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.