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2 OVERVIEW OF THE LINKS BETWEEN SUSTAINABILITY AND HUMAN HEALTH This chapter provides an overview of past events and existing frameworks that make linkages between sustainable development and human health. The chapter opens with insights into the global sustainability movement, followed by comments on how to turn the global spotlight to environmental health and sustainability issues through primarily U.S. policy processes. The role that climate change plays in sustainability and health is then outlined, and additional speakers make connections to noncommunicable diseases, economic productivity, and systems frameworks. The chapter closes with a brief discussion of these varied areas and perspectives. RIO+20 AND HEALTH: ROADS LEADING FROM THE RIO EARTH SUMMIT IN 1992 TO 2012 Wilfried Kreisel, Ph.D. Consultant, Energy and Health Former Executive Director, Health and Environment World Health Organization Wilfried Kreisel explained that during the events leading up to the Rio Earth Summit in 1992, health was not a primary concern of the global sustainability movement. He noted that the environmentalists and conservationists governing sustainability advocacy did not directly focus on health issues, so health and sustainability remained detached. For instance, the 1987 report Our Common Future by the World Commission on Environment and Development confronted challenges ultimately 5

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6 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY presenting health harms such as toxic wastes and food security, but it did not specifically address health (WCED, 1987). This report became one of the major foundations for the 1992 Rio conference, he said, presenting an uphill battle for placing health on the agenda. Kreisel stated that in 1989, the World Health Organization (WHO) Director-General, Dr. Hiroshi Nakajima, made the crucial decision to entwine health and environment as one of its key program priorities. Kreisel pointed out that this provided the opportunity to look more in depth at health and the environment. He noted that founding of the WHO Commission on Health and Environment followed. Its task was to review the linkages between the environment, health, and development, which also spurred the creation of expert panels to analyze these links and prepare reports for the 1992 Rio Earth Summit pertaining to food and agriculture (WHO, 1992a), energy (WHO, 1992b), industry (WHO, 1992c), and urbanization (WHO, 1992d). Leading up to 1992, it was the work of these commissions, panels, and groups that laid the foundation for emphasizing health at the Rio Earth Summit. Kreisel noted that work from the WHO Commission on Health and Environment was used to influence Agenda 21 and the Rio Declaration, the ensuing documents from the Rio Earth Summit. Health became the cornerstone of Principle 1 of the Rio Declaration, which states that “Human beings are at the center of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature” [emphasis added] (UN, 1992). He explained that Agenda 21 covered diverse, broad issues, including conservation and management of resources for development, social and economic dimensions, and means of implementation, all converging on health (UN, 1993). Each of the chapters of the agenda concentrated on chemicals, fresh water quality, managing hazardous wastes, and the protection of atmosphere, and all explicitly made linkages to health (UN, 1993). Chapter 6 was devoted to protecting and promoting human health, and contained five broad priority program areas (UN, 1993):  Meet primary health care needs, particularly in rural areas.  Control communicable diseases.  Protect vulnerable groups.  Meet the urban health challenge.  Reduce health risks from environmental pollution and hazards.

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 7 It should be noted that noncommunicable diseases and climate change were not included with the other health topics in Agenda 21. Kreisel noted that the goal was to comprehensively develop an intersectoral plan of action for health and emphasize the need for disease prevention over cure. He stated that Agenda 21 was one of the broadest agendas for action developed to date, and despite being 20 years old, needs little refinement today. In the years following the Rio Earth Summit, Kreisel explained, WHO acted assertively to grow the seeds that had been sown. The World Health Assembly Resolution on Health and Environment was issued in 1993 (WHO, 1993). WHO then developed a Global Strategy for Health and Environment in 1993 (WHO, 1993) and a corresponding Action Plan in 1994 (WHO, 1994). The regional offices followed by developing regionally appropriate strategies. At the national level, more than 100 environmental health action plans arose around the world (WHO, 2002). He stated that fledgling coordination between local, regional, and global entities also emerged, as was represented by the Intergovernmental Forum on Chemical Safety (UN, 2000). In 2000, the Millennium Development Summit gave rise to the Millennium Development Goals (MDGs) (UN General Assembly, 2000). Kreisel noted that the eight health-related MDGs focused on issues such as poverty, primary education, and environmental sustainability. Two years later, the MDGs were reaffirmed in Johannesburg at the World Summit on Sustainable Development (UN, 2002). He explained that this summit was a milestone as countries recommitted to agreed targets to reduce HIV prevalence, improve chemical production and risk assess- ment procedures to reduce harms to human health and the environment, and enhance cooperation to reduce air pollution. Although there has been much progress working toward the MDGs, Kreisel stated that there are still sizeable implementation gaps. He noted that many member states do not affirm that public health and its linkages to the health of the environment are central to sustainable development. Additionally, the health sector has yet to play an active role in sustain- able development policies and strategies. He explained that convergence of economic and social development with environmental protection and health has been limited, and there is little coherence between environmental and health policies. Dissociating health and environmental concerns has limited the advancement of the MDGs, he said, and many countries are not on pace to achieve key goals. Of the 84 countries for

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8 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY which data are available (out of 144), only 45 are on track to reach their poverty-reduction targets (World Bank and International Monetary Fund, 2009). Looking forward, new and emerging challenges, in particular climate change, have been exacerbated in developing countries by poverty, the rapid pace of rural and urban migration, competition for scarce resources, and the concomitant challenges to provide food, infrastructure, and access to basic health, water, and energy services (UN General Assembly, 2010). In addition to poverty concerns, there is a struggle to mitigate the equity gap within poor countries, where narrow- ing wealth disparities within a nation has become paramount. Kreisel stated that the time has come not only to review and assess what has been achieved on the basis of the “spirit of Rio” put forward in 1992 but also to build upon it and revive its promise of integration, unity, and aspiration (UN General Assembly, 2010). He noted that the excitement and hope experienced 20 years ago are needed to tackle modern crises and recommit political will to sustainable development. Today, problems are often discussed as though they are separate, but climate change, biodiversity loss, and scarcity of raw materials are really one and the same problem. He explained that effectively integrated, intersectoral policies are needed to address these problems—only then is sustainable development achievable. The convergence between the three pillars of sustainable development—environmental, social, and economic—is a concept of the green economy. Unfortunately, some developmental and social dimensions, in particular poverty eradication and health, have not been adequately covered in some of the policy prescriptions on the green economy (UN General Assembly, 2010). Kreisel emphasized that it is imperative that the centerpiece of sustain- able development be health, and health be linked to all three pillars. To further health in the sustainable development arena, Kreisel stated that the health sector should review and clearly present evidence about the health consequences of climate change and the expected health impacts of mitigation strategies. Within the economic sectors of transport, electricity generation, and housing, he said, there are large and instant health co-benefits to adopting green economy policies. He noted that the health sector could become an energetic supporter of this budding green economy and help to galvanize public investment in sustainable infrastructure (including public transport, renewable energy, and building retrofits to improve energy efficiency) to mitigate and adapt

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 9 to climate change (UN General Assembly, 2010). Encouraging green economy actions has the potential to  avert a large proportion of chronic obstructive pulmonary disease due to smoke from indoor cookstoves (Wilkinson et al., 2009);  reduce cardiovascular and respiratory disease from air pollution as private motorized transport is replaced by walking, cycling, and public transport (Boone-Heinonen et al., 2009); and  improve health equity by lessening exposure to pollution and expanding access to clean air and water, nutritious food, and health care facilities (WHO, 2011b). Kreisel stated that when communicating the potential health benefits from the green economy and concomitant mitigation of climate change, it is paramount to restructure the arguments within a health paradigm. He noted that evaluation of health effects touches the core of a debate that has stalled climate change negotiations—the debate about who gains and who might lose—but health co-benefits present a “win-win” situation for most people, in particular those in developing countries. As WHO prepares for Rio+20, Kreisel said, it focuses on and advocates for health in all policies. He stated that policy decisions in other sectors really affect health outcomes, and health governance through healthy public policies needs to be maintained or improved. As mentioned, emphasizing the health co-benefits of the green economy is of great importance. He noted that it is also imperative to advocate for the prevention of environmentally and occupationally related diseases, since approximately 24 percent of the global burden of disease can be avoided by known cost-effective environmental and occupational health interventions (Smith et al., 1999; WHO, 2006). Additionally, he said, the health sector should lead by example by greening itself and reducing its ecological footprint. Moving forward, Kreisel stated, the strategies described here have the potential to improve global health and the health of the planet.

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10 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY UNDERSTANDING THE GLOBAL COMMITMENT TO ADDRESSING ENVIRONMENTAL AND HEALTH ISSUES David J. van Hoogstraten, Esq. Director, Policy and Regulatory Affairs BP Wind Energy, North America, Inc. David J. van Hoogstraten began by addressing how to turn the global spotlight onto environmental health issues, since it can be challenging to get people’s attention. He asked the question of whether it takes a critical event or a series of events that need to be addressed urgently to capture the attention of people, or if it requires the media to fan the flames of concern. Van Hoogstraten noted that with regard to climate change, he believes that a catastrophe or large forcing event is likely needed for the United States and the international community to place this on the global agenda. He pointed out that climate change, and ozone depletion as another example, are clearly global issues that cannot be addressed by other frameworks and mechanisms at the country level, even if countries act bilaterally or regionally. However, many areas where the global community has focused in recent years could have been dealt with regionally or bilaterally, such as transboundary movement of hazardous wastes, protection of biodiversity, and prior informed consent for the transboundary movement of toxic chemicals and pesticides. He explained that in order to be placed on the global agenda, the global environmental health issue needs sufficient political will and media attention, in addition to cataclysmic conditions. For the first 50 years after World War II, international environmental efforts primarily relied on the working of the United Nations and the World Health Organization. Today, there is a large network of nongovernmental organizations (NGOs), including the World Wildlife Fund, Greenpeace, the United Nations Foundation, the Bill and Melinda Gates Foundation, and the Clinton Global Initiative, that have invested in the past two decades in sustainability and poverty elimination. Van Hoogstraten pointed out that often these organizations have been able to launch programs and provide services that governments used to deliver. A number of avenues are available to accomplish their goals; for example, these NGOs have used the power of the Internet to connect with and inform the broader public. Those investments have sparked the media’s attention, and the NGOs now have a continuous and growing following.

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 11 Van Hoogstraten added that these efforts have paved the way to allow for greater public participation in current efforts and solutions. Current Situation for International Environmental Agreements In order to understand the mechanism behind getting the international community to address an issue, stated van Hoogstraten, you need to understand the global environmental health treaty process, and multinational environmental health and safety agreements. He noted that the institution through which new environmental issues are placed on the global agenda has historically been the United Nations Environment Programme (UNEP) Governing Council. At the annual governing council meeting, proponents of a particular approach propose the adoption of a binding or nonbinding resolution to an international environmental or conservation challenge. When consensus on negotiating an international agreement is reached at the governing council, an international negotiating committee (INC) is appointed. The INC is composed of appointed representatives (often led by UN General Assembly members) who develop a negotiating schedule, which can run over a couple of years. Van Hoogstraten stated that the INCs have been criticized for including members who are neither conversant with the issues nor authorized to speak for more powerful segments of their governments, but noted that there appears to be better coordination today. Van Hoogstraten explained that at the country level, for coherent national positions to be developed, treaty negotiation requires coordination among various agencies with very different mandates. In the United States, negotiations begin at the State Department by invoking the Interagency Circular 175 (or C-175) process. The C-175 process outlines regulations developed by the State Department to ensure the proper exercise of the treaty-making power. Specifically, the Circular 175 procedure seeks to confirm that the making of treaties and other international agreements by the United States is carried out within constitutional and other legal limitations, with due consideration of the agreement’s foreign policy implications, and with appropriate involvement by the State Department. (U.S. Department of State, 2012)

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12 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY The Department of State developed a handbook, Supplementary Handbook on the C-175 Process: Routine Science and Technology Agreements, in response to a National Research Council report The Pervasive Role of Science, Technology, and Health in Foreign Policy: Imperatives for the Department of State (NRC, 1999) that recommended the streamlining of the process and an interagency review of proposed international agreements. The C-175 process is very intricate, van Hoogstraten stated, with complicated interagency involvement to assess the impact a proposed agreement may have on international trade, economic affairs, defense, the environment, and so forth. In the United States, van Hoogstraten noted, political factors including the lack of bipartisan consensus on international environmental issues has prevented the ratification of many international environmental and conservation agreements. Furthermore, for the United States to be- come a party to any treaty, it must be ratified by the U.S. Congress. Van Hoogstraten explained that this has proven extraordinarily difficult, even in cases when other countries have taken major steps to accommodate U.S. positions during the negotiation process (which has hurt U.S. credibility), and exemplifies the need to communicate with Congress as agreements move forward. Van Hoogstraten noted that even upon joining a global environmental agreement, the enforcement mechanisms remain weak and there is little leverage to influence outcomes and action. Generally, he said, moral persuasion of peers and the spotlight of world opinion (often made brighter by the Internet) are what prompt countries to adhere to these agreements. Making the Case for Environmental Health in Rio+20 Van Hoogstraten explained that the Rio+20 conference is a convocation of countries getting together to develop a plan of action that will not be legally binding, but will be binding as a political statement. Unfortunately, he noted, this conference could not fall at a worse time, given the current economic climate and lack of media focus and grassroots demand for concerted government action with respect to global environmental issues. The preparations made by the United States for the Rio+20 conference have involved mainly the Environmental Protection Agency (EPA) and the Department of State’s Bureau of Oceans and International Environmental and Scientific Affairs. Beyond this, there has been limited involvement from other agencies and high- level political officials.

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 13 Despite these difficulties, Rio+20 still presents opportunities to elevate health issues onto the global environmental agenda. Van Hoogstraten noted that green energy development and green technology may play an important role in the context of sustainable development. However, there is a need to rebrand these issues in order to make clear links to the health agenda. He stated that international concerns about sustainable development are increasingly viewed in the context of poverty eradication rather than environmental protection and health promotion. When it comes to renewable energy development (e.g., wind, solar, biofuels), instead of emphasizing low- or no-carbon emissions and combating global warming, the messaging could focus on the salutary human health effects of renewable energy sources: the fact that there is no particulate matter emitted, no or low water usage, and no hazardous wastes. He emphasized that these could be rebranded as clean energy sources, as well as healthy energy sources. Final Remarks Van Hoogstraten pointed out that focusing on human health aspects of multifaceted issues like climate change will likely foster progress within developed country governments. He noted that many countries have not been willing to discuss climate change at international meetings, which suggests that a different framework for tackling environmental challenges should be adopted. For example, if the international effort to reduce black carbon emissions could focus on human health—highlighting premature deaths caused by respiratory diseases, particularly among women and children—it may gain stronger and wider support. Van Hoogstraten noted that the U.S. government does not yet have a unified strategy with respect to the role it will play in major global commitments to address key environmental challenges. He added that there is no driving issue, there are few financial commitments, and there is the ongoing risk of raising unreasonable expectations in the United States. Although all U.S. parties involved in the planning are eager to consider how to add human health to the sustainability equation, he said, there is a very small window of opportunity prior to the conference and time is quite short.

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14 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY CLIMATE CHANGE: THE NEED FOR LINKAGES FOR SUSTAINABILITY AND HEALTH Carlos Corvalán, Ph.D. Senior Advisor on Risk Assessment and Global Environmental Change Pan American Health Organization Carlos Corvalán noted that the meaning of sustainable development was first made prominent in the Brundtland Commission Report of 1987, which defined it as “development that meets the needs of the present without compromising the ability of future generations to meet their own needs” (WCED, 1987). The 2002 World Summit on Sustainable Development held in Johannesburg further elaborated on sustainable development, recognizing that it rests on three interdependent and mutually reinforcing pillars (UN, 2002)—the economic, social, and environmental pillars. Corvalán stated that each pillar may be addressed in its own way, but for sustainable development to be fully realized, these pillars must be integrated. Climate Change and Health Corvalán explained that the 2007 International Panel on Climate Change (IPCC) report describes the linkages between the economic, social, and environmental pressures and climate change (IPCC, 2007). The dynamics that surround socioeconomic development and the drivers of climate change, he stated, eventually increase or threaten the vulnerabilities and result in a decline in human health. Socioeconomic development, he noted, includes production and consumption patterns, technology, trade, and sociocultural preferences (and the fossil fuel energy required to support these practices). Together, these alter the demand for energy and resources, which can lead to increased emissions of greenhouse gases and aerosols. In turn, he said, increased concentrations of greenhouse gases in the atmosphere are a driver of climate change, which can cause temperature and precipitation changes, sea level rise, and increased extreme weather events. Human health is of great concern, since climate change can cause changes in ecosystems, water resources, and food security that affect human health; additionally, human health is impacted directly through air pollution, heat waves, and extreme climate events. Corvalán emphasized that human health is at the

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 15 end of a very long chain of events surrounding socioeconomic development and the drivers of climate change. Corvalán stated that a similar pattern is observed when thinking more broadly about environmental health risks. In Figure 2-1, health is located in the center, surrounded by proximal risk factors, such as air pollution, radiation, water and sanitation, and chemicals, that all impinge upon health directly. Corvalán noted that more distal factors serve as drivers for the proximal causes; these include climate change, migration, degraded ecosystems, water scarcity, and desertification. Climate change is so important because it has the ability to influence many other environmental health risk factors, as depicted by the extended arrows in Figure 2-1. In the long term, stated Corvalán, everyone is vulnerable to climate change, but there are many populations that are likely to be dispro- portionately affected or unable to adapt. These include the poor, children, pregnant women, indigenous populations, the disabled, and the aged (PAHO, 2011). By 2050, the population over the age of 65 will have increased substantially, so that many countries, perhaps the whole world, will be where developed countries are today (UN, 2009). He noted that this population may be unable to cope with the extreme weather that is predicted to be a feature of climate change. Within the past decade, there have been heat waves in Europe (2003), Australia (2009), and China (2010); historical flooding in Mexico (2007) and Pakistan (2010); and violent weather events like hurricanes and cyclones around the globe (World Meteorological Organization, 2011). He stated that these events are all consistent with climate change predictions and may especially imperil the elderly and other vulnerable populations. Corvalán emphasized that it is important to recognize that instead of working together the three pillars of sustainable development have been disconnected, with global crises occurring under each. Under the social pillar, there has been an ongoing poverty crisis, a food crisis, and an increasing inequality crisis. Regarding the economic pillar, the past few years have witnessed a global financial crisis and an ongoing energy crisis. Finally, in the realm of the environmental pillar, ecosystem degradation has become pronounced, and, as already mentioned, the effects of climate change are starting to materialize. He noted that work under the three pillars could be integrated to avoid these crises and to further sustainable development.

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30 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY he said, but also to address all of the hazards and adverse consequences and to design for sustainability. This approach incorporates the entire life cycle of chemicals, which includes the origins of materials, manu- facturing, distribution, and disposal. Anastas added that this approach has been adopted by corporations around the world and has been recognized by the U.S. Presidential Green Chemistry Challenge Award since 1996 in areas ranging from medicine, to energy, to electronics, to chemicals, to agriculture, and beyond. BOX 2-1 Twelve Principles of Green Chemistry 1. It is better to prevent waste than to treat or clean up waste after it is formed. 2. Synthetic methods should be designed to maximize the incorporation of all materials used in the process into the final product. 3. Wherever practicable, synthetic methodologies should be designed to use and generate substances that possess little or no toxicity to human health and the environment. 4. Chemical products should be designed to preserve efficacy of function while reducing toxicity. 5. The use of auxiliary substances (e.g., solvents, separation agents, etc.) should be made unnecessary wherever possible and innocuous when used. 6. Energy requirements should be recognized for their environmental and economic impacts and should be minimized. Synthetic methods should be conducted at ambient temperature and pressure. 7. A raw material of feedstock should be renewable rather than depleting wherever technically and economically practicable. 8. Reduce derivatives—unnecessary derivatization (blocking group, protection/ deprotection, temporary modification) should be avoided whenever possible. 9. Catalytic reagents (as selective as possible) are superior to stoichiometric reagents. 10. Chemical products should be designed so that at the end of their function they do not persist in the environment and break down into innocuous degradation products. 11. Analytical methodologies need to be further developed to allow for real-time, in-process monitoring and control prior to the formation of hazardous substances. 12. Substances and the form of a substance used in a chemical process should be chosen to minimize potential for chemical accidents, including releases, explosions, and fires. SOURCE: Anastas and Warner, 1998.

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 31 Although traditional production systems try to anticipate and resist disruptions, Anastas noted that they are still vulnerable to unforeseen factors. He pointed out that an alternative is to design systems with inherent resilience by taking advantage of fundamental properties such as diversity, efficiency, adaptability, and cohesion. Anastas explained that the elements of resilience include reversibility (a system’s reaction to a perturbation that does not prevent the system from returning to its original level of function); adaptability (a system’s ability to change in response to new system conditions to continue to function at the highest level); and awareness (a system’s ability to be aware of changes in system conditions that have the potential to disrupt system function). He noted that while this is not a mature science, experiences of designers and scientists have demonstrated that it is possible to reduce toxicity by modifying molecules and designing product characteristics with elements of resilience. Anastas stated that green chemistry learns from nature and focuses on biomimicry, which involves examining natural models and processes to solve human challenges. As an example, the current ceramics production process is resource intensive, involving heating, beating, and treating materials. However, the molecular design of the naturally occurring abalone shell affords this material greater hardness than ceramics. Not only is the molecular design environmentally benign, he noted, but the shell has certain advantages to high-tech ceramics in its comparative malleability under stress. Anastas highlighted that unifying performance metrics will be critical to investing in this biomimicry approach. 21st-Century Challenges When the United States began to value environmental protection in the 1970s, said Anastas, the goals were to address the obvious and egregious problems that surrounded the country. He noted that today’s 21st-century challenges are broad in scope, nuanced in their complexity, and pervasive in their effects. He stated that it will take a new approach to address climate change, energy choices, multipollutant exposures, diminished water quality due to agriculture, and chemical and biological terrorism. He added that this means moving away from an environmental protection paradigm that focuses on what you need to stop doing, what you need to reduce, what you need to eliminate, what you need to ban, or what you need to minimize. Anastas suggested that a better approach may be to focus on what society can create, innovate, and transform

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32 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY through new sustainable design frameworks. He emphasized that there is a need to leapfrog toward solutions that break these research and industry silos—moving toward an integrated and transdisciplinary research approach. DISCUSSION A brief discussion followed the presentations and the remarks are summarized in this section. Kreisel asked a question of van Hoogstraten, inquiring whether health could really be a driving force for sustainable development within the Rio+20 agenda. Van Hoogstraten stated that while some people may argue against focusing on health or note that it is a risky choice, there can be a benefit in repackaging the same issue in a different way, and emphasized that the health aspects of some of these complex problems may provide that opportunity. John Balbus then noted that U.S. interagency working groups are often lacking the leadership or perspective of the U.S. Department of Health and Human Services (HHS), which may make it difficult for health to be central to these debates. Balbus asked van Hoogstraten to elaborate on the high-level discussions and considerations that often take place separately from these interagency processes. Van Hoogstraten agreed that many interagency working groups, in which he participated, could have and should have had a voice from HHS. With regard to the other question, he said many of these issues never actually result in a high-level group convening, which is what you want to have happen. He suggested that you should use the stakeholders and constituent groups to try to get a high-level group to focus on your issue, and noted that adding an ambassador to the process—who is a well-known figure, has a great deal of respect, and can speak with the heads of state from the United States and other governments—could also facilitate the process. Daniel Schrag commented on the idea of utilizing systems thinking to achieve a solution that fits climate change, biodiversity, human health, and sustainable development together in harmony, which was outlined in the presentation from Corvalán. Schrag noted that this idea is often deceptive, since hard choices that need to be made often involve conflict between these areas. For example, he said, options to solve the problem of fossil fuel emissions may be harmful to biodiversity, and there may be

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 33 energy options that benefit human health but negatively impact the climate. Schrag emphasized the need to realize the real trade-offs and difficult choices that exist when discussing systems solutions to these complicated issues. Juli Trtanj then returned to the discussion around the Rio+20 conference and noted the need to advocate for integrating health across the working group topic areas (e.g., jobs, energy, cities, food, water, oceans, and disasters) or placing a discrete health topic area on the agenda. She explained that climate change may not be highlighted at the conference and suggested strategizing on how the health community can deliver on something and articulate it to make it viable. She stated that this will likely require support from inside and outside the federal government to practically put messaging forward and deliver on what is outlined. Shifting to points made in the presentation from Birnbaum, Robert Goldsmith commented on her description of essentially two sets of human diseases—those that are macroenvironmental (e.g., water, air, and the like) and those that are microenvironmental (e.g., diet and nutrition). Goldsmith stated that there appears to be a perfect storm brewing in some developing locations where ecological disruption from development is still occurring and where Western restaurant chains are changing the local diet. Goldsmith asked Birnbaum to comment on how a more systematic approach could be taken to investigate what could be a perfect storm where these noncommunicable morbidity contributors are coming together in populations. Birnbaum noted that some NIEHS grantees are trying to investigate these issues in terms of vulnerability assessments; for example, some studies at the international level are looking at the association between obesity, diabetes, and heart disease and multiple kinds of microenvironmental stressors (including nutrition) and macroenvironmental stressors (beyond chemical exposures). Jamie Bartram added a comment on the household, community, and global exposures that Birnbaum outlined with the environmental risk transition (depicted in Figure 2-3). He noted that those scales of exposure relate to many infectious outcomes as well as many toxic exposures and their associated outcomes. Bartram stated that when we look at a level beyond the community level, but still less than the global level, in many cases we can see the co-benefits of interventions for different environmental and infectious exposures, and this ability to demonstrate co-benefits can strengthen the overall argument for environmental health as a component of the public health agenda.

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34 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY Edward Doyle then came back to Birnbaum’s comment regarding lost economic productivity from noncommunicable diseases. He noted the lack of traction on some of these issues within the policy arena because of the current focus on budget issues and jobs, and asked if we can develop economic arguments to support a public relations campaign for the environmental and health issues. Birnbaum agreed that this is important and pointed out that The Lancet published a series of articles in November 2010 looking at ways to economize the benefits of climate change mitigation in order to exemplify the money that could be saved from health care expenditures. She continued to state that there is a need to develop accountability measures and economizing information on the advantages of controlling diseases related to environmental exposures, and to generate a larger effort around these areas. Balbus noted that there are many issues at the intersection of environmental health economics and sustainable development. For example, he said, it is difficult to put a value on premature mortality, and when looking across countries, economists often tie that to GDP per capita, which puts the value of life in a developing country at a fraction of the value of life in the United States. Balbus stated that most public health professionals would disagree with this approach of discounting in economics; not just the traditional discount rate of future values but also the discounting across cultures and countries based on their wealth. He noted that to further sustainable development on an international scale, we need to find language that economists and public health professionals can use to address the issue of disparities in a more ethical and productive way. Following up on comments from Anastas, William Sullivan asked the presenter to reflect on his first point regarding the need for four planet Earths if the world’s population had the same level of consumption as North America, Japan, and Western Europe. Anastas noted that in order to address the consumption issue, we do not just need improved efficiency; we really need to fundamentally change the function and performance of sectors (such as energy, lighting, or food production). He continued to state that this may require a shift from an economy based on material flows to one of performance and value in order to meet sustainability conditions. John Spengler responded to the biomimicry approach that Anastas presented and noted that academic institutions have not applied this to fully integrate and implement sustainability, from individual jobs to performance metrics. Anastas agreed with the points made by Spengler and stated that the current organizational, reward, and metric systems are all fundamentally in opposition to many

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OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 35 of the things that are most sustainable. Spengler went on to note that 5- year community assessment plans and transportation plans conducted by the U.S. Department of Housing and Urban Development (HUD) and the U.S. Department of Transportation (DoT), respectively, have only been integrated recently. Anastas pointed out that HUD, DoT, and EPA came together on this issue wonderfully and noted that the Committee on Environment, Natural Resources, and Sustainability of the National Science and Technology Council is looking into additional interagency sustainability initiatives that can pull across the federal agencies.2 Hernando Perez emphasized that occupational health seems con- spicuously absent in these discussions and asked Anastas to comment on whether or not he thinks this is something that should be incorporated into green chemistry. Anastas stated that occupational health is indeed included in the discussions he is involved with and described work he did with the BlueGreen Alliance to ensure that unions were aware of changes that could be made in manufacturing, transport, and extraction that directly affect them and improve environmental conditions. However, Anastas noted that occupation health could be emphasized more. Lynn Goldman highlighted how Anastas was able to look far ahead in his presentation to lay out an approach to completely change the current U.S. landscape, noting that change needs to occur not just with government and regulatory systems but also with universities, industry, and so forth. She emphasized that the whole concept of resilience is about people incorporating ideas about sustainability and design from the very beginning of everything. Hartwig de Haen concluded by noting the varied perspectives that were presented during this session. On the one hand, he said, we heard that health needs to be placed at the center of these discussions about sustainable development, and there is a clear and logical way to accomplish this through the Rio+20 conference. On the opposite extreme, he said, we heard that health people are too naïve to engage in these discussions because they just see things from one point of view; they do not understand trade-offs or the complexity of the issues. Because the health community is often viewed this way, he was happy to be reminded of this when putting health into perspective for global agendas. He also noted that we heard the U.S. government can exert its 2 Additional information on the Committee on Environment, Natural Resources, and Sustainability of the National Science and Technology Council can be found at http://www.whitehouse.gov/administration/eop/ostp/nstc/committees/cenrs.

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