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Health in the Context of Processes to Develop Post-2015 Goals and Sustainable Development Goals

This chapter presents a summary of a webinar on Health in the Context of United Nations (UN) Processes to Develop Post-2015 Goals and Sustainable Development Goals (SDGs). The focus of the webinar was to review the key points and gaps in existing efforts to develop new goals and indicators for the post-2015 development agenda and discuss how best to incorporate environmental health indictors into the indicator development process. The first presentation, from Kumanan Rasanathan, United Nations Children’s Fund (UNICEF), was an overview of the Global Thematic Consultation on Health, which assembled inputs from people and organizations around the world on how best to reflect health in the post-2015 development agenda. The second presentation, from John Norris, Center for American Progress, provided an overview of the UN report (2013), A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development, developed by the UN High-Level Panel of Eminent Persons for the Post-2015 Development Agenda. The third presentation, from Andrew Haines, London School of Hygiene and Tropical Medicine, specifically addressed health linkages to the goals and indicators proposed by the UN High-Level Panel in the New Global Partnership report. The chapter concludes with highlights of the discussion that followed the presentations.

OPENING

John Balbus, senior advisor for public health at the National Institute of Environmental Health Sciences and co-chair of the Global Environmental Health and Sustainable Development Innovation Collaborative, provided an overview of the webinar topic. He began by noting that the



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2 Health in the Context of Processes to Develop Post- 2015 Goals and Sustainable Development Goals This chapter presents a summary of a webinar on Health in the Context of United Nations (UN) Processes to Develop Post-2015 Goals and Sustainable Development Goals (SDGs). The focus of the webinar was to review the key points and gaps in existing efforts to develop new goals and indicators for the post-2015 development agenda and discuss how best to incorporate environmental health indictors into the indicator development process. The first presentation, from Kumanan Rasanathan, United Nations Children’s Fund (UNICEF), was an overview of the Global Thematic Consultation on Health, which assembled inputs from people and organizations around the world on how best to reflect health in the post-2015 development agenda. The second presentation, from John Norris, Center for American Progress, provided an overview of the UN report (2013), A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development, developed by the UN High-Level Panel of Eminent Persons for the Post-2015 Development Agenda. The third presentation, from Andrew Haines, London School of Hygiene and Tropical Medicine, specifically addressed health linkages to the goals and indicators proposed by the UN High-Level Panel in the New Global Partnership report. The chapter concludes with highlights of the discussion that followed the presentations. OPENING John Balbus, senior advisor for public health at the National Institute of Environmental Health Sciences and co-chair of the Global Environ- mental Health and Sustainable Development Innovation Collaborative, provided an overview of the webinar topic. He began by noting that the 7

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8 INCLUDING HEALTH IN GLOBAL FRAMEWORKS global burden of disease is related in part to environmental exposure, and the need to recognize this relationship in current global development projects is crucial, so that the health impact can be measured and any adverse effects prevented. As noted above, the UN High-Level Panel of Eminent Persons released a report providing a framework for integrating new goals and measurable targets into the post-2015 development agenda. Balbus noted that previous Collaborative webinars addressed aspects of the post-2015 development agenda including UN processes and ways to provide input, reasonable goals and indicators for environmental health and sustain- ability, and health equity and social justice considerations.1 He added that the webinar build on those themes in an effort to provide useful information to the global community as the post-2015 agenda and SDGs are developed. THE GLOBAL THEMATIC CONSULTATION ON HEALTH AND INCORPORATING ENVIRONMENTAL HEALTH INTO THE POST-2015 DEVELOPMENT AGENDA Kumanan Rasanathan, M.B.Ch.B., M.P.H., FAFPHM Health Specialist, UNICEF Kumanan Rasanathan began with the context of health in the post- 2015 agenda, which he identified as an entry point for developing potential targets and indicators for an environmental health agenda. He praised the UN High-Level Panel for performing well in the face of much concern about reconciling the many different and sometimes conflicting agendas. He explained that the process would now move to intergovernmental discussion, with the challenge of preserving the value of the targets under the Millennium Development Goals (MDGs) while allowing for broader issues to be addressed, including the role of institutions and the role of governance (see Box 1-2 for a detailed list of the MDGs and related targets). A schematic of the post-2015 Development Agenda process produced by the UN Foundation is shown in Figure 2-1. 1 A summary of these webinars is available at http://www.iom.edu/Reports/2013/ Global-Development-Goals-and-Linkages-to-Health-and-Sustainability.aspx (accessed September 30, 2013).

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 9 The criticism of the original MDGs as an enterprise too much under the control of a few people at the top, resulted in a participatory process for the post-2015 development agenda. There was a huge amount of consultation and work that fed into the UN High-Level Panel, including country consultations, thematic consultations, regional consultations, civil society interaction, and much more. For example, the Global Thematic Consultation on Health—conducted and managed by UNICEF, the World Health Organization (WHO), and the governments of Botswana and Sweden—established a process that was as open as possible and that eventually led to a final report. Drafts of the report were placed on the Web for comment, and a final meeting was convened that brought together members of the UN High-Level Panel, member state representatives, civil society representatives, leaders of the H82 international health agencies, and key academic leaders. The challenge with a participatory process is that in order to please everyone, the end result could have become a unwieldy compendium of everybody’s wish list, with far too many indicators and targets. The final report, submitted to the UN High- Level Panel and the Secretary General, focused on five general areas: 1. Lessons learned from MDGs. 2. Health priorities in the post-2015 era. 3. The role of health in the broader post-2015 development agenda. 4. Potential goals and targets. 5. Lessons learned from the implementation science of goals and targets from the MDGs. Health goals, Rasanathan said, need to be considered not just in terms of achievements in the health sector, but also in terms of sustainable development and well-being, in general. The health goals of the new agenda are a continuation of the MDGs, addressing child and maternal health, HIV, malaria, and other diseases, but adding noncommunicable diseases. He added that there is a need to consider the contributions of 2 The Health Eight (H8) comprises leaders of the eight global international health agencies: the Bill & Melinda Gates Foundation; GAVI (formerly the Global Alliance for Vaccines and Immunization); the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Joint United Nations Programme on HIV/AIDS; UNICEF; United Nations Population Fund; WHO; and the World Bank. The H8 meets to discuss challenges to scaling up health services and improving health-related MDG outcomes.

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10 FIGURE 2-1 Schem F matic of the post-2015 development agenda process. a NOTES: HoSG = Heads of State Gover N H rnments; MDGs = Millennium Develop M pment Goals; OWG = Open Working G G Group; SDG = Sustainable Developm Goal; SDS Ne S ment etwork = Sustainable Development Solu e utions Network; SG = Secretary General UN = United l; Nations; UNGA = UN General Assembly WG = Working Group. N y; G SOURCE: UN Foun S ndation and Dalber Analysis, 2013. Reprinted with per rg rmission from the U Foundation. UN

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 11 other sectors to health, such as social determinants and people’s living conditions. He also indicated strong support for the idea of universal health coverage, which had been the subject of a UN General Assembly resolution in 2011. Affordability of service is a challenge, with coverage and quality of service as additional complicating factors. Measuring achievement of goals is difficult, and Rasanathan cited the healthy life expectancy31measure as potentially useful, although the methodology may not yet be sufficiently developed. He added that there could have been more targets identified in the goals, and noted that the only target listed under universal health coverage was immunization, which distressed many proponents of that goal who had hoped for more. However, other important health-related issues were added or further highlighted, such as • reducing death from national disasters, • water and sanitation, • birth registration, • reducing violent deaths, and • climate change. Rasanathan stressed that this is an ongoing process that will continue to be dealt with at future General Assemblies. Developing indicators is a task that presents many challenges, and presents much opportunity for further clarification. Rasanathan concluded by offering a view on how environmental health issues could be better linked to the current process. The environ- mental health community could consider targets and indicators that have already been put forward as well as links between different sectors and different goals and targets. The environmental health community could also consider different options in positioning environmental concerns, such as focusing their efforts in the health sector or in the environment or energy sectors. Rasanathan urged a policy of thinking strategically and being more aggressive in putting potential targets and indicators on the table for consideration and debate. 3 Healthy life expectancy is based on mortality and morbidity data that is used to calculate the average number of years that a person can expect to live in full health (free from disability or disease) when taking into account years lived in less than full health due to disease and injury. Further information is available at http://www.who.int/healthinfo/statistics/indhale/en (accessed September 9, 2013).

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12 INCLUDING HEALTH IN GLOBAL FRAMEWORKS OVERVIEW OF THE REPORT A NEW GLOBAL PARTNERSHIP: ERADICATE POVERTY AND TRANSFORM ECONOMIES THROUGH SUSTAINABLE DEVELOPMENT John Norris, M.P.A. Executive Director, Sustainable Security and Peace Building Initiative, Center for American Progress John Norris began by describing efforts leading up to the release of the UN High-Level Panel report on A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development. He characterized the recent UN Rio +2042Summit as “something of a train wreck,” adding that there was a perception that the whole process of multilateralism had faltered. The UN High-Level Panel had to deal with the disappointment this perception caused. They wanted to build on the successes of the existing MDGs in the report and preserve parts of the agenda that had been effective, such as those concerning health and education—but, they also had to confront the failures of the agenda, such as initiatives on the environment. The record of MDG implementation during the past 13 years has been uneven, Norris said, noting that although millions have moved from poverty into middle income status, traditionally marginalized populations have often been left behind. This issue brings to light the tension between the anti-poverty and environmental communities, which Norris described as a considerable source of tension in the UN High-Level Panel. Each community feared the other would divert funding from its issues, and trying to resolve this conflict was central to the High-Level Panel’s work. Another important issue was the difference between the procedures and funding landscape in 2000 compared with 2013. The original MDGs were produced behind closed doors, largely by a handful of represent- atives from the UN, some key member states, and international financial institutions. Creating the post-2015 agenda was envisioned as a much more transparent process, involving civil society, implementing partners, private philanthropy, and the business community. To achieve this, the UN held a series of consultations in more than 100 countries around the 4 Rio +20 is the short name for the UN Conference on Sustainable Development which took place in Rio de Janeiro, Brazil, in June 2012, 20 years after the 1992 Earth Summit in Rio. More information is available at http://www.uncsd 2012.org/about.html (accessed August 26, 2013).

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 13 globe, which Norris credits with changing the agenda in important ways that may help in subsequent intergovernmental negotiations. Norris also noted that the amount of official development assistance has diminished over time, with less going to environmental issues, health issues, and development in general. However, development funding from foreign direct investment, domestic resource mobilization, and private philanthropy is increasing. The High-Level Panel felt that this change in funding sources should be reflected in a constructive way in the post- 2015 agenda. The UN High-Level Panel’s main achievement in the report on A New Global Partnership: Eradicate Poverty and Transform Economies Through Sustainable Development was resolving the tension between the anti-poverty and the environmental communities, said Norris. The panel set a goal of eradicating extreme poverty by 2030, but emphasized that this was to be accomplished within a framework of sustainability. He added that the agenda is truly universal, and designed to be applied to all countries, whereas the original MDGs were largely designed by donor nations to deal with recipient countries. This focus on universality—for instance, the willingness of the United States and the Organisation for Economic Co-operation and Development (OECD), in particular, to examine some of their own environmental problems—helped to convince key Latin American actors on the High-Level Panel to participate. Norris mentioned that in a welcome change, environmental concerns are now included within multiple goals and targets. Another important change in the report, Norris said, is an emphasis on institutions, governance, and peace. More than 40 percent of the world’s poor live in areas afflicted with violence and turmoil. Poverty, health, and environmental issues cannot be dealt with until these areas are helped to emerge from conflict. Norris added that budget transparency and a more informed and connected public can lead to better choices in the use of the environment, health spending, and other investments. Unfortunately, not all member states agree on these topics, although he stressed that the process of setting goals and targets was based on consensus. In terms of specific goals and targets in heath, Norris stated that there is a lot of continuity with the original MDGs (see Box 2-1 for a list of the universal goals proposed by the UN High-Level Panel). Infant and child mortality, maternal mortality, and sexual and reproductive health and rights were part of the original goals, and have been expanded in the new

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14 INCLUDING HEALTH IN GLOBAL FRAMEWORKS BOX 2-1 Universal Goals from the UN High-Level Panel Report 1. End poverty 2. Empower girls and women and achieve gender equality 3. Provide quality education and lifelong learning 4. Ensure healthy lives 5. Ensure food security and good nutrition 6. Achieve universal access to water and sanitation 7. Secure sustainable energy 8. Create jobs, sustainable livelihoods, and equitable growth 9. Manage natural resource assets sustainably 10. Ensure good governance and effective institutions 11. Ensure stable and peaceful societies 12. Create a global enabling environment and catalyze long-term finance SOURCE: UN, 2013. agenda, to which noncommunicable diseases also have been added—an addition Norris noted was important in terms of environmental health. Including healthy life expectancy as a target was discussed but was not adopted, which Norris said was disappointing. He noted that healthy life expectancy is a fairly new concept, and some public education within the intergovernmental process is needed before it can be accepted. He also noted that healthy life expectancy makes a good proxy indicator for many goals, across many sectors, and in many countries. The section of the agenda that dealt with environmental issues was challenging, Norris said, adding that although global climate negotiations, trade talks, and financial discussions could not be addressed though the UN High-Level Panel, areas of consensus were identified. Environmental targets under Goal 7 (securing sustainable energy) included the Sustainable Energy for All initiative, which proposed doubling the rate of renewables in the global energy mix, and doubling the global rate of improvement in energy efficient buildings, industry, agriculture, and transport.53This 5 According to the report of the UN High-Level Panel, this goal implies a 2.4 percent annual efficiency gain by 2030 compared with 1.2 percent, which was achieved from 1970 to 2008, according to the Global Energy Assessment from the International Institute of Applied Systems Analysis (http://www.iiasa.ac.at/

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 15 initiative has been well received, said Norris. The effort to reduce fossil fuel subsidies is complicated by the enormous sums of money at stake, and although it has been approved at the G8 and G20 levels,64it has not achieved much success. The concept of sustainable consumption and production touches on many environmental areas. Strategies such as post-harvest waste reduction, agricultural efficiency, sustainable fisheries, and water and sanitation improvements have not only a significant environmental impact, but also a significant economic one, and they generate a lot of popular support. Norris noted that agreement on clear numbers and measures to gather these data is needed to further specific environmental targets in the post- 2015 agenda; otherwise, they are likely to be ignored, as occurred in the MDG process. For example, for MDG 7 (ensuring environmental sustain- ability) and Target 9 (integrating the principles of sustainable development into country policies and programs and reversing the loss of environmental resources),75the data underlying these efforts are not very robust, in part because consensus was lacking when the target levels and associated indicators were developed. Norris doubted that member states agreed on the definition of deforestation or which forests would be included in Indicator 25 (proportion of land area covered by forest), and added that there were concerns about land use, with consequent legal implications for both developed and developing nations. Overall, these efforts were not very data-driven, leaving much work to be done for the post-2015 agenda. Norris concluded his presentation with the observation that environmental and poverty reduction issues need to be considered together, and that financial discussions about these should not just include member states and the international and financial institutions alone. Financial discussions should be broader and include the private sector, private philanthropy, and civil society. Only then can the necessary support and resources be assembled and mobilized to meet this very ambitious agenda. web/home/research/Flagship-Projects/Global-Energy-Assessment/Home-GEA. en.html [accessed September 9, 2013]). 6 The G8, or Group of Eight, is an assembly of world leaders who meet annually to discuss global issues. The G20, or Group of Twenty, is an assembly of finance ministers and central bank governors. 7 See http://www.unmillenniumproject.org/goals/gti.htm (accessed August 28, 2013).

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16 INCLUDING HEALTH IN GLOBAL FRAMEWORKS RESPONSE TO FINDINGS AND RECOMMENDATIONS IN THE UN HIGH-LEVEL PANEL’S REPORT Sir Andrew Haines, M.D. Professor of Public Health and Primary Care London School of Hygiene and Tropical Medicine Andrew Haines began his presentation by noting concern about the possible marginalization of health in the post-2015 agenda—of the 11 thematic groups for discussion, only 1 included health. Of the MDGs themselves, 3 are specifically concerned with health, and 18 of the 48 indicators are specifically linked to health (and many more are indirectly linked). Only one sustainable development goal is likely to be adopted, he added, which will attempt to integrate both universal health coverage and the determinants of health. There are problems with developing a simple set of indicators for universal health coverage, and Haines noted that the UN High-Level Panel did not include catastrophic health expenditure, an important element of universal health coverage. Health Linkages in the Proposed Goals Many of the 12 proposed universal goals in the UN High-Level Panel’s report are inextricably linked to health, said Haines: • Goal 1 (ending extreme poverty) is crucial for the improvement of health. • Goal 4 (ensuring healthy lives) provides an opportunity to track selected noncommunicable diseases and develop indicators that also reflect some of the environmental determinants of health. • Goal 5 (ensuring food security and good nutrition) focuses on reducing stunting, wasting, and anemia, although the other end of the spectrum—overweight and obesity—is not addressed. • Goal 7 (securing sustainable energy) suggests increased use of renewable energy sources, which would result in less air pollution and therefore fewer associated health issues. • Goal 11 (ensuring stable and peaceful societies) calls for reducing violent deaths by 100,000 by an agreed date, as a possible indicator. Goal 11 also provides an opportunity to address road injuries, which cause about 1.3 million deaths per year. Road transport is increasing and is a major source of greenhouse gas

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 17 emissions. The increase in traffic combined with the dangerous state of roads and lack of enforcement of traffic regulations, particularly in low- or middle-income countries, not only causes road injuries (a major burden on health systems) but also inhibits active travel (e.g., walking and cycling). • Goal 12 (creating a global enabling environment and catalyzing long-term finance) stresses the importance of preventing an increase in the global average temperature of more than 2 degrees Celsius. Many scientists believe that if this increase is exceeded, major changes could ensue that threaten global security and human health in the future. Haines discussed the dangers mentioned in Goal 12 in greater detail, noting that in the 2012 World Bank report Turn Down the Heat, depending on which global emissions pathway is followed, a global mean temperature rise of 4 degrees Celsius could be exceeded by the end of the century—which would have major implications for health and development. He added that, as also noted by Norris, although the UN High-Level Panel report stressed the importance of abolishing fossil fuel subsidies, these subsidies and unsustainable agricultural policies have proved remarkably difficult to eradicate. Indicators for Linking Health and Sustainability Citing an article by Rockstrom and colleagues (2009), Haines turned to a consideration of “planetary boundaries,” defined as “the safe operating space for humanity with respect to the Earth system . . . associated with the planet’s biophysical subsystems or processes.” He noted that three of the nine boundaries defined in the article that have already been reached: climate change, human interference with the nitrogen cycle, and biodiversity loss. There is a need, he said, to determine which indicators best reflect the damage to these global systems with particular implications for human health. For instance, climate change might lead to a reduction in grain yields and changes in water availability, and both would have a major impact on human health. In the quest to identify linkages between health and sustainability, Haines noted that environmental change and its impact on agricultural systems—with the subsequent effect on human nutrition—provides an excellent source of potential indicators. These might be divided into two policy types. The first policy type would be directed toward enhancing

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18 INCLUDING HEALTH IN GLOBAL FRAMEWORKS sustainability through reducing damage to the environment (for instance, by reducing greenhouse gas emissions), while the second would focus on increasing the resilience of populations to adverse environmental conditions (for instance, by developing hardier agricultural seeds). Agriculture Haines expounded on the range of linkages among agricultural productivity and agricultural systems, environmental sustainability, and human health, noting that livestock production is a significant contributor to climate change, particularly through methane emissions. Developing a metric to link agricultural sustainability with health is complicated by the many complexities of animal product consumption, and fruit and vegetable intake might be simpler to measure. Around 1 billion people are currently food insecure and indicators of undernutrition are gaining support (such as stunting, which has implications for cognitive development and future risks of developing noncommunicable diseases). Obese and overweight people tend to contribute higher per capita greenhouse gas emissions (Edwards and Roberts, 2009) because they tend to consume more food and may use motorized transport more than individuals of normal weight. Water and Sanitation Climate change risks and the depletion of aquifers are important challenges for freshwater availability, Haines said. For example, sea- level rise due to both climate change and local environmental changes can contribute to salination of coastal water sources. The achievements of a sustainable safe water supply together with hygienic sanitation in the home are very worthy goals. A suggested indicator for this goal area is the proportion of income spent on water—an important contributor to poverty in many developing countries. Disaster Resilience Indicators for disaster resilience are hard to develop but might assess how health facilities might not only be made more resilient to floods and other extreme events, but also assess for reliable clean energy and clean water supplies, including in emergencies. Sustainable Cities Although sustainable cities are an important issue—more than half of the world’s population lives in cities, and this number will only increase in the future—they are not featured much in the UN High-Level Panel’s

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 19 report. Local city administrations might be challenged to develop their own set of indicators for sustainable cities, as the drivers of sustainable development are not necessarily federally controlled. Options for short urban journeys by active travel (walking and cycling), public transport, and injuries per kilometer travelled might serve as indicators. Air Pollution Air pollution is a major factor in ill health, as noted in the 2010 Global Burden of Diseases, Injuries, and Risk Factors Study (Lim et. al., 2012), which estimated that approximately 3.5 million deaths per year are attributable to household air pollution from solid fuels and 3.2 million deaths result from ambient air pollution (with contributions from household sources). Good measures of ambient fine-particulate air pollution are available in an increasing number of sites around the world, and data about the source of household energy could be readily collected. Healthy Housing Urban slums are mentioned in the report from Lim and colleagues (2012). Haines maintained that low-cost housing for the poor should be available and should include basic essentials for healthy life: safe drinking water, clean heating and cooking, and resilience to heat and cold. Healthy Life Expectancy Healthy life expectancy is increasingly available as a metric. Haines urged more national statistical agencies to collect data about healthy life expectancy, so that the effectiveness of maximizing health throughout life can be measured. Both universal health coverage and the environ- mental and social determinants of health are contributing factors to a healthy life expectancy. Final Remarks Haines concluded his presentation by noting that although they have not been globally achieved, the MDGs have helped to focus international and national efforts and should be the foundation of continuing efforts. He added that better metrics for monitoring progress toward universal health coverage should be developed. In addition, indicators of “health in all policies” that both reduce environmental damage (e.g., greenhouse gas emissions) and improve health and resilience to environmental change should be developed.

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20 INCLUDING HEALTH IN GLOBAL FRAMEWORKS DISCUSSION A brief discussion among the speakers and participants followed the presentations. Their remarks are summarized in this section. Are the Goals Achievable? The first question addressed to the speakers concerned whether these goals—worthy though they may be—are actually achievable in the real world, with its increasing population, increasing poverty and unemploy- ment, and widening gaps between rich and poor. Haines responded that although it is difficult to persuade either emerging economies or high-income countries to change their lifestyles to facilitate sustainable development for the rest of the world, it is an ambitious program that should be attempted. He said that to simply accept the status quo is wrong. He added that policies such as reducing fossil fuel subsidies are a good option, particularly with the cost of renewables dropping worldwide. The biggest challenge, he said, is in the food and agricultural sector. Human diets are culturally specific and depend on personal preference. To change or modify diets on a mass scale is a difficult project, although, of course, diet has changed as a result of changing food availability. Local initiatives are most successful, and policy changes are much easier at the local rather than the national level. Norris responded that the UN High-Level Panel members and the UN Secretary General worked hard to identify goals and targets that were ambitious, but achievable. Certain options were included because the panel believed the international community and member states could manage them, while others were deliberately excluded because they were unlikely to be achieved within the 15-year period. For instance, the extreme poverty measure was set at $1.25 per day because that amount was viewed as mostly achievable in 15 years, whereas $2.00 per day was not. There was agreement about ending preventable childhood mortality because it was potentially achievable within 15 years, whereas ending preventable maternal mortality was not considered possible within 15 years. The panel’s general approach was to take the original goals and extend them. Although the members could not, of course, put an end to all of the world’s ills, Norris felt they had done better than expected. Rasanathan responded that these high-profile goals led to improved results, and that simply identifying the goals inspired new investment,

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PROCESSES TO DEVELOP POST-2015 DEVELOPMENT GOALS 21 resources, monitoring systems, and mechanisms to deliver services. He regretted that some of the new targets lacked numerical indicators, adding that one of the real strengths of the MDGs was the ability to assess their progress. He also noted that including too many potentially unachievable goals not only increases technical difficulties, but also could affect the political landscape by creating an impression of failure. Human Security as Part of the Framework The second question involved the dimension of human security, newly added as a fourth dimension to the framework for sustainable development. (The 1992 framework only included social, environmental, and economic dimensions.) A participant noted that no mention had been made of this dimension by the speakers and asked for their opinions on the topic. Haines responded by noting that security is addressed within many of the universal goals in the UN High-Level Panel’s report. He noted that food security is mentioned in Goal 5, reducing deaths from natural disasters is mentioned in Goal 1, and reducing violence is mentioned in Goal 11. Norris responded by stressing the importance of peace, stability, and the pressures that push families and individuals into vulnerability, adding that these are difficult matters that are a source of contention in the intergovernmental negotiations. He urged the creation of an accurate database to track yearly violent deaths per country as a starting point. He also emphasized the importance of legal and property rights, and access to social services, and disparaged the tendency in the UN to always discuss security issues in terms of Chapter 786authority instead of more personal perspectives. Rasanathan responded that security is the issue in which there has been the least progress in the MDGs, and that the impact of violence on communities is difficult to measure, with specific targets not yet identified. Discussing Goals with Local Governments: Are Toolkits Available? The final question asked what resources or toolkits were available for engaging local municipalities in the discussion about the goals and policies presented by the speakers. 8 Chapter 7 of the United Nations Charter: “Action with Respect to Threats to the Peace, Breaches of the Peace, and Acts of Aggression.”

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22 INCLUDING HEALTH IN GLOBAL FRAMEWORKS Norris responded by noting that the role of municipalities in the post- 2015 agenda was very prominent in the discussion, although substantial data collection would be needed to achieve these goals. Balbus responded by referencing ICLEI (originally International Council for Local Environmental Initiatives but changed to ICLEI— Local Governments for Sustainability), an organization dedicated to assisting local governments with sustainability. He suggested that ICLEI’s website (www.icleiusa.org) could furnish the resources and toolkits required. REFERENCES Edwards, P., and I. Roberts. 2009. Population adiposity and climate change. International Journal of Epidemiology. doi:10.1093/ije/dyp172. Lim, S. S., T. Vos, A. D. Flaxman, G. Danaei, K. Shibuya, H. Adair-Rohani, M. A. AlMazroa, M. Amann, H. R. Anderson, K. G. Andrews, M. Aryee, C. Atkinson, L. J. Bacchus, A. N. Bahalim, K. Balakrishnan, J. Balmes, S. Barker-Collo, A. Baxter, M. L. Bell, J. D. Blore, F. Blyth, C. Bonner, G. Borges, R. Bourne, M. Boussinesq, M. Brauer, P. Brooks, N. G. Bruce, B. Brunekreef, C. Bryan-Hancock, C. Bucello, R. Buchbinder, F. Bull, R. T. Burnett, T. E. Byers, B. Calabria, J. Carapetis, E. Carnahan, Z. Chafe, F. Charlson, H. Chen, J. S. Chen, A. T.-A. Cheng, J. C. Child, A. Cohen, K. E. Colson, B. C. Cowie, S. Darby, S. Darling, A. Davis, L. Degenhardt, F. Dentener, D. C. Des Jarlais, K. Devries, M. Dherani, E. L. Ding, E. R. Dorsey, T. Driscoll, K. Edmond, S. E. Ali, R. E. Engell, P. J. Erwin, S. Fahimi, G. Falder, F. Farzadfar, A. Ferrari, M. M. Finucane, S. Flaxman, F. G. R. Fowkes, G. Freedman, M. K. Freeman, E. Gakidou, S. Ghosh, E. Giovannucci, G. Gmel, K. Graham, R. Grainger, B. Grant, D. Gunnell, H. R. Gutierrez, W. Hall, H. W. Hoek, A. Hogan, H. D. Hosgood, D. Hoy, H. Hu, B. J. Hubbell, S. J. Hutchings, S. E. Ibeanusi, G. L. Jacklyn, R. Jasrasaria, J. B. Jonas, H. Kan, J. A. Kanis, N. Kassebaum, N. Kawakami, Y.-H. Khang, S. Khatibzadeh, J.-P. Khoo, C. Kok, F. Laden, R. Lalloo, Q. Lan, T. Lathlean, J. L. Leasher, J. Leigh, Y. Li, J. K. Lin, S. E. Lipshultz, S. London, R. Lozano, Y. Lu, J. Mak, R. Malekzadeh, L. Mallinger, W. Marcenes, L. March, R. Marks, R. Martin, P. McGale, J. McGrath, S. Mehta, Z. A. Memish, G. A. Mensah, T. R. Merriman, R. Micha, C. Michaud, V. Mishra, K. M. Hanafiah, A. A. Mokdad, L. Morawska, D. Mozaffarian, T. Murphy, M. Naghavi, B. Neal, P. K. Nelson, J. M. Nolla, R. Norman, C. Olives, S. B. Omer, J. Orchard, R. Osborne, B. Ostro, A. Page, K. D. Pandey, C. D. H. Parry, E. Passmore, J. Patra, N. Pearce, P. M. Pelizzari, M. Petzold, M. R. Phillips, D. Pope, C. A. Pope, J. Powles, M. Rao, H. Razavi, E. A. Rehfuess, J. T. Rehm, B. Ritz, F. P. Rivara, T.

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