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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
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 âHuman beings are at the center of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with natureâ [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): ï· Meet primary health care needs, particularly in rural areas. ï· Control communicable diseases. ï· Protect vulnerable groups. ï· Meet the urban health challenge. ï· Reduce health risks from environmental pollution and hazards.
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
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 âspirit of Rioâ 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 problemsâonly then is sustainable development achievable. The convergence between the three pillars of sustainable developmentâenvironmental, social, and economicâis 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
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 9 to climate change (UN General Assembly, 2010). Encouraging green economy actions has the potential to ï· avert a large proportion of chronic obstructive pulmonary disease due to smoke from indoor cookstoves (Wilkinson et al., 2009); ï· 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 ï· 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 negotiationsâthe debate about who gains and who might loseâbut health co-benefits present a âwin-winâ 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.
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 peopleâs 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 mediaâs attention, and the NGOs now have a continuous and growing following.
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 agreementâs foreign policy implications, and with appropriate involvement by the State Department. (U.S. Department of State, 2012)
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 Stateâs Bureau of Oceans and International Environmental and Scientific Affairs. Beyond this, there has been limited involvement from other agencies and high- level political officials.
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 healthâhighlighting premature deaths caused by respiratory diseases, particularly among women and childrenâit 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.
14 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY CLIMATE CHANGE: THE NEED FOR LINKAGES FOR SUSTAINABILITY AND HEALTH Carlos CorvalÃ¡n, Ph.D. Senior Advisor on Risk Assessment and Global Environmental Change Pan American Health Organization Carlos CorvalÃ¡n noted that the meaning of sustainable development was first made prominent in the Brundtland Commission Report of 1987, which defined it as âdevelopment that meets the needs of the present without compromising the ability of future generations to meet their own needsâ (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)âthe economic, social, and environmental pillars. CorvalÃ¡n 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 CorvalÃ¡n 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. CorvalÃ¡n emphasized that human health is at the
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 15 end of a very long chain of events surrounding socioeconomic development and the drivers of climate change. CorvalÃ¡n 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. CorvalÃ¡n 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 CorvalÃ¡n, 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. CorvalÃ¡n 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.
16 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY FIGURE 2-1 Climate change impacts on other risk factors. NOTE: Climate change affects health directly (for example, increased frequency of heat waves affects the health of vulnerable populations, in this case children, outdoor workers, and the elderly). Proximal environmental health risks (inner circle), such as radiation, air pollution, and vector-borne diseases, negatively affect health and can have negative effects. There are also distal environmental health risks (outer circle) that can affect the proximal causes. Climate change, a distal threat, impinges upon proximal causes and can exacerbate the risk they pose to health. Thus, climate change can affect health directly and indirectly. SOURCE: CorvalÃ¡n, 2011. An Agenda for Action CorvalÃ¡n explained that WHO and the Pan American Health Organization (PAHO) have developed a global action plan to address the implications of climate change for health and health systems. He described the plan as comprised of four parts, the first of which is to gather more evidence on the type of interventions that should be implemented to ensure that climate change adaptation is carried out properly. Second, those in the health sector need to raise awareness about climate change (which may involve making them aware of what they can do) and work to reduce the carbon footprint of the health sector. The
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 17 third part is to establish partnerships because climate change is too broad an issue for any one sector to tackle alone. He noted that the health sector needs to become a leader where health issues are concerned. Fourth, adaptation strategies need to be adopted to strengthen health systems in areas that are likely to be affected by climate change. CorvalÃ¡n stated that the green economy will be one key issue at the Rio+20 conference and will provide an opportunity to discuss climate change mitigation. UNEP defines a green economy as one that results in âimproved human well-being and social equity, while significantly reducing environmental risks and ecological scarcitiesâ (UNEP, 2010, 2011). He explained that the notion of a green economy is an important step forward because it signifies attention to climate change mitigation. The UNEP report (UNEP, 2011) described the green economy as substi- tuting clean energy and low-carbon technologies for fossil fuels, thus addressing climate change. As outlined above, climate change has serious implications for human health, he said, and by fostering a green economy these negative health effects may be lessened. As the Rio+20 conference approaches, WHO and PAHO are attempting to secure renewed political commitment for sustainable development and to ensure that health is incorporated in sustainable development planning. CorvalÃ¡n emphasized that it is also time to define a new paradigm for the sustainable development movement with fully integrated dimensionsâenvironmental, social, and economicâwith health placed at the center. With this new agenda, he said, there is an opportunity to achieve action in climate change, health, and sustainable development for the global community.
18 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY CURRENT AND EMERGING CHALLENGES AND OPPORTUNITIES FOR ENVIRONMENTAL HEALTH: SUSTAINABILITY, NONCOMMUNICABLE DISEASES, AND OPPORTUNITIES FOR LINKAGES Linda S. Birnbaum, Ph.D., D.A.B.T., A.T.S. Director, National Institute of Environmental Health Sciences National Institutes of Health Linda S. Birnbaum began by noting that the National Institute of Environmental Health Sciences (NIEHS) is committed to reducing the burden of disease and disability related to environmental factors, not only in the United States but also throughout the world. She stated that it is critical that science be translated into information and actions that will protect public health and improve peopleâs lives, especially heading into the Rio+20 conference. Birnbaum shared her perspective on the link between environmental health research carried out by the NIEHS and the needs of developing countries. She stated that the institute aims to support economic growth that is sustainable in terms of both natural resources and social systems, as well as in terms of human health. However, health is too often left out or discounted in discussions of sustainable development when other factors such as economics hold sway. She noted that this is a mistake. Birnbaum explained that the impact of development on human health and the resulting long-term effects on sustainability should be critical in all such discussions. The NIEHS has supported scientific endeavors relevant to sustainable development for decades. As global populations increase and resources become scarce, she stated, the NIEHS will continue to work to ensure that health is not only not left out of the equation but that it is given a high priority, too. Birnbaum noted that environmental health may be seen as inherently global. Many pollutants such as mercury, greenhouse gases, and particulate matter are widely distributed around the planet, affecting human health far from the emission sources. She explained that the experiences of industrialized countries with adverse health impacts from polluted air, water, and land are becoming increasingly relevant around the world as less-developed countries are rapidly strategizing on how to achieve similar industrialization. In the race to achieve a higher standard of living, she said, public health is at risk of being compromised. Yet,
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 19 there is also the potential for disease prevention and public health protections that have been achieved in wealthier countries to be realized in developing countries. Throughout its history, Birnbaum explained, the NIEHS has been consistently committed to the goals of protecting and improving global environmental health. Upon opening its doors, the institute welcomed scientists and students from around the world for training and collaborative research. She noted that 36 years ago the NIEHS was named by the WHO as the collaborating center for environmental health effects. For 27 years, the NIEHS has supported a cooperative agreement with the International Program on Chemical Safety, through which it has helped to provide scientific leadership and expertise to efforts to protect public health worldwide from the effects of toxic chemicals. Birnbaum stated that in addition to training partnerships, the NIEHS has funded critical research in collaboration with other countries to better understand the impacts of environmental exposures among the most affected. For example, the NIEHS funded studies of populations in the Seychelles and Faroe Islands who consume high amounts of mercury from fish and other seafood, studies which have helped improve the understanding of neuro- developmental effects of mercury exposure. She explained that this research has contributed to consumption guidelines for pregnant mothers to protect the health of their unborn children. For 12 years, NIEHS funding has supported the study of arsenic contamination of tube wells in Bangladesh. She noted that the tube wells were meant to provide pure, clean water and improve agricultural production, but tragically led to widespread toxic effects from the presence of arsenic in the groundwater. The NIEHS not only documented disease effects, but its work has resulted in a public health intervention of testing thousands of wells and guiding residents to safer drinking water sources. Birnbaum stated that another area where NIEHS is not just studying the problem but also funding research involved in public health interventions is that of indoor air pollution caused by cookstoves. Nearly 2 million people around the world die every yearâand others are made sick or disabledâas a result of exposure to smoke from fuels burned in indoor cookstoves (Bruce et al., 2000; WHO, 2011c). The NIEHS is currently the largest funder of cookstoves and health research at the National Institutes of Health, supporting pioneering studies that have documented health improve- ments from replacing cookstoves. She noted that these are just three examples of environmental exposures that are major contributors to poor health around the world.
20 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY Sustainable Development and Health Birnbaum noted that WHO estimates that approximately 24 percent of the overall global burden of disease is attributable to environmental factors (WHO, 2006). The range of impact is considerable, from 12 percent in the wealthiest countries to as much as 40 percent in the poorest countries (WHO, 2004). She stated that this figure represents not just an ongoing tragedy but also a ripe opportunity for primary prevention. Birnbaum explained that there are many definitions of both sustainability and sustainable development, but one often-cited definition is from the United Nations World Commission on Environment and Developmentâs Brundtland Report (WCED, 1987). âSustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needsâ (emphasis added). Although environmental health is not explicitly mentioned here, she said, clearly the terms of sustainable development cannot be met without its consideration. She noted that being able to meet the needs of the present requires not just economic development but also good health. She added that not compromising the ability of future generations requires the ability to avoid environmental insults that can persist through generations as well as persistent and ongoing toxic pollution related to new or increasingly used technologies. From an environmental health point of view, sustainable development involves the effect of the environment on health, the resulting impact on development, and subsequent effects directed back to the environment and health (see Figure 2-2). She noted that for those who continue to suffer in poverty, traditional sanitation risks and environmental exposures continue to create barriers to individuals, community, and national economic growth, productivity, and well-being. Birnbaum stated that these are the needs of the present. Additionally, she said, the needs of future generations are reflected in how development affects the environment, and its resulting impact on health. Development has benefited the health of billions of individuals, she said, but it has also created environmental changes that have led to new exposures and threats to human health. She explained that determining how to achieve
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 21 FIGURE 2-2 Sustainable development. NOTE: âSustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needsâ (WCED, 1987). The environmental health paradigm recognizes that the environment can affect health and development; consequences from development can also affect the environment and health. Top panel: For those who are at risk from inadequate sanitation and environmental exposures, the environment has the greatest impact on health. Economic development and productivity are impeded by the failure to improve health. Ameliorating environmental health risks and allowing populations to flourish are necessary to meet the needs of the present. Bottom panel: Development can alter the environment, which can impact health. Socioeconomic development can produce pollution that persists in the environment, exposing vulnerable populations and threatening health. Avoiding environmental insults from development is necessary to ensure that future generations are able to meet their own needs. SOURCE: Birnbaum, 2011.
22 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY development without these unintended consequences is an essential principle of sustainable development. Birnbaum stated that environmental health risks can be impediments to sustainable development through multiple pathways, depending on the stage of development and the types of diseases that predominate at that stage. She noted that this is reflected in the concepts of the epidemiological transition and environmental risk transition that occur with progressive economic development (see Figure 2-3). With the epidemiological transition, the types of diseases that make the largest contribution to mortality and the burden of disease change from communicable, maternal, perinatal, and nutritional diseases (Group I conditions) to noncommunicable diseases (Group II conditions). Birnbaum explained that the environmental risk transition describes the changing contribution of environmental risks that occurs with development, and thus underlies the epidemiological transition. In the early stages of development, local exposures such as smoke from cookstoves or impure water have direct and immediate effects. Increased development gives way to exposures at the community level and ultimately the global level, such as climate change and global mercury transport from burning fossil fuels, which produce effects that are delayed. In rapidly developing countries, it is possible to observe populations simultaneously engaged in multiple stages of the transition (creating a double burden of exposure and disease among many in the poorest areas of these countries). She stated that in terms of addressing environmental health barriers to development, there is substantial progress to be made for all the conditions. Birnbaum explained that Group I conditions, the traditional diseases of poverty, contribute a large share to the global burden of disease owing to their impact on young individuals, resulting in death or disability at a young age. She noted that they take an enormous emotional and economic toll on families and societies. The Group II chronic conditions also have a significant component attributable to environmental factors (WHO, 2006). She stated that the death rate from noncommunicable diseases is higher in low- and middle-income countries, dispelling the myth that noncommunicable diseases are primarily a problem of the developed world. In fact, 80 percent of deaths from noncommunicable diseases occur in low- and middle-income countries (WHO, 2011a). She noted that a greater proportion of people die from noncommunicable diseases at a younger age in low- and middle-income countries.
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 23 FIGURE 2-3 A changing landscape for environmental health: The epidemiological and environmental risk transitions. NOTE: The epidemiological transition describes how, concomitant with economic development, the types of diseases that make the greatest contribution to mortality shift from communicable, maternal, perinatal and nutritional diseases (Group I) to noncommunicable diseases (Group II) like diabetes and stroke. The environmental risk transition underlies and contributes to the epidemiological risk transition. This is the progression from local exposures with direct and immediate effects to community exposures with both immediate and delayed effects, and global exposures that primarily have delayed effects. SOURCE: Birnbaum, 2011. For example, it is estimated that 30 percent of noncommunicable disease deaths occur in individuals under the age of 60 in low- and middle- income countries as opposed to 13 percent in high-income countries (WHO, 2011a). According to a study by Abegunde and colleagues (2007), nearly $84 billion of economic productivity will be lost from 2005 to 2015 as a consequence of cardiovascular disease, diabetes, and stroke in 23 low- and middle-income countries. Birnbaum explained that this has important implications for development, given that in much of the developing world individuals pay out of pocket for health care expenses, thus compounding lost productivity from noncommunicable diseases with the financial burden of living with a chronic disease. The greatest effects of this fall increasingly on poorer people within these countries, where a vicious cycle may occur in which poverty exposes people to noncommunicable disease risk factors and the treatment for the resulting diseases may drive families further toward poverty (WHO,
24 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY 2011a). In the United States, health care expenditures account for up to 17 percent of the gross domestic product (CMS, 2009). For low- and middle-income countries, she said, this type of expenditure in health care would be a tremendous barrier to development, making the role of prevention critical. The NIEHS Promotes Health in Development Birnbaum noted that the NIEHS is actively supporting research on both sides of the epidemiological transition, furthering the idea of environmental health as a prerequisite for development. With regard to Group I communicable diseases, the NIEHS is funding cookstove research that is providing essential information for reducing the burden of respiratory tract infections in children. As for Group II noncommun- icable chronic diseases, the NIEHS is conducting research on air pollution, both outdoor and indoor, as well as on carcinogenesis, developmental toxicity, and the fetal basis of adult disease, especially in respect to endocrine disruption. She stated that this work will help to address sustainable development by helping to meet the needs of the present. Birnbaum explained that addressing the rising burden of noncommunicable diseases and their environmental determinants, especially in low- and middle-income countries, will pay the greatest economic dividends as countries progress through the epidemiologic transition. This includes the importance of building research in programmatic capacity to understand pathophysiological mechanisms and strategies for prevention, and decreasing injuries through improved road traffic safety and prevention of occupational hazards. Birnbaum stated that it is clear in examining the relationship between health and development that causality goes both ways. Without question, she said, development has resulted in economic growth and enormous health benefits for individuals in middle- and high-income countries. However, development has been accompanied by unintended effects on the environment, which have in turn had adverse effects on health. Looking through the lens of health, she said, the challenge moving forward is to understand how the rest of the world can reap the benefits of development while ensuring that unintended environmental health consequences are avoided. Birnbaum pointed out that we need to extend our understanding of the health consequences of future development (including industrialization, rapid evolution of technology, urban
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 25 expansion, and globalization) as well as effective ways to address those threats. Birnbaum explained that much of the work in environmental health to date has been focused at the household and community levels. She stated that the larger-scale consequences of the environmental effects of development and what they mean for human health are only beginning to be recognized. These effects include climate change, urbanization, and the disruption of essential ecosystem services like biodiversity, soil health, and coastal protection. Understanding the potential negative health effects of global environmental change, she said, and the manner by which they can be averted is at the core of the discussion of sustainable development. Birnbaum stated that the NIEHS is addressing the future needs of sustainable development through a growing research program on the health implications of climate change. A report published in NIEHSâs journal Environmental Health Perspectives and authored by the U.S. Global Change Research Programâs interagency cross-cutting workgroup (Interagency Working Group on Climate Change and Health, 2010) identifies linkages between climate change and a number of its human health effects. Importantly, this report not only outlines the various ways that climate change and its impacts may affect different disease categories but also highlights how these disease categories may be affected by measures taken to reduce greenhouse gases or adapt to climate change. To help fill the research gaps identified in the report, the NIEHS is funding research on population vulnerability to climate change impacts, which will support pilot studies to help define vulnerability factors, develop methods, and build a community of researchers in this important area. The NIEHS also sponsored a series of studies (Friel et al., 2009; Haines et al., 2009; Markandya et al., 2009; Smith et al., 2009; Wilkinson et al., 2009; Woodcock et al., 2009) published in 2009 that explored ways in which efforts to reduce greenhouse gas emissions in diverse sectors of society could have health co-benefits. She explained that these studies showed that climate change mitigation measures could also reduce risk factors that contribute to communicable and noncommunicable disease in the following categories: household energy, land transport, low carbon electricity, food and agriculture, and short- lived greenhouse gas pollutants. In summary, Birnbaum stated, the NIEHS is providing critical scientific information in an effort to achieve sustainable and healthy
26 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY development. She noted that this information is needed to ensure that the needs of the present are met without compromising the ability of future generations to meet their needs as well. To help coordinate work in these areas, the NIEHS is developing a global environmental health and sustainable development program. Through this program, she said, the institute will increase interactions and partnerships with other federal agencies and international organizations that have the ability to help translate science into effective environmental health and sustainable development programs, policies, and initiatives. SUSTAINABILITY FRAMEWORKS AND OPPORTUNITIES FOR LINKAGES WITH HEALTH Paul Anastas, Ph.D. Assistant Administrator for the Office of Research and Development and Science Advisor U.S. Environmental Protection Agency Todayâs Challenge Paul Anastas stated that in addition to focusing on sustainability, his presentation would touch on the frameworks or constructs of green chemistry and the need for systems thinking to achieve transformative innovation. He started with the idea of persistence, noting that if the worldâs population lived at the same state of development as North America, Japan, and Western Europe, then we would need the equivalent of four Earths to provide all the needed resources and to allow for sustained ecosystems, sustained health, and so forth. He added that one can argue whether this projection is an overestimate or underestimate, but the message is clear: the efforts of humankind need to focus on how to achieve our goals with the one Earth we have. Anastas stated that central to this effort is addressing the grand challenges of sustainability, by simultaneously engaging with the environment, the economy, and society (see Figure 2-4). Additionally, he said, solutions to the challenges we face are within our power to design, such as how to design products that are not toxic and do not persist or bioaccumulate in the environment, people, or wildlife.
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 27 Today Tomorrow Future Goal FIGURE 2-4 The challenge of sustainability: connecting the environment, the economy, and society. NOTE: Currently there is a connection among the three systems: the environment, the economy, and society. To broaden and achieve the goal of sustainability it is important to fully integrate these areas and engage the three systems with equal importance (as depicted in the future goal). SOURCE: Anastas, 2011. Anastas pointed out that the current state of manufacturing and design includes a large percentage of toxic materials that are released into the environment with impacts that may not be easily reversed. In the United States, the Toxics Release Inventory (TRI) is a publicly available database used to track information on toxic chemical releases and waste management activities (U.S. National Library of Medicine, 2013). In 2011, 4.09 billion pounds of toxic chemicals were disposed of or released directly to the air, water, and land. However, he explained, these numbers are only a tip of the iceberg as only 650 toxic chemicals and toxic chemical categories out of more than 78,000 in commerce are tracked under the TRI (EPA, 2013). Anastas stated that there are frequent newspaper headlines about potential environmental health concerns from everyday products ranging from tainted toothpaste to lead-laced baby bibs to formaldehyde in clothing. He added that whether the concern is based on science or on public perceptions, these incidents tend to reduce confidence in products and may present a danger to our health and our environment. Anastas noted that U.S. agencies have been devoting tremendous resources to making our air cleaner and our water less contaminated. However, said Anastas, it is time to assess the current approaches and how we formulate these problems. In current efforts, decision makers and scientists may be striving to do the âright thingsâ for air, water, and land, but is this
28 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY approach advancing sustainability? He highlighted that the currently fragmented efforts to address environmental health need a systematic view. For example, climate change is inextricably linked to energy; energy is inextricably linked to water; water to agriculture; agriculture to human health; and yet our approaches are too often reactionary and fragmented along statutory or organizational lines. Anastas stated that it is time to think about decision making as an integrated, interrelated system if society is to make significant progress. As Lisa Jackson noted in her remarks at a separate meeting of the National Academy of Sciences in November 2010, âSustainability is about understanding that environmental challenges do not obey bright lines or numeric limits. They are not constrained by disciplinary boundaries or the boxed walls of an organizational chart. Itâs about ensuring that we see the big picture, and are not addressing one environmental issue only to create another consequence in the processâ (EPA, 2010). Anastas said that as we think about providing basic services and products, a more systems-oriented approach, which starts with sustainability, should be adopted. He noted that current environmental efforts are not integrated and are likely to have unintended consequences such as ï· renewable biofuels that compete with our ability to provide food; ï· water purification processes that use acutely lethal substances whose byproduct can be carcinogenic; ï· photovoltaicsâwhich convert solar radiation into direct current electricityâthat involve rare, toxic metals; ï· pesticides that increase crop yields but have toxic and bioaccumulative effects; and ï· energy-saving fluorescent light bulbs that rely on the neurotoxin mercury. What is clear from these examples, he added, is that unintended consequences do not have to be unanticipated. Anastas stated that the traditional linear approach of creating value for society with products and energy can be characterized as a cycle in how society thinks about its materials and energy flows. However, when a sustainability approach is used, the focus moves from trying to improve conditions (exposures to chemicals, how chemicals are handled, and putting scrubbers on smokestacks) toward the nature of materials
OVERVIEW OF SUSTAINABILITY AND HUMAN HEALTH 29 themselves. âHistorically, environmental protection has been shaped by such questions as ï· What is the maximum amount of pollution that can be emitted into the air without sacrificing regulatory compliance? ï· What is the highest level of toxicity that can be present in our products without breaking the law? ï· How many people must fall ill before a standard needs to be strengthened?â (EPA, 2010). Anastas stated that the traditional approach was and is essential to help assess and manage environmental risk. He noted that this is the way the EPA has operated for more than four decades; it has focused on how much environmental pollution could be allowed under the constraints of risk and law. Anastas emphasized that the opportunity now is to focus on the protection of environmental sustainability and conservation. âIt is the difference between treating disease and pursuing wellness,â he said. The question becomes, how do we think differently with regard to material and energy flows to provide a framework for sustainability? Anastas pointed out that there is a wide range of approaches to describe operational frameworks that are sustainable, including industrial ecology, natural step, environmental systems management and engineering, design for environment, green engineering,1 and, as discussed below, green chemistry. Green Chemistry Anastas identified green chemistry as critical for the shift toward sustainability and making linkages to health. Green chemistry aims to redesign the material basis of our society and economy including the materials used to generate, store, and transport energy and other consumer products. And, it seeks to design processes and products to reduce or eliminate the use or generation of hazardous substances. Anastas stated that there are 12 principles of green chemistry (see Box 2- 1) that are not merely noble goals to benefit the birds and trees but rather a comprehensive design framework that protects human health. The goal is not only to reduce waste generation by employing waste management, 1 Green engineering is defined as the design of systems and processes that reduce the use of hazardous substances while minimizing energy usage and the creation of unwanted byproducts (Anastas et al., 2000).
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 derivativesâunnecessary 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.
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 systemâs reaction to a perturbation that does not prevent the system from returning to its original level of function); adaptability (a systemâs ability to change in response to new system conditions to continue to function at the highest level); and awareness (a systemâs 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 todayâs 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
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 silosâmoving 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 processâwho 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 governmentsâcould 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 CorvalÃ¡n. 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
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 diseasesâthose 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.
34 PUBLIC HEALTH LINKAGES WITH SUSTAINABILITY Edward Doyle then came back to Birnbaumâs 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 worldâs 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
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 naÃ¯ve 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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