Environmental determinants of health: how can global health governance contribute?

The following opinion piece has appeared, in two different forms, on Sense & Sustainability and in ASviS‘s newsletter.

According to a 2012 study by the World Health Organization (WHO), environmental factors are directly or indirectly responsible for almost 13 million deaths worldwide, or about twenty-three percent of all deaths. Overall, more than one third of lower respiratory infections, over half of diarrhoeal diseases, forty-two percent of malaria infections, one fifth of all cancers and a significant proportion of chronic obtrusive respiratory diseases and cardiovascular diseases are attributable to environmental determinants of health, including household and outdoor pollution, lack of access to clean water and sanitation, proliferation of disease vectors, and exposure to chemicals.

To put it simply, environmental conditions, and more specifically the changing ecological dynamics which characterize the Anthropocene, help to determine whether people are healthy, and how long they live. By undermining the benefits that people obtain from healthy ecosystems, environmental degradation effectively acts as both a cause and a multiplier of health threats, and as the level of global environmental change dangerously approaches the threshold of the planetary boundaries which regulate the resilience of the Earth system, the deterioration of human well-being will likely increase and be characterized by surprise and uncertainty.

Environmental determinants represent an insidious threat to public health for three different reasons. First, because they are driven by unsustainable patterns of resource consumption, technological development and population growth which operate almost entirely outside of the boundaries of the health sector, and thus are particularly difficult for traditional health actors  to engage with. Secondly, because in the past environmental degradation has coincided with a stark improvement in health outcomes, a condition that has described as “mortgaging the health of future generations”. Finally, because environmental impacts on health are usually uneven across life course, geography and gender, and they also operate in different ways with respect to different diseases, thus making it hard to design holistic public health strategies for prevention and response. The question, then, becomes an obvious one: how could health-focused institutions, and particularly the WHO, the United Nations agency tasked with guiding and supporting policy-making on health issues, contribute?

A global health approach to environmental degradation?

At first glance, it would seem misguided to think that health as a sector of global governance could ever be fit for the purpose of addressing the environmental determinants of ill health. From a pragmatic perspective, global health actors are simply not in the position to deal with the whole range of environmental risk factors operating across different levels of governance and spatial scales, including chemicals, biodiversity loss, land degradation, climate change, and water and air quality. From a historical perspective, despite the fact that over the last few decades several environmental agreements have explicitly incorporated health considerations within their preambles, in specific provisions or even as their primary objectives, the international institutions patrolling the two areas of health and environment have usually operated with separate and unlinked agendas.

At the same time, the situation appears to have evolved in recent years, owing to attempts at fostering a greater collaboration between the work of the WHO and other international institutions (for example, the UN Environment Programme/WHO’s Health and Environment Linkages Initiative and the UNECE/WHO-Europe’s Protocol on Water and Health) as well as to WHO’s increasingly vocal leadership on the public health implications of climate change, culminating in the 2016 Marrakech Declaration on “Health, Environment and Climate Change”.

In this context, two important developments can be emphasized. First, from a legal standpoint, the interlinkages between health and environment have increasingly been framed in the language of human rights, through the emergence of the concept of a ‘right to a healthy environment’. Whilst the understanding of the obligations that such a right would impose on governments and private actors varies greatly, the sharp increase in domestic and international litigation linked with environmental health considerations cannot be ignored, and will arguably play a growing role in complementing the ‘compliance’ gap which characterizes many international environmental regimes. Secondly, from a broader political standpoint, health considerations might be used (and indeed, increasingly are) as a catalyst for raising ambitions and creating political momentum around a certain environmental issue, as recently shown by the advocacy of WHO, the Climate and Clean Air Coalition (CCAC) and the Government of Norway on the health risks of short-lived climate pollutants as part of the BreatheLife global campaign.

Environment and health: the necessity of targeting co-benefits

Beyond courts and political leadership, however, there are several additional ways in which the nature of WHO as a normative and technical support agency could be harnessed in addressing the environmental determinants of health. These of course, are not meant to undermine the authority of environmental governance actors. On the contrary, they could be key in reaping the full health co-benefits that can come from environmental policies, whilst in turn encouraging bolder ambition and integration among different regimes.

First, the uptake of multi-sectoral approaches to policy design, such as the concept of Health in All Policies (HiAP) and the One Health approach, appears necessary to operationalise the linkages between Sustainable Development Goal 3 (‘Ensure Healthy Lives and Promote Well-Being for All at All Ages’) and the other Goals and targets contained in the 2030 Agenda. For example, greater mutual supportiveness can arise from the improvement of environmental impact assessment laws, with a view to ensure an adequate consideration of the interplay between health and environment impacts in decision-making. Despite a consensus on the need to integrate Health Impact Assessments (HIAs) and EIAs, such an integration remains problematic. On the one hand, EIAs rarely incorporate assessments of pathways between environmental exposures and health outcomes. On the other, the promotion of HIAs as a separate tool greatly contributes to fragmentation and unnecessary overlaps. In this context, renewed UNEP/WHO efforts under the Health and Environment Linkages Initiative could be instrumental in providing the necessary assistance to countries seeking to develop more integrated frameworks for impact assessment.

Secondly, WHO’s expertise can be leveraged to promote a more effective implementation of multilateral environmental agreements. Focusing in particular on capacity-building for risk reduction, risk assessment and improved coordination among sectors and stakeholders, WHO can help by fostering development of national action plans, use of guidelines and standards, and dissemination of training materials (one recent example involving a Secretariat report on the contribution of the health sector to safe chemical management). In addition, WHO can provide strong evidence of health impacts arising from environmental degradation and/or green economy strategies, due to its expertise on health metrics and indicators, and accordingly contribute to strengthening and harmonizing surveillance and monitoring of progress. Finally, WHO should promote the resilience of health systems in the face of environmental change (including climate change). This would entail encouraging the inclusion of health elements into national climate adaptation plans, ensuring an effective training and management of health personnel to deploy in disaster response, and providing specific guidance on the improvement of public health infrastructure and the assessment of vulnerability and adaptation costs.

During his election campaign, Dr. Tedros Adhanom, the new Director-general of the WHO, has effectively laid out a vision for placing health at the center of the global sustainable development agenda, and accordingly identified environmental change as one of his top five priorities. As the SDGs turn two years old this September, the urgency of streamlining such a vision into the work of the organization and in the wider UN system grows stronger with each day.

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The challenges of global health reform in the 21st century

This brief article was originally written for the newsletter of the Global Health Centre of the Graduate Institute of Geneva. Its aim is to introduce the second year of the research project on “How to Break the Gridlock in Global Health Governance”, on which I am working as one of the two principal investigators.

When looking at the changing landscape of global health over the course of the last two decades, it appears evident that the significant progress and breakthroughs that have occurred in this relatively short period of time have also left a number of issues unaddressed.

On the one hand, the three Millennium Development Goals (MDGs) relating to health have remained unmet, despite huge improvements in low- and middle-income countries with respect to infectious diseases as well as reproductive, maternal and child health. On the other, the emergence of new (and often unprecedented) health threats, such as those represented by the shifting burden of disease and mortality towards non-communicable diseases, more severe outbreaks and pandemics, and increasing risks associated with climate change and environmental degradation (link), poses troubling questions over the capability of the global health system to deal with the ever increasing interconnectedness and complexity characterising the field.

In this context, a central challenge to make the global health system fit for the 21st century is that of understanding what kind of role governance has played in some of the major achievements, and in particular what has made specific advancements possible; why certain solutions were chosen over others; and whether those solutions can now provide valuable insights into how to deal with emerging issues.

From such perspective, it can be argued that global health governance has witnessed a significant degree of institutional innovation and political agency, both within and beyond the World Health Organization (WHO) and other multilateral agencies, and WHO itself has demonstrated to be capable of organizational learning in the aftermath of health crises such as SARS and H1N1.

At the same time, however, two major concerns remain. First, these developments have been mainly driven by cosmopolitan moments which opened limited windows of opportunity for reform but left some of the structural weaknesses of the current governance architecture unaddressed. More specifically, the possibility of identifying pathways that may lead to gridlock in global health governance, while not entirely representative of the post-1990 global health landscape, certainly represents a critical alarm bell for a system which is called upon to deliver on the targets set by Sustainable Development Goal 3 while dealing with the daunting task of tackling the broader determinants of health in an increasingly interconnected world.

Secondly, as evidenced by the recent High-level meeting on antimicrobial resistance (AMR), which yielded a strong political declaration at the 71th Session of the United Nations General Assembly, increasing importance is attached to global health and its implications for national and international security, economic well-being, and economic and social development. In this sense, the shift of global health from sectoral issue to major topic discussed in the highest spheres of politics and governments, constitutes not only an opportunity but also an additional challenge for the global health governance system: as it creates the conditions for mobilizing action, it also requires multi-sectoral approaches to be adopted, coordination among actors to be strengthened, and increased institutional flexibility to be achieved.

At the Global Health Centre, the ongoing research project on “How to break the gridlock in global health governance”, which is currently entering its second year, is trying to provide an answer to these complex challenges and highlight potential options for reform by conducting in-depth research about how pathways to gridlock have manifested themselves across different health threats; identifying institutional changes and responses; and uncovering the causal dimensions between them. As such, the project will not only be able to provide a valuable contribution to the current understanding of how global health governance has evolved in the past two decades, but also, more importantly, describe how such gridlock has been overcome or can now be avoided.

Funded by the Swiss Network for International Studies (SNIS) and working with a number of different partners across academia, international organisations, civil society, and the private sector, “How to break the gridlock in global health governance” started in October 2015 and is expected to last for two years.

  • Download research summary (pdf)