Planetary health care and Barbara Starfield´s legacy


Barbara Starfield advanced academic scholarship on the role of primary care in health systems and universal health coverage. Her research on equity contributed to evidence-informed health policymaking1. On June 10th 2021, we commemorate her 10th death anniversary.

Starfield described four attributes of primary care- first contact, continuity of care, comprehensiveness, and coordination – and three derivative attributes – family centeredness, cultural competency and community orientation2. In these times of worsening environmental problems that affect health, primary care must be updated to meet the demands of the Anthropocene – the current geological era connoting the enormous impact of human activities on human and ecosystem health3. The new field of planetary health (PH)4 not only seeks to address these 21st century challenges but also reestablishes humanity’s lost connection with the health of the planet, an essential value that has been embedded in indigenous wisdom for millennia5.

Primary care tackles root causes of ill health by caring not only for patients but also for their families, communities and societies. Today in the era of PH, this commitment must be extended to include the care for the ecological systems that sustain humanity’s health.  A declaration made by the World Organization of Family Doctors (WONCA), called  for action on planetary health6. To encompass this new role, it is time to consider adding an eighth attribute – Planetary Health Care (PLHC) – to Starfield’s primary care framework (Figure 1).

Figure 1. Planetary Health Care (PLHC) as the eighth attribute in Starfield’s Primary Care Framework

PLHC must be underpinned by key PH principles such as interconnection within nature, equity and social justice, systems and complexity thinking, acknowledgement of the state of health in the Anthropocene, and movement building and systems change – which are core domains in a newly developed framework for PH education by the Planetary Health Alliance7. These principles, especially equity, are very much aligned with Starfield’s essential primary care attributes.

In the coming months and years as the current global health crisis ensues, PCPs can demonstrate PLHC by harnessing their innate advocacy role to ensure that COVID-19 is the ‘last pandemic’ that humanity will ever face8. The clarion call from PCPs must emphasize on ‘deep prevention’9 by advocating for mitigation of climate change, biodiversity loss and land use change – which create conditions for the emergence of new outbreaks. The protection of these planetary boundaries requires major societal transformations such as shifting towards renewable energy, adopting the ‘planetary health diet’10, and sustainable urbanization. This advocacy role also intersects with a concept that is more familiar with PCPs – primordial prevention, which pertains to protecting entire populations from health risks in the first place11.

Another aspect of PLHC is ensuring that healthcare does not contribute to the planetary crisis through its own ecological footprint. It is estimated that the combined healthcare systems of all countries generate 4.4% of the world’s total greenhouse gases. If the healthcare system was a country, it would be the fifth largest emitting nation12. Beyond carbon emissions, the healthcare sector  also contributes to other forms of environmental pollution13. To ‘do no harm’ not just to patients but also to the planet, primary care must be recognized and strengthened as a corner-stone of climate-smart healthcare14.

PLHC also intensifies primary care advocacy around disease prevention and health promotion. This strategy will not only contribute to the achievement of Sustainable Development Goal 3, but will also reduce the demand for health services and eventually reduce healthcare’s emissions15. Routine evidence-based medicine inside the clinic, optimizes care, equity and prevention, all of which can generate significant co-benefits for both patients and PH16,17.

Ultimately, PLHC requires PCPs to interrogate the current political economy that drives PH damage and foster alternative blueprints for a healthier future18. In the same vein that primary care is founded on the right to health, PLHC must be underpinned by a social movement guided by the principles of human rights, recognizing that health is inextricably linked to the enjoyment of the right to a healthy environment19. PCPs can be in the forefront of whole-of-society activism for PLHC.

Dr. Starfield revolutionized thinking and practice around primary care health systems, and health equity. In the era of COVID-19 and climate change, the addition of PLHC as a key tenet of primary care is both a fitting tribute to Starfield’s legacy and a necessity for our future.


Enrique Falceto de Barros is a Family Doctor and  Professor of Medicine in Universidade de Caxias do Sul and Chair of the World Organization of Family Doctors (WONCA) Working Party on the Environment.

Mayara Floss is a Family Doctor and  a PhD candidate at the Universidade de São Paulo, member of the WONCA Working Party on the Environment, and coordinator of the WONCA online course “Planetary Health for Primary Care.”

Renzo Guinto is an Associate Professor of the Practice of Global Public Health and Inaugural Director of the Planetary and Global Health Program of the St. Luke’s Medical Center College of Medicine-William H. Quasha Memorial in the Philippines.

Tatiana Souza de Camargo is a biologist and  Professor of Science Education at Universidade Federal do Rio Grande do Sul, Member of the Planetary Health group at the Institute for Advanced Studies at Universidade de São Paulo.

Marcelo Rodrigues Gonçalves is a family doctor, PhD in epidemiology, professor at UFRGS, scientific coordinator of TelessaúdeRS-UFRGS.

Alan Abelsohn is a Family Doctor and  Associate Professor of Family and Community Medicine at University of Toronto and Provost of the WONCA Working Party on the Environment.

Airton Tetelbom Stein is a Public Health Professor at the Federal University of Health Sciences of Porto Alegre and family physician of Conceicao Hospital.


We thank members of the WONCA Working Party on the Environment and the Planetary Health Alliance for additional inputs and feedback .

Competing Interest : None

Handling Editor : Soumyadeep Bhaumik

Provenance : The article is not peer-reviewed


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