bushfire smoke, air pollution, and heat.
    • By public health advocacy for community and health system adaptation to the health effects of climate change, and for mitigation of climate change through policies that result in a decrease in greenhouse gas emissions.
    • By being more aware of their personal carbon footprint.
    • By helping to address issues of greenhouse gas emissions, waste, and energy efficiency in the health system
13. It is increasingly recognized that hospitals and healthcare have a significant impact on environmental health. In Australia, the healthcare system is responsible for up to 7% of national greenhouse gas emissions, as well as significant quantities of waste and water usage. The Sustainable Development Unit in the UK has led the way in demonstrating how health system reforms can make an impact: the NHS reduced greenhouse gas emissions by 11 per cent between 2007 and 2015, even with an 18 per cent increase in healthcare activity. This resulted in an estimated saving of 90 million pounds ($155 million AUD) annually. ^[22]  Effective management of waste can provide opportunities to reduce operational costs and the environmental impacts of an organisation as well as reducing risks to staff and patients.^[23]

Thank you for your article Kris. It is profoundly important to understand the impact on Women’s Health – this is my core business and of course affects my life and my girls’ lives. The references for this article by Kris are at the bottom of this blog. I know it’s a long blog, but devoting more time to reading about this desperate situtation is what we all need to do.

I remember when my kids were born. It feels like yesterday. My first born Katie is 36 soon. Where did those 36 years go? I feel the same as I did 36 years ago, but obviously I’m not the same. I’m panicking about different things to what I panicked about in those days. I’m panicking that it is estimated that we will reach these things called tipping points in less than a decade; that we are facing mass extinction of many animals – including our iconic koalas (not the koalas I hear you say); that our shores will be inundated due to rising sea levels; and so it goes on.

Greta Thunberg, for one so young is full of wise words and I am just going to quote her directly:

“You must take action. You must do the impossible. Because giving up is never an option. I’m not that special. I can’t convince everyone. I’m just going to do what I want to do and what will have the most impact. We can’t save the world by playing by the rules, because the rules have to be changed. Everything needs to change – and it has to start today.Together and united, we are unstoppable. I often talk to people who say, ‘No, we have to be hopeful and to inspire each other, and we can’t tell [people] too many negative things’ . . . But, no — we have to tell it like it is. Because if there are no positive things to tell, then what should we do, should we spread false hope? We can’t do that, we have to tell the truth.” And as Alan Finkle (our Special Adviser to the Australian Government on Low Emissions Technology in December 2020) has said: ‘Resistance is futile, change is coming’

And I am sorry but if you are not losing sleep over these issues – you have to ask yourself – Why not? Why do I not fret about what our children are inheriting from this generation? What is wrong with me? 

[1] Sorensen C, Murray V, Lemery J, Balbus J (2018) Climate change and women’s health: Impacts and policy directions. PLoS Med 15(7): e1002603. https://doi.org/10.1371/journal.pmed.1002603

[2] Australian Women’s health Network 2014, The Impact on Women’s health of Climatic and Economic Disaster, www.awhn.org.au

[3]  Doctors for the Environment Australia, Climate Change and Health in Australia, Factsheet, 2016. https://www.dea.org.au/wp-content/uploads/2017/02/DEA_Climate_Change__Health_Fact_Sheet_final.pdf

[4] Barreca A, Schaller J, The impact of high ambient temperatures on delivery timing and gestational lengths, Nature Climate Change, 2019, https://doi.org/10.1038/s41558-019-0632-4

[5] Basu R, Sarovar V, Malig B, Association Between High Ambient Temperature and Risk of Stillbirth in CaliforniaAm J Epidemiol. 2016;183(10):894–901

[6] Basu R, Malig B, Ostro B, High Ambient Temperature and the Risk of Preterm DeliveryAm J Epidemiol 2010;172:1108–1117

[7] Nathalie Auger, William D Fraser, Audrey Smargiassi, Marianne Bilodeau-Bertrand, Tom Kosatsky, Elevated outdoor temperatures and risk of stillbirth, International Journal of Epidemiology, Volume 46, Issue 1, February 2017, Pages 200–208, https://doi.org/10.1093/ije/dyw077

[8] Wang J, Williams G, Pan X, Exposure to Heat Wave during Pregnancy and Adverse Birth Outcomes. Epidemiology 2019;30: S115–S121

[9] Ha S, Zhu Y, Liu D, Sherman S, Mendola P. 2017. Ambient temperature and air quality in relation to small for gestational age and term low birthweight. Environ Res155:394–400, PMID: 28258738, 10.1016/j.envres.2017.02.021.

[10] Kim J, Lee A, Rossin-Slater M, What to Expect When It Gets Hotter: The Impacts of Prenatal Exposure to Extreme Heat on Maternal and Infant Health. NBER Working Paper No. 26384
October 2019

[11] Air pollution and child health: prescribing clean air World Health Organisation 2018

[12] https://www.wecaninternational.org/why-women

[13] Schraufnagel DE et al. Air Pollution and Noncommunicable Diseases: A Review by the Forum of International Respiratory Societies’ Environmental Committee, Part 2: Air Pollution and Organ Systems. Chest. 2019 Feb;155(2):417-426.

[14] Bové, H., Bongaerts, E., Slenders, E. et al. Ambient black carbon particles reach the fetal side of human placenta. Nat Commun 10,3866 (2019) doi:10.1038/s41467-019-11654-3

[15] Abdo M et al. Impact of Wildfire Smoke on Adverse Pregnancy Outcomes in Colorado, 2007–2015. Int. J. Environ. Res. Public Health 2019, 16(19), 3720

[16] Parkinson D and Zara C. The hidden disaster: domestic violence in the aftermath of natural disaster Australian Journal of Emergency Management Volume 28, No. 2, April 2013

[17] Markandya A, Sampedro J, Smith SJ, et al. Do health co-benefits compensate the economic costs of the Paris climate agreement? Lancet Planetary Health 2018; 2: e126–33.

[18] https://www.drawdown.org/solutions/women-and-girls

[19] https://www.bbc.com/news/world-australia-50497492

[20] Hayes, K., Blashki, G., Wiseman, J. et al. Climate change and mental health: risks, impacts and priority actions. Int J Ment Health Syst 12, 28 (2018) doi:10.1186/s13033-018-0210-6

[21] https://www.reuters.com/article/us-global-climatechange-women/climate-change-a-man-made-problem-with-a-feminist-solution-says-robinson-idUSKBN1JE2IN

[22] https://ama.com.au/ausmed/healthcare-sector-can-address-carbon-emissions

[23] https://www2.health.vic.gov.au/hospitals-and-health-services/planning-infrastructure/sustainability/waste