Anthony G. Capon

Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation-Lancet Commission on planetary health

Earths natural systems represent a growing threat to human health. And yet, global health has mainly improved as these changes have gathered pace. What is the explanation? As a Commission, we are deeply concerned that the explanation is straightforward and sobering: we have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting natures resources, human civilisation has fl ourished but now risks substantial health eff ects from the degradation of natures life support systems in the future. Health eff ects from changes to the environment including climatic change, ocean acidifi cation, land degradation, water scarcity, overexploitation of fi sheries, and biodiversity loss pose serious challenges to the global health gains of the past several decades and are likely to become increasingly dominant during the second half of this century and beyond. These striking trends are driven by highly inequitable, ineffi cient, and unsustainable patterns of resource consumption and technological development, together with population growth. We identify three categories of challenges that have to be addressed to maintain and enhance human health in the face of increasingly harmful environmental trends. Firstly, conceptual and empathy failures (imagination challenges), such as an over-reliance on gross domestic product as a measure of human progress, the failure to account for future health and environmental harms over present day gains, and the disproportionate eff ect of those harms on the poor and those in developing nations. Secondly, knowledge failures (research and information challenges), such as failure to address social and environmental drivers of ill health, a historical scarcity of transdisciplinary research and funding, together with an unwillingness or inability to deal with uncertainty within decision making frameworks. Thirdly, implementation failures (governance challenges), such as how governments and institutions delay recognition and responses to threats, especially when faced with uncertainties, pooled common resources, and time lags between action and eff ect. Although better evidence is needed to underpin appropriate policies than is available at present, this should not be used as an excuse for inaction. Substantial potential exists to link action to reduce environmental damage with improved health outcomes for nations at all levels of economic development. This Commission identifi es opportunities for action by six key constituencies: health professionals, research funders and the academic community, the UN and Bretton Woods bodies, governments, investors and corporate reporting bodies, and civil society organisations. Depreciation of natural capital and natures subsidy should be accounted for so that economy and nature are not falsely separated. Policies should balance social progress, environmental sustainability, and the economy. To support a world population of 9-10 billion people or more, resilient food and agricultural systems are needed to address both undernutrition and overnutrition, reduce waste, diversify diets, and minimise environmental damage. Meeting the need for modern family planning can improve health in the short termeg, from reduced maternal mortality and reduced pressures on the environment and on infrastructure. Planetary health off ers an unprecedented opportunity for advocacy of global and national reforms of taxes and subsidies for many sectors of the economy, including energy, agriculture, water, fi sheries, and health. Regional trade treaties should act to further incorporate the protection of health in the near and long term. Several essential steps need to be taken to transform the economy to support planetary health. These steps include a reduction of waste through the creation of products that are more durable and require less energy and materials to manufacture than those often produced at present; the incentivisation of recycling, reuse, and repair; and the substitution of hazardous materials with safer alternatives. Despite present limitations, the Sustainable Development Goals provide a great opportunity to integrate health and sustainability through the judicious selection of relevant indicators relevant to human wellbeing, the enabling infrastructure for development, and the supporting natural systems, together with the need for strong governance. The landscape, ecosystems, and the biodiversity they contain can be managed to protect natural systems, and indirectly, reduce human disease risk. Intact and restored ecosystems can contribute to resilience (see panel 1 for glossary of terms used in this report), for example, through improved coastal protection (eg, through wave attenuation) and the ability of fl oodplains and greening of river catchments to protect from river fl ooding events by diverting and holding excess water. The growth in urban populations emphasises the importance of policies to improve health and the urban environment, such as through reduced air pollution, increased physical activity, provision of green space, and urban planning to prevent sprawl and decrease the magnitude of urban heat islands. Transdisciplinary research activities and capacity need substantial and urgent expansion. Present research limitations should not delay action. In situations where technology and knowledge can deliver win-win solutions and co-benefi ts, rapid scale-up can be achieved if researchers move ahead and assess the implementation of potential solutions. Recent scientifi c investments towards understanding non-linear state shifts in ecosystems are very important, but in the absence of improved understanding and predictability of such changes, eff orts to improve resilience for human health and adaptation strategies remain a priority. The creation of integrated surveillance systems that collect rigorous health, socioeconomic, and environmental data for defi ned populations over long time periods can provide early detection of emerging disease outbreaks or changes in nutrition and non-communicable disease burden. The improvement of risk communication to policy makers and the public and the support of policy makers to make evidence-informed decisions can be helped by an increased capacity to do systematic reviews and the provision of rigorous policy briefs. Health professionals have an essential role in the achievement of planetary health: working across sectors to integrate policies that advance health and environmental sustainability, tackling health inequities, reducing the environmental impacts of health systems, and increasing the resilience of health systems and populations to environmental change. Humanity can be stewarded successfully through the 21st century by addressing the unacceptable inequities in health and wealth within the environmental limits of the Earth, but this will require the generation of new knowledge, implementation of wise policies, decisive action, and inspirational leadership.

The Lancet CommissionsSafeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health

Earths natural systems represent a growing threat to human health. And yet, global health has mainly improved as these changes have gathered pace. What is the explanation? As a Commission, we are deeply concerned that the explanation is straightforward and sobering: we have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting natures resources, human civilisation has fl ourished but now risks substantial health eff ects from the degradation of natures life support systems in the future. Health eff ects from changes to the environment including climatic change, ocean acidifi cation, land degradation, water scarcity, overexploitation of fi sheries, and biodiversity loss pose serious challenges to the global health gains of the past several decades and are likely to become increasingly dominant during the second half of this century and beyond. These striking trends are driven by highly inequitable, ineffi cient, and unsustainable patterns of resource consumption and technological development, together with population growth. We identify three categories of challenges that have to be addressed to maintain and enhance human health in the face of increasingly harmful environmental trends. Firstly, conceptual and empathy failures (imagination challenges), such as an over-reliance on gross domestic product as a measure of human progress, the failure to account for future health and environmental harms over present day gains, and the disproportionate eff ect of those harms on the poor and those in developing nations. Secondly, knowledge failures (research and information challenges), such as failure to address social and environmental drivers of ill health, a historical scarcity of transdisciplinary research and funding, together with an unwillingness or inability to deal with uncertainty within decision making frameworks. Thirdly, implementation failures (governance challenges), such as how governments and institutions delay recognition and responses to threats, especially when faced with uncertainties, pooled common resources, and time lags between action and eff ect. Although better evidence is needed to underpin appropriate policies than is available at present, this should not be used as an excuse for inaction. Substantial potential exists to link action to reduce environmental damage with improved health outcomes for nations at all levels of economic development. This Commission identifi es opportunities for action by six key constituencies: health professionals, research funders and the academic community, the UN and Bretton Woods bodies, governments, investors and corporate reporting bodies, and civil society organisations. Depreciation of natural capital and natures subsidy should be accounted for so that economy and nature are not falsely separated. Policies should balance social progress, environmental sustainability, and the economy. To support a world population of 9-10 billion people or more, resilient food and agricultural systems are needed to address both undernutrition and overnutrition, reduce waste, diversify diets, and minimise environmental damage. Meeting the need for modern family planning can improve health in the short termeg, from reduced maternal mortality and reduced pressures on the environment and on infrastructure. Planetary health off ers an unprecedented opportunity for advocacy of global and national reforms of taxes and subsidies for many sectors of the economy, including energy, agriculture, water, fi sheries, and health. Regional trade treaties should act to further incorporate the protection of health in the near and long term. Several essential steps need to be taken to transform the economy to support planetary health. These steps include a reduction of waste through the creation of products that are more durable and require less energy and materials to manufacture than those often produced at present; the incentivisation of recycling, reuse, and repair; and the substitution of hazardous materials with safer alternatives. Despite present limitations, the Sustainable Development Goals provide a great opportunity to integrate health and sustainability through the judicious selection of relevant indicators relevant to human wellbeing, the enabling infrastructure for development, and the supporting natural systems, together with the need for strong governance. The landscape, ecosystems, and the biodiversity they contain can be managed to protect natural systems, and indirectly, reduce human disease risk. Intact and restored ecosystems can contribute to resilience (see panel 1 for glossary of terms used in this report), for example, through improved coastal protection (eg, through wave attenuation) and the ability of fl oodplains and greening of river catchments to protect from river fl ooding events by diverting and holding excess water. The growth in urban populations emphasises the importance of policies to improve health and the urban environment, such as through reduced air pollution, increased physical activity, provision of green space, and urban planning to prevent sprawl and decrease the magnitude of urban heat islands. Transdisciplinary research activities and capacity need substantial and urgent expansion. Present research limitations should not delay action. In situations where technology and knowledge can deliver win-win solutions and co-benefi ts, rapid scale-up can be achieved if researchers move ahead and assess the implementation of potential solutions. Recent scientifi c investments towards understanding non-linear state shifts in ecosystems are very important, but in the absence of improved understanding and predictability of such changes, eff orts to improve resilience for human health and adaptation strategies remain a priority. The creation of integrated surveillance systems that collect rigorous health, socioeconomic, and environmental data for defi ned populations over long time periods can provide early detection of emerging disease outbreaks or changes in nutrition and non-communicable disease burden. The improvement of risk communication to policy makers and the public and the support of policy makers to make evidence-informed decisions can be helped by an increased capacity to do systematic reviews and the provision of rigorous policy briefs. Health professionals have an essential role in the achievement of planetary health: working across sectors to integrate policies that advance health and environmental sustainability, tackling health inequities, reducing the environmental impacts of health systems, and increasing the resilience of health systems and populations to environmental change. Humanity can be stewarded successfully through the 21st century by addressing the unacceptable inequities in health and wealth within the environmental limits of the Earth, but this will require the generation of new knowledge, implementation of wise policies, decisive action, and inspirational leadership.

Climate Change and Health in the Urban Environment: Adaptation Opportunities in Australian Cities

Urban populations are growing rapidly throughout the Asia-Pacific region. Cities are vulnerable to the health impacts of climate change because of their concentration of people and infrastructure, the physical (geographical, material, and structural) attributes of the built environment, and the ecological interdependence with the urban ecosystem. Australia is one of the most highly urbanized countries in the region and its already variable climate is set to become hotter and drier with climate change. Climate change in Australia is expected to increase morbidity and mortality from thermal stress, bacterial gastroenteritis, vector-borne disease, air pollution, flooding, and bushfires. The cost and availability of fresh water, food, and energy will also likely be affected. The more vulnerable urban populations, including the elderly, socioeconomically disadvantaged groups, and those with underlying chronic disease, will be most affected. Adaptation strategies need to address this underlying burden of disease and inequity as well as implement broad structural changes to building codes and urban design, and infrastructure capacity. In doing so, cities provide opportunities to realize “co-benefits” for health (eg, from increased levels of physical activity and improved air quality). With evidence that climate change is underway, the need for cities to be a focus in the development of climate adaptation strategies is becoming more urgent.

The history, geography, and sociology of slums and the health problems of people who live in slums

Massive slums have become major features of cities in many low-income and middle-income countries. Here, in the first in a Series of two papers, we discuss why slums are unhealthy places with especially high risks of infection and injury. We show that children are especially vulnerable, and that the combination of malnutrition and recurrent diarrhoea leads to stunted growth and longer-term effects on cognitive development. We find that the scientific literature on slum health is underdeveloped in comparison to urban health, and poverty and health. This shortcoming is important because health is affected by factors arising from the shared physical and social environment, which have effects beyond those of poverty alone. In the second paper we will consider what can be done to improve health and make recommendations for the development of slum health as a field of study.

Human Health and Climate Change: Leverage Points for Adaptation in Urban Environments

The design of adaptation strategies that promote urban health and well-being in the face of climate change requires an understanding of the feedback interactions that take place between the dynamical state of a city, the health of its people, and the state of the planet. Complexity, contingency and uncertainty combine to impede the growth of such systemic understandings. In this paper we suggest that the collaborative development of conceptual models can help a group to identify potential leverage points for effective adaptation. We describe a three-step procedure that leads from the development of a high-level system template, through the selection of a problem space that contains one or more of the group’s adaptive challenges, to a specific conceptual model of a sub-system of importance to the group. This procedure is illustrated by a case study of urban dwellers’ maladaptive dependence on private motor vehicles. We conclude that a system dynamics approach, revolving around the collaborative construction of a set of conceptual models, can help communities to improve their adaptive capacity, and so better meet the challenge of maintaining, and even improving, urban health in the face of climate change.

Planning for the health of people and planet: An Australian perspective

Health at the Heart of Spatial PlanningStrengthening the Roots of PlanningHealth and the Urban PlannerHealth Inequalities and PlacePlanning for the Health of People and Planet: An Australian Perspective Jenny Crawforda; Hugh Bartonb; Tim Chapmanc; Martin Higginsd; Anthony G. Capone; Susan M. Thompsonf a Royal Town Planning Institute, London, UK b WHO Collaborating Centre for Healthy Cities and Urban Policy, University of the West of England, Bristol, UK c Homes and Communities Agency—Advisory Team for Large Applications (ATLAS), Ashford, UK d Public Health Directorate, NHS Lothian, Edinburgh, UK e National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia f Faculty of the Built Environment, University of New South Wales, Australia

Improving the health and welfare of people who live in slums

In the first paper in this Series we assessed theoretical and empirical evidence and concluded that the health of people living in slums is a function not only of poverty but of intimately shared physical and social environments. In this paper we extend the theory of so-called neighbourhood effects. Slums offer high returns on investment because beneficial effects are shared across many people in densely populated neighbourhoods. Neighbourhood effects also help explain how and why the benefits of interventions vary between slum and non-slum spaces and between slums. We build on this spatial concept of slums to argue that, in all low-income and-middle-income countries, census tracts should henceforth be designated slum or non-slum both to inform local policy and as the basis for research surveys that build on censuses. We argue that slum health should be promoted as a topic of enquiry alongside poverty and health.

Urbanism, climate change and health: systems approaches to governance

Effective action on climate change health impacts and vulnerability will require systems approaches and integrated policy and planning responses from a range of government agencies. Similar responses are needed to address other complex problems, such as the obesity epidemic. Local government, with its focus on the governance of place, will have a key role in responding to these convergent agendas. Industry can also be part of the solution - indeed it must be, because it has a lead role in relevant sectors. Understanding the co-benefits for health of climate mitigation actions will strengthen the case for early action. There is a need for improved decision support tools to inform urban governance. These tools should be based on a systems approach and should incorporate a spatial perspective.

Climate change and Australia's healthcare system - risks, research and responses.

Climate change will affect human health, mostly adversely, resulting in a greater burden on the health care system, in addition to any other coexistent increases in demand (e.g. from Australias increasingly ageing population). Understanding the extent to which health is likely to be affected by climate change will enable policy makers and practitioners to prepare for changing demands on the health care system. This will require prioritisation of key research questions and building research capacity in the field. There is an urgent need to better understand the implications of climate change for the distribution and prevalence of diseases, disaster preparedness and multidisciplinary service planning. Research is needed to understand the relationship of climate change to health promotion, policy evaluation and strategic financing of health services. Training of health care professionals about climate change and its effects will also be important in meeting long-term workforce demands.

Health impacts of urban development: key considerations.

The urban environment is an important determinant of health. Health impact assessment is a tool for systematic analysis of the health consequences of urban development and management. This paper identifies key considerations, including opportunities for physical activity, food access and local economic development. Time use by urban residents has health implications. The schedule for infrastructure development in new release areas (in particular transport, education and health infrastructure) also has health implications. Health impacts should be considered a primary outcome of urban development and management.