Robert Marten

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.

An assessment of progress towards universal health coverage in Brazil, Russia, India, China, and South Africa (BRICS)

Summary Brazil, Russia, India, China, and South Africa (BRICS) represent almost half the worlds population, and all five national governments recently committed to work nationally, regionally, and globally to ensure that universal health coverage (UHC) is achieved. This analysis reviews national efforts to achieve UHC. With a broad range of health indicators, life expectancy (ranging from 53 years to 73 years), and mortality rate in children younger than 5 years (ranging from 10·3 to 44·6 deaths per 1000 livebirths), a review of progress in each of the BRICS countries shows that each has some way to go before achieving UHC. The BRICS countries show substantial, and often similar, challenges in moving towards UHC. On the basis of a review of each country, the most pressing problems are: raising insufficient public spending; stewarding mixed private and public health systems; ensuring equity; meeting the demands for more human resources; managing changing demographics and disease burdens; and addressing the social determinants of health. Increases in public funding can be used to show how BRICS health ministries could accelerate progress to achieve UHC. Although all the BRICS countries have devoted increased resources to health, the biggest increase has been in China, which was probably facilitated by Chinas rapid economic growth. However, the BRICS country with the second highest economic growth, India, has had the least improvement in public funding for health. Future research to understand such different levels of prioritisation of the health sector in these countries could be useful. Similarly, the role of strategic purchasing in working with powerful private sectors, the effect of federal structures, and the implications of investment in primary health care as a foundation for UHC could be explored. These issues could serve as the basis on which BRICS countries focus their efforts to share ideas and strategies.

Overcoming social segregation in health care in Latin America

Latin America continues to segregate different social groups into separate health-system segments, including two separate public sector blocks: a well resourced social security for salaried workers and their families and a Ministry of Health serving poor and vulnerable people with low standards of quality and needing a frequently impoverishing payment at point of service. This segregation shows Latin Americas longstanding economic and social inequality, cemented by an economic framework that predicted that economic growth would lead to rapid formalisation of the economy. Today, the institutional setup that organises the social segregation in health care is perceived, despite improved life expectancy and other advances, as a barrier to fulfilling the right to health, embodied in the legislation of many Latin American countries. This Series paper outlines four phases in the history of Latin American countries that explain the roots of segmentation in health care and describe three paths taken by countries seeking to overcome it: unification of the funds used to finance both social security and Ministry of Health services (one public payer); free choice of provider or insurer; and expansion of services to poor people and the non-salaried population by making explicit the health-care benefits to which all citizens are entitled.

Universal health coverage is a development issue

864 www.thelancet.com Vol 380 September 8, 2012 The recent Rio+20 United Nations Conference on Sustainable Development, in Rio de Janeiro, Brazil, took place 20 years after the fi rst global conference on the environment and development and 10 years after the World Summit on Sustainable Development. Although much of the discussion focused on the environment, poverty reduction, and sustaining economic growth, the resultant resolution contained an important paragraph for the global health community:

Global Surgery 2030: a roadmap for high income country actors

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the worlds new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Priority-setting for achieving universal health coverage.

Abstract Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation’s resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost–effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities – implicitly or explicitly – it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Implementing pro-poor universal health coverage.

Universal health coverage (UHC) - the availability of quality affordable health services for all when needed without financial impoverishment - can be a vehicle for improving equity health outcomes and financial wellbeing. It can also contribute to economic development. In its Global Health 2035 report the Lancet Commission on Investing in Health (CIH) set forth an ambitious investment framework for transforming global health through UHC. The CIH endorsed pro-poor pathways to UHC that provide access to services and financial protection to poor people from the beginning and that include people with low income in the design and development of UHC health financing and service provision mechanisms.

Building resilient health systems: a proposal for a resilience index

Health system resilience begins with measurement of critical capacities ahead of crisis say Margaret E Kruk and colleagues

Commission on Global Governance for Health: what about power?

The Lancet—University of Oslo Commission on Global Governance for Health (Feb 15, p 630) articulates the various global non-health sector influences on health—namely, the global political determinants of health. The recognition of these eff ects is not new, but articulating a compelling way to refer to them is a useful contribution and will help to shape the future research agenda. The Commission highlights the way in which some actors are able to exert disproportionate levels of influence to serve their interests. We commend the Commission for identifying these serious power disparities in global governance, and illustrating their profound implications for health. The Commission has provoked attention to these political realities and created an important discussion. Yet the Commission’s recommendations, as the companion Youth Commission noted, “are likely to be influenced by the same diverging interests and power asymmetries described by the Commission”. We would like to propose a possible path forward. To tackle the global political determinants of health, there is fi rst a need for more rigorous analysis of how national, international, and institutional actors shape and infl uence the global political determinants of health. The Commission refers to power, but it does not consider the need to better understand empirically how power is expressed in global health governance. The fields of international relations, sociology, and philosophy, however, do apply power as a conceptual lens for understanding how actors behave. While global health scholars led by Gill Walt have explored how power is expressed and exercised, power could be particularly useful to understand the global political determinants of health. There are a number of analytical frames to better understand or investigate power. Robert Dahl proposed power as decision making (ie, A forcing B to do A’s choice against B’s will). Peter Bachrach and Morton Baratz argued for the importance of non-decision making (A confi nes B’s spectrum of possible choices); this has also been called the mobilisation of bias. Steven Lukes considered power as thought control (ie, A makes B want A’s choice). Together these three approaches to assess power, be it overt, covert, or latent, present one possible framework. Michael Barnett and Raymond Duvall presented another frame based on four approaches to power—namely, compulsory, institutional, structural, and productive forms. These frameworks, or a mix of them, could be a useful place to begin. A greater and more explicit focus on power as a tool for analysis of global political determinants of health can help to illuminate how actors create and exploit disparities to serve their interests. Crucially, a better understanding of power, which is especially important with the rise of non-health and non-state bodies’ influence over the global policy environment within which health systems must navigate, will allow for the design of policies and processes to redress disparities.