Participant roundtable series: Advancing/Planetary Health

Planetary health – Improving human health by healing the planet

The rising impact of environmental changes on human health has become ever clearer in recent years, with numerous dangers stemming from climate change and ecosystem degradation.  The recent Ebola outbreak is but one fearsome example. The dangers range from pollution and ozone depletion, to declining freshwater resources, to ocean acidification and the loss of biodiversity. These trends are not only causing changing patterns of known diseases and health threats. They are raising the likelihood that new, unknown diseases will emerge – Ebola was identified in 1976. MERS (Middle East Respiratory Syndrome) has turned up in the Middle East only a few years ago – and that public health challenges will only increase with continued environmental decline.

Scientists and policy makers are calling for deeper and broader research on the interactions between human health and the rapidly changing planetary environment. As a result, there is a rising awareness that tackling these challenges may require radical new approaches, new ways of thinking and an entirely new discipline.

Why call for a new field of study and action? From the field of “medicine” to the evolution over the past century of “public health,” and onward to the more recent conceptions of “international health” and “global health,” each shift from one conceptual framework to another has sparked fundamental changes in the way the world takes on its most pressing health challenges. In the last century, for example, the creation of the modern field of public health, to which the Rockefeller Foundation’s first initiative contributed, in 1913, involved huge changes in public policy, the creation of new government agencies and programs, transformations in training, and radical changes in public expectations. 

These shifts were driven in large part by industrialization, urbanization and eventually globalization, with each mass trend triggering new kinds of threats to the health of individuals and communities. Now, with massive environmental changes underway with important local to planetary implications the time is right to revisit how we think about human health and how we organize our efforts to support it. 

To consider these questions and address the global public health challenge posed by dramatic environmental change, The Rockefeller Foundation and British medical journal The Lancet co-convened a Commission on Planetary Health, which was launched at a meeting at the Foundation’s Bellagio Conference Center in Italy in July 2014  More than 30 high-level participants, including scientists, entrepreneurs, public health experts, business executives and government leaders met to better understand planetary system disturbances, and to explore possible solutions to future threats. Insights from this meeting are captured in this Visionaries Unbound report (link to report) and will be further explored in more detail in the Planetary Health Commission report, expected in mid-2015.

Fred Boltz, Managing Director for Ecosystems and Claudia Juech, Associate Vice President and Managing Director of Strategic Research, The Rockefeller Foundation

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Health impoverishment, technology and the environment

An interview with Sania Nishtar, founder and president, Heartfile and co-char of the World Health Organization's Commission to end Childhood Obesity

Q: Tell me about health impoverishment and its link to the environment.

A: Health impoverishment describes the heavy financial burden of healthcare. Most developing countries do not provide universal healthcare coverage. This forces most individuals to pay healthcare costs out of pocket, exposing them to enormous financial risk from illness. High debt, bankruptcies, avoiding treatment or the medicines that could help them heal because they are too costly are common outcomes associated with illness.

But health impoverishment can be even more catastrophic with extreme weather because events like storms or floods are often unexpected, and their health impact, on top of other property loss costs, can be severe and expensive. Moreover, these events often trigger massive migrations from affected areas, compounding difficulties covering basic healthcare costs, particularly among the poor and vulnerable.

In my own country, Pakistan, massive floods in 2010 displaced 20 million people over a landmass the size of Italy. At Heartfile Financing, we were equally inundated with requests to help with funds to support injuries related to these floods. Even the well-to-do, who would have otherwise been able to support their treatment, needed to be helped because leaving their homes had stripped them of their ability to pay for healthcare. This is just one example of how an environmental stress can worsen health-related financial risk. 

Q: Part of your work also involves leveraging technology for health. How can technology help reduce humanity’s vulnerability to illnesses triggered by climate change?  Please tell me about a few recent advances in this area.

A: The use of technology in information systems has huge potential. Both big data style early warning systems and public health and sanitary surveillance systems can help decrease human vulnerability to illnesses related to environmental stresses. Some of the recent innovations include health warning systems, integrated surveillance for human and animal diseases, monitoring of water supplies after rainfalls, and air pollution measurements.

Pakistan for example, is one of the top twenty global warming hotspots in the world. Through vulnerability mapping we can better predict extreme events such as floods and droughts due to monsoon variability. The country could also benefit from linking its Geographic Information System with early warning capabilities related to floods. This could provide timely information to disaster management and healthcare agencies. Interactive features to update information dynamically could improve its use, particularly for coordination, to pool resources and to avoid the overlap of costly and complex efforts.

Q: Indonesia is rolling out universal health care.  What role do you believe each sector can play in the provision of health care in developing countries, particularly as concerns illnesses linked to our environment? What innovations are underway that might help create better health care outcomes in a country considering expanded health coverage from the inter-sectoral point of view? 

A: The provision of government-backed Universal Healthcare Coverage (UHC) has normally responded to the national or financial needs of healthcare. But UHC should not be just about care.  UHC should also address how social or other factors influence the quality of our health, including environmental stresses.

Many sectors and institutions could help shift this approach. But the biggest challenge lies in the area of collaboration, which can fortify communication between and collective action by different sectors. This is critical not just for health but for development outcomes more broadly. Governments consist of many fragmented ministries and departments, with little motivation to work collaboratively. The innovation that might make the biggest impact, then, is not a technology-grounded one but one that is process related.  Governments and international agencies need new skills to tap the potential of inter-sectoral collaboration. New development paradigms can help us work innovatively across systems for creative cross-sectoral collaboration. 

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Ecosystems and novel diseases in new places:  How should we respond?

An interview with Fred Boltz, managing director, Ecosystems, The Rockefeller Foundation

Q: How are our ecosystems linked to human health?

A: Natural ecosystems, such as rainforests, coral reefs and rivers, are linked to human health in three key ways.

First, ecosystems produce foods such as fish, fruits and nuts that nourish us.  Ecosystems also produce medicines and the genetic blueprints for pharmaceuticals that keep us healthy.  Both the current and potential uses of these ecosystem “provisioning services” are a key natural asset for human health security.

Secondly, natural ecosystems are reservoirs for disease as well as the animal and insect carriers of disease. Mosquitos and malaria are one example; Lyme disease, West Nile virus, Ebola, bird flu and numerous other diseases also have animal or insect hosts.  When in their natural habitat, these “hosts” are rarely in contact with humans.  Moreover, their natural predators limit the growth of vector populations and, by extension, the potential for transmission of the diseases they carry.  So the state of natural habitats – their plant and animal diversity, structure and climatic conditions – determines their suitability for animal hosts and vectors of disease and their transmission to humans. If ecosystems degrade through, for example, pollution, deforestation, or excessive hunting or fishing, natural predators decline and no longer limit the populations of disease hosts, such as deer for Lyme disease. Moreover, in these situations, humans increase contact with disease carriers such as mosquitoes and ticks. Thus, nature’s ability to regulate certain diseases declines.  The human risk of disease exposure thus also rises.

Thirdly, degraded ecosystems are a direct source of human air and water-borne illnesses.  Respiratory ailments are commonly caused or worsened by air pollution. Many water-borne diseases take root and spread in polluted waters including diarrhea, giardia, schistosomiasis and cholera.  Polluted and degraded lands and waters are superb incubators and transmitters of disease.

Q: Have different sectors recognized the link between climate change and human health? If so what are they doing about it?

A: The appearance of diseases in places where they haven’t historically been makes the link between climate change and health more apparent.  For example, malaria and Dengue fever have been found in Europe, and West Nile virus has occurred along the US East coast.  While we cannot unequivocally say that climate change triggered their arrival, greater incidence of these and other diseases traditionally found in tropical zones in more Northern latitudes will likely be driven by climate change. As countries in higher latitudes become warmer and wetter, they will become a more suitable environment for tropical diseases and their animal and insect carriers.  

Secondly, climate change can increase the exposure of humans to new diseases, because changes in climatic conditions impact the state of natural ecosystems and the species that normally reside in them.  With increasing disease host and carrier populations, a decrease in natural predators and increased human contact, new diseases may emerge. So as the climate shifts so too will the exposure of humans to new health threats.

But this is not very prominent in the public health discourse. That’s why we’re holding this meeting. We’re not well-prepared for the (formerly unlikely) appearance of new diseases and of known diseases in new places, both of, which will become increasingly common with climate change, continued ecosystems degradation and more human disease exposure. Moreover, no longer are diseases restricted to distant locales – someone contracting a new virus across the globe can be in Manhattan tomorrow. Add a rising likelihood of new disease threats to the rapid emergence of pandemics and we have an urgent global public health threat. 

As you look 15 years ahead, what are some possible solutions? What are the obstacles, and how can they be overcome?

One solution is protecting and strengthening the ability of our natural ecosystems to adapt and thrive as the climate changes so that they continue to supply important services like regulating disease, and producing the foods and medicines we need. As the climate changes, natural ecosystems and the species that live in them must be able to change and to shift to new regions. 

Secondly, we need to recognize and react to the possible changes in the occurrence of disease and the emergence of new diseases so that we can prepare for human health threats. If malaria, Dengue and West Nile virus become more common in higher latitudes or new viruses emerge from human-animal interactions, we must be prepared to address them locally and help prevent or reduce their rapid transition to pandemics.

Lastly we need to mitigate known sources of illness triggered by ecosystems pollution and degradation. We need to care for the environment in which we live. 

We can overcome obstacles by prioritizing efforts to address human health – ecosystem interdependencies in global public health policy and by acting to get ahead of this threat. Environmental change must be recognized as a significant global health concern.  We must anticipate new health threats related to global change, prepare for them, and respond proactively. 

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Why the environmental – human health link matters, and what we can do about it
An interview with Andy Haines, professor, London Schooly of Syhiene and Tropical Medicine 

Q: Why should the public care about environmental changes and their impact on human health?

Some years ago the World Health Organization (WHO) estimated that environmental factors contribute to about a quarter of the global burden of disease. These result from established risks like air pollution, insufficient or tainted water supplies, and poor sanitation.

The WHO recently estimated that, worldwide, around 7 million people a year die as a result of air pollution. They die from fine particles in our atmosphere that come from the burning of fossil fuels such as coal or in diesel engines, or from indoor, household sources such as inefficient cook stoves burning wood, dung or coal, particularly in poor countries.

But increasingly scientists and health experts are also studying  the effects on health from major environmental shifts such as climate change, land use changes, biodiversity loss and ocean acidification, due to more carbon dioxide dissolving in oceans.

Q: How do these changes manifest themselves in our daily lives and where is this link most prevalent?

Climate change will result in changes in temperature or rainfall, and in the increased frequency of extreme events such as heatwaves, droughts or floods with a range of potential impacts on human health. The World Health Organization has estimated that in 2000 around 150,000 deaths a year were attributable to climate change from causes such as malaria, diarrheal disease and under nutrition with the potential for increased impacts in the future.

Nutrition is a particular concern because climate and other environmental changes can reduce crop yields, particularly in tropical and sub-tropical regions, and adversely affect the nutrient content of food. For example micronutrients like zinc and iron in some crops are diminished by higher levels of C02 in the atmosphere.

Some projections suggest that, without decisive action, global average temperatures could be four degrees higher by the end of the century, posing serious threats to the well-being and economic development of countries, particularly in subtropical and tropical regions but with worldwide implications. Land use changes such as deforestation are another concern with adverse implications for health and the environment.  Moreover, poorly designed structures such as dams and irrigation projects, for example, increase exposure to a wide range of diseases including those spread by mosquitoes like malaria, because they may increase breeding sites.

How serious is this issue and what can we do about it?

Environmental changes pose a serious threat to health because we are changing the climate and our environment more widely, in unprecedented ways. These changes are impacting many species, as well as the soil and oceans at a time when world population continues to grow, perhaps to around 10 billion by the end of the century.

To help address these problems, governments can implement policies to reduce greenhouse gas emissions and other environmental changes. In many cases such policies can also directly improve health. If we reduce coal burning, for example, we also reduce climate change, fine particulate air pollution, and ocean acidification.

Governments can also develop policies that help us adapt, for example, by reducing crop losses from climatic and other environmental changes. Today, we aren't aware of the full costs of our lifestyle choices and government policies. These are hidden costs. We need to create the right incentives for the private sector to produce products that enable us to change our lifestyle choices for less of an impact on our climate, oceans and forests.

Individuals, for example, can help address the problem by using mass transit and walking and cycling more often. This will both improve their health and the health of their fellow citizens and reduce greenhouse gas emissions. And they can better insulate their homes, so that they use less energy.

Shifting one’s diet away from animal products, like beef, which are responsible for high greenhouse gas emissions, and other environmental changes, in favor of fruit and vegetables – particularly in developed countries – is another way to help improve health and environmental outcomes for both humanity and the planet.

If we are more aware of the impact of our lifestyle choices on the environment today we can help improve the prospects of future generations.

Together we can move forward towards a more sustainable future that benefits both the environment and human health.

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Human connections and collaboration

Overcoming healthy planet obstacles by taking charge

Connectedness defines our world today. We are networked, cabled and linked by air, road, rail and information networks of every kind. Yet, one of the most basic levels of interconnectedness – the link between our health and wellness, and the health of the planet – passes us by.

Our basic connections to clean water, clean air and renewable and replenishable natural systems are often ignored, with obvious consequences.

In Beijing last November, the 3rd Plenum of the 18th Communist Party declared they were entering the Age of Ecological Civilization. And not a minute too soon. The air in Beijing is now hazardous to the health of its citizens.  It is visible, it smells, it burns the throat and causes respiratory problems. But China is not alone.  Many developing countries and even some European cities periodically experience air pollution levels well above safe thresholds.

As the human population grows the need to address health issues manifests itself in many ways. On one end is it the problem of obesity – too many calories and too little exercise, increasing addictions to sugar and ever-rising levels of diabetes.  But in developing countries the challenge of good health is often far more basic:  As populations urbanise and fight for land in densely populated areas their ability to supplement nutrition and increase physical resilience with home grown produce diminishes.

Together, however, local groups are taking charge – and innovating. Moving examples exist everywhere of small communities fighting to clean up their neighbourhoods, restore dignity and livelihoods, and their own ability to feed their families. Reclaiming verges and park land from litter not only provides a better environment but has also helped contribute food for schools and feeding schemes.

Roof top gardening has become quite fashionable in some cities. Apart from allowing trendy restaurants access to locally sourced ingredients, these facilities also have the potential to feed the poor in the inner cities.  Rooftops could also be better used to capture rain water, helping to manage the problems of periodic flooding. Both of these ideas have the potential to overcome the other great problem of our times – unemployment at local and semi-skilled levels.

But health is more than nutrition. It is also impacted by our air and water quality, sanitation and people’s sense of security and their ability to work and feed themselves in safe ways. All developing countries, including South Africa, struggle with this issue. Air pollution, in particular, is galvanizing action.

Worldwide opposition is rising to burning coal, in part because of its links to climate change, but also because of the burden of respiratory disease that accompanies it in most places. That burden seems to fall on the poor more than others. Quantifying the impact is always a challenge but the trends are clear.

But problems such as air pollution can only be overcome by working together.  Health impact assessments and health indicators are part of many country approaches now, but they are notoriously complicated because health is so multi-factoral. But they can help shift the trajectory.

Together, we need to recreate the connection between our health as people and that of the environment– and between the daily choices we make that harm the planet and our health. If we fail to recognize and respond to this connection, planetary disasters and human disease will rise, and along with these, social protests and economic upheaval. The time is ripe to fortify our links, to break the cycle.

Karin Ireton, director of Sustainability at the Standard Bank South Africa

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Science must inform decision-making to save our ecosystems – and our health

For centuries, communities have altered their land and natural systems with seemingly little impact. They have tapped the bounty that nature supplies – or our “ecosystem services” like clean air and water, food, fuel, and even recreation – unabated.  But in the last 50 years things have changed.  We have altered our environment so dramatically that entire ecosystems and their basic benefits on which we depend for our health and development are at risk.  Some suggest we are undergoing a modern-day “epidemiological transition” or a shift in our patterns of health and disease due to ecological changes and globalization.

To make more informed decisions, we need a more calibrated, coordinated approach to both scientific research and policy that shows why ecosystems matter.  The tight interplay between human health/well-being and environmental changes such as global climate change, land use shifts, acid in our oceans, biodiversity loss, and a diminished supply of freshwater as we draw down our resources demands that experts work across their areas of expertise and take a “systems” approach to identify and solve these enormous challenges.  Decision-makers need to ground their plans and policies with the best science.  They need to understand complex challenges and take advantage of opportunities to collaborate with scientists. 

Research on ecosystem change and human health can strengthen tools we already use to help us move towards sustainability.  Systems modeling tools, for example, can help decision-makers understand the interplay between the economic, societal (health and welfare) and environmental impacts of decisions under consideration. Such modeling tools can help decision-makers, technical experts and the public better understand each other’s needs so that they can make better long-term decisions. 

We also need to use sustainability indicators for areas such as resource consumption (such as energy use per GDP or capita) which reflect the interactions between changes in our economieshealth and the environment.  Such indicators can help communities measure progress towards sustainability goals. 

And we need to strengthen the link between the production of scientific knowledge and how it is applied.  Long ago laws and policies to protect water and air quality were created.  Other areas demand more and complex scientific research to inform decisions and policies.  But to produce ‘high-impact’ science – science that matters for decision-makers – decision-makers must be included in scientific research process.  For scientists, this means a new way of engaging government officials to better understand exactly what decision-makers do, how they do it, and what science they need (how deep, how broad, how sure) so that they can act on it.  Depending on which environmental change-human health connections are under discussion, policy-makers from many areas - healthcare, natural resources, land use planning, agriculture, fisheries – may need to be part of the conversation.  Connecting early and often with decision-makers can also help scientists identify when and how to engage with their study plans, findings or data to help move the conversation – and action – forward.

The United Nations’ Sustainable Development Goals (SDGs)or a set of environmental goals governments have agreed to pursue are but one example of emerging opportunities for ecosystem-health science to inform the  development of benchmarks against which countries can measure progress, and to identify tools and best practices to help them get there.  But channeling science into policy demands the joint commitment of scientists, policy makers and those who are implementing their decisions.

One principle underlying the SDGs is the need for innovative collaboration. This means leaders and experts from government, businesses, universities, non-profits and the public need to work together in an organized way.  Such coordination will not only reduce each party’s work load due to less overlap and pooled resources but will also help already stretched decision-makers make and implement better and more effective evidence-based decisions.

Montira J. Pongsiri, PhD, MPH Environmental Health Scientist, U.S. Environmental Protection Agency  Former Science Advisor, U.S. Mission to the Association of Southeast Asian Nations  

Disclaimer:  the information presented here does not represent the official views and policy of the EPA or of the U.S. government.  No part of this article should be considered an endorsement or recommendation by the EPA or the U.S. government.