Johannes Hugo

Professor Johannes Hugo is Head of Family Medicine at the University of Pretoria, South Africa. His work focuses particularly on community-orientated care, including homelessness.

This interview took place on 28 March 2023.

Timestamps

00:00 Introduction

07:46 When did you become aware of the impact of climate change on health?

11:15 What is the impact of climate change on health in South Africa

18:12 What changes do you expect to see in the future?

26:22 How can we mitigate the impact?

27:34 What can we do?

32:53 Any final thoughts?

Transcription

Interviewer:

So if we could just start off with you just saying a little bit about yourself, where you work and what you do.

Johannes Hugo:

Okay, I'm Johannes Hugo and I'm a family physician and I've worked in academic settings since 1989. Before that, I worked in rural health in some mountainous part of the country. And since then, I've been in, first in the family medicine department in the University of, Medical University of South Africa called Medunsa. And since 2006, I'm at the University of Pretoria and I am, I retired as the head of department two years ago, and since then I've been running a community-oriented primary care research unit called the UP COPC Research Unit. And in that I am involved in a large range of projects, which is often implementation type work, implementation research, which through the COVID era, the COVID times, also had its own specifics. We are running a large substance use intervene, community based substance use program in Pretoria or Tshwane since 2016 where we do harm reduction and opioid substitution and all related stuff, which then also links with homelessness and care of homeless people. And in COVID, we then were heavily involved in the care of homeless people in shelters and all the issues around substance use and withdrawal and primary care and all that's related to that. The other thing that happened in COVID is we were working with a mining company which, where we implemented community oriented primary care in mining communities. I mean, the mine has an obligation to support the mining host communities. And that was one of the things that happened. And then when COVID happened, we were on a very short notice, heavily involved with the mines in COVID control and COVID management where we did all the community-based work. If they pick up workers at the mine that were infected, we were taking them home, looking after the families, did the home testing, support the families, home treatment, et cetera. And then also that moved into testing and vaccines and all of those things. That has come to an end now, the end of 2022. But we're still involved in mining communities. And in the development, the whole issue is to develop areas so that when the mine is no more there, that life can continue. So that's one thing. The other thing that I'm involved with is, I think they call it [HPSS], it's population surveillance. So there are, it's long-term surveillance. It's called SAPERIN South Africa Population Research Infrastructure Network. So there are, I think it's now six sites in the country of which three are rural and we were the first urban site. So this is home-based population surveillance on a regular basis. And we do it in the inner city or in an urban setting where we do an inner city high rise building and then a township area, with backyard dwellings, et cetera, and then a large informal settlement area. So that's what we do on that side. And then I mentioned about substance use and then we also starting to develop a one health platform and interventions that's more, yeah, human health, animal health, environmental health, in the platforms where we work and also developing new platforms and transdisciplinary work, et cetera. Yeah, I think - so at the moment, I'm doing limited clinical work, mostly in the substance use project. But I am involved and in touch with a wide range of care. Yeah, and we work on care coordination as a huge thing, you know, between the home, the hospital, the clinic and that type of work. And I'm also exploring what we do and what we develop in terms of complexity theory and the things that goes around that. And we do quite some work on collaboration assessments and facilitating collaboration within organisations or in the health system or etc. And at the moment I'm at the seaside for some time to see if I can do some writing or something. But anyhow, that's where we are.

Interviewer:

Thank you very much. That's quite an impressive range of things. But I particularly wanted to ask you about what you were saying about your environmental work and the one medicine side of things. And I'm interested to know your thoughts on the connection between climate change and health. You know, is that, when did you become aware of that being something that was relevant or important?

Johannes Hugo:

Yeah, in our, in our work, we work with people, for example, from the built environment who look specifically at heat and heat stress and heat and that impact on health and mitigation of heat, especially in the informal settlements. So we are aware that this is becoming a major issue, if not the main issue. And that's why we regard the vehicle of one health, some people call it planetary health, but apparently it's not the same thing, but that's why we are taking the one health thing, because they, you can, I'm, it gives you a framework for that to be to be done and the climate change you know I've always been aware of environmental issues I mean as a family physician the importance of context is there. And the issue of inequities is also related to that. And then the important, I mean, the pain of mining, I mean, mining is such a big thing in Africa and the impact that has, you know, so environment things are upfront there. Where I live in Pretoria, I live in a mountain gorge with natural forest and fantastic diversity of nature and trees and things like that. So I've got that side of it and then the exposure on what is being done on the other side. And then recently the I mean, it just became clear. I am aware of climate change and health action groups. But I do not make the time to participate in that particularly, partly because you can just do that much. So yeah.

Interviewer:

Thank you. So you mentioned there the heat aspect. Is that the main way that you are seeing the manifestation of climate change where you are? And what sort of health implications has that had or is that having?

Johannes Hugo:

I think the one thing of heat is partly because you can measure it and you can work with it and people are doing it. But it is important in one sense because informal settlement housing is at the moment the fastest growing housing development in our province, Gauteng, which is the central province of the country. So it's not whether it's good or bad or whatever, that is life. And that's why we do a lot of our work in informal settlements, and building, basically people build with corrugated iron. So extremes are there. And there's some work about that and the effect on health, maternal health, infant health. But I think there's still very little known. The people who work with the heat issue I discussed with a week ago, they measure these extreme heats or going over their thresholds and its sort of how often do you go over the threshold? That's the issue. But what is noticeable at the moment is that the people who live there don't necessarily complain. So they either have ways of dealing with it by living outside or things like that, or they are tolerant. And so I think it still needs to be seen. I mean, the fact that somebody doesn't complain about hypertension doesn't necessarily mean that the hypertension is not important. So we wouldn't know. But I think heat is one thing we are definitely looking at because it is an issue and we can. The extreme weather thing with the floods is becoming to be quite an issue. I've just read about a village in the Eastern Cape where they had such regular flooding that they would probably have to move the village. And that's a very old village. So it's not an informal settlement. In informal settlements, by nature, you get flooding because they built in flooding areas because it's open. So flooding, definitely. Whether we would then look at waterborne diseases is another thing. And then the whole area of zoonosis. That's why the collaboration with veterinary science and with virology, et cetera, is important. So yeah, those are the things that I'm looking… and then I think also that, that's not, environmental, environmental health has a very important impact on people in informal settlements and poorer areas in our part of the world, because environmental management just doesn't happen. I mean, if you talk sanitation, refuse removal and all of those, but I mean, you can't classify that as climate change stuff. It's just pure environmental management. But I think that the changes, which would also be economic changes, you know, economics at the level, at the level of inequality and poverty that we see or deal with you, you are very close to a threshold that economic changes just directly impact on health, access to health and food security and those things. So we are, we are starting to look at that. I mean, the point is you, will you think you look at it and then it reaches a tipping point that you didn't expect or things are just, I mean, that's why I try to school myself in complexity theory about that. So yeah, heat we're looking at, but we are clearly aware that there are other things. It also depends on where. I mean, we work in the mine. You get mines in the semi-desert areas and heat is definitely an issue there. But then also droughts and those type of things. Yeah. Maybe the conclusion is that I know there's a lot happening, but I don't know detail about a lot.

Interviewer:

Thank you very much. So this, what I'm about to ask probably slightly contradicts everything that you've just said when you're talking about the complexity of it all. And it's a slightly impossible question, but I'm just curious what your thoughts are in terms of what we might see, you know, in 5, 10, 20 years time. You've talked about what's happening now, do you have any thoughts on how things are likely to progress in terms of the impact of climate change on health?

Johannes Hugo:

The safest question is that we don't have an idea, but we need to at least attempt ideas. I think the human people, I don't know, do you call them a human race or the human species or, probably doesn't demonstrate the ability to respond. I mean, you think that people would respond, but they don't. And I think the political developments globally in many, many, many, many countries is just of such a nature that, to think of, would King Henry the VIII have worried about the environment? I don't know. You know, obviously the likes of Putin and many other people just don't have a concern. And they influence what happens in the world. Whether you like them, they actually impact on what happens. And it is not as though it's an isolated issue, it's a trend. You have your issues in the UK and we have it in our country. It's not just political power, it's criminality actually. I think the criminality element of power, human power in the world, is just becoming more visible and explicit, obviously. It has been there for millennia. But I think the combination of that as well as the pressure of people, I'm expecting things to worsen more rapid than we would have hoped in terms of that. What we will see, I think hunger is probably going to be one of the important things that will indicate that things aren't working or that, the damage to infrastructure could also significant influence development and stuff. I mean, we see this in our country that the combination of poor governance and criminality and non-maintenance and then on top of that you get these more frequent natural disasters, means that infrastructure is deteriorating. Now what that impact would be on environmental health is devastating because of the sewage. Sorry for the pun, but the sewage mess. And then you get similar things around transport, but then the health impacts of those. We could, I think we could expect more local health outbreaks type things, cholera and those type of things. Malaria distribution could also change significantly. And yeah, I mean, the previous week we had the Cyclone Freddy that just repeated itself like never before, Malawi, Mozambique. We didn't have a lot of that in South Africa, but I mean in Malawi it's quite disastrous. So the point of that is that these things become more frequent, so that's going to have an impact on economic development, the availability of food and work. So what was gained in terms of development on the vulnerable in a place like Africa is reversing fast. And that is now after COVID with what that happened, you know, the COVID, so, but that will also depend on how resilient local populations are and whether we will get more of local autonomous responses because that's just, that's just the only option that's there. In Africa, I don't see the formal public response being able to do anything useful because it's already struggling because of what I explained. And then, yeah, so, and then what would be, what are the interests of China, Russia and America in all of this? And would they, so I think it's probably complexifying in that sense, but if we want to mitigate that, that's really the question. I mean, where do you start? I think to prevent it, I think it's out of our hands and I am actually negative about that. So yeah, I just quickly looked at the, no, I just saw that there's an article on the review of primary health care and climate change responses in Africa. And there's very little that actually happens. There's some things written about. Being in primary care, I think that's where we will see the trouble and we'll have to deal with it. Yeah, I don't know. I think I'm rambling.

Interviewer:

No, it's very, it's very, very interesting. Thank you. So, you've touched on this already, but before we finish up, I just wanted to ask, you know, if there is anybody watching this who wants to be proactive, who wants to do anything, I know that you were saying that, you know, there's an element of sort of almost fatalism sometimes to it. But is there anything on a governmental level, on an institutional level or on a personal individual level, which you think people can do or should be doing that would have, on some level help or have an impact?

Johannes Hugo:

You know, I mean, obviously we respect the humans around us, but I would say respect the non-human life around you, that to me would be… I mean, in the millennia before, people actually respected their land because the land looked after them. But nowadays, our life is just so totally out of touch. That to me would be one thing. I mean, how do you change behaviour? How do you drive less or how do you develop a city? So maybe I would say at least scientists, which they probably are doing, I mean, they made the point now about climate change coming and they are not believed, but that's fine. But I think it's now a matter of working a lot on mitigation. What are you going to do in your community if things change that much? And yeah, I don't know if the ordinary people can actually do something about the global thing or the internet... I mean, we... the corruption in society has got a direct impact on the environment and climate change because it's about fossil-based energy and it's about getting resources from the soil. And okay, so I think at least be vigilant and if you can talk, talk, but for yourself and your family, embrace the trees and the bugs and the sky and whatever. In terms of health, be prepared that you won't, you will be caught off guard, but at least think about how what's changing in your practice or in where you work and how that can, and how that's going to change and how you can respond to that. Again, it sounds a bit lame to me, but I don't… okay, maybe, maybe, maybe if you look at if you look at complexity, perhaps we should be more vigilant to look at emergence. See what is emerging somewhere that is unexpected and that may help. I mean, to me, that's probably the only thing that could give me hope is to say that there are things going to happen that I don't know about that may either wipe out two thirds of human beings, which would be sad, but that may be the only solution or actually bring solutions. So read complexity and watch for emergence.

Interviewer:

Thank you very much. So I've run out of things to ask you now. Is there anything that you haven't already said on this subject that you'd like to say or anything that I should have asked that I haven't asked?

Johannes Hugo:

No, I think I've said that. Maybe I just now remember when we had that session that came before, I was very interested in the work that the anaesthetists were doing. So I think the people that are working on this, what I would call detailed investigation of the impact of the actual health or medicine practice, I think that's necessary. Actually all these medicines and things, I mean, that I think that work is important. I'm not doing that. But if that work is done, that needs support because it's tangible and it can be cumulative. And the important thing of that is the UN or the COP [show number thing] with all these heads of state flying there with their own airplanes and the motorcades going whatever, so if then as health workers we say we're interested and we want to work for climate change, but in our practice, we kill the world, then it's a contradiction so I think that work that's done, I would really support. I'm not in that, but I would support that and I would watch that and I would, yeah. I think that's what I wanted to add maybe.