Planetary health Improving human health by healing the planet

The human health impacts of accelerating global environmental change are likely to be the biggest humanitarian challenge of this century.

Samuel Myers, research scientist, Harvard School of Public Health

Summary of a meeting hosted by The Rockefeller Foundation

With insights from

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Introduction from the Rockefeller Foundation

Since its birth more than 100 years ago, The Rockefeller Foundation has worked in public health because it believes good health underpins human progress. Its efforts have ranged from developing the vaccine for Yellow Fever to strengthening disease surveillance systems to advising several Asian and African governments on their new Universal Health Care coverage efforts.

Over time, this focus on public health has flowed into work on the Foundation’s other three “pillars”: improving cities, ecosystems and livelihoods. Bolstering these pillars, the organization believes, best helps meet its two primary goals: advancing inclusive economies that expand opportunities for more

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The Planetary Health meeting was convened by The Rockefeller Foundation and The Lancet with support from The Rockefeller Foundation.

broadly shared prosperity, and building greater resilience by helping people, communities and institutions prepare for, withstand and emerge stronger from acute shocks and chronic stresses.

In this century, the link between environmental change and human health has become ever more apparent. Malaria is arriving in new places as temperatures climb. Global environmental change is causing rare plant species to vanish along with the forests that harbor them. Such plants could be a key ingredient in a life-saving medicine. The alarming rate at which these changes occur could have catastrophic consequences not just on our health, but also on the systems and structures that form the bedrock of humanity. The very survival of our species and civilization is thus at risk. All this begs the question: What if the environment is unable to take care of us because we have not taken care of it?

To consider this interdependency and address the potential health crisis implied by dramatic environmental change, in July 2014 The Rockefeller Foundation and British medical journal The Lancet convened a meeting on “The Future of Planetary Health” at the Foundation’s Bellagio Conference Center in Italy. More than 30 high-level participants, including scientists, entrepreneurs, public health experts, business executives and government leaders met to better understand planetary system disturbances, and to explore possible solutions to future threats. Insights from the meeting flowed into a subsequent smaller Rockefeller Foundation–Lancet Planetary Health Commission meeting.

“The Future of Planetary Health” was the third in the Foundation’s series of high-level meetings focused on imagining a very different future by 2025 in its four pillar areas. By bringing together diverse, sometimes opposing perspectives, the Foundation hopes to help develop vital strategies and solutions that will fortify humanity’s ability to anticipate and adapt to rapidly emerging opportunities and challenges. For more information on the series, please go to www.visionariesunbound.com. The Economist Intelligence Unit wrote this summary report, with the exception of the Introduction and Conclusion, which were written by The Rockefeller Foundation.

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Planetary Health brought together more than 30 experts to explore ways to improve human health by healing the planet

Executive Summary

Humanity’s heavy ecological footprint on the planet is well known. Factories, farms, cars and our consumption patterns have changed the earth and its natural environment in many irrevocable ways. Far less understood is how these environmental changes are influencing human health. Signs have surfaced that point to a startling link between these two areas, and beg for action. These include a rise in the incidence of or exposure to tropical disease such as Dengue fever as temperatures rise in higher latitudes and natural habitats like forests disappear, and a rise in famine, flood, drought and intense storms stemming from climate change.

Now is the time for a focused study on the complex, interdependent and powerful impact of natural systems change on our human health, say prominent scientists such as Richard Horton. Ignoring or failing to address these changes, Horton, The Lancet editor-in-chief argues, threatens our social fabric, systems, structures and civilization.

As evidence mounts and attention shifts to this urgent area, a number of ideas are emerging. Many of these surfaced at a July 2014 “Future of Planetary Health“ meeting, hosted by The Rockefeller Foundation. They range from harnessing data, analytics and predictive modeling to build the business case for different policy and natural resource

The progress we’ve made in global health is only sustainable if we also consider the health of the planetary systems on which human health depends.Judith Rodin, president, The Rockefeller Foundation

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use decisions; to storytelling to inform and incite action; to bringing new players, such as millennials and local communities into the fold to lead behavioral change.

Five of these are believed to be particularly applicable to help solve some of the critical, enmeshed challenges. They are outlined below. These ‘future solutions’, or key recommendations, emerged from discussion among five working groups that focused on the human health impacts of changes in our planet’s climate, biodiversity, land-use and in its marine and freshwater ecosystems:

1. Better governance structures for managing global resources: Coveted global “commons” such as freshwater, air, forests and oceans have not been sufficiently protected, because market economies often fail to fairly value healthy commons, or to extract costs for damaging them. To help protect the ocean commons and reduce overfishing, the Oceans Working Group proposed an oceans-focused United Nations agency. To provide a viable commercial alternative to the current fishing industry, the group recommended establishing and scaling up a sustainable aquaculture industry by 2030. Other suggested goals included developing a global fisheries lab to measure and monitor the health of wild fisheries through, for example, innovative technologies such as deep-sea robots monitoring progress in rebuilding fish stocks.

2. Evidence-based input about the likely impact of land-use changes to influence decision-making: Those who make land-use decisions often fail to grasp the positive and negative impacts of their decisions on the health of often distant ”downstream” communities, particularly in areas with robust agro-industrial development around rapidly growing cities. To better inform natural resources management and public health decisions, the Land Use Working Group proposed case studies to explore the human health impact of ecosystem changes on such areas as infectious diseases, nutrition and mental health. Such studies may demonstrate how alternative approaches that explicitly account for the public health consequences of environmental change can increase system sustainability and resilience. To provide city leaders with real-time, relevant information for key decisions, the group also recommended generating relevant health and environmental data through personal and site-based monitoring. Such quantifiable measures might trigger a range of market-based solutions, such as payments for ecosystems services or tax incentives.

3. More evidence-based information about the potential benefits of ecosystems protection to spur policy change: Policy makers will be more apt to craft laws and incentives and fund programs that protect vital ecosystems with quantitative measures of their benefits. The Biodiversity Working Group proposed the increased use of national ”natural capital” accounts, forecasting models and environmental-impact statements to help measure the long-term human health impacts of environmental change to motivate businesses, communities and government to change their behavior.

4. New business models to deliver scarce resources to underserved and vulnerable regions: Vital goods and services like water often fail to reach the poor in small and remote villages because infrastructure costs are prohibitively high. But many innovative financing and delivery schemes have emerged that make this possible and protect the environment. Such models—including microfinancing, crowdsourced

Are we able to act quickly enough to reverse our course?Montira Pongsiri, environmental scientist, US Environmental Protection Agency1

1In her personal capacity

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funds and payment-for-ecosystem-services programs—were the cornerstone of the Freshwater Working Group’s proposal to help bring clean water to the world’s 1 billion people with insufficient to no water supply. Suggested building blocks include web-based proposal templates for communities to begin fund-raising efforts, and a global Water Corps to advise communities on building and maintaining water infrastructure. Small-scale water-collecting solutions like cisterns, open data for stakeholders to track water distribution and conservation progress, and alternative payment currencies such as “water coin” (like Bitcoin) were among other recommendations.

5. The creation of an entirely new field to focus attention, resources and action on this urgent area: At watershed moments in history, new institutions and ways of thinking have surfaced for a singular focus on critical issues. The Climate Change Working Group called for an entirely new discipline to tackle accelerating and complex problems linked to the environmental change–human health nexus in a rapid and

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We need more minds like those who built cathedrals. They will never see the light of day until it is finished. But they continue to work.Derek Yach, senior vice president, Vitality Group

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calibrated way. It recommended communications campaigns and convening investors and funders within a year to finance and focus on the programmatic aspects of this new field. The commission and future work will explore this undertaking.

As we pass critical environmental thresholds, the threats are great to both human health and survival. We can intervene and shift bit by bit the trajectory of environmental change and these threats. We can collaborate across many sectors that are directly impacted by these changes, such as environmental science, food production, construction and public health.

But without a distinct focus by public-health practitioners on the accelerating, complex and profoundly interdependent drivers of ecological change and human health, our very civilization is at risk. Only then will all the critical players in the private sector, government and science fall into place, to advance research, policies and action at global, regional and local levels.

We must be disruptive and revolutionary. Change cannot be incrementalFred Boltz, managing director of Ecosystems, The Rockefeller Foundation

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Human health and the environment have been interwoven since the beginning of time. Temperate conditions helped societies thrive in lush coastal regions like Mesopotamia, the Mediterranean and the Mississippi Delta over five millennia. Rainfall quantity and soil quality in an agrarian world first determined health and wealth and drove the development of a merchant economy, as cotton, fish and timber were bought, sold and traded. As a result, some societies prospered and others floundered. These forces ebbed and flowed, largely with the earth’s natural order.

The coal furnaces and factories of the Industrial Revolution changed all that. A surge in production brought prosperity to many. But the belching smokestacks of the 1800s rained toxins on many homes and farms and triggered lung infections; progress in the use of chemicals and fertilizers improved lives, but also often brought unintended health consequences, such as other diseases. Medicine made great gains over that time, as public-health systems and resources to fund them triggered medical innovation, treatment and cures. But scientists struggled to keep pace with the spate of new illnesses.

Still, in no other era has the natural rhythm of our planet’s weather, air and land-use patterns changed so dramatically as in our own, largely due to humanity’s very visible hand. While the world is much wealthier than it was a century ago, the wealth accumulation has come at a price to our planet’s lungs and our own. Paradoxically, while illness triggered by discrete environmental impacts such as pollution has decreased with improvements in medicine, water and food safety, the vulnerability of our health increases due to unpredictable climate change patterns. Rising affluence and rapid population growth are likely to accelerate the pace of environmental change and threats to human health.

Scientists and policy makers are sounding the alarm. They are calling for deeper and broader research into the interdependent and complex nature of the relationship between our environment and our health so that governments, organizations and companies can respond more effectively. They are also calling for institutional change to address threats to our enmeshed environmental, human health and social and economic systems as we cross critical thresholds. By devising the right strategies and spotting opportunities to shift the trajectory, experts hope to improve our stewardship of the planet and safeguard human health.

Improving human health by healing the planet

Planetary health

Why did the Mesopotamian and Roman civilizations collapse? What was the role of environmental factors?Richard Horton, editor-in-chief, The Lancet

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Climate change is seen as a remote threat in space and time.Howard Frumkin, dean, School of Public Health, University of Washington

To imagine a different future by 2025 and surface strategies that may help us get there, in July 2014 British medical journal The Lancet and The Rockefeller Foundation convened a high-level, four-day conversation with experts for an honest assessment of the health of the earth and of humanity—and the connections between the two. The meeting aimed to identify gaps in our knowledge and to build an accelerated, global and multi-sectoral plan to advance research and spur action.

It also sought to inform international policy and incite proactive responses before we cross critical environmental thresholds. With the world population set to soar to 9.6 billion by 2050—and with more than half of all people already living in cities— addressing this problem is all the more urgent.

Global leaders at the meeting hailed from over 30 institutions, organizations and companies, including Harvard Medical School, the United Nations, the African Development Bank, the X-Prize Foundation, PepsiCo and Monsanto (see list of participants in the appendix).

“The world is undergoing enormous stress. Many parts of the world are suffering from the human footprint, which is testing the biosphere’s capacity,” said Richard Horton, editor-in-chief of The Lancet, at the meeting’s opening. “If we transcend critical environmental boundaries, we get into deep trouble. Meanwhile, we struggle with partisan gridlock, stressed financial institutions and fractured nation-states. As we move forward, I have a feeling of immense danger,” he said. “How do we present the science to motivate behavioral change?”

The conversation

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A useful starting point for understanding the environmental and human health nexus is “planetary boundaries,” or tipping points in our planet’s air, land, fresh water and ocean natural systems that are most influenced by environmental shifts. These boundaries were defined in 2009 by a group of 28 internationally renowned scientists (http://www.stockholmresilience.org/21/research/research-programmes/planetary-boundaries/planetary-boundaries/about-the-research/the-nine-planetary-boundaries.html). The framework considers changes in our natural systems, including ozone levels, biodiversity loss, atmospheric greenhouse gases, ocean acidification, land use change (see chart, pp. 11), and other environmental changes that threaten the conditions under which humanity can “safely operate.”

If one or more of these boundaries is breached, altered environmental trajectories could cause rapid, nonlinear and irreversible changes in planetary systems that could jeopardize the very survival of the human species. Notably, three planetary boundaries have already been crossed—those of climate change, biodiversity and the global nitrogen cycle—according to the framework’s architects. Atmospheric CO2 has increased by 40% since 1800, primarily from burning fossil fuels and land-use changes that have resulted in increased polar-sheet ice melting, a sea-level rise of 0.19 meters since 1900 and ocean acidification.

Planetary Boundaries

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1. STRATOSPHERIC OZONE LAYER This layer of the atmosphere filters out ultraviolet radiation (UV) from the sun. Its thinning allows more UV to reach the ground, which can increase the incidence of skin cancer. Though the Antarctic ozone hole suggested a bypassed threshold, Montreal Protocol actions have reversed this trend.

2. BIODIVERSITY Changes in biodiversity due to human activities were more rapid in the past 50 years than at any time in human history according to the 2005 Millennium Ecosystem Assessment. High rates of extinction and ecosystem damage can be slowed by efforts to preserve threatened species, critical habitats and connectivity. Further research is underway to determine whether a boundary based on extinction rates is sufficient.

3. CHEMICALS DISPERSION Toxic compound emissions from heavy metals, synthetic organic pollutants and radioactive materials can persist in the environment for a very long time, and their effects are potentially irreversible. Chemical pollution can result in reduced fertility and potentially permanent genetic damage within ecosystems. Persistent organic compounds, for example, have reduced bird populations dramatically and impaired reproduction and development in marine mammals.

4. CLIMATE CHANGE The Earth has already transgressed the planetary boundary and is approaching several Earth system thresholds. Climate change is driving the Earth system into a much warmer state with intensified climate impacts. These include summer polar sea-ice loss which is seemingly irreversible and sea levels metres higher. Weakened or reversed terrestrial carbon sinks due to ongoing deforestation and agricultural emissions is another potential tipping point. How long remains before large, irreversible changes become unavoidable is an open question.

5. OCEAN ACIDIFICATION Greater ocean acidity, currently more than 30% over pre-industrial levels, reduces the amount of available carbonate ions, an essential ‘building block’ used by many marine species for shell and skeleton formation. Rising acidity threatens the growth and survival of organisms such as corals and some shellfish and plankton species, which would change the structure and dynamics of ocean ecosystems globally. The boundaries are tightly interconnected since atmospheric CO2

concentration is the controlling variable for both the climate and the ocean acidification boundaries.

6. FRESHWATER CONSUMPTION AND THE GLOBAL HYDROLOGICAL CYCLE Human pressure now largely determines the function and distribution of global freshwater systems. Consequences include global-scale river flow changes and vapour flow shifts arising from land use change. Shifts in hydrology may be abrupt and irreversible. Because water is increasingly scarce—by 2050 about half a billion people may be water-stressed—a boundary related to consumptive freshwater use and water resilience is a vital index for human development.

7. LAND SYSTEM CHANGE Forests, wetlands and other vegetation types have primarily been converted to agricultural land, seriously reducing biodiversity, and impacting water flows and the biogeochemical cycling of carbon, nitrogen and phosphorus and other important elements. Collectively, these local land cover changes have consequences for Earth system processes on a global scale.

8. NITROGEN AND PHOSPHORUS INPUTS TO THE BIOSPHERE AND OCEANS The biogeochemical cycles of nitrogen and phosphorus have been radically changed by humans as a result of many industrial and agricultural processes. Fertilizer production and application results in dramatic increases of emissions not absorbed by plants. When in rain, these pollute waterways and coastal zones or accumulate in the terrestrial biosphere. Large amounts of applied nitrogen and phosphorus end up at sea and can push marine and aquatic systems across ecological thresholds.

9. ATMOSPHERIC AEROSOL LOADING Through their interaction with water vapour, aerosols play a critically important role in the hydrological cycle affecting cloud formation and global-scale and regional patterns of atmospheric circulation, such as monsoons in tropical regions. They also change how much solar radiation is reflected or absorbed in the atmosphere. Humans change the aerosol loading by emitting atmospheric pollution and also through land-use change that increases the release of dust and smoke into the air. Inhaling highly polluted air causes roughly 800,000 people to die prematurely each year.

The nine planetary boundaries

Source: Stockholm Resilience Centre; www.stockholmreslience.org/Rockefeller Foundation

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Scientists are now studying the links between global environmental changes affecting the earth’s essential support systems and human health. These primary health impacts were explored in a background paper presented at the meeting by The Lancet. The paper examines possible strategy and policy shifts to prevent or reduce the damage, and proposes interdisciplinary and collaborative research to better inform decisions.

The potential range and extent of impacts on human health are startling and beg for action. For instance, fisheries, a key global food source, are already collapsing in many parts of the world due to overfishing. The interplay of this alarming trend with rising acidity in our oceans threatens serious further damage. (Ocean acidity has increased by around 30% since the Industrial Revolution due to the absorption of carbon dioxide, and could double again by 2050.)

Climate change alone will potentially trigger a rise in under-nutrition, heat-related deaths, some vector-, food- and water-borne diseases, and floods, drought and intense storms, according to the United Nations’ Intergovernmental Panel on Climate Change (IPCC). In 2006, the World Health Organization (WHO) estimated that environmental factors contribute to nearly a quarter of all human diseases, from established risks like air pollution, insufficient or tainted water supplies, and poor sanitation. But that number is probably much higher when accounting for the environmental-change-related risks we are only now beginning to understand.

Of the nine planetary boundaries, the interplay of four—climate change, biodiversity loss, land use and freshwater consumption—creates perhaps the most immediate challenge to both planetary and human health. Our land-uses have a particularly heavy ”ecological footprint.” Forest clearing for farming, timber or land development can erode biodiversity, fragment and pollute watersheds, rob the soil of key nutrients, and reduce the natural infrastructure that serves as buffers against extreme weather events and human vulnerability.

The immediate and alarming health impacts of these changes are many and varied. They include the rising prevalence and faster spread of disease from insect and mammal carriers, such as Lyme disease, West Nile virus, bird flu and hemorrhagic viruses including Ebola. Many waterborne diseases, from cholera to typhoid fever to shistosomiasis, are transmitted through human exposure to polluted waters and to natural parasites. Natural ecosystems regulate disease incidence and transmission. It is particularly challenging to confront the rising incidence of, and human exposure to, these diseases as the ecosystems harboring the causes of disease, their carriers and their natural predators are damaged or disappear.

Areas of risk

Our success with the easier health problems may bring some cause for optimism. But the next set of challenges due to rapidly changing environmental conditions is far more complex, with multiple interactions. These threaten all our gains in health. Samuel Myers, research scientist, Harvard School of Public Health

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Diseases are also appearing in abnormal locales as weather patterns shift. Malaria and Dengue fever have surfaced in Europe, and the West Nile virus on the U.S. East Coast. As higher latitudes and altitudes become warmer and wetter, they become more suitable environments for “tropical” diseases and their animal and insect carriers. These diseases can spread quickly and rapidly become epidemics as air travel and contact with those across the world rise. The world is ill-prepared for the migration of diseases to new places, driven by climate change, continued ecosystems degradation, and the rising exposure of people to such diseases.

The links between biodiversity loss and human disease transmission are thoughtfully explored in “Biodiversity Loss Affects Global Disease Ecology,” by Montira J. Pongsiri and others in the December 2009 issue of Bioscience, also distributed prior to the meeting (http://www.epa.gov/ncer/biodiversity/pubs/bio_2009_59_11.pdf).

Respiratory diseases like asthma are rising along with CO2 emissions, too. In fact, air pollution is now the world’s single largest environmental health risk. Approximately 7 million people died in 2012 as a result of air pollution (one in eight of total global deaths), according to WHO, double the organization’s earlier annual estimates. The deaths are the result of fine particles in our atmosphere that come from burning coal or diesel fuel, industrial emissions, and from indoor, household sources, such as inefficient cook stoves or burning wood, dung or coal, particularly in poor countries. Many of these air pollutants also contribute to climate change.

Human health will increasingly suffer in the future as a result of the environmental changes that are affecting the basic human needs of water and food. In some regions, less water is likely to be available for human use, for sanitation, hygiene and food production due to changes in temperature, rainfall and pollution, and water overuse. Pollinators like bees that help trigger and increase food production may also disappear when their natural habitats vanish. Lastly, the nutritional quality of the food we eat may fall with a rise in atmospheric CO2 levels. For example, in some crops, micronutrients such as zinc and iron fall with a rise in atmospheric CO2 levels.1

Without decisive action, global average temperatures could rise four degrees above pre-industrial levels by the end of the century, posing serious threats to our well-being and to global economic development, according to the IPCC.

1Myers, Samuel S., et al. “Increasing CO2 threatens human nutrition.” Nature510.7503 (2014): 139-142.http://www.nature.com/nature/journal/v510/n7503/abs/nature13179.html

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A recent and comprehensive overview of the complex impacts of environmental change beyond biodiversity loss and climate change is “Human Health Impacts of Ecosystem Alteration” (http://www.visionariesunbound.com/static/pdf/PNAS%202013%20Human%20health%20impacts%20of%20ecosystem%20alteration.pdf), by Samuel Myers of the Harvard School of Public Health and others, published in the November 2013 issue of Proceedings in the National Academy of Sciences, and distributed prior to the meeting. It explores current findings in this emerging field and suggests filling gaps in our knowledge that could advance both policy and decision-making among land-use planners, conservationists and public-health practitioners. The authors point to unprecedented change in the earth’s natural systems evidenced by the transformation of nearly half the world’s ice-free landmass into cropland, the felling of half our temperate and tropical forests, and the construction of 800,000 dams, which today affects the flow of 60% of the world’s rivers.

Among the human-health impacts of these land-use changes are the loss of nutrients from wild foods and fish; the cardiorespiratory impacts of reduced air quality; and food insecurity and population displacement.

Still, the research into environment-health linkages remains patchy, the paper’s authors say, because it has often focused on a specific disease, rather than the impact of environmental change on several aspects of human health, and often on just one possible trigger, though there may be several. Some of these triggers may foster negative health effects in some communities but bring health benefits to others. Malaria exposure, for example, may rise from the interplay of deforestation, altered biodiversity and human migratory patterns, and dam and irrigation projects. But that same dam or irrigation project could improve access to clean electricity and water for irrigation and for food production for other or future populations. The authors also contend that both poor communities and future generations face disproportionate consequences because the breadth and pace of the erosion of natural systems is expanding with population growth and increasing prosperity.

They suggest broadening research efforts beyond snapshots of one disease in a particular place to comparisons of environmental links across locations. They also advocate expanded research into highly prevalent infectious diseases that have clear links to environmental change, such as malaria, diarrhea, Dengue and Chagas disease. And they encourage studies of the links between natural-system changes and nutrition and food productivity, and the health value of ecosystem services. Among the areas the authors believe particularly merit further research, including field experiments and modeling, are animal husbandry; land-use changes and zoonotic

Recent Research

We need new institutions and incentives, and tools to for intersectoral collaborations and asset mapping.Sania Nishtar, founder and president, Heartfile

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diseases; and health outcomes driven by multiple changes, such as resource scarcity, land-use changes and climate change.

The tight link between the biosphere and our health is becoming ever more apparent. But this connection remains poorly understood and largely invisible to the public. The result is little action to safeguard our planet and our well-being.

“Let’s connect the dots between health and the environment and appreciate the interdisciplinary nature of these fields. What are the pressure points? What are the areas of dynamism? Think fifteen years out and develop a road map and strategies for change,” urged Vijay Vaitheeswaran, The Economist’s China business and finance editor, who facilitated the meeting. “There is tremendous opportunity to strengthen links and shape organizational change.”

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There is no time to waste in developing road maps and strategies for change. Even as we work to improve our understanding of the size, scope and complexity of the environmental changes we are experiencing and their impact on humanity, we must mobilize several forces to take action.

An expansive range of sound strategies are emerging to tackle these complex and interlinked problems, many of which were discussed in Bellagio. They include:

1. Use evidence-based science to drive policy change. Scientists and policy makers speak different languages, operate in different time frames and respond to different incentives. Broadly speaking, policy makers represent their constituencies and build coalitions for broader action that provide a basis for change, while managing political risk. Simple language and clearly articulated, quantifiable “high-impact” proof matters most to decision makers. For instance, information on the immediate impact of environmental changes on the health of their constituencies could help convince policy makers to develop new laws, incentives and resources to address these linkages. “This is very different from building the body of objective evidence [that scientists seek],” said Anthony Kaplan, director of Global Health at United Nations University.

2. Harness data, analytics, predictive modeling and other innovative tools to build the business case for change and to reduce the impact of natural-resource extraction and use through more-efficient, holistic approaches that involve local communities. Collecting vast data from satellites and handheld devices, examining them with analytical tools, and modeling how different choices can alter environmental outcomes can help inspire powerful behavioral change among businesses and individuals. Quantifying the impacts and possible savings that could be realized by incentive-based initiatives, such as programs that pay individuals to protect the environment (for example, to prevent cattle grazing near rivers or streams), could help scientists and government leaders win the support of companies and the public – and inspire them to act.

“We need to bring financiers, economists, accountants, scientists and engineers together to create open-source tools to join up everyone on real practical outcomes for human and ecological health,” said Professor Peter Head, an engineer and executive chairman of the Ecological Sequestration Trust. “This is the moment. We have earth observations, adequate data computing power, systems algorithms and communications bandwidth to use it all from the cloud.”

Strategies

It’s not a scientific, intellectual discussion. How do we get people engaged? Anne Fudge, Trustee, Rockefeller Foundation

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3. Raise awareness and galvanize action on the full breadth of climate risks. Hurricane Sandy and Typhoon Haiyan focused attention on the link between climate change and extreme weather events. Such storms have severe implications for health, life and property loss, if they cause a breakdown of water-supply systems vital to sanitation and irrigation, enable the spread of disease, or slow the delivery of critical supplies to health clinics and hospitals. But scientists, activists and others must also find ways to raise awareness of the slower-moving and less dramatic – but possibly even more alarming – impacts of climate change, such as the loss of ”buffers” to shore up coastlines against storm surges, vanishing reefs due to ocean acidification, and the spread of disease to new regions. Only under the glare of the spotlight can we raise awareness and inspire behavior change.

4. Cross-pollinate ideas across sectors through collaboration, coalitions and change agents. Business executives respond to profits and shareholder pressure, scientists to breakthrough research and peer recognition, government officials to a smoothly functioning society and satisfied constituencies, individuals to their wellbeing and happiness. Each group has a role to play in raising awareness and sharing ideas about effective ways to solve the environmental/human-health change nexus problem. These areas of self-interest need to be explored, incentives aligned and concrete actions assigned to each party, if we are to have rapid, coordinated and systems-based responses. Challenges include winning buy-in from large, complex institutions and overcoming ”pride of ownership” issues. Particular efforts should be made to level individual silos and to agree on a common language.

5. Storytelling to inform, incite action and change behavior. Campaigns that speak to the heart rather than the head are more likely to inspire broad individual and collective change in how we live, what we buy and eat, and how we move. “Naming and shaming” can help keep a check on businesses and individuals. But illustrating a new vision of prosperity, such as the Joint US-China Collaboration on Clean Energy (JUCCCE) campaign ”China Dream,” may more effectively alter people’s outlooks and lifestyles now and in the future. Sharing personal stories about the impact of our consumption habits on the health of our planet and that of our community may spark change. The media, marketers and advertisers must be engaged in telling stories about people and places that offer meaning and messages that will move people. “People’s thinking is guided by set patterns and beliefs. While we need the science, science has precious little to do with how people reach conclusions,” said Howard Frumkin, dean of the School of Public Health at the University of Washington. “We need to understand much better how to change behavior.”

6. Harness generational power to push for change. Millennials are viscerally aware of the environmental harm that human activities are reaping on the planet in an era that is better informed about the planet’s declining capacity to sustain the human species. This cohort has also shown a willingness to act; many demonstrate personal dissatisfaction through protests and with their wallets through green purchases. The collective power of young people can be further harnessed by identifying and enlisting youth leaders, targeting Millennials with information campaigns, and collaborating with the social enterprises they have

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founded. “Whose earth are we talking about? There’s a mismatch between those who pollute and those who suffer the consequences,” said Dr. Frumkin.

7. Bring new players into the fold and identify leaders to accelerate action. Engaging and connecting groups like businesses, financiers and local communities can broaden awareness and trigger quick, calibrated action. We need to find new approaches for natural resource use that are more sustainable and environmentally friendly, to finance these measures in creative ways, and to inspire local communities to demand market-based change through their purchases, activities and protests. To do so we must identify champions and change agents in these groups and work with them to harness their power. “This is about corporate survival and death. It’s not about CSR,” said Derek Yach, founder of the Vitality Group, referring to corporate social responsibility. “PepsiCo was given a license to operate in perpetuity. They have to be long-term stewards of the earth. It’s absolutely material to the bottom line of companies, not because it’s a nice thing to do.”

8. Tear down old structures, such as institutions, incentives and disciplines, to advance work in this area. Deeply rooted incentives and approaches to research at universities and research centers often dissuade scientists from working with outsiders to accelerate the real-world applications of their work. The tenure process, the slow pace of academic publishing, empire building, and the tenacity with which researchers pursue research are among the obstacles that too often get in the way of progress. Public health needs to become less prescriptive and more proactive. “Like a dog with a bone, people don’t like to give up on their ideas,” said The Economist’s Vaitheeswaran.

9. Create new structures and initiatives to galvanize action. The unprecedented environmental changes occurring on our planet and the widespread and potentially catastrophic consequences of changes yet to come demand a radical rethink of how to confront and tackle the challenges we all face. Incremental change will not suffice. New institutions, leaders and approaches are required to heal our planet and safeguard human health. “Unless there is a global mindshift in thinking this will be at the margins,” said Michael Meyers, managing director at The Rockefeller Foundation.

You’re a lot more effective when you engage the crowd.Paul Bunje, XPRIZE Foundation

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A handful of promising solutions are taking shape that address specific problems at the nexus between human health and environmental change and do so in ways that address the knotty and interlinked forces at work. Working groups focusing on the human health impacts of changes in our planet’s climate, biodiversity, land-use and in its marine and freshwater ecosystems in Bellagio identified a number of emerging solutions for future problems that particularly merit exploration, including:

1. Better governance structures for managing global resources:

Coveted global “commons,” such as air, forests and oceans, have not been sufficiently protected. A key reason for this is the failure of market economies to adequately value healthy commons or to extract costs for damaging them. For example, oceans cover 70% of the earth’s surface, absorb half the world’s ever-rising levels of CO2, supply fish that nourish some 2.5 billion people, and employ millions in the $200 billion fishing industry. Yet the two-thirds of the oceans that lie outside natural boundaries are currently unregulated, with fish stocks at or beyond their ability to replenish themselves. A predicted doubling in demand for fish by 2050 is particularly worrisome. The commercial importance of oceans is also rising as sea ice melts, clearing the way for new seafaring routes, oil drilling and mineral extraction and the specter of growing territorial disputes. There are far-reaching implications for the human populations who depend on fish for nutrition and livelihoods.

To help protect the ocean commons—and, specifically, to rapidly reduce overfishing—the Oceans Working Group explored a range of possible solutions. It recommended establishing a new oceans-focused United Nations agency to regulate this shared resource and territory, and to forge guidelines to ensure the health of the oceans. To provide a viable commercial alternative to the current fishing industry, it recommended establishing and scaling a sustainable aquaculture industry by 2030 to meet rising human demand and reduce the overfishing of wild populations. Other recommendations included developing a global fisheries lab to monitor and track the health of wild fisheries, and to quantify the link to the physical and economic health of the communities that depend on them.

Change might come from the use of innovative technologies, such as deep-sea robots that monitor our progress in rebuilding fish stocks; and creative

Future solutions

We need to stop talking to people’s heads, but to their hearts. We need to use emotion.Peggy Liu, founder, Joint US-China Collaboration on Clean Energy

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campaigns that have broad appeal, such as “Saving Dora,” built around the star of the upcoming sequel to ”Finding Nemo.”

“It’s unrealistic to dismantle a massive industry without presenting a viable commercial alternative,” said Freya Williams, group head of Business + Social Purpose at Edelman. “In our optimistic narrative, we’re focusing on abundance and opportunity.”

2. Evidence-based input about the likely impact of land-use changes to influence decision-making:

Those who make land-use decisions often fail to grasp the potential far-reaching impacts of their decisions on human health. These choices can cause significant harm—or bring benefits—to the health of often distant “downstream” communities, or to those in rapidly growing urban areas, as land near cities is developed for industrial or agricultural use.

To better inform natural-resources management and public health policy and decisions, the Land Use Working Group proposed a range of solutions. These include case studies to document the human health impacts of changes to environments within cities and of alterations of ecosystems in more remote, pristine areas. Case studies would focus on environmental changes believed to disproportionately influence human health in such areas as respiratory, waterborne and infectious disease, and in nutrition and mental health. This type of explicit analysis of the public health impacts of environmental change would emphasize co-benefits for human health, sustainability and system resilience.

The group also recommended a “climate-friendly cities portfolio” to generate relevant health and environmental data through personal and site-based monitoring, to provide city leaders with real-time, relevant information as they make key decisions.

These approaches would provide quantifiable measures of health impacts, which would facilitate a range of market-based solutions such as payments for ecosystems services or tax incentives to solve pressing problems at the environmental change–human health nexus.

3. More evidence-based information about the potential benefits of ecosystems protection to spur policy change:

Decision makers are often unaware of the benefits that healthy ecosystems bring to human health, of the complex interactions among their components (including people), and of the negative consequences of environmental change on natural systems.

As participants in the Biodiversity Working Group noted, policy makers will be more apt to craft policies and incentives and fund programs that protect vital ecosystems with quantitative measures of their benefits. One approach is through the use of national “natural capital” accounts – or logs of the values of each

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Don’t give up on anything; we need to pursue parallel paths.Anne Fudge, Trustee, Rockefeller Foundation

country’s ecosystems’ resources and servicing capabilities, and changes to their condition over time. Such tools—as well as forecasting models and integrated health-environmental impact statements that help measure the long-term human health impacts of environmental change—might motivate businesses, communities and governments to change their behavior.

Quantifying the long-term human health consequences of environmental change and clearly communicating findings to authoritative organizations like WHO and the World Bank could also inform global and country guidance and technical assistance. The group urged the United Nations to recognize the biodiversity–human health link in the UN’s Sustainability Development Goals, which is a set of global guidelines being established to help ensure that sufficient natural resources are available for the prosperity and health of future generations.

4. New business models to deliver scarce resources to underserved and vulnerable regions:

Vital goods and services like electricity and water often fail to reach the poor in small and remote villages because infrastructure and delivery costs may be prohibitively high. Other barriers include ineffective but entrenched methods of supplying these goods and services, due to vested business or government interests and a lack of awareness within local communities that there are affordable and decentralized alternatives for such services. At the same time, local communities are rarely motivated to protect the natural resources they depend on for food, sanitation and other services. But in recent years, a number of innovative financing, delivery and incentive models have emerged that can make the supply of these vital goods and services more efficient and scalable—while protecting the environment.

Such models include microfinancing, crowdsourced funds, and outsourced and payment-for-ecosystem-services programs. These approaches were the cornerstone of the Freshwater Working Group’s proposal to help bring clean water to the world’s over 1 billion who lack access to safe drinking water. As building blocks, the group suggested raising funds through initiatives like the Whole World Water campaign; providing web-based proposal templates to communities to begin fund-raising efforts; and a global Water Corps to advise communities on building and maintaining new infrastructure. It also proposed small-scale water-collecting solutions like cisterns; conservation measures such as watershed protection to help make communities environmental stewards, and monitoring and fixing leaky pipes to maximize the supply available.

Finally, the group suggested opening up access to data sources on the web so that stakeholders can track water distribution and progress on conservation for the benefit of both the community and funders; enabling payment with alternative currencies like “water coin,” (a proposed currency similar to bitcoin); and the establishment of pilot cities to test project elements needed in arid, coastal and temperate environments, so that several formats can be created that apply to similar locales. “There are a lot of ways to scale once you get past the limiting factors,” said Peggy Liu, founder of JUCCCE.

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5. The creation of an entirely new field to focus attention, resources and action on this urgent area:

At watershed moments in global history, new institutions and ways of thinking have surfaced for a singular focus on critical issues. Such was the case with the Marshall Plan, the United Nations Earth Summit and U.S. civil rights legislation.

Indeed, as the existential nature of the threat of environmental change on our health, our social and political systems, and our society becomes more apparent, a global reframing and rethinking of the tangle of issues is required. This was the determination of the Climate Change Working Group. It called for entirely new institutions and approaches to tackle accelerating problems in a rapid and calibrated way. Scholars and business and government leaders must come together to develop a road map to address planetary health, and to roll it out. Only when many disciplines converge in a holistic manner to build and shape new institutions will true and rapid progress be possible, the group argued. This requires the concerted creation of a new field of study and practice: an integrated and institutionalized field of planetary health.

“Our entire conversation about how we communicate the challenges and engage our institutions is rational and linear,” said Paul Bunje of the XPRIZE Foundation. “But these challenges are complex and exponential. We should communicate in the same way. We need an army of thinkers, doers and communicators to establish a holistic field of Planetary Health.”

To get there, we will need communications campaigns. To achieve a goal of creating a professional class exclusively focused on this field with established leaders by 2020, we will need to convene in the next year funders, investors and insurers to finance and focus on the programmatic aspects of this new field. Global centers of excellence could be valuable, too. With concerted effort, “by 2020 this will all exist,” predicted Bunje. “We will be unstoppable.”

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As we look ahead to a world in which our health will suffer from stretched resources and stressed systems, the environmental harm we have wrought weighs heavily. To be sure, governments and businesses that rely on nature for food production, raw materials, energy and freshwater are increasingly aware of the impact of our activities on the planet. But the world has yet to grasp the complex and far-reaching human health consequences of our choices.

Yet our civilization continues to evolve, to innovate, to achieve scientific breakthroughs, and to find novel solutions that could yet be our salvation. As experts underscored at the Planetary Health meeting and beyond, solving these problems requires deep and broad collaboration across many sectors, dramatic institutional and system change, and moving storytelling that can inspire behavioral change.

Many of the strategies and solutions the experts have identified can be put into ac-tion in a piecemeal fashion. But truly understanding and addressing the problem of ecological change and its health impact requires a more radical approach, new ways of thinking and an entirely new discipline dedicated to exploring solutions and imple-menting widespread change. We at The Rockefeller Foundation stand ready to help drive this process forward. We hope you will join us on this journey.

Conclusion

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Bottom, left to right: Steven Osofsky, Montira Pongsiri, Carolyn Whelan, Judith Rodin, Robert Garris, Gabriela Burian, Peggy Liu, Paul Bunje, Fred Boltz and Selina Lo

Middle: Ann Fudge, Tara Acharya, Samantha Silberberg, Fernanda Bak, Elizabeth Williams, Howard Frumkin, Derek Yach, Sarah Whitmee, Srinath Reddy Kolli, Agnes Soucat, and Natasha Loder

Top: Michael Myers, Wai Chiong Loke, Peter Head, Richard Horton, Braulio Ferreira de Souza Dias, Samuel Myers, Subhrendu Pattanayak, Anthony Capon, Sania Nishtar and Vijay Vaitheeswaran

Planetary healthMeeting Participants

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1. Tara AcharyaSenior Director, NutritionPepsiCo

2. Chris BeyrerProfessor, EpidemiologyJohns Hopkins University

3. Fred BoltzManaging Director, EcosystemsRockefeller Foundation

4. Paul BunjeSenior Director, OceansXPRIZE Foundation

5. Gabriela BurianEnvironment LeadMonsanto – Sustainability

6. Anthony CaponDirectorUnited Nations University

7. Braulio Ferreira de Souza DiasExecutive SecretaryConvention on Biological Diversity

8. Alex EzehExecutive DirectorAfrican Population and Health Research Center

9. Howard FrumkinDean and Professor, University of WashingtonEnvironmental & Occupational Health

10. Ann FudgeTrusteeThe Rockefeller Foundation

11. Robert GarrisManaging DirectorThe Rockefeller Foundation

12. Andy HainesProfessor of Public Health and Primary CareLondon School of Hygiene and Tropical Medicine

13. Peter HeadExecutive ChairmanThe Ecological Sequestration Trust

14. Richard HortonEditorThe Lancet

15. Srinath Reddy KolliPresident Public Health Foundation of India

16. Peggy LiuChairpersonJUCCCE

17. Selina LoSenior EditorThe Lancet

18. Natasha LoderMidwest CorrespondentThe Economist

19. Wai Chiong LokeDirector of DevelopmentJurong Health Services

20. Sarah MoltonSenior Business AnalystWellcome Trust—Sustaining Health

21. Michael MyersManaging DirectorThe Rockefeller Foundation

22. Samuel MyersResearch ScientistHarvard School of Public Health

23. Sania NishtarPresident and CEOHeartfile

24. Steven OsofskyExecutive Director, Wildlife Health & Health PolicyWildlife Conservation Society

25. Subhrendu PattanayakProfessor, Public Policy & EnvironmentDuke University

26. Montira PongsiriEnvironmental ScientistEnvironmental Protection Agency

27. Judith RodinPresidentThe Rockefeller Foundation

28. Timothy ShortenThe Lancet

29. Agnes SoucatDirector, Human DevelopmentAfrican Development Bank

30. Vijay VaitheeswaranChina Business EditorThe Economist

31. Peter WardProfessor of GeobiologyUniversity of Adelaide

32. Sarah WhitmeePostdoctoral ResearcherUniversity College London – CBER

33. Freya WilliamsExecutive Vice PresidentEdelman

34. Derek YachFounderThe Vitality Institute

The Planetary health meeting was convened by The Rockefeller Foundation and The Lancet with support from The Rockefeller Foundation.