Non-communicable diseases

Cardiovascular and renal health effects of managed aquifer recharge to lower drinking water salinity in southwest coastal Bangladesh: a stepped-wedged cluster-randomized trial

Authors: Abu Mohd Naser1Solaiman Doza2Mahbubur Rahman2, Leanne Unicomb2Ruhel Gazi2Raisul A Robin2, Rabiul Karim2Kazi M. Ahmed3William Burgess4Mohammad Shamsudduha4Howard Chang5Thomas F. Clasen1Matthew O. Gribble 1Stephen P. Luby6
Author Affiliations: 1Department of Environmental Health Sciences Rollins School of Public Health, Emory University; 2International Centre for Diarrhoeal Disease Research, Dhaka; 3Department of Geology, University of Dhaka4Department of Earth Sciences, University College London; 5Department of Biostatistics, Rollins School of Public Health, Emory University; 6Woods Institute for the Environment, Stanford University

Background: Drinking brackish water has been associated with high blood pressure among communities in southwest coastal Bangladesh. The objective of this study was to evaluate the impacts of managed aquifer recharge (MAR), a hydro-logical intervention to lower drinking water salinity by pumping rainwater and pond water to dilute brackish aquifers, on blood pressure and urine protein in southwest coastal Bangladesh.

Methods: We conducted a stepped-wedge cluster randomized trial (NCT02746003) with 5 monthly visits among 1,191 participants from 542 households in 16 communities. At each visit subsequent to baseline, 4 additional communities were randomized to receive MAR water access. We measured salinity of the households’ drinking and cooking water and measured participants blood pressure, weight and 24-hour urinary total protein, sodium, potassium, calcium, magnesium and creatinine all visits. Participants’ socio-demographic data, height and confounder information was collected during the baseline visit. We used multilevel regression models to estimate effects of MAR water on participants’ systolic blood pressure and urine protein using participant-, households- and community-level random intercepts and reported cluster robust standard error. We performed intention-to-treat and per-protocol analyses.

Findings: Participants randomized to have access to MAR water had 1.89 (95% CI: 0.51, 3.27; p=0.007) mmHg higher mean systolic blood pressure, and 1.39 (95% CI: 0.23, 2.55; p=0.018) mmHg higher mean diastolic blood pressure than communities with no access to MAR when adjusted for age, sex, body mass index, physical activity, religion, smoking and socio-economic status. The ratio of median 24-hour urine protein among participants with and without access to MAR water was 1.10 (95% CI: 0.96, 1.25; p= 0.159) in the fully adjusted model. When access to MAR water was provided, 40% of households in 2nd , 21% in 3rd, 20% in 4th and 40% in last visit reported that they did not consume MAR water for drinking and cooking. Households reported exclusive use of pond water for drinking (51 — 79%) and cooking (89 — 95%) prior to MAR access. Per-protocol analyses estimated that participants consuming MAR water for both drinking and cooking purposes had 1.13 (95% CI: -0.43, 2.70; p=0.157) mmHg higher systolic blood pressure.

Interpretation: Our findings show no evidence that MAR systems reduced blood pressure and urine protein of the population. Although the intention-to-treat analyses suggest MAR interventions increase population blood pressure, poor adherence to the MAR intervention due to availability of pond water limits the intention-to-treat findings.

Analysis of Airborne Particulate Matter Values Between Air Quality Monitoring Sites in Imperial County, California, as an Indication of Geographic Influences on Lung Health During Drought Periods

Authors: Aubrey Doede1Robert Davis2
Author Affiliations: 1University of Virginia School of Nursing; 2Environmental Science, University of Virginia

Background: 2012-2016 marked California’s worst drought in over a century. Droughts are expected to recur in broader areas as a result of anthropogenic climate change. The Salton Sea, a landlocked depression without natural river inflow, is almost entirely dependent on agricultural irrigation of Imperial Valley’s 475,000 acres of farmland, though its water level has been diminishing due to decreased precipitation and river flow. Exposure of the lakebed and ground heating in an already-arid climate may cause an increase in airborne particulate matter (PM), reactive nitrogen, and ground-level ozone, exacerbating asthma symptoms. While Imperial County’s asthma-related pediatric emergency department admissions were among the highest in California and double of the entire state during the most severe drought years, past analyses have not taken into account environmental mediators with specific geographic granularity. Methods: Data from the United States Drought Monitor and the five air quality monitoring stations (AQMS) within Imperial County were used in the analysis between the years 2006-2016. Windowing was used to match closest weekly drought reports to the closest six-day PM collection periods. Upon visually examining the data, lower values appeared to drive the correlation between AQMSs. Therefore, in two time series – all years and non-drought years only – all values for PM10<75ppm were removed, and remaining values were used to measure correlations between AQMSs. Findings: Coarse (PM10) levels across all years were poorly correlated (adjusted r2=0.12-0.66, p<0.05). When removing drought years (2012 onward), these values were slightly more correlated than those obtained from all observed years (adjusted r2=0.31-0.57, p<0.05). When removing PM10 values under 75ppm, the correlation coefficients for these values deteriorate when examining only the outlying values (adjusted r2=-0.026-0.30, p<0.05). Interpretation: The lack of consistency between AQMSs during high PM10 days and during drought years suggests that AQMSs do not experience the same change in air quality, especially on days most likely to cause asthma exacerbations. This lends evidence to a geographic component of air quality differences and the potential for children near rural farmland to be more susceptible to asthma and lung disease. Future research regarding respiratory health in drought areas will provide a perspective on underrepresented local and regional environmental challenges. Drought is one of the most expensive natural events from a number of economic and public health vantage points, and findings in support of the health implications of agriculture and water use have broader potential implications for water policy, drought mitigation strategies, and health improvement.

Future Wildfires and Air Pollution-Related Health Damages

Authors: Henry Roman1Meredith Amend1, Maria val Martin2Susan Anenberg3
Author Affiliations: 1Industrial Economics, Inc.; 2Department of Chemical and Biological Engineering, University of Sheffield; 3Milken Institute School of Public Health, George Washington University,

Climate change is expected to increase wildfire frequency and intensity around the globe. Examples of these impacts can already be observed in the recent historical record, and as the effects of climate change continue to intensify over the coming century, several studies predict a continuation of this trend. A recent modeling study demonstrated that global area burned may increase by approximately 8% by 2050 and 30% by 2100. This increase has the potential to nullify anticipated declines in anthropogenic sources of fine particulate matter (PM2.5), as wildfires become more dominant sources of PM2.5 around the globe. We use these model simulations of wildfire area burned from the present day to 2100 to generate the first quantitative estimates of the magnitude and economic value of air pollution-related health impacts worldwide associated with future fire activity.

We analyze projected PM2.5 for two alternative scenarios considering both climatic and socio-economic drivers of fire activity, where climatic changes are characterized by representative concentration pathways (RCPs) and socio-economic drivers by shared socio-economic pathways (SSPs). We apply the U.S. Environmental Protection Agency’s Environmental Benefits Mapping and Analysis Program – Community Edition (BenMAP-CE) and the 2015 Integrated Exposure Response (IER) Function from the Global Burden of Disease study to quantify the global health impacts associated with fire-related emissions for the present day and future under the two scenarios at a resolution of 0.1 degree x 0.1 degree worldwide. Results presented include the health burden from wildfire PM2.5 globally, by world region, and by country, for the present day, 2050 and 2090 under two scenarios of climate change and socioeconomic development.

Air Quality, Airborne Diseases and Sustainability: Interpreting Human Health taking Case Study of Kolkata, India

Authors: Md Senaul Haque1, Ram Babu Singh1,2
Authors Affiliations: 1Department of Geography, Delhi School of Economics, University of Delhi; 2International Geographical Union (IGU)

Background:
The current phase of urbanization which on the other hand could do better to be termed as “Asian Phase of Urbanization” are mainly concentrated to the megacities which resulted the existing city to grow larger and thus come the concern of human health while living in a megacity. The emerging researches at megacities in developing countries have found to be focused on air pollution risk where exposure has been termed as an inevitable phenomenon. The current paper thus drew to interpret the level of pollutants present in the ambient air and resultant health outcome in the form of respiratory diseases that people encounters while exposed to the pollutants at varied micro environment. The criteria pollutants evaluated are Suspended Particulate Matter (SPM), Respirable Particulate Matter (RPM), Sulphur dioxide (SO2), Oxides of Nitrogen (NOx).

Methods:
The West Bengal Pollution Control Board (WBPCB), under the guidance of National Air Monitoring Programme (NAMP), monitored air quality in the district of Kolkata at 17 stations. The monitoring of pollutants in these stations was carried out for 24 hours with a frequency of twice a week to have 104 observations in a year. Air quality assessment has drawn with applying the method termed Exceedance Factor (EF) where the presence of listed pollutant’s (RPM, SPM, NO2 and SO2) annual average concentration get classified into four different categories namely critical, high, moderate and low pollution. A health assessment had followed with structured questionnaire at nearby dispensaries which fall under areas with varied air pollution level. Three dispensaries have been surveyed with 100 respondents.

Findings and Interpretation:
Out of total 17 ambient air quality monitoring stations, 5 fallen under critical and remaining 12 locations under high category of NO2 concentration while for RPM, 4 recorded critical and 13 under high pollution category. The causes for much concentration of NO2 and RPM have been identified as vehicular emission (51.4 %) followed by industrial sources (24.5 %) and dust particles (21.1 %). It shown that respondents with respiratory diseases (85.1 %) has outnumbered water borne diseases (14.9 %) across the three surveyed dispensaries and include ARI (60 %), COPD (7.8 %), UTRI (1.2 %), Influenza (12.7 %) and AFB (3.4 %). Although the pollution level had recorded critical, only 39.3 % of the respondents have felt that outdoor (air) pollution has affected their health. People’s awareness need to be enhanced besides addressing some sustainable measures to curb the pollution.

Animal to plant-sourced food shifts as a key climate change mitigation strategy

Author: Helen Harwatt1
Author Affiliation: 1Planet Friendly Food

Background: Current commitments to the Paris Agreement are consistent with up to a 3.7°C rise this century. If current commitments to the Paris Agreement are implemented, by 2030 the emissions budget for 1.5°C will be depleted and the budget consistent with staying below 2°C will be almost exceeded. For the Paris Agreement to remain achievable, strong and rapid pre-2020 and pre-2030 mitigation is urgently required, in addition to enhanced longer term commitments. Given the expected growth of methane (CH4) emissions over this time frame, and its intense warming potential, it is imperative to consider CH4 reductions in addition to other major greenhouse gases (GHGs). The main source of global CH4 emissions, the livestock sector, has so far laid relatively low in climate discourse, with CO2 emissions from the fossil fuel sector receiving most attention regarding mitigation requirements and measures. This research demonstrates the necessity of also adopting near term mitigation options in the livestock sector, via animal to plant-sourced food shifts, to deliver the best chance of meeting the Paris Agreement.

Methods: A review of the literature regarding climate change mitigation targets, the role of CH4 in reducing the risk of temperature tipping points, and the contribution of animal agriculture was conducted. Estimates of the types and scale of benefits delivered by a range of animal to plant-sourced food shifts were derived. A potential implementation pathway for animal to plant-sourced food shifts was identified.

Findings: Animal to plant-sourced food shifts can make a key contribution to achieving the Paris Agreement, and deliver important co-benefits related to environmental sustainability, food security, public health and biodiversity. Inaction on implementing animal to plant-sourced food shifts could result in almost half of the GHG budget for 2030 being taken for animal agriculture, not counting growth related to demand shifts in developing economies. There are options that can be implemented over a relatively short time frame and deliver substantial GHG reductions and co-benefits, while shaping the way for further animal to plant-sourced food shifts. While the implementation pathway was set out at the sectoral, global level, the principles can also be applied at the level of individual country, state, business, or consumer.

Interpretation: Animal to plant-sourced food shifts can play a key role in climate change mitigation and simultaneously contribute to other planetary health goals. There are identifiable pathways that deliver substantial benefits in the near term, applicable to policy makers, business and publics.

Modelling and mapping the spatial distribution of urban road traffic emission, health risks and social economic status in Ho Chi Minh City, Vietnam

Authors: Thi Phuong Linh Le1, Abraham Leung2
Author Affiliations: 1Vietnam Aviation Academy; 2Griffith University

Background:
PM2.5 pollutants emitted from road vehicles is a significant cause of mortality developing cities. PM2.5 levels in Ho Chi Minh City (HCMC), Vietnam are dangerously high. Annual mean PM2.5 levels ranged from 172,30 to 560,88 μg/m3, significantly exceeding acceptable levels of 300 μg/m3 (daily 1 h max). Many studies have considered the health impacts of air pollution. There is, however, scant attention on assessing the socio-spatial equity and health burden of traffic air pollution. Previous studies indicate that proximity to higher levels of traffic is associated with the increased mortality risk. In addition, populations with lower socioeconomic status (SES) are more likely to be exposed to higher air pollution levels than groups of higher SES. This study investigates whether the public health burden is associated with urban road traffic emission in HCMC and whether reducing air pollution will lead to the reduction in the number of hospital admissions, premature deaths and number of years of life lost (YLL). The associations between air pollution and SES in HCMC was also explored.

Methods:
The damage function approach, offered by the Benefits Mapping and Analysis Program (BenMAP) software tool, is used to estimate mortality risk and economic health burden of PM2.5 concentrations on population. The results of 19 districts and 5 suburban districts in HCMC are analysed and mapped. Sensitivity analysis is also applied to estimate air pollution reduction effects under different scenarios.

Findings:
In HCMC, PM2.5 from the emission of on-road vehicles is estimated to contribute up to 780 (95% CI: 340-1180) hospitalisations, 320 premature deaths (90% CI: 240-570), and 4600 YLL (90% CI: 3600-7600). Motorcycle, truck and bus are the main sources of PM2.5 emission, associated with 210 (95 % CI: 160-320) deaths each year. Groups with lower SES are at higher risk for adverse health outcomes than low poverty neighbourhoods. Sensitivity analysis shows that reducing PM2.5 exposure by 5%, 10%, and 15% would result in fewer premature deaths, fewer hospital admissions and a high gain of life-years.

Interpretation:
This study offers a rapid and efficient estimate of traffic air pollution risk. Further analysis can be performed in cities with similar settings. The findings suggest that reducing motor vehicle emissions, especially from motorcycle, truck and bus could produce substantial health benefits. This calls for better land use and transport planning. Mode shifts from motor vehicles to public/active transport is urgently needed for urban areas in developing countries.

Analysis of Airborne Particulate Matter Values Between Air Quality Monitoring Sites in Imperial County, California, as an Indication of Geographic Influences on Lung Health During Drought Periods

Authors: Aubrey Doede1, Robert Davis2
Author Affiliations: 1University of Virginia School of Nursing; 2Environmental Science, University of Virginia

Background: 2012-2016 marked California’s worst drought in over a century. Droughts are expected to recur in broader areas as a result of anthropogenic climate change. The Salton Sea, a landlocked depression without natural river inflow, is almost entirely dependent on agricultural irrigation of Imperial Valley’s 475,000 acres of farmland, though its water level has been diminishing due to decreased precipitation and river flow. Exposure of the lakebed and ground heating in an already-arid climate may cause an increase in airborne particulate matter (PM), reactive nitrogen, and ground-level ozone, exacerbating asthma symptoms. While Imperial County’s asthma-related pediatric emergency department admissions were among the highest in California and double of the entire state during the most severe drought years, past analyses have not taken into account environmental mediators with specific geographic granularity.

Methods: Data from the United States Drought Monitor and the five air quality monitoring stations (AQMS) within Imperial County were used in the analysis between the years 2006-2016. Windowing was used to match closest weekly drought reports to the closest six-day PM collection periods. Upon visually examining the data, lower values appeared to drive the correlation between AQMSs. Therefore, in two time series – all years and non-drought years only – all values for PM10<75ppm were removed, and remaining values were used to measure correlations between AQMSs.

Findings: Coarse (PM10) levels across all years were poorly correlated (adjusted r2=0.12-0.66, p<0.05). When removing drought years (2012 onward), these values were slightly more correlated than those obtained from all observed years (adjusted r2=0.31-0.57, p<0.05). When removing PM10 values under 75ppm, the correlation coefficients for these values deteriorate when examining only the outlying values (adjusted r2=-0.026-0.30, p<0.05).

Interpretation: The lack of consistency between AQMSs during high PM10 days and during drought years suggests that AQMSs do not experience the same change in air quality, especially on days most likely to cause asthma exacerbations. This lends evidence to a geographic component of air quality differences and the potential for children near rural farmland to be more susceptible to asthma and lung disease. Future research regarding respiratory health in drought areas will provide a perspective on underrepresented local and regional environmental challenges. Drought is one of the most expensive natural events from a number of economic and public health vantage points, and findings in support of the health implications of agriculture and water use have broader potential implications for water policy, drought mitigation strategies, and health improvement.

Quantifying the health effects of climate change upon pollen allergy

Authors: Iain Lake1Felipe Colon1, Natalia Jones1
Author Affiliations: 1School of Environmental Sciences, UEA

Background: Globally, pollen allergy is a major public health problem, but a fundamental unknown is the likely impact of climate change. To our knowledge, this is the first study to quantify the consequences of climate change upon pollen allergy in humans. The study focussed upon the annual herbaceous plant common ragweed (Ambrosia artemisiifolia) in Europe. Ragweed is highly invasive; it thrives on disturbed land, with each plant producing ≤ 62,000 seeds per year. Ragweed is particularly harmful for public health because each plant produces a large amount of pollen (≤ 1 billion grains a year).

Method: A process-based model estimated the change in ragweed’s range under climate change. A second model simulated current and future ragweed pollen levels. These findings were translated into 2 different measures of health burdens. Changes in pollen sensitisation rates were estimated using a dose–response curve generated from a systematic review and from current and future population data. Changes in allergy symptoms were modelled by first obtaining dose-response relationships between pollen and symptoms from a cohort of sensitised individuals. These relationships were applied to future pollen loads. Future pollen models considered two different suites of regional climate/pollen models, two greenhouse gas emissions scenarios [RCPs 4.5 and 8.5], and three different plant invasion scenarios. A second set of health impacts were obtained.

Findings and interpretation: Sensitization to ragweed will more than double in Europe, from 33 to 77 million people, by 2041–2060. According to our projections, sensitization will increase in countries with an existing ragweed problem (e.g., Hungary, the Balkans), but the greatest proportional increases will occur where sensitization is uncommon (e.g., Germany, Poland, France). Higher pollen concentrations and a longer pollen season may also increase the severity of symptoms. Our quantitative estimates indicate that ragweed pollen allergy will become a common health problem across Europe, expanding into areas where it is currently uncommon. Control of ragweed spread may be an important adaptation strategy in response to climate change.

Planetary health in action: A community-based approach integrating conservation, livelihoods, and healthcare in Indonesian Borneo

Authors: Jonathan Jennings1, Kinari Webb1
Author Affiliations: 1Health In Harmony

Program Background, Context and Aim:
Gunung Palung National Park (GPNP), a 90,000-hectare protected area in Indonesian Borneo, is home to spectacular biodiversity and covers a vital watershed that supports more than 60,000 people from 23 villages. More than 70% of lowland forests within the park’s buffer zone were deforested between 1988-2002 (Curran et al, 2004); forest cover inside GPNP decreased by 18.7% from 1992 to 2004, accelerated by illegal logging after decentralization in 1999 (Zamzani et al, 2009).

Health In Harmony’s (HIH) pilot program, Alam Sehat Lestari (ASRI), offers a disruptive model that combines access to affordable, high quality healthcare, opportunities for alternative livelihoods, and conservation programs to restore GPNP. In 2007, HIH and ASRI initiated a process of radical listening to identify drivers of deforestation and help the communities design and execute solutions. After more than 400 hours of community meetings, villages unanimously agreed they could stop logging if they had access to high-quality, affordable healthcare and training in alternative livelihoods. Today, ASRI’s integrated programs: monitor logging activity through community meetings and satellite imagery; provide healthcare in ASRI’s hospital, which offers non-cash payment options and discounts to villages that stop logging; make alternative livelihood opportunities available; and reforest the park to restore critical habitat.

Methods:
A 2007 baseline, followed by a 2012 and 2017 quantitative survey were conducted in 25 villages surrounding GPNP to understand the health and conservation changes in these communities. Pairs of trained nurses systematically interviewed 1,300 households in the region.

Findings:
The baseline survey found the communities bordering GPNP were extremely poor, with an average income of $13USD per month. Healthcare services were unavailable or of extremely low quality, and the nearest hospital was 2-12 hours away. Poverty and a lack of access to affordable healthcare left people with few choices of livelihoods, and many turned to logging. Follow-up quantitative surveys described a positive change: an estimated 1,350 logging households (HH) in 2007 declined to 450 HH in 2012, and to 150 HH in 2017 (an 89% decline from baseline). GIS data revealed a stabilization in primary forest loss and an increase in secondary forest growth. Additionally, the 2012 survey found 52% of previous loggers were farming. Health indicators also improved: from 2007 to 2012, infant mortality declined from 3.4 to 1.2 deaths per 100 households. To date, ASRI has treated nearly 30,000 patients and maintained a patient dropout rate of <1% for tuberculosis treatment.

Interpretation:
Programming improved the health of the people and forest in the GPNP region. This integrated approach to conservation, healthcare, and livelihoods protects ecosystems while empowering individuals to improve community well-being.

Monitoring toxic cyanobacteria blooms in the Lower Columbia River Basin

Authors: Joseph Needoba1Stuart W. Dyer2Tawnya D. Peterson1
Author Affiliations: 1OHSU-PSU School of Public Health, Oregon Health & Science University; 2School of Medicine, Oregon Health & Science University

Background
At the planetary scale the occurrence and severity of cyanobacteria blooms appear to be increasing, likely due to warming temperatures and changes in nutrient availability in freshwater habitats. These harmful algae blooms represent a public health threat when people are exposed to cyanotoxins through contact with contaminated water or from eating contaminated food. Consistent with this trend, we have documented recurring seasonal blooms of freshwater cyanobacteria throughout the Lower Columbia River Basin, USA. We have also monitored for the presence of the compound beta-Methylamino-L-alanine (BMAA). BMAA is a non-proteinogenic amino acid produced by cyanobacteria and has been linked to human neurological diseases resembling Amyotrophic Lateral Sclerosis. To date BMAA is not monitored by regional government agencies and thus represents an unknown threat to public health in the states of Oregon and Washington.

Methods
Field sites were visited monthly between April and September over three consecutive years to collect samples and to deploy and service in situ sensors to observe variability in water quality over time. Cyanobacteria blooms were identified by microscopy and by the presence of the algal pigment phycocyanin via in situ sensors. BMAA measurements were made using existing protocols to allow for low level detection via Liquid Chromatography coupled to tandem Mass Spectrometry.

Findings
Between 2014-2017 we have consistently documented blooms of several cyanobacteria species throughout a greater than 220 km stretch of the lower Columbia River and its tributaries. The blooms are typically found in the intertidal habitats and sloughs, however seasonal blooms of Microcystis spp. have occurred every year in the main channel of the Willamette River tributary that have triggered public health warnings by the Oregon Health Authority. Measurements of BMAA throughout the region indicate that when cyanobacteria are present BMAA can be detected at concentrations ranging from 0.05 – 1.2 ng/mg-cells.

Interpretation
Cyanobacteria blooms in the Columbia River Basin represent a little understood threat to public health, however, their emergence in recent years is cause for concern. We detected BMAA in conjunction with blooms of Microcystis spp. and other cyanobacteria, suggesting that human exposure to this compound is possible. BMAA is not currently monitored by regulatory agencies and thus uncertainty exists related to its distribution and association with cyanobacteria blooms. Our results indicate that BMAA is widespread in the Lower Columbia Basin and future research efforts should include BMAA analysis to better understand its potential threat to human health.

One Health, gender and biodiversity conservation

Authors: Julie Garnier1, Richard A. Kock2
Author Affiliations: 1Odyssey Conservation Trust; 2The Royal Veterinary College

Conserving the most threatened ecosystems and biodiversity is vital to human health and wellbeing and to planetary health but is proving increasingly challenging. Natural ecosystems continue to lose resilience and function under increasing pressures driven by human demographics, unsustainable food production patterns and global overconsumption trends. Increased awareness and efforts to mitigate against such trends now occur as the overuse of our finite planet’s resources translates into new health challenges associated with climate change and the emergence of novel diseases. Addressing these new challenges with the novel One Health approach which recognizes the interconnectedness between human health, animal health and environmental health is increasingly proving to be effective.

In biodiverse areas and natural ecosystems, maintaining environmental health has traditionally been based on increasing or establishing new protected areas (PAs). New targets are regularly being established, such as in the recent Agenda 2030 for Sustainable Development. However, local and indigenous communities living in such areas constitute the poorest and most marginalized segments of the population in their countries. Through their traditional environmental knowledge and resource management systems, they are the custodians of unique biocultural heritages on which Planetary Health relies. Biodiversity conservation efforts will not be sustainable unless the issues of health, poverty and livelihoods are addressed in these communities.

By examining the roles and responsibilities of local and indigenous women in supporting functional ecosystems, we show their pivotal role at the interface and their vulnerability to a wide range of global priority health concerns, including infections and non-communicable illnesses. The drivers of such vulnerability include social and geographical marginalization, poor access to health services and reproductive and sexual information, restricted access to resources, malnutrition, air and water quality, human and animal conflict. We suggest that a One Health approach with a gender perspective can contribute to the Agenda 2030 for Sustainable Development and specifically to the objectives of biodiversity conservation and poverty reduction in threatened ecosystems.

When health care undermines planetary and human health: a conceptual framework

Authors: Martin Hensher1Ben Canny1, John Tisdell2, John Tisdell3
Author Affiliations: 1School of Medicine, University of Tasmania; Tasmanian School of Business and Economics, University of Tasmania; 3Curtin Learning and Teaching, Curtin University

Background:
Health care is now one of the largest sectors of the world economy, accounting for some 10 per cent of global Gross Domestic Product (GDP). It is implausible that such a large industry would not contribute to human pressure on planetary boundaries. The aim of this project is to develop a conceptual framework that identifies the mechanisms by which the production and consumption of health care may cause damage to both natural systems and to human health, by applying concepts from ecological economics to the study of health care systems.

Methods:
A review of the ecological economics and sustainable consumption literature on overconsumption, misconsumption and uneconomic growth; review of the literature on the environmental impacts of health care; review of the literature on overuse, overdiagnosis and overtreatment in health care. Synthesis of review results into a conceptual framework to identify areas of impact and potential for action to reduce impacts.

Findings:
Health care production and consumption can be broadly divided into that which is beneficial (i.e. improves human health) and that which is not beneficial (either yields little or no benefit, or causes harms to human health). Growing evidence suggests that a significant proportion of health care utilisation and expenditure yields no benefit to patients, while potentially exposing them to harm. At the same time, all health care production potentially has negative ecological impacts – through use of non-renewable natural resources, release of CO2 and other greenhouse gases, direct waste disposal, and indirect release of pharmaceutical and other waste products (e.g. via excretion) that may damage natural systems.

Interpretation:
Even while “right care” brings great benefits to human health, health care also displays the characteristics of overconsumption (individual consumption choices that are not compatible with maintaining a society or species’ life support systems in aggregate) and of misconsumption (consuming in a way that undermines an individuals own well-being), through the well-documented problem of overuse of health care. Health care thus contributes to the problem of uneconomic growth – increased production and consumption whose social and ecological costs outweigh their benefits. The elimination or minimisation of overdiagnosis, overtreatment and overuse would allow the elimination of a significant portion of the adverse ecological consequences of modern health care, with no negative impact on human health. Policy attention could then focus more closely on minimising the negative ecological impacts of beneficial health care.

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