Health promotion is an important component of primary prevention. Health promotion also includes protection of populations from harmful health consequences of climate change. Deforestation is a major factor among others which have resulted in drastic climate change (Buizer et al 2014). Intergovernmental Panel on Climate Change (IPCC) has estimated that the surface temperature of earth has risen by 0.6 degree celcius during 20th century (IPCC 2001). There are also projections that the surface temperatue of earth will raise by minimum of 1.5-2 degre celcius by the end of 21st century even if strong mitigation efforts are done (World Bank 2012).
The World Bank Report further says that the temperature could rise by 4 degree celcius with low mitigation efforts (ibid). The 40c warmer world will affect human survival badly by affecting agriculture, natural resources like water, ecosystems, economy, development and health (ibid). There is interdependence between human health and its natural environment. The relationship was one of symbiosis prior to industrialisation where nature used to provide resources to humans and the humans in turn used to preserve the environment.
With the increased industrialisation and unplanned urbanisation, larger and larger emission of greenhouse gases took place, which resulted in global warming and increased frequency of disasters such as hurricanes, typhoons, earthquakes, tsunamis and floods. There are inter-linkages between climate-change, health and development (Ruhil 2016). It is the poor who gets most affected by climate-change, resulting in poor health, pushing him in to even deeper poverty (Lang and Raynor 2012). The coming sections of this article discusse climate-change as socio-ecological determinant of health; and the analysis of chosen intervention along different criteria such as equity and sustainability.
- Socio-ecological determinants –
Environmental hazards are major socio-ecological determinants of health. Climate-change has resulted in a warmer world and has posed threat to the health of populations which will continue to increase in coming times (Confalonieri et al 2007). Vectors and infectious agents are very sensitive to changes in temperature, humidity and precipitation; which has led to increased rate of infectious diseases with increased climate change (ibid). These changes have also resulted in increased breeding sites for mosquitoes and increased survival time of mosquitoes which have further resulted in increased prevalence of malaria, dengue, Chikanguinea, Zika virus and other related diseases (WHO 2011, Vankleef et al 2010). Meningococcal meningitis is another example of seasonal disease which has increased due to climate change, especially in Burkina Faso (colombini et al 2009).
Climate change as instigated by deforestation, leads to increased frequency of disasters and thus the associated epidemics of cholera and other diarrhoeal diseases (UNICEF & WHO, online). It has been predicted that if strong mitigation efforts are not taken, the earth will be warmer by 4 degree Celsius, by the end of century; and heat events will be very frequent; which itself is a threat to human health especially the health of children and elderly (IPCC 2012). The depletion of ozone layer over Antarctica region have resulted in increased exposure to UV radiations leading to increased prevalence of skin cancers (Ferlay et al 2010). Deforestation has also resulted in increased environmental pollution and thus increased exposure of populations to unsafe levels of particulate matter (PM10) and thus increased incidences of respiratory illnesses including Asthma (WHO online). The increased incidence of Asthma is also associated with relatively longer pollination seasons nowadays attributed to climate change (WHO 2009).
The intervention chosen here include mangrove restoration in Asia to mitigate climate change. The intervention includes restoring 10 hectares of mangrove forests in four countries i.e. India (Pulicat lake in Tamilnadu state), Sri-Lanka, Cambodia, and Thailand. The intervention will be carried out by local communities and will also generate sustainable livelihoods for them, along with mitigation of climate-change (MAP online).
The mangroves will be grown in, “tree nurseries” or “household gardens” or “community gardens” for preparation before plantation at actual site. The methodology used for plantation will be, “EMR (Ecological Mangrove Restoration)” which work in compliance with nature and is a natural method of regeneration of forests. The work will also be done for long term conservation of species. The ‘demonstration gardens’ and ‘environmental education centres’ will be established to inform tourists, students and local residents about the importance of conservation of mangroves. The vision of the intervention is to establish sustainable mangrove ecosystems which will help mitigating climate change and thus will aid in health promotion of populations at a larger systems level.
- (i) The intervention of mangrove restoration in Asia to mitigate climate change is health promoting against the, “Ottawa Charter for Health Promotion” as the analysis follows. The Ottawa charter for health promotion was first international conference on health promotion held at Ottawa (Canada) on 21 November 1986 (WHO online). The charter identifies a stable eco-system as a pre-requisite for health. The charter advocates that environmental factors among many other factors could be either favourable or harmful to human health. The charter also advocates that human-beings should take control of the determinants of their health and prevent them from exploitation, including environment. The charter recommends that community should participate in health promotion activities and the interventions should be applicable to the local settings. In the selected mangrove restoration intervention, communities participated in mangrove plantation and the techniques were locally acceptable and were implemented by local people (MAP online). Now the intervention will be evaluated across five intervention areas of health promotion as proposed by Ottawa Charter of Health.
The first action area is building healthy public policy. The intervention was a co-ordinated action involving MAP Asia in Thailand, EMACE Foundation and the Nagenahiru Foundation from Sri-Lanka, Center for Research on New International Economic Order (CReNIEO) from India, Fisheries Action Coalition Team (FACT) from Combodia. The intervention also included advocacy with policy makers of the four countries and their active involvement (MAP online).
The next action area includes creating supportive environments for health. The charter recognises that there is an inextricable link between individuals and their environment, thus there should be a socioecological approach in health promotion interventions. It is essential to take care of our natural environment. The charter recognizes the need to conserve our natural resources.
The third action area includes strengthening community action for health. The intervention used in Mangrove Restoration Project was a community-based intervention which had built community capacity by engaging them in training workshops, at the same time providing them sustainable livelihood work.
The fourth action area proposed by Ottawa charter was developing personal skills. As stated previously the community people were trained and involved in this intervention. They were further trained to prevent any further destruction of mangrove forests.
The fifth action area of the Ottawa Charter includes Re-orienting health care services toward prevention of illness and promotion of health. As stated previously climate change is a major socio-ecological determinant of health (Ruhil 2016) and de-forestation is largely responsible for climate-change (ibid). Thus health-care services cannot exist in isolation of its environment and the intervention of mangrove plantation was also well in compliance with this action area of Ottawa Charter.
- (ii) In 2008, the Commission on Social Determinants of Health identified 3 principle areas of action for health promotion (CSDH 2008). The chosen intervention i.e. mangrove restoration in Asia, fits into all the 3 principle areas of action for health promotion as recommended by WHO Commission on Social Determinants of Health. These are described as follows.
First principle area of action is to improve daily conditions of life in which people are born, live, grow, work and age. The chosen intervention will improve environmental conditions and will mitigate climate change. Thus the intervention will improve the daily conditions of life. Also the intervention will provide sustainable livelihoods to local community people and thus will improve their living conditions.
Second area of action is to tackle the structural determinants of daily living conditions. It includes equitable distribution of power, money and resources. The chosen intervention will mitigate climate change which is a very strong structural determinant of health as described in section2. Also the intervention will reduce inequity of power, money and resources; by providing sustainable livelihoods to local community people and empowering them.
Third area includes expanding the knowledge base, raising public awareness and developing a trained workforce for health promotion. The intervention includes workshop trainings of community people and also establishment of ‘demonstration gardens’ and ‘environmental education centres’ to establish sustainable mangrove ecosystems. Thus this intervention is compliant with all the three areas of action for health promotion as recommended by WHO Commission on Social determinants of health.
3 (iii) Kickbusch outlined 5 key determinants of health for the 21st century, which are political, commercial, social, environmental and behavioural determinants of health. (Kickbusch 2012). Although the chosen health intervention of mangrove restoration in Asia is congruent with all 5 of them; the political and commercial determinants are discussed in detail here. The environmental determinant has already been discussed in section 2. Kickbusch has argued that policy making is very critical for health promotion and political will is required to implement health promotion interventions. The commercial power or power of markets has a strong force to mobilise resources. The chosen intervention was Funded by the Ministry or Economic Cooperation and Development (BMZ) and the Foundation Ursula Merz; partnered with the Center for Research on New International Economic Order (CReNIEO), India, the Fisheries Action Coalition Team (FACT), Cambodia, the Nagenahiru Foundation, Sri Lanka, the EMACE Foundation, Sri Lanka; and the Global Nature Fund of Germany, the project holder.
Thus the intervention had a strong political and commercial will, which came together in partnership and implemented the project successfully. The commercial interests under such intervention are due to corporate social responsibility (CSR) and fundings provided by government. The political set-up may not have enough expertise to conduct such projects themselves, thereby the corporate sector step-in and the association results in a symbiotic relationship which synergises the health of communities. In the selected intervention, the main organisation was MAP (Mangrove Action Project) which has an international network of over 450 NGOs, 300 scientists and academics spread across 60 nations. Thus institutional capacity of commercial forces is immense which needs to be mobilised for health promotion; as did in this intervention. The organisations involved have a bottom-up approach and work at grass-roots level in consultation with local communities. Such a strategy adopted by political and commercial organisations, is vital for health promotion interventions to be successful.
3 (iv) The systems approach involves looking at health problems from a complex approach i.e. from individual level perspective to a large policy level perspective and all the levels in-between (Allender et al 2015). The complex thinking involves the interaction of health determinants across micro, meso and macro levels of social systems (Fisher et al 2016). The chosen intervention of mangrove plantations is in congruence with systems approach and complex thinking lens. The climate change is a macro level determinant of health and thus the intervention of mangrove plantation act at macro level. The intervention also acts at micro and meso levels. The intervention generates sustainable livelihoods for community people and thus directly acts at individual level or micro level. The intervention will provide better environment for communities living in these areas and thus will improve their health.
Thus the intervention also acts at meso level. Thus the intervention involves a holistic approach which is based on interrelations between environment and health. It requires systems thinking or complex thinking to understand these interrelations and further implementing some solutions those also involving systems approach. If the intervention will only focus on individual level, then new individuals will keep adding to the intervention group, and it will be a mammoth task to counsel them one by one. Thus it becomes imperative to act on meso level and macro level determinants of health. Climate change is also one such larger structural level determinant of health as explained previously. The intervention of large-scale Mangrove restoration and working further for their ecological sustainability in future, is really an effective way of health promotion, which is in congruence with systems approach (Allender et al 2015) and complex thinking approach (Fisher et al 2016).
The intervention will also generate sustainable livelihoods for the local community people which will improve their daily living conditions and thus will improve their health. Thus the intervention uses systems approach and complex thinking in many ways. Environment plays an important role in health promotion as well as protecting people from ill health. This has also been described in previous sections. If we will limit ourselves to treatment of patients one by one; without acting upon structural causes which are making the people ill at the first place; new patients will keep adding to the pool; and it will always be a plethora of task; without any effective results in the long run. Thus it is very important to incorporate systems approach and complex thinking in our interventions. This particular intervention of mangrove restorations in Asia is very well compliant with systems approach and complex thinking.
3 (V) The health interventions should promote synergies between health equity and sustainability (Baum and Fisher 2010). Health equity is a central and principle criteria while evaluating any health promotion intervention (Tolan et al 2016). The health promotion intervention should do justice with the vulnerable sections of society (ibid). All the sections of society should enjoy equitable access to health resources, health care and health promotion (ibid). The chosen intervention also targeted vulnerable groups and included community plantation of mangroves for their health promotion, simultaneously providing them sustainable livelihoods. Reduction of Global warming is also important to promote synergies between health equity and action on sustainable development, as mentioned in the report of WHO Commission on Social determinants of Health (Baum and Fisher 2010).
Baum and Fisher in his article talked about bringing political and economic reforms to reverse climate change (ibid). The chosen intervention of mangrove reforestation in Asia is also in congruence with the model suggested by Baum and Fisher. The intervention involved partnership between national governments and private organisations. The political will and commercial power was harnessed for the health promotion of vulnerable groups in Asia, by starting mangrove reforestation projects in five countries of Asia. The world leaders have pondered upon synergies between climate change mitigation, health equity and sustainability, since 1972 when first global conference on the “environment and development” was held at Stockholm (Blewitt 2015).
The issues were further discussed in the publication, “limits to growth” (ibid). The discussions continued during Agenda 21, 1992 Earth Summit, 1997 Kyoto protocol, 2002 Johannesburg summit, millennium development goals and now sustainable development goals (ibid). All these platforms reaffirmed that climate change mitigation efforts are imperative to promote synergies between health equity and sustainability (ibid). Millennium development goals were a set of comprehensive 8 goals which also included health as well as environment as essential action areas to achieve sustainability. Now sustainable development goals (SDGs) went one step ahead towards linking the 17 broad areas towards sustainability; which obviously included health and the environment. Thus the chosen intervention of mangrove reforestation in Asia to protect vulnerable communities from the harmful health impact of climate change, is also a step in the same direction.
Health promotion includes interventions aimed at improving health of populations and preventing illness. The interventions could be designed to act on individual/ micro level; or contextual/ meso level; or structural/ macro level or all of them. The chosen intervention of mangrove restoration in Asia was one such intervention to act at all the three levels i.e. micro, meso & macro. At structural level, the intervention was aimed at mitigating climate change which is a major socio-ecological determinant of health. The high temperatures could affect the health directly by heat stroke especially in children and elderly. The climate change results in increased breeding of vectors & parasites resulting in increased prevalence of infections. Climate change also increase the pollinating season resulting in increased prevalence of allergies. There is also increased frequency of disasters which results in morbidity and mortality directly as well as indirectly due to cholera epidemics during disasters.
The intervention of mangrove restoration in Asia to mitigate climate change is also health promoting against the, “Ottawa Charter for Health Promotion” as the charter identifies a stable eco-system as a pre-requisite for health. The chosen intervention fits into all the 3 principle areas of action for health promotion as recommended by WHO Commission on Social Determinants of Health. The chosen intervention was also congruent with the five key determinants of health outlined by Kickbusch i.e. political, commercial, social, environmental and behavioural. The chosen intervention of mangrove plantations is in congruence with systems approach and complex thinking lens. The intervention also promotes synergies between health equity and sustainability. To conclude, it is very important to access and analyse an intervention along the parameters of social determinants, systems approach, complex thinking, health equity and sustainability. There should be synergies along all parameters.
Allender S, Owen B, Kuhlberg J, Lowe J, Nagorcka-Smith P, Whelan J, et al. (2015) A Community Based Systems Diagram of Obesity Causes. PLoS ONE 10(7): e0129683. https://doi.org/10.1371/journal.pone.0129683.
Baum, F., & Fisher, M. (2010). Health equity and sustainability: extending the work of the Commission on the Social Determinants of Health. Critical Public Health, 20(3), 311-322.
Blewitt J. ( 2015). Understanding sustainable development. 2nd edition. Routledge.
Buizer, M., Humphreys, D., & de Jong, W. (2014). Climate change and deforestation: The evolution of an intersecting policy domain. Environmental Science & Policy, 35, 1-11.
Colombini, A., Bationo, F., Zongo, S., Ouattara, F., Badolo, O., Jaillard, P., ... & Da Silva, A. (2009). Costs for households and community perception of meningitis epidemics in Burkina Faso. Clinical infectious diseases, 49(10), 1520-1525.
Confalonieri U et al. Human Health. In: Parry ML et al (eds). Climate Change 2007: Impacts, adaptation and vulnerability. Contribution of working group II to the fourth assessment report of the intergovernmental panel on climate change. Cambridge University Press 2007; 391431.
CSDH (2008). Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva, World Health Organization.
Ferlay J et al. (2010). GLOBOCAN 2008 U1.2, Cancer incidence and mortality worldwide: IARC Cancer Base No. 10 (Internet). Lyon, France: International agency for research on cancer; 2010. Available from: https://globocon.iarc.fr, [Accessed 26 May, 2017].
IPCC (Intergovernmental Panel on Climate Change). (2001). Climate Change 2001: The Scientifi c Basis. Cambridge University Press, Cambridge, UK.
IPCC (Intergovernmental Panel on Climate Change). (2012). Managing the risks of extreme events and disasters to advance climate change adaptation. Special report of working groups I and II of the intergovernmental panel on climate change. Cambridge, UK & New York, USA: Cambridge University Press 2012.
Kickbusch, I. (2012). Addressing the interface of the political and commercial determinants of health. Health Promot Int, 27 (4), 427-428. doi: 10.1093/heapro/das057.
Lang T and Raynor G. (2012). Ecological public health: The 21st century’s big idea? An essay by Tim Lang and Geof Raynor. BMJ 2012; 345: e5466. doi: 10.1136bmj.e5466.
MAP (Mangrove Action Project) (online). Mangrove restoration and reforestation in Asia. Available from: https://mangroveactionproject.org/mangrove-restoration-and-reforestation-in-asia/, [Accessed 27 May 2017].
Ruhil R. (2016). Climate Change, Public Health and Sustainable Development: The Interlinkages. Indian Journal of Public Health Research & Development, 7(3), 144-149.
Tolan, P., V. McBride Murray, A. Diaz, and R. Seidel. 2016. Life Span and Legal/Policy Research as Dual Focuses for Identifying and Implementing Opportunities to Realize Health Equity. Discussion Paper, National Academy of Medicine, Washington, DC. https://nam. edu/wp-content/uploads/2016/10/Life-Span-and-Legal-Policy-Research-as-Dual-Focuses-for-Identifyingand-Implementing-Opportunities-to-Realize-HealthEquity.pdf.
UNICEF & WHO. JMP Biennial Report. Progress on drinking water and sanitation, 2012 update. New York & Geneva: UNICEF & WHO. www.wssinfo.org.
Van Kleef E, Bambrick H, Hales S. The geographic distribution of dengue fever and the potential infl uence of global climate change. Tropl K Anet 2010.
WHO (World Health Organisation). (2009). Global risks: mortality and burden of disease attributable to selected major risks. Geneva: World Health Organisation 2009.
WHO (World Health Organisation). [Internet] https://www.who.int/phe/health_topics/outdoorair/databases/burden_disease/en/index.html, [Accessed 26 May 2017].
WHO (World Health Organisation). World Malaria Report. Geneva: World Health Organisation 2011.
World Bank. (2012). Turn down the Heat. Why a 40 c warmer world must be avoided. A report for the World Bank by the Postdam Institute for climate impact research and climate analytics 2012.
World Health Organization. (online). The Ottawa Charter for Health Promotion. Adopted on 21 November 1986. Available from: https://www.who.int/healthpromotion/conferences/previous/ottawa/en/, [Accessed 27 May 2017].