Why we need a fossil fuel non-proliferation treaty.

Deaths from heat waves, hospital evacuations due to floods and wildfires, asthma exacerbations from heat-amplified air pollution, drought-related malnutrition emergencies, changing patterns of infectious disease—every year it becomes clearer why pollution and climate change are the greatest threats to health and health systems of our time. Many health benefits are expected if average global temperature is kept closer to 1·5oC than 2oC above preindustrial levels. Concerningly, in the latest Intergovernmental Panel on Climate Change (working group 1) Assessment Report only the lowest emissions scenario shows temperatures staying below 1·5oC, and this is only after a brief period of overshoot. Globally, plans exist to produce more than double the amount of fossil fuels in 2030 than would be consistent with limiting global surface temperature warming to 1·5oC.

The power of the planetary health community has not been fully harnessed to protect health and health systems from fossil fuel-related pollution. This failure is particularly problematic when considering people who are disproportionately affected and have done the least to cause the problem, including Indigenous land defenders, people in low-income and middle-income countries (LMICs), young people, and those yet to be born.

A Fossil Fuel Non-Proliferation Treaty has been proposed as a mechanism to effectively and equitably ensure safer amounts of fossil fuels remain in the ground. Precedent is set by the Nuclear Non-Proliferation Treaty, which was positively influenced by global relationships among health practitioners joined in common cause. The International Physicians for the Prevention of Nuclear War were awarded a Nobel Peace Prize for their efforts in 1985. Support for the Fossil Fuel Non-Proliferation Treaty is one mechanism via which the global health sector can be allies to those who are vulnerable and deliver the healthy response to climate change that our patients require.

Support of the Fossil Fuel Non-Proliferation Treaty can be indicated via sign-on at the individual, organisational, or jurisdictional level. The call for a treaty has now been endorsed by WHO and more than 100 Nobel laureates, as well as by academics, health organisations, and individual health workers from around the globe.

The initiative has three pillars. The non-proliferation pillar aims to end expansion of fossil fuel infrastructure and production. This pillar will probably require the creation of a global public register to map fossil fuel reserves. Regular analysis, similar to that reported in the Emissions Gap Report, conducted by a body such as the International Energy Agency or the UN Environment Program, could identify whether countries’ aggregate production phase-down targets and policies align with a 1·5oC scenario. The fair phase-out pillar would direct a coordinated reduction in fossil fuel production, and could include extraction limits and the removal of fossil fuel subsidies. The just transition pillar would support employment and the social and structural determinants of health. A new Global Transition Fund could operate as part of the UN Green Climate Fund, with additional funds coming from redirected fossil fuel subsidies or collected via a global carbon tax. Paired with increased funding for adaptation, attainment of development goals requires massive expansion of initiatives to enhance low-carbon energy and transport in LMICs, growth which could be catalysed by this initiative.

Planetary health-focused policy work by the health sector to drive decarbonisation has often centred around demand-side interventions seeking to reduce consumption of fossil fuels via a transition to lower-pollution options for energy, food, and transport. These interventions have been supported by narratives around reducing climate-related impacts to health and health care, as well as maximising the health co-benefits of transition, including savings to health systems. Given the emergent need to save lives from pollution and climate change-related harm, we must learn to employ both supply and demand-side interventions. Analysis suggests that compared with demand-side interventions, policy instruments targeting fossil fuel extraction might have greater public acceptability as a result of clear concrete mechanisms, an appreciation of local negative effects of fossil fuel extraction, straightforward measurement and accounting, and the perception that a higher proportion of costs will be borne by industry. By mobilising supportive constituencies domestically and fostering international cooperation, supply-side policies can create positive feedback effects that expand the politically feasible set of climate policies over time, and should thus be adopted immediately.

The local health effects of fossil fuel extraction are understudied, particularly with respect to Indigenous groups, low-income communities in all countries, and in LMICs. Research tends to focus on single discrete toxic exposures, neglecting cumulative effects and the effects of disrupted ecosystems and compromised determinants of health. The mismatch between timelines involved in research and those guiding project approval leaves advocates leaning heavily on the precautionary principle, without the local data required to effectively counter narratives around the potential economic and employment benefits of projects. Substantial power imbalances often exist between project proponents and communities, which manifest as vastly unequal resources for study, communications, and lobbying to influence decision makers. Economic disparities resulting from colonialism might lead communities to support projects despite known harms, with consent granted because of an absence of other options.

Where there is power there is push-back: Indigenous land defenders and environmental activists have been harassed, targeted, and killed, and physicians advocating for planetary health on behalf of the communities they serve have had their employment and licenses to practice threatened. Adding the Fossil Fuel Non-Proliferation Treaty to the toolkit will allow planetary health advocates to influence supply-side discussions bolstered by a global consensus around the necessity of fossil fuel phase-out for planetary wellbeing, normalising the work, providing safety in numbers, and changing the power dynamic.

Near-term health benefits are expected from a reduction in fossil fuel-related pollution; it will decrease toxic discharges into water from extraction and downstream industries related to fossil fuels, such as petrochemicals, plastics, and pesticides. The almost one in five deaths worldwide found to be due to fossil fuel-related air pollution in 2018 will be reduced. Reductions in fossil fuel-related pollution might also improve aerosol-perturbed rainfall patterns, enhancing water and food security in densely populated regions of India, northern China, central America, west Africa, and the Sahel region. Particularly meaningful benefits to the social, structural, and ecological determinants of health could be seen in communities with a strong connection to land and country, as is the case with many Indigenous people.

From nuclear disarmament to tobacco control to mercury phase-out, the health sector has a history of advocating for healthy public policy on behalf of its patients. We are privileged to bear responsibility for health at a moment when action taken to leave fossil fuels in the ground can play a definitive role in improving health not only now, but for all future generations. It is time for the planetary health community to apply time, money, and talent to the support of the Fossil Fuel Non-Proliferation Treaty.

We declare no competing interests.