HEALTH PROMOTION CHALLENGES |
Emerging health issues: the widening challenge for population health promotion
National Centre for Epidemiology and Population Health, Australian National University, Canberra, Australia
Address for correspondence: Colin D. Butler, Senior Research Fellow in Global Health, School of Health and Social Development, Faculty of Health, Medicine, Nursing and Behavioural Sciences, Deakin University, 221 Burwood Hwy, Burwood 3125 Victoria, Australia. E-mail: colin.butler{at}deakin.edu.au
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SUMMARY |
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The spectrum of tasks for health promotion has widened since the Ottawa Charter was signed. In 1986, infectious diseases still seemed in retreat, the potential extent of HIV/AIDS was unrecognized, the Green Revolution was at its height and global poverty appeared less intractable. Global climate change had not yet emerged as a major threat to development and health. Most economists forecast continuous improvement, and chronic diseases were broadly anticipated as the next major health issue.
Today, although many broadly averaged measures of population health have improved, many of the determinants of global health have faltered. Many infectious diseases have emerged; others have unexpectedly reappeared. Reasons include urban crowding, environmental changes, altered sexual relations, intensified food production and increased mobility and trade. Foremost, however, is the persistence of poverty and the exacerbation of regional and global inequality.
Life expectancy has unexpectedly declined in several countries. Rather than being a faint echo from an earlier time of hardship, these declines could signify the future. Relatedly, the demographic and epidemiological transitions have faltered. In some regions, declining fertility has overshot that needed for optimal age structure, whereas elsewhere mortality increases have reduced population growth rates, despite continuing high fertility.
Few, if any, Millennium Development Goals (MDG), including those for health and sustainability, seem achievable. Policy-makers generally misunderstand the link between environmental sustainability (MDG #7) and health. Many health workers also fail to realize that social cohesion and sustainability—maintenance of the Earth's ecological and geophysical systems—is a necessary basis for health.
In sum, these issues present an enormous challenge to health. Health promotion must address population health influences that transcend national boundaries and generations and engage with the development, human rights and environmental movements. The big task is to promote sustainable environmental and social conditions that bring enduring and equitable health gains.
Key words: sustainability; transitions; globalization; health promotion
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INTRODUCTION |
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The Ottawa Charter (1986) was forged only 8 years after the historic Alma Ata meeting, which had declared Health for All by 2000. With hindsight, the goal of shaping a new and healthier world was already in jeopardy (Werner and Sanders, 1997
). Perhaps, aware of this nascent weakening of the prospects for population health, the global health promotion community called for the revitalization of ambitious large-scale thinking. New strategies were devised to energize healthy individual and community behaviours, reflected in phrases such as ‘healthy choices should be easy choices’ and ‘healthy public policy’. Nevertheless, over the ensuing two decades, the adverse social, economic and environmental trends that were already beginning to jeopardize, Health for All in 1986 have strengthened. Further, economic globalization, with increasingly powerful transnational companies shaping global consumer behaviours, has tended to make unhealthy choices the easier choices, including cigarettes, fast-food diets, high-sugar drinks, automated (no-effort) domestic technologies and others. These changes have occurred despite an increased understanding of the fundamental determinants of population health. Some of these foundations of health are at risk, and in some regions, hard-won health gains have recently been reversed. Recent attempts to re-focus attention on global public goods, such as in the Millennium Development Goals (MDGs), are weak in comparison to the scale of today's problems.
There is an urgent strategic need for health promotion to engage with the international discourse on ‘sustainability’. To date much of the discussion and policy development addressing ‘sustainable development’ has treated the economy, livelihoods, energy supplies, urban infrastructure, food-producing ecosystems, wilderness conservation and convivial communal living as if they were ends in themselves: the goals of sustainability. Clearly, those are all major assets that we value. But their value inheres in their being the foundations upon which the health and survival of populations depend. The ultimate goal of sustainability is to ensure human well-being, health and survival. If our way of living, of managing the natural environment and of organizing economic and social relations between people, groups and cultures does not maintain the flows of food and materials, freshwater supplies, environmental stability and other prerequisites for health, then that is a non-sustainable state.
In this paper, we discuss several of the emerging health issues. Lacking space to be comprehensive, we focus upon infectious diseases, the decline in life expectancy in several regions, the increasingly ominous challenge of large-scale environmental change and how globalization, trade and economic policy relate to indices of public health. Other emerging health issues not discussed here also reflect major recent shifts in human ecology. They too pose great environmental or social risks to health. They include urbanization, population ageing, the breakdown of traditional culture and relations and the worldwide move towards a more affluent diet and its associated environmentally damaging food production methods (McMichael, 2005).
There are two fundamental causes for the selected emerging health risks. First, most important, is the global dominance of economic policies which accord primacy to market forces, liberalized trade and the associated intensification of material throughput at the expense of other aspects of social, environmental and personal well-being. For millions in the emerging global middle class, materialism and consumerism have increased at the expense of social relations and leisure time. The gap between rich and poor, both domestically and internationally, has increased substantially in recent decades (United Nations Development Program, 2005). Inequality between countries has weakened the United Nations and other global institutions. Foreign aid has declined, replaced by claims that market forces will reduce poverty and provide public goods, including health care and environmental stability.
The second fundamental threat to the improvement and maintenance of population health is the recent advent of unprecedented global environmental changes. The scale of the human enterprise (numbers, economic intensity, waste generation) is now such that we are collectively exceeding the capacity of the planet to supply, replenish and absorb. Stocks of accessible oil appear to be declining. Meanwhile, the global emissions of carbon dioxide from fossil fuel combustion, and of other greenhouse gases from industrial and agricultural activities, are rapidly and now dangerously altering the global climate. Worldwide, land degradation, fisheries depletion, freshwater shortages and biodiversity losses are all increasing. The human population, now exceeding 6500 million, continues to increase by over 70 million persons per annum. The number of chronically undernourished people (over 800 million) is again increasing, after gradual declines in the 1980s and early 1990s (Food and Agricultural Organization, 2005). Famines in Africa remain frequent, and 300 million undernourished people live in India alone. Meanwhile, hundreds of millions of people are overnourished and, particularly via obesity, will incur an increasing burden of chronic diseases, especially diabetes and heart disease.
The scale of these health risks is unprecedented. The global food crises of the 1960s were averted by the subsequent Green Revolution. Today, a broader-based revolution is required, not only to increase food production (again), but also to promote peace and international cooperation, slow climate change, ensure environmental protection, eliminate hunger and extreme poverty, quell resurgent infectious diseases and neutralize the obesogenic environment. This enormous population health task goes well beyond that envisaged by the MDGs.
It is, of course, difficult to get an accurate measure of these emerging risks to health. Some, such as climate change, future food sufficiency and the threat from weapons of mass destruction, may prove soluble. However, because of the inevitable time lag in understanding, evaluating and responding to these complex problems, the health promotion community should now take serious account of them. There is an expanding peer-reviewed literature on these several emerging problem, areas. To constrain health promotion by sidestepping them would be to risk being ‘penny wise but pound foolish’.
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EMERGING AND RE-EMERGING INFECTIOUS DISEASES |
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In the early 1970s, it was widely assumed that infectious diseases would continue to decline: sanitation, vaccines and antibiotics were at hand. The subsequent generalized upturn in infectious diseases was unexpected. Worldwide, at least 30 new and re-emerging infectious diseases have been recognized since 1975 (Weiss and McMichael, 2004
). HIV/AIDS has become a serious pandemic. Several ‘old’ infectious diseases, including tuberculosis, malaria, cholera and dengue fever, have proven unexpectedly problematic, because of increased antimicrobial resistance, new ecological niches, weak public health services and activation of infectious agents (e.g. tuberculosis) in people whose immune system is weakened by AIDS. Diarrhoeal disease, acute respiratory infections and other infections continue to kill more than seven million infants and children annually (Bryce et al., 2005). Mortality rates among children are increasing in parts of sub-Saharan Africa (Horton, 2004).
The recent upturn in the range, burden and risk of infectious diseases reflects a general increase in opportunities for entry into the human species, transmission and long-distance spread, including by air travel. Although specific new infectious diseases cannot be predicted, understanding of the conditions favouring disease emergence and spread is improving. Influences include increased population density, increasingly vulnerable population age distributions and persistent poverty (Farmer, 1999). Many environmental, political and social factors contribute. These include increasing encroachment upon exotic ecosystems and disturbance of various internal biotic controls among natural ecosystems (Patz et al., 2004). There are amplified opportunities for viral mixing, such as in ‘wet animal markets’. Industrialized livestock farming also facilitates infections (such as avian influenza) emerging and spreading, and perhaps to increase in virulence. Both under- and over-nutrition and impaired immunity (including in people with poorly controlled diabetes—an obesity-associated disease now increasing globally) contribute to the persistence and spread of infectious diseases. Large-scale human-induced environmental change, including climate change, is of increasing importance.
These causes of infectious disease emergence and spread are compounded by gender, economic and structural inequities, by political ignorance and denial (particularly obvious with HIV/AIDS in parts of sub-Saharan Africa). Iatrogenesis (as with HIV in China and partial tuberculosis treatment in many developing countries), vaccine obstacles and the ‘10/90 gap’ (whereby a minority of health resources are directed towards the most severe health problems) add to this unstable picture.
We inhabit a microbially dominated world. We should therefore frame our relations with microbes primarily in ecological (not military) terms. The world's infectious agents, perhaps with the exceptions of smallpox and polio, will not be eliminated. But much can be done to reduce human population vulnerability and avert conditions conducive to the occurrence of many infectious diseases. This is an important focus for health promotion.
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DECLINING REGIONAL LIFE EXPECTANCY |
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The upward trajectory in life expectancy forecast in the 1980s has recently been reversed in several regions, especially in Russia and sub-Saharan Africa (McMichael et al., 2004b
). These could, in principle, be either temporary aberrations or unconnected to one another. However, identifiable factors appear to link these declines.
The fall in life expectancy since 1990 in Russia is unprecedented for a technologically developed country. Many proximal causes have been documented, including alcoholism, suicide, violence, accidents and cardiovascular disease. Multiple drug-resistant tuberculosis is widespread in Russian prisons. Collectively, these factors reflect social disintegration and crisis (Shkolnikov et al., 2004).
In sub-Saharan Africa, HIV/AIDS has combined with poverty, malaria, tuberculosis, depleted soils and undernutrition (Sanchez and Swaminathan, 2005), deteriorating infrastructure, gender inequality, sexual exploitation and political taboos to foster epidemics that have reduced life expectancy, in some cases drastically. Adverse health and loss of human capital, caused by disease and the out-migration of skilled adults, have helped to ‘lock-in’ poverty. More broadly, indebtedness and ill-judged economic development policies, including charges for schooling and health services, have also impaired population health in Africa, following decades of earlier improvement. The intersectoral implications for health promotion are clear.
Conflict, most notoriously in Rwanda (André and Platteau, 1998), has also occurred on a sufficient scale to temporarily reduce life expectancy for some populations in sub-Saharan Africa. Age pyramids skewed to young adults have almost certainly played a role in this violence (Mesquida and Wiener, 1996), together with resource scarcity, pre-existing ethnic tensions, poor governance and international inactivity when crises develop.
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GLOBAL ENVIRONMENTAL CHANGE |
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Sustainable population health depends on the viability of the planet's life-support systems (McMichael et al., 2003a
). For humans, achieving and maintaining good population health is the true goal of sustainability, dependent, in turn, on achieving sustainable supportive social, economic and environmental conditions. Today, however, human-induced global environmental changes pose risks to health on unprecedented spatial and temporal scales. These environmental changes, evident at worldwide scale, include climate change, biodiversity loss, downturns in productivity of land and oceans, freshwater depletion and disruption of major elemental cycles (e.g. environmental nitrification) (McMichael, 2002). In coming decades, these long-term change processes will exact an increasing health toll via physical hazards, infectious diseases, food and water shortages, conflict and an inter-linked decline in societal capacity.
We currently extract ‘goods and services’ from the world's natural environment about 25% faster than they can be replenished (Wackernagel et al., 2002). Our waste products are also spilling over (e.g. carbon dioxide in the atmosphere). Hence, there is now little unused global ‘biocapacity’. We are thus bequeathing an increasingly depleted and disrupted natural world to future generations. Although the resultant adverse health effects are likely to impinge unequally and, often, after time lag, this decline could eventually harm, albeit at varying levels, the entire human population.
Global climate change now attracts particular attention. Fossil fuel combustion, in particular, has caused unprecedented concentrations of atmospheric greenhouse gases. The majority expert view is that human-induced climate change is now underway (Oreskes, 2004). The power of storms, long predicted by climate change modellers to increase (Emanuel, 2005), appears (in combination with reduced wetlands and failure to maintain infrastructure) to have contributed to the 2005 New Orleans flood. WHO has estimated that, globally, over 150 000 deaths annually result from recent change in the world's climate relative to the baseline average climate of 1961–1990 (McMichael et al., 2004a). This number will increase for at least the next several decades.
The most direct risks to future health from climate change are posed by heatwaves, exemplified by the estimated 25 000 extra deaths in Europe in August 2003, storms and floods. Climate-sensitive biotic systems will also be affected. This includes: (i) the vector–pathogen–host relationships involved in transmission of various infections, vector-borne and other, (ii) the production of aeroallergens and (iii) the agro-ecosystems that generate food. Recent changes in infectious disease occurrence in some locations—tickborne encephalitis in Sweden (Lindgren and Gustafson, 2001), cholera outbreaks in Bangladesh (Rodó et al., 2002) and, possibly, malaria in the east African highlands (Patz et al., 2002)—may partly reflect regional climatic changes.
Changes in the world's climate and ecosystems, biodiversity losses and other large-scale environmental stresses will, in combination, affect the productivity of local agro-ecosystems, freshwater quality and supplies and the habitability, safety and productivity of coastal zones. Such impacts will cause economic dislocation and population displacement. Conflicts and migrant flows are likely to increase, potentiating violence, injury, infectious diseases, malnutrition, mental disorders and other health problems.
These and other categories of global environmental changes, often acting in combination, pose serious health risks to current and future human societies (Figure 1). The important message here is that, increasingly, human health is influenced by socio-economic and environmental changes that originate well beyond national or local boundaries. The major, perhaps irreversible, changes to the biosphere's life-support system, including its climate system, increase the likelihood of adverse inter-generational health impacts.
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EMERGING HEALTH ISSUES AND THE MDGs |
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In 2000, UN member states agreed on eight MDGs, with targets to be achieved by 2015. Four MDGs refer explicitly to health outcomes: eradicating extreme poverty and hunger, reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other infectious diseases. Figure 2 shows how the MDG topic areas relate to the emerging health issues discussed here.
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Many of the MDG targets are already in jeopardy. Although all are inter-linked, the ‘environmental sustainability’ MDG has fundamental long-term importance. Without it, the other concomitants of sustainability—economic productivity, social stability and, most importantly, population health—are unachievable. An additional reason to advance the MDGs is because that will slow population growth rates and thus reduce our collective ecological footprint (Wackernagel et al., 2002
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THE FALTERING DEMOGRAPHIC AND EPIDEMIOLOGICAL TRANSITIONS |
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Both the demographic and epidemiological transitions are less orderly than predicted. In some regions, declining fertility rates have overshot the rate needed for an economically and socially optimal age structure. In other countries, population growth has declined substantially because of the reduced life expectancy discussed earlier (McMichael et al., 2004b
). Relatedly, the future health dividend from recent reductions in poverty may be lower than that once hoped because of the emergence of the non-communicable ‘diseases of affluence’, including those due to obesity, dietary imbalances, tobacco use and air pollution.
In the 1960s, there was widespread concern over imminent famine, affecting much of the developing world. This problem was largely averted by the ‘Green Revolution’ during the 1970s and 1980s. Meanwhile, the earlier view that unconstrained population growth had little adverse impact upon environmental amenity and other conditions needed for human wellbeing gained strength. However, in the last few years, this position has been re-evaluated (United Nations Department of Economic and Social Affairs Population Division, 2005). There is an increasing recognition of the adverse effects of rapid population growth, especially in developing countries, including from high unemployment when population increase outstrips opportunity.
Some argue that unsustainable regional population growth is characterized by age pyramids excessively skewed to young age, high levels of under- and unemployment and intense competition for limited resources. These circumstances jeopardize public health. Where there is also significant inequality and/or ethnic tension, catastrophic violence can result (André and Platteau, 1998; Butler, 2004).
Although Russia and parts of sub-Saharan Africa have vastly different demographic characteristics, there are important similarities in their recent declines in life expectancy. Both regions have a significant scarcity of public goods for health (Smith et al., 2003). In Russia, there is a lack of equality, safety and public health services. In many parts of sub-Saharan Africa, there is inadequate governance and food security as well as public safety and public health services. Viewed on an even larger scale, the miserable conditions for millions of people in these regions accord with a global class system, in which privileged groups in both developed and developing countries act (often in concert) to protect their own position at the expense of others (Butler, 2000: Navarro, 2004).
The growth of the global population and its environmental impact means that we may now be less than a generation from exhausting the biosphere's environmental buffer, unless we can rein in our excessive demands on the natural world. If not, then the demographic and epidemiological transitions, already faltering, will be further affected. Population growth may then slow not only because of the usual development-associated fertility decrease but also because of persistently high death rates elsewhere.
Meanwhile, the growing awareness of these issues, the publicity of the MDGs, the ongoing campaigns against poverty and Third-World debt, calls for public health to address political violence and the renewed vigour of social movements for health (McCoy et al., 2004) affords new potential resources and collaborations to the global health promotion effort. These should be welcomed and acted upon.
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GLOBALIZATION, TRADE, ECONOMIC POLICY AND FALTERING GLOBAL PUBLIC HEALTH: TOWARDS A UNIFYING EXPLANATION |
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The health benefits of the complex social, cultural, trade and economic phenomena that comprise ‘globalization’ are vigorously debated. Although differing viewpoints (Bettcher and Lee, 2002
) are inevitable, the strength of this debate signifies that the net gain for population health from globalization is uncertain. Several important health dividends often attributed to globalization have plausible alternative explanations. Many health gains in developing countries may be the time-lagged result of development policies and technologies introduced before the era of structural adjustment and partial economic liberalization, which heralded modern globalization. The accelerated demographic transition in China is a greatly under-recognized role in that country's rapidly growing wealth, as were China's earlier investments in health and education.
Proponents of gobalization assert that free trade, via ‘comparative advantage’, will benefit all populations. In reality, wealthy populations have long tilted the economic and political playing field in ways that ensure a disproportionate flow of trade benefits towards privileged populations (Mehmet, 1995). A powerful real-politic impediment to the complete removal of trade-distorting national subsidies is that this would probably entail a relatively greater loss for wealthy populations than for the poor. In contrast, the economic disadvantages incurred to date through partial market deregulation have largely been confined to relatively poor and politically weak populations in developed countries.
The pre-eminence of modern economic theory presents a major obstacle for health promoters. The narrow focus of the World Trade Organization, which largely discounts the often adverse social, environmental and public health impacts of trade, underscores the problem. Dominant economic theory evolved when environmental limits were considered remote (Daly, 1996). These theories assume that increased per capita income will offset the non-costed losses, whether these affect social welfare, environmental resources or public health. Critiques of these theories note that the harshest costs of modern economic practices fall upon ecosystems and populations with little current economic power or value, including generations not yet born.
Mobility of capital brings development, but capricious capital flight can create great hardship, including for public health. Deregulated labour conditions facilitate cheap goods, but they concentrate occupational health hazards among powerless workers. Increased labour mobility and steep economic gradients weaken family and community structures, contribute to ‘brain drain’ and promote inter-ethnic tensions. Many indices of inequality, including in health, income and environmental risk, have risen in recent decades (Butler, 2000; Parry et al., 2004).
Most critical commentary of globalization (George, 1999) is conceptual, emphasizing the adverse experiences of the disadvantaged and unborn. In contrast, the experiential feedback of the main beneficiaries of modern economic policy is largely positive. A major challenge for the promoters of health (and other forms) of justice is to adduce stronger evidence to convince policy-makers (themselves largely beneficiaries of globalization) to promote public goods, even though this may diminish the relative privilege of policy-makers and their constituencies. This is a difficult but essential task for health promotion.
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EMERGING HEALTH ISSUES: THE CHALLENGES FOR HEALTH PROMOTION |
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In sum, global and regional inequality, narrow and outdated economic theories and an ever-nearing set of global environmental limits endanger population health. On the positive side of the ledger, there have been some gains (e.g. literacy, information sharing and food production, and new medical and public health technologies continue to confer large health benefits). Overall, though, reliance on economic, especially market-based, processes to achieve social goals and to set priorities and on technological fixes for environmental problems is poorly attuned to the long-term improvement of global human well-being and health. For that, a transformation of social institutions and norms and, hence, of public policy priorities is needed (Raskin et al., 2002
). Population health can be a powerful lever in that process of social change, if health promotion can rise to this challenge. Many of these contemporary risks to population health affect entire systems and social–cultural processes, in contrast to the continuing health risks from personal/family behaviours and localized environmental exposures. These newly recognized risks to health derive from demographic shifts, large-scale environmental changes, an economic system that emphasizes the material over other elements of well being and the cultural and behavioural changes accompanying development. Together, these emerging health risks present a huge challenge to which the wider community is not yet attuned. The risks fall outside the popular conceptual frame wherein health is viewed in relation to personal behaviours, local environmental pollutants, doctors and hospitals. In countries that promote individual choice and responsibility, there are few economic incentives for the population's health.
Health promotion must, of course, continue to deal with the many local and immediate health problems faced by individuals, families and communities. But to do so without also seeking to guide socio-economic development and the forms and policies of regional and international governance is to risk being ‘penny wise but pound foolish’. Tackling these more systemic health issues requires multi-sectoral policy coordination (Yach et al., 2005) at community, national and international levels, via an expanded repertoire of bottom-up, top-down and ‘middle-out’ approaches to health promotion.
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CONCLUSION |
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The essential principles of the Ottawa Charter remain valid. However, today's health promotion challenge extends that foreseen in 1986 and requires work at many levels. There is need for proactive engagement with international agencies and programs that bear on the socio-economic fundamentals in disadvantaged regions/countries. Many low- and middle-income countries require financial aid from donor countries to achieve the health-related MDGs, to deal with emerging and re-emerging infectious diseases and to counter the emerging health risks from human-induced global environmental problems. Linkages between the health sector and civil society, including those struggling to promote development, human rights, human security and environmental protection, should be strengthened.
We need to understand that ‘sustainability’ is ultimately about optimizing human experience, especially well-being, health and survival. This requires changes in social and political organization and in how we design and manage our communities. We must live within the biosphere's limits. Health promotion should therefore address those emerging population health influences that transcend both national boundaries and generations. The central task is to promote sustainable environmental and social conditions that confer enduring and equitable gains in population health.
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