John M. Balbus, senior advisor for public health at the National Institute of Environmental Health Sciences and co-chair of the Institute of Medicine (IOM) Global Environmental Health and Sustainable Development Innovation Collaborative, opened the third webinar by highlighting the focus on making linkages among sustainable development, equity, and social justice. He noted that this relates to the overarching goal of the webinar series, which is to discuss how environmental health is integrated with issues of sustainable development. He explained that the second webinar addressed new approaches to connecting sustainable development across sectors (including the agricultural, energy, health, and transport sectors) and ideas about how to create crosscutting indicators to support the post-2015 development agenda process and the Sustainable Development Goals (SDGs). Balbus stated that achieving sustainable development not only requires creating bridges among the traditional pillars (economic development, social development, and environmental protection), but also reducing harmful exposures for those who are most vulnerable around the world. He noted that this leads us to confront issues of poverty, inequity, and social justice as they relate to sustainable development.
Úrsula Oswald Spring, Ph.D.
Professor and Researcher, Regional Centre of
National Autonomous University of Mexico
Úrsula Oswald Spring began her presentation by describing issues related to global environmental change that are affecting human health. She explained that we have witnessed a constellation of changes during
the past few centuries in different spheres—involving both natural and human components—that have contributed to global environmental change. The human population has tripled during the past century, greenhouse gas emissions have escalated, and the global temperature has risen, bringing greater nitrogen fixation and flux to coastal zones. In turn, these changes have created an enormous loss of biodiversity and species extinction in land and sea.
Oswald Spring noted that natural ecosystems produce an abundance of services on which humans depend. For instance, populations rely on provisioning services, or products obtained from ecosystems (such as food, water, and air); supporting services, or processes needed for the production of all other ecosystem services (such as the nutrient, sulfur, and carbon dioxide [CO2] cycles); and regulating services, or benefits that are obtained from ecosystem regulation (such climate regulation and water purification, which are crucial for discussions on global environmental change). One other area that often gets lost in the discussion is the cultural component, or the immaterial benefits obtained from ecosystems related to cultural heritage. She noted that human health is at the center of all these services, because human well-being is impacted by changes in ecosystems that directly or indirectly affect good social relations, material minimums, security, freedom, and choice.
Oswald Spring stated that experts are seeing unprecedented changes in the world’s ecosystems. During the past 30 years, increasing fresh water stress and water pollution have occurred throughout the world. In the past several decades, 20 percent of the world’s coral reefs were lost and another 20 percent were degraded. In addition, 35 percent of the mangrove forests, which are considered the most biodiverse areas on earth, were lost during this same period. The amount of water in reservoirs has quadrupled since 1960,1 withdrawals from rivers and lakes have doubled in the same time period, and today most surface water (70 percent worldwide) is used for agriculture (Millennium Ecosystem Assessment, 2005a). All of these processes have changed the world’s ecosystems and the services they provide.
These changes have related costs, Oswald Spring noted. Extinction rates among mammals, birds, and amphibians are 1,000 times higher than what was seen in the fossil record (Millennium Ecosystem Assessment, 2005b). Soil degradation is also increasing worldwide, which has implications for food production and water availability given that healthy
1 More reservoirs have been built since 1960. Water in reservoirs may be used to supply drinking water, generate hydroelectric power, provide irrigation, support recreational activities, and other uses.
soils are crucial to sustaining many ecosystem services. Speaking directly to the links with health, in 1990 about 30 percent of the world population, or 1.5 billion people, were exposed to dengue vectors, one of the most important viral vectorborne diseases sensitive to global warming and climate change. By 2085 it is estimated, based on climate change and population projections, that 50 to 60 percent of the world population, or 5 to 6 billion people, will be at risk for dengue transmission (Hales et al., 2002).
Distribution of the Health Impacts Related to Climate Change
Because the webinar focuses on inequality, Oswald Spring stated, we should examine how health impacts related to climate change are distributed throughout the world. Figure 4-1 provides a visual representation of countries (a) scaled by their total CO2 emissions from 1950 to 2000 in the top graphic and (b) scaled by estimates of per capita mortality from climate change in 2000 in the bottom graphic (Patz et al., 2007; WHO, 2008). One can see that Africa, which has almost no CO2 emissions, is the continent most affected by the health burden of climate change, followed by India. In effect, climate change is threatening to widen the health inequalities the already exist between rich and poor populations, exposing those in regions with the greatest disease burden to additional and disproportionate health risks (WHO, 2008). In order to reduce the burden of disease from climate change within these vulnerable populations, Oswald Spring said, regions need both mitigation and adaptation processes.
During natural disasters, Oswald Spring noted, large populations can be vulnerable to droughts, floods, extreme temperatures, windstorms, wildfires, earthquakes, landslides, volcanic eruptions, and wave surges. From 1974 to 2003, disasters caused an estimated 2 million deaths and affected more than 5 billion people worldwide. Drought was the largest contributor, accounting for 44 percent of the deaths and 36 percent of other impacts (injuries, homelessness, etc.) (Guha-Sapir et al., 2004). Oswald Spring stated that about 1 billion people are now living in arid or semi-arid regions worldwide, which makes them vulnerable to climate change and highly exposed to drought that can threaten their lives.
Role of Gender in Health Impacts Related to Natural Disasters
Oswald Spring pointed out that gender also affects vulnerability to the impact of natural disasters. Gender is not only understood as masculinity and femininity, but also includes an understanding of the roles, norms, values, behavior, social representation, responsibilities, necessities, and expectations in society, as well as sexuality and sexual behavior. Gender factors can create a division of labor, power, and responsibilities and impact
FIGURE 4-1 Inequalities related to greenhouse gas emissions (top) and health impacts related to climate change (bottom).
NOTES: Maps are density-equalizing cartograms in which the sizes of the 14 World Health Organization regions are proportional to estimated greenhouse gas emissions and mortality related to climate change. The bottom map shows estimated mortality (per million people) for four climate-sensitive health effects (malaria, malnutrition, diarrhea, and inland flood-related fatalities) by the year 2000.
SOURCE: Oswald Spring, 2012. Adapted from Patz et al., 2007.
the distribution of resources and benefits within society. Oswald Spring noted that the socially most vulnerable include girls and women in southern regions of the world where the socioeconomic status of women is low. It appears that natural disasters exacerbate existing inequalities in societies, in that increased female disaster mortality rates are linked with poor economic and social rights for women (Neumayer and Plümper, 2007). These rates may also be due to women’s trained and self-assumed social responsibilities to care for others, often at the cost of their own lives (Oswald Spring, 2008). Natural disasters can lead to dramatic gender gaps in mortality, where women often account for 70 to 80 percent of those who die during these events (as seen with the 2004 Asian tsunami, the 2005 Pakistan earthquake, or Hurricane Stan in 2005 in Guatemala and Mexico).
A New Adaptation System for Sustainable Development
Oswald Spring stated that we need a new adaptation system that makes links among human capital (including gender issues, human adaptation, and human capabilities), environmental capital (including ecosystem processes, energy and ecological resources, and natural recycling), income and commodities, and science and medicine to create a human population with sustainable economic systems and energy processes to meet growing challenges (see Figure 4-2). She noted that energy processes should attempt to reduce fossil fuel usage and increase use of alternative fuels (e.g., small hydropower, solar, wind, and waves) in order to meet future energy demands in a sustainable manner that maintains human health and the environment. She also pointed out that the new adaptation system needs a different economic model for life that includes a distributive way to advance the health and wealth of populations. Oswald Spring explained that this transition to sustainable development will be a much better approach if it also focuses on overcoming poverty and addressing disaster risk management. These interconnections were included a recent Intergovernmental Panel on Climate Change (IPCC) special report (Managing the Risks of Extreme Events and Disasters to Advance Climate Change Adaptation) in which the issues of sustainability, poverty, adaptation to climate change, and disaster risk management were considered together to identify systems transformations to address vulnerable populations at high risk. This includes integrating adaptation and disaster risk management approaches into the social, economic, and environmental policy domains to tackle inequalities that sustain poverty and limit access to resources (IPCC, 2012). She noted that in order for this integrated approach to be successful, decision makers need to change their worldview and mindset related to how they approach, react to, and value these interlinkages. By working together, she said, stakeholders can influence and create policies locally, nationally, and internationally to achieve this sustainable transition.
FIGURE 4-2 New adaptation system for sustainable development.
NOTE: EROEI = energy returned on energy invested, HDI = Human Development Index.
SOURCE: The Pelican Web (2011). Reprinted with permission from The Pelican Web.
Sir Michael G. Marmot, M.D., Ph.D.
Professor of Epidemiology and Public Health,
Director of the International Centre for Health and Society,
University College London
Building off the previous presentation, Michael G. Marmot noted that equity and poverty are important topics to discuss for two reasons: (1) the degree of poverty and social disadvantage can render people more susceptible to environmental challenges, and (2) these issues can be addressed by aligning policies on the physical and biological environments with those on the social environment. He pointed out that three major reviews support this approach: (1) Closing the Gap in a Generation (2008) from the Commission on Social Determinants of Health, (2) Fair Society, Healthy Lives: The Marmot Review (2010) from the Strategic Review of Health Inequalities in England, and (3) Review of Social Determinants of Health and the Health Divide in the WHO European Region: Final Report (2013). He stated that the European Review utilized a model based on the accumulation of positive and negative effects on health and well-being during the life course stages (prenatal, early years, working ages [16 to 64 years], and older ages) from the wider society, the broader macrolevel (which includes topics that Oswald Spring presented), and systems of governance. Marmot explained that all societies have social hierarchies, but the magnitude of health and equity that follows from social and economic inequity is not the same in different countries. When comparing the absolute inequality in male death rates by level of education across European countries, the magnitude varies enormously, with countries in Eastern Europe experiencing much greater inequalities than countries in the west, north, and south (Mackenbach et al., 2008).
Assessing Health Inequalities During the Life Course Stages
Prenatal and Early Years
Beginning with the prenatal and early years of the life course, Marmot stated, possible causes of inequalities can be assessed. For instance, a comparison of child poverty rates2 before and after social
2 Child poverty rate is defined as the percentage of children in families with less than 60 percent of needed median income.
FIGURE 4-3 Child poverty rates before and after social transfers for 2009.
SOURCE: Marmot, 2012. Data from European Union Statistics on Income and Living Conditions.
transfers3 shows that child poverty rates decreased by approximately 10–30 percent after making social transfers within various European countries (see Figure 4-3). He noted that poverty, a key determinant of
3 Social transfers are defined as cash and in-kind transfers to provide a minimum income and livelihood security for poor and vulnerable populations.
health, is affected by the fiscal policy of governments, and that social transfers and social policy can do an enormous amount to decrease child poverty rates within countries. As a second example, Marmot pointed out that access to preschool is impacted by wealth in different countries of Central and Eastern Europe and the Commonwealth of Independent States of the former Soviet Union. In all of these countries, access varies significantly by wealth quintile, with approximately 0–10 percent of those in the poorest quintile having access to preschool compared to 15–75 percent of those in the richest quintile in each country (Marmot, 2012). He explained that access to preschool, which is a key determinant of early childhood development and children’s readiness for school, is an important predictor of the outcome of education, which in turn influences adult socioeconomic conditions and inequities in adult health.
Marmot noted that early childhood development and education are drivers of unemployment in the working ages. Again, comparing the countries of Central and Eastern Europe and the Commonwealth of Independent States, unemployment among 15- to 24-year-olds is considerably greater than unemployment among the total population (see Figure 4-4). He explained that government policy and macro-level changes affect unemployment rates, which in turn impact health. During the recent economic downturn across Europe, a 1 percent rise in the unemployment rate was associated with a 0.8 percent rise in suicide and a 0.8 percent rise in homicide (Stuckler et al., 2009). Marmot pointed out the policies of austerity will predictably increase unemployment and result in similar negative outcomes. Government policies that decrease unemployment (or increase employment) are crucial to protect the health and well-being of the population.
Looking at the situation among older people, Marmot said, the English Longitudinal Study of Ageing (ELSA) shows that inequalities persist across income quintiles. He noted that for people aged 50 years and older, spending on basic resources (fuel, domestic food, and clothing) as a percent of income rises steeply among the poorer groups (see Table 4-1). For instance, people in the richest quintile spent 16 percent of their income on basics compared to 48 percent of the people in the poorest quintile. He pointed out that the economic downturn made things much harder for the people at the bottom, whose spending on the basics increased by 12.5 percent during 2008–2009 compared to 2004–2005.
FIGURE 4-4 Unemployment rates in the countries of Central and Eastern Europe and the Commonwealth of Independent States for 2009.
SOURCE: Marmot, 2012. Data from UNICEF TransMONEE Database.
TABLE 4-1 Spending on Basics as Percent of Income
Spending on Basics as Percent of Income 2008/2009
Percentage Point Change in Spending as Percent of Income from 2004/2005–2008/2009
SOURCE: Marmot, 2012. Data from English Longitudinal Study of Ageing (see http://www.ifs.org.uk/ELSA/about [accessed August 14, 2013]).
Policies to Promote Health Equity and Sustainable Development
Marmot stated that he believes government spending really makes a difference in the health of people. Evidence from Stuckler and colleagues (2010) supports the idea that the higher the social welfare spending per capita, the lower the all-cause mortality (see Figure 4-5). Additional analyses from the ELSA study showed that each additional $100 increase in social welfare spending was associated with a 1.19 percent decrease in all-cause mortality. Marmot emphasized that pursing policies of austerity in the face of economic problems will likely harm people lower in the social hierarchy and result in adverse impacts on health. Overall, issues of health equity and sustainable development need to be addressed together because they are both part of social justice. He noted that evidence shows that policy at the local level, the national level, and the international level can have huge impacts on the lives people are able to lead, and hence impact health and health equity.
FIGURE 4-5 Relationship between social welfare spending and all-cause mortality in 18 European Union countries for 2000.
NOTE: Social spending per capita has been adjusted by purchasing power parity, which is the number of units of a country’s currency required to buy the same amounts of goods and services in the domestic market as the U.S. dollar would buy in the United States.
SOURCE: Stuckler et al., 2010. Reprinted with permission from the BMJ Publishing Group Ltd.
Katherine Rogers, D.Phil.
Executive Manager, Office of the Executive Director
United Nations Children’s Fund (UNICEF)
Katherine Rogers presented information on A Promise Renewed, a UNICEF program and global movement to decrease preventable maternal, newborn, and child deaths. She noted that the program aligns with Millennium Development Goal (MDG) 4—to reduce child mortality—and is intended to sustain the progress of MDG 4 well beyond 2015 (the target end year for the MDGs). She stated that A Promise Renewed brings together public, private, and civil society actors committed to advocacy and action supporting maternal, newborn, and child survival at the national, subnational, and local levels.
Despite seeing tremendous progress to tackle preventable death worldwide, the global decline in preventable child death remains uneven with variable progress across regions, populations, and specific causes of mortality (UN, 2013). National averages often mask deep disparities that exist within and between countries, and evidence shows that by applying an equity focus to child survival, to address disparities with targeted interventions, significant declines in the global under-5 mortality rate can be achieved. For example, in low-income, high-mortality countries, each additional million dollars invested in reaching the most vulnerable children can avert up to 60 percent more child deaths than current approaches (UNICEF, 2010). She explained that a modeling exercise presented at the Childhood Survival Call to Action event—convened by the governments of Ethiopia, India, and the United States in collaboration with UNICEF—demonstrates that all countries can lower child mortality rates to 20 or fewer deaths per 1,000 live births by 2035 and save approximately 45 million lives (UNICEF, 2012). This is an important milestone toward the ultimate goal of ending preventable child deaths.
Rogers stated that these results can be achieved by utilizing four broad global strategies: (1) sharpening and scaling up high-impact country plans addressing child mortality, (2) building and mobilizing a global child survival movement to strengthen accountability, (3) communicating and celebrating national progress, and (4) mobilizing resources to foster innovative partnerships. Implementing high-impact strategies goes well beyond the field of health and requires coordinated cross-sectoral support from a full spectrum of public and private groups and coalitions that can influence health outcomes for women and children. She noted that focusing on the socioeconomic determinants of mortality is critical to achieving sustainable results. By incorporating conventional work on maternal, newborn, and child survival with an emphasis on issues like
women’s empowerment, it is possible to equip women and families with the skills and confidence to make healthy decisions on their own and invest in the sustainable development of communities as a whole.
Thinking about the post-2015 development agenda, Rogers said, it is important not to lose sight of the fact that the health and well-being of children is one of the most compelling indicators of society’s progress as a whole. She noted that since June 2012, 164 governments, 185 civil society organizations, 220 faith-based organizations, and more than 1,000 individuals have signed a pledge of their commitment to maternal, newborn, and child survival. Each signature represents renewed commitment to work across sectors, issues, and specific interventions to end preventable child deaths.
A brief discussion among the speakers and participants followed the presentations. Their remarks are summarized in this section.
How to Achieve the Right Balance in Investments
Balbus began the discussion by commenting on how framework diagrams depicting the interactions among social equity, justice, environmental exposures, and health often appear complicated and somewhat circular. He noted that intervening on the social level will likely improve the health of people and often reduce their environmental exposures. By reducing people’s environmental exposures, it is possible to also improve their health and alleviate some factors that perpetuate poverty. Balbus then asked the speakers to share their thoughts on how to achieve the right balance between investing in environmental sectors, or in upstream sectors on the environmental side of the framework, and investing in education, poverty alleviation, social welfare payments, and other options that address the root issues of poverty.
Marmot noted that he has two types of responses to the question. First, the answer to the question is clearly going to depend on the level of income or level of development of a country. For instance, in a slum in Nairobi where it may cost more to buy a liter of water than in London, for example, the lack of availability of clean water that people can afford is going to be key. In contrast, in the countries of Central and Eastern Europe, people do have clean water, enough food, and shelter, so simply focusing on water and shelter would be ineffective in Central and Eastern Europe. So, Marmot noted, the mix will depend on the general background of low-, middle-, and high-income countries. Marmot’s second response focused on the inequity in early childhood development or in child health across high-, middle-, and low-income countries. He
explained that one possible approach to this is to reduce the level of social and economic inequality in society, because that is driving the inequities in early childhood development and child health. While working toward that goal, which could take a while, it is important to break the link between people’s social and economic position and the quality of childhood development and health. Marmot noted that this may require access to high-quality services for early childhood development or improved education of women. Having first stated that the mix will depend on country factors, one should not disregard the need for education and early childhood development in low-income countries that may also need water and shelter. As stated by previous speakers, education and empowerment of women are even more important in low-income countries. Marmot noted that, overall, decision makers need to pay attention to both material conditions and to social and economic drivers of health and development.
Oswald Spring stated that with regard to the circular approach to social and environmental impacts, the poorest countries or transition countries clearly have a more complex approach to deal with, as Marmot described. Moving through the circular social impact, education is on one side and public services on the other side. In Mexico, a program to provide larger scholarships to girls than boys resulted in more girls attending school and improved the education of girls as well as their reproductive health. The World Bank found educating girls and young women could lead to improvements in the gross domestic product of a country. Moving through the environmental impact, natural disasters and management of extreme events are crucial issues in poverty alleviation. So, Oswald Spring said, it is important to work simultaneously on the social, educational, and health parts when considering the environment in order to give the next generation the potential to live better. She highlighted that this will require much more involvement from civil society to ensure that the most vulnerable and in-need people are reached.
Relationship Between Social Welfare Spending and All-Cause Mortality
Bernard Goldstein, professor emeritus in the Department of Environmental and Occupational Health at the University of Pittsburgh, then shifted the discussion to the data presented by Marmot on the relationship between social welfare spending and all-cause mortality among European countries (see Figure 4-5). He pointed out that although the countries of Central and Eastern Europe have not caught up with the rest of Europe in terms of improved social programs, there still appears to be a wide range of social welfare spending among the other European countries but very little difference in mortality. In addition, Goldstein
stated, it is unclear if the social welfare spending captured includes government spending as well as spending by civil society or charitable groups who are involved in alleviating poverty and dealing with gender equality.
Marmot noted that the graph he presented included only government expenditure on social welfare, but agreed that the contributions from civil society are also important. Addressing the question about the range of social welfare spending and all-cause mortality, Marmot stated that Figure 4-5 looks somewhat curvilinear and is exaggerated by the Czech Republic, Hungary, Poland, and Slovakia data points. However, there are substantial differences in the mortality of the older members of the European Union that are not trivial (e.g., mortality differences between Ireland and Sweden). As presented earlier, government can reduce child poverty through taxes and transfers (see Figure 4-3), but the quality of early childhood development is not influenced by government expenditure alone. For instance, attendance at formal early childhood development centers makes a difference, particularly for children from deprived families, but less so for children from well-off families. Although the evidence supports childhood development centers, he said, it may be provided by civil society or families rather than by government, highlighting the importance that civil society plays in these issues.
Addressing Health Equity, Social Justice, and Sustainable
Commenting on the concepts of health equity and social justice, Balbus noted that it appears that two levels of approach are required: (1) the more operational approach through concrete actions that address specific indicators, and (2) the more philosophical approach related to a humanistic concept of policy. He asked the speakers to address how governments may incorporate both the operational approach and the philosophical approach to achieve change.
Marmot stated that many of the systematic inequalities in health that exist between social groups are judged to be avoidable by reasonable means and hence are unfair or inequitable. As such, any policies that lead to these avoidable health inequities are unfair. Marmot pointed out that what he sees in many European countries (which likely is occurring elsewhere) is governments stating that they used to be concerned about green issues and reductions in carbon emissions, but given the economic problems the country must drop the green goals and focus on economic growth. The idea that abandoning environmental protection will promote economic growth is questionable at best and contradicted by the evidence at worst. Marmot stated that he believes decision makers cannot pursue environmental goals without pursing poverty reduction and cannot
pursue economic development without also pursuing fairness, justice, and environmental goals at the same time.
Rogers noted that to change the traditional concept of politics, the onus cannot necessarily be placed on governments alone. She explained that over the next few years, especially with regard to the post-2015 development agenda and other global processes, the responsibility rests increasingly with civil society networks and community-based constituencies that are involved in advocating for increased government responsiveness when it comes to equitable outcomes. She added that the best way to achieve this is to make sure community-based groups and civil society networks have the data and analysis they need to hold governments accountable.
Oswald Spring stated that on the philosophical side, it is important to change the business-as-usual mindset into a transitional process. For this reason, it may be more strategic to speak about the transition to sustainability instead of sustainable development. In the past 20 years following the 1992 United Nations Earth Summit, the environmental community has not been able to alleviate the destructive development processes that occur worldwide. Oswald Spring pointed out that in order to achieve equity and justice, mindsets need to change at both the macrolevel and microlevel. She noted that it is necessary to overcome destructive consumerism and create policies that link business with environmental protection, social justice and poverty alleviation, and social equity to confront the new uncertainty people throughout the world are experiencing. Oswald Spring added that it is important to carefully choose the indicators that are utilized to link the social and environmental domains in order to stop the process of destruction and reveal the types of development processes (e.g., mining, oil exploitation, natural gas extraction, etc.) that continue to destroy the wide range of resources we have on earth and bring new threats to health and survival.
Balbus noted that this is the final webinar in the 2012 series from the IOM Global Environmental Health and Sustainable Development Innovation Collaborative. He hopes that the summaries of all three webinars will serve as a valuable resource for the post-2015 development agenda process and other global processes related to sustainable development and creation of new SDGs.
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