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International Institute for Sustainable Development (IISD)

Report Part Title: Introduction: The health–environment nexus

Report Title: Health in the Global Environmental Agenda: Report Subtitle: A policy guide Report Author(s): Elizabeth Willetts, Liz Grant, Jennifer Bansard, Pia M. Kohler, Tatjana Rosen, Paola Bettelli and Mika Schröder Report Editor(s): Pamela Chasek, Chris Spence Published by: International Institute for Sustainable Development (IISD) (2022) Stable URL:

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1.0 Introduction: The health–environment nexus

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Health in the Global Environmental Agenda

1.1 The Purpose of This Guide This guide seeks to facilitate a common understanding and build a bridge between the health and environmental sectors on global environmental governance. The guide focuses on four main areas: biodiversity, climate change, pollution, and food systems. Across agendas, the United Nations (UN) is prioritizing the interconnection of biodiversity loss, climate change, and pollution, as well as integrated approaches to address what the UN Environment Programme (UNEP, 2021) calls a triple planetary crisis. At the same time, food system transformation is a leading issue on both environmental and health agendas because current models accelerate both environmental degradation and the prevalence of diet-related disease. All four areas have profound impacts on human health in acute and chronic ways. This guide aims to achieve multi-sectoral engagement on these issues. It analyzes the frameworks of select global environmental agreements through a health lens, providing conceptual links and technical input on health concepts that can be used to de- silo internal expertise.

The calls for increased cross-sectoral “engagement” at the health–environment nexus are broad.1 Challenges exist on both sides of the nexus. The health sector cites barriers to broad uptake of health considerations across sectors. The environmental sector has limited technical capacity to adequately consider and frame health issues in its work, though its work impacts health outcomes. Broadly speaking, meaningful participation by either environmental or health actors in each other’s decision-making forums is surprisingly lacking. This policy guide intends to investigate more closely what “engagement” means in a practical sense by evaluating entry points within negotiations. It further reviews the presence of health actors and issues in selected multilateral environmental agreements (MEAs).

These concepts can be dense and as daunting as learning a new language. But by placing elements of global health policy, global environmental law, and simplified technical concepts side by side, we offer an opportunity to consider integrating joint ideas and building capacity. With this guide, we hope to enhance discussion at the health–environment nexus.

1.2 Multi-Sectoral Health Governance A clean environment and intact ecosystems are essential for the health and well-being of humans and all other living organisms. However, the human impact on the environment has created a series of negative effects on the health of the planet, its ecosystems, and humanity through, for example, new exchanges of microbes, air and water pollution, hazardous wastes, and toxic chemicals.

1 E.g., a) “Most global environmental agreements...cite threats to health as a major concern” (Article 30, WHO, 2020b); b) the 2021 UN High-level Political Forum on Sustainable Development noted challenges in cross- forum engagement and the need for interlinkages between MEA processes (UN Economic and Social Council, 2021), c) World Economic Forum’s (2021) Trade for Tomorrow: A Collective Call to Action to Make Trade Work For All ( all/) ; d) UNEP’s (2019) Global Environment Outlook – GEO-6: Healthy Planet, Healthy People (https://wedocs.; e) the evaluation of the GEF integrated approach from the 60th session in 2021 (see: Evaluation_of_GEF_Integrated%20Approach_for_the_Drivers_of_Environmental_Degradation_0.pdf).

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Health in the Global Environmental Agenda

Many integrated health and environmental decisions incorporated into landmark global agreements over the last 50 years have yet to operationalize.2 One reason for this is that health governance models generally view public health outcomes as being achieved solely through the health sector. However, health sector policies cannot comprehensively address all elements that determine human health (Rasanathan et al., 2018). Moreover, as a whole, institutions and sectors are unfit to manage the externalities they produce—for example, pollution (Dasgupta, 2021). A more effective model would include health and non-health actors in public health decision making and implementation in what is called a multi-sectoral health governance model (Dasgupta, 2021; de Leeuw, 2017).

Many sectoral policies that impact community health and well-being are governed under the global environmental agenda. Yet, most health professionals and other experts are not well connected to these processes (see, for example, World Health Organization [WHO], 2019b). Diverse expertise, such as in public health and epidemiology, is important to inform environmental decision-making bodies (Kohler, 2020). Though there is a new groundswell of interest through organizations like the Wellcome Trust’s Climate and Health programme, the Planetary Health Alliance, and Lancet Planetary Health, and in calls to action by the health sector,3 guidance is needed to channel current momentum and interest on health and environmental issues into meaningful engagement at the nexus of these fields. A key barrier to interdisciplinary work is understanding the language of international environmental law and identifying entry points in the challenging architecture of MEAs. To move forward, major de- siloing needs to occur.

A second reason that health and environmental decisions are not operational is that the adoption of a holistic perspective is slow. Conceptual frameworks that link a healthy environment and healthy people are gaining momentum at the health–environment nexus and include Planetary Health, One Health, and the social and environmental determinants of health (see Box 1). These narratives take a systems approach to health and well-being and connect society to the environment. They should become part of a common vocabulary.

1.3 The Policy Shift Into the Health–Environment Nexus Acknowledgement of the health–environment nexus is growing, as is evident across organizations and forums. At a high level, leaders have signalled an interest in shifting global activities toward integrated and cross-disciplinary work at the health nexus.

Health themes are emerging in global environmental research and decision making. UNEP began promoting Planetary Health themes in its Healthy Environment, Healthy People report in 2016. The Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) decided at its 7th session in 2019 to produce a thematic “nexus” assessment on biodiversity, food, health, and climate. The Dasgupta Review, a recent economic analysis on the environment in a national context sponsored by the United Kingdom Treasury, reinforced how declining biodiversity impacts health, well-being, and food provision, including

2 Including the Stockholm Declaration (1972), the WHO Global Strategy for Health and Environment (1993) (WHA 46.20), and the 2030 Agenda on Sustainable Development (2015). 3 See, for example,

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Health in the Global Environmental Agenda

by contributing to poverty traps (Dasgupta, 2021). The report also emphasized that neither unhealthy environments nor unhealthy people are good for economies.

Independently, but parallel to work on biodiversity–health interlinkages, health became a formal component to the UN Framework Convention on Climate Change (UNFCCC) work on adaptation (Nairobi work programme) in 2013 (UNFCCC, 2013a). The climate–health nexus continues to expand as an emerging evidence-based field as outlined in the 2017 UNFCCC Secretariat synthesis on Human Health and Adaptation. Elite climate scientists and integrative thought leaders now direct the influential Pathfinder Initiative on transformative solutions for a post-carbon society at the London School of Hygiene and Tropical Medicine.4

Box 1. Holistic frameworks for multi-sectoral health governance

Planetary Health

The paradigm for global social and economic policies governing human populations and resources has gradually transitioned over the last 5 decades. Initially, these policies encompassed broad but siloed environmental and development topics. Over time, the paradigm came to include less siloed and more comprehensive analyses under the umbrella of “sustainable development.” The Planetary Health approach to sustainable development takes this narrative to the next level by comprehensively analyzing the environment and human health interlinkages, from local to global scales, in one development paradigm. The field of Planetary Health is driven by worrisome global health trends, a dramatic decline in natural resources, and increasingly erratic global environmental changes whose effects simultaneously impact the economy, equity, and well-being. Framed by the idea of the Anthropocene era, Planetary Health approaches a) recognize the human role in ecological degradation and the cycle of negative impacts degradation has on human health and b) provide an inherent rationale for cross- disciplinary decision-making on social and economic issues at all scales and regions in both short- and long-term scenarios.

One Health

One Health is a cross-sectoral approach recognizing that humans, animals, and plants, by sharing the same environment, have inherent health interlinkages. Developed by the Wildlife Conservation Society in 2004, this concept has recently catapulted into the limelight due to the COVID-19 pandemic and its presumed zoonotic underpinnings. One Health unites the fields of human and veterinary medicine and the livestock sector on overlapping themes, including food safety, zoonoses, microbiome diversity, and antibiotic resistance. Its aim is to harmonize policies that have impacts on multiple sectors. In 2021, this narrative was recognized across MEAs, the G20, and in the decision to establish a new convention on pandemics.

4 See

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Social and Environmental Determinants of Health

The social determinants of health (WHO, 2021j) is now a widely understood concept in public health and clinical medicine. It is an important term largely absent from environmental discourse. The social determinants of health are all the social, non-health reasons a person may be unhealthy or stressed and otherwise not be able to achieve optimum health compared to others in the same society. These include differences in education, urban design and environmental surroundings, and socio-economic status, including gender and forms of discrimination. In a sense, the social determinants are stressors of inequality, disproportionately affecting mental health, exposure to environmental degradation, or access to health care.

As the “determinants of health” concept has broadened to encompass environmental determinants of health, macroscopic issues such as climate change, pollution, and wildlife habitat destruction have come into focus. The quality of air, water, soil, and land and marine ecosystems are all environmental determinants of health.

Together, these socio-ecological determinants of health are key to delivering effective, compassionate, and equitable health care. A child’s development is affected by a lack of access to educational resources, a social determinant, in a similar way to how childhood is affected if lacking access to—or a relationship with—green space, an environmental determinant. Both are fundamental to a holistic approach to physical and mental well- being in medicine.

Global health leaders recognize how non-health sectors impact health outcomes and how the implementation of preventative health measures greatly falls outside public health mandates (Rasanathan, 2021). These non-health sectors are strongly linked to the environment, including transportation, energy, water, and agriculture. The landmark Marmot Reviews in 2010 and 2020 outlined how non-health factors determine health and drive inequities. The WHO (2021n) estimates that these determinants account for 30–55% of health outcomes.

Integration was a key theme at recent global assemblies. The third UN Environment Assembly (UNEA) in 2017 adopted a resolution on environment and health (UNEA, 2018). This resolution affirmed interlinkages between environment and health; the importance of joint work, including on health inequalities; and the need for a precautionary approach. In 2021, the 74th session of the World Health Assembly (WHA, 2021a) adopted a new resolution on the social determinants of health that put in motion an operational framework to measure, assess, and address these determinants across sectors.

Leaders of the global economy echo these ideas. The September 2021 Declaration of the G20 Health Ministers encourages integration for resilience, multi-sectoral actions on the determinants of health, and, among others, that the centre of a “governance transformation of health” includes principles of sustainability, a holistic vision, and a One Health approach (G20, 2021).

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Work to establish a health–environment nexus is in its infancy. Across the UN system, MEAs, and international environmental organizations, there are opportunities to advance dialogue and action to build this nexus.

1.4 Human Right to the Environment Environmental equity and health equity are linked, but the fields of environment and health law remain distinct (Morin & Blouin, 2019). Few institutions link global environment and global health governance in their provisions.

A “breakthrough moment” occurred in October 2021 when the UN Human Rights Council (HRC) adopted a resolution recognizing the human right to a safe, clean, healthy, and sustainable environment: “sustainable development…and the protection of the environment, including ecosystems, contribute to and promote human well-being and…the enjoyment of the highest attainable standard of physical and mental health” (UN HRC, 2021, pp. 1–2).

A merger between human rights and environmental law could significantly change the governance landscape at the health–environment nexus. The human right to a healthy environment is a huge step forward in advancing the Sustainable Development Goals (SDGs) and building common agendas among MEAs. The potential implications of this right include strengthening environmental laws and policies, improving implementation and enforcement, enhancing public participation in environmental decision-making, addressing environmental and social injustices, and healthier ecosystems (Morgera, 2020; UN HRC, 2018).

Global environmental law experts assert that the application of human rights law would reinforce urgency and more broadly shared prioritization of biodiversity conservation issues. It would also contribute to policy coherence on the SDGs and build alliances across sectors, such as with the health sector (Morgera, 2021). It also invites a fundamental reconsideration of chemicals governance. An ideally “safe, clean, healthy” environment would be one where humans are not exposed to unsafe levels of chemicals. This thinking builds momentum for adopting a circular economy and shifting thinking away from pollution as a necessary by- product of growth, production, and consumption.

Climate change law is likely to also advance in new ways. For one, the UN HRC strengthened the effectiveness of this resolution by appointing a new Special Rapporteur on the promotion and protection of human rights in the context of climate change, who will follow and track progress on climate change and equity across the UN (UN HRC, 2021). The climate change Special Rapporteur will join a growing environmental cohort of environmental Rapporteurs, including on human rights and the environment, on toxics and human rights, and on safe drinking water and sanitation.

Advancements in the field of human rights strengthen the foundation of the health– environment nexus.

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