Planetary health, ecological public health relationship between climate change and public health globally and locally.Part of Birmingham University International Masters seminar series

1. Save the planet or save the NHS?
A story of sustainable development, resilience and
health , thinking globally acting locally
John Middleton
President-Elect UK Faculty of Public
Health

2. Public health:
‘promoting health, preventing disease, prolonging life through
the organised efforts of society’
Sustainable development:
‘protecting resources from one generation to the next’
Environmental justice:
‘the pursuit of equal justice and equal protection under the law
for all environmental statutes and regulations without
discrimination based on race, ethnicity, and /or socioeconomic
status.’
Security:
freedom from danger, social, military, environmental

3. The history of human health and
environmental health improvement in the
UK go together
Global health and UK health are
interrelated
Health promotion Is green promotion
Health, sustainable development,
reducing inequalities and security are
interrelated
We have been paralysed by health
service reorganisation- but could the
health service benefit by ‘thinking global
and acting local’?

4. Part 1 –Thinking global

6. • Food and obesity
• Physical activity
• Travel related
trauma and death
• Access to green
space and health

8. Unfair resource use causes illness
and death directly...

9. …there are MUCH greater health
risks for the least empowered though:

11. The Birmingham
Tornado, 2005

19. Save the planet, or save the NHS?
• A short history of public health
• The future of health improvement
• Looking at environment, economy and their
resulting inequalities

20. Save the planet, or save the NHS?
A (very) short history of public
health
• Sanitory revolution

24. Save the planet, or save the NHS?
A (very) short history of public
health
• Inequalities in health
• The economics of health :some
examples

26. Shaw et al.
Critical public health
2001,11:289-304

27. Shaw et al
Critical public health,
2001;11:289-303

30. Source: The poverty site http://www.poverty.org.uk/09/index.shtml

32. CHD Mortality 2000-2005
MALES, Less than 65 years
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
90.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell
FEMALES, Less than 65 years
0.00
5.00
10.00
15.00
20.00
25.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell
PERSONS, Less than 65 years
0.00
10.00
20.00
30.00
40.00
50.00
60.00
2000 2001 2002 2003 2004 2005
Rateper100,000
West Midlands England Sandwell

35. Save the planet, or save the NHS?
The new environmental health
Environmental justice
Ecological public health
The future public health

40. Rockefella Lancet Planetary Health
commission

44. Climate Change occurring faster than
expected?
• IPCC’s 5th Assessment Report
• Increasing rates of:
– Global Greenhouse Gas emissions
– Ice melting (Arctic sea ice, Greenland/Antarctic ice-
sheets, alpine glaciers)
– Sea level rise
– Carbon stored in permafrost = x2 atmospheric carbon

50. Sources of global greenhouse gas emissions
(2000)
From: Stern (2006)
Source: Stern N. The Stern review: the economics of climate change. Cambridge. Cambridge University Press,
2006. under the terms of the click-use licence

52. Growing burden of climate disasters
(UNDP 2007)
• Greatest impacts in developing
countries
• Weather related insurance
losses going up faster than
population, inflation and
coverage
• Climate change may be
contributing
• Increases in floods, droughts,
lightning strikes, intensity of
tropical cyclones

54. = presently suitable, becoming unsuitable by 2050
= presently unsuitable, becoming suitable by 2050
NET CHANGE IN POPULATION AT RISK BY 2050
Rogers D and Randolph S. The global spread of malaria in a future, warmer
world. 2000 Science; 289:1763-1765.

55. Impacts on food prices of global
temperature increases
Source: IPCC WG II (2007).

56. Are the zones
being pushed
south, by
warming?
… and here?
Health Consequences?
Marked wet
summer and
dry winter
Wet summer
and low winter
rainfall
Uniform
rainfall
Marked wet
winter & dry
summer
Low
rainfall
Wet winter & low
summer rainfall
AridWinter dominantWinter
Summer dominant Summer Uniform
Crucial for
wheat-belt
Australia: Climate change, seasonal rainfall
zones, farm yields, health impacts

58. The 1995
Chicago heat
wave led to
approximately
700 heat-
related
deaths in
Chicago over
a period of
five days

59. AUGUST 2003
Temperature distribution
across Europe on 10
August 2003 at 1500hrs
British Summer Time

60. France, August 2003
~14800 deaths (30,000+ in Europe)

61. MORTALITY IN PARIS, 1999-2002 v 2003
peak: 13 Aug

62. Intervention measures can reduce
impacts Hajat et al 2010
• Short term strategies
– Weather based warning systems
– Heat advice
• Long term strategies
– Improve care of elderly
– Housing design
– Reduce urban heat island (more
green spaces, trees)
Reduced impact of 2006 heat
wave in France- 2000 deaths
vs 6500 predicted
Fouillet et al 2008

64. From Alcamo and Heinrichs, 2002. In: Dialogue on Water and Climate, 2003.
Water critical regions
Medium water stress today & future increase in stress plus HDI>0.8
A2 scenario, ECHAM4, 2020s

66. Health impacts of floods in low
income countries
 Immediate deaths and injuries
 Infectious diseases - leptospirosis, cholera and diarrhoeal
diseases, hepatitis, respiratory diseases, vector-borne
diseases e.g. Rift Valley fever, malaria.
 (NB floods may also wash away vector breeding sites e.g.
highland Tanzania 1997)
 Secondary to economic losses
 Long term mental health effects
- depression, suicide

67. Floods: impacts on health in UK
• Immediate - death, injuries, hypothermia,
electrocution
• Near-term - small risk of gastro-intestinal
infections and respiratory disease
• Near-Long term (>6 months) - mental
health consequences. e.g. In 2000 after
Lewes floods 48% adults showed
‘Psychological distress’ compared with
12% controls
• Increased demands on health system
Methods: Systematic literature
review of published
epidemiological studies Hajat et
al 2003

68. Possible flooding in the UK by 2080s

70. Many millions more people are projected to be flooded
every year due to sea-level rise by the 2080s
Source: IPCC Wg II, TSI 2007.

72. Ten tips for better health: Dave Gordon
– don’t be poor, if you can stop, if you cant, try not to be poor for
long
– don’t have poor parents
– own a car
– don’t work in a stressful low paid manual job
– don’t live in a damp house
– be able to afford a foreign holiday and sunbathe
– practice not losing your job and not becoming unemployed
– take up all the benefits you are entitled to
– don’t live next to a busy road or a polluting factory
– learn how to fill in complex housing benefit asylum applications
before you are homeless and destitute

74. From Alcamo and Heinrichs, 2002. In: Dialogue on Water and Climate, 2003.
Water critical regions
Medium water stress today & future increase in stress plus HDI>0.8
A2 scenario, ECHAM4, 2020s

75. Fairer and
more sustainable
global health…

76. The world map reflecting production related to climate change.
“Climate Change presents the biggest threat to health in the 21st Century” The Lancet (373;9697 pp 1659-
1734, May 16-22 2009).
Who produces the greenhouse gases?

77. Who bears the burden?
The world map reflecting mortality related to climate change.
“Climate Change presents the biggest threat to health in the 21st Century” The Lancet (373;9697 pp 1659-
1734, May 16-22 2009).

78. • All based on an
unsustainable
economic model
• consumerism
• status
• trust
• social cohesion
• Unequal societies are
less sustainable

82. Health co-benefits
1. Traditional person focussed benefit
– Physical activity, diet, mental health, trauma, air
pollution…
2. Benefits for health care system
– Congruent with policy direction for many health care
systems: care closer to home, empowered, self
care, better use of drugs, better use of ICT,
prevention
3. Benefits for international (health) inequity
– Cost effective leap frogging from pre-industrial, pre-
carbon to post carbon, missing out high carbon step
in the middle
– Justice: Contraction and convergence
– Energy: Concentrated solar power (CSP), much
from warmer and poorer countries

86. Within 6 hours, deserts receive more energy than the world uses in a year.

87. COP21 Paris Agreement

88. Food and Agriculture Sector
• Source of 10-12% of global greenhouse-gas emissions
• Change in land-use (eg. deforestation) significant contributor
to global emissions (adds further 6-17%)
• Total emissions from sector set to rise by up to 50% by 2030
• Four-fifths (80%) of total emissions in sector arise from
processes involved in livestock production

89. Pathways to health

90. Health effects
• Case studies: UK and the city of São Paulo, Brazil
• Assumed that 30% reduction in livestock production would
decrease consumption of animal source saturated fat by 30%
• Estimated association of intake of animal source saturated fat
with risk of ischaemic heart disease
• Substantial benefits from decreased burden of heart disease
– UK: ~15%↓ (~ 18,000 premature deaths averted)
– São Paulo: ~16%↓ (~ 1000 premature deaths averted)

91. SUMMARY
[1] There is strong evidence that greenhouse gas emissions
from the burning of fossil fuels are changing the global
climate
[2] The projected rate and magnitude of change will have
adverse impacts on ecological systems and populations
in many regions, especially in low income countries
where the capacity to adapt is limited
[3] The challenge is to ensure more equitable but
sustainable development that enables human societies
to live within the Earth’s regenerative capacity

92. Carbon footprint of the National Health Service

93. Procuring for Carbon Reduction
• NHS carbon footprint 18.6 MtCO2
• 59% related to upstream goods and services procured, (11
MtCO2)
• P4CR – Roadmap, guidance and pilots
• Carbon Disclosure Project
• Sustainable Food guide for hospitals
• Energy efficiency guide for
medical devices

94. Part 2- Acting local

95. Welcome to Sandwell

96. Welcome to Sandwell

97. Neptune forge 1930

98. Neptune health park, 1999

99. ‘health promotion is green promotion’
– sound housing policy
– education: esp: early years
– economics -inequalities in income
– cycling and walking
– tobacco control
– Community nutrition: local agriculture and food
cooperatives
Ottawa charter: healthy public
policy

100. Save the planet, or save the NHS?
Sustainable development =
resilience
Local food supply

102. The food desert becomes
the fat swamp

104. Salop drive and Ideal for All Growers

107. Save the planet, or save the NHS?
Sustainable development =
resilience
• Community cohesion
• Community support networks
• Community advice and money

109. Save the planet, or save the NHS?
Sustainable development = resilience
Cycling and walking
Safe routes to school
Plan settlements to reduce car useage

113. Supportive environments Sandwell :
Hateley Heath : new playgrounds

117. Supportive environments: Hateley Heath housing

118. Supportive environments:
Hateley Heath housing

119. Supportive environments: Hateley Heath housing

122. Options for
life ife self
built
community
centre

123. Getting research into practice? John Middleton Lancet Public Health Research
Conference 29th November 2013
A box plot of the
Baseline SAP
measures for the
Sandwell MBC
housing stock,
1st April 2001, by
housing type,
n=25,595 dwellings

124. Getting research into practice? John Middleton Lancet Public Health Research
Conference 29th November 2013
A box plot of the
Baseline SAP
measures for
the Sandwell
MBC housing
stock,
31st March
2011, by
housing type,
n=25,595
dwellings

125. Birmingham
Sandwell /
Urban Living
Smart
housing
manifesto
2004

126. i- House,
demonstration house
West Bromwich 2008

127. Good corporate citizen award
38 apprentices
Rationalisation of offcies : 6
leases surrendered
890 tonnes of CO2 reduction
£200k saved

128. COP21 Paris Agreement

129. COP21 Paris Agreement

130. COP21 Paris Agreement

131. COP21 Paris Agreement

132. COP21 Paris Agreement

133. COP21 Paris Agreement

134. COP21 Paris Agreement

135. COP21 Paris Agreement
‘Climate complacency’

136. COP21 Paris Agreement

137. The UK government has even
imposed a legal obligation upon
itself, under the Infrastructure Act
2015, to “maximise economic
recovery” of the UK’s oil and gas.

141. COP21 Paris Agreement

142. COP21 Paris Agreement

144. In the decade between 2001 and 2011, global military
spending increased by an estimated 92 percent, according
to Stockholm International Peace Research, although it fell
by 1.9 percent in real terms in 2013 to $1,747 billion. At the
same time, according to the draft of a new study from the
International Peace Bureau (1), almost 10 gigatons of
carbon dioxide equivalent has been released into the
atmosphere. According to the Global Carbon Project, 2014
emissions are set to reach a record high. Could there be
some connection between rising military expenditures and
rising carbon emissions?

151. The green recovery ?

153. Conclusions
Policies that address both public health and climate change
are more attractive than focusing on either in isolation.
The health gains associated with climate change mitigation
policies should feature in Climate Change negotiations
A ‘low carbon’ world could be a healthier world

154. Thank you
John Middleton
Johnmiddleton@phonecoop.coop

155. Action now…
1. SDC Good Corporate Citizenship
toolkit
– www.corporatecitizen.nhs.uk/
2. NHS Carbon Trust Management
Programme
– http://www.carbontrust.co.uk/
carbon/publicsector/nhs/
3. Sustaining a Healthy Future
– www.fph.org.uk
4. NHS Confederation briefings
– http://www.nhsconfed.org/Publications/
briefings/Pages/Briefings.aspx
5. NHS Carbon Reduction Strategy
and 2030 health care scenarios
– www.sdu.nhs.uk
See notes of this slides for some of the most important specific actions

156. References
• Climate and Health Council (www.climateandhealth.org)
Global health, global warming, personal and professional
responsibility, Cambridge Medicine, Pencheon D, Vol 2, No 22, 2008
• Stott R, Healthy response to climate change, BMJ 2006;332;1385-1387
• Gill M, Why should doctors be interested in climate change?
BMJ Jun 2008; 336: 1506
• Griffiths J, Alison Hill, Jackie Spiby and Mike Gill, Robin Stott Ten
practical actions for doctors to combat climate change, BMJ
2008;336;1507
• Sustaining a healthy future: www.fph.org.uk
• Griffiths J et al, The Health Practitioner's Guide to Climate Change,
Earthscan 2009
• Pencheon D, Health services and climate change: what can be done?
J Health Serv Res Policy. Editorial Jan 2009
• UCL Health Commission/Lancet: Managing the Health effects of
Climate Change. May 2009
• The health benefits of tackling climate change, Wellcome/LSHTM, Nov
2009
• Sustainable Development Commission: http://www.sd-
commission.org.uk/pages/health.html