Dr Courtney Howard is an Emergency Physician in Yellowknife, and is a nationally- and globally-recognized expert on the impacts of climate change on health, and in the broader field of planetary health. As the first female board President of the Canadian Association of Physicians for the Environment (CAPE) she has been involved in policy and advocacy-related work on active transport, plant-rich diets, integrating health impact assessments into environmental assessments, fossil fuel divestment, carbon pricing, coal phase-out, and the health impacts of hydraulic fracturing. She is also on the steering committee of the Planetary Health Alliance and the editorial advisory board of the Lancet Planetary Health.
Dr. Courtney Howard spoke with Ashley Hopkinson on May 24, 2024. Click here to read the full conversation with insights highlighted.
Ashley Hopkinson: Can you introduce yourself and tell me a little bit about what you do?
Dr. Courtney Howard: Hi, I’m Dr. Courtney Howard. I’m an emergency physician here in Yellowknives Dene territory in the Canadian Subarctic. I have been an (emergency doctor) for about 15 years, and I’ve been working on a healthy response to climate change for almost that long. I’m a past president of the Canadian Association of Physicians for the Environment. I’m the vice chair of the Global Climate and Health Alliance. I’m on the steering committee of the Planetary Health Alliance and the editorial advisory boards of the Journal of Climate Change and Health and the Alliance of Planetary Health.
Ashley Hopkinson: That’s amazing. How did those two worlds, environmental work and public health, begin to collide for you?
Dr. Courtney Howard: I was a new (emergency physician) and I wanted to work for Doctors Without Borders. So, they said, “Hey, if you want to work for us, you have to go north and learn to work with culturally diverse populations with fewer tools.” So I went to the High Arctic and I just happened to pick up a book on climate change as I was going through the Edmonton Airport. I read it on my way up. I was just at that stage of having just finished my medical training where I was conscious that I didn’t really know anything other than medicine. So, I really was just trying to be an adult and accidentally ended up with a new career path because I read it is one of the most rapidly warming places in the world. It is already over three degrees Celsius warmer than (it was) when an 80-year-old was born.
(When I asked about it), people there said, “Oh, well I didn’t know that, but it makes sense because we’re seeing ice melting much sooner in the spring. It’s much less solid to walk on. It makes it difficult for us to hunt and to fish.” It was really changing the way of life for the Inuit, Dene, and Gwich’in people who live there and also in this part of the north.
So, since then, we’ve had wildfires. So, I did a study looking into the health impacts of the wildfires. We saw a full doubling of emergency department visits for asthma and a 50% increase in pneumonia after two and a half month’s of smoke exposure.
Last year, we had to evacuate our entire hospital, which is a 100-bed hospital, to two different provinces because fires were coming so close to this community. So, it’s had a really profound impact on not only health amongst my patient population and my community, but also our health systems. Diagnoses get easier to make when the effects are more severe. Because we’re warming so fast, it’s just easier to see the impacts up here. That’s how I became involved pretty close to the beginning of mainstream medical work on climate change and health.
Ashley Hopkinson: What do you think is missing from the conversation we’re currently having about climate and health? What will it take to get us beyond noticing it and actually gain the momentum to address some of what we see?
Dr. Courtney Howard: So, I like the way Marshall Ganz talks about the head, the heart, and the hands. When I first started doing this, I mostly addressed people’s heads. So, I would go to the Canadian Medical Association General Counsel with a motion — and I’m a researcher, so I’d have all sorts of appendices of different studies, but people would veer away. It took me a long time to understand why.
Essentially, what I was doing was, I was relaying a diagnosis to them that had potential impacts on everyone they loved, on themselves, and on every patient they would ever treat. So, I didn’t appreciate at the time that I was coming to them with an emotional ask as well as a cognitive and a practical ask.
So, I’m writing a book right now, and in fact, it’s structured heart, head, hands. What I now understand is that really one of the first aspects of this is to grapple with the emotions it brings up for us, to surface the emotions we all have, to talk about them, to help people realize they’re not alone. Those emotions are perfectly normal reactions to a situation that poses a real and practical threat to ourselves and our families. That can help us then explicitly go through a process of grief that most of us will have to go through. Many of us have gone through grief in other parts of our lives, whether due to the death of a loved one or a different type of (circumstance). So, we’re familiar with a lot of the tools that have helped us through those processes.
I’m a dancer, so I’ve always danced when I’ve been upset, (or spent) time in nature, time with my children. When you think about how different allowing yourself time for those activities is than the prevailing ethic within the environmental community, which is work, work, work, work, work, work, work, work, work, you can see how quite different that approach is. So, I really like the approach put forward by a researcher named Panu Pihkala, and he recommends… basically, he says there’s three components to working on climate from an open-hearted place. One is actually doing the work of breathing and addressing anxiety. One of them is action and one of them is sometimes taking a break, having a conscious break.
When I look at it, that’s how I’ve been getting through. It’s funny when you read something that describes, “Oh, actually, that’s what I’ve been doing for the last 15 years.” But it’s helpful because it makes you not feel guilty for taking a break, and it makes you value the emotional work that you’ve put in. It helps you encourage other people, your colleagues, your friends, and coach them through that process.
When I first started, I was not centered in my emotions. So, thinking about it as a physician, I wasn’t as patient-centered or as audience-centered as I really needed to be in order to help other people buffer their emotions. Because at the end of the day, we take action based on how we feel, not based on data. We may strategically choose our targets based on data, but whether or not we do something is all about whether we’re motivated to get off the couch, and that motivation, that is entirely a heart-level affair.
So, surfacing the work of the heart, doing the work of the heart puts each one of us individually in a better place to then walk into a room and be able to center ourselves to the people there and figure out, “Okay, how can I help them do their work of the heart, help us come to a common understanding of the head, and then move from that to a strategic action pathway that we will implement with our hands?” So that, I think, is a way that we can simply end up doing higher quality work in a more compassionate way and end up actually getting more done. So, since I’ve started working with that, things have gotten so much better. Then I start talking about what we’ve already done because…we actually now have a bit of a body of work within climate change and health.
The Canadian Association of Physicians for the Environment was very important in helping to lend the voice of health to the successful phase-out of coal-fired power in the Canadian province of Ontario. So, that’s the single largest decrease in greenhouse gas emissions of any policy in North America.
I did a public policy degree last year, (and realized that) success begets success. It’s like a winning hockey team or a winning basketball team. We start to bandwagon on success. People see that a group is getting stuff done, and they want to help. They want to be part of that. So, what you then get is an injection of resource, financial capital, social capital, human capital, and political capital that allows you to take on a more ambitious next target and gives you a greater chance of getting that done.
It just really builds like that. So, we help to lend the voice of health to our plant-rich food guide. So, Canada now has a very planetary-health-friendly food guide as well as our national price on carbon.
The domestic work helped us move some of that internationally. So, as part of the Global Climate and Health Alliance — which the Canadian Association of Physicians for the Environment helped to found — we are actually the health arm of the Powering Past Coal Alliance. So, we can help to mobilize health actors preferentially from around the world to do similar work to what we did here in Canada. We’re working on doing that in other areas too.
What I’m really excited about right now is the work that we’re doing in healthcare specifically. So, healthcare globally employs about 45 million people who are mostly trusted messengers within their community. So, if you look at those Ipsos-Reid surveys of who is trusted, it’s usually nurses at the top, doctors, pharmacists, and scientists. We’re embedded in communities.
I live in a rural place. There aren’t a lot of climate scientists here, but there are quite a few doctors and tons of nurses. So, we are people who exist at the intersection of science and practice, and we allocate as a global health sector about 10% of global world product. So, I did a pretty substantial paper last year looking at social tipping interventions by the health community.
We really think that because our purchasing extends from electricity to transport to food to infrastructure, if we all move towards a low carbon, climate-resilient way of doing things, we actually have the potential to shift money, to shift thought, and to shift policy to the extent where we can help to tip some of these tipping points within the clean energy sector, clean transportation, and food.
Because we actually build stuff, we actually build hospitals, what happens then is it becomes a visual symbol of the future for people. That influences behavior in an entirely different way than it does when I’m just standing in front of a group of people giving a presentation. It’s a vision that people can start to move towards.
There’s evidence that solar panels themselves go viral, and we’ve actually had that happen. We put some up on our roof and people stop by. They want to know, “How much did that cost? What does your electricity bill look like? Who did it for you? What’s the process?” There’s actually academic work done (that shows) that’s what’s going to happen if you put solar panels up. That’s one of the reasons why once solar panels go up in a neighborhood, you start to see more and more and more.
Ashley Hopkinson: More and more and more.
Dr. Courtney Howard: Yeah, it’s not that different. Honestly, humans work at the individual, organizational, national, and international levels, not that differently than kids do on the playground when someone shows up with a new pair of shoes.
Ashley Hopkinson: Yes. Can you tell me more about some of the “hands work”? How have you built the kind of momentum that makes people want to be a part of the movement?
Dr. Courtney Howard: We had an incredible couple of weeks at COP26. So, a friend of mine who I’ve been working with for a long time, Nick Watts, helped to found the Global Climate and Health Alliance. He was my boss at the Lancet Countdown on health and climate change. He then became the chief sustainability officer for the National Health Service in the UK, which is one of the world’s biggest employers. In Canada, we have 14 medical systems. In the UK, they only have one, the NHS. So, basically, he’s got this investment practice decision tree that I’ve started trying to replicate in Canada. I now appreciate it as an incredible opportunity.
In the UK, they really have been at the forefront of climate change and health since the beginning. They don’t have a strong fossil fuel lobby. So, they’re not walking into the wind the way we are here in Canada or you are in the US. It’s not like there’s nothing, but it’s not the same order of magnitude. So, they don’t have a ton of jobs in extraction. Coal isn’t nearly as big a thing as it used to be. Their academic community and their health community have been able to do a much more thorough job at quickly getting the work into mainstream institutions, (like) universities and hospitals. So, they actually carbon footprinted their whole health system. Over 10 years ago, a man named David Pension did that, and Nick did a Master’s with David Pension and ended up, when they decided to scale it, getting hired to do it.
Canada still only has vanishingly few people getting paid to do this. Nick had 170 staff and 10 years of data. So, he showed up at COP26 in Glasgow with a prototype of their zero-emissions ambulance — it’s gorgeous, shiny with all of the appeal of a cool truck that either a kid has or that anyone has. This gorgeous and wonderful paramedic who’d helped to design it showed everybody…how this is ergonomic and just better for everybody’s back, and this is how it works. They were parked in the parking lot.
At the same time, we had a sign-on asking countries to commit to a WHO program that was co-sponsored by the COP presidency on climate-resilient, low-carbon health systems. We thought maybe eight countries would sign up, but the U.S. actually signed on at the halfway point.
I think (we had) some of the known communication advantages of the health frame: everybody wants to be healthy, everybody wants the world to be healthy. There’s tons of studies that show that. We had this clear vision of the future that (attendees are) walking past on their way to and from different meetings. So, we ended up with 50 countries signing up. So, what happened then was between COP26 and COP28, which we just had, everybody had to try to figure out what to do. So, the WHO created a secretariat. Everyone who knew what they were doing became part of it.
Because the countries actually committed, they’ve made an external commitment, they have to deliver. So, Canada’s all scrambling to figure out what to do. The U.S. is scrambling to figure out what to do. So, we showed up at the first health day at COP28, and 49 health ministers in an official session took two minutes to tell their country’s plan.
Two years ago, I only had words like “climate resilient health systems” said by my best friends. There were five people I could talk to about this. Then there I was at COP28, and I walked in as the minister from Nepal was talking about how they were baselining their country’s emissions.
So, what it shows me is that when you paint a vision of the future that’s credible, and you have proof points that can help people envision it, and you have a clear yes or no question that requires people to learn enough of the material to make a decision, and you have a time-limited process and peer pressure and a couple of powerful first movers, then you genuinely can change the world fast. Having now been part of that, (I) can’t unknow something like that. You can never wake up in the morning ever again and say, “What I do doesn’t matter.” So then you just start looking to replicate it. So, we’ve replicated that.
We’ve used a very similar process to get Canadian medical schools signed on to this thing called the Declaration on Planetary Health. Same thing, they signed on, and then they were like, “What do we do?” That is pretty much the stage a lot of people were at…So, 16 out of the 17 (schools) signed on. (The other is) supportive. They’re still coming to the meetings.
(I was hired) to make the roadmap this last winter, and it is a proper roadmap. That states, ‘these are the structures we need to advocate, we need to build, we need to get funding for this.’ We’re in the midst of the final approval for that. So, it went very, very slowly for a very, very long time. Now it is going very, very fast.
It’s interesting how work at the individual level, community level, national, and international level, how it all influences each other. So, what I’m really appreciating is how aligned work by a group of people at all of these different levels can lead to all of these positive feedback loops that just become a mutually reinforcing wave. We’re in the middle of it.
Ashley Hopkinson: Awareness is growing around the need for climate-resilient health systems, but are you finding any challenges, particularly from the perspective of working at the intersection, as a practitioner, and researcher, all the way down to the middle? How are you managing those challenges?
Dr. Courtney Howard: So, I’m our Canadian Medical Association board member, and it was really hard helping people to realize that the environment is not lateral to the other work that we do but is foundational to it on the agenda.
In fact, the gap analysis that I just did showed that the number one challenge is that senior leaders don’t know what they don’t know. So, we’ve all been unconsciously marinating in a fossil fuel-generated narrative. That’s what people hear from their politicians. That’s what people hear from a lot of the mainstream media. It’s not an evidence-based narrative. They’re unconsciously, particularly senior leaders, working with a mental model that’s actually inaccurate.
Even though my people care about evidence, they haven’t gone to read the Alliance of Planetary Health. They haven’t gone to read the Journal of Climate Change and Health. But because it’s not an actual learning issue for them, they don’t know. Because so many of them control the agenda, it’s this face of power that I again wouldn’t have named until I took Marshall Ganz’s class.
So what has worked has been describing a planetary health nest where the ecological foundations are the foundation of society that then allow us to build the buildings and the educational systems that give rise to the social determinants of health, which is the next layer of the nest. Then all of that enables us to build supply and staff the healthcare systems where we go to work. So, basically, I have drawn this planetary health nest with my hands in every meeting I have been in for five years. Finally, it lands. So, when the surgeon understands, that gives him meaning in life. Because before that, he was seeing it as an environmental thing; something that Greenpeace does. When people understand that this is material to their day-to-day work, that’s when it starts to be able to move into the reaches of the hierarchy that controls the agenda. That has really, really helped.
(Another) challenge related to that is funding because (senior leaders) control the budget. Until those senior leaders have their a-ha moment, people are just doing the work off the side of their desks. I’m still marginally paid to do this work, but I can see that that is very likely to change because there’s just no way we’re going to get done what we need to get done if this is all on the side of everyone’s desk. That was actually one of the main conclusions of the landscape analysis and roadmap that I put together because everyone’s saying the same thing. It’s like, “Look, we have to actually get our health system ready to potentially evacuate for a wildfire.” I can’t do that on my one afternoon every three weeks that you may or may not be paying me for.
So, it’s one of these things where you have to do a fair bit of the work in order to get the senior leader briefed enough that they are convinced that this is worth their investment of social capital, political capital, and financial capital. But we’re just getting there. It’s patchy. It’s already happening over here, but it hasn’t happened at scale yet. (There are) governmental structures that we need to scale. So, we need a federal secretariat to help lead this work. We’ve got one, sort of, but they’re under-resourced too. We need provincial secretariats to help lead this work.
But I think the potential is (in) the communications frame. So, we know that portraying all of this in terms of health is the most motivating narrative frame across population segments across the world. We know that that’s people’s bottom line: they want to be well. They want their kids to be well. They want their families to be well. That’s what we all want: health, safety, and happiness, really.
So, as people to make the connections, it really helps to have the health sector coming on board in a mainstream way, because, really, once you understand the planetary health nest, you understand how all of us contribute to wellbeing.
So, as an urban planner, you can see how your work to create a more walkable environment is, in fact, the work of healing. Same with architects. Same with energy engineers. It’s helping your community become healthier and more well.
I believe the health sector has a strong potential to change the overall mainstream narrative so that it’s increasingly clear (what) we need in order to be able to offer people a good life without exceeding planetary boundaries. (We can) move their heart to actually want to know about (how to take action with their) hands. So, I think as we get better at (helping people) understand what the benefits are of making this transition, and we see more of these visual symbols of what’s working, I think we’re going to see further momentum. This is, of course, happening at a time when Mother Nature is making the diagnosis much more apparent to everybody. You can’t really ignore it. So, she’s driving us here.
(We need to be) as loud as we can be saying, “And this is the pathway to salvation.” Because, of course, we’re up against right-wing strong men who are taking a countervailing narrative saying, “Follow me. I have the answers. Hand your power over to me,” which is tempting for people to do when they’re scared. So, it’s really a moment where we need to be really working together, leaning into the work of organizing, which is something scientists and doctors really don’t appreciate, don’t understand how to do. It’s not a thing within medicine.
Ashley Hopkinson: COVID-19 was somewhat of a tipping point in terms of the connection between health access and economic well-being. There was some investment, but I don’t think the investment was sustained in a lot of these areas where we saw gaps. Do you see something similar happening with climate and environment?
Dr. Courtney Howard: We saw some big investments in climate change and health. There are big commitments, certainly bigger than we’ve seen before at COP28. Of course, (there is a disparity in) climate investment between high-income countries and lower-income countries and within countries between higher-income people and lower-income people, (the latter of whom suffer the consequences of) resource extraction. So, Indigenous communities, Black communities, that’s where people site their fracking. That’s where people site the oil sands. They have less power, and they’re less able to say, “No, not in my backyard.” So, unfortunately, there’s tremendous and mostly unstudied health impact from these resource extraction sites.
I’ve been trying to make the case for these studies for 12 years. I made less progress on that than anything else that I’ve done, although it’s starting to get harder for editorial advisory boards to pooh-pooh it. I’ve been trying to publish commentary on how we need to increase studies into the local health impact of the oil science published for about five years. Publishers are just scared. Do they want to expend their political capital on this? One journal told me that because the entire focus of the article is calling for more studies… “We don’t think you’ve presented enough information to support your thesis.” Really? Really, editorial advisory board?
Ashley Hopkinson: It’s tough.
Dr. Courtney Howard: Yeah. It’s part of, again, this problem that the people in power don’t know what they don’t know. Partly because of that, they’re not willing to spend their capital on it. I think we’re coming to a place where, thank goodness, we’ve been talking about environmental racism more, where it’s becoming much more difficult for people to come up with any narrative for why those studies shouldn’t be done. Once we do the studies, they generally show alarming things, which of course, you would expect in an area with so many known toxic compounds.
At the end of the day, I think a lot of this — at least for the health community and the science community — is about shifting from our mental model, which says, ‘this is about evidence,’ to understanding it’s about narrative and power and that we might not be the right people to lead that.
I went to the Blavatnik School of Government at Oxford, and one of my professors (just) launched a book. All they do all day is analyze power and figure out how to get their own way. That is all they do. Some of the smartest people in the world in a particular building and campus, that’s what they do.
When I’m with the scientists, they’re like, “Why isn’t my study being applied?” These are the conversations we have.
I’m like, “Well, Joe, did you do power analysis? Do you have an initiative? Have you found a target? Have you talked to…” Nope. Well, guess what? It doesn’t jump out of PubMed.
We’ve been brainwashed into thinking that evidence is the answer. Evidence is the first step of an evidence-based solution. Scientists and doctors don’t understand power. It’s not what we’ve been trained to do. They haven’t actually even identified that there’s a skills gap or a resource gap. They’re just confused. They just think that the world should operate according to evidence, and that has to do with the way we’re trained to honor evidence above all else.
Meanwhile, these people often don’t know what they don’t know about what they know.
So, really a lot of it has to do with us bringing all of the smart people into the same room, using words that everyone understands. So, ditching the jargon, ditching acronyms, making it okay for experts to admit that they don’t know things. We’re so siloed, and we put such a societal priority on expertise that there’s a lot of people who are scared to say they don’t understand something.
So, when you have your economist in the room with a scientist, he has to be humble enough and vulnerable enough to say, “Could you please explain what an endocrine disruptor is? Because I actually don’t know that word.” Meanwhile, the scientist needs to be humble enough to say, “What’s a power analysis? Should I be power mapping?”
So normalizing asking “dumb questions,” normalizing that feeling of vulnerability and surfacing it when we’re in those spaces, I think, is really important for us to unlock…this potential energy that exists within these communities that when we bring them together. Because if you don’t name it, everyone’s going to sit there silently just feeling like an imposter and being scared to be outed as not knowing something because their whole life depends on being an expert.
It’s my belief and hope that a shared focus on wellbeing can be the thing that gets us all into the room together and working towards goals that we can all agree on.
Ashley Hopkinson: That’s wonderful. Thank you.
Click here to read the full conversation with insights highlighted.
Ashley Hopkinson is an award-winning journalist, newsroom entrepreneur and leader dedicated to excellent storytelling and mission-driven media. She currently manages the Solutions Insights Lab, an initiative of the Solutions Journalism Network. She is based in New Orleans, Louisiana.
* This conversation has been edited and condensed.
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