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References

doi: 10.1111/1753-6405.12212

1. Caldecott B, Tilbury J, Ma Y. Stranded Down Under? Environment-related Factors Changing China’s Demand for Coal and What this means for Australian Coal Assets. Oxford (UK): University of Oxford Smith School of Enterprise and the Environment; 2013 Dec. p. 1–78. 2. Swan J. Tony Abbott’s business adviser says Australia taken ‘hostage’ by ‘climate change madness’. The Age. 2013 Dec 31. 3. Chen Y, Ebenstein A, Greenstone M, Li H. Evidence on the impact of sustained exposure to air pollution on life expectancy from China’s Huai River policy. Proc Natl Acad Sci. 2013;110(32):12936–41. 4. Deaton A. The Great Escape: Health, Wealth, and the Origins of Inequality. Princeton (NJ): Princeton University Press; 2013. 5. Niu S, Jia Y, Wang W, He R, Hu L, Liu Y. Electricity consumption and human development level: A comparative analysis based on panel data for 50 countries. Int J Electrical Power Energy System. 2013;53: 338–47. 6. Gohlke JM, Thomas R, Woodward A, CampbellLendrum D, Prüss-Ustün A, Hales S, et al. Estimating the global public health implications of electricity and coal consumption. Environ Health Perspect. 2011;119(6):821–6. 7. Peters GP, Andrew RM, Boden T, Canadell JG, Ciais P, Le Quéré C, et al. The challenge to keep global warming below 2°C. Nature Climate Change. 2013;3(1):4–6. 8. Carbon Tracker. Unburnable Carbon 2013: Wasted Capital and stranded Assets. London (UK): Carbon Tracker Initiative in Collaboration with Grantham Research Institute on Climate Change and the Environment, LSE; 2013 Apr. p. 1–40. 9. Juniper T. What has Nature Ever Done for Us? London (UK): Profile Books; 2013.

Correspondence to: Professor Alistair Woodward, Section of Epidemiology and Biostatistics, School of Population Health, The University of Auckland, Private Bag 92019, Auckland 1142, New Zealand; e-mail: [email protected]

Determinants of health: the contribution of the natural environment Peter W. Tait,1 Anthony J. McMichael,2 Elizabeth G. Hanna2 1. Ecology and Environment Special Interest Group, Public Health Association Australia 2. National Centre for Epidemiology and Population Health, Australian National University, Australian Capital Territory

“Somehow, modern public health had almost forgotten the primacy of the humanenvironmental interface, despite this being a component part of the original sanitarian vision … Public health professions today need to think and act ecologically if they are to help reshape the conditions that enable good health to flourish.” 1

O

ver the past few decades, social determinants - especially the distribution of power, knowledge, wealth and opportunity - have been increasingly recognised as important for human health.2-4 Despite a now extensive literature 5-15 there has been much less societal and public health recognition of the vital importance of a well-functioning natural environment, with its ecosystems and other biophysical processes, to sustaining human livelihoods and prosperity, complex industrial society and, ultimately, human health and wellbeing. The environment and its natural systems have long been taken for granted in developed, urbanising, societies. This lack of an ecological understanding of the dynamic relationship between humans and the rest of the natural world, and the life-support role played by those natural systems, has resulted in an overly intensive and disruptive human interaction with the natural world. In the public health sector, this incomplete understanding means that advice and inputs from the health-professional arena have contributed little to the wider public task of sustaining the natural environment. In this Editorial, we briefly describe the dimensions that comprise the humanenvironment relationship. Within the term ‘environment’ we include both the natural and the human constructed, or ‘built’, environment. The ecosystems and their functions (sometimes, presumptuously, called ‘services’) are the core of the systemic natural

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environment, and are described in Figure 1. Health is the focus here, although this is only one aspect of well-being. We argue the need for increased recognition of the importance for health of the environment and its ecosystems, and re-introduce the concept that a healthy environment is a fundamental determinant of health – of current and future generations of humans15 and of other species (many of which we depend on). Consequently, stronger public health-based advocacy for action to protect environmental integrity becomes a central health promotion measure.16 In addition to the adverse health effects of localised environmental, often chemical, pollution and microbiological contamination of food and water – all well established as core public health foci – there are, increasingly, wider categories of environmental influence on human health that usually impinge on whole communities, even populations. Those influences occur via human-induced disturbances of: • The range of ecosystem functions and biophysical cycles – including the carbon cycle (central to human-induced climate change) and the world’s cycles of nitrogen, phosphorus and sulphur – that meet a population’s physical and socioeconomic needs for clean air, fresh water, climatic stability, support for food production (nutrient cycling, soil health, pollinators and biodiversity), shelter, and that help manage and recycle human society’s waste streams.17-19 • The amenity that natural places and ‘Nature’ provide for human psychological, cultural and ‘spiritual’ wellbeing.17,20-24 ‘Nature deficit disorder’ is the term used to describe the symptomatology of increased rates of behavioural disorders, anxiety and sadness observed among people with limited contact with nature.25

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Figure 1: Ecosystem functions and health.

Via these processes, the natural and human-modified environment plays a vitally important role in influencing the foundations of wellbeing, viability and stability of all societies, including complex industrial societies; their wellbeing and health, their productivity, and their material, social and aesthetic conditions of living. Examples of the dynamic, ecological relationship between humans and the environment follow. Despite the natural environment’s great regenerative capacity to disseminate, decontaminate, and replenish itself, large populations living beyond the regenerative powers of the natural environment impair ecosystem functions. Larger populations extract more water, more fish, apply chemicals to ramp up food yields and burgeoning wastes contaminate near and distant ecosystems, the air, soils and waterways. Ultimately, human influence pushes passed the point where natural systems can recuperate, reducing capacity to provide sufficient clean water, clean air, fertile soils and clean foods. Further anthropogenic pressures beyond that point, further diminish the environment’s capacity for support, provisioning and regulating. Currently, disruption of global environmental systems, for instance reduced air quality, deforestation or changes in the climate system, directly and indirectly contribute to the burden of ill-health and overtly illustrate the environment-health link. Such health effects include the millions who suffer airpollution related cardio-respiratory diseases,26 the thousands who die annually across the planet from heat stress,27 and the millions

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who are affected annually by floods. Further poor environmental public health, such as lack of access to clean water, remains a leading cause of child mortality. 28 These effects are compounded by pressure from the growing human population. The magnitude of these environmentally induced health burdens means that the natural environment cannot be viewed merely as a tangential health determinant. Importantly, the transboundary nature of much contemporary environmental degradation and disruption means that the exposure to threats affects the rich and poor, although there is definite inequity to that exposure and capacity to manage it. Emerging threats to humanity from resource exploitation and environmental degradation include resource constraints, such as ‘peak oil’,29 or those affecting agriculture and food yields, such as ‘peak phosphorus’,30 and the threat of global fresh water shortages.31 Threats to agriculture and livestock productivity arising from resource scarcity compound the looming effects of global warming. The combined effects will manifest as food insecurity, nutritional deficits and consequential disease vulnerability.32 Without substantial intervention, these mounting systemic stresses will amplify other preexisting environmental threats to health. The capacity for human society to feed itself in a resource-constrained, increasingly adverse climate is of major public health importance. Such threats deserve heightened health sector attention and engagement. While chemicals such as ozone-depleting substances and greenhouse gases disrupt

environmental systems at a global scale, poorly managed waste products from domestic, agricultural and industrial activity continue to generate environmental chemical pollutants which contribute to human illness, both via direct local pathways and, often, by spreading diffusely at regional and global scales. Such pollutants include pesticides, urban and industrial air pollution; residual lead in places such as Broken Hill, Port Pirie and Mt Isa; mercury;33 and arsenic and other chemical contaminants in rivers, soil and food.34 Clear evidence now implicates exposures to industrial and agricultural chemicals in developmental problems and other illnesses, including congenital malformations, cancers, diabetes, allergenicity, generalised immune disorders, asthma, neurological and behavioural conditions, endocrine disruption, and, perhaps, obesity and autism.35-43 Global urbanisation trends have increasingly divorced the majority of humans from direct contact with nature as a health-sustaining provider. Concomitantly, recognition of the fundamental human dependence upon healthy ecosystems has attenuated in the popular mindset.10,19 Yet rarely is the health sector heard in policy debates on environmental protection. Anthropogenic influences on ecosystem services now occur on a scale and timehorizon beyond the conventional frame of reference for ‘determinants of health’. The magnitude and interconnectivity of human-induced disruptions and depletions of environmental systems loom increasingly large as a fundamental, mostly negative, influence on health and longevity in coming decades in countries around the world.44 This has major equity consequences not only in the present world but between present and future generations.15 Equity considerations reminds us that both the environmental and social determinants of health remain strongly practically and politically linked. The association between socioeconomic disadvantaged and poor living conditions is well documented. The driving forces underpinning many of the social determinants of chronic diseases match the socio-economic influences that drive environmental degradation. A common element to both is poorly regulated corporate behaviour.45 Corporate behaviour exists in an economic system that has been founded on

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assumptions and models that disregard and externalise the ecological and social costs of their actions. These systems make the following flawed and dangerous assumptions:

spaces reduces the heat island effect and enhances urban biodiversity.49 • Temperature stable house design contributes further to reducing risks of heat stress on very hot days. Such factors reduce peak electricity demand, reduce emissions and improve air quality. 50,51

1. Prosperity derives from endless wealth accumulation and growth in population, resource use and waste generation on a finite planet.

• Green health care options have been shown in the United Kingdom Sustainability Development Unit to provide both more cost-effective health care and reduced greenhouse gas emissions.52

2. Natural resources are boundless. 3. Their value exists only as commodities for sale or trade. 4. Any damages to ecosystem supports in the pursuit of profits are legitimate (discountable) externalities. The manifest consequence of these assumptions is depletion of the capacity of the Earth’s natural system to support human health. It behoves the health sector to challenge these environmentally destabilising assumptions in defence of human health and wellbeing. Society, through government, needs to regulate economic activities and corporate practice so that ecological ‘costs’ are no longer ignored, discounted or externalised. Major policy decisions that have consequences for the environment and society, and which adversely affect human health, have mostly lacked input from the health sector. Full accounting of social, health and environmental costs and benefits is required in policy-making processes, in order to ensure policies promoting long-term ecologically sustainable, healthy populations. Thinking broadly enables synergies between protecting the environment and health whereby positive actions in one domain can deliver co-benefits in the other. Successful examples include: • Co-benefits for health and ecological sustainability: Promotion of active transport, such as walking and bicycling, reduces greenhouse gas emissions, improves urban air quality with consequent reduction in respiratory and cardiac diseases, and improvements in psychological wellbeing flow from better community amenity.46-48 • Sustainable urban design: Open and green natural spaces promote active transport, increase recreational potential for physical activity which reduce cardiovascular disease, and contribute to mental wellbeing. Furthermore, urban layout with features such as water and green

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As occurs with politically contentious issues such as food standards and substance misuse (tobacco and alcohol), which pit vested interest against the common good, public health needs to engage routinely at the environmental-health interface to advocate for protection of fundamental ecosystem functions in areas such as: • River systems: especially cross border (Murray Darling Basin, Danube), relating to food production, amenity, waste management • Fracking: where it threatens prime agricultural land and scare water supplies in poorly understood underground aquifers • Energy choices: where some options have proven health harms at local and global dimensions. The importance of modifying human activities to live within the planet’s presumed safe operating limits12 therefore has a direct health and health care dimension. By reintroducing the environmental aspects of public health, in an updated and expanded framework, as they relate to the ecosystem supports for human society, public health can again fulfil its commitment to create ecologically sustainable, healthy human societies, which promote healthy individuals. In conclusion, we emphasise that the environmental influence on health extends, increasingly, beyond the effects of chemical pollution and infectious diseases, although these remain important aspects of public health. Today’s extended influences on population health as provided by the natural environments’ ecological and biophysical systems, are the fundamental source of provision, regulation and support for human society, and on a broader level furnish healing, cultural and spiritual amenity to individuals. The condition of these systems are increasingly disrupted and depleted by

human activity. In recent times, the ‘new’ public health focus on social determinants has eclipsed this more fundamental set of determinants.15 Environmental damage, or protection and rehabilitation, similarly to the distribution of power, wealth and opportunity, is socially and culturally determined and so is inherently political. Since long-term environmental protection and rehabilitation are important to protect human health and wellbeing, there is clear need for the public health profession to recognise and respond to the centrality of the environment for health; environmental protection at local and global scales is a vital health promotion measure.

Acknowledgements The authors thank Mardie Townsend, Glenda Verrinder, Clive Rosewarne and Sarah Lantz.

References 1. Lang T. Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof Rayner. Br Med J. 2012;345:e5466. doi: http://dx.doi.org/10.1136/bmj. e5466. 2. World Health Organization. Ottawa Charter for Health Promotion. Geneva (CHE): WHO; 1986. 3. Marmot MG, Wilkinson RG, editors. Social Determinants of Health. 2nd ed. Oxford (UK): Oxford University Press; 2006. 4. Wilkinson RG, Pickett K. The Spirit Level: Why More Equal Societies almost Always do Better. London (UK): Allen Lane; 2009. 5. Meadows DH, Meadows DL, Randers J, Behrens WW III. The Limits to Growth: A Global Challenge; A Report for the Club of Rome Project on the Predicament of Mankind. New York (NY): Universe Books; 1972. 6. McMichael AJ. Planetary Overload: Global Environmental Change and the Health of the Human Species. Cambridge (UK): Cambridge University Press; 1993. 7. McMichael AJ. Climate Change and Human Health. Geneva (CHE): World Health Organization, World Meteorological Organization, United Nations Environment Programme; 1996. 8. Confalonieri U, Menne B, Akhtar R, Ebi K, Hauengue M, Kovats R, et al. Human health. In: Parry M, Canziani O, Palutikof J, van der Linden P, Hanson C, editors. Climate Change 2007: Impacts, Adaptation and Vulnerability Contribution of Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge (UK): Cambridge University Press; 2007. 9. Corvalan C, Hales S, McMichael A. Ecosystems and Human Well-being : Health Synthesis: A Report of the Millennium Ecosystem Assessment. Geneva (CHE): World Health Organization; 2005. 10. McMichael AJ. Human population health: sentinel criterion of environmental sustainability. Curr Opin Environ Sustain. 2009;1(1):101-6. 11. McMichael A, Lindgren E. Climate change: present and future risks to health, and necessary responses. J Intern Med. 2011;270(5):401-13. 12. Rockström J, Steffen W, Noone K, Persson Å, Chapin III F, Lambin E, et al. Planetary boundaries:exploring the safe operating space for humanity. Ecol Soc. 2009;14(2):32. 13. Hanna E, McMichael A, Butler C. Climate Change and Global Public Health: impacts, research and actions. In: Parker R, Sommer M, editors. The Routledge International Handbook on Global Public Health. Oxfordshire (UK): Routledge; 2011.

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29. Raffle AE. Oil, health, and health care. Br Med J. 2010;341:c4596. doi: 10.1136/bmj.c4596 30. Cordell D, Rosemarin A, Schröder J, Smit A. Towards global phosphorus security: A systems framework for phosphorus recovery and reuse options. Chemosphere. 2011;84(6):747-58. 31. Kummu M, Ward P, de Moel H, Varis O. Is physical water scarcity a new phenomenon? Global assessment of water shortage over the last two millennia. Environ Res Lett. 2011;5:034006. doi:10.1088/17489326/5/3/034006. 32. Patz J, Corvalan C, Horwitz P, Campbell-Lendrum D. Human Health and the Rio Conventions: Biological Diversity, Climate Change and Desertification [Internet]. Geneva (CHE): WHO; 2012 [cited 2012 Nov 26]. Available from: http://www.who.int/globalchange/publications/ reports/health_rioconventions.pdf 33. United Nations Environment Programme. Global Mercury Assessment [Internet]. Geneva (CHE): UNEP; 2002 [cited 2010 Dec 14]. Available from: http://www. chem.unep.ch/mercury/Report/Final%20report/finalassessment-report-25nov02.pdf 34. Balbus JM, Boxall ABA, Fenske RA, McKone TE, Zeise L. Implications of global climate change for the assessment and management of human health risks of chemicals in the natural environment. Environ Toxicol Chem. 2013;32 (1):62-78. 35. Sly P, Hanna E, Giles-Corti B, Immig J, McMichael T. Environmental Threats to the Health of Children in Australia: The Need for A National Research Agenda [Internet]. Perth (AUST): Australian Research Alliance for Children and Youth ARC/NHMRC Research Network; 2008 [cited 2008 Mar 2]. Available from: http://www.aracy.org.au/publicationDocuments/ top_environmental_threats_to_the_health_of_ children_in_australia_the_need_for_a_national_ research_agenda_2008.pdf 36. Giles-Corti B, Macintyre S, Clarkson JP, Pikora T, Donovan RJ. Environmental and lifestyle factors associated with overweight and obesity in Perth, Australia. Am J Health Promot. 2003;18(1):93-102. 37. Choi SM, Yoo SD, Lee BM. Toxicological characteristics of endocrine-disrupting chemicals: developmental toxicity, carcinogenicity, and mutagenicity. J Toxicol Environ Health B. 2004;7(1):1-23. 38. Sanbornn M, Colee D, Kerrr K, Vakill C, Saninn LH, Bassill K. Pesticides Literature Review. Toronto (CAN): The Ontario College of Family Physicians; 2004. 39. Hanna E. Environmental Health and Primary Health Care: Towards a New Workforce Model. Melbourne (AUST): La Trobe University; 2005. 40. Weselak M, Arbuckle TE, Wigle DT, Krewski D. In utero pesticide exposure and childhood morbidity. Environ Res. 2007;103(1):79-86. 41. Dietert RR, Dietert JM. Early-life immune insult and developmental immunotoxicity (DIT)-associated diseases: Potential of herbal-and fungal-derived medicinals. Curr Med Chem. 2007;14(10):1075-85.

42. Heindel JJ. Role of exposure to environmental chemicals in the developmental basis of disease and dysfunction. Reprod Toxicol. 2007;23(3):257-9. 43. Lee D-H, Lee I-K, Porta M, Steffes M, Jacobs D Jr. Relationship between serum concentrations of persistent organic pollutants and the prevalence of metabolic syndrome among non-diabetic adults: results from the National Health and Nutrition Examination Survey 1999–2002. Diabetologia. 2007;50(9):1841-51. 44. McMichael AJ, Butler CD. Promoting global population health while constraining the environmental footprint. Ann Rev Public Health. 2011;32(1):179-97. 45. Tait P. On the need to transform governance to regulate corporations for the survival of homo sapiens. In: Butler CD, Dixon J, editors. Healthy People, Places and Planet or From Healthy Workers to a Healthy Planet: Reflections Based on Tony McMichael’s Four Decades Contribution to Epidemiological Understanding. Canberra (AUST): Australian Nationsl University Press; 2014 in press. 46. Rissel CE. Active travel: a climate change mitigation strategy with co-benefits for health. N S W Public Health Bull. 2009;20(1-2):10-13. 47. Woodcock J, Edwards P, Tonne C, Armstrong BG, Ashiru O, Banister D, et al. Public health benefits of strategies to reduce greenhouse-gas emissions: urban land transport. Lancet; 2009;374(9705):1930-43. 48. Giles-Corti B, Foster S, Shilton T, Falconer R. The cobenefits for health on investing in active trnsportation. N S W Public Health Bull. 2010;21(5-6):122-7. 49. Bambrick H, Capon A, Barnett G, Beaty M, Burton A. Climate change and health in the urban environment: Adaption opportunities in Australian cities. Asia Pac J Public Health. 2011;23 Suppl 2:67S-79S. 50. Hanna L. Could we acclimatise to the hotter summers to come? The Conversation [Internet]. 2013 [cited 2013 Feb 13] January 1. Available from: http://theconversation. com/could-we-acclimatise-to-the-hotter-summers-tocome-11507 51. Newman P, Matan A. Green Urbanism in Asia: Can Asian Cities Lead the World in Reducing their Resource and Waste Footprint? Singapore (SGP): World Scientific Publishing; 2013. 52. Sustainable Development Unit. Business Plan [Internet]. Cambridge (UK): SDU; 2013 [cited 2013 Dec 17]. Available from: http://www.sdu.nhs.uk/sd_and_the_ nhs/

Correspondence to: Dr Peter W. Tait, Ecology and Environment Special Interest Group, Public Health Association Australia, 91 David Street, O’Connor, Australian Capital Territory, 2602; e-mail: [email protected]

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