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Exploring How Public Health, Nature, and Their Interconnections Are Valued
WORKING TOGETHER TO RESTORE HUMAN AND PLANETARY HEALTH
Presented by Teddie Potter, University of Minnesota
Humans are changing the planet and not just its climate, said Potter. Humans are clearing forests, acidifying the ocean, reducing biodiversity, increasing desertification, and polluting soil, water, and air
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1 This list is the rapporteurs’ summary of the main points made by individual speakers (noted in parentheses), and the statements have not been endorsed or verified by the National Academies of Sciences, Engineering, and Medicine.
ecosystems. She elaborated on the wide range of human-related environmental changes and human health impacts: human-caused climate change is leading to rivers and lakes drying up, increases in extreme weather events that harm communities, rising temperatures, and rising sea levels that threaten coastal communities and ecosystems. These human-caused changes are also affecting human health via cardiovascular changes, respiratory changes, mental health issues, heat strokes, increasing antimicrobial resistance, and increasing exposure to vector-borne diseases. Quoting a 2019 report from the Lancet Countdown project, Potter said, “The life of every child born today would be profoundly affected by climate change and other planetary health issues, with populations around the world increasingly facing extremes of weather, food, and water insecurity, changing patterns of infectious disease and a less certain future. Without accelerated intervention this new era will come to define the health of people at every stage of their lives” (Watts et al., 2019, p. 1837).
Potter defined the concept of planetary health as “a solutions-oriented, transdisciplinary field and social movement focused on analyzing and addressing the impacts of human disruptions to Earth’s natural systems on human health and all life on Earth.” Planetary health, she said, is a hopeful, forward looking concept that proposes a way to co-create a more positive future for everyone and the planet.
In 2021, the Planetary Health Alliance released a Planetary Health Education Framework that can be adapted to and used by different fields of higher education to create a shared knowledge and lexicon as a first step to begin reversing the harm that humans are inflicting on the planet (Aguirre et al., 2021). The framework comprises five core domains (Figure 3-1):
- Interconnection within nature. Humans and nature are inseparable.
- The Anthropocene and the harms to Earth’s life support system.2
- Equity and social justice and the benefits of solutions that work for everyone.
- Systems thinking and complexity, or the idea that humans are part of a massive, complex system in which a change in one location can produce unintended consequences in others.
- Movement building and systems change through effective communication.
Potter also referred to the 2021 São Paulo Declaration on Planetary Health, a globally crowdsourced document that addresses how to bring about a fundamental shift in the way humans live on Earth (Planetary Health Community, 2021). She called this shift the “Great Transition” and believes that achieving it will likely require rapid and deep structural changes across most dimensions of human activity. Potter said that everyone—engineers, teachers, urban planners and designers, farmers, and others—will need to be part of this Great Transition to restore the health of the planet and all who live on it, and the Declaration outlines steps that every sector of human society could take to address the health of the planet (Planetary Health Community, 2021).
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2 The term Anthropocene is used by some to refer to a geological era where human activities are the main driving force in shaping the Earth’s environment. It was first used by Paul Crutzen in 2000. See an overview at https://doi.org/10.1007/s13280-020-01489-4 (accessed March 30, 2023).
SOURCE: Guzmán et al. (2021).
For example, the guidance for the health sector calls for reorienting all aspects of health systems toward planetary health and committing to achieve a nature-positive, carbon-neutral health care system by 2040. Disease prevention, health promotion, health system resilience, and health equity must lie at the heart of this transition, explained Potter. Accordingly, this guidance asks for the health sector to examine, discuss, and be mindful of the social and ecological determinants of health; the need for green spaces to provide social, recreational, and mental health benefits; air, soil, and water quality; and access to affordable nutritious diets, particularly for lower-income communities.
Rather than solely focusing on the harmful effects humans have had on planetary health, Potter said, there needs to be a clear vision of a hopeful future if people work together. “If we link arms and share knowledge across disciplines, the future is very positive,” she envisioned. In her view, it is possible to create a just future that works for everyone and restores the health of all life on the planet. “It is absolutely possible, but we need people to show up,” Potter concluded.
INTEGRATING INDIGENOUS ECOLOGICAL KNOWLEDGES TO FOSTER RESILIENCE
Presented by Ann Marie Chischilly, Northern Arizona University
Chischilly pointed out that there are 574 federally recognized Native American and Alaska Native tribes in the United States. In addition, approximately 100 tribes are recognized at the state level,
and approximately 100 tribes are seeking state recognition. Together, tribal members have accumulated Indigenous traditional ecological knowledges (ITEKs). ITEKs, she said, are valuable, significant, and valid in their own right, and they do not need validation by the methods of Western science to be considered legitimate. Rather, she explained, science needs to respect traditional methods of defining, valuing, and validating ITEKs.
While no legal definition of ITEK exists, Chischilly defines it as “the knowledge that my grandmother has given my mom, then given to me, and I will then give to my son.” In 2015, a federal advisory committee on climate change and natural resource science recognized the value of ITEKs and proposed guidelines for using traditional knowledge (Advisory Committee on Climate Change and Natural Resource Science, 2015). The committee also provided a primer on why climate change affects tribal communities in a significantly different way than nontribal communities.
In 2017, the Environmental Protection Agency acknowledged the value of ITEKs as part of its efforts to restore land and remediate contaminated sites, and in November 2021, the White House issued a memorandum to all department and agency heads that named ITEKs as one of the many important bodies of knowledge that can contribute to evidence-based federal policies and decision making. Chischilly noted that a joint commission for environmental cooperation among the United States, Canada, and Mexico has compiled a roster of ITEK experts.
Chischilly then described a set of principles for engaging tribes (Box 3-1). She also listed eight guidelines for engaging Indigenous Peoples in research projects that will involve using ITEKs, noting in particular the importance of involving tribal leadership instead of engaging only with specific community member(s), given that ITEK is tribal knowledge. The eight guidelines are as follows:
- Understand ITEKs key concepts and definitions.
- Recognize that Indigenous Peoples and holders of ITEKs have a right not to participate.
- Understand and communicate risks for Indigenous Peoples and Knowledge Holders.
- Establish an institutional interface by developing formal research agreements.
- Provide training on ITEKs for all staff early and often.
- Provide specific directions, including mitigation plans, to ensure that protections are upheld.
- Recognize the role of multiple knowledge systems even in the same tribe.
- Develop guidelines for review of grant proposals that includes tribal consultation.
As an example of how tribes can contribute knowledge to addressing climate change, Chischilly cited a report that the Institute for Tribal Environmental Professionals issued in August 2021 (STACC Working Group, 2021). Ninety tribal experts wrote the Status of Tribes and Climate Change Report that includes 30 tribal personal narratives. The report was shared with the Senate and other policy makers, and the Intergovernmental Panel on Climate Change held a hearing on the report.
One concept Chischilly has heard and seen in Indigenous communities is the idea of “nothing about us without us,” which means that researchers should not write anything about the Indigenous community without tribal participation and without free and prior informed consent. The tribal community at large has been working on author recognition and reciprocity—that is, informing the tribes of the research outcomes to benefit the community. Chischilly reiterated Potter’s comments about working together to ameliorate the effects of climate change on all life on Earth, adding that ITEKs recognize that animals, plants, air, water, land, and fire are relatives and sacred beings that live among humans and that their health is as important as human health for humans to thrive.
ENVIRONMENTAL CHANGE AND PUBLIC HEALTH IN AFRICA
Presented by James Hassell, Smithsonian Institution
In 2021, the World Wide Fund for Nature (WWF) partnered with Hassell and his collaborators to evaluate the effects of environmental stewardship on public health and implications for valuing and evaluating the co-benefits of sustainable natural resource management and public health. This was part of WWF’s work on developing its new Africa strategy to examine the public health effects of its applied work in six areas: providing nature-positive finance, greening development, promoting sustainably managed landscapes, improving climate change adaptation and mitigation, protecting critical biodiversity areas, and engaging communities.
Hassell and his team first conducted a systematic literature review on the natural environment and health throughout Africa. From this review, they generated a causal loop model where nodes represent different components of causal pathways that link social and environmental drivers to human health and lines represent up- or down-regulation of the effects between two nodes (Hassell et al., 2021). To simplify the complexity of this model, Hassell’s team generated three targeted systems maps: one on pathogen spillover, one on food and water security, and one on ecosystem services. Each map looks at how specific public health outcomes emerge from changes within African landscapes.
In conducting the literature review, Hassell identified a geographic bias in the research, particularly on zoonoses in domestic animals, that was concentrated on a few countries. This bias, he posited, has its foundation in historical inequality and instability that influences how international resources for research are distributed. The take-home message, he said, is that to make progress in addressing knowledge gaps, there needs to be a concerted effort to address this historical inequality and its effect on which countries and public health priorities receive research support.
A second gap that he identified was the differences in valuation of research or policy actions between stakeholders—that is, how linking environmental change to public health can bring value to
different stakeholders such as communities, landscape managers, public health practitioners, and policy makers. Communities, for example, need assessments on the benefits or costs of environmental interventions that support public health. Landscape managers might be looking to implement win/win solutions for biodiversity and health and to monitor the effect of landscape management activities on public health. Public health practitioners might want to identify and track risks, detect shocks to the system, and monitor long-term public health trends linked to environmental change. Policy makers, he added, would benefit from information to set and track progress toward meeting targets.
Hassell pointed to major challenges in moving from research and data collection in the field to addressing the needs of these beneficiaries. The first challenge is a lack of baseline data. While there is no shortage of data generated by long-term public health surveillance systems, Hassell did not know of unifying guidelines to identify what types of health data are most suitable for integration with other environmental data streams. There is also limited spatiotemporal coordination between collecting public health and socioecological data.
Connecting baseline data on public health and environmental drivers requires models that can explain how changes in the environment shape people’s health, said Hassell. These models exist, particularly for climate-sensitive diseases such as vector-borne diseases, but they tend to be constrained by data that are typically localized in scope, given that localized research projects generate the data. These models are important to create decision-supporting tools and platforms that can address the needs of the stakeholders, he explained. Decision-supporting tools might include those that can project public health outcomes into future environments, which would enable natural resource managers and public health professionals to test interventions and explore some of the economic tradeoffs between sustainable development activities and health.
On a broader scale, Hassell pointed out, a portfolio of indicators that link the data from public health and from environmental change would enable policy makers to connect action plans for public health with action plans for sustainable resource management and conservation. These indicators would also allow policy makers to measure progress toward meeting policy goals. It might even be possible to connect a good indicator set to financial asset classes within natural capital frameworks, and bring economic value to the effects on public health that stem from sustainably managed natural resources in the environment.
Hassell said there is precedent for linking on-the-ground data collection to indicator frameworks within public health, environmental change, and planetary health systems. For example, the Lancet Countdown on health and climate change has developed robust indicator frameworks that integrate data on public health and climate change within hazard exposure risk frameworks. Hassell noted that the Global Observatory on Pollution and Health may also have similar projects. Looking to the future, Hassell suggests that broader frameworks and standards for data collection are needed to enable scaling from independent research projects and identifying robust variables that can interpolate between on-the-ground data collection and public health outcomes.
Q&A DISCUSSION
Moderated by Katie Arkema, Pacific Northwest National Laboratory
Arkema asked Potter if she could elaborate on the similarities and differences between the roles that health care and public health professionals can play in advancing the planetary health movement to address the effects of climate change. Potter replied that health care and public health are interconnected and lie on a continuum regarding where care delivery occurs. This interconnectedness could mean that
investing in public health and preserving and restoring natural ecosystems will reduce the investment required to treat people for acute or chronic illnesses in the future.
Chischilly responded to a request to provide examples of her work with tribes by pointing to the work she does for the Institute for Tribal Environmental Professionals, including reports such as the Status of Tribes and Climate Change Report and the Status of Tribal Air Report that federal agencies use to guide some of their activities. Chischilly also conducts research that focuses mostly on the effects of uranium mining on tribal communities.
Arkema asked Hassell if the disparities between the amount of research conducted on different topics in different African countries are leading to a misunderstanding about some of the primary issues the region faces around public health and environmental health. Hassell first pointed out that economic interests drive much of the research. As an example, he explained that interest in food and livestock production is the main driver of research in East Africa, while the focus is on the aquatic ecosystem in West Africa because fish are an important commodity and source of income. Since there are areas in Africa where research is limited or non-existent, Hassell said, researchers will likely miss contextual differences such as those between East and West Africa, particularly in terms of how different communities in those regions interact with the environment, why a healthy environment is important to the communities, and how that need links to public health. Arkema commented that this is likely to be an issue regardless of the region, highlighting the need to engage people in the local communities, whether through Western science or traditional ways of knowing to identify issues that need to be addressed.
Reflections on the Presentations
Presented by Sarah Olson, Wildlife Conservation Society, and John Balbus, U.S. Department of Health and Human Services
Olson commented that the three speakers highlighted exciting opportunities to better integrate public and ecosystem health to foster resilience. Resilience is in demand, she said, because of multiple global crises—the biodiversity crisis, the climate crisis, the social justice crisis, the crisis triggered by the COVID-19 pandemic and underlying drivers of health burdens that remain unaddressed, and the crisis arising from authoritarian challenges to democracy—that are intertwined and connected to humanity’s relationship with nature. In that regard, she noted that the alternative values and ways of relating to nature that Chischilly discussed regarding Indigenous knowledge, promoted through respect and reciprocity among the research community, could shift the paradigm so humanity could live in greater harmony and oneness with the natural world. Olson reflected that Chischilly’s presentation spoke to the reckoning about society’s relationship with nature and the danger of Western and colonial values of prioritizing economic growth at all cost.
Potter’s presentation, said Olson, highlighted the urgency of addressing the effects of climate change on human health and the efforts that public health professionals have put into creating educational resources and global guiding documents focused on this urgent issue.
Olson thought that the framework underlying Hassell’s bottom-up research plans for the African region could guide research in Latin America and Southeast Asia. His presentation highlighted the importance of thinking about how to bridge on-the-ground activities with efforts to influence decisions from local communities and public health and land use planners. This workshop, she said, offers the opportunity to think about how to translate knowledge into action and future research, with each sector or stakeholder finding opportunities to integrate their knowledge and activities.
Olson then spoke about a new effort, Wild Health Net,3 that will bring sectors together to build and grow national wildlife surveillance systems. She noted that only 6 percent of countries in the world report wildlife health or conduct zoonotic disease surveillance activities (Machalaba et al., 2021), and while the World Organisation for Animal Health has provided guidance and frameworks for how to conduct national wildlife health surveillance, most countries do not have the infrastructure to build the necessary system. Her organization is addressing this deficiency by engaging its network of people working on the ground and using existing data collection platforms that can enable park rangers more than 1,000 protected areas to report wildlife health events.
Her organization has used this system to track the spread of African swine fever to Southeast Asia via a wild boar, and to detect mass die-offs of birds caused by avian influenza and the connection to domesticated poultry. The system also detected the appearance of lumpy skin disease, which normally affects cattle, in the endangered banteng in Laos, which led to the Laotian government to craft a policy designed to prevent further incidents. Her organization is working to roll this system out in more countries and hopes to expand the coalition of actors in the Wild Health Net Consortium with the recognition that the challenges of addressing the five crises she mentioned likely surpass the capabilities of any single organization.
Balbus remarked that the three presentations highlighted the development and application of frameworks for connecting the health of ecosystems, the proximity and access to those ecosystems, and human health. He noted the valuable discussion on the profound philosophical and scientific contrasts between Indigenous Peoples and the colonizing societies4 that moved onto their land and how integrating Indigenous and Western frameworks5 might lead to making better decisions going forward.
Balbus noted several concepts regarding climate change and health equity that emerged from the presentations. The first is that, for the past 15 years, the climate and health community has emphasized the health benefits arising from climate mitigation, such as health benefits from reducing air pollution through reducing fossil fuel emissions, and the economic value from improving human health exceeds the cost of the mitigation measures. This example and others point to the important benefits for human health and the profound implications for health equity that can result from broader climate actions. Adding the human health benefits to other benefits of protecting and restoring ecosystems is an important step that can influence policy.
He commented that studies of intact ecosystems, biodiversity, spillover prevention, and pandemic prevention are related to, yet different from, studies on contact with and access to green spaces in urban areas. Therefore, Balbus emphasized the need to distinguish between research frameworks that examine the intactness of and services provided by natural ecosystems and those that
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3 See https://oneworldonehealth.wcs.org/Initiatives/WildHealthNet.aspx (accessed November 24, 2022).
4 “Colonization” and related terms describe a multifaceted problem that include overlapping or adjacent social, policy, scientific, and economics issues rooted in race that include displacement from the land, extractive capitalism, and racism in governance, among others. While specifying isolated issues can enable more in-depth considerations of potential research, scientific, and policy solutions, it is also important to understand the interconnection between these issues.
For an example of applying these considerations to addressing climate change, see https://doi.org/10.1007/s11625-021-00960-9 (accessed March 30, 2023).
For a discussion on addressing these considerations in the context of environmental change challenges, see https://doi.org/10.1080/10705422.2019.1658677 (accessed March 30, 2023).
For a collection of publications that examine the different aspects of this complex, multifaceted problem, see https://doi.org/10.3167/ares.2018.090101 (accessed March 30, 2023)
5 “Western frameworks” is used here to broadly refer to knowledge generated through methods and paradigms derived from the scientific method associated with the European Renaissance. See https://www.ipbes.net/glossary/western-science (accessed March 30, 2023).
examine health benefits from contact with nature in blighted areas. Both Taylor Ricketts, from the University of Vermont, and Hassell addressed some gaps between these two areas.
Balbus also noted the need for more granular research questions. Using the example of a hypothetical project to cover a highway bisecting a blighted urban neighborhood with a park, he pointed out that key questions in determining whether this project would produce benefits commensurate with its cost include identifying how air quality from the highway below could affect the green space above and any potential health effects, and whether it would be necessary to filter out particulates coming from the highway to produce the desired health benefits.
In another example where a wildlife migration corridor is built over the highway, a key consideration through the ecosystems health lens is how to design the migration corridors such that expanding human land use will not impair natural adaptation to climate change. Research may also be needed to compare the overall health impacts between having the highway with migration corridors as mitigation measures compared with the original ecosystem.
Balbus said that the new office that he is leading within the Department of Health and Human Services has the mission of helping local communities, particularly those that bear the greatest burden of health disparities, become more resilient to the health impacts of climate change. In that regard, the information coming from this workshop will be very valuable in informing decisions about how to spend the money in the Inflation Reduction Act and the Bipartisan Infrastructure Law.
Discussion with the Plenary Speakers and Panelists
Arkema asked the three speakers (Potter, Chischilly, and Hassell) and two panelists (Balbus and Olson) for their thoughts on how to reconcile the different ways of understanding the relationships between public health and nature, and the importance of each. Hassell focused on the challenge of evidence gaps as a reflection of how people from different areas of expertise rarely work together on applied, on-the-ground research. He proposed finding a way, perhaps through geographically focused symposia, to bring together researchers, practitioners, and policy makers from these different backgrounds to develop a common understanding of what the policy needs are from other perspectives. This co-development approach could help researchers understand how to design their research to address policy-relevant questions.
From a policy perspective, Balbus said, there are qualitative and quantitative aspects for engaging in this type of synergistic work. The qualitative side is underway, thanks in part to the COVID-19 pandemic which illuminated how upstream systemic forces are primary drivers of health and that the health system and human services system could work together to address those upstream forces. However, he continued, even though the natural and built environments are among the recognized upstream social determinants of health, they are generally excluded from health care screening, data gathering, and reimbursement mechanisms. As a result, quantitative data are lacking to make the economic case that investing in the natural environment will produce a return in the form of lower health care utilization.
Potter highlighted that current research operates according to a modern reductionist narrative of breaking problems into segments that then become the province of subject specialists. This framework is changing to reflect an older view in which everything is interconnected, prompting questions about who and what knowledge is missing and how one set of knowledge may interact with other sets of knowledge. An encouraging sign for Potter is that the education students receive today better reflects the more connected view of the world.
Mechanistic versus Relationship Models
Arkema then asked for some examples of the mechanisms involved in mediating the connections between ecosystem health and human health and how a better understanding of these mechanisms could inform policy. Potter said she wants to shift the narrative toward understanding and gaining a deep respect for relationships rather than mechanisms, as well as acknowledging that humans cannot continue to dominate nature and that actions today will affect what will happen to people born in the future. Mechanistic thinking, she continued, implies holding oneself to be an unbiased observer rather than part of the relationship between humans and nature. On the other hand, Potter encouraged, thinking in terms of relationships and being part of those relationships can lead to ways of healing broken or severed linkages and healing the hierarchies that have placed one type of human over another or humans over other species.
Balbus added that while he agrees that the broken relationship between humans and nature has contributed greatly to the current crises, there is still a need for quantitative data and mechanistic evidence to support decisions that can equitably protect people from the effects of climate change. Hassell suggested that a framework that accounts for these relationships may be key for building and parameterizing models that can make predictions about what might work to accomplish the mission that Balbus noted. Hassell acknowledged that it is challenging to integrate human behaviors into models, but there are examples of bottom-up modeling for emerging infectious diseases where risk is determined through ecological factors interacting with human behavior and environmental change. Such models provide the opportunity to integrate a fine-scale understanding of people’s relationships with the environment in a way that leads to a better understanding of risk and that is not captured by top-down approaches to modeling risk at a broader scale.
Engaging with Traditional Knowledge
Arkema posed the question of how to engage with traditional knowledge to help understand adaptation strategies for climate change. Potter stressed that traditional knowledge systems are equal to evidence from Western science or science-based decision making. She added that this acknowledgement is not about political correctness or inviting people with other viewpoints to the table but about utilizing all of humankind’s available knowledge, instead of just one subset, to face the major and critical challenge of climate change. Not using knowledge developed over eons is equivalent to approaching this crisis blindly, she said.
In agreement with Potter, Balbus also pointed out the connection to environmental justice. A fundamental tenet of environmental justice is empowering communities to have significant decision-making power over what happens in the place where they live. Nowhere is this more important, he said, than for tribal nations, which have largely been prevented from exercising their autonomy through their exclusion in the decision-making process and the historical and continued displacement from their land. Acknowledging the significant value of Indigenous knowledge and a different way of making decisions could empower tribal nations to make decisions about the spaces where they live.
Engaging the Community as Collaborators
As an example of how to engage local community as a partner in a project, Potter recounted how an under-resourced community in North Minneapolis asked her to share information about planetary health and how the community could protect itself from the effects of climate change. She and her collaborators went to the community and listened to its members with an open mind and without any preconceived notions. After first hearing about what the local community was experiencing and what it
needed, her team brought in resources from researchers and the nearby university that enabled the community members to take on a leadership role going forward. This approach, said Potter, was to lift up the local community so it could lead its own transformation rather than coming in to prescribe predetermined solutions.
Hassell described a project in Kenya that looked to quantify how people are interacting with animals and whether these interactions were potentially exposing them to health risks from the surrounding environment. The research team provided the community with Global Positioning System trackers to create a map of where local community members were going and then compared that with information the team gathered on the environment. The research team also asked the community members to draw maps of their environment and then explain why and how they interacted with elements in those environments. The second approach is expected to provide a much richer understanding of people’s interactions with nature and a better interpretation of risk.
Arkema said she also uses participatory mapping in her work and has found that it serves to bring knowledge back to the local community and show the community members that their ideas have become a core part of the policy discussions and analysis. Feedback from community members shows this is a powerful way of helping them feel they have been heard and that their vision for the future have been integrated into development planning.
Closing Remarks
Potter said she is most often asked if there is still time to adapt to the human-caused environmental changes. To this question, she says yes, but only by sharing knowledge across disciplinary boundaries and working together. Balbus noted that social discourse that discounts science creates an enormous challenge for addressing climate change and its effects on human health. At the same time, he has found that the issue of conserving natural spaces has broad appeal across the spectrum of American society. He also thought that discussions at the intersection of contact with nature, intact natural ecosystems, and public health could create space for many value systems and should be included in the design of projects and communication strategies. Arkema added that the health of natural systems has been a shared value among different stakeholders for many years, but it is valued in different ways by different sectors.
Hassell compared the current social sentiment and research practices regarding public health and environmental change to where the biodiversity conservation field was 10 to 20 years ago in linking biodiversity to environmental change. In his view, there are important lessons in how the biodiversity conservation community came together to set data standards and collect critical data that link biodiversity changes to drivers of environmental change. The resulting observatories and networks facilitated open data sharing and the development of indicators and ways of monitoring biodiversity. Those successes could be a source of inspiration going forward.
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