Prof. K Srinath ReddyPresident, Public Health Foundation of India

Health In The Era Of Sustainable Development

SDGs

MDGsStrong Focus on MCH & Communicable Diseases

Higher Investment In Health

Strong Focus On

MCH

NCDs

CDs

UHC

“ Health leaps out of Science and draws nourishment from the

totality of Society”

- Gunnar Myrdal (Swedish Economist, Nobel Laureate 1974)

HEALTH SYSTEM PEOPLE

SOCIAL DETERMINANTS

(OF HEALTH & NUTRITION)

Societal Personal

- Water - Income

- Sanitation - Education

- Food System - Occupation

- Environment - Social Status

- Social Stability - Gender

- Development - Networks

- Workforce

- Infrastructure

- Drugs, Vaccines & Technologies

- Financing

- Information Systems

- Governance

POLITICAL & ECONOMIC SYSTEM

PHYSICAL ENVIRONMENT (Four Themes)

• Urban Design and Transport

• Air Pollution

• Agriculture and Food Systems

• Climate Change

URBAN DESIGN & TRANSPORT

• Conducive To ‘Active Living’• Physical Safety (Traffic, Crime)• Water, Sanitation • Clean Air• Accessible Health Services• Disaster Resilient • Climate Resilient

URBAN DESIGN & TRANSPORT(Determinants of Active Living /Physical Activity)

• Land Use Mix Access• Residential Density• Street Connectivity• Safety• Infrastructure• Aesthetics• Perceived Distance To Destinations• Public Transport• Pollution (?)

• Air Pollution is the world’s single largest environmental/pollution health risk.

In 2012• ~7 million people died prematurely due to

air pollution.

• 2.7 million premature deaths were attributable to ambient air pollution.

• 4.3 million premature deaths attributable to household air pollution.

Source: WHO, 2014

AIR POLLUTION

Diarrhea / LRI / Other InfectionsCardio & CirculatoryChronic RespiratoryNeoplasms

Source: IHME, 2013, Lim et al 2012

Key Risk Factors - Global (GBD 2010)

• Annually , 3.3 million

people worldwide die prematurely from the effects of outdoor air pollution (mostly PM2.5).

• In 2010, 75% of such mortality occurred in Asia -1.4 million in China and 650,000 in India.

• This number will double by 2050 to 6.6 million if emissions continue to rise.

Death By Breath

(Max Planck Study. Nature, Sept 2015)

Household Air Pollution3 billion people cook with solid biomass fuels• Low-middle income countries: burden borne by women and children.

>50% under 5 deaths are due to pneumonia (Risk Factor: soot inhaled from household air pollution)

• Diseases: Pneumonia, stroke, Ischemic Heart Disease, Chronic Obstructive Pulmonary Disease, Lung cancer

• South Asia shoulders the biggest burden

“Having an open fire in your kitchen is like burning 400 cigarettes an hour.”- Kirk Smith

Burdens from HAP and AAP in India (GBD 2010)

Source: IHME, 2013, Lim et al 2012

Deaths DALYs

Ambient Air Pollution (PM2.5)

627,426

17.7 million

Household Air Pollution

~ 1 million

31 million

• 16,000 cities monitor and report ambient air quality• Only 12% of the people living in those cities

reside in cities where this complies with WHO guideline levels

• Most polluted cities in the world: • Asian cities: Karachi, New Delhi, Kathmandu, Beijing.• Latin American cities: Lima, Arequipa.• African cities: Cairo.

Burden in LMICs - Ambient Air Pollution

NEED BETTER METRICS FOR INTEGRATED EXPOSURE MEASUREMENT AND ESTIMATION OF HEALTH EFFECTS

• Establishing and strengthening baseline relationships– Links to cardiometabolic risk factors with chronic exposure– Gathering greater evidence of association with Diabetes in adults and

endocrine disruption in children– Strengthening evidence for multi-generational epigenetic effects– Source and pollutant-specific effects (toxicity of various components of PM)– Impacts of ultrafine particulates

• Predictive models– Building on and localizing the work of the GBD– Developing early warning systems

Air PollutionResearch Response : Priorities

•Estimating benefits and costs of action–Air pollution and climate co-benefits–Economic case : estimating the health costs

•Health System Response –Health Workforce Preparedness–Health Care Access And Quality

Air PollutionResearch Response : Priorities

HUMAN HEALTH

ANIMAL HEALTH

PLANT HEALTH

SOIL HEALTH

2013-16

Metrics : Messages for Decision Makers

The need for action• Agriculture and food system policies must make a greater contribution to

improving nutrition.

• Low and middle income countries are burdened by persistent undernutrition and rapidly growing overweight, obesity and diet-related non-communicable diseases.

• Existing tools used to measure nutrition links to agriculture and other food policy interventions capture only parts of the food system.

• Evidence based policy making requires more rigorous and specific metrics relating to all of the food system elements and their dynamic interactions over time.  

DATA GAPS ON DIETS AND FOOD SYSTEMS• New metrics are needed to measure diet quality and

sufficiency, as well as food system efficiency and sustainability. Improvements are needed in five key areas:

• Improving data on actual food intake (currently lacking in most countries of the world)

• Agreement on how to measure diet quality

• Metrics that measure women’s roles in defining dietary choices

• Metrics to measure the food environment within which diet choices are made

• Metrics to measure the health of food systems overall.

DATA STARVATION

• Six Nutrition Goals set By World Health Assembly (2012)

• More than half the countries do not collect statistics to

monitor progress

• 40% of countries which do – rely on surveys conducted

once in a decade

We Live In A World

This Will Get Worse If We Don’t CHANGE!

Where Food Systems Are

Threatening The Environment

And

Environmental Degradation

(From A Variety of Sources)

Is Threatening Food Systems

Climate Change Through Nutrition Lens-1By 2100

40% of the world’s land surface will likely experience altered climates

Up to 2050

• Agricultural output is projected to:Fall by 2% per decade (due to impact of climate change on crop and livestock production)

• Food Demand is projected to: Rise by 14% per decade (due to population growth, urbanisation, poverty reduction)

Climate Change Through Nutrition Lens-2

• Higher production of staple crops will not be enough to make agriculture more resilient to climate change or better able to address the world’s need for improved diets

• Nutrient rich crops are more susceptible to droughts, pests, diseases and temperature fluctuations

• Higher CO2 in atmosphere may reduce nutrient content of staple crops

• Soil degradation also reduces nutrient quality

Sub-Saharan Africa and South Asia are particularly prone to productivity losses from climate change because major staples in these regions are often already grown above their optimum temperature, with as much as 10% yield loss for +10C of warming predicted in some locations.

www.sdsn.org TG07

Nutrition-sensitive Food Systems Can Also Be Climate-smart

• While evidence of effective climate change actions remains scarce there is ample evidence already of how to enhance diets and food systems in the context of weather shocks and price volatility.

• Climate-smart actions supportive of nutrition means focusing on diverse, high quality, healthy diets.

• Win-win solutions lie in the diversification of agricultural investments, mitigating climate-related stresses on crop and livestock quality, greater resource use efficiency along value chains, and protecting diet quality in the face of supply and food price shocks.

Policy Recommendations• Support variety of food production systems to minimize risks and enhance the

supply of more diverse foods in the diet;• Promote efficiency, including waste minimization, along the entire food value chain

to meet higher food demand and enhanced resource use, while achieving dietary diversification

• Focus domestic research and investments on mitigating climate-related food system shocks and volatility, and adapting those systems to longer-terms stresses;

• Establish robust social protection programmes that stablise and enhance consumer purchasing power, thereby protecting their diets and nutrition in the face of supply shocks;

• Researchers should generate rigorous empirical evidence on effective investments along food value-chains that are resilient to climate changes while delivering positive dietary outcomes.

CLIMATE CHANGE WILL HARM HEALTH IN MANY WAYS

• Vector Borne Diseases: Wider Reach; Higher Death Toll

• Water Insecurity

• Food Insecurity

• Extreme Climatic Events

• Displaced Populations

• Vulnerable Human Settlements

Mapping Links Between Climate Change and Health• Most expected impacts will be adverse but some will be beneficial.• Expectations are not for new health risks, but rather changes in frequency or severity of

familiar health risks

Variations in Earth’s average surface temperature, over the past 20,000 years

• Unequivocal evidence on climate change: rising sea levels and global temperatures, retreating glaciers, extreme events, etc.

• Since the industrial revolution, atmospheric CO2 has increased by 1/3rd.

• IPCC projects an increase in global temperatures by at least 1.8°C by 2100 in the best case. Up to 5.8°C if nothing is done.

• An increase in sea levels between 9 and 88 cm in the next century.

• MOST OF THIS CHANGE IS RELATED TO HUMAN ACTIVITY: ANTHROPOGENIC.

Climate Change: Evidence and Trends

Direct Effects Of Climate Change

Mainly from extreme events:• Temperature extremes: Eg. The 2003 European Heat wave.

Most deaths were in vulnerable populations eg, the elderly with pre-existing diseases.– Over 70,000 estimated to have died in the hottest summer since

1540.• Disasters: (Floods, Tsunamis)

Indirect effects of climate change

Act via:

• Changing patterns of disease: vector borne diseases

• Water sanitation and hygiene related diseases.

• Food shortages: reduced crop yields in the lower latitudes.

• Migration and population change.

Climate Change and Malaria under Different Scenarios (2080)• Increase: East Africa, Central Asia, Russian Federation• Decrease: Central America, Amazon [within current vector limits]

Change o f consecutive m onths

> +2

+2

-2

< -2

A1

B2

A2

B1 Van Lieshout et al. 2004

Storms/FloodingFlooding is heavily concentrated in AsiaMost human exposure to flood is in Asia. The top ten countries – in absolute and relative terms - are in south and south east Asia.

From: Environment Solutions: www.environmentsolutions.dk Source: 2009 Global Assessment report on Disaster Risk Reduction

2012 Flood in Pakistan (September)• Monsoon floods in Pakistan during September, killed

more than 400 people and affected more than 4.5 million others: – Tens of thousands have been made homeless by

heavy flooding in the provinces of Balochistan and Sindh – where 2.8 million were affected.

– The worst floods were in 2010, when almost 1,800 people were killed and 21 million were affected.

• During 2011, many Asian countries experienced flooding, including Bangladesh, China, India, Japan, Laos, North Korea, Pakistan, Thailand, the Philippines and Singapore.

BBC news: 28 Sept 2012

Climate Change and ConflictDeviations from temperature and

precipitation patterns correspond to statistically significant rises in conflict

1-degree increase in temperature (warmer) increased the frequency of interpersonal conflict by 2.4% and intergroup conflict by 11.3%

Source: Climate and Conflict, National Bureau of Economic Research: October 2014Marshall Burke, Solomon M. Hsiang, Edward Miguel

Health Co-benefits Of Climate Change Mitigation

Benefits in NCD risk factor reduction

• Public transport: cycling etc.– In addition to reduced carbon emissions, improved physical activity-

reduced risk of NCDs

• Reduced red meat consumption

• Air pollution mitigation: reduced respiratory illnesses

INDUSTRIAL SCALE LIVESTOCK BREEDING

Obesity CVD Cancer

Climate Change (↑ Methane; Deforestation)

Food Crisis(Grain Diversion)

Pandemics (Zoonotic Diseases rising)

+ +

WATER

Climate Change: Methods Required to Assess Vulnerability

• Estimating the current distribution and burden of climate-sensitive diseases

• Estimating future health impacts attributable to climate change – across and within countries

• Identifying current and future adaptation options to reduce the burden of disease.

Source: Kovats, et al., 2003

C O P 21( Paris ; December 2015 )

COP OUT! CLAP IN!

CO-OP 195CATCH 22?

MULTISECTORALITY

MULTISECTOREALITYNeed for Transdisciplinary Research

Persons

PeoplePopulations

PLANET