Richard Smith: Non communicable disease and sustainable development

Richard SmithThere is a sense that if you are not working at something that helps counter climate change (or climate disruption, as it should be called) then you are wasting your time. You are Nero, and Rome is burning. Those of us who work on non communicable disease (NCD) are “lucky” in that most of what needs to be done fits with reducing the harm from climate change. The time has come for the “NCD agenda” to be integrated with the broader “sustainability agenda,” and this was the focus of a joint meeting this week between the London School of Hygiene and Tropical Medicine and the Lancet.

Much of the meeting focused on climate disruption itself, and it was hard not to think that we are headed towards catastrophe—sometime in the second half of this century when I’ll be dead, but my children and others I love will not. I often think how awful it must be to die at a time of universal horror—like Henry James dying in 1916—and I fear that that may be my fate after a very lucky and privileged life (in which I’ve consumed the carbon of some 10 000 people living in rural Africa).

Robert Watson, one of the world’s leading climate scientists who was chair of the Intergovernmental Panel on Climate Change from 1997 to 2002, told us that the world had very little chance of keeping global warming below 2 degrees centigrade and only a 50:50 chance of keeping it to 3 degrees centigrade. The world has warmed by 0.8 degrees centigrade over pre-industrial temperatures, and the end of the century could see an increase of 7 degrees centigrade, a figure at which life would probably become impossible. Catastrophe will come not from more malaria or even from increased deaths from extreme temperatures and weather events, but from thirst, famine, mass migration, and war—the familiar Horsemen of the Apocalypse.

These predictions depend on a wide range of factors, not the least being whether the world manages eventually to make a serious response. Watson was not optimistic. China is now the world’s biggest emitter of carbon, having increased very rapidly in recent years, but in per capita terms it is still way below the US, Europe, and other developed countries. And the problem has been created by the high living of people in rich countries. Salvation can come only from rich countries dramatically reducing their per capita carbon consumption and emerging nations like China and India accepting that they can never reach the level that is current in the US.

Unfortunately the aspiration of the world’s people is to live like Americans—driving their own cars (perhaps two) and eating meat five days a week. It’s calculated that we need five earths for everybody to live that way, and three if everybody were to live like Europeans. Only people in rural areas in Africa and Asia live at a level that needs only one planet, and, as Tim Laing, food guru, said “Nobody wants to eat like people in Malawi.” Food is responsible for about a third of global carbon emissions, and, said Laing, we have a food system that is a tremendous success in that “capital plus science” has put 38 000 different products into supermarkets, but is madness in that it’s wholly unsustainable. (In passing, he noted that the horsemeat scandal is a dream come true in that it shows clearly to people the madness of the system.)

But are you going to stop driving, flying, and eating meat, dairy products, and fish? Probably not, especially as you stopping will make no difference if everybody around you carries on. One speaker asked the audience how many did not fly last year: it was a handful. The level of change we need to make as individuals and societies has never been achieved by any country at any time, said Paul Wilkinson, a professor at the London School.

One thing that might motivate you to change is to avoid having a heart attack or stroke, and you’re even more likely to change once you have had one. Luckily what’s good for you is good for the planet.

That’s one of the main drivers for integrating work to reduce the burden of NCD into work to create a sustainable way of living, and now is the time to talk about this as the world is launched into devising (in horrible jargon) the “post development agenda” (known to the cognoscenti as PDA, all of whom have another kind of PDA—a personal digital assistant). The Millennium Development Goals  (the MDGs), which grew out of the Millennium Declaration, come to an end in 2015. Although missing some important issues like human rights and equity, and unlikely to be achieved in some countries, the MDGs are generally seen as a good thing, not least in that they brought most of the world together on an important programme. So they will be replaced by the SDGs (Sustainable Development Goals), and many different groups are debating what should be in those goals.

Health has to compete with issues like poverty, climate change, the economy, hunger, human rights, security, and is not the world’s top concern. That is one reason, said George Alleyne, former director general of the Pan American Health Organisation, for embedding (his chosen word) NCD into the PDA. Alleyne follows Nobel prize winner Amartya Sen and American philosopher Martha Nussbaum in preferring to talk about human development and argues that health is both an important outcome of development and an input to development.

The three strands of development are social, economic, and environmental, and we who think about NCD are used to the idea that social, economic, and environmental trends are major causes of the pandemic of NCD—as people move from working in fields to call centres, get richer, buy cars, smoke, drink alcohol, and eat more meat and fatty, calorie rich foods. But NCD also contributes to all three strands—creating young widows, plunging families into poverty, driving up health costs, driving inequity, and reducing social cohesion. So, argues Alleyne and others, NCD should be embedded in the SDGs with clear targets.

Something that might well be included in the SDGs is universal health coverage (often called inevitably UHC) as it’s fashionable, partly as a reaction to the MDGs and vertical programmes like the Global Fund for AIDS, TB, and malaria, which have been disease based, and prioritised one kind of suffering over another, and denuded health systems in some low and middle income countries. Universal health coverage will be important in reducing the burden of NCD, but, Alleyne emphasised, it will not be enough in that many of the measures that are needed to counter NCD—like raising taxes on tobacco, shifting agriculture, and encouraging public transport—lie outside the health system.

Following on from Alleyne, Andy Haines, former dean of the London School, spelt out some of the practical ways in which NCD and sustainability fit together. Insulating houses and fitting cookstoves for the half of the world that cooks with biomass like wood and dung will save both lives and carbon, as will building up public transport and encouraging walking and cycling. Ian Roberts, another professor from the London School, said how he responds to the common phrase “It’s too dangerous to cycle in London,” by “It’s too dangerous not to.” If you take up cycling you will on average lose a week of life from a road traffic accident and another week from exposure to pollution, but gain 32 weeks from increased physical activity. Some of the biggest gains in both lives and carbon come from changing diets, reducing consumption of meat and dairy products, and increasing consumption of fruit and vegetables. Then shifting electricity generation from coal and oil to wind, sun, tide, and nuclear not only reduces carbon emissions, but also reduces suffering and death from air pollution. Another “co-benefit” (more jargon) of all of this is a saving in healthcare costs.

The group from the London school and others have put all this together in a series in the Lancet and calculated that increased cycling and walking and reduced car use could save the NHS some £17 billion over 20 years.

I left the meeting hovering between despair and optimism. My guts and much of my head tell me that solving climate change is beyond humans, but I recognise that we really know nothing about the future and that I need to go on with making my minuscule contribution (although it must be doubtful that that contribution outweighs the negative side of my carbon consumption, meaning that dying could be my biggest contribution). I’m now convinced that it doesn’t make any sense for us to beat the NCD agenda on its own and that it must be absorbed into sustainable development.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.