Meeting Report
INFORMAL MEETING TO REVIEW THE DRAFT REGIONAL STRATEGY ON HEALTH AND THE ENVIRONMENT FOR THE WESTERN PACIFIC (2017–2021)
27–29 January 2016 Manila, Philippines
WPR/DNH/HAE(01)/2016 Report series number: RS/2016/GE/14(PHL)
English only
REPORT
INFORMAL MEETING TO REVIEW THE DRAFT REGIONAL STRATEGY ON HEALTH AND THE ENVIRONMENT FOR THE WESTERN PACIFIC (2017–2021)
Convened by: WORLD HEALTH ORGANIZATION
Manila, Philippines 27–29 January 2016
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines July 2016
NOTE The views expressed in this report are those of the participants of the Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) and do not necessarily reflect the policies of the conveners.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017– 2021) in Manila, Philippines from 27 to 29 January 2016.
CONTENTS ABBREVIATIONS ................................................................................................................................................ i SUMMARY .......................................................................................................................................................... ii 1. INTRODUCTION ............................................................................................................................................ 1.1 Background ......................................................................................................................................... 1.2 Objectives ............................................................................................................................................ 1.3 Opening remarks ................................................................................................................................. 1.4 Introduction of participants and organization of the meeting .............................................................. 2. PROCEEDINGS ............................................................................................................................................... 2.1 Challenges and the changing context of health and the environment ................................................. 2.2 Environmental health from different health dimensions ..................................................................... 2.3 Overview of the draft Regional Framework on Health and the Environment for the Western Pacific (2017–2021) .............................................................................................................. 2.4 How environmental health functions in countries? ............................................................................. 2.5 Panel discussion on countries' experience in environmental health .................................................... 2.6 Options for institutional arrangements for addressing environmental health risks by Member States ..................................................................................................................................... 2.7 Extra scientific presentations .............................................................................................................. 1 1 1 1 1 2 2 3 4 5 5 6 8
3. CLOSING ......................................................................................................................................................... 9 4. CONCLUSIONS AND RECOMMENDATIONS ........................................................................................... 9 4.1 Conclusions ................................................................................................................................................ 9 4.2 Recommendations ..................................................................................................................................... 10 4.2.1 Recommendations for Member States ............................................................................................... 10 4.2.2 Recommendations for WHO ............................................................................................................. 10 ANNEXES ......................................................................................................................................................... Annex 1. List of participants .......................................................................................................................... Annex 2. Agenda ............................................................................................................................................ Annex 3. Programme of activities .................................................................................................................. 11 11 13 15
Keywords Climate change / Environmental health / Governance / Regional health planning / Social determinants of health / Sustainable development
ABBREVIATIONS CDC COP15 COP21 EBD EHP IPCC LDC MDG MOE MOEP NCD NEHAP Rio+20 SDG WaSH WHO Centers for Disease Control and Prevention 15th session of the Conference of the Parties (Copenhagen) 21st session of the Conference of the Parties (Paris) environmental burden of disease Environment and Health Process Intergovernmental Panel on Climate Change least developed country Millennium Development Goal Ministry of Environment Ministry of Environmental Protection noncommunicable disease national environmental health action plan United Nations Conference on Sustainable Development Sustainable Development Goal water, sanitation and hygiene World Health Organization
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SUMMARY An Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) was held in Manila, Philippines on 27–29 January 2016. The meeting objectives were as follows: 1) to review and provide technical inputs to the draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021); 2) to provide guidance on how the World Health Organization (WHO) can best support Member States in implementing the draft regional strategy; and 3) to advise on how to make the strategy an integral part of national processes and actions for the achievement of the environmental health targets of the Sustainable Development Goals (SDGs) and other related national, regional and international initiatives or opportunities. Environmental risks arising from economic development and natural causes are among the major public health burdens in this Region. Increased efforts are needed to mitigate and adapt to environmental risks and improve health outcomes. The proposed regional strategy on health and the environment would help to overcome barriers and enact efficient multisectoral action, address the significant environmental burden of disease, strengthen the role of the health sector in environmental policy-making and address the environmental footprint of the health sector itself. Following the direction of the First Meeting of Western Pacific Region Policy Advisers on Environment and Health in August 2015, this informal review meeting gathered environmental health experts and relevant WHO staff to work towards an enhanced draft strategy to present at the Member States’ consultation on 26–28 April 2016. Based on feedback, the title was changed to Western Pacific Regional Framework for Action on Health and Environment on a Changing Planet: benchmarking with the Sustainable Development Goals. With the SDGs and targets approved by United Nations Member States in September 2015, a key focus of the meeting was to analyse how the framework for action could harness Member States' efforts to achieve the SDGs for the benefit of health and the environment, and conversely, how action on environmental health could indeed benefit national SDG efforts. Conclusions: Overall, participants who attended the informal consultation were satisfied with the content and depth of the draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) which was renamed later to the Western Pacific Regional Framework for Action on Health and Environment on a Changing Planet. Inputs from this informal meeting were used in improving the document for the proposed Member States consultation scheduled to be held in the middle of 2016. Salient inputs include strengthening roles and functions of the health sector in environmental health, improving networking with various stakeholders and linkages of environmental health with the Sustainable Development Goals. The health effects of environmental degradation are powerful arguments in advocating environment-related SDGs Recommendation for Member States 1) Member Sates are encouraged to read the updated and enhanced framework and provide feedback no later than the Member States’ consultation in late April 2016. Recommendation for WHO Secretariat 2) WHO is requested to update and send out the updated and enhanced framework to Member States as soon as possible.
1. INTRODUCTION 1.1 Background
An Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) was held at the WHO Regional Office in Manila, Philippines on 27–29 January 2016. The regional strategy on health and the environment is intended to help to overcome barriers to multisectoral action, address the significant burden of disease attributed to environmental risk factors, strengthen the role of the health sector in environmental policy-making and address the environmental footprint of the health sector itself. Inputs from this review meeting would be used to update the draft for presentation at a Member States’ consultation in April 2016. The final document would then be proposed as an agenda item at the sixty-seventh session of the WHO Regional Committee for the Western Pacific in October 2016. 1.2 Objectives
The objectives of the meeting were: 1) to review and provide technical inputs to the draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021); 2) to provide guidance on how WHO can best support Member States in implementing the draft regional strategy; and 3) to advise on how to make the strategy an integral part of national processes and actions for the achievement of the environmental health targets of the Sustainable Development Goals (SDGs) and other related national, regional and international initiatives or opportunities. 1.3 Opening remarks
Dr Shin Young-soo, WHO Regional Director for the Western Pacific, opened the meeting by presenting key health and environmental concerns in the Region. Environmental risk factors such as unsafe water, inadequate sanitation, poor air quality, climate change and toxic and hazardous waste exposure are some of the most serious health threats. In the Western Pacific Region, an estimated 2.9 million deaths occur each year due to indoor and outdoor air pollution. This represents a disproportionate 41% of the global burden. There are also significant disparities in the impacts of air pollution on high- and low-income countries. Strong health and environment programmes at the regional and country levels, as well as committed leadership across the health and environment sectors, are needed to address these challenges. The draft regional strategy on health and the environment is intended to establish the direction and identify priorities for WHO’s Health and the Environment programme. Member States will be consulted on the resulting draft strategy on 26–28 April 2016, and the final document will be submitted to the sixty-seventh session of the Regional Committee in October 2016. 1.4 Introduction of participants and organization of the meeting
Dr Mohd Nasir Hassan, Coordinator, Health and the Environment unit, WHO Regional Office for the Western Pacific, invited all participants to introduce themselves. The list of participants appears in Annex 1. Following the self-introductions, Dr Hassan reviewed the agenda and programme of the meeting. These appear in Annexes 2 and 3, respectively. It was agreed that the conduct of the meeting would be informal. No chair or co-chair was designated.
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2. PROCEEDINGS 2.1 Challenges and the changing context of health and the environment
Regarding the origin of diseases, health fails when genes are unable to adapt in time to maintain the state optimized for a changing environment. The environment has recently been found to be far more responsible for disease than our genes. There was much optimism for new treatments at the turn of the millennium based on the human genome project, but it was found that the probability that such genetic variability would cause disease was just 5%. While the heritability of high blood pressure is 30–60%, only 10% of diabetes and coronary disease cases can be explained by genetics. Rather than people with noncommunicable diseases (NCDs) not reproducing, it is desirable to attempt to return the environment to its former quality. On climate, the temperature of the planet is now rising 20–30 times faster than the previous record. While there is a very slow cooling trend throughout the Holocene, the rate of environmental change is unprecedented. In 2015, Earth reached one degree of warming above the Holocene average. The rate of change is key to whether adaptation is possible in terms of genes, society, human settlements, health systems and urban areas. This would be worth measuring not just at national level but in localities. The latest figures on environmental burden of disease (EBD) were presented. The Western Pacific Region fares much worse than any other region in terms of ambient air pollution. Resulting mortality comes mainly from NCDs like stroke and cancer. The numbers for climate change are not as large – 150 000 deaths per year or a minimum of 250 000 from 2030, as revealed at fifteenth session of the Conference of the Parties (COP15) in 2009. Yet it is perhaps the biggest EBD growth area. From 2006 to 2012, the burden has gone down for water, sanitation and hygiene (WaSH) but up for air pollution. The need to account for the built environment was raised in areas such as housing and cities. The potential distortion of overall figures by big countries is real. As such, more regional and local analysis may be needed for a clearer picture, as well as an introduction and explanation of "ecozones". The mandate of WHO to address environmental health comes from Constitution Article 2(b): “to promote, in cooperation with other specialized agencies where necessary, the improvement of nutrition, housing, sanitation, recreation, economic or working conditions and other aspects of environmental hygiene”. This regional framework1 is the culmination of efforts to link the health and environment sectors since 1972. The rise of civil society, and the difficulty facing ministries of health as a broker with other sectors, called for a new way of working. The sustainable development agenda is based on environmental, economic and social drivers, although there was disagreement over the validity of the "triple bottom line", where economics seemed to trump the other elements every time for decision-makers. Climate change is a threat multiplier, although some areas like chemicals and radiation are not directly related to climate. 2.2 Environmental health from different health dimensions
Traditionally, the environment is seen by communicable disease experts as a reservoir of infectious agents such as foodborne, waterborne and vector-borne diseases, as well as zoonoses. This thinking has produced enormous gains, with improvements to sanitation and water quality probably the most beneficial initiatives, along with immunization. But this perspective is much too limited. Interaction with the environment is a big driver of disease. For example, overcrowded housing causes gastroenteritis, pneumonia, tuberculosis and trachoma, among others, and crowded cities can incubate 1
From this point forward, “framework” will be used in place of “strategy” because of a decision made to change the structure and purpose of the document. A more detailed explanation can be found in section 2.3.
-3emerging diseases. Environmental degradation such as deforestation raises malaria risks, causes flooding and affects water quality. Climate change boosts vectors and pathogens, and affects water quality in droughts and floods. For the framework, climate change is the "burning platform". There are 200–300 public health events in the Region per year, and the number of environmentrelated events is increasing. Other examples of prominent environment-related disasters are the Fukushima nuclear meltdown in 2011, Indonesian forest fires and methanol poisoning in Cambodia in 2015. We must invest more during “peace time” – building core capacities and managing disaster risks. Much of the Region’s population is under constant ecological stress. Extreme climate is a fact of life all over northern Asia. Emergency preparedness becomes the default, but a framework can help heads of state to think about what will be happening in 2030. Lack of safe water is frequently cited as a reason that hospitals shut down in such situations. At Alma Ata (1978), WaSH was a very visible aspect of environmental health in WHO. As the context has changed – shifting to climate change – green health care has become an obvious new aspect. A very important role of WHO is to cater to the health sector and systems. Bringing the environmental agenda to the health sector is a unique function of WHO. But this framework also has a role in building a new paradigm – from a focus on the health sector, to climate and environmental health. It was underlined that universal health coverage is not merely the domain of ministries of health, and that the framework should focus not on strengthening health ministries but on the system to create health. It was also stressed that health ministries have a stewardship role to educate. 2.3 Overview of the draft Regional Framework on Health and the Environment for the Western Pacific (2017–2021)
The background of health in the development agenda was presented. At Rio+20 in 2012, the existing framework of the social, economic and environmental pillars of development was critiqued by countries for sequestering health in the social pillar. The result of the criticism was The Future We Want, in which health was put in the mission statement twice, as an outcome and indicator of all dimensions of development. Initially conceived as a strategy, the draft framework is a less prescriptive document that offers guidance for Member States and helps them to examine what they are doing. Originally, the strategy aimed to enhance the ministries of health focus on health and the environment, articulating what a health and environment system is and looking for leverage points for accelerated action. This framework would allow policy engagement between sectors at country level and be as practical as possible, taking into account the diversity of how environmental health is governed around the Region. A participant felt it was not clear whether the document was a strategy, an action plan or a framework. This decision would determine how it needed to be written. A framework does not need expected outcomes or a time limit; rather, it is a manifesto. Outcomes do not need to be specific, but rather, robust. For example, the meaning of “significantly reduce mortality from air pollution” could differ by region or country, and be negotiated later. With a framework, we can discuss priorities, ethical principles, and the values behind them. A strategy would need certain chapters on specifics, and an action plan would need targets. It was very important that the framework reflect the Region’s diversity. The Member States in the Western Pacific range from tiny to huge, rich to very poor. Not all Member States can have the same priorities when it comes to implementation. However, they share common concerns, interests and commitments. We must stratify, with provision for tailoring to domestic purposes. That can be done by defining regional and national priorities. SDGs are for everybody, while Millennium Development Goals (MDGs) were only for developing countries. Having a common regional framework would also help donors providing resources to other countries in the Region. It was questioned whether any
-4SDGs could be excluded from the framework. For example, in the Pacific, SDG14 (Life on the water) is crucial, but it was excluded from the framework. When it comes to the issue of including other sectors, how do national systems achieve the SDG work? If we want to be useful to national processes, we must understand how they work. This dimension was not really included. It was suggested that the framework should be a living document and follow the national planning cycles, like a WHO country cooperation strategy. After the launch of the SDGs in September 2015, all governments are grappling with how to address the sustainable development agenda. Malaysia has already started, and Cambodia is about to start. The SDGs did not capture all important health issues, but the issue is to align and emphasize. Once we have a regional framework, all countries should be able to renew and update their environmental health programmes. “Health in all policies” was raised as a possible governance mechanism to bring together all ministries and their data, research and workforce, using available tools – money (joint budgeting or at least joint planning) and legislation. Presentation of groupwork and summary of Day 1 Professor Peng Gong, Director, Centre for Earth System Science, introduced his programme at Tsinghua University, China. There, 28 professors, including ecologists, ocean scientists, social scientists and computer scientists, are working to build an earth systems model. As the largest programme of its kind in China, 16 faculties are working on climate change modelling, and about 60 students are building computer programmes based on global activities. The programme has secured stewardship of the world’s fastest supercomputer, and it has strong support from the local government and state. A quantitative tool to assess drought, flooding, extreme weather events and their impacts on humans and their health is being applied. The goal is to build a programme to generate quantitative evidence that can be shared with various sectors to advise policy. Dr William Steffen, Emeritus Professor, Australian National University, presented the International Geosphere-Biosphere Programme and three of its innovative concepts from 1998 to 2005: (1) the Great Acceleration, showing how the human enterprise sweeps up after 1950 but that gains in health and development had come at a high price; (2) the Anthropocene, a proposed new geological epoch taken up by scientists (the first time that a biological species has changed Earth); and (3) "planetary boundaries", which provides a context for how to deal with well-being, physical and mental health, and prosperity. The group tasked with discussing how to address the SDGs within the framework concluded that all 17 SDGs are related to health, but suggested using SDG13 (climate action) as an overarching SDG for the whole document. There was concern that while the SDGs are trying to integrate everything, society works more in silos and sectors. The SDGs are an opportunity to work with others, and environmental health is an aspect of the health sector needing the involvement of other sectors, including business and civil sectors. It was pointed out that the SDGs are “indivisible and integrated”, so rather than dividing them, the framework should provide a rationale that explains why it focuses on specific SDGs more than others. The plenary concluded that the framework should focus on the SDGs most germane to the ministry of health, while working out linkages with all SDGs in an annex. It was noted that climate change is very important and politically a "door-opener" in many countries, but as environmental health is a broader problem, the title of the document should include the wording, “health and environment on a changing planet”. 2.4 How environmental health functions in countries
The varied institutional approaches to environment and health in China, Malaysia and Singapore were presented, along with the diverse approaches used in the 53 countries of the WHO European Region, where the process of negotiating priorities has been completely handed over to Member States. While the European Region overall has gained 10 years of healthy life expectancy over 30 years, there was agreement that any significant further progress can only be addressed through determinants of health rather than diseases. The health issues are very complex in nature – the spaghetti-shaped obesity system map in the United Kingdom is a case in point. The European Environment and Health Process
-5(EHP), since the 1989 Frankfurt Charter, sets principles, objectives and an ethical framework with priorities. However, for the EHP to be relevant for the 21st century, an era of great ecological concern, a roadmap was drafted by WHO, reviewed by the Ministerial Board, presented for public consultation to all Member States and partners, and discussed and endorsed. The key role of the WHO European Centre for Environment and Health in Bonn, financed by Germany, was canvassed. It was felt that lessons from Europe could be useful for the Western Pacific Region as it prepares the framework, which is focused on structure. The European framework is designed to push national development. However, Europe is still limited by the lack of a common global platform on health and the environment. The WHO Director-General does not lack interest, but climate change is only 1% of WHO’s budget. As more processes or strategies are developed in the six WHO regions, the closer we will get to a common understanding. Environment and health problems are complex. There is often a mindset that the right structure will fix a problem, but complex problems mean that there are many actors with different motivations and purposes. As such, a different governance system that includes non-state actors is needed. How do you recognize nodal governance as well as governments in order to prevent chaos? 2.5 Panel discussion on countries' experience in environmental health
In Australia, health is administered by the states, with the federal level providing some financing. Each state government has a specific environmental health unit, but it is a struggle to choose which of the models outlined in the framework – "embedded", "linked" or "networked" – it fits. While the Environment Department handles air quality issues, the Bureau of Planning is responsible for the built environment. The framework needs to take an adaptive management response, because the situation will always be fluid. Moreover, political will and action is lacking. Western Australia relies on a 1911 law, and the budget for environmental health makes up only 1% of the overall budget. The environmental health department is very reactive – health impact assessments are seen as an impediment to economic development. The Pacific islands have commonalities: environmental health services are centralized in the ministry of health, as enshrined in public health acts from the 1930s – they fit the "embedded" model. Environmental health officers or inspectors form a unit with regular budget, working in vector control, food safety, building inspection and occupational health. Only a few countries like Fiji and Solomon Islands have enough capacity to really do their job. In the Republic of Korea, the system is “linked”. The Ministry of Environment (MOE) was set up in the 1970s, but the environmental health department was established only in 2005. The Environmental Health Act was approved by the MOE and endorsed by the Ministry of Health and other relevant ministries in 2006, and it became law in 2008. The budget for the national environmental health action plan (NEHAP) is US$ 1 billion for five years, or US$ 200 million per year. In China, the two leading agencies are the Ministry of Health and the Ministry of Environmental Protection (MOEP). While the Health Ministry has an environmental hygiene division, the MOEP has a division of environment and health. Amid criticism about city development issues – congestion, ghost cities, garbage mountains – an Environment and Health Action Plan was developed and surveys were promulgated including one on the Huaihe River Basin, a heavily polluted cancer cluster. An environment and health forum is held every five years. There is a lack of human resources in environmental health science in China – smart people are needed in provinces and counties, rather than just in Beijing. The central Government has responsibility for United Nations activities, but very little discussion is heard in the academic circles about accomplishing SDGs or other United Nations matters – the President needs to say anything before it is done. In Malaysia, the Ministry of Health pursues the environmental health agenda with other agencies. The Sector of Occupational and Environmental Health was set up within the Ministry of Health in 1971. However, it was not prepared in 2011 for the public outrage over the proposed Kuantan rare earth processing plant and its lack of a disposal plan for radioactive waste. The Engineering Services
-6Division of the Ministry of Health is now secretariat of NEHAP 2012. Challenges include identifying links between environmental problems and health outcomes, and the fact that that social determinants of health come under different agencies. Most of the upstream activities are beyond its control. Instead, the agency stresses health implications for other sectors to do their jobs effectively. NEHAP is just one platform to identify environmental health gaps. It is clear that a country’s setting and history can influence the attitude of officials when it comes to public health. The Regional Forum, for example, is a very important source of influence in the Republic of Korea. In terms of shaping agenda and mindset, the involvement of academics in ministries of health has been a key factor in promoting environmental health, as they can educate officials so they are continuously updated. The involvement of ministries of education could also be very important for SDGs, sustainable development and educating the next generation. In countries like Australia, the concept of environmental health needs to be broadened so it is not perceived as just implementing rules around waste management and noise, for example. Pacific island countries are well known for challenges and failures such as the MDGs, but COP21 recognized small island states and least developed countries (LDCs) as countries in special need of support through global climate financing. So much money is available around climate change for different sectors, but not for health. Donors are under pressure to increase funding for climate change and health. It is up to us to package our work to meet this request from donors. 2.6 Options for institutional arrangements for addressing environmental health risks by Member States
The framework will not be able to provide specific guidance for 36 different countries and areas. Yet it needs to be relevant to both China and Nauru, for example. We must come up with elements appealing to all Member States, regardless of their size or bureaucratic structures. Three existing models of environment and health governance – “embedded”, “linked” and “networked” – were originally proposed, but in reality, it is difficult to clearly categorize countries. The arrangements might differ by issue, as in Australia. To submit to the Regional Committee, the meaning of the models would need to be made clear – either as recommendations, or development phases, with "embedded" as the traditional model and with countries redistributing roles in health and environment as they developed. It was suggested that these styles of governance should not be called "models" but rather options or strategies around which actions could be grouped. A good example of this in Australia is VicHealth – a health foundation in Victoria that is funded by tobacco tax and promoted by WHO as a way to boost health promotion. More such innovative ideas in this area are needed for ministries of health to change. While the "networked" model is prevalent in Europe, the lead agency is almost always the MOE. After the development of NEHAPs in 1999, Belgium established the Committee on Health and Environment, with its own budget line and staff. In Macedonia, the health minister heads the Health and Environment Committee and has the power to close down power plants or whatever needs to be done. In most of the countries there is a system of public health institutes, publicly owned and linked to the ministry of health, but actually independent. They do not have power to do inspections or close facilities, but they will do health impact assessments. There are policy functions, technical functions and implementation functions – a different area from health promotion. The health minister sets standards and other ministers implement or regulate. The intelligence part is the responsibility of the health sector. To define actions by countries, it was suggested that the nine essential public health functions were needed in the environmental health area. However, it was pointed out that these related only to health. In tobacco control, there are health sector priority actions in an action plan – one about mobilizing society, one about improving sector capacity. Our audience is not just the health sector, so
-7consideration must be given to engaging legislators in different sectors. It is both about the ministry of health and influencing partners. It was suggested that rather than a prescriptive table, the framework should just provide broad range of key essential functions of the environmental health unit and leave the institutional arrangement to the country. Group presentations on the adaptive management models The various features and merits of each "adaptive management model" were canvassed in group work. It was suggested that two further actions be added to the "embedded" model, one on capacity-building, due to the retirement of environmental health officers after the 1990s peak, and one on service delivery, obvious but essential. In a “linked” system, the ministry of health has internal capacity but does not have direct ownership of environmental health actions; therefore, the overarching adaptive management option for ministries of health would be the three points: promote and champion health, forge strong partnerships, and provide advice and technical support. The “networked” approach should be issue-driven – different depending on the issue. It was pointed out that when working across sectors, language is key, which is why “health and the environment” works better than “environmental health”, which has a different meaning to other sectors. In some cases, other sectors would lead. As you go forward in this rapidly changing world, sectors have to blend and work together. It was highlighted that people are more important than structure. In academia, which sits in silos, it takes a particular type of person to make a network run – a person with empathy and social skills. This will vary by issue and over time. We are in a rapidly changing world, so flexibility and nimbleness are very important. The importance of enforcement power was underlined. Occupational health, for example, traditionally falls under the health ministry in many countries, but the minute it is transferred to the labour ministry, the health sector loses the power to enforce occupational health regulation. Enforcement enables monitoring and surveillance. The “networked” model is good, but enforcement is often lacking, making it unsustainable. The need to involve civil society in the core actions was raised. In reality, organized civil society is taking the lead in this area, but its role is lacking in our framework. Community empowerment could be an action to reflect the leadership coming from the informal sector. Capacity-building emerged as a key factor in the discussion of environmental health units. In the Philippines, for example, the number of sanitary inspectors has been static for more than 30 years, and WHO has done little to improve this situation. We may also expand laboratories and other aspects of environmental health. Three sections were proposed in place of the models. Section 1 could be service delivery and capacity-building at government level. The government must possess core capacity in environmental health, regardless of which agency leads. The units in many instances are weak, so resources and knowledge must be upgraded. And to cope with the speed of change, they also must work faster. A quantum leap must be made to manage health and environment at country level. Section 2 could be new ways of accelerating health action on a changing planet, with models/options on how to work better on environmental health.
-8Section 3 would be provocative – about understanding the planet, but acting in the neighbourhood. How do we bridge the gap between what scientists know and what regular people know? There is a need for more dialogue and communication between the informed and uninformed. 2.7 Extra scientific presentations
Dr William Steffen presented on Anthropocene, starting with an overview of human history. For the vast majority of human life, we were hunters–gatherers. Only in the last 10 000 years, during the Holocene epoch, have we had civilization. For most of this period, the climate has been incredibly stable and warm, allowing humans to develop agriculture. The progress of the human enterprise has been sweeping upwards since the mid-20th century. At the same time, the Earth system has been destabilizing into a much warmer state. Average temperature is moving 170 times faster than normal and all indicators are disturbed. In 2000, Paul Crutzen called the current era – when human activity has been the dominant influence on climate and the environment – the Anthropocene, proposing it as a new geological epoch. 1950 is the most popular start date for this era. One aspect is the industrialization of land since 1700, and this could reach a tipping point. The other is climate, where global surface temperature has been shooting up since 1950. We already have had 1 °C of temperature rise since 1950, and the Intergovernmental Panel on Climate Change (IPCC) projects a 6 °C rise by 2100. But this is where the economic system is driving. On the basis of existing emissions we are already committed to a 2 °C rise. It took the Earth 7000 years to move out of the Ice Age; the same amount of temperature rise is happening in a century. Scientists are starting to study a tipping point between 2 and 4 °C, from which there would be no return. During the time of the dinosaurs, the climate was about 5 °C hotter than now, suited to reptiles but not mammals. Collapse of civilization is possible. Normally the Holocene should go on for another 50 000 years, and if we can slowly reabsorb the carbon emissions, we could get it back on track. The whole idea of planetary boundaries is to keep track of the key conditions that enable people to survive and prosper, to keep Earth in a habitable state. Climate is moving quickly toward the red zone, whereby humans would not be able to continue to survive and prosper. Participants felt that the Paris Agreement of COP21 has achieved little in the way of concrete action. Since emissions to date have basically committed the planet to warming of 2 °C, it was argued that much faster action was required by all concerned. There were echoes of the discussion 25 years ago. On an optimistic note, governments want to keep to global temperature rise at 1.5 °C. Now that Australia is on board too, there is more ammunition to stop opening coal mines and to start investing seriously in renewable energy. In addition, human behaviour is non-linear. Faced with a disastrous future, we will change our behaviour. China is predicting an emission peak of 2025 to 2030; however, it may be reaching the peak already. China has had a history of under promising and over delivering. Without the Paris Agreement, the decade would have been lost in terms of global commitment to emissions reduction. It is a legally binding agreement that mentions 1.5 °C – included because Pacific island countries were united on this figure, as a matter of national survival. Australia made the empty promise of 1.5 °C to the Pacific in order to be able to keep mining. The strong stance taken by vulnerable countries was crucial. These countries should be viewed as pioneers and champions on this issue.
-9Dr Hong felt that the Anthropocene period should be defined as starting from the industrial revolution, with the pace accelerating in the past 50 years. If we see the whole picture of the last 10 000 years, we see exponential growth on a track that is not changeable. This applies to technology and population – and the tipping point or "singularity" was fast approaching. 3. CLOSING Dr Hassan thanked participants for their contributions, indicated that Dr Steffen and Professor Peng would be called on for more long-term contributions, and thanked Dr Corvalan for superb documentation and diagrams. Dr Mercado praised the Regional Director for infusing resources, support and his own vision in the health and environment field. She commended the group for its freshness and the revolutionary new title for the framework. It should be able to inspire the public health leaders of the Western Pacific to work on saving people. 4. CONCLUSIONS AND RECOMMENDATIONS 4.1 Conclusions 1) Following the input of earth systems scientist Dr William Steffen, it was agreed to integrate the concept of accelerated planetary change into the framework and to include it in the new title: Western Pacific Regional Framework for Action on Health and Environment on a Changing Planet: benchmarking with the Sustainable Development Goals. 2) It was agreed that climate change was a risk multiplier, exacerbating many other risks, but that aspects not directly related to climate change such as chemical and radiological threats would not be neglected. 3) It was agreed that the prime focus of the framework would be the environmental health unit of the ministry of health with additional recognition of the role of the health sector, broadly defined. 4) It was agreed that the existing framework's original scheme of three models of institutional arrangements in the field of health and the environment would be replaced by a tripartite structure of "Health and environment unit–New ways of working (including reference to the models) for the health sector to adapt to accelerating change–Action with community/collaborating centre/scientist engagement". 5) As part of the "New ways of working" component, knowledge generation through networking with academia and the business sector was agreed to be vital. 6) It was agreed to link the essential public health functions expounded by the United States Centers for Disease Control and Prevention (CDC) and the WHO Regional Office for Europe to the health and environment functions envisaged for all Member States. 7) It was agreed that the framework should apply to all Member States, and that in larger countries the agreed essential functions should be replicated at each government level. 8) The framework would be benchmarked against the SDGs as well as international environmental agreements, chiefly the Paris Agreement.
- 10 9) The importance of all SDGs to health and vice-versa was underlined, to differing degrees according to country. 10) It was agreed to respect national planning cycles, like the WHO country cooperation strategies. 4.2 Recommendations 4.2.1 Recommendations for Member States 1) Member States are encouraged to read the updated and enhanced framework and provide feedback on or by the Member States’ consultation in late April. 4.2.2 Recommendations for WHO 2) WHO is requested to update and send out the updated and enhanced framework to Member States as soon as possible.
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ANNEXES Annex 1. List of participants 1. TEMPORARY ADVISERS Dr Daud Abdul Rahim, Head of Occupational and Environmental Health Sector, Noncommunicable Disease Section, Disease Control Division, Ministry of Health Malaysia, Level 2, Block E3, Parcel E, Federal Government Administrative Complex, 62590 Putrajaya, Malaysia. Email: drhjdaud@moh.gov.my Professor Peng Gong, Director, Centre for Earth System Science, Tsinghua University, S818 Meng Minwei Science and Technology Building, Beijing 100084, China. Email: penggong@tshinghua.edu.cn Professor Yun-Chul Hong, Director, Institute of Environmental Medicines, College of Medicine, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, Republic of Korea. Email: ychong1@snu.ac.kr Dr Reiko Kishi, Professor, Centre for Environmental and Health Sciences, Hokkaido University, 1-7, Kita 28, Higashi 5, Higashi-ku, Sapporo, Japan. Email: rkishi@med.hokudai.ac.jp Dr Wilfried Kreisel, Former Executive Director, Health and Environment, WHO headquarters, Auf dem Esch 9, 33619 Bielefeld, Germany. Email: kreiselw@wanadoo.fr Dr William Steffen, Emeritus Professor, Australian National University, 222 City Walk, Apartment 409, Canberra ACT 2601, Australia. Email: will.steffen@anu.edu.au 2. CONSULTANT Dr Carlos Corvalan, Consultant, 20/64-70 Spoffoth Street, Cremorne, NSW 2090, Australia. Email: corvalanc@gmail.com 3. OBSERVER Dr Helen Brown, Teaching Lead Occupation and Environment, Director of WHO Collaborating Centre for Environmental Health Impact Assessment, School of Public Health, Curtin University, Perth 6845, Australia. Email: h.brown@curtin.edu.au 4. SECRETARIAT Mr Richard Bradford, Consultant, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Telephone: +63 2 5288001, Facsimile: +63 2 5289043, Email: bradfordr@who.int. Dr Roy Cosico, Consultant, Disaster Risk Management for Health, Division of Health Security and Emergencies, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: cosicor@who.int. Dr Mohd Nasir Hassan, Coordinator, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: hassanm@who.int.
- 12 Dr Mark Jacobs, Director, Division of Communicable Diseases, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: jacobsma@who.int. Mr Swee Lian Khew, Technical Officer, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Ms Minkyung Kim, Intern, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines.. Dr Rokho Kim, Environmental Specialist, WHO Office in the South Pacific, Level 4, Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji. Email: kimr@who.int. Dr Ailan Li, Director, Division of Health Security and Emergencies, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: lia@who.int. Dr Vivian Lin, Director, Division of Health Systems, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: linv@who.int. Dr Srdan Matic, Coordinator, Environment and Health, WHO Regional Office for Europe, 8, Scherfigsvej, DK-2100 Copenhagen 0, DenmarkEmail: SMA@euro.who.int. Dr Susan Mercado, Director, Division of NCD and Health through the Life-Course, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: mercados@who.int. Dr Rodel Nodora, Technical Officer, Country Support Unit, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: nodorar@who.int. Ms Hyein Park, Volunteer, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Mr Alexander von Hildebrand, Technical Officer, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Dr Aya Yajima, Technical Officer, Malaria, Other Vectorborne and Parasitic Diseases, Division of Communicable Diseases, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines. Email: yajimaa@who.int. Mr Jungsub Yeom, Technical Officer, Health and the Environment, WHO Regional Office for the Western Pacific, United Nations Avenue, Manila 1000, Philippines.
- 13 Annex 2. Agenda Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) 27–29 January 2016, Manila, Philippines
(1) (2) (3) (4) (5) (6) (7) (8) (9) (10)
Opening Challenges and the changing context of health and the environment Environmental health from different health dimensions Regional Framework on Health and the Environment for the Western Pacific (2017–2021) How environmental health functions in countries Panel discussion on countries' experience in environmental health Policy options for different institutional arrangements for health and the environment systems of Member States in the regional framework Roles of WHO and WHO collaborating centres to support Member States on health and the environment Conclusions and recommendations for next steps Closing
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Annex 3. Programme of activities Informal Meeting to Review the Draft Regional Strategy on Health and the Environment for the Western Pacific (2017–2021) 27–29 January 2016, Manila, Philippines Day 1: 27 January 2016 (Wednesday)
Time 08:30–09:15
Activity Opening session Welcome remarks
Responsible Person/s
Dr Susan Mercado, Director, Division of NCD and Health through the Life Course, WHO Regional Office for the Western Pacific Dr Shin Young-soo, WHO Regional Director for the Western Pacific
Opening address
Introduction of participants Objectives of the meeting Dr Nasir Hassan, Coordinator, Health and the Environment, WHO Regional Office for the Western Pacific
09:15–09:45 09:45–10:45
Group photo and mobility break Challenges and the changing context of health and the environment Origin of diseases Environmental burdens of diseases in the Western Pacific The changing context of health and the environment Facilitated by Dr Susan Mercado Professor Dr Yun-Chul Hong, WHO Temporary Adviser Dr Carlos Corvalan, WHO Consultant Dr Wilfried Kreisel, WHO Temporary Adviser
- 16 Time 10:45–11:45 Activity Environmental health from different health dimensions Communicable diseases Dr Mark Jacobs, Director, Division of Communicable Diseases, WHO Regional Office for the Western Pacific Dr Li Ailan, Director, Division of Health Security and Emergencies, WHO Regional Office for the Western Pacific Dr Vivian Lin, Director, Division of Health Systems, WHO Regional Office for the Western Pacific Facilitated by Dr Vivian Lin Responsible person/s
Health emergencies and disasters
Aligning environmental health into health systems 11:45–12:15 12:15–13:15 13:15–13:45 General discussion Lunch break Overview of the draft Regional Framework on Health and the Environment for the Western Pacific (2017–2021) How can WHO support Member States in achieving sustainable development goals (SDGs) relevant to health and the environment? Objectives, vision, strategic intent and guiding principles of the regional framework Approaches and pillars/dimensions of the regional framework Mobility break Group work: Group 1: SDGs
Dr Susan Mercado
13:45–14:15
Dr Carlos Corvalan
14:15–14:45 14:45–15:15 15:15–15:45 15:45–16:45
Dr Nasir Hassan Dr Susan Mercado
Mr Alexander von Hildebrand, Technical Officer, Health and the Environment, WHO Regional Office for the Western Pacific Dr Rokho Kim, Environmental Specialist, Division of Pacific Technical Support, WHO Office in the South Pacific Dr Carlos Corvalan Dr Carlos Corvalan and Dr Nasir Hassan
Group 2: Objectives, vision, strategic intent and guiding principles of the Regional framework Group 3: Approaches and pillars/dimensions of the Regional framework 16:45–17:00 17:00 Wrap-up Reception at Al Fresco
- 17Day 2: 28 January 2016 (Thursday)
Time 08:30–09:30 09:30–10:10
Activity Presentation of group work and summary of day 1 How environmental health functions in countries? Countries in the Western Pacific Region
Responsible person/s Facilitated by Dr Carlos Corvalan Facilitated by Dr Vivian Lin Mr Khew Swee Lian, Technical Officer, Health and the Environment Unit, WHO Regional Office for the Western Pacific
Countries in the European Region
Dr S'rdan Matic, Coordinator, Environment and health, WHO Regional Office for Europe
10:10–10:30 10:30–12:15
Mobility break Panel Discussion on countries' experience in environmental health Facilitated by Dr Rodel Nodora, Technical Officer, Country Support Unit Division of Programme Management, WHO Regional Office for the Western Pacific
Australia
Dr Helen Brown, Head of Centre, Curtin University, WHO Collaborating Centre for Environmental Health Impact Assessment Professor Peng Gong WHO Temporary Adviser Dr Daud bin Abdul Rahim, WHO Temporary Adviser Dr Rokho Kim, Environmental Specialist, Division of Pacific Technical Support, WHO Office in the South Pacific Professor Yun-Chul Hong
China Malaysia Pacific islands
Republic of Korea 12:15–13:15 13:15–13:45 Lunch break Options for institutional arrangement for addressing environmental health risks by Member States Plenary discussion
Dr Susan Mercado
13:45–14:15
Facilitated by Dr Nasir Hassan
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Time 14:15–16:00
Activity Group Work: Group 1: Embedded Systems
Responsible person/s
Mr Jung-sub Yeom, Technical Officer, Health and the Environment Unit, WHO Regional Office for the Western Pacific
Group 2: Linked Systems Group 3: Networked Model 16:00–16:15 16:15–17:15 17:15 Mobility break Presentation of group work Wrap up
Dr Rodel Nodora Dr Srdan Matic
Facilitated by Dr Carlos Corvalan
Day 3: 29 January 2016 (Friday)
08:30–09:00 09:00–09:20
Summary of day 2 Roles of WHO and WHO collaborating centres to support Member States on health and the environment–Dimensions/Pillars 1 and 2 Roles of WHO and WHO collaborating centres to support Member States on health and the environment–Dimensions/Pillars 3, 4 and 5 Mobility break Group work: Group 1: Roles of WHO and WHO collaborating centres to support Member States on health and the environment–Dimensions/Pillars 1 and 2 Group 2: Roles of WHO and WHO collaborating centres to support Member States on health and the environment– Dimensions/Pillars 3, 4 and 5
Dr Carlos Corvalan Dr Nasir Hassan
09:20–09:40
Dr Alex Hildebrand
09:40–10:00 10:00–11:00
Dr Rokho Kim
Mr Alexander von Hildebrand
11:00–12:00 12:00–13:00 13:00–14:00
Presentation of group work Lunch Conclusions and recommendations for next steps Dr Susan Mercado Dr Nasir Hassan Dr Carlos Corvalan
14:00
Closing session
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