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Richard Jarvis

, Angie Bone

, and Alex G. Stewart

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After reading this chapter the reader will be familiar with:

  • the key definitions and principles of sustainability,

  • the scope of sustainability and its relationship to health protection,

  • the contribution of sustainability to the response to climate change and other global threats, and

  • the practical actions that should be considered by individuals and groups.

29.1 Key concepts of sustainability in health protection

The concept of ‘sustainable development’ has gained attention in health protection in the last few years. The idea brings to the fore many issues that affect health and environmental quality now and in the future, linking very local issues and actions with the largest global problems, such as climate change.

There are various definitions of sustainable development. The simplest and most widely accepted definition comes from the World Commission on Environment and Development led by former Norwegian Prime Minister, Gro Brundtland:1

Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs.

(WCED 1987)

The terms ‘sustainable development’ and ‘sustainability’ are often used interchangeably. Sustainability is the set of conditions that meet current need without compromising the ability of future generations to meet their own needs, while sustainable development is the plan of action required to achieve this.

This definition refers to meeting needs, which in public health terms includes the complex interaction of need, supply, and demand and how they apply to groups and populations. The definition also implies that there are limits to:

  • resources available within the planet’s ecosystem,

  • the current state of technology available, and

  • the ability of humans to organize themselves to address potential threats.

Sustainable development is usually described by the ‘three pillars’, which is the interaction of the economy, social equity, and the environment (WCED 1987) (Figure 29.1).

Fig. 29.1 The three pillars of sustainable development

Fig. 29.1 The three pillars of sustainable development

To achieve sustainability all three pillars must be addressed together. For example, an intervention that addresses economic development and the environment but not social equity will generate a viable situation, but may not be fair nor equitable.

There are a variety of perspectives on the relative importance of the three pillars and on the most effective and efficient path to sustainability. Several view Western capitalist economics as the underlying cause of most of the planet’s problems and challenge the inclusion of the economy as a pillar. Nevertheless, these viewpoints still rely on some model of economy to achieve sustainability.

29.2 Health protection and public health as components of sustainable development

The relation of sustainable development to public health and health protection can be seen by examining each of the three pillars.

  • Environment: polluting the environment creates source–pathway–receptor linkages with the potential directly to harm human health. Air pollution is a good example of the interaction of environmental sustainability with health protection. There is good evidence that the combustion of fossil fuels, especially from road traffic, releases fine particulates that increase cardiovascular morbidity and mortality (COMEAP 2010). In England, local authorities may designate Air Quality Management Areas as areas of special need due to high levels of atmospheric pollutants, and are required to make plans to improve air quality and take action to prevent its detrimental effects. Other perspectives of sustainable development go further, viewing humans as part of the environment and their health as part of the health of the environment.

  • Social equity: fundamentally unequal societies cannot be sustainable societies, nor can they be healthy; communities that have high social cohesion tend to experience better overall health than those that do not. The evidence shows a direct association between socio-economic status and residence on or near areas of environmental degradation (WHO 2010) in a similar pattern to the association between socio-economic status and health.

  • Economy: two major reports employed economic evaluation on areas of interest to public health. The first, the Wanless Report (2002), was the UK’s first assessment of long-term healthcare funding arrangements. The second, the Stern Review (2006), was a review of the economics related to climate change. Despite these reports looking at very different areas, their results were surprisingly similar. Wanless recommended that public health needed investment now in order to prevent much greater healthcare costs later. Stern concluded that the cost of mitigating climate change would be far outweighed by the direct costs of the effects of climate change and attempts to adapt to its effects. Both concluded that it is more expensive to do nothing. Nevertheless, there is limited evidence to date of positive action resulting from these reports.

While links between the three pillars, health protection, and public health may initially appear opaque, it can be seen that sustainability is fundamental to protecting and improving health—in fact, without sustainable development there can be no public health. The importance of sustainable development in achieving good health has been recognized in the English health sector’s Sustainable Development Strategy (NHS and PHE 2014).

29.3 Sustainability and tipping points

Sustainable development is a means to help humans survive and prosper as a species into the future. This assumes that some existential threat to human survival or life as we know it is coming into play.

Planet earth can be viewed as a closed ecosystem in which everything except solar and gravitational energy is finite. There are a very wide number of components of this ecosystem, such as living things, the chemical and physical environments. Within such systems, a change to one aspect often affects many other components. The Gaia Hypothesis, initially developed by J.E. Lovelock (1972, 1974) suggests that the planet has homoeostatic mechanisms in the same way that living organisms do. These mechanisms normally act to restore equilibrium when a change is made. However, they do not have limitless capacity to adjust and, like physiological mechanisms, may suddenly change to amplify rather than reduce the change once a certain limit is reached. The point at which the change takes place is known as the tipping point.

Tipping points are important because they can be used to predict how much damage we can do to the planet before it becomes irreversible. The first major publication in this area, The Limits to Growth (Meadows 1972) made predictions for potential tipping points in human population, industrialization, pollution, food production, and resource depletion using mathematical modelling. Updates have been published at regular intervals and the 40-year update (Bardi 2011) showed that the reality followed the 1972 predictions very closely.

Planetary tipping points are now combined into the wider idea of planetary boundaries as described by researchers at the Stockholm Resilience Centre (Table 29.1). Nine boundaries have been assessed to decide whether the tipping point has been reached or is close to being reached. It therefore defines a ‘safe operating space’ for humanity. The concept is further developed with a public health and economic perspective to reflect minimum human needs as the ‘doughnut of social and planetary boundaries’ (Raworth 2012).

Table 29.1 Planetary boundaries

Planetary boundary


Assessment of tipping point

Climate change

The global CO2 concentration exceeded 400 ppb in 2014. It is likely to exceed tipping point in the near future. Loss of summer polar sea ice highly likely to be irreversible.

Increasing risk

Biosphere integrity (genetic and functional diversity)

Loss of biodiversity with extinctions. Anthropogenic extinction rates greater than at any time outside the four mass extinctions the planet has experienced.

  • Genetic diversity

    • High risk

  • Functional diversity

    • Boundary not yet quantified

Land system change

Human-driven land uses are key contributors to loss of diversity.

Increasing risk

Fresh water use and global hydrological cycle

Beginning to have global level effects, including the availability of drinking water.


Bio-geochemical flows (nitrogen and phosphorus)

Reactive nitrogen and phosphorus released on large scale due to human activities.

High risk

Ocean acidification

Due to dissolved CO2.


Atmospheric aerosol loading

Affects cloud formation and weather system behaviour.

Boundary not yet quantified

Stratospheric ozone depletion

Increases ground level UV exposure.


Chemical pollution and novel entities

Boundary not yet quantified

Source: data from Raworth K. A safe and just space for humanity: Can we live within the doughnut? Oxfam Discussion Papers (Oxford: Oxfam International, 2012), Copyright © 2012 Oxfam International,, accessed 01 Oct. 2015; Stockholm Resilience Centre. (2015) Quantitative evolution of the boundaries,, accessed 18 Nov. 2015.

It is clear from the planetary boundaries that have been exceeded or are likely to be exceeded in the near future, particularly climate change, that we are living way beyond our means.

Climate change is its own planetary boundary. It is beyond reasonable doubt that anthropogenic carbon emissions have changed the global climate. The general consensus is that global warming of 2ºC is now inevitable, irreversible, and requires significant adaptation, as Stern predicts. This has been agreed internationally as a feasible target and is supported by an agreement to reduce carbon emissions be 80% by 2050. Climate change in excess of this (some models are now predicting warming of 4ºC or more) would have a wide range of potentially catastrophic effects. These include but are not limited to sea-level rise, loss of agricultural land and desertification, increased frequency and intensity of extreme meteorological events, habitat loss, and increasing rate of mass extinctions. All of these effects compound trends against other planetary boundaries.

Meeting the challenge of climate change is the need and challenge of the current generation. We are already likely to have compromised future generations’ abilities to meet their own needs. The consequence of not acting now is that the impacts will become immeasurably worse.

Not all the planetary boundaries are moving in the wrong direction. In the 1970s it became apparent that stratospheric ozone production was decreasing and that ‘holes’ in the ozone layer had formed over the poles. There was concern that should this continue it would lead to raised ultraviolet light exposure with a wide variety of negative effects, including increasing incidence of human skin cancer. The cause was identified as anthropogenic chlorofluorocarbons (CFCs), mainly used as refrigerants, which migrate to the stratosphere and catalyse ozone (O3) to oxygen (O2). The solution was the global eradication of the use of CFCs as agreed in the 1987 Montreal Protocol. CFC use has dramatically reduced and ozone depletion has reversed. This demonstrates that where there is a clear threat, it can be possible to reach international agreement and to implement a global solution. Attempts to do the same with global warming still prove problematic despite 20+ years of international effort to agree a solution.

29.4 The health co-benefits of sustainable development

Actions to improve sustainability or to mitigate or adapt to climate change are often beneficial to health. Positive effects are called ‘health co-benefits’.

A frequently described health co-benefit is the positive effect on cardiovascular health from reduced reliance on internal combustion engines for travel. Most trips in the UK are over relatively short distances—a few kilometres at most—and most take place in urban environments and in private cars (Department for Transport 2013). Changing the mode of transport to public mass transport (buses and trains) reduces the carbon dioxide emitted per trip. Changing it to cycling or walking almost eliminates the carbon burden, and has positive benefits in terms of cardiovascular morbidity and mortality through both exercise and reduced levels of fine particulate pollutants, improves mental health, and helps reduce obesity and rates of diabetes mellitus.

Changing our eating preferences and the agricultural practices that serve these preferences can have similar benefits. In the Western world we have a meat-rich diet and this contributes to cardiovascular problems and obesity, and is associated with a variety of cancers. It is also unsustainable in terms of the carbon burden, greenhouse gas emission, and the use of water and land associated with rearing food animals. In particular, cattle produce a lot of methane, which is a potent greenhouse gas, and their rearing is particularly carbon-intensive compared to vegetable or fruit growing. Where the ground is fertile enough to support it, growing vegetables and fruit is much more sustainable. If the Western world can change its dietary preferences away from meat and towards a more vegetable- and fruit-based diet it is likely to have health co-benefits in reducing obesity, and reducing both cardiovascular disease and a variety of cancers.

Household energy is a global problem, though for different reasons in the developing and developed world. Most cooking in the developing world is done using wood or kerosene and using makeshift or low efficiency stoves and this is associated with high particulate emissions. Changing to high-efficiency biomass-using stoves that are no more expensive to mass-produce would improve the fuel efficiency, help to move to sustainable fuel sources, and improve health by reducing fine particulates. In the developed world, addressing the problem of cold homes and fuel poverty through improved domestic energy efficiency improvements can have physical and mental health benefits, as well as reduce carbon emissions and contribute to developing a ‘green’ economy. In 2015, most electricity was still generated by burning fossil fuels (mainly coal) which is not only unsustainable in terms of exploiting fossil fuel resources and the release of carbon dioxide, but is also responsible for a high burden of disease associated with fine particulate emissions. Moving from fossil fuels to renewables for the bulk of electricity generation is key in combating climate change and would lead to major reductions in the burden of cardiovascular and respiratory disease worldwide.

29.5 Practical local actions

Most of what we can practically do as public health professionals occurs, and has effects, at the local level. Using the lens of the three pillars allows interventions to be designed that make public health action more sustainable, and/or maximizes the public health co-benefits of sustainable development. The power of groups to deliver sustainability from the ground up and influence decision makers and those in authority should not be underestimated.

Some such contributions of individuals and groups include:

  • turning electrical devices off when not in use,

  • reducing travel by using teleconferences and public transport,

  • walking or cycling whenever possible,

  • learning how to use the heating/air-conditioning system appropriately,

  • reducing, reusing, and recycling materials,

  • avoiding unnecessary printing by reading documents on-screen,

  • using appliances as long as possible. Repair instead of replace,

  • reducing water usage: showers instead of baths; avoiding leaving water running,

  • making the most of local suppliers, especially for food, and

  • using the stairs instead of the lift if appropriate and possible.

Ideas and solutions are likely to be locally specific, but most of the above can be implemented with minimal effort in every location. A few issues may be beyond an individual’s control (e.g. travel policy), but most are not. It is not just about being green, but about balancing our needs to do business in the most economical way. All local organizations and agencies need targets to help focus on sustainability; everyone needs to ask themselves continually what they are doing to improve their contribution to sustainability.

Some specific examples include:

  • ‘Dr Bike’ scheme: on one of Public Health England’s sites with several hundred staff, one staff member ran lunch-hour bike maintenance sessions, supporting and teaching maintenance. This kept more people cycling than otherwise, improving their health through exercise, saving money on transport, and reducing carbon emissions. Social contact improved as well as (workplace) community resilience as a result.

  • Access to nature benefits physical and mental health; urban green infrastructure plays a key role in mitigating urban heat and flood risk, improving air quality and social cohesion. London’s Pocket Park programme is creating or improving 100 areas of greenery, including play spaces, community orchards, green gyms, and wildlife gardens.

  • Sefton Air Quality Management Area: Sefton is a coastal authority with its main route of access to the port of Liverpool on a steep hill controlled by traffic lights. Lorries leaving the port wait at the lights before accelerating uphill with cold, inefficient, engines, causing high levels of fine particulate and nitrogen oxide pollution. Sefton designated the junction an Air Quality Management Area, which enabled it to install sensors in the roadway to detect lorries (but not cars) before they reach the junction, and change the traffic lights accordingly. Lorries do not idle or accelerate. As a result, air quality has improved and noise has been reduced, to the benefit of the local population and commuters.

29.6 Conclusions

Sustainability is fundamental to protecting and improving health and relies on the conglomeration of small individual actions as well as actions by large industries and countries. Public health and health protection are intricately interlinked with all three pillars of sustainability (economic development, environment, social equity) and actions to improve health should support sustainability. Sustainable development can be achieved through meeting current needs without compromising the ability of future generations to meet their needs. While some factors that drive the planet towards irreversible damage are close to the point of no return, there is still much that can be achieved by concerted individual and corporate action.


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                  Further reading

                  Mcoy D. 2014. The science of anthropogenic climate change: what every doctor should know. BMJ, 349: g5178.Find this resource:


                  1 It is not incidental that Gro Brundtland was appointed to lead the World Commission on Environment and Development due to her strong background in science and public health. This emphasizes the importance of public health professionals being prepared to take on political and diplomatic leadership roles.