Erin Rusch, Rapporteur · Erin Rusch, Rapporteur Roundtable on Environmental Health Sciences,...

Erin Rusch, Rapporteur

Roundtable on Environmental Health Sciences, Research, and Medicine

Board on Population Health and Public Health Practice

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NOTICE: The workshop that is the subject of this workshop summary wasapproved by the Governing Board of the National Research Council, whosemembersaredrawnfromthecouncilsoftheNationalAcademyofSciences,theNationalAcademyofEngineering,andtheInstituteofMedicine.This activity was supported by contracts between the National Academy ofSciences and the National Institute of Environmental Health Sciences(HHSN26300013).Theviewspresenteddonotnecessarilyreflecttheviewoftheorganizationsoragenciesthatprovidedsupportforthisactivity.ThissummaryisbasedontheproceedingsofaworkshopthatwassponsoredbytheRoundtableonEnvironmentalHealthSciences,Research,andMedicine. Itis prepared in the form of a workshop summary by and in the name of therapporteurasanindividuallyauthoreddocument.

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Suggestedcitation:IOM(InstituteofMedicine).2014.GlobalDevelopmentGoalsand Linkages to Health and Sustainability:Workshop Summary.Washington,DC:TheNationalAcademiesPress.

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PLANNINGCOMMITTEEFORTHEWEBINARSERIES ONGLOBALENVIRONMENTALHEALTHAND

SUSTAINABLEDEVELOPMENT1

Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshoprapporteurandtheinstitution.

JOHNM.BALBUS,SeniorAdvisorforPublicHealth,NationalInstituteofEnvironmentalHealthSciences,NationalInstitutesofHealth,Bethesda,MD

LUIZA.GALVO,AreaManager,SustainableDevelopmentandEnvironmentalHealth,PanAmericanHealthOrganization,Washington,DC

BERNARDD.GOLDSTEIN,ProfessorEmeritus,DepartmentofEnvironmentalandOccupationalHealth,UniversityofPittsburgh,PA

FRANKLOY,U.S.Representativetothe66thSessionoftheGeneralAssemblyoftheUnitedNations,Washington,DC

KUMANANRASANATHAN,HealthSpecialist,KnowledgeManagementandImplementationResearchUnit,UnitedNationsChildrensFund,NewYork,NY

JUDITHN.WASSERHEIT,ProfessorandViceChair,DepartmentofGlobalHealth,UniversityofWashington,Seattle

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ROUNDTABLEONENVIRONMENTALHEALTH SCIENCES,RESEARCH,ANDMEDICINE1

InstituteofMedicineforumsandroundtablesdonotissue,review,orapproveindividualdocuments.Theresponsibility for thepublishedworkshopsummaryrestswiththeworkshoprapporteurandtheinstitution.

FRANKLOY(Chair),U.S.Representativetothe66thSessionoftheGeneralAssemblyoftheUnitedNations,Washington,DC

LYNNR.GOLDMAN(ViceChair),Dean,SchoolofPublicHealthandHealthServices,GeorgeWashingtonUniversity,Washington,DC

HENRYA.ANDERSON,StateHealthOfficer,WisconsinDivisionofPublicHealth,Madison

JOHNM.BALBUS,SeniorAdvisorforPublicHealth,NationalInstituteofEnvironmentalHealthSciences,NationalInstitutesofHealth,Bethesda,MD

JAMESK.BARTRAM,DonandJenniferHolzworthDistinguishedProfessor,DirectoroftheWaterInstitute,UniversityofNorthCarolinaatChapelHill

LINDAS.BIRNBAUM,Director,NationalInstituteofEnvironmentalHealthSciences,NationalInstitutesofHealth,ResearchTrianglePark,NC

LUZCLAUDIO,AssociateProfessor,MountSinaiSchoolofMedicine,NewYork,NY

DENNISJ.DEVLIN,SeniorEnvironmentalHealthAdvisor,ExxonMobilCorporation,Irving,TX

RICHARDA.FENSKE,ProfessorandAssociateChair,SchoolofPublicHealthandCommunityMedicine,UniversityofWashington,Seattle

ALISTAIRFRASER,VicePresidentofHealth,RoyalDutchShell,TheHague,Netherlands

LUIZA.GALVO,AreaManager,SustainableDevelopmentandEnvironmentalHealth,PanAmericanHealthOrganization,Washington,DC

BERNARDD.GOLDSTEIN,ProfessorEmeritus,DepartmentofEnvironmentalandOccupationalHealth,GraduateSchoolofPublicHealth,UniversityofPittsburgh,PA

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RICHARDJ.JACKSON,ProfessorandChair,DepartmentofEnvironmentalHealthSciences,FieldingSchoolofPublicHealth,UniversityofCalifornia,LosAngeles

SUZETTEM.KIMBALL,DeputyDirector,U.S.GeologicalSurvey,U.S.DepartmentoftheInterior,Reston,VA

JAYLEMERY,AssistantProfessorofEmergencyMedicine,President,WildernessMedicalSociety,UniversityofColorado,Aurora

ANDREWMAGUIRE,VicePresidentforEnvironmentalHealth,EnvironmentalDefenseFund,Washington,DC

LINDAA.MCCAULEY,DeanandProfessor,NellHodgsonWoodruffSchoolofNursing,EmoryUniversity,Atlanta,GA

ALMCGARTLAND,OfficeDirector,NationalCenterforEnvironmentalEconomics,U.S.EnvironmentalProtectionAgency,Washington,DC

DAVIDM.MICHAELS,AssistantSecretaryofLabor,OccupationalSafetyandHealthAdministration,Washington,DC

CANICENOLAN,SeniorCoordinatorforGlobalHealth,EuropeanCommission,Brussels,Belgium

MARTINA.PHILBERT,Dean,SchoolofPublicHealth,UniversityofMichigan,AnnArbor

CHRISTOPHERJ.PORTIER,Director,NationalCenterforEnvironmentalHealthandAgencyforToxicSubstancesandDiseaseRegistry,CentersforDiseaseControlandPrevention,Atlanta,GA

PAULSANDIFER,SeniorScienceAdvisortotheAdministrator,NationalOceanicandAtmosphericAdministration,U.S.DepartmentofCommerce,Charleston,SC

JOHND.SPENGLER,Professor,HarvardSchoolofPublicHealth,Boston,MA

LOUISW.SULLIVAN,PresidentEmeritus,MorehouseSchoolofMedicine,Atlanta,GA

ANNEM.SWEENEY,Professor,DepartmentofEpidemiologyandBiostatistics,TexasA&MUniversity,CollegeStation

G.DAVIDTILMAN,Director,CedarCreekEcosystemScienceReserve,RegentsProfessor,UniversityofMinnesota,St.Paul

PATRICIAVERDUIN,ChiefTechnologyOfficer,GlobalResearch&Development,ColgatePalmoliveCompany,Piscataway,NJ

NSEDUOBOTWITHERSPOON,ExecutiveDirector,ChildrensEnvironmentalHealthNetwork,Washington,DC

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HAROLDZENICK,Director,OfficeofResearchandDevelopment,NationalHealthandEnvironmentalEffectsResearchLaboratory,U.S.EnvironmentalProtectionAgency,ResearchTrianglePark,NC

IOMStaff

CHRISTINECOUSSENS,StudyDirector(untilAugust2013)ERINRUSCH,AssociateProgramOfficerHOPEHARE,AdministrativeAssistantROSEMARIEMARTINEZ,Director,BoardonPopulationHealthand

PublicHealthPractice

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Reviewers

Thisworkshopsummaryhasbeenreviewedindraftformbypersonschosenfortheirdiverseperspectivesandtechnicalexpertise,inaccordancewith procedures approved by the National Research Councils ReportReviewCommittee.Thepurposeofthisindependentreviewistoprovidecandidandcriticalcommentsthatwillassisttheinstitutioninmakingitspublishedworkshopsummaryassoundaspossibleandtoensurethatthesummary meets institutional standards for objectivity, evidence, andresponsiveness to the study charge. The review comments and draftmanuscriptremainconfidentialtoprotecttheintegrityoftheprocess.Wewish to thank the following individuals for their review of thisworkshopsummary:

JayGraham,GeorgeWashingtonUniversityCaniceNolan,EuropeanCommissionWilliamSonntag,U.S.EnvironmentalProtectionAgencyKimberlyThigpenTart,NationalInstituteofEnvironmentalHealthSciences

Althoughthereviewerslistedabovehaveprovidedmanyconstructivecommentsandsuggestions,theydidnotseethefinaldraftoftheworkshopsummarybeforeitsrelease.ThereviewofthissummarywasoverseenbySusanJ.Curry,UniversityofIowa.AppointedbytheInstituteofMedicine,shewasresponsibleformakingcertainthatanindependentexaminationofthisworkshopsummarywascarriedoutinaccordancewithinstitutionalprocedures and that all review comments were carefully considered.Responsibility for the final content of this summary rests entirelywiththerapporteurandtheinstitution.

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Contents

1 INTRODUCTION 1 OverviewofSustainability,2 PurposeoftheWebinarSeries,5 StructureoftheSummary,6 References,7

2 REFLECTINGONTHEMILLENNIUMDEVELOPMENTGOALS ANDPOST2015DEVELOPMENTAGENDA 9 PositioningHealthinthePost2015DevelopmentAgenda,APerspectivefromUganda:MillenniumDevelopmentGoalsandthe

10

Environment,13 LessonstoApplytothePost2015DevelopmentAgendaProcess,15 Discussion,18 References,22

3 HEALTHGOALSANDINDICATORSFORSUSTAINABLE DEVELOPMENT 23 BridgingtheGapBetweentheMillenniumDevelopmentGoalsand

JoiningHealthandSustainableDevelopmentGoalsThroughLow PrinciplesofSustainableDevelopmentandClimateChange,24

CarbonPolicies,30 MetricsforHealth,Development,andtheEnvironment,36 Discussion,42 References,45

4 LINKSAMONGSUSTAINABLEDEVELOPMENT,HEALTH EQUITY,ANDSOCIALJUSTICE 51 GlobalEnvironmentalChangeandImpactsonHumanHealthand

PoliciestoAddressHealthEquity,SocialJustice,andSustainable

OntheGroundPerspectiveonAddressingHealthEquityand

SocialJustice,51

Development,57

SustainableDevelopment,62 Discussion,63 References,67

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xiv CONTENTS

APPENDIXES

A WEBINARAGENDAS 69B WEBINARSPEAKERBIOSKETCHES 75

1

Introduction

The Roundtable on Environmental Health Sciences, Research, andMedicinewasestablishedin1998andprovidesastructuredopportunityfor regular and open communication among experts interested inenvironmental health topics from a variety of government, academic,industry, and consumer groups. Throughmeetings and workshops, theRoundtablehasfocusedonthestateofenvironmentalhealthsciencesanddecisionmaking,identificationofpopulationsvulnerabletoenvironmentalhazards, and translation of environmental health research into publichealth practice. The Roundtable defines the environment broadlyadefinitionthatincorporatesthenatural,built,andsocialenvironmentsandconsidershowchangesintheenvironmentcanimpacthumanhealththroughdirectandindirectpathways(IOM,2006).InSeptember2012,theRoundtableestablishedtheGlobalEnvironmental

HealthandSustainableDevelopment InnovationCollaborativeasanadhocactivitytoprovideanadaptablepathwayfordiscussingissuesrelatedtosustainable development and for sharing scientific information acrossUnited Nations (UN) system entities, international and governmentalorganizations,academia,theprivatesector,andcivilsociety.TheInnovationCollaborativeiscomposedofRoundtablemembersandotherstakeholderswithasharedinterestindevelopingcooperativeactivitiesandstrategiesto advanceglobal goalson sustainabledevelopment andhumanhealth.Through multidisciplinary collaboration, the Innovation Collaborativeseekstoconnectandleverageexpertiseacrossavarietyoffieldsrelatedtosustainabledevelopment,includingeconomics,energy,environmentalsciences,medicine,publichealth,andhealthcommunication.The Innovation Collaborative held a series of webinars in October,

November, andDecember 2012 to help inform the post2015 development agenda process that was under way and being led by the UN.Provided below is a brief background of key events and reports thatinformed the planning of the webinar series, as well as details on thepurposeofthewebinarseriesandtheoverallstructureofthissummary.

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2 GLOBALDEVELOPMENTGOALS

OVERVIEWOFSUSTAINABILITY

The term sustainability comes from the concept of sustainabledevelopment defined in the 1987 report Our Common Future by theBrundtlandCommission of theUnitedNations as developmentwhichmeetstheneedsofcurrentgenerationswithoutcompromisingtheabilityoffuturegenerationstomeettheirownneeds(WCED,1987).Sustainabledevelopment is supported by three pillarsthe economic, social, andenvironmental dimensionswhere health is both an outcome of and aprecondition for all three pillars (UN, 2012). Being built on multipledisciplines,sustainabledevelopmentfollowsanintegratedsystemsbasedapproachtoencompasstheaimsofdevelopment,includinghumanwellbeing,qualityoflife,freedom,andopportunity(NRC,2011).Becauseofthis approach, sustainability frameworks are increasingly utilized toaddressintractableproblemsthroughouttheworld,particularlygrowingchallengesaroundglobalenvironmentaldegradationandpoverty(NRC,2011).In 1992, sustainable development was formally endorsed by the

internationalcommunityatthehistoricUNEarthSummitheldinRiodeJaneiro, Brazil. Box 11 includes a list of the international sustainabledevelopment conferences anddocumentsdiscussed in this chapter.TheEarthSummitresultedinthecreationofAgenda21,anambitiousactionplan for global sustainable development (UN, 1993), and the RioDeclaration,whichoutlined27principles forglobal sustainability (UN,1992).Forexample,Principle1oftheRioDeclarationstatesthathumanbeingsareatthecenterofconcernsforsustainabledevelopment...theyareentitledtoahealthyandproductivelifeinharmonywithnature(UN,1992),clearlyarticulatingthatprotectinghumanhealthisthecornerstoneofsustainabledevelopment.Principle4goesontostatethatinordertoachieve sustainable development, environmental protection shallconstitute an integral part of the development process and cannot beconsidered in isolation from it (UN, 1992). This principle placesenvironmental protection on an equal plane with development, arequirementtoensurethatresourcesareavailableforpresentandfuturegenerations.TheRioDeclarationalsohighlightstheneedtoeradicatepovertyand

decrease disparities in standards of living to achieve the objectives ofsustainabledevelopment.Followingtheseefforts,worldleadersgatheredinNewYorkCity in2000for theMillenniumSummitandadopted theMillenniumDeclaration(UNGeneralAssembly,2000),whichgaverisetotheMillenniumDevelopmentGoals(MDGs).TheMDGsareasetofeight healthrelated development goals intended to reduce extremepoverty throughout the world, protect the environment, and improveconditionsforvulnerablepopulations(seeBox12).Eachgoalincludesa

3INTRODUCTION

series of timebound targets for achieving and trackingprogress acrosscountries through 2015. In 2002, the MDGs were reaffirmed at theWorld Summit on Sustainable Development in Johannesburg, SouthAfrica (UN, 2002), and a plan of implementation was developed thatreinforced the interdependent components of sustainable development(economicdevelopment,socialdevelopment,andenvironmentalprotection)andoverarchingobjectives,includingpovertyeradication,improvedhumanhealth, andprotection andmanagement of the natural resourcesbase. Following the 2005 UNWorld Summit, the MDG targets wereupdated to incorporate intergovernmental agreements from the event;Targets 5B, 6B, and 7B were added, and Target 1B was added as arevisionofaprevioustargetlistedunderMDG8.

BOX 1-1 International Sustainable Development Conferences and Documents

Conferences 1992: Earth Summit (Rio de Janeiro, Brazil) 2000: Millennium Summit (New York, United States) 2002: World Summit on Sustainable Development (Johannesburg, South

Africa) 2005: World Summit (New York, United States) 2012: United Nations (UN) Conference on Sustainable Development

(Rio+20 Conference) (Rio de Janeiro, Brazil) Documents

Our Common Future (WCED, 1987) Rio Declaration (UN, 1992) Agenda 21 (UN, 1993) Millennium Declaration (UN General Assembly, 2000) Report of the World Summit on Sustainable Development (UN, 2002) 2005 World Summit Outcome (UN General Assembly, 2005) The Future We Want (UN, 2012)

Despitetheseefforts,manyoftheMDGshavenotbeenachieved,andadverse trends have been reported for several of the environmentaltargets(UN,2013).Forexample,globalcarbondioxideemissionshaveincreasedbymorethan46percentsince1990,nearlyonethirdofmarinefish stocks are overexploited, and an estimated 863 million peoplecontinue to reside in slums in the developing world (UN, 2013). Onepossibleexplanation for this slowprogress is lackof integrationacrossthe social, economic, and environmental priorities found in theMDGs(Hainesetal.,2012).Inaddition,thedraftingprocessprimarilyinvolved


BOX 1-2 Millennium Development Goals (MDGs) and Targets

1. Eradicate extreme poverty and hunger 1A. Halve, between 1990 and 2015, the proportion of people whose

income is less than $1 per day 1B. Achieve full and productive employment and decent work for all,

including women and young people 1C. Halve, between 1990 and 2015, the proportion of people who

suffer from hunger 2. Achieve universal primary education

2A. Ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling

3. Promote gender equality and empower women 3A. Eliminate gender disparity in primary and secondary education,

preferably by 2005, and in all levels of education no later than 2015

4. Reduce child mortality 4A. Reduce by two-thirds, between 1990 and 2015, the under-5 mortality

rate 5. Improve maternal health

5A. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio

5B. Achieve, by 2015, universal access to reproductive health 6. Combat HIV/AIDS, malaria, and other diseases

6A. Have halted by 2015 and begun to reverse the spread of HIV/ AIDS 6B. Achieve, by 2010, universal access to treatment for HIV/AIDS

for all those who need it 6C. Have halted by 2015 and begun to reverse the incidence of

malaria and other major diseases 7. Ensure environmental sustainability

7A. Integrate the principles of sustainable development into country policies and programs and reverse the loss of environmental resources

7B. Reduce biodiversity loss, achieving, by 2020, a significant reduction in the rate of loss

7C. Halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation

7D. By 2020, to have achieved a significant improvement in the lives of at least 100 million slum dwellers

5INTRODUCTION

8. Global partnership for development 8A. Develop further an open, rule-based, predictable, nondiscriminatory

trading and financial system 8B. Address the special needs of the least developed countries 8C. Address the special needs of landlocked developing countries

and small-island developing states 8D. Deal comprehensively with the debt problems of developing

countries through national and international measures in order to make debt sustainable in the long term

8E. In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries

8F. In cooperation with the private sector, make available the benefits of new technologies, especially information and communications

NOTE: Please see The Millennium Development Goals Report 2013 for a detailed assessment of global and regional progress made toward the MDGs and targets: http://mdgs.un.org/unsd/mdg/Resources/Static/Products/ Progress2013/English2013.pdf (accessed August 14, 2013). SOURCE: UN, 2008.

experts from theUNsystem (who took the targets from the text of theMillennium Declaration) and lacked direct participation from civilsocietyandnongovernmentalorganizations (NGOs); as a result, implementation was slow in some countries and regions (UN System TaskTeamonthePost2015UNDevelopmentAgenda,2012;Vandemoortele,2011).

PURPOSEOFTHEWEBINARSERIES

In June 2012, world leaders and participants from government,NGOs,theprivatesector,andcivilsocietygatheredinRiodeJaneiroforthe UN Conference on Sustainable Development to honor the 20thanniversaryofthe1992EarthSummit(commonlyreferredtoasRio+20).The official discussions of the Rio+20 Conference highlighted sevenareas forpriority attention (decent jobs, energy, sustainable cities, foodsecurityandsustainableagriculture,water,oceans,anddisasterreadiness),and focused on issues related to the green economy in the context ofsustainabledevelopmentandpovertyeradication.A formal outcome documentwas prepared at the conclusion of the

conferencethatreaffirms

theneedtoachievesustainabledevelopmentbypromotingsustained,inclusiveandequitableeconomicgrowth,creatinggreateropportunities

http://mdgs.un.org/unsd/mdg/Resources/Static/Products


for all, reducing inequalities, raising basic standards of living,fostering equitable social development and inclusion, and promoting the integrated and sustainable management of naturalresourcesandecosystemsthatsupports,interalia,economic,social,andhumandevelopmentwhilefacilitatingecosystemconservation,regenerationandrestoration,andresilienceinthefaceofnewandemergingchallenges.(UN,2012).

The document also highlights the need for a set of SustainableDevelopment Goals (SDGs) that address and incorporate all threedimensions of sustainable development and that can be integrated intotheUNpost2015developmentagenda(aglobalframeworkthatisbeingdevelopedtomaintaintheprogressoftheMDGsbeyond2015).ThefollowuptotheRio+20Conferenceprovidesanopportunityfor

guidance on the post2015 development agenda framework and theSDGs,whichwilllikelyconvergeandbeadoptedattheSeptember2015UNGeneralAssembly.Thechallengeistoachievecollectivesupportforeffective,meaningful,concise,andeasytocommunicateglobaldevelopmentgoalsthatwillfocusonthethreeareasofsustainabledevelopmentandbenefitthehealthofpopulationsattheglobal,regional,andnationallevels. In an effort to provide varied perspectives that may benefithigherlevel policy discussions, the Global Environmental Health andSustainable Development Innovation Collaborative hosted a webinarseriesduringOctober,November,andDecember2012.Thestatementoftask for the webinar series can be found in Box 13. The webinarscovered lessons learned from theMDG process and insights on topicsand goals that may be considered for inclusion in the developmentframeworks being debated and negotiated at the global level. Anindependentplanningcommittee(whoserolewaslimitedtoplanningthewebinar series in accordance with the procedures of the NationalResearch Council [NRC]) invited experts within the fields ofenvironmental and global health to present their experiences andthoughts on the topic areas and encouraged representatives fromgovernment,academia,andcivil society toparticipate in thediscussionsessionsthatfollowedthepresentations.

STRUCTUREOFTHESUMMARY

Thissummarywaspreparedbytheworkshoprapporteurasafactualsummaryofwhatoccurredduring thewebinars.Allviewspresented inthe summary are those of thewebinar participants. The summary doesnotcontainanyfindingsorrecommendationsbytheplanningcommitteeortheRoundtable.

7INTRODUCTION

BOX 1-3 Statement of Task

An ad hoc committee will plan and conduct a public three-part webinar series (workshop) on Sustainable Development Goals (SDGs) and human health. The webinars will feature invited presentations and discussions to look at possible health-related measures and metrics that can be utilized for creating new SDGs as the Millennium Development Goals sunset in 2015. The workshop will focus on fostering discussion across academic, government, business, and civil society sectors to make use of existing measurements that can be adapted to track progress of global sustainable development and human health. The committee will develop the webinar agendas, select invited speakers and discussants, and moderate the discussions. A workshop summary based on all three webinars will be prepared by a designated rapporteur in accordance with National Research Council policies and procedures.

Thepresentationsanddiscussions thatoccurredduring thewebinarsaresummarizedinthesubsequentchapters.Chapter2considerslessonslearned from the MDGs and opportunities for aligning environmentalhealth objectives with the post2015 development agenda. Chapter 3includesprovideperspectivesonpossiblehealthgoalsandindicatorsforsustainable development while making connections to climate change.Chapter 4 provides insights on making linkages between sustainabledevelopment,healthequity,andsocialjustice.Thewebinaragendascanbe found in Appendix A, and the speaker biosketches are included inAppendixB.

REFERENCES

Haines, A., G. Alleyne, I. Kickbusch, and C. Dora. 2012. From the EarthSummit toRio+20: Integrationofhealthandsustainabledevelopment.TheLancet379(9832):21892197.

IOM (Institute of Medicine). 2006. Rebuilding the unity of health and theenvironment in rural America.Washington, DC: The National AcademiesPress.

NRC (National Research Council). 2011. Sustainability and the U.S. EPA.Washington,DC:TheNationalAcademiesPress.

UN (United Nations). 1992. Report of the United Nations conference onenvironment and development, Rio de Janeiro, Brazil, 314 June 1992.A/CONF.151/26.NewYork:UnitedNations.

UN.1993.EarthSummit:Agenda21.TheUnitedNationsprogrammeofactionfromRio.NewYork:UnitedNations.


UN. 2002. Report of the World Summit on Sustainable Development.Johannesburg,SouthAfrica,26August4September2002.A/CONF.199.20.NewYork:UnitedNations.

UN. 2008. Official list of MDG indicators. http://mdgs.un.org/unsd/mdg/host.aspx?Content=indicators/officiallist.htm(accessedAugust14,2013).

UN.2012.Thefuturewewant.A/CONF.216/L.1.NewYork:UnitedNations.UN.2013.TheMillenniumDevelopmentGoalsreport2013.NewYork:UnitedNations.

UN General Assembly. 2000. United Nations Millennium Declaration.A/RES/55/2.NewYork:UnitedNations.

UN General Assembly. 2005. 2005 World Summit Outcome. A/60/L.1. NewYork:UnitedNations.

UN System Task Team on the Post2015 UN Development Agenda. 2012.Review of the contributions of the MDG agenda to foster development:Lessons for the post2015 UN development agenda. Discussion note.http://www.un.org/millenniumgoals/pdf/mdg_assessment_Aug.pdf(accessedAugust20,2013).

Vandemoortele, J. 2011. TheMDG story: Intention denied.Development andChange42(1):121.

WCED (World Commission on Environment and Development). 1987. Ourcommon future. Edited by G. H. Brundtland. Oxford: Oxford UniversityPress.

http://www.un.org/millenniumgoals/pdf/mdg_assessment_Aug.pdfhttp://mdgs.un.org/unsd/mdghttp:A/CONF.199.20

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ReflectingontheMillenniumDevelopmentGoalsandPost2015DevelopmentAgenda

John M. Balbus, senior advisor for public health at the NationalInstituteofEnvironmentalHealthSciencesandcochairof the InstituteofMedicineGlobalEnvironmentalHealthandSustainableDevelopmentInnovation Collaborative, opened the first webinar by highlighting theglobalburdenofdiseaseattributable to themodifiableenvironment.Henotedthatworldwideabout24percentofalldisabilityadjustedlifeyears(oryearslostfrombothdisabilityanddeath)isrelatedtoenvironmentalfactors (WHO, 2006), which range from the biological environment(such as water pollution) to the chemical environment (such as airpollution)tothebuiltenvironment(includingroadtrafficaccidents).Theburden of disease related to the environment is highest in the poorestcountries of the world, and in these parts of the world sustainabledevelopmentcanprovidetheopportunityforabettereconomiclifeandimprovedhealththroughsustainabledevelopmentdecisionsinformedbyenvironmentalhealthconsiderations.Balbus emphasized that one of the key goals of sustainable

developmentistobringenergy,transportationservices,andothereconomicservicestopeoplewhoarelackingtheseresourcesinawaythatdoesnotcompromise theneedsof futuregenerations.Substantialhealthbenefitscanbeobtainedfromsustainabledevelopmentpoliciesaroundtheworldthatfocusonclimatechangemitigation,transportation,agriculture,foodconsumption,householdenergy,andlargescaleenergyproduction;and,inmanycases,theeconomicbenefitsofthesepolicieswouldsignificantlyoffsettheassociatedcosts.However,toachievehealthbenefitsfromthesepolicies,effortsneed

to takeplace throughout theworld inministriesoutside theMinistryofHealth.Balbussaid that inorder to implementdirectenergypoliciesorchange urban planning or transportation systems, the public healthcommunity needs to work in an intersectoral way to raise awarenessaboutthehealthimpactsfromothersectorsthathaveastrongholdonthehealthoffuturegenerations.

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Althougha siloed approach topolicydevelopment facilitates clarityin communication, it often can lead tomissed opportunities to addresstheinterrelationshipsamongeconomicandsocialdevelopment,environmental protection, and human health (Balbus and Wasserheit, 2012).Balbusemphasizedthatmanyexistingsilosneedtoberemoved,startingwiththeareasthathavethegreatestpublichealthimportanceandgreatestscientific rigor. In order to achievewide acceptance across sectors andmakeprogress,thecostofthepolicyorinterventionneedstobereasonable,thebenefitsneedtobemeasurableandsizable,thelanguageneedstobeunderstandable to all sectors, and all stakeholders need to strive forsimplicitysimplicityinthearticulationofgoals,inthecommunicationofinterlinkages,andinthecreationoftargetsandindicators.

POSITIONINGHEALTHINTHEPOST2015DEVELOPMENT AGENDA

MariaNeira,M.D. Director,PublicHealthandEnvironment

WorldHealthOrganization

In thinking about the post2015 development agenda, Maria Neirabegan by referencing a recent report to the United Nations (UN)SecretaryGeneral, Realizing the Future We Want for All. The reportoutlines the importance of working with a circle mentality thatincludes environmental sustainability, inclusive social development, inclusive economic development, and peace and securitywith a significantfocusonsustainability,equality,andhumanrightsincreatingthepost2015developmentagenda(seeFigure21).Thisframeworkbuildson the three pillars of sustainable development (economic, social, andenvironmental)andaddsafourthgoalofpeaceandsecurity; thesefourareasareallenablersofthethreefundamentalprinciples(humanrights,equality,andsustainability)oftheglobalvision(UNSystemTaskTeamon the Post2015UNDevelopmentAgenda, 2012a). In thinking abouthowtopositionhealthwithintheagenda,Neiranotedthatitisextremelyimportant to understand the post2015 development agenda process,particularlythearchitecturecreatedundertheSecretaryGeneral.

UnderstandingthePost2015DevelopmentAgendaProcess

TheSecretaryGeneralsHighLevelPanelofEminentPersonsonthePost2015DevelopmentAgendawascreatedtoproposeaframeworkfor

11

the post2015 development agenda and deliver a report to the UNGeneralAssembly by the second quarter of 2013.Neira noted that theframework may include post2015 Millennium Development Goals(MDGs)orSustainableDevelopmentGoals(SDGs),alongwithdataandworkinformedbythe2012UNConferenceonSustainableDevelopment(Rio+20Conference)andongoingcountrylevelconsultationsoftheUNDevelopment Group (UNDG). The HighLevel Panel is cochaired bythree individuals: SusiloBambangYudhoyono, President of Indonesia;Ellen JohnsonSirleaf,PresidentofLiberia; andDavidCameron,PrimeMinisterof theUnitedKingdom

FIGURE21Proposedintegratedframeworkforrealizingthefuturewewant forallinthepost2015developmentagenda. SOURCE:UNSystemTaskTeamonthePost2015UNDevelopmentAgenda, 2012a.

. Inaddition,30countriesareassistingwiththeprocess.Neiraemphasizedtheneedtoworkwithinthisstructure

MILLENNIUMDEVELOPMENTGOALSANDPOST2015AGENDA


to ensure that health is included in the post2015 development agendaprocess.InadditiontotheHighLevelPanelandUNDGcountryconsultations,

thereare11thematicconsultationsplanned,whichwillbeledbyappointedUNagencies (seeBox21).Thearchitectureofall thesegroupscanbecomplicated and will likely initiate competition among different topicareasandproposedgoals.ThehealthconsultationwillbeledbytheWorldHealth Organization (WHO) and the United Nations Childrens Fund(UNICEF),withSwedenandBotswanaplayingafundamentalroleintheplanningprocess,andwillconcludeinJanuaryorFebruary2013withafinaleventinBotswana.Neirahighlightedtheneedtoalsousetheotherthematic areas, such as consultations for water or energy, to includehealthasanindicatorandmakeprogressinthosesectorspolicies.Theseadditional efforts will be fundamental to including health goals in thepost2015developmentagenda.

BOX 2-1 11 Global Thematic Consultations for the Post-2015

Development Agenda Process

1. Inequalities (across all dimensions) 2. Health (including MDG 4, MDG 5, MDG 6, and noncommunicable diseases) 3. Education (primary to tertiary and vocational) 4. Growth and Employment (investment in productive capacities, decent work,

and social protection) 5. Environmental Sustainability (including biodiversity and climate change) 6. Governance (accountability at all levels) 7. Conflict and Fragility (conflict and post-conflict countries, and those prone

to natural disasters) 8. Population Dynamics (including aging, international and internal migration,

and urbanization) 9. Hunger, Nutrition, and Food Security 10. Energy 11. Water

AchievingaGreaterFocusonHealth

Inworking on the health thematic consultation,Neira said that it isimportant to emphasize achievements and investments made in thehealthrelatedMDGsinordertosustainthiswork.Shenotedthatthereisaneedforgreaterrecognitionandfocusonthemeansaswellastheends.

13MILLENNIUMDEVELOPMENTGOALSANDPOST2015AGENDA

For example,we as a global community need to recognize health as ahumanright,needstrongerandmoreresilienthealthsystems,needmoreinnovationandefficiencytorespondtofinancialconstraints,andneedtoaddresstheeconomic,social,andenvironmentaldeterminantsofhealth.Allofthiscallsforamultisectoralresponse.Insteadoflookingforwhatcouldbethenewhealthgoals,Neiranoted,thepublichealthcommunityshouldbuildacaseforwhyhealthisaconcernforallpeopleandisinfluencedby,aswellascontributesto,policiesacrossawiderangeofsectors.Theoverarching goal being proposed by WHO in order to accommodate andmaintainthevisibilityofalltheinternationallyagreeduponhealthgoalsisuniversalhealthcoverage.Thevisionofuniversalhealthcoveragewillensure that all people have coverage and access to health services andhavefinancialriskprotectionforpayingforcare.Althoughuniversalhealthcoverageisanimportantoverarchinggoal,

Neira again noted the importance of including health in many of theproposedthematicconsultations.Forthethematicconsultationonwater,healthrelatedgoalsshouldbeframedtousehealthasawaytomeasureprogressinthewaterandsanitationsectors;inthiswaythosegoalswillhaveaveryclearandpositiveimpactonthehealthofpeople.Similarly,for energy, using health as an indicator of achievements and progressmade by good energy policies will likely serve as a better outcome,which will garner popular support for policies that have more diffuseoutcomes,suchasreducingcarbondioxide(CO2)emissions.

ClosingRemarks

Neira closed by stating that the post2015 development agendaprocessisobviouslyaworkinprogress,andshehopesthatattheendoftheprocesstheresultswillincludeagreaterfocusonhealthwithinwhatissuretobeacomplicatedpost2015developmentagenda.

APERSPECTIVEFROMUGANDA:MILLENNIUM DEVELOPMENTGOALSANDTHEENVIRONMENT

DavidSerwadda,M.B.Ch.B.,M.Sc.,M.Med.,M.P.H. ProfessorofDiseaseControlandEnvironmentalHealth, MakerereUniversitySchoolofPublicHealth,Uganda

DavidSerwaddabeganhispresentationbypointingout thateachofthe eightMDGs lays out overarchinggoals and specific targets for theworldtoworktowardby2015(seeBox12inChapter1foracompletelist of goals and targets). MDG 7 focuses on ensuring environmentalsustainability,butthisgoalislinkedtomanyotherMDGoutcomes.He


statedthatitisimportanttoseetheinterconnectionsbetweenMDG7andMDGs1,2,3,4,and8tounderstandhowthemanagementoftheenvironmentactsontheothergoals.Forexample,Target7C(tohalve,by2015,the proportion of people without sustainable access to safe drinkingwaterandbasicsanitation)hasconnectionstoimprovedtimesavingforwomenandthepromotionofgenderequality(MDG3),andreductionsinwaterbornediseasesthatcanleadtoreducedchildmortality(MDG4).

CoordinatingImplementationofGlobalDevelopmentGoals

Takingastepback,SerwaddasharedhisexperiencewithevaluatingWHOsGlobalStrategyforHealthforAllbytheYear2000,notingthatmanyofthegoalssetforthisglobalstrategywerenotachievedby2000.One of the reasons for falling short, which is still prevalent today, isfocusing implementation efforts on independent outcomes, despite thefactthattheprocessofachievingthegoalsisquiteinterrelated.SerwaddaemphasizedthattheMDGsareimplementedinsilos,withalackofgoodsystematiccoordinatedplatformsforimplementation.TakingacloserlookatcoordinatingMDGefforts,Serwaddausedthe

topic of water sanitation to exemplify the complexity of managingresources. In Uganda, as well as many countries in Africa, water andsanitationsurveillancetakeplaceintheMinistryofHealth.HenotedthattheMinistryofHealthisabletoidentifyhugegrowinghealthproblemsassociated with poorquality water and sanitation, most of which isindicatedbydiarrhealdiseasesandhighmorbidityandmortalityratesinchildren less than 5 years of age.However, theMinistry ofWater andSanitationa completely separate ministryis responsible for themanagement of these resources. This makes it difficult to effectivelyachieve Target 7C, because the public health community that tracksprogressinthisareahasverylittleinputintheimplementationofwaterandsanitationresources.Serwaddapointedoutthatthisagainhighlightstheissueoflookingattheoutcomes,ratherthantheprocessofhowtheoutcomesareachieved.InlookingattheMDGprocess,onewillquicklyrealize that most of the direct and indirect impacts on health andeducation are actually found outside the directly relevant goals.Serwadda emphasized that this is a significant problem that should beaddressed moving forward with the post2015 development agendaprocess.

ImpactofPopulationGrowthinAfrica

Serwadda then shifted to the challenges associated with Africanpopulation growth.By 2050Africa is projected to be the secondmostpopulous continent in theworld,which is driven in large part by highfertility rates (UN, Department of Economic and Social Affairs,


Population Division, 1999, 2009). He explained that this populationgrowth is increasing deforestation as the need for household energysourcesexpands. Inaddition, the increasedneed forhousing is causingrapiddevelopmentoflandwithpoorprovisionsofwaterandsanitation.Serwaddanotedthatpopulationgrowthisalargedriverofhealthimpactsandwillrequirespecificmanagementtoreduceitspotentiallysignificantimpactsontheenvironmentandotherhealthoutcomes.Forexample,effortstoreduceHIVby50percentarecontinuallyimpactedbyadenominatorthatisincreasingallthetime;thishasdifficultimplicationsontheresourcesthat are needed to move this cause forward. Looking at the MDGs,reproductivehealthisemphasized,buttheMDGsdonotspecificallytalkaboutchildbirthrates,andforpost2015,asfarasAfricaisconcerned,this is going to be a huge issue that needs to be addressed movingforward.

ClosingRemarks

Insummaryandconsideringthepointsmadeabove,Serwaddanotedthe need to implement a country framework that builds, adds, andsupplementseachMDGgoal inacoordinatedmanner,withaviewthatsomeMDGs,particularlythoserelatedtohealth,aresignificantlyimpactedbyfactorsoutsidethehealthsector.Heemphasizedthatpopulationgrowthis an enormous driver thatwill have significant impacts inAfrica thatdirectlyandindirectlyaffecttheMDGs.Serwaddasaidthisneedstobecomprehensivelyaddressedbecausepopulationgrowthnotonlyunderpinsmanyresourceneedsbutalsocancreateaviciouscycleintermsofbeingabletomeetendtargetsforglobaldevelopment.

LESSONSTOAPPLYTOTHEPOST2015DEVELOPMENTAGENDAPROCESS

ZehraAydin,M.A. SeniorProgramOfficer,

UnitedNationsEnvironmentProgramme

Zehra Aydin began by noting that the Millennium Declaration,adoptedin2000,ledtothedevelopmentoftheMDGs(seeChapter1formoredetail).Shesaiditwouldbeworthlookingthroughthisdocumentagaintoinspireideasoncollectiveresponsibilitiesforcurrentandfuturegenerations. For example, the Millennium Declaration recognized thatin addition to our separate responsibilities to our individual societies,we have a collective responsibility to uphold the principles of humandignity, equality, andequityat theglobal level . . . especially themost


vulnerable and, in particular, the children of the world, to whom thefuturebelongs(UNGeneralAssembly,2000).

LessonstoLearnfromtheMDGs

Aydinnoted that thereareseveralpositive lessons to learn fromtheMDGexperience.The two thatare themost important, shesaid,are tohavefewgoalstofocuseveryonesattentionandtohavegoalsthatshiftthe attention of policy makers to thinking about sustainability. Withrespect to the former, she said, the Millennium Summit allowed theworldcommunitytopresentthousandsoftargetsandgoalsfromnumerousintergovernmentalmeetingsandconferences,andfocusing theattentiononafewgoalswaswelcomedbymanypeople.TheMDGsalsomovedtheattentionofpolicymakers,fromlookingateconomicgrowthanddevelopment to thinkingabout theeconomy,society,andenvironment togetherinasustainabledevelopmentmanner.But some of the positive lessons also contained some negative

aspects,Aydinnoted.Forinstance,thetargetsandgoalswereselectivelychosen from the textof theMillenniumDeclaration,and theMDGsdonot reflect all of the internationally agreedupon goals included in thatdocument (UNSystemTaskTeamon thePost2015UNDevelopmentAgenda,2012b).Importantissues,suchashumanrights,unemployment,andpeaceandsecurity(amajorissuethataffectsallof thegoals)wereleft out of theMDGs. In the case ofMDG 7, this goal was based onenvironmentalprotection,buttheassociatedtargetsandindicatorsdonotnecessarilymatch the intentionandcontentprovidedin theMillenniumDeclaration. For example, the emphasis on climate change, which ispresent in theMillenniumDeclaration through theagreeduponneed toreducegreenhousegasemissionsand thenumberandeffectsofnaturaldisasters,doesnotappearanywhereintheMDG7framework(seeTable21). In addition, not all of the MDG targets were well defined orincludedwellselected indicators (e.g., tohalvepovertyor reducechildmortalityby twothirdsdoesnot take intoaccountpopulationdynamicsfrom 1990 to 2015). These are lessons to learn from in the post2015developmentagendaprocess.

ElementsofthePost2015DevelopmentAgendaProcess

Aydin explained that the post2015 development agenda process hasthree elements. First, the process is expected to build on the existingMDGs,becausenotallof the targetsof thesegoalshavebeenachieved.Second, theprocessprovides theopportunity to improve thecontextoftheexistingMDGs,perhapswithbettertargetsandindicators.Third,theprocessprovidesanopportunitytoidentifynewgoalsasaglobalcommunity


TABLE21MDG7(EnsureEnvironmentalSustainability):TargetsandIndicators

Targets IndicatorsTarget7A:Integratetheprinciplesofsustainabledevelopmentintocountrypoliciesandprogramsandreversethelossofenvironmentalresources

Target7B:Reducebiodiversityloss,achieving,by2010,asignificantreductionintherateofloss

Target7C:Halve,by2015,theproportionofpeoplewithoutsustainableaccesstosafedrinkingwaterandbasicsanitation

Target7D:By2020,tohaveachievedasignificantimprovementinthelivesofatleast100millionslumdwellers

7.1Proportionoflandareacoveredbyforest7.2CO2emissions,total,percapitaandper$1grossdomesticproduct7.3Consumptionofozonedepletingsubstances7.4Proportionoffishstockswithinsafebiologicallimits7.5Proportionoftotalwaterresourcesused

7.6Proportionofterrestrialandmarineareasprotected7.7Proportionofspeciesthreatenedwithextinction

7.8Proportionofpopulationusinganimproveddrinkingwatersource7.9Proportionofpopulationusinganimprovedsanitationfacility

7.10Proportionofurbanpopulationlivinginslums*

* The actual proportion of people living in slums is measured by a proxy, represented by the urban population living in householdswith at least one of four characteristics: (1) lack of access to improved water supply; (2) lack of access to improved sanitation; (3) overcrowding (three or more persons per room);and(4)dwellingsmadeofnondurablematerial. SOURCE:UN,2008.

and confront emerging challenges (such as inequality) affecting bothdevelopedanddevelopingcountries.MovingtotheUNprocess,Aydinhighlightedtwokeyelements.The

firstelement,alsomentionedbyNeiraduringherpresentation,istheUNSystem Task Team report to the SecretaryGeneral on the post2015developmentagenda.Aydinnotedthatthethreefundamentalprinciplesequality, sustainability, and human rightsproposed in Realizing theFuture We Want for All should be the basic building blocks of theframework for the next development agenda (see Figure 21). Thesecond element in the UN process includes national consultations that


will takeplaceinupto100countriesandglobal thematicconsultationson 11 specific themes (see Box 21). The national consultations aresupported by the UN Development Group and are being organizedthrough collaborationwith the UNOffice of the Resident Coordinatorand the national governments. These consultations could provide anentry point for colleagues and counterparts at other national scienceacademiestocontributetothenationaldiscussion.Aydinsuggestedthatmobilizingthesegroupscouldenhancethescientificbasisoftheprocess.Although the global thematic consultations reference 11 separate

themes, with crosscutting issues looking at human rights and genderequality,theseconsultationswillnotoccurinsilos.Aydinsaidthereareefforts under way to encourage linkages among the themes (such asdiscussing environmental sustainability along with education, health,food security, or population dynamics) to assess relationships amongthese issues.All of the thematic consultationswill startwith a call forpapers and virtual conversation, followed by an expert or leadershipmeeting,and thena final report that synthesizesall the findings.Whenthese contributions are completed, the process goes into the intergovernmental stage from June 2013 through the end of 2015, anddiscussionswill focusonproducingagloballyagreeduponnewdevelopmentagendathatwilltakeeffectin2016.Inclosing,Aydinnotedthatshehopesthatbyworkingtogether, the

national science academies canmobilize their networks and colleaguesfromallpartsoftheworldtocontributetothisprocess.

DISCUSSION

Abriefdiscussionamongthespeakersandparticipantsfollowedthepresentations.Theirremarksaresummarizedinthissection.

AnIntersectoralApproachtoAchievingGlobalDevelopmentGoals

BalbusbeganthediscussionsessionbynotingtheinterestingprocessissuesthatweredescribedinthepresentationfromAydin,includingtheidea of points of entry into the process and the role of the nationalscienceacademiesatthecountrylevel.HealsohighlightedapointfromSerwadda, the idea thatbreakingdownsilos shouldnot come from thevery top down to the country level, but that each country needs anintersectoral approach to achieving global development goals that canwork within the context of each individual countrys culture andgovernment structure. Balbus then presented the first question to thegroup,askingforadditionalideasonhowtooperationalizethisproposedapproachatthecountrylevel.


SerwaddabeganbynotingthatmostoftheMDGswereframedatthe10,000foot level and that adoption of the MDGs were more or lessagreeduponthroughtheUNsystem,ratherthanhavingbottomupinputfromthecountrylevel.Hestatedthattheprocesslackedarigorouscountrydiscussion todetermineexactlyhowtheMDGsshouldbe implementedandwhether thegoalswere realistic.Serwaddawenton to say that theconsultation process referenced in Aydins presentation is probablytrying to rectify this, because the discussions are starting from thecountrylevelandmovingup.Hethinksthatthisprocessfacilitatesmoredialogueandmoreawarenessofwhatisrequiredtoimplementtheglobalgoalsandtheprocesstoachievetheoutcomes.Aydinstatedthatshewasalsointriguedbythesuggestionthat there

couldbeanapproach toachieve theglobaldevelopmentgoals ineverycountryandnotedthattherehasbeenaneffortinthatdirectionthatcouldperhapsbebuiltuponinthepost2015developmentagendaprocess.Sheexplained thatafter the1992RioSummit therewasadecision that thecountrieswoulddeveloptheirsustainabledevelopmentframeworks(forexample, somecalled itNationalAgenda21,andquitea fewcountriesdevelopedframeworks),but thenattentionwasdiverted to theMillennium Summit. However, she said, the existing country frameworkswhether called National Agenda 21, National Council for SustainableDevelopment, or something elsecould survive, and include not onlythe three pillars of sustainable development but also other globalconcerns related to peace and security.Aydin noted that the additionaldimensionofpeaceandsecuritypresentedintheintegratedframeworkinRealizing the Future We Want for All (see Figure 21) completes thecycleofsustainabledevelopmentbecause,aslearnedovertime,whenaconflict breaks out, all efforts to address sustainable development arelost.There isanopportunity for thecountry level tobecomebettercoordinated, she said, because part of the problemat the country level islackofcoordinationacrossthedifferentministries.Sheemphasizedthatthe four basic building blocks of the vision for the post2015 developmentagendaenvironmental sustainability, inclusivesocialdevelopment,inclusive economicdevelopment, andpeace and securitywill provideincentivesforministriestoincreasecommunicationatthecountrylevel,which in turn will hopefully eliminate confusing mandates or mixedmessagesthatoftenarisefromnotcommunicatingacrossministries.Neira noted that there are multiple consultative and delegative

processesoccurringatthemoment,eachwithcomplicatedmechanisms,and suggested the need to propose very pragmatic solutions to addressthe difficult processes. She highlighted the importance of involving allstakeholdersandrelevantgroupsintheprocess,butinapragmaticwaytomovetowardconsensus.Shesaidtheprocessatthecountrylevelhasbeenextremelyclearandstraightforwardandensuringthismultisectoral


approach is fundamental to the process, aswell as facilitating countrylevelinvolvementwithallthethematicconsultations.WilliamSontag,globalenvironmentalinformaticsspecialistwiththe

Office of International and Tribal Affairs at the U.S. EnvironmentalProtectionAgency, provided a few additional points. He said it seemsthat the successful MDGs around human health aspects (such ascardiopulmonarydisease, cleandrinkingwater, andchemical exposure)willlikelycontinueinthenextagenda,buttheneworsomewhatdifferenttypes ofmeasures and goals that are needed should be explored in thepost2015 context.These could include looking at population health inurbanareas,theconnectionofecosystemservicesprovisioningtohumanhealth,ortheconnectionbetweenbiodiversityandhumanhealth.Followinga point made by Aydin during her presentation, Sontag noted thatconsultation efforts should focus on the development of appropriateindicatorsunderMDG7orundertheSDGs,inordertoassessthemajorimpacts that connect the environment with human health. In addition,current work to develop earlywarning or assessment informationsystems could be helpful to this process, as well as the possibility ofutilizing crowd source citizenparticipation tohelp identify informationonpopulationandpublichealth.

HighestPriorityGoalsfor thePost2015DevelopmentAgendaorSDGs

Balbus presented the second question for the group. If one werewriting these SDGs or post2015 development goals, he asked, whichone would be placed at the top of the list, or which goal is the mostimportant?Serwadda noted that it is very difficult to pick one important goals

thatoverridestheothers,becausesomanyofthevariablesthatproducethedesiredoutcomesareinterrelated.Hesaidthatitisimportanttoworkonmultiplefrontsinordertomakeanimpact.Neiraalsonotedthatthisisanextremelydifficultquestion,butWHO

isexploringthepotentialforusinguniversalhealthcoverageasawaytoaccommodate a wide range of health concerns (such as polio, AIDS,tuberculosis,malaria,andmortalityrelatedtononcommunicablediseases(NCDs),whichisbecomingamajorissue).WHOisproposinguniversalhealthcoverageasanoverarchinggoalandawaytoutilizethebenefitofhealth policies in other sectors, including transportation, energy, urbanplanning,waterandsanitation,andmanyothers,wherehealthcanbeagoodindicatorofprogress.Aydinnotedthatshewouldliketoseeagoalonclimatechangewith

correspondingindicatorsthatwouldmakelinkagestothefourpillarsthatare emerging for the next development framework; there would be anindicatoronhowmuchtheeconomyisgreening,howmuchthesociety


is learning to be green, and how improved management of naturalresourcesispreventingconflict.AsecondhighpriorityforAydinwouldbe a goal on inequality, because research shows thatwhen a society ismore equal, many of the illnesses and problems aremoremanageable(fromhealthtoeducationtotheenvironment);however,wheninequalitygrows,anegativecycle thatfeeds intomoreproblemsandinequality isestablished.PauloBuss, formerpresidentof theOswaldoCruzFoundation (also

known as FIOCRUZ), noted his agreement with the WHO choice ofuniversalhealthcoverage,butsaiditisimportanttoensurethedefinitionis broad and goes beyond the provision of clinical health services to amore comprehensive idea of universal health systems, which wouldincorporatepublichealthmorebroadly.Sontagnotedtheneedforaverystrongconnectionbetweenwhatever

indicatorsarechosenandurbansustainability,astheurbansustainabilityagendaisextremelyimportant.

MakingIntersectoralLinkagesinthePost2015DevelopmentAgendaProcess

JudyWasserheit,vicechairoftheDepartmentofGlobalHealthattheUniversity ofWashington School of Public Health, provided the thirdquestionforthegroup,askinghowthecallforpapersandothercomponentsof thepost2015developmentagendaprocesswillbestructured inordertobuildintersectorallinkagesbetweenhealthandnonhealthsectorsfromthefoundationup.AydinsaidmanylessonshavebeenlearnedfromtheMDGsprocess

that will help to improve the next development agenda. One of thelessons learned at theUN is theneed forUNcoherence at the countrylevel to preventworking in silos. This approach is being piloted in 30countries,where thefocus isonworking togetherasoneat thecountrylevel rather than in separate agencies. She noted that this process hasbeen beneficial; even though it requires more giveandtake, thisultimatelyleadstobetterresultsforeveryoneinvolved,makingitawinwinapproach.ByapplyingthelessonsfromthisoneUNprocesstothenewdevelopmentagendaatleastatthecountrylevel,therewillbemorecoherenceand lesspossibility forasiloedapproach.Aydinemphasizedthat during the past several decades, UN teams have learned that themore theyconnectand themore theycollaborate, thebetter theresults,whichisperhapsthesimplestanswer.Neira then said she is not sure if the call for papers will force

stakeholders to work on intersectoral collaboration. She noted that ifindicators aredevelopedunder each thematic category tomeasurehowmuch intersectoral collaboration is taking place, this may create a


mechanism that will force these collaborations and prevent a siloedapproach.Balbus remindedpeople to reference theWHOwebsiteonhealth in

the green economy (http://www.who.int/hia/green_economy/en [accessedOctober 18, 2012]) to review discussion papers on indicators for othersectors that emphasize health content to better understand how theseindicatorsmayfacilitateintersectoralcollaboration.

REFERENCES

Balbus, J.M., and J.Wasserheit. 2012.Seeking synergy:Newperspectivesonaddressing interrelated global health and development problems.Commentary, Institute of Medicine, Washington, DC. http://www.iom.edu/~/media/Files/PerspectivesFiles/2012/Commentaries/EHSRTSeekingSynergy.pdf(accessedAugust20,2013).

UN(UnitedNations).2008.OfficiallistofMDGindicators.http://mdgs.un.org/unsd/mdg/host.aspx?Content=indicators/officiallist.htm (accessed August14,2013).

UN General Assembly. 2000. United Nations Millennium Declaration.A/RES/55/2.NewYork:UnitedNations.

UN System Task Team on the Post2015 UN Development Agenda. 2012a.Realizingthefuturewewant forall.Report to theSecretaryGeneral.NewYork:UnitedNations.

UN System Task Team on the Post2015 UN Development Agenda. 2012b.Review of the contributions of the MDG agenda to foster development:Lessons for the post2015 UN development agenda. Discussion note.http://www.un.org/millenniumgoals/pdf/mdg_assessment_Aug.pdf(accessedAugust20,2013).

UN, Department of Economic and Social Affairs, Population Division. 1999.Theworldatsixbillion.NewYork:UnitedNations.

UN, Department of Economic and Social Affairs, Population Division. 2009.World population prospects: The 2008 revision, highlights. New York:UnitedNations.

WHO(WorldHealthOrganization).1981.Globalstrategyforhealthforallbytheyear2000.Geneva:WorldHealthOrganization.

WHO. 2006. Preventing disease through healthy environments. Towards anestimateof theenvironmentalburdenofdisease.EditedbyA.PrssUstnandC.Corvaln.Geneva:WorldHealthOrganization.

http://www.un.org/millenniumgoals/pdf/mdg_assessment_Aug.pdfhttp:http://mdgs.un.orghttp://www.iomhttp://www.who.int/hia/green_economy/en

3

HealthGoalsandIndicatorsforSustainable Development

John M. Balbus, senior advisor for public health at the NationalInstituteofEnvironmentalHealthSciencesandcochairof the InstituteofMedicineGlobalEnvironmentalHealthandSustainableDevelopmentInnovationCollaborative,openedthesecondwebinarbyhighlightingtheoverarchinggoalofthewebinarseries,whichistoilluminatethecriticallinkagesbetweensustainabledevelopmentandenvironmentalhealth.Asa shortterm target, thewebinar series is intended to inform thecurrentUnitedNations (UN)development agendaprocess,which is setting thestage for new Sustainable Development Goals (SDGs) and post2015development goals. The webinars are designed to provide scientificinformationabouthowhealthandsustainabilityarelinkedandalsooffersomenewideasonhowtointegrateenvironmentalhealthintothetargetsandmetricsofrelevantSDGs.Duringthefirstwebinar(seeChapter2),the discussion focused on how the Millennium Development Goals(MDGs) created silos that were helpful in simplifying messaging butmade intersectoral coordination difficult at the country level. Balbusemphasized that this webinar will look at ways to achieve multidisciplinary collaboration in international processes related to the post2015developmentagendaandSDGs,focusingonaspectsthatcancreatereal synergies and benefits that can leverage financial investments andorganizationalsupportacrossdifferentsectors.

23


BRIDGINGTHEGAPBETWEENTHEMILLENNIUM DEVELOPMENTGOALSANDPRINCIPLESOFSUSTAINABLE

DEVELOPMENTANDCLIMATECHANGE

KristieL.Ebi,Ph.D.,M.P.H. IndependentConsultant,

ClimAdapt,LLC

In thinking about how to move the MDGs into alignment withsustainable development, Kristie L. Ebi explained that in addition toidentifyingspecific tasks, there isaneedto thinkbroadlyabouthowtopromote health within sustainable development. Achieving the SDGswill requiremore than an engineering approach to the world, where aproblemisrecognizedandatechnologicalsolutionidentified.Topdownapproaches to improving public health have worked effectively for awide range of issues, which is why theMDGs and other inspirationalgoalsmainlytakethiskindofapproach.However,theseapproachesareunlikely to be sufficient to address the challenges presented by globalenvironmentalchangeand theneed toachievesustainabledevelopmentgoals; working with other sectors to address current and future challengeswillbecritical.Further,itisimportanttorecognizethatonesizemay not fit all with respect to global goals and targets to further sustainabledevelopment.

WickedProblemsandManagingClimateChange

Ebi noted that wicked problems, a term used in social planning,applies to this discussion.Awicked problem is one that is difficult orimpossible tosolvebecauseof incomplete,contradictory,andchangingrequirements that are often difficult to recognize (Wikipedia, 2013). Inaddition, because of complex interdependencies, efforts to solve oneaspect of a wicked problem may reveal or create other problems(AustraliaPublicServiceCommission,2007).Ebinotedthat thosewhowork in climate change may immediately recognize how this termapplies: therearehighlevelsofuncertaintyabouthowspecificchangeswill occur in the atmosphere and what those changes will ultimatelymean at a particular location at a particular time. Because of thecomplexities, efforts to solve one part of a wicked problem can causeproblemssomewhereelse.Thiscanbeseenwithclimatechangeeffortsundertaken in one sector, such as agriculture orwater,which can thenaffecthumanhealth.Sheexplainedthatactionstoaddresshealthorotherrisks of climate change cannot be taken independently from what isbeingdoneinothersectorsbecausetheycouldaffectotherproblems.It

25HEALTHGOALSANDINDICATORSFORSUSTAINABLEDEVELOPMENT

is the responsibility of public health professionals to ensure that problemsarereducedorresolved.

MDGsandClimateChange

FocusingontheMDGs,Ebidescribedhowclimatechangeislikelytointeract with MDG 1 and why achieving Target 1Cwhich seeks tohalve,between1990and2015,theproportionofpeoplewhosufferfromhungermaybeachallenge(allMDGsarelistedinBox12inChapter1). Figure 31 is a map of the world scaled in terms of underweightchildren, rather than geographic size. China, Ethiopia, Indonesia, andNigeriahavethelargestpopulationsofunderweightchildren,andalmost50percentofthechildrenlessthan5yearsofagelivinginBangladesh,India,andNepalareunderweight (UNDP,2004).Figure32shows theprogress achieved to reach MDG 1 up to 2007. The red areas depictwherethereisnoprogressoradeteriorationofprogresssince1990.Ebi noted that many challenges have made it difficult to alleviate

extremehungerandpovertythroughouttheworld.Onecontributormaybeclimatechange.Research lookingathowclimatechangemayaffectcurrent crop production, particularly the cereal crops, shows thatobservedincreasedtemperaturechangesfrom1980to2008areassociatedwithdecreasedcropyieldsinmanyoftheplaceshavingdifficultyachievingTarget 1C (Lobell andField, 2007). Some regions have seen increasedproduction;warmertemperatureshavebeenbeneficialtowheatyieldsinAustralia, Canada, and theUnited States and tomaize yields in India.Riceyieldshavedecreased in anumberof areas throughout theworld,showing(inpart)thenegativeimpactsofincreasedambienttemperatures.Researchprojectingyieldsofcerealcropsinachangingclimateindicatesthatincreasinglocaltemperaturesinthemidtohighlatitudeswillhavebenefits in coming decades, but any increase in temperature in lowlatitudeareaswillresultinreducedyields(Easterlingetal.,2007).Thisreductionincerealgrainswilllikelyimpacttheplacesthatcurrentlyhavethe biggest problems with undernourished children and exacerbateexistingstrugglestofeedthosechildren.Projectionsofhowoftenthehighestrecordedtemperaturesfrom1985

to2005willoccurinfuturetimeperiodsindicatethatwithinthenextfewdecadesinAfrica,therecouldbea40percentincreaseintherecurrenceof these very high temperatures (Diffenbaugh and Giorgi, 2012). Thecurrent1in20yearextremetemperaturewilloccuraboutonceevery510 years within a couple of decades in many places throughout theworld.Linkingthisbacktothetemperaturesensitivityofcrops,inmanypartsofthetropics,cerealcropsarealreadygrowingattheedgeoftheirtemperaturetolerance.Effortsareunderwaytodevelopdroughtand

26

FIGURE31WorldMapperviewoftheworldscaledintermsofunderweightchildren. SOURCE:Worldmapper,2006.Copyright2006SasiGroup(UniversityofSheffield)andMarkNewman(Universityof Michigan).

FIGURE32ProgresstowardMDG1:Hungertarget.

NOTE:Thecalculationofprogresscomparescountrylevelinformationontheprevalenceofundernourishment(20052007)

withtheratesthatexistedin19901992(thebaseperiodforthehungertarget).TheprojectionforreachingMDG1in2015

assumesthetrendsbetweenbothperiodscontinue.Developedcountriesarenotconsidered.

SOURCE:FAO,2010.ReprintedwithpermissionfromtheFoodandAgricultureOrganizationoftheUnitedNations.

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saltresistant crops for these changing environmental conditions. Theresearchtodevelopnewcultivarscantakemanydecades,shesaid,oftenwith an equally long period of time needed to deploy new varieties tofarmers.Ebi stated that it is apparent that climate change is presenting a

significantchallengetoachievingthe1CTarget.TheMDGtargetsweredeveloped thinking about how to solve the problem of undernourishedchildren but not thinking broadly across all the systems, particularlythose affected by climate change. The challenges of global environmentalchangearecallingonpublichealthprofessionalstotakeamuchbroader perspective on how systems are changing,what these changesarelikelytomeanforhumanhealth,howthesekindsofchangescanbestbemanaged, andwhat options are available for improving the lives ofchildrenaroundtheworld.

InteractionsAmongNutrition,Disease,andClimateChange

Ebinotedthatthenumberofundernourishedchildrenisaffectednotonly by how many cereal grains are available. It also is important tounderstandothercausesof food insecurity.Forexample,undernutritionandmalaria interact in that undernourished children aremore likely tosuccumb to malaria, and children with malaria are more likely to beundernourished.Temperatureandprecipitationareamongtheimportantdeterminants of geographic shifts in the incidence of malaria becausetheyaffectmosquitoandparasitelifecyclesandbehaviors(ParhamandMichael,2010).Thus,shesaid,thereisastrongsystemofinterdependenciesacrossundernutrition,malaria,andclimate.Additionally, Ebi explained, there is an interdependency between

childrenwho aremalnourished, the incidence of diarrheal disease, andclimate. Children with diarrheal disease have a reduced capacity toabsorb nutrients, which means they become malnourished much moreeasily. A range of environmental factors is associated with diarrhealdisease, including acute weather events such as flooding and heavyrainfall (Cann et al., 2012). As temperatures around the world haveincreased, heavy rain events have also increased because warmer airholdsmorewater.This increases thenumberof floodingevents,whichare associated with more frequent outbreaks of waterborne diseases(including diarrheal disease), especially in lowincome countries. Asshown in Figure 33, climate change will greatly increase the risk ofdiarrheal disease based on temperature projections alone, with newregions becoming susceptible and currently susceptible regions seeingincreased diarrheal disease rates (Kolstad and Johansson, 2011). Thiswillchallengemuchoftheexcellentworkofcontrolprogramscompletedtodatethathavefocusedoninvestmentsinsanitationandaccesstosafedrinkingwater(WHOandUNICEF,2009).


FIGURE 33Projected changes in the risk of diarrheal disease with climatechange.NOTE: The values are shown with distinct colors according to the corresponding values(theempiricallyderivedincreasesintherelativeriskforeach1Ctemperatureincrease).Bluecorrespondsto =0.03,turquoiseto =0.06,yellowto =0.08,andorangeto =0.11.Ineachplot,relativeriskprojectionsareshownfor20102039(left),20402069(middle),and20702099(right).SOURCE: Kolstad and Johansson, 2011. Reprinted with permission fromEnvironmentalHealthPerspectives.

Ebi stated that the health risks of climate change arise from theinteractions of three factors: (1) how climate changewill alterweatherpatternsandwhat thismeans, for example, for ecosystems that supportmosquito populations; (2) who or what is exposed to these changingweather patterns; and (3) the underlying vulnerability of the exposedpopulations.Itoftendoesnottakeanextremeeventtocauseanextremeimpact, which was the case in Zimbabwe in 2008, where the largestcholera outbreak in Africa followed a heavy rain event (IPCC, 2012).The reason there was such a large outbreak was the very high susceptibilityandpoorpublichealthamongthepopulationinZimbabwe.

PrinciplesforSDGs

Ebi emphasized that sustainable development can be considered aseries of aspirational goals and a plan for how to achieve those goals.Usually, theplansare fairly straightforwardandappear relativelyeasy,but the reality is often quite different. Surprises certainly will occur,particularly with climate change. Thresholds are likely to be crossed,althoughthereislimitedunderstandingofwhereandwhentheywillbeencountered, such as from interactions across food,water, and energy.


Theremaybesetbacksfromfactorsthatarenottakenintoconsideration.This calls for a flexible approach, not just to set goals for sustainabledevelopment,butalso tocreateflexibilityso thenecessary information,tools,andpolicyinstrumentsareavailabletoaddresschallengesastheyarise.

JOININGHEALTHANDSUSTAINABLEDEVELOPMENT GOALSTHROUGHLOWCARBONPOLICIES

SirAndrewHaines,M.D. ProfessorofPublicHealthandPrimaryCare, LondonSchoolofHygieneandTropicalMedicine

Andrew Haines began by stating that his talk would focus on theimportance of bringing together health and sustainable developmentusing the example of strategies that both reduce greenhouse gasemissionsand improvehealth.Henoted that there isanewwindowofopportunity with the review of the MDGs and through the proposedSDGs to integrate health and broader development issues into newgloballyagreedupongoals.

HealthCobenefitsfromGreenhouseGasReductionStrategies

Lookingatthepotentialprojectionsforcarbondioxideemissionsovertime, different scenarios are projected based on the IntergovernmentalPanelonClimateChange(IPCC)reportfrom2007(seeFigure34).Thescenarios are shown in the colored lines on the graph, and the blackdottedlineshowswhatisactuallybeingobserved.Itwilllikelybeextremelydifficult, Haines said, to keepwithin the 2C thatmany climatologistsperceiveasthelimitabovewhichdangerousclimatechangeoccurs(forinstance,increasesinextremeeventsandwidescalemeltingoficecaps).He emphasized that it is important to try to reduce greenhouse gasemissionquitedramatically, and inorder to achieve this, industrializedcountries(liketheUnitedKingdomandUnitedStates)needtocuttheiremissionsbyapproximately80percentby2050.Thiskindofchallengecanbequitedifficultpolitically,especiallyconsideringthecost,buttherewill be many benefits to decreasing carbon dioxide emissions in thefuture.Haines explained that there are many cobenefits that arise from

greenhousegasreductionstrategies,inadditiontoanybenefitsthatoccurfrom reducing climate change itself. The studies he and his colleagueshavedone lookpredominatelyat foursectorshousing, transport, food

FIGURE34FossilfuelcarbondioxideemissionscomparedtotheIntergovernmentalPanelonClimateChange(IPCC)marker scenariosusedforclimateprojections. NOTES:RCP=RepresentativeConcentrationPathway.ThefourRCPtrajectoriesdisplayedinthefigurecomefromtheIPCC andrepresentapossiblerangeofradiactiveforcingvaluesintheyear2100. SOURCE:Petersetal.,2013.ReprintedwithpermissionfromGlenP.PetersandCorinneLeQur. 31


andagriculture,andelectricitygenerationinbothlowandhighincomesettings.Ineachofthose,therearestrategiesthatcanresultinsubstantialreductions in greenhouse gas emissions and can also improve humanhealth,insomecasesinarelativelyshorttimeperiod.Thestudiesconsiderdifferent strategies in the four sectors and look at both greenhouse gasemissions and human health implications of the strategy in questioncomparedwith a businessasusual strategywithout specific policies toreducegreenhousegasemissions.InthecaseoftheUnitedKingdom,theClimateChangeAct set a target for at least an80percent reductionof1990 levels of greenhouse gas emissions by 2050. The emissionreductions studied were intended to put the country on a trajectory tomeettheseemissionreductions.

HouseholdEnergySectorThefirst sectorHainesoutlinedwashouseholdenergy. Inacountry

liketheUnitedKingdom,therearemanyinefficienthousesthatallowalot of heat to escape through thewalls andwindows.A research teamconductedastudythatmodeledtheeffectsofimprovedhouseholdenergyefficiencyandventilationcontrol toachieve thedesiredgreenhousegasemissionreductions(Wilkinsonetal.,2009).Henotedthatindesigningenergyefficient housing, it is important to consider ventilation controlimprovementsinadditiontoinsulationcontroltoavoidincreasedindoorairpollutionthatmayresultfromsealingthehousestoreduceheatloss.Theresultsofthestudyshowedthatapproximately90deathspermillionin theUK population could be avoided annually from energyefficientupgrading, not including the benefits from addressing cold exposure.This would also result in saving roughly 41 million tons of carbondioxidecomparedwith2010baselinevalues(Wilkinsonetal.,2009).Haines noted that in lowincome countrieswhere the MDGs are

particularly relevant as they are currently configuredhousehold airpollutionisamajorriskfactorforacuterespiratoryinfectionsinchildrenandchronicobstructivepulmonarydisease inwomen(Wilkinsonetal.,2009).Astudyinvestigatedthehealthandclimatebenefitsof installingapproximately150millionimprovedefficiencycookstovesinIndiaovera 10year period (Wilkinson et al., 2009). Although the numbers mayseem ambitious, saidHaines, China implemented a similar program inthe1980sinwhich100millionimprovedcookstoveswereinstalledoverthe same period. These cookstoves are relatively cheap to install andmaintain, costing less than $50 per household every 5 years or so. Incomparison to traditional openfire or very inefficient cookstoves, amodern cookstove can greatly reduce household air pollution andgreenhouse gas pollutants (such as black carbon and ozone precursors,including methane and carbon monoxide) by up to 1 billion tons ofcarbondioxideequivalentover10years.Animprovedcookstoveprogramof this magnitude could avert 2 million premature deaths, mainly in


women and children, over a decade (Wilkinson et al., 2009). Hainesemphasized that this initiative directly impacts some of the MDGs,particularly those related to childmortality, and is particularly relevantfor thecountrieswheremuchof thepoorestpartof thepopulationuseseitheropenfiresorinefficientcookstoves.

UrbanTransportSectorThesecondsectorHainesoutlinedwasurbantransport.Henotedthat

thissectorisresponsibleforalargeandgrowingamountofgreenhousegas emissions inmany countries and impacts air pollution, road trafficinjuries,and,veryimportantly,sedentarylifestyles.Obesityanddiabetesratesaregoingupinmanypartsoftheworld,conditionsthatarepartlyrelatedtosedentarylifestyles.Hainesnotedthatoneofthemostimportantwaysof increasingpeoplesphysical activity is changing theirhabitualactivities of daily living, particularly walking (or cycling) to school,work,shops,andsoon.This typeofactivity is increasinglydifficult inmany urban environments.Hainesmentioned a study thatmodeled theeffect of different travel scenariosinvestigating the differences inincreased active travel (cycling and walking for short distances), lowcarbondriving(moreefficientcars),andbusinessasusualpolicies(withoutspecific policies to reduce greenhouse gas emissions)in the cities ofLondon andDelhi (Woodcock et al., 2009). This study looked at howintroducingthesenewstrategiescouldreducegreenhousegasemissionsand also impact human health. Active travel had the largest effect onhealth because sedentarism is such an important risk factor for sevenmajorconditions(ischaemicheartdisease,cerebrovasculardisease,dementia,breastcancer,diabetes,depression,andbowelcancer).Accordingtothescenario developed in the study, heart disease, stroke, dementia, andbreastcancercouldbereducedbyupto19percent,18percent,8percent,and13percent,respectively,inLondon(Woodcocketal.,2009).Hainesnotedthattheremaybeincreaseddeathsandinjuriesduetoroadtrafficcrashes as more people cycle and walk (a 19 to 39 percent increase),even if road vehicle use is reduced; however, this drawback is vastlyoutweighedbyallthebenefitsthatwouldoccur(Woodcocketal.,2009).Haines discussed another study that assessed the possibility of

avertinghealthservicesexpendituresasaresultof thesesametransportstrategies(Jarrettetal.,2012).NationalHealthServiceexpendituresthatcould be averted by the increased active travel scenario in the UnitedKingdomwerebrokendownbyyearandbyhealthoutcome.Overa20yearperiod,thesavingscouldtotalUK17billion(in2010prices)withadditional savings accumulating after this period. Reducing theprevalence of diabetes had the largest impact because diabetes is socostlytothewholesystem(Jarrettetal.,2012).Hainesnotedthatpeopleoften live with diabetes for many years and that over that time theyaccrue extensive costs to the health system (perhaps higher than the


studyprojections,whichdonotincludetheeffectsofreducingobesitytoavoiddoublecounting).Bypreventingsomecasesofdiabetes,inadditiontothepotentiallylargesavingsforthehealthsystem,therewillbepotentialimprovementsinlaborproductivityandothersocialbenefits.

FoodandAgricultureSectorThe third sectorHaines outlinedwas food and agriculture. He noted

thatonagloballevelthefoodsupplysystemissomewhatdysfunctionalroughly1billionpeoplearesufferingfromhungerandatthesametimeobesityisgrowingaroundtheworld.Approximately40percentofallthegrainharvestedintheworldisfedtoanimals(Smil,2000),andlivestockaremajorcontributorstogreenhousegasemissions(particularlythroughmethane from ruminants).Haines summarized results from amodelingstudy that investigated the health impact of reducing animalsourcesaturated fat by30percent and replacing itwithpolyunsaturated fat ofplant origin. In a country similar to the United Kingdom and a citysimilartoSoPaulo,Brazil,

The authors of the study chose theUnitedKingdom and So Paulo,Brazil,because both populations consume similar amounts of saturated fat; however,the United Kingdom is a highincome country and emits large quantities ofgreenhouse gases, whereas Brazil is an emerging economy with increasinggreenhouse gas emissions. So Paulo is the largest city in Brazil, with apopulationofapproximately10.4millionin2010(Frieletal.,2009).

1theburdenofischemicheartdiseasecouldbereducedbyapproximately15percent(thisisequivalentto2,850and2,180disabilityadjustedlifeyears[DALYs]permillionpopulationin1year in theUnitedKingdom and So Paulo, respectively) (Friel et al.,2009).Hainesnotedthatalthoughitisimportanttoimprovetheefficiencyof energy use in the agriculture and food sector, this alonewill not besufficient to achieve the kind of targets needed to adequately reducegreenhouse gas emissions in order to stabilize the climate. In highconsumptioncountriesliketheUnitedStatesandtheUnitedKingdom,itisdifficulttoavoidtheconclusionthatreducinganimalproductconsumptionisneededandwillprovideadditionalhealthbenefitsfromincreasingfruitandvegetableconsumption,asoutlinedinthestudyfromFrielandcolleagues.

ElectricityGenerationSectorThe fourth sector Haines outlined was electricity generation. He

summarized a study that examined the health burden associated withequivalentcarbondioxideemissionsfromdifferentsourcesofelectricitygeneration(MarkandyaandWilkinson,2007).Theresultsindicatedthatlignite,coal,and,toasomewhatlesserextent,oilproducealargeamountofgreenhousegasemissionsandalsoproducelargehealthimpactsfromairpollutionandaccidents(seeFigure35).Nuclearenergyproducedthe

1


lowesthealthimpactsaccordingtothisanalysis,butiscontroversialforreasonssuchaswasteandpotentialaccidents.Hainesstatedthatrenewableenergysources(forexample,solarorwind)arenotshowninthefigure,buttheywouldclearlybeatthebottomleftcorner,belowgasandcloseto nuclear, becausemany renewable technologies do not produce fineparticulateairpollution,whichisthemajorriskfactorfromthecombustionof coal and lignite. Haines highlighted that there is a range of newtechnologiescomingtothemarket(includingrenewabletechnologiesforclean energy) that offer great promise for reducing not only carbondioxide emissions, but also fineparticulate air pollution and thus thehealthburdenfromoutdoorairpollution.Forexample,onenewtechnologyinvolves placing solarconcentrating power panels on a vertical towercontainingmoltensodium,whichthendrivesturbinestogenerateelectricity.Haines suggested that the whole electricity supply of North AmericaandEuropecouldbesuppliedbysolarconcentratingpowerestablishedintheNorthAmericandesert,ifappropriateinvestmentsweremade.

FIGURE35 Electricity generation and air pollution impacts from equivalent carbondioxide(CO2)emissions. NOTE:(a)deathsfromairpollutionandaccidentsand(b)casesofserious illnessfromairpollution. SOURCE: Markandya and Wilkinson, 2007. Reprinted from The Lancet, Copyright2007,withpermissionfromElsevier.


ClosingRemarks

Hainesconcludedbysayingthatthereisarangeofpoliciesinatleastthese four sectors, and possibly in others, that can both help addresspublichealthprioritiesandpromotesustainabledevelopment,particularlybymitigatingclimatechange.Consideringthe impactsof thesepoliciesonbothenvironmentalgoalsandhealthgoalssimultaneouslywillmakethemmuchmore attractive topolicymakers than focusingoneither inisolation.Hainesstatedthathispresentationhadoutlinedthepotentialforsomemetricsandgoals,whichwouldbethetopicofthenextpresentation.For example, both sustainable development and public health targetscould focus on household air pollution, active travel, and lowcarbongenerationofelectricity.Hainesemphasizedthatthehealthgainsassociatedwiththesemitigationpoliciesareinadditiontothebenefitsfromreducingclimatechange,andthesehealthgainscanlikelyhelpaverthealthservicecostsandalsooffsetthecostofimplementinglowcarbonpolicies.

METRICSFORHEALTH,DEVELOPMENT,ANDTHE ENVIRONMENT

ChristopherJ.L.Murray,M.D.,D.Phil. Director,InstituteforHealthMetricsandEvaluation

UniversityofWashington

ChristopherJ.L.MurraynotedthathewouldpresentcurrentevidencefromtheGlobalBurdenofDiseaseStudy20102tosupportsomeofthelinkages between health and the environment highlighted by previousspeakers.Thenhewouldprovideabriefoutlineofdesirableattributesforproposedmetricsforthepost2015developmentagenda.

TheGlobalBurden ofDisease Study 2010was published as seven separatearticlesinTheLancetinDecember2012.Furtherinformationonthestudyandlinks to the articles can be found at http://www.thelancet.com/themed/globalburdenofdisease(accessedAugust20,2013).

GlobalBurdenofDiseaseStudy2010

TheGlobalBurdenofDiseaseStudy2010 is the latest versionof a20yeareffort tosystematize theevidenceon thestateofhealtharoundtheworld by disease, injury, and risk factor. In the current study, 291diseasesandinjuriesand67riskfactorsareevaluatedatthecountrylevelovertime.Murraynotedthatlookingatchangeinhealthovertimewilllikely be essentialwhen thinking about someof the issues thatwill be

2

http://www.thelancet.com/themed/global


important as the post2015 development agenda is established (furtherdetailonthisprocessisprovidedinChapter2).In looking at the health changes from 1990 through 2010, Murray

said, three largedrivershavebeen identified and studied indetail.Thefirst is a demographic transition, namely, larger population size and anolderpopulation,whichcanhaveprofoundeffectsontheleadinghealthproblems.Thesecondisacauseofdeathtransition,wherethereisamarkedshiftawayfromtheburdenassociatedwithcommunicablediseases(suchas diarrhea and pneumonia) to the burden from noncommunicablediseases(NCDs)(suchascardiovasculardiseaseanddiabetes).Thethirdis a disability transition,where there is a progressive shift to disablingconditions that do not necessarily cause death, but cause a substantialfractionoftheburdenofdisease(suchasmentalhealth,substanceabuse,andmusculoskeletaldisorders).Theimpactofthesetransitionscanbeseeninchangesinpopulation

measures over this 20year period.Murray explained that measures ofDALYsa measure of healthy years of life lost that captures bothprematuremortalityandillnesshaveshiftedawayfromburdeninchildren(althoughmanychildrenare still affected) towardburden inyoungandmiddleagedadults.Henotedthatthisshiftismovingatasteadypace,sodecadebydecadetheburdenwilllikelyprogressivelyshiftfromchildrento adults. In addition, the disability transition has impacted thedistributionoftheburdenofdiseasebetweenyearsoflifelostandyearslosttodisability.Whenlookingat21regionsaroundtheworld,yearslosttodisability in1990accounted for roughly10percentof theburdenofdiseaseintheleastdevelopedregionsandalmost40percentinthemostdevelopedregions(Murrayetal.,2012).In2010,yearslosttodisabilitysubstantiallyincreasedincomparisontoyearsof lifelost inallregions,and generally increased with the demographic and epidemiologicaltransitionwith the most profound shifts occurring in transitionalregions (e.g., East Asia, tropical Latin America, theMiddle East, andNorthAfrica).Theyears lost to disability in regionswith an advanceddemographic and epidemiologic transition accounted for approximately50percentoftheburdenofdisease(includingWesternEuropeandhighincome areas of theAsian Pacific andNorthAmerica) (Murray et al.,2012).Murray explained that shifts in the burden of disease have changed

therankingoftheleadinghealthproblemsfrom1990to2010(Murrayetal.,2012).InFigure36,theredboxesindicatecommunicable,maternal,neonatal, and nutritional disorders, which have become less prevalentbetween1990and2010.Forexample,overthetwodecades,diarrheahasdecreasedbyabout50percentintermsoftheburdenofdisease,despiteincreases in population over this time frame. The blue boxes indicateNCDs,whichhaveincreasedbetween1990and2100.

FIGURE36Rankswith95percentuncertaintyintervalsforthetop25causesofglobaldisabilityadjustedlifeyearsin1990 and2010,andthepercentchangewith95percentuncertaintyintervalsbetween1990and2010. SOURCE:Murrayetal.,2012.ReprintedfromTheLancet,Copyright2012,withpermissionfromElsevier.

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TheleadingcauseofglobalDALYsisnowischemicheartdisease(upbyabout29percent), and,movingdown the list, there isaprogressivetransition from communicable diseases to NCDs over the past twodecades.However,HIVisupfrommuchlowerlevelsin1990andmalariahasremainedrelativelyconstantfrom1990to2010.Thegreenboxesinthefigureindicateinjury.Murrayhighlightedthatroadinjurieshaveseenabouta34percent increase in theburdenofdiseaseover thisperiodoftime,andthismaybeimportantfortransportagendas.Whenlookingattheglobalburdenofdiseaseattributabletodifferent

risk factors, high blood pressure is at the top of the list in terms ofcontributingtothepercentofDALYs,followedbytobaccosmokingandalcoholuse(Limetal.,2012).Murraynotedthathouseholdairpollutionfromburningsolid fuels isnumber4on the list,which isan importantfinding for thinking about connections to the environment. Ambientparticulate matter pollutio

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