Salute ed Ambiente: i dati, le tendenze e le sfide per una nuova prevenzione primaria

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1 Salute ed Ambiente: i dati, le tendenze e le sfide per una nuova prevenzione primaria Roberto Bertollini MD MPH Senior Adviser and Coordinator Public Health and Environment WHO Headquarters 1 Preventing disease 2009

2 Le evidenze 2 Preventing disease 2009

3 Reduced exposures SO 2 emissions have been substantially reduced between 1980 and 2000, preventing many respiratory diseases European Region European Union Commonwealth of Independent States WHO Health for All database Sulphur dioxide emissions, kg per capita per year

4 Some exposures pose a challenge After decrease, PM 10 concentrations are stable, leading to a loss of life expectancy Source: EMEP and IIASA Loss of life expectancy in months

5 Improved knowledge Changes in threshold values and corresponding regulatory standards following increased knowledge on health effects of lead

6 Improved knowledge Air quality guideline values 2000 vs PM10 Daily mean No value 50 Annual mean No value 20 SO2 10 minutes mean Daily mean Annual mean 50 Not needed NO2 Daily mean Annual mean Ozone Daily maximum 8 hour mean WHO air quality guidelines, 2005

7 Burden of Disease Study: Background No systematic review and calculation of the preventive potential of the environment available WHO's 2002 Comparative Risk Assessment (CRA) has provided partial results Relevant to address the "modifiable" environment How much health gain could be achieved by environmental interventions 7 Preventing disease 2009

8 Method systematic reviews and expert opinion Systematic reviews or CRA cover only about one third of expected environmental contributions (10 risks, 45 diseases) Completed systematic literature reviews with expert opinion Experts from or selected by WHO programmes, and authors from key publications Global representation of experts More than 100 experts contributed 8 Preventing disease 2009

9 What is the modifiable environment? Pollution UV and ionizing radiation, noise, EMF Occupational risks Built environment, incl. housing, land use, roads Agricultural methods, irrigation schemes Man-made climate change, ecosystem change Related behaviour, e.g. hand-washing 9 Preventing disease 2009

10 How much disease could be prevented by modifying the environment? Current evidence - best conservative estimate 24% 40% World average 30% 20% 10% 0% Attributable fraction AFR-D AFR-E AMR-A AMR-B AMR-D EMR-B EMR-D EUR-A EUR-B EUR-C SEAR-B SEAR-D WPR-A WPR-B Sub-region 10 Preventing disease 2009

11 Diseases with largest environmental contributions (I) Diarrhoea Lower resp. infections Other unintentional inj. Malaria Road traffic injuries COPD Perinatal conditions Ischaemic heart dis. Childhood cluster Lead-caused MMR Drownings HIV/AIDS 0 1% 2% 3% 4% 5% 6% % of global disease burden in DALYs 11 Preventing disease 2009 Environmental fraction non-environmental

12 Diseases with largest environmental contributions (II) Malnutrition Cerebrovascular dis. Asthma Tuberculosis Suicide Depression Poisonings Falls Hearing loss Violence Lymphatic filariasis Lung cancer 0 1% 2% 3% 4% 5% 6% % of global disease burden in DALYs 12 Preventing disease 2009 Environmental fraction non-environmental

13 Inequalities Ability to assess the burden of disease DALYs due to environmental factors/1000 capita Data from WHO, Country profiles of environmental burden of disease, 2007

14 Health inequalities in Europe DALYs due to environmental factors/1000 capita by country, Iceland Israel Switzerland Sweden Monaco Malta Netherlands Italy Norway San Marino Austria Germany France Spain Cyprus Andorra Ireland Luxembourg United Kingdom Belgium Denmark Finland Portugal Slovenia Greece Czech Republic Croatia TFYR of Macedonia Slovakia Poland Bosnia-Herzegovina Armenia Serbia-Montenegro Georgia Hungary Bulgaria Albania Uzbekistan Turkey Romania Lithuania Republic of Moldova Azerbaijan Latvia Estonia Ukraine Belarus Kyrgyzstan Tajikistan Turkmenistan Kazakhstan Russian Federation WHO, 2007

15 Within Region BoD differences in children ,000 40,000 5,000 30,000 24,000 20,000 42,000 10, ,000 19,000 0 EURO A EURO B EURO C Outdoor and indoor air pollution, lack of water and sanitation Injuries

16 Le tendenze e le sfide 16 Preventing disease 2009

17 New exposures Percentage Mortality exceedance Global warming is a matter of fact 12 August 2003 (Inserm, 2007)

18 Global Environmental Changes: health risks Stratospheric ozone depletion Skin damage/cancer Eyes (cataracts, etc.) Immune suppression Social disruption, conflict, impoverishment, mental health impacts Climate change Direct impacts Thermal stress: death, disease events, injury Storms, cyclones, floods, fires Sea-level rise: physical hazards, displacement Land cover (forest, etc) Land use: soils Fresh water: glaciers river flows chemistry Human predation Biodiversity changes, & ecosystem disruption Food production: systems/methods Infectious disease risks Changes in ecology/numbers of host species, vectors (mosquitoes, etc.) e.g. pollination Food yields: nutrition and health Immune function: susceptibility Avian flu, Nipah virus, BSE, etc. Oceans: Anoxic zones Algal blooms Warming Acidity (CO 2 ) Urbanisation: population size, consumerism, energy use, etc. Marine food web Poverty, crowding, hygiene; physical hazards; infectious disease risks Impacts on urban coastal populations, esp. Based on original, prepared for Earth System Science Partnership (McMichael, 2006)

19 Environmental Health Risks Widening our field of vision Reduced farm yields Impaired livelihoods Nutritional status Health impacts Specific chemical exposure Cancer Agriculture Crop farming Livestock production Use of chemicals Effects of temperature and soil moisture on plant growth Nitrogenous fertiliser Nitrous oxide Methane Potent greenhouse gases Climate change Health impacts

20 Concentrations of Main Greenhouse Gases over Past 2,000 Years (IPCC 2007) 2005 CO 2 now CO 2 ppm N 2 O ppb Carbon Dioxide (CO 2 ) Nitrous Oxide (N 2 O) Methane (CH 4 ) CH 4 ppb CO 2 N 2 O CH 4 Year

21 Projected Global Warming: IPCC (2007) Greenhouse gas emission scenarios (see # below) Atmospheric concentrations remain as at 2000 A2 2020s 2090s Av. surface warming, o C o C A1B o C Year # Future climate scenarios modelled on 3 different emissions projections in 21 st Century: A2 relatively high B1 0 o 3.5 o 7.0 o (Temp Rise, o C) A1B mid-level emissions B1 low INTERGOVERNMENTAL PANEL ON CLIMATE CHANGE, 2007: SYNTHESIS REPORT, p. 46.

22 Climate Change: occurring faster than expected IPCC 2007 Assessment now looks conservative. Recent research shows increases in: Global GH Gas emission rate Ice melt rate (Arctic sea ice, Greenland, Antarctic, alpine glaciers) Sea level rise Saturation of carbon sinks (land and sea) Estimated carbon stored in permafrost = 2 x atmospheric C [Schuur et al., 2008]

23 : Reported increase in methane release from Siberia and Russian Arctic Western Siberia peat bog: 70 bn tonnes of methane: 2000 times > annual human-caused methane release 25% of total global land-based methane stores

24 Sea-level Rise: Diverse Health Risks Physical risks Storm surges Flooding (including disrupted sanitation diarrhoea risk) Saltwater intrusion Freshwater supplies Coastal agriculture/horticulture under-nutrition Fish nursery damage (reefs/mangroves): food & nutrition Brackish coastal water: mosquito breeding (e.g. A. vigilax) Community disruption/displacement: Mental health risks, infectious disease, tension/conflict, etc.

25 Climate Change: Impact Pathways What is important? Climate Change Impacts Direct impacts (extreme events, heatwaves, air pollutants, etc.) Physical systems (river flows, ocean temp, soil moisture) Biological cycles Ecological linkages Human Health: Injuries/deaths Thermal stress Infectious diseases Malnutrition Mental stresses Other disorders Indirect impacts ecologically mediated Economic impacts infrastructure, production, growth Indirect impacts socially mediated

26 Climate Change and Health: Paths, Examples Impacts, via: Climate change Responses Meteorological conditions, exposures Human/social consequences of climate change Mitigation actions Warming Humidity Rainfall/drying Extreme events Displacement (e.g. sea-level rise) Slums/shanties, emigration: many hlth risks Shifts in farming Land-clearing new microbe contacts Malnutrition Stunting; infection susceptibility Alternative energy Transport choices Livestock production (esp. ruminants & methane) Examples of health impacts Salmonella; mosquitoes (malaria, dengue) heat-stress at work Food yields: nutrition Injury/death; infection outbreak; depression and stress disorders Hydropower: snails and Schistosomiasis Clean air: cardio-resp. diseases Physical activity Diet/health impacts (excess red meat colon cancer) Adaptation actions Crop substitution Water shortage Unexpected nutrient deficiencies Water tanks mosquitoes

27 Mortality Impacts of Climate Change: Year 2000 Estimated annual deaths due to climate change: malnutrition (~80K), diarrhoea (~50K), malaria (~20K), flooding (~3K) 14 WHO regions scaled according to estimated annual death rates due to the change in climate since c (Patz, Gibbs et al, 2007: based on McMichael, Campbell-Lendrum, et al, 2004)

28 Cumulative Emissions of Greenhouse Gases Countries scaled according to cumulative emissions (billions of tonnes CO 2 -equivalent) up to (Patz, Gibbs, et al, 2007)

29 Climate and Infectious Disease Climatic conditions set geographic and seasonal boundaries of possible transmission. Many other environmental, social and behavioural factors, and public health strategies, determine where/when transmission actually occurs.

30 Daily hospitalizations for diarrhoea, by daily temperature: Lima, Peru Daily Hospitalisations Overall estimate (from regression analysis): 7% increase in daily cases per 1 o C rise Daily temperature El Niño event 1993 Checkley et al, Lancet

31 Influence of Seasonal Rainfall, Surface Water, and Crowding on Cholera Occurrence, Madras region Based on: Ruiz-Moreno, Pascual, Bouma, et al, EcoHealth 2007; 4: Study of 26 districts, Madras Presidency, south-east India, Cholera Risk (water-borne) transmission water dilution effect human crowding effect Cholera Risk (human-to-human) transmission Shallow Water Depth Flood

32 (days) Malaria Transmissibility: Temperature and Biology Plasmodium Incubation time P.vivax P.falciparum (per day) Mosquito Biting frequency Survival probability (per day) Temp ( C) Temp ( C) Temp ( C) TRANSMISSION POTENTIAL Temperature ( C) Based on Martens WJM, 1998

33 Climate Change and Malaria Potential transmission in Zimbabwe Baseline Climate suitability: red = high; blue/green = low Harare Bulawayo Ebi et al., 2005

34 Climate Change and Malaria Potential transmission in Zimbabwe Baseline Climate suitability: red = high; blue/green = low Harare Bulawayo Ebi et al., 2005

35 Climate Change and Malaria Potential transmission in Zimbabwe Baseline Climate suitability: red = high; blue/green = low Harare Bulawayo Ebi et al., 2005

36 Global Hunger Map, Sources: FAO 2005; WHO 2006; UNICEF 2005 FAO estimates of food insecurity & under-nutrition: c. 2000: 820 million 2007: 923 million 2008: 963 million Global Hunger Index (%) Most hunger > 30% 20-29% 10-19% Least hunger <10% No data Not included

37 Modelled impact of climate change, by 2080, on cereal grain harvests World -0.7 Developed countries +5.9 Developing countries -5.6 % Change in Yield* Southeast Asia -5.2 South Asia Sub-Saharan Africa -5.7 Latin America +8.9 * mid-range figure From: Tubiello & Fischer, 2007

38 Avoiding the Unmanageable Mitigation and Adaptation Managing the Unavoidable

39 Adaptation to Climate Change: from primary to tertiary prevention Reduce exposures [primary] Safe water, and sanitation Improve food yields; distribution and access Vaccine programs Legislation/regulation (air quality, land-use, etc.) Alterations in built environment Early warning systems Detect and arrest emerging problems [secondary] Surveillance and monitoring Adaptation/extension of vector control programs Nutrient supplementation Respond / treat [tertiary] Emergency response to extreme weather events Early detection and treatment of infected persons Mental health services, counselling; community support

40 Averting Climate Change: Immediate Collateral Benefits to Health Wise emissions reduction (mitigation) policies will provide health co-benefits another important research topic Our response to climate change could thus become a transformative vehicle for revitalising health promotion and for achieving true, sustainable, primary prevention of disease.

41 Climate Change Mitigation (Abatement) Health Co-benefits of Cleaner Air Technologies to reduce greenhouse emissions & resultant outdoor air pollution (particulates, SO 2, ozone) (~0.8 million deaths/year in cities) Energy-efficient cook-stoves, and clean non-solid fuels, in low-income countries (1.6 million deaths/year from indoor air pollution: women and children)

42 Health co-benefits of: Active transport and food policies that reduce greenhouse gas emissions Reductions in: - Inactivity (~1.9 million deaths/year worldwide) - Injuries (~1.2 million deaths per year) Animal foods intake in highconsumption countries (Coronary heart disease, diabetes, some cancers, etc) Brrrp

43 Climate-Friendly Solution to the Overweight/Obesity Epidemic

44 Climate Change and Health Sector: Historic Challenge/Opportunity Health sector has both good science and moral weight on its side: Attaining, maintaining and sustaining the population s health and wellbeing is society s prime goal. Primary Prevention within Sustainability Framework Seek, via research and policy, convergence of three great related agendas: Reduce health inequities Eliminate poverty (major source of poor health) Stabilise global climate, to minimise heath-risks

45 Climate Change & Health: Paths & Impacts; Research and Policy Foci Natural environmental processes ( forcings ) Added pressure on environment Human society: Pop n size, density Culture, institutions Economic activity Climate - environmental changes, affecting: Meteorological conditions Water flows Food yields Physical environmental safety Microbial patterns, activity Extreme weather events Mitigation of Climate Change: Reduce GHG emissions Adaptation: Reduce health impacts/risks Unintended effects Human impacts: Livelihoods Social stability Health Health Cobenefits? 4 Risks better recognised Based on: McMichael et al., Brit med J, 2008

46 Need for new science-policy interface Extent of community response Initial research Stakeholder involvement Precautionary monitoring of developmental exposures Risk assessment Focused research Evidencebased action Precautionary action to protect children and women Time / Degree of scientific certainty

47 Climate change and health: preparing for unprecedented challenges. WHO Director General Margaret Chan. December, 2007 With impoverished populations in the developing world the first and hardest hit, climate change is very likely to increase the number of preventable deaths. The gaps in health outcomes we are trying so hard to address right now may grow even greater. This is unacceptable. 47

48 Thank you 48 Preventing disease 2009