Commissioner for Health Sustainable Development Commission, UK.
Sustainable development is a long-term, whole-systems approach that gives equal weight to five principles: living within environmental limits; a strong, healthy and just society; a sustainable economy; good governance, and using sound science responsibly. By promoting sustainable development we help to prevent chronic disease. By preventing disease we help to promote low carbon living and prevent damage to the environment.
The policies we need to safeguard human life on the planet are the same or very similar to those we need to prevent human illness in general and chronic disease in particular. Global warming presents enormous new challenges to the way different countries treat each others' citizens and to the way welfare systems across the world deal with risk and disadvantage. So, we need to transform social policy-at local, national and global levels, to meet the needs of the modern world.
Chronic disease is a global problem. The World Health Organization (WHO) says 66 per cent of all premature deaths are due to chronic diseases. In the next decade, it is estimated that nearly 400 million people will die of a chronic condition.
In the developed world, there are three factors that greatly exacerbate the problem and point to higher rates and greater costs in future:
1. One is the rising epidemic of obesity-bringing with it grave risks of heart disease, cancer and diabetes. In England, one in four is affected and the rates are rising rapidly. This currently costs US$ 7.4 billion (£3.7 billion) every year.
2. The second factor is the rising levels of mental ill-health. The WHO has predicted that by 2020, depression will be the second greatest contributor to the burden of disease for all ages and both sexes 1. We are learning that above a certain level, higher income does not make people happy any more. People in richer countries suffer from high levels of stress, anxiety and depression. These mental illnesses often lead to physical disorders. A recent report in The Lancet found that depression is more dangereous to health than the four major chronic conditions: angina, arthritis, asthma and diabetes2 . In England alone, one in 6 is affected by mental health problems and it costs the country US$ 152 billion (£76 billion) a year-in health and social care services, lost economic output, and associated costs.
3. The third factor is the ageing population. In the last two decades in England, life expectancy for men increased by just over 5 years, but healthy life expectancy increased by less than three years. So, more people are old and ill-suffering, in the main, from chronic mental and physical illness.
Furthermore, both poverty and insecurity result in chronic disease. So, what can be done to prevent chronic disease? According to the WHO, the causes are known, the risks are largely preventable and the key is to focus on risk factors that link across the major killer diseases.
The three overlapping risk factors are: exercise, diet, and human contact with natural environment. It is with these 'upstream' determinants of health that we find the greatest synergy between sustainable development and health.
There is strong evidence that physical inactivity is related to ill health. As a factor that contributes to heart disease, lack of exercise can be looked upon as serious as smoking.
In England, as in many other countries, very few people take exercise. Two in three men and three in four women fail to take the recommended minimum of 30 minutes' moderate activity five times a week. This is partly because of the vast increase in the use of private car for transportation and also due to the road traffic conditions.
Reduction in motorised road traffic-and the resultant reduction of air pollution-combined with an increase in physical activity through walking and cycling would have multiple benefits like: reductions in lung disease, asthma, obesity, diabetes, cardiovascular disease, osteoporosis and certain cancers; improvements in mental health. This can also significantly reduce CO2 emissions and other environmental damages that in turn present threats to the cohabitant's health and well-being.
It's a virtuous cycle. Public policies that promote sustainable and active travel-for everyone, not just the middle-classes, can reduce the risks of chronic disease, combat global warming and help us all live with the resources of one planet instead of three.
A poor diet made up of processed foods that are heavy in fat sugar and certain artificial additives is harmful for physical and mental health. It is an acknowledged cause of obesity and depression.
Processed foods are energy-intensive. Food items which are transported over long distances have a larger carbon footprint. Conversely, food bought locally helps to stimulate local economies, create jobs, reduce poverty and give people greater control over their own lives-all important determinants of health.
Public procurement, planning, regulation and transport policies are all levers for government to promote sustainable food production and help people, regardless of their income, to maintain a good diet. This approach is now being actively applied by a group of hospitals in Cornwall, south-west England. They buy food from local suppliers, improving the diet of patients and staff and helping to bring new jobs into the area-all as a way of improving health and using resources more efficiently over time.
This suggests another virtuous cycle. Fresh, affordable, locally produced food is good for health and better for the environment.
There is sound evidence that people who have contact with natural environments have better physical and mental health. They take more exercise, feel better about themselves and reduce their risks of getting ill. A Dutch study has shown that the more green space people have access to, the better their general health would be-and the relationship is the strongest for lower socio-economic groups. Research in Chicago, USA, compared groups of people living in buildings with and without trees and grass nearby. Those without trees and grass had a less positive attitude to life, while those with trees and grass around, used public space more often and made more social contacts, which is also known to have positive effects on health. Another study of patients recovering from gall bladder surgery found that those who looked out on greenery recovered faster than those who looked out on a brick wall.
Accessible, usable, natural green space encourages physical activity. Exercising in pleasant, natural surroundings improves people's self-esteem and mood (hence the growing popularity of green gyms).
Protecting green spaces-everything from wilderness and open countryside to parks, tree-lined streets and gardens-can help to protect the environment and-on the right scale-combat global warming.
The Royal Commission on Environmental Pollution remarked in 2007. "The evidence is sufficiently strong (for planners) to recognise the health benefits of green space and to build green space into new and existing developments".
Here is another virtuous cycle. Public policies that promote and safeguard high quality natural environments-and public access to them, especially for low-income groups-can promote better physical and mental health, reduce the risks of chronic disease and help to sustain the resources on which human life depends.
Barriers to change
It is simply not sustainable to address chronic disease as something that just needs to be managed. But, why do governments and health systems continue to give higher priority to managing rather than preventing ill health?
We must recognise the danger of 'producer capture'. Health professionals are trained, managed and rewarded in ways that favour treatment and care, rather than prevention. Professional interest in treatment and care tends to drain away the lion's share of resources-human energy, professional skills, political capital or financial resources-from the prevention agenda.
Much more money is invested in research into the efficacy of clinical interventions than into preventative measures. Politicians who run health systems want 'quick wins' to woo their electorates and have little patience with the unglamorous long-term efforts of prevention. In some countries-including England-health systems are still organised and run separately from local government and struggle to work in partnership with those who run services that influence the wider determinants of health-education, planning, housing, transport. Media campaigns exert a vital influence over political behaviour and public opinion-newspapers and television usually find it easier to tell stories about things that go wrong than about things that prevent problems occurring.
And there are alluring 'downstream' solutions that can fulfil a health professional's desire to 'win the battle against disease' but these solutions detract attention from doing what it takes to make that battle redundant. For example, why worry about urban planning to encourage walking and cycling and to increase access to green spaces, or about agricultural policy to increase access to fresh local food-if you can prescribe a pill such as statins and show positive results in clinical trials (even if the intervention remains controversial )?
Meanwhile, there is robust evidence showing that:
In 2002, a report for the UK Treasury anticipated that failure to pursue what Derek Wanless, the author, called a 'fully engaged scenario' (focussing on preventing ill health and making better use of current resources), would cost the NHS up to US$ 60 billion (£30 billion) extra every year by 2020 .
There are some encouraging signs. The climate and health council, set up under the auspices of the British Medical Journal, has begun an intensive campaign to persuade doctors that it is their duty as guardians of health to reduce carbon emissions and promote sustainable practices. Another prestigious medical journal, The Lancet, has embraced the agenda, running a series on energy and health.
The National Health Service for England and Wales has set up a unit to promote what it calls 'good corporate citizenship', encouraging the NHS to spend that US$ 192 billion (£96 billion) to promote sustainable development-through procurement, employment, managing energy, buildings and transport. A web-based toolkit for NHS managers promotes this approach, showing that sustainable development can make good business sense and-crucially-help to prevent illness and improve health.
The WHO now advocates action on climate change-to reduce the causes and address the risks presented by global warming, especially for vulnerable people, with a view to improving population health .
In summary, it is possible and necessary to give higher priority to preventing chronic disease. Public health protagonists have been arguing the case for decades, but there is a new sense of urgency when it is linked with mounting concerns about climate change.
The key message is that we must move towards a more sustainable social policy. That means preventing what we can-probably preventing three-quarters of all chronic disease; pursuing the goals of sustainable development by preventing chronic disease; preventing disease by means of sustainable development; and releasing resources so that we can sustain our capacity to manage unavoidable disease in the longer term. If we do this, there is a double prize to be enjoyed-better health and quality of life, and more efficient use of resources, which in turn safeguards the future health and well-being of our children and grandchildren, the long-term viability of our health and social care services, and the natural resources on which human life depends.
Anna Coote is the Commissioner for Health on the UK Sustainable Development Commission. She is a policy analyst and writer specialising in health and social policy, sustainable development and public involvement. She is a Fellow of the Royal Society of Public Health.
1WHO initiative on depression, 2007
2 The Lancet Vol 370 September 8, 2007
3 The Lancet Vol 369 January 20, 2007 169 Comment Are lipid-lowering guidelines evidence-based?
5 WHO Europe, 2005, Health and Climate Change: the "now" and "how".