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4 SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES This chapter considers food and water at the nexus of sustainable development. Although other ecosystem services are critical to environmental health, these two resources generate continued health concerns through means such as infections, antibiotic resistance, under- and over-nutrition, and exposures to chemicals. As noted by the speakers, it is clear that humans are putting greater pressure on natural resources to meet basic needs for a growing population. These challenges are subject to national and global policy debate: for example, about how countries will assure food and water security. A summary of the presentations follows in which the speakers outline strategies for improved management of these resources. FOOD SYSTEMS, SUSTAINABILITY, AND PUBLIC HEALTH Molly Anderson, Ph.D. Partridge Chair in Food and Sustainable Agriculture Systems College of the Atlantic Molly Anderson began her presentation by stating that although the terms “food systems” and “agriculture” are often believed to be synony- mous, agricultural production is only the beginning of the food system. She noted that food systems are extensive, and they include food processing, food sales and distribution, food preparation, and, ultimately, food consumption. Anderson emphasized that food systems require diverse inputs, from seeds, fertilizer, and animal stock for agriculture, to financial capital, machinery, labor, energy, and water, which are necessary for all parts of the system to function. Additionally, there are 65

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66 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY institutions that govern control of, access to, and use of inputs by different actors in the food system. Anderson noted that food production and food systems are affected by and reside at the center of social, economic, and environmental concerns (McIntyre et al., 2009a,b). From an environmental perspective, food systems are interwoven with soils, water, climate, and biodiversity. Anderson proposed that social implications of food systems, culture, traditions, and gender roles usually play a part in determining what food is produced, who labors, and who profits. From an economic perspective, marketing practices and trade are tightly interlaced with profit; additionally, these three areas interact with each other, as depicted in Figure 4-1. For example, economic value can be assigned to environ- mental services, and culture can dictate which foods are cultivated and commercialized. Anderson pointed out that history indicates that an attempt to maximize any one of the economic, social, or environmental aspects will result in trade-offs for the other two areas. In the existing food system, Anderson said, several years of overemphasizing the economic side by increasing production has resulted in serious social and environmental impacts. Food Systems and Public Health Anderson stated that hunger and malnutrition provide major linkages between food systems and public health. The number of undernourished people in the world has steadily increased in recent years, reaching an estimated 1.023 billion individuals in 2009 (FAO, 2010), resulting in a world food crisis. The number of undernourished people decreased to 925 million globally in 2010 (FAO, 2010). However, the Food Price Index spiked again in 2011, to a higher level than in 2009 (FAO, 2011). Anderson noted that when the numbers are released for 2011, there will likely be even greater hunger and malnutrition, above the 1.023 billion of undernourished people in 2009. Anderson added that high food prices show no sign of abating. Climate change is also connected to food systems, said Anderson, with projected effects on food, water, ecosystems, and risk of abrupt and major irreversible changes. With just over a 1 degree Celsius increase in the global temperature, the frequency of extreme weather events (e.g., rising intensity of storms, forest fires, droughts, flooding, and heat waves) will increase (IPCC, 2007). Agricultural yields will decrease in

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 67 FIGURE 4-1 The inescapable interconnectedness of agriculture’s different roles and functions. NOTE: Social, economic, and environmental concerns are tied to food production. Social factors, such as culture, tradition, and gender roles, can determine the types of food produced, and which members of society bear the labor and cost burdens. Economic factors, such as trade and income, also impinge upon food production. Environmental factors, such as water and soil quality, affect (and are affected by) food production. These three aspects interact with each other (for example, in the assignment of monetary values to environmental services). An effort to maximize one aspect, such as the economic outcomes of food production, will undermine the other two (social and environmental) aspects. SOURCE: IAASTD, 2008. Design by UNEP/GRID-Arendal, Ketill Berger (http://www.grida.no/graphicslib/detail/a-multifunctional-perspective-of- agriculture_1097). many developed regions, as seen in Figure 4-2 (Cline, 2007). Anderson noted that although some posit that temperature increases will cause yields in higher latitudes to increase and benefit those who dwell there, this may be offset by the unpredictability of precipitation in these same areas. If farmers cannot foretell precipitation patterns, they will be unable to make informed decisions about what to plant and when to plant, which will limit their efficient use of resources to maintain a reliable food

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68 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY supply. Overall, Anderson stated that there are no winners from climate change because of the resulting instability in the food system. Anderson noted that modern food production systems are also creating environmental impacts and instability by degrading vital resources necessary for food production. According to the Global Assessment of Human Induced Soil Degradation, 40 percent of the land for global food production has been degraded, and this number will likely increase if current land use practices continue (Wood et al., 2000). Water shortages have begun and are likely to intensify as water withdrawal as a percentage of total available water increases (UNEP, 2008). Anderson stated that if less fresh water is available per capita FIGURE 4-2 Agricultural productivity: Projected changes due to climate change. NOTE: An increase in average temperature is a predicted consequence of climate change. This temperature shift is likely to affect agricultural yields. Tropical, subtropical, and some temperate areas will witness a decrease in yields, which may be as great as 50 percent. Higher-latitude regions may experience an increase in agricultural productivity by as much as 35 percent. However, other effects of climate change, such as altered precipitation patterns, may undercut some of these yield increases. SOURCE: Cline, 2007. Design by UNEP/GRID-Arendal, Hugo Ahlenius (http://www.grida.no/graphicslib/detail/projected-agriculture-in-2080-due-to- climate-change_15f0).

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 69 food production systems will need to develop more efficient methods for water usage in the future. Additionally, marine resources are being over- exploited, causing some marine ecosystems to crash (UNEP, 2007). Anderson explained that aquaculture is being used to replace fishing in order to meet increased demands for fish and seafood, but these methods introduce new environmental problems and are not a cure-all for food systems and public health in that they are often not sustainable and cannot be expected to meet all future protein needs. Anderson outlined how the industrialized food production model that developing countries have been encouraged to adopt creates a multitude of negative environmental impacts. These farming methods may degrade soil via salinization, compaction, and nutrient depletion, and exacerbate climate change due to high energy requirements (McIntyre et al., 2009a,b; Woods et al., 2010). Industrial animal agriculture techniques at concentrated animal feeding operations can create bacteria that are resistant to antibiotic treatment (Gilchrist et al., 2007). These concentrated animal feeding operations also concentrate animal waste, and this can lead to exposure to pathogens and air quality problems (Heederik et al., 2007). Anderson noted that food safety risk is exacerbated in centralized processing systems because foods from different sites are mixed together during processing and then redistributed over a wide geographical area such that any contamination is distributed widely, as happened, for example, during a 2006 incident of fresh spinach contamination by E. coli 0157:H7 that killed 3 people and sickened 199 (CDC, 2006). Industrialized farming also results in occupational exposure to hazardous chemicals in pesticides (Calvert et al., 2008). Finally, diet-related diseases are linked with the products and policies that are intimately connected with this particular way of producing food (Lang et al., 2009). Anderson emphasized that it is clear that food systems are intrinsically tied to virtually every environmental health issue. Trends in Food Systems As a consequence of the Green Revolution, stated Anderson, the total production of food increased from the late 1960s to the present day. She described that this was due to an increase in the productivity of commodity crops (not necessarily the staple crops on which people in developing countries rely) through the use of high-yielding varieties and energy intensive practices (such as irrigation and fertilization) spreading

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70 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY around the globe (Huang et al., 2002). Anderson noted that the energy required for industrialized agriculture, particularly fertilization, will likely restrict how much longer industrialized agriculture will be a viable option for food production. Anderson pointed out that despite the steep augmentation in yield per capita and the drop in the price of food, food consumption still is grossly inequitable among developed and developing nations (FAO, 2012). Gender Issues Anderson stated that there has been an inequitable distribution of the benefits from research and development on food systems. She explained that one of the biggest sources of inequality is gender, since relatively few women are trained for agricultural research and extension, and in some countries, particularly sub-Saharan countries where women farmers are in the majority, there are cultural barriers that prevent women who are responsible for growing the crops from working with male extension support staff (FAO, 1997). Women in these countries are often unable to benefit from extension and training services on new technologies (FAO, 1995). Research Funding Anderson proposed that similarly concerning are the long-term declines in research funding and the shift from public to private sources of funding in industrialized nations. Additionally, there has been market and power concentration within the food system over the past 40 years so that decisions about food are currently in the hands of a few businesses at the trading, processing, and retail levels. Anderson noted that this limits opportunities for small-scale farmers in the food system. Global Value Chains Trends can also be seen in global value chains, as depicted in Figure 4-3. Anderson explained that independent farmers of commodity crops in Sector II are either disappearing or are contracting with transnational corporations in Sector I that sell undifferentiated goods globally. Large, vertically integrated supermarkets and processing centers are consuming independent grocers and independent packers, she said, so that Sector II is disappearing because of pressures from Sector I. On the other side of

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 71 FIGURE 4-3 Global value chain trends. NOTE: Global value chains can be characterized by their level of integration (a continuum from global integration to fragmentation; vertical axis) and by the types of signals to which they respond (a continuum from primarily economic signals to multifunctional [social, environmental, welfare, safety] signals; horizontal axis). These classifications create four types of products and value chains: commodities and other undifferentiated goods sourced transnationally from vertically integrated supply chains (Sector I); commodities and other undifferentiated goods sourced locally and regionally from independent producers and sold by independent grocers (Sector II); goods differentiated by geographic indicators that are only sold locally (e.g., at farmers’ markets) by producers who follow environmentally sustainable practices (Sector III); and triple-bottom-line and animal-welfare-certified goods from producers who internalize all environmental and social costs (Sector IV). These value chains have undergone change in recent years. The independent producers and grocers have been contracting with transnational corporations (Sector II is being absorbed by Sector I). Producers in Sectors III and IV have become more responsive to economic signals in order to stay competitive, shifting closer to Sector I. SOURCE: M. D. Anderson and L. Firbank, unpublished.

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72 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY the spectrum, Anderson noted, small, locally oriented farms in Sector III provide differentiated goods, and certified food producers (fair trade, humane certified, etc.) in Sector IV are sensitive to environmental and social concerns. Recently, the number of players in the market for certi- fied goods has expanded; so producers and distributors in Sector IV have begun paying closer attention to prices to compete with similar companies (shifting these sectors closer to Sector I). Anderson stated that the market share of Sectors III and IV is important, because focusing on multifunctional and local/regional agricultural systems is likely to decrease negative impacts on smallholders. IAASTD and the Way Forward Anderson noted that the aims of the International Assessment of Agricultural Knowledge, Science, and Technology for Development (IAASTD) were to review more than 60 years of publications to assess the impacts of agricultural knowledge, science, and technology on reducing hunger and poverty, improving rural livelihoods and human health, and facilitating true sustainable development (McIntyre et al., 2009a,b). It was intergovernmental, interdisciplinary, and sponsored by many organizations (such as United Nations agencies and the World Bank). Developing and industrialized nations, men and women, civil society, and government representatives were all involved in leadership roles. Anderson highlighted the following key messages from the IAASTD: 1. Investment in agriculture needs to increase and be redirected, with investments that target rural areas and strengthen farmers’, women’s, and community organizations. Also, there should be investment in technology that is appropriate for local control, paired with a commitment to assist farmers in acquiring what they need to become entrepreneurs, especially securing access for smallholders and women. 2. The methods through which agricultural knowledge is generated, distributed, and used needs to be altered. Local farmers should be invited into the process, and institutions should be more responsive to farmers’ needs. To achieve this, traditional and scientific knowledge should be integrated, for example, through participatory farmer-scientist partnerships; investments should be

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 73 made in education and technical assistance, especially for women, as well. 3. Fair, equitable access to resources and markets is necessary, as is democratic decision making. Public institutions should focus on public goods, and antitrust and competition regulations should be implemented. Laws of ownership should be revised to allow secure access by women and smallholders. To become more democratic, discussions about the world food system need to allow all major stakeholders to participate in the decision making. 4. Managing for multifunctionality is crucial, and it involves empowering marginalized stakeholders to participate in the food system. Investment should be balanced between the environ- mental, social, and economic aspects of agriculture. Market and trade policies that provide fair returns to food system workers should be implemented. Ecosystems should be maintained and restored. 5. Management for resilience is necessary. Diversity should be promoted at all scales, from crops to business models; food reserves should be accumulated so that food is available when needed. Decentralized food systems can create buffers that will ease food shocks brought on by disasters, famine, or other system shocks. As seen with the 2007–2008 financial crisis, shocks can reverberate through the globalized food system if buffers are not in place. Anderson argued that solutions to the problems of modern food systems can be shaped by multi-stakeholder assessments and United Nations assessments. She stated that reform of food governance mechanisms, such as recent reform of the Food and Agriculture Organization (FAO) of the United Nations Committee on Food Security, can play an important role in altering food systems. Anderson added that rights-based approaches to food and development that increase participation and focus on vulnerable populations such as women, children, and smallholders may have a substantial chance at success. She explained that this is because these strategies focus on the “how” of development, which is at least as important as the “what.” Anderson emphasized that when attention is on identifying the most vulnerable people and what they need, there is the most promise of actually having an impact on food security and malnutrition.

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74 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY NATURAL RESOURCES, SUSTAINABILITY, AND HEALTH Jamie Bartram, Ph.D. Don and Jennifer Holzworth Distinguished Professor and Director of the Water Institute University of North Carolina at Chapel Hill Jamie Bartram began by stating that water, health, and sustainable development are interconnected. He noted that these linkages were recognized during the Rio Summit and in Agenda 21, which was adopted in 1992 by 178 governments globally. In fact, he said, the supporting documents from the workshop included a specific chapter on water resources addressing protection of the quality and supply of freshwater resources that also addressed drinking water, sanitation, and hygiene. Accelerating since that time, stated Bartram, substantive shifts have occurred in the development of policy and the management of water at the international level; these efforts have largely followed two tracks, one focused on the human need for water, generally coupled with sanitation, and the other focused on water resources and their management. Bartram noted that the former has included  declaration of the International Drinking Water Supply and Sanitation Decade (the 1980s);  establishment in response to the end-of-decade review of the Water Supply and Sanitation Collaboration Council, initially hosted by the World Health Organization (WHO);  establishment of the Millennium Development Goals (MDGs) including a target for drinking water at the Millennium Summit in 2000;  reaffirmation of the MDGs and the inclusion of sanitation alongside water as a target in 2002;  declaration of the Decade “Water for Life” in 2006–2015;  declaration of the International Year of Sanitation in 2008;  declaration in 2010 by the UN General Assembly that recognized the human right to water and sanitation and follow-up by the Human Rights Council;  establishment by the United Nations Secretary-General of “Sustainable Sanitation: Five-Year Drive to 2015”; and

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 75  passage of the World Health Assembly Resolutions related to water in 2011. Of the two water policy tracks mentioned, Bartram noted that the track focused on water resources and their management has included specific concern for transboundary water and more recently often emphasized integrated water resources management (IWRM)—a policy and management approach that recognizes that water has many different and sometimes competing uses that need to be reconciled at the watershed level. Bartram stated that efforts that have used this approach include the Global Water Partnership, which was established in 1996 with the backing of a limited number of governments to advocate for integrated water resources management; the World Water Council, which was also reestablished in 1996 with the support of a limited number of governments to principally but not exclusively focus on water resources; and the World Commission on Dams, which was a time- limited body established in 1998 to address the international concern principally about large dams and their management. Bartram explained that within the UN system there have been proposals to develop the United Nations Environment Programme (UNEP) into a single environmental agency within the UN system. Contrastingly, he noted that “UN-Water” was established to increase coordination and coherence across more than 27 UN bodies that are involved in water issues, recognizing that water (and environment more broadly) are cross-cutting issues that benefit from integration in other disciplines and sectors. Evidently, he emphasized, there is overlap and potential competition between these water, sanitation, and hygiene perspectives for policy and financing at the international, national, and local levels. Bartram stated that since the advent of the MDGs, time-bound quantified targets have been supported by coherent monitoring efforts for provision of drinking water and sanitation. He explained that this has been accompanied by a trend toward greater transparency and accountability as evidenced by the series of regional intergovernmental sanitation conferences and MDG monitoring. Most recently, the recog- nition of the human right to water and sanitation by the UN General Assembly and its Human Rights Council has facilitated policy attention around this issue and is likely to contribute to future accountability at the country level.

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78 FIGURE 4-5 Access to improved drinking water sources, 1990–2015. NOTE: Improved sources include sources protected from contamination up to around 30 minutes collection time from the household. Despite meeting the goal for 2015 (to halve the proportion of the population without sustainable access to safe drinking-water), 672 million people will remain unserved (9%) in 2015. SOURCE: WHO/UNICEF, 2010. Reprinted with permission from the World Health Organization and UNICEF.

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 79 process and of human interaction with water that may be polluted. For example, Bartram explained, the majority of emerging and reemerging infections in recent decades are from zoonotic sources, and the associated health concerns are likely to be intensified because of the water cycle linkages between livestock waste and human populations. However, within public health and water management, human interaction is often viewed as a separate process from the underlying natural water cycle. Batram noted that in the future this paradigm will likely be challenged and found deficient as the extent of human impact on the underlying cycle is increasingly appreciated. Thus, he said, a new logic in water management is likely needed (including management to protect and improve health) to directly address the interconnectedness among the natural water cycle and the overlapping water demands by humankind. Bartram stated that managing the waters needed for drinking, recreation and bathing, agriculture (including irrigation), seafood production, and so forth, is expensive and problematic. He noted that the costs (in both financial and health terms) are largely associated with the practice of using water routes for waste disposal. In fact, he said, the self- purification capacities of many water resources are limited and the ecosystem services they render to humankind in the form of waste treatment are often underappreciated and overloaded. Bartram noted that this management approach is reflected in legislation. For example, he added, most countries strictly regulate the direct use of wastewater, whether it is for toilet flushing or for agriculture, and yet do not think it is necessary to regulate the indirect use of that same wastewater once it is discharged into water resources that may be used for human contact and in food production. Bartram emphasized that these practices contribute to the intensification process referred to above and lead to inconsistencies in health protection, whether it is between hazards or between exposure routes. Bartram pointed out that a specific challenge to effective water resource management and use relates to the multiple sectors that interact with water and the diverse disciplines engaged in its management. Bartram stated that effective future management will require multidisciplinary perspectives in order to integrate and understand water- related hazards, which will likely challenge team members who use different vocabulary and different underlying approaches. Bartram noted that there are fundamental differences in how stakeholder groups understand and describe risk. Even within the discipline of public health,

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80 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY he said, risks associated with radiation, infectious diseases, toxic chemicals, and nutrient intake deficiencies cannot be readily compared and discussed meaningfully. Water Needs in the Future Bartram stated that there are currently two available technological approaches to sanitation. At one extreme, sewerage is associated with extremely high costs, environmental pollution, adverse health effects, and use of large quantities of water; but, sewerage is aspired to over the alternative extreme, which is some form of ground latrine. Neither model is ideal, said Bartram, and thus incentives are needed to encourage engineers, managers, and entrepreneurs to develop alternatives that are affordable, applicable in high-density and disperse rural settings, not reliant on costly long-term fixed infrastructure, and able to facilitate public health protection and recovery of the nutrient resources contained in human excreta. Bartram noted that while such options are not unimaginable, they are needed and unavailable today. Bartram explained that one of the consequences of economic development has been a change in the way that water is used in the immediate human environment leading to an intensification of water resources—wanting water to do more things. For example, legionellosis was first recognized in 1976, and, in effect, a natural bacterial occupant of the water environment became a health issue because humankind was doing something new with water. Bartram noted that Legionella species are found in aquatic environments and thrive in warm water and warm, damp places, such as potable water distribution systems, cooling towers and evaporative condensers, natural spas, hot tubs, and swimming pools. Bartram stated that such environments are common in health care facilities, hotels, schools, and ships, and many of these environments are disproportionately used by more vulnerable population groups. In more recent times, he added, nontuberculous mycobacteria have emerged as a similar problem: for example, for people living with HIV/AIDS. Bartram emphasized that hazards arising from microbial growth are emerging, and such emergence is likely to continue with intensification of the water cycle and human interaction with it. The current model, said Bartram, is that society changes the way it uses water and then awaits the emergence of a health problem in order to respond. Bartram asked for a new model where public health proactively looks for opportunities to identify and

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 81 preventively solve problems. Such an approach, he said, would secure efficiencies and synergies in problem solving. Bartram stated that the application of a health impact assessment to water resources management would be illustrative. Frequently, irrigation schemes have been associated with the introduction or exacerbation of schistosomiasis and substantive adverse health impacts. Once schemes are established, he added, introduction (or retrofitting) of water management measures to control risk is costly and complex. Bartram noted that health impact assessments provide a means to identify the potential future risk and in doing so, enable less costly and potentially more effective measures to be engineered from the outset. On a larger scale, stated Bartram, increasing numbers of countries around the world are experimenting with the use of desalination to provide or supplement drinking water. Although the total capacity is increasing, there is a lack of information on health effects of consumption of the resulting water. Bartram highlighted that there are anecdotal reports of dental problems because of decreased fluoride intake and some suggestive evidence for reduced calcium and magnesium intakes associated with bone and heart disease. This example, he said, underscores the disengagement between the health community and proactive public health engagement in management of water to protect and improve health. Bartram emphasized that the health system has opportunities to steer policy and technology changes for potential benefit, but to be effective, the field needs to be actively engaged and positioned ahead of the curve. Bartram pointed out that energy provides examples of more distal links between water and health. He noted that the way society manages water has a large energy consequence, with some reports suggesting that 20–40 percent of energy use in midsized cities in developed nations is being used on water and sanitation (California Energy Commission, 2006; WEF, 2011). Those developed cities have been shown to be inefficient in pumping water, as approximately 20 percent of all treated and pumped water is lost through water leakage (Environment Canada, 2004). Bartram stated that similar trends are seen in irrigation systems. For cities and nations that are grappling with managing water and energy resources, Bartram noted that there are opportunities to improve the system with direct and indirect health benefits. Until the 1970s, stated Bartram, environmental health was embedded in the health systems of many countries. Following the UN Conference

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82 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY on the Human Environment in 1972 and the Mar del Plata conference in 1977, he said, countries began to create ministries of the environment, environmental agencies, or similar bodies such as the Environmental Protection Agency in the United States. Bartram noted that many of these agencies were created by cutting all or part of the environmental health capacity from ministries of health in order to seed the creation of a new agency. He added that one of the unintended consequences was that environment and health diverged, and the discipline and practice of environmental health lacked effective leadership. As the world starts to focus on the post-2015 development agenda, he noted, there is an opportunity for environmental health to act as a driver of the path forward. As part of this effort, he said, there is a need to identify the co- benefits and recognize that health does not invariably align with sustainable development. Bartram emphasized that without health system engagement, opportunities to exploit synergies and opportunities to avert or minimize risks will be missed. However, health systems are often poorly engaged in these processes, and when engaged, they are poorly equipped to participate. Thus, Bartram noted a need for primary leadership and better coordination between the health system and environmental health (see Figure 4-6). DISCUSSION A discussion followed the presentations summarized above. Richard Jackson noted that the 20th-century approach to addressing challenges was to fragment the issue into smaller and smaller pieces, while the 21st century sees value in integration and horizontal thinking. Jackson stated that the stovepipes that were artificially created cannot adequately address the need to move toward sustainable, mutually beneficial solutions. Paul Wilkinson asserted that many solutions to proceed sustainably are already known, especially for energy and climate change. Wilkinson suggested that it is a question of decision making. Lynn Goldman stated that a disconnect between health and the environment occurred when environmental health was moved from health agencies to environmental agencies. Goldman noted that in order for the health agency to be involved, there is a need to communicate why the linkages between the environment and health are important.

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SUSTAINABILITY LINKS TO FOOD AND WATER RESOURCES 83 FIGURE 4-6 Health sector functions to secure environmental health. SOURCE: Rehfuess et al., 2009. More health for your buck: Health sector functions to secure environmental health. Bulletin of the World Health Organization 87: Figure 1, page 881. Reprinted with permission from the World Health Organization.

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84 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY However, Kirk Smith noted that many in the environmental health community benefit from not being associated with ministries of health as toxicological results are reported as odds ratios and not in a burden of disease context. Smith stated that there is concern in the field about decision makers not acting, but this may in part be caused by scientists providing information that makes it very difficult for decision makers to act. Wilfried Kreisel noted that urbanization is continuing to increase, primarily in developing countries. Kreisel stated that this trend will have an effect on sustainable agriculture and water availability. Anderson pointed out that rural urban migration is related to trade policies and the lack of available land on which to adequately make a living. Anderson explained that there is a need to ensure that rural areas offer the same opportunities as urban areas to stave off urbanization. At the same time, Anderson said, there have been opportunities to create urban agriculture zones in many cities around the world to meet access to locally grown food. Anderson further noted that urban agriculture has its own challenges as heavy metals, such as lead, can be in the soil. Similarly, Bartram noted that climate change and extreme weather events are a growing concern as a significant number of the population live on the coast. Bartram stated that large coastal cities face a number of unanswered questions including how these regions can grow and remain sustainable. For example, Bartram said, with increased urbanization, there is a larger human footprint, which can result in runoff and contamination of seafood. As the world begins to move toward sustainability, Bartram emphasized, these issues need a multidisciplinary approach to address them. REFERENCES California Energy Commission. 2006. Refining estimates of water-related energy use in California. PIER Industrial/Agricultural/Water End Use Energy Efficiency Program. CEC‐500‐2006‐118. Sacramento, CA: Navigant Consulting, Inc. Calvert, G., J. Karnik, L. Mehler, J. Beckman, B. Morrissey, J. Sievert, R. Barrett, M. Lackovic, L. Mabee, A. Schwartz, Y. Mitchell, and S. Moraga- McHaley. 2008. Acute pesticide poisoning among agricultural workers in

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