Politics of Coordination in Environmental Health

The Journal of Transdisciplinary Environmental Studies vol. 14, no. 2, 2015

Jesper Holm*, Bente Kjærgård and Erling Jelsøe, Department of Environmental, Social and Spatial Change, Roskilde University, Denmark. *Corresponding author: [email protected]

Abstract: Since mid-1980s a growing number of coordination efforts between public health and environmental policy sectors have emerged in the EU and nationally. In local projects, policies, and international regimes various ad hoc initiatives to long-term strategies have evolved. These efforts are full of proclamations on the interconnectedness of environment and health but, in fact, severe drawbacks in policy sector coordination have occurred. This paper provides analytical tools from Jordan and Lenschow’s (2010) work on environmental policy integration for studying the efforts and paradoxes in sector coordination. Based on this, an overview of the various approaches to coordinative efforts, from an international level to a specific national setting (Denmark), is presented in order to discuss whether and how firm policy coordination is substantiated, and to what extent it is a realistic option. The most important conclusion is that in spite of numerous policy coordination efforts on international levels, both the public health sector and the environmental protection sector in Denmark, as well as in most other EU states, do not seriously address the need for coordinating efforts, or perhaps, more precisely, neglect to place this on the agenda, separately or jointly. We suggest that only governmental hegemonic projects on sustainable health or environmental health promotion assisted by research, institutions, and strong local innovation programmes on selected areas could combine social and environmental factors and allow for a more permanent sector policy integration.

Key words: WHO, UN, national strategies for environmental health, sector policy integration

Introduction The establishment of modern environmental and environmental conditions. But still, the environ- public health policy in all western industrialised mental health situation is deteriorating in many countries in the last forty years can be considered areas (EEA, 2010,2015). This record is due to many to be partially successful in terms of the speed and reasons, but here we highlight two specific policy range of policy development. Environment and areas. The first is the overall poor implementation of health, however, are deeply rooted in each other, environmental health policies, that is, that policies which we are reminded of now and then when for environmental and public health policy coor- major hazards such as the Fukushima nuclear ac- dination or integration (EHPI) are lacking. There cident occur, or when scientific discovery reveals are numerous rational arguments for the obvious that certain persistent health problems, such as the benefits of a firm policy and regulatory coordination declining sperm counts of men, are embedded in between environmental and health prevention or

The Journal of Transdisciplinary Environmental Studies, ISSN 1602-2297 http://www.journal-tes.dk/ Holm et al.: Politics of Coordination in Environmental Health policy integration for so-called environmental health … the environmental health approach has traditionally regulations.1 Accordingly a common understanding, centred on protection of population health through iden- the concepts and realities of health and environment tifying, monitoring and controlling the environmental are important and vital dimensions in one another’s hazards which produce disease in populations. The ap- realms. The challenges to react to this are manifold, proach has its origins in the earliest days of the modern but the one we look at here lies in the historically public health movement and, by assuring the quality of established and current separation of the two areas domestic, community and occupational environments has in terms of functional systems. greatly expanded lifespans and improved health and wellbeing for communities and individuals. Underpinned The second reason for poor environmental health by advances in epidemiology and the biological under- conditions is the relatively unchanged continuity of standing of disease, the disease-centred, hazard-focused environmental- and health-harmful policies of other approach to environmental health remains a cornerstone departments, such as energy, transport, agriculture, of public health activity (WHO, 2012: p. 14). spatial development, or economics that counteract the protection efforts of health and environmental Definitions of the degree to which positive health policies. Environmental and public health poli- assets are incorporated into environmental health cies still largely follow the ‘down-stream’ approach differ among authors and institutions, as does the (OECD, 2001). Both health promotion/prevention question of whether these are situated as part of pub- and environmental protection need strong support lic health, environmental efforts, or in broader insti- from other groups, other sectors and other systems. tutional and regulatory arrangements of controlling, Within the health system and the environmental assessing and understanding their relationship. For system it is clear that health and environment our purpose here we refer to the WHO’s definition: depend on non-health and non-environmental factors to which the policies of other sector must Environmental health comprises those aspects of human contribute. How to bring in and steer non-health health, including quality of life, that are determined by or environment perspectives in order to increase physical, chemical, biological, social and psychosocial health becomes an articulated challenge of govern- factors in the environment. It also refers to the theory ance (Knudsen & Andersen, 2014). Kickbusch and and practice of assessing, correcting, controlling, and Gleicher (2012) argue that the governance for health preventing those factors in the environment that can perspective is closely linked to whole-of-society ap- potentially affect adversely the health of present and proaches about involving stakeholders from civil future generations (WHO, 1997a). society and the private sector to find innovative solutions. Whole-of-society approaches are seen In the EU’s regular reports on the European state of as keys to giving health or environment a more the environment, environmental health is one out prominent position in policies other than health of four focus areas (besides nature and biodiversity, or environmental sector policies. From this point climate change, and natural resources). Here, ageing of view, sector coordination appears to be a pivotal in the European population places pressure on health precondition for the success of both health promo- costs and enhances a focus on preventive measures tion and environmental policies. up-stream to the so-called civilization diseases. The European Environment report, State and Outlook In order to unfold the built-in dilemmas and con- 2010, states: tested attempts to what obviously seems to be a good idea, in the paper we study the various strategies for Degradation of the environment, through air pollution, furthering environmental and public health sector noise, chemicals, poor quality water and loss of green policy coordination or integration. space, combined with lifestyle changes, may be contribut- ing to substantial increases in rates of obesity, diabetes, diseases of the cardiovascular and nervous systems and 1. Environmental Health Problems cancer — all of which are major public health problems Internationally the environment and public health for Europe’s population […] Reproductive and mental correlations are conceptualised in the concept of health problems are also on the rise. Asthma, allergies, environmental health. Historically, […] and some types of cancer related to environmental

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pressures are of particular concern for children. […] live in affluent areas. Social and environmental The World Health Organization (WHO) estimates the inequalities result in health inequalities because environmental burden of disease in the pan-European the burden of exposure to pollution is uneven, and region at between 15 and 20% of total deaths, and 18 the same exposure causes unequal impacts within to 20% of disability adjusted life years (DALY) (EEA, different communities due to differences in mitiga- 2010: p. 91). tion capacities. Spatial concentration of poverty and wealth lead to imbalanced capabilities when it A comprehensive list of areas relevant to environ- comes to the communities’ access to political influ- mental health is difficult to provide due to the dy- ence that may hinder a polluting built environment namic and evolving set of possible conditions caus- or enhance health promoting parks, libraries, and ing environment-related diseases. A non-exhaustive so on. Polluting industries, waste dumps, highways, overview of the most important areas includes: air and concrete deserts neighbouring poor commu- pollution, food safety, the built environment, injury nities expose these communities to many sorts of prevention, land use planning, noise, pollution, stressors and pollution. At the same time, the local occupational health, chemical safety, radiation, composition of violence, non-access to health care tourism, waste management and water manage- institutions, deprived groups, alienation from politi- ment (WHO, 2000: p. 34). However, more specific cal institutions, etc., make up a social context that knowledge on environment-related diseases has weakens mitigation and the ability to cope within increased during the last decades and has drawn at- vulnerable communities that experience less social tention, not least, to climate change-related diseases. and economic capital (Schulz & Northridge, 2004). The dynamic character of environmental health is In its report ‘Environmental health inequalities in stated in the most recent state and outlook report Europe’, the WHO (2012) concluded that dispari- from the European Environment Agency: ties exist in all regions and countries in Europe in terms of environmental health-risks, and provided In addition to established problems — such as air a number of recommendations aimed at tackling pollution, water pollution and noise — new health is- inequalities in environmental health, including risks sues are emerging. These are associated with long-term in relation to vulnerable populations. The report environmental and socio-economic trends, lifestyle and documents disparities in noise in housing, access to consumption changes, and the rapid uptake of new green space, and tobacco smoke at work and at home chemicals and technologies. Furthermore, the unequal (based on self-reporting). It is recommended that the distribution of environmental and socio-economic condi- inequality perspective, as such, should be addressed tions contributes to pervasive health inequalities (EEA, in urban planning, etc. (WHO, 2012: p. 111). 2015: p. 115).

Thus, socioeconomic factors, in addition to pollu- 2. The Challenges to Basic Co- tion from production, mobility, and resource han- Ordination of Health and Environment dling, significantly affect peoples’ lives and health. Environmentally oriented health regulation will Half of the world’s population is living in urban en- have to build on the various ways in which hu- vironments — projected to increase to 60% within mans, embedded in socio-economic circumstances, the next 20 years — and the quality of life in cities interact with the environment. This needs to take throughout the world has been declining (Moeller, into consideration that environmental health bur- 2005: p. 8). The decline is greater than the impact densthey can derive from multiple sources, that the from pollution per se, as environmental health takes impacts are socio-economically unevenly distrib- us deeper into the intertwined mechanisms of public uted, and that the elements in the environment are health and environment. Health oriented environ- constantly interacting. As a consequence, interven- mental science builds on public health, discloses tions in health may result in new problems in other the social inequalities in exposure to pollution, in health or environmental areas (Moeller, 2005; see beneficial social contexts, and in health behaviour also Pedersen, Land & Kjærgård in this TES issue). and social relationships. People who live in economi- Many of the types of environmental health problems cally depressed neighbourhoods are less healthy than require combined knowledge and practical skills those with the same socio-economic status who from public health and environmental sciences, as

89 Holm et al.: Politics of Coordination in Environmental Health well as practical coordination in administrative sys- that the relationship between environmental, social tems in order to build up prevention and control. and economic factors is central to all policies and This goes beyond the initial development of envi- that equity in health should be integrated into environmental regulation with assistance from human ronmental policies at all levels. Thus, as an example, toxicology and public health-sciences in establishing the report advocates for framing food consumption thresholds on toxic substances, ambient environ- and agricultural policies in the context of food safety, mental quality standards, and so on. But despite accessibility (economically), and nutrition and sus- determinations to raise firm environmental health tainability (Marmot et al, 2012: p. 1023). policies, it has rarely had any institutional coordinative impacts on politics that, for almost 50 years, The complexity of new environmental health prob- remain compartmentalised and sectored in public lems, stemming, for example, from climate change health and environmental policies respectively. or the long-term impacts of chemical substances Public health issues were initially part of western from non-point sources, gives rise to new regulatory hygiene and hazard regulations and, subsequently, in complexities that the hitherto established environ- chemical risk-oriented environmental policy. Since mental regulation system seems unprepared to deal then, various changes in sector coordinating efforts with. Since the late 1980s a number of international on environment and public health have emerged policies and actions have thus been directed towards as a result of changes in problem pressure, policy efforts to further integrate or coordinate public health discourses, institutional structures, and governing and environment sector policies, recognising the regimes/styles. Yet the innovations from public need for an effective Environmental Health Policy health integrated environmental policies and regu- Integration (EHPI)(WHO, 1989). This followed lation withered away along political problem focus a parallel growth in effort at environmental policy shifts to biodiversity, environmental infrastructure, integration in a number of policy sectors. In the resource depletion, and business options in ecologi- international policy regimes on health promotion cal modernisation, and, perhaps, because of the basic and sustainability (see Almlund & Holm in current hindrance for firm policy sector integration (Holm, TES issue) there is a similar focus on the need to sec- Hansen &Søndergaard, 2003). In many environ- tor co-ordinate health and environment. Already in mental health problem areas, where environment the Charter of the first international conference on health co-ordinated regulation have disappeared or health promotion in Ottawa in 1986, it was stated: policy makers have refrained to intervene, instead corporate and civic deliberation have taken over, and Our societies are complex and interrelated. Health have become a major issue in greening products, as cannot be separated from other goals. The inextricable in food and cosmetics (Holm & Stauning, 2002, links between people and their environment constitutes Holm 2004, Kickbusch & Payne (2003)) the basis for a socio-ecological approach to health. The overall guiding principle for the world, nations, regions Seen from public health and health promotion sec- and communities alike, is the need to encourage recipro- tor policies, the environmental and occupational cal maintenance — to take care of each other, our com- health policy sectors were initially delivering the munities and our natural environment (WHO, 1986). basic, necessary structural means to handle a number of public health problems, and the expectations of The forerunner to the Rio Declaration on Sustain- strengthening their contribution to public health ability, the Brundtland Commission’s report, system- have been maintained. Therefore, for decades, public atically tried to connect the seemingly incompatible health policy sectors, internationally, have called for goals of economic competitiveness, social and health policy coordination as reflected in many statements development, and environmental protection, and, and agendas:Thus as The Commission on Social hence, to ensure sustainable development. For devel- Determinants of Health, who stated the many sec- opment to be sustainable it must meet basic human tors, other than health, that are essential for public needs such as housing, water supply, sanitation, and health — a number of other policies are at least as health care (WCED, 1986). Post Rio, UN declara- important, if not more important than the public tions and policies health targets have been integrated health sector policies (CSDH, 2008). The latest re- into conventions on Agenda 21, biodiversity, and port in this respect (Marmot et al, 2012) advocates climate change mitigation. Equally WHO addressed

90 The Journal of Transdisciplinary Environmental Studies (TES) the health integrated sector policies efforts since EHPI contradicts this form of sectorial policy Adelaide in 1989 (WHO, 1989) formulation and implementation. It is therefore of interest for our purpose here to look at the different At first glance the call for firm sector coordination political approaches2 that have occurred in coordi- and integration for environmental health policies nating, merging or integrating the two policy sectors. seems unproblematic because so much environ- When it comes to handling climate change impacts, mental regulation, both historically and at present, or the subtle diffusion of chemical substances, or is related to human health issues and many political local resilience building in water flow areas, some of declarations celebrating the sector integration. In the current knowledge systems contain an integrated some states, such as Sweden and Switzerland, the his- public health and environment perspective for ana- torical rise of regulations and institutions on health lytical, planning and design purposes. But these areas and environment became clearly integrated within are exceptions from the normal co-existence of the environmental health systems. In Sweden, several in- two knowledge and regulations systems. tegrative research and regulatory institutions and professions have emerged in environmental health risk assessments, and studies and politics of certain areas, 3. Divergent Sector Policy Rationalities such as chemical exposure to children, have evolved in Handling Environmental Health more strongly compared to other European countries In Denmark the policy sectors of public health, (see the later discussion on Swiss efforts). Yet, in most health promotion and prevention have, since the countries the two parallel — public health and envi- mid-1980s usually been associated with behavioural ronment — sectorial institutionalised developments campaigns and instructions as to what is healthy to have followed their own lines of regulatory systems, eat, or what lifestyle is healthy in a broader sense rationalisation, professions, monitoring systems and (Vallgårda, 2003). It is often emphasised that it is communication. It is thus an up-hill task for policies, possible to promote health via optional behaviour in programmes and institutional arrangements within everyday life — hence the focus in the policy texts, sectored political systems (administration, ministries, and in practice, on motivation, social capital and policies, rules, laws) when there are calls for tighter network conditions that can support the individual collaboration, integration (EHPI), or coordination. in making a difference. That is, self-regulation tech- There is a severe risk of de-coupling due to different nologies for taking personal responsibility. codes, agendas, resources, power structures, and part- nerships. This is basically due to the fact that policy By contrast, environmental politics has historically sectoring is a political reflection of a functionally been linked to notions of pollution threats to hu- differentiated modern society, where sub-systems of mans, animals, water and air; threats that are gener- political, economic, scientific, and moral commu- ated outside of the private sphere and are therefore nications have stabilised ensuring an ever growing a matter of regulation, experts and politicians. In complexity of communication (Luhmann, 1996). order to handle health-hazardous substances and The call for policy sectors to deliver political power, materials and the health effects from air pollution, knowledge and resources to other sectors may easily climate, food and everyday products, environmental become a power game of keeping the cards close to health regulations operate through means such as one’s chest. Current governance models seem not thresholds or prohibition of toxic, carcinogenic and well suited to carrying out the necessary policy shifts other substances in water, air and products. There that EHPI implies. is a widespread set of knowledge systems behind environmental health that operates using hazard Governmental agencies are highly specialized, they have assessments of substances and materials, exposure accumulated specific knowledge to govern their particular studies (how we are affected and how much), and policy field, they build up a network with their target dose-response studies (that assess the amounts that groups and they are path dependent regarding their cause diseases), as well as various risk studies that goals and instruments. Thus, the modern state pursues focus on areas such as the urban environment or contradictory policy targets easily (Jacob & Volkery, cancer and the environment (Moeller, 2005). 2003: p. 3).

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Environmental health regulation mostly focuses on governmentality politics of self-regulation. Citizens chemicals, particles and substances that are foreign are encouraged to be self-managing in the handling to the body, how humans are exposed to these, and of hazardous substances. For example, in Denmark how to assess the quantities and mixtures the human an Information Centre for Environment and Health body can tolerate or not tolerate. This regulation is was established to inform about legal, but harmful predominantly based on scientific evidence with products and substances and about healthy con- increasingly complex knowledge content, and on sumer choices.3 a number of international data bases derived from epidemiology or investigations in the laboratory. So a new self-governing orientation of risks has In addition, a number of agencies balance and emerged based on a paradigm that consumers and consolidate these data, and a number of organisa- citizens share the burden of guilt and responsibility tions assign data of specific information value. The for the pollution problems and, therefore, can and resulting knowledge is mediated through politi- must choose the form, amount of products, places cisation and balancing procedures linked to the and behaviour — so as best to avoid exposure. The environmental health-related risk control through health consequences of environmental issues have which, over decades, standards, risk communica- come much more into focus like since the 1970s tion, and regulation have developed a process that when environmental health first appeared on the has institutionalised a special environmental and agenda. Thus, environmental health increasingly risk-related health perception (Holm, Kjærgård & draws together the behavioural education approach Pedersen, 1997). Environmental regulation is based in health promotion and everyday knowledge about on residual principles, such as proportionality (ef- the self-management options as a key impetus for forts and the effects of intervention and expenditure environmental and health optimisation. In Denmark must match each other), evidence, and the polluter in particular, this tendency towards a more liberal ap- pays principle. Commands and prohibitions are nor- proach to health governance has been pronounced, in mally given only where there is conclusive scientific contrast, for example, to Sweden (Vallgårda, 2003). evidence of harmful effects, which is the impetus for a strong politicised dispute about when the effects Another response to the knowledge and skills gap in are harmful, what scientific evidence exists, whether risk handling is the use of the precautionary prin- the effort is commensurate with the effect, and so ciple in the environmental regulation of products on. (Rank, 2005). and producers — in special cases we may prohibit substances in certain products if suspected that they With the complexity of the dispersion of hazardous are harmful, even if no rigorous proof exists but only substances into all spheres of life, problems have a well-founded probability. But the principle has met arisen as a consequence of basing environmental difficulties in being implemented nationally and is health regulation solely on strictly science-based dependent on national business interests. Due to evidence. Often, in principle, there is no scientifi- strong lobbying (EEA, 2013), and in the EU, the cally definite way to make the right choices for what principle has primarily been used for cosmetics and is called ‘wicked problems’ (Conklin, 2005), and toys. However, the principle have a say in environ- it is common knowledge that a number of highly mental campaigns from non-regulatory bodies; the problematic mixtures of chemicals to which we are former Danish Information Centre for Environment exposed are not yet regulated (EEA, 2013). On top and Health, funded by the Government, often com- of this there are problems that can barely be defined, municated to consumers to follow a precautionary because there are no final, simple solutions and practice in consumption (avoiding certain products), because the cause-and-effect chains are unique or rather than awaiting legal norms, permissions and unknown. Governance by stakeholder involvement prohibitions to withdraw products from the market in voluntary substitutions has been tried, but, most (The Information Centre, 2010). This means that often, public participation in risk prevention means the active consumer and citizen were encouraged that it is used to by-pass the command-and-control to act in relation to a very wide variety of scientific regime that actually has only limited control. Con- sources and uncertain information on the basis of sequently, in this context, authorities are changing the precautionary principle. Without these kinds of to a more reflexive campaign management and a scientific-informed practical knowledge guidelines,

92 The Journal of Transdisciplinary Environmental Studies (TES) we are left with great uncertainty and confusion in culture in the area, and that research and knowl- handling general risk awareness (Breck, 2001) and edge production will not cut across the structural we are vulnerable to the purely symbolic-based mir- (regulation) and behaviour-oriented (everyday life) roring forms of everyday environmental choices that approaches. are not based on scientific knowledge but on cultural and social norms (Halkier, 1999). There is, of course, Knowledge, motivation, power and competence to a large reservoir of practical knowledge present in verify, avoid and compensate for the environmental everyday life, which, reasonably, acts as a guideline health conditions in everyday life are, therefore, for environmental priorities — but it is nevertheless the starting point for an environmentally oriented a challenge for citizens to handle it themselves. health promotion effort. But this knowledge is so unevenly distributed that policies solely of individual This is where a genuine environmental health ap- self-regulation on environmental health de-facto proach, informed by public health social science, become politics of health inequalities. could guide politics to direct attention to the preconditions for a strong private policy regime of communities and individuals. Empowerment 4. Health and Environment Co-Ordination politics and the preconditions for community-based Means and Politics self-regulation would be of interest here, where a firm regulation of standards and prohibitions fails. 4.1 Sector Coordination – What is It? And, it is precisely here that internationally, an When we discuss the interrelation between health environment-oriented health regime (Environmen- promotion and environmental policy and the cross- tal Health Promotion) has gained a foothold. This over between the two, we may distinguish between is defined as: various levels and strategies (inspired by Jacob & Volkery 2003; Lenschow, 2002a, 2002b): (...) Any organized level and activity in health promotion aimed at assessing change and preventing the circum- • Double gains by the twin policies are fulfilled stances in the environment, posing a potential danger to by chance. the health and quality of life among present and future • Deliberate cooperation efforts to ensure that generations (Parker et al, 2004). sector policies take a consideration of unin- tended impacts on health/environment in Kegler and Miner (2004) state that with environ- enacting — thus a focus on side effect outcome. mentally oriented health promotion two different • Deliberate combination efforts to foster certain cultures or expert knowledge regimes meet. The public health politics for the benefit of the first is the scientific, the environmental risk and environment and vice versa — coordinated, exposure regime with an emphasis on the preven- win-win synergy intended outcome. tion and reduction of hazardous substances etc. • Designed from coordinated, developed and in the surroundings. The second is the health fully integrated political processes between promotion regime that provides us with a social equally weighed sector parties or objectives. science and humanities focus on learning and social This is a focus on the policy cooperation processes. behaviour, emphasising community and individual • Deliberate use of self-regulatory, coordinative capacity building and empowerment. Interestingly, and other institutional efforts to take environ- in Denmark environmental health promotion falls ment and health into consideration. This we between two stools: structural health prevention on may call steering technologies and institutions risks, and health promotion relating to opportu- for coordination. nities to mobilise certain groups of individuals to act on healthier lifestyles (Danish Health Agency, Some political systems and constitutions may be 2007). Since the early 1970s, interdisciplinary in- better than others for policy integration, but here stitutes and programmes have housed intervention we focus on policy coordination options within the studies and background knowledge in the field of polity or systemic level. Thus we focus on the policy environmental health, but it is often thought to field of coordination-integration-inclusion that may lack a more systematic knowledge base and expert develop as a deliberate effort of outcome and process

93 Holm et al.: Politics of Coordination in Environmental Health merging on various levels: the political-strategic in both the environmental and public health sec- level, sector planning, enacting laws, coordinating tors relies upon other sectors (business, tax, social codes of self-steering among business, forwarding welfare, education etc.) to deliver, whereas there is best practice communication, network governance, a long-term reciprocal call for co-operation specifi- and coordinating terms on specific interventions as cally between the public health and environment in urban development, etc. policy sectors.

Jordan and Lenschow (2010) define policies as envi- 4.2 International Environmental Health Co- ronmentally or health integrated ‘when policy makers Ordination Politics in “non”-environmental [+non- public health] sec- In the last three decades, the WHO Europe and tors recognize the environmental [+ public health] the EU Commission have developed several in- repercussions of their decisions and adjust them by stitutions, proclamations and activities to declare, appropriate amounts’ (Jordan & Lenschow, 2000: promote and establish effective policy integration p. 111). If policy coordination is understood as inte- mechanisms when it comes to environmental and grating environmental or health needs in the policy public health policies or health promotion,4 as well outputs of the specific sectors, EHPI represents an as internalising aims from these two sectors within internalisation of the environmental or health effects the rest of the policy sectors. As early as 1977, the of a sector. To evaluate the progress of this output- WHO Europe initiated the long-term policy goal of oriented view, the main focus is on policy outputs the Health for All strategy in the European region by and impacts. From this perspective EHPI implies a the year 2000, which emphasised the links between substantial policy change in the different domains environment and health and subsequently formu- of government. lated goals in environmental health. When the EU ratified the Health for All strategy in 1984, it was Here we focus on the policy sector coordination stated that health depends on a variety of environ- efforts that enhance environmental health concern mental factors, and eight goals were established for and institutionalisation, which substantially sup- environment and health. The WHO Commission port the aims of both political areas. Sector policies on Health and Environment was formed, and at the deal with many concerns other than the immediate first of its Conferences on Environment and Health, policy targets but we do not discuss to what degree held in Frankfurt in 1989, The European Charter for there is a mutual win-win or reciprocal advantage Environment and Health was approved as an exten- in integrating the environmental and public health sion of the Health for All strategy — an important sectors — in, for example, administrative, resource, step for the joint development of public health and market, and power interests. This would be more environmental policy. The emergence of environ- obvious to discuss in sector policy coordination mental health as an integrated field of public policy between, for example, environmental and technol- followed the publication of the report, Our planet, ogy policy sectors. our health (WHO, 1992).

Lafferty and Knudsen (2007: p. 25) argued that de- At the WHO’s second Conference on Environ- cisions (and their ensuing policies) should prioritise mental and Health in 1994, the EU declared its the environment by ensuring that ‘every effort is commitment to develop National Environmental made to assess the impact of [sector] policy on the and Health Action Plans (NEHAP), which were life-sustaining capacities of the affected ecosystem’ monitored by the WHO European Environment (Jordan & Lenschow, 2010: p. 148). The same and Health Committee, representing a important normative standpoint, it could be argued, is inher- step toward enhancing a supra-national planning ent in the call for public health concern in all other regime with obligations to its member states. The few sector policies within the Ottawa regime of health studies that compare NEHAP’s results across Europe promotion (see the article by Almlund and Holm in tend to consider them as rather positive (Forbat, this TES issue). According to this line of thought, 2015: p. 716, WHO, 1999). Oft cited outcomes all other sector policies and plans are supposed to are better political attention to environmental health evaluate and adjust their activities for the positive issues, the increase in the collaboration between health outcome. So the call for policy coordination public sectors (mainly environment and health) and

94 The Journal of Transdisciplinary Environmental Studies (TES) private actors (NGOs and firms), and the accelera- Development (Rio, 1992) were the first to address tion of legislative initiatives. The most substantial firm sector integration (see Almlund and Holm, impacts were seen in some Eastern European states this TES issue) by calling for healthy public policy with the establishment of fundamental regulatory and sustainability policy. The World Commission institutions where monitoring of health conditions on Environment and Development (WCED), were not linked to environmental burdens. The Swiss and the series of Conferences on Environment and NEHAP is worth mentioning for its innovative ap- Development first held in Rio, continue until today proach that shows the options of the NEHAP tool. with outputs such as Agenda 21, COP’s on Climate Change, and the Convention of Biodiversity, which have all promoted sector integration. In particular, NEHAP was part of the Swiss Action Plan for the Agenda 21 process and regulations has fostered Sustainable Development (Swiss Federal Office of a number of localised environmental health promo- Public Health 1997). The Federal Office of Public tion projects and strategies below the national sec- Health and the Swiss Agency for the Environ- tor policy level. The WHO conferences on health ment, Forests and Landscape jointly guided the promotion with charters and declarations have development process. A concept working group continued with new regulatory, methodological was formed consisting of representatives of the or policy area foci. From this regime another good cantons and municipalities and campaigning example of the integrative approach to health is the NGOs as well as representatives from the science WHO Healthy Cities Project. This explores health sector and of professional groups. This concept and sustainable development in relation to Europe’s working group formulated the central idea of cities and towns, and states that health is both an the Swiss NEHAP: the promotion of health and important objective for people and a main compo- wellbeing of all people in a healthy environment nent of the process towards sustainable development. (Kahlmeier, Kiinzli, Braun-Fahrländer (2002). The underlying understanding here is that human The plan was based upon selection of priorities health and sustainable development are inextricably on sector level along the following criteria: im- linked, and that health is both an important objec- pact on ecology and health, scientific evidence tive for wellbeing and wealth and a main component of the relevance of the problem and of a causal for achieving sustainable development (Kjærgård, association, long-term negative effects, economic Land & Pedersen 2014; WHO, 1997b). However, burden, political sensibility, perception in the cross-sector collaboration and citizens’ involvement society, and relation to the European programme. is often lacking in the local healthy cities projects Another leading question in this process was (Hancock, 1996). on which topics the link between environment and health could be communicated easily. The So the mid-late 1980s was the gründer period of a ranking resulted in the choice of the following global agenda on environmental health sector policy three areas: Well-being and nature, mobility and integration, and the politics of policy coordination housing (ibid.). took off. Since then differing approaches have been followed — from internalization to more humble But lack of integration of scientific knowledge into requests for policy sector coordination. The so-called public administration, low capacity to build inter- Cardiff Process of the EU is a prominent example of sectoral collaboration, and a limited conception this development from holism to sector integration of environmental health resulted in the closure of and back to environment/health in all policies. In the Switzerland’s NEHAP in 2007. According to a study mid 1990s many states and the EU adopted some of by Forbat (2015), a lack of political awareness of the policy instruments explicitly mentioned in the environmental health issues and relevant systems Brundtland report: integrated policy assessment of administration and indicators were behind poor as health and environmental impact assessment; institutional long-term results. The study states the strategic and programmatic planning; sustainability necessity of a true interdisciplinary and intersectoral strategies; institutional mechanisms; the merging of approach for environmental health policies to suc- government departments, and green budgeting. In ceed. Initially, the two holistic policy regimes on spite of the substantial means to pursue sector co- Health Promotion (WHO, 1986) and Sustainable ordination, the analysis of observers is that it failed

95 Holm et al.: Politics of Coordination in Environmental Health to settle the matter: the tension between political recent ‘Health 2020’ policy framework and strategy claims, practical assets, and implementation contin- launched by the Regional Office for Europe (WHO, ued as they came up against hard political realities 2013) draws on the same approach in the call for in the sectors (Jordan & Lenschow, 2010). Thus, general governance for health. This is supposed to in the 2001 EU Sustainable Development Strategy, contribute to initiating action across the state, the environmental policy integration was no longer an private sector and civil society through a network issue, and the 2009 review of the Sustainable Devel- governance approach. This new form of collaborative opment Strategy can be seen as a move to mainstream governance aims at ‘creating resilient communities sustainable development into sector policies. and supportive environments’ by promoting health and wellbeing at the individual level and the com- The politically ambiguous relationship between EPI/ munity level, by enhancing collaboration between EHI and sustainable development/health promotion the environmental sector and the health sector to in the EU has remained; meanings have fluctu- manage environmental risks, create healthy settings, ated over time from holism to sector integration, and by expanding interdisciplinary and inter-sectoral and back again as new problems challenged sector collaboration (WHO, 2013: p. 20). So today (2015) policies, or as the power positions of the two policy it is the public health sector that is the initiator of sectors have changed (Adger & Jordan, 2009). In calls for coordinating efforts and internalising health 2010, a call for strict policy coordination, entitled in the environmental sector policies, but the strate- Health in all Policies, again targeted specific groups gies and political argumentations remain the same. and problems, and the4 WHO and the EU jointly agreed upon the Parma Declaration at the Confer- In September 2015 the UN launched the Transform- ences on Environment and Health. The reason for ing our world: the 2030 Agenda for Sustainable Devel- the new health-in-all turn was the above mentioned opment (UN, 2015), where a healthy environment, health and environmental impacts of climate change; resource use, health promoting empowerment and chemical health risks to children; a growing number such like are highlighted. A group of 17 Sustainable of vulnerable groups affected by poor environmental, Development Goals with 169 associated targets working and living conditions; socio-economic and are described as integrated and indivisible, thus gender inequalities in the human environment and presenting and even stronger focus on an integra- health, amplified by the financial crisis; and, finally, tive approach to health promotion and sustainable concerns raised by persistent, endocrine-disrupting development. So the discourses of policy integration and bio-accumulating harmful chemicals and (nano) are strengthened, but the means and power of the particles (WHO, 2010b). UN remains.

For health promotion, the call for health-integrated In the following, we will show how these regimes and coordination has been strong, but real implementa- supra-national state politics have influenced health tion has been absent in most EU states due to the and environmental sector policy coordination in a weak position of public health and health promotion specific national setting, that of Denmark. policies as compared to economic policy sectors. During the whole period the WHO and the EU have continued to articulate new policy attention 4.3 Milestones of the Environmental and documents and to gather vast amounts of scientific Health Policy Sectors in Denmark. data and reports on environmental health. Whereas Given that national policies, including interaction environmental based calls for policy sector integra- between sector policies, are displayed in specific in- tion have been somewhat detached since the sus- stitutional frameworks and are the results of specific tainability path lost momentum, the public health historical developments, by way of introduction we sector has gained momentum, which is reflected in will briefly describe the relevant policy structures the WHO Adelaide Statement of 2010 on Health and institutional frameworks around health and in All Policies. This was the foundation for invoking environmental policies in Denmark. the health sector’s special key role in placing health on the agendas of other sector policies, in local In Denmark the executive power of the government communities, in business and in the media. The has been administered under a ministerial system

96 The Journal of Transdisciplinary Environmental Studies (TES) since the first constitutional act of 1849. The two took away the regional expertise. In 2005–2008 most central ministries with respect to environ- major municipality and budget reforms laid the mental policy (EP) and health policy (HP) are the basis for the current political administrative struc- Ministry of Environment, established in 1971, and ture, consisting of a number of state agencies under the Ministry of Health, which has existed since ministries, and 5 regions and 98 municipalities that 1925. A general policy to promote certain structural vary considerably with regard to the number of in- and technological changes to protect human health habitants and the socio-economic structure. Since from hazards has existed in Denmark to various the economic decline in 2008 onwards, disputes degrees since the beginning of the 20th century and, on centralisation and decentralisation have become within the traditional risk-oriented environmental a central topic on the political agenda. The debate policy institutions, several R&D, information, and has concerned burden sharing and the separation of standardisation institutions have been established political and economic responsibility. Even though (Christiansen, 1988). A specialised series of envi- neo-liberal political ideologies have dominated the ronmental health offices, regulations, standards, agenda since the beginning of the 1980s and, indeed, and knowledge systems have developed over the still influence politics, it has been vital for all Danish years with focuses on pesticides, noise, air-pollution, governments to maintain some sort of welfare-based human toxins, bacteria etc. An explicit policy area political legitimacy. The dominant policy style in the concerned with public health (PH) first came into parliament and in local government has been flex- being at the beginning of the 1970s, and efforts in ible; the sector ministers or the government govern environmental PH were only launched in 1985–86. through guidelines and negotiations, leaving it open A deliberate environmental health promoting (EHP) to various local interpretations. orientation on environmental health inequity, as we have seen in Switzerland, in EU programmes, and For the EP sector this development has indicated a in the WHO, does not exist in Denmark. continuous politico-administrative conflict around the burden sharing of environmental costs and the It is the policy sector of EP that has been respon- duties between central and local authorities. Whereas sible for environmental health orders, regulations of initially, the environmental regulation of industry nuisance, discharges into urban watercourses, and and agriculture was decentralised, the last twenty air-pollution. These regulations date back to the years has seen the development of various forms middle of the nineteenth century; the first law on of centralisation. In the 1970s new environmental nature preservation was passed in 1917 and the first regulation was introduced following the establish- act concerning urban planning and development ment of the Ministry of the Environment containing was passed in 1925. But a genuine policy on envi- elements of health prevention and, in particular, the ronmental protection began as late as 1972 with the act on chemical substances and products in 1979. first Environmental Protection Act and the establish- Similarly, the existing legislation of safety at work ment of the Ministry of Environment that covered that dates back to the end of the 19th century was all fields of EP. Since then a comprehensive number succeeded by a more comprehensive act on occupa- of regulatory, monitoring, research and subsiding tional health in 1977. These regulatory initiatives institutions have been developed within the Ministry. were structural in character and had a preventive aim. In respect of the HP sector, the opposite to There are three levels of public administrative com- EP has occurred; the municipalities were, under the petence with respect to Danish EP and HP: the structural reform in 2007, delegated obligations to ministries, the regions, and the municipalities. For establish health promotion and public health poli- HP the municipalities and regions play an important cies, as enacted in the National Health Act in 2007 role, they co-operate with regional semi-public R&D (Dirckinck-Holmfeldt, 2015; Lau et al, 2012). institutions for technology innovation and network- In 1984 Denmark joined the WHO Health for All ing. In respect of EP, Denmark is characterised by a strategy together with other countries in the WHO delegation of implementation and administration of European region. In 1988 the Danish parliament the environmental protection act to state agencies, decided that the Health for All goals should form regional centres and local authorities; the recent re- the basis for Danish health policy. This was fol- form of the Danish administrative structure in 2007 lowed by a programme for prevention by the Danish

97 Holm et al.: Politics of Coordination in Environmental Health government with contributions from 12 different defined as environmental health. To be sure, none ministries. This programme formed the basis for a of the components of health promotion or public number of initiatives most of which were marked health, such as empowerment, social capacity and by an emphasis on campaigning directed towards resilience, or spatial and social inequity in environ- individual lifestyles and health related habits in mental health, were mentioned. This was followed by relation to, for example, smoking, alcohol and nu- the Danish Health and Medical Authority’s report, trition. Efforts oriented towards living conditions Think health into the environment (Danish Health were basically ignored (Kamper-Jørgensen, 2010; and Medical Authority, 2010), that appeared as Almlund and Holm this issue). a catalogue of possible sector-coordinated efforts that, after the structural reform, the municipalities, There was also an emphasis on local activities in with their more broadly defined task in the health the preventive work, such as the Danish healthy promotion area, were supposed to undertake. Both city network that was one of the initiatives during of these more recent policy reports represent more the 1990s where a connection between health and comprehensive and ambitious attempts to promote sustainability was most clearly stressed (Kjærgård, sector integrated efforts in the field of environmental Land & Pedersen, 2014). The Rio declaration from health. Further initiatives, however, were said to 1992, which very clearly stated the mutual interde- await the implementation of the above-mentioned pendence of health and sustainable development, structural reform, but this has not yet been picked had no follow-up as regards public health policies up. Thus, it still remains to be seen to what extent in Denmark. The only activities during the 1990s these proposals will be turned into actual policies. that to some extent reflected an orientation towards Furthermore, the extent to which will be based on, integrated activities and which, at same time, could and able to support inequality in health, community be said to have a component of bottom-up citizen health promotion activities, and climate change involvement, are the healthy cities movement and related health adaptation is unclear. the local Agenda 21 activities (Holm, 2010). Some of the international policy initiatives of the 1990s, There are still several environmental health initiatives such as The European Charter for Environment and on the ground that are not covered by these initia- Health (1989) and the Environmental Health Action tives and in relation to which more isolated ‘stand Plan for Europe (WHO, 1994) were implemented alone’ efforts seem to pop up, and sometimes disap- by Denmark, but rather late and only symbolically, pear, when temporary funding is withdrawn or when since none of them had any apparent effects on there is a change of government etc. Among these Danish policy. It was only at the beginning of the health and environment integrated project efforts we new millennium that the Danish Environmental note: the Information Center for Environment and Protection Agency issued a report as an implementa- Health; local Agenda 21 initiatives on sustainable tion of the EU and the WHO’s NEHAPs with the urban development and climate mitigation; public significant title, Environment and health are con- procurement schemes of eco-healthy products etc.; nected (Danish Health Protection Agency, 2003). the healthy cities network; and the market-oriented Herein there is an updated introduction to, and an national administration of standards for organic understanding of how environmental conditions can farming. For the latter, organic labelling and regula- affect the health of the population. Besides giving an tion schemes were politically enacted outside of the overview of specific health effects of environmental health and environmental policy sectors but within hazards, the report points to how the population food and agriculture policy. This has been a suc- can be negatively affected by environmental factors cessful institutional framework for the production and important sources. It describes the efforts by and approval of organically farmed products that, the authorities to cope with the problems and co- in turn, has formed the basis for consumers and operative governance efforts in the respective fields public social service institutions to meet the rising of environmental issues. Other policies, such as the eco-health preferences. But the organic labelling and well-established regulatory framework regarding market schemes have not been connected to a more chemical hazards, the regulation of the use of pes- integrated health and environmental policy. ticides, food safety and traditional hygiene, despite their obvious importance, were quite narrowly

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5. Conclusion and Perspectives the reasons behind it. In spite of numerous policy Looking across the long period of environmental coordination attempts on international levels, both health sector coordination politics has revealed a the public health sector and the environmental flourishing number of international initiatives with protection sector in Denmark, as in most other EU varying degrees of coordination and internalisa- states (according to Jordan & Lenschow, 2010), tion. There seem to be ever running cycles of new do not seriously address the need for coordinating initiatives from simple co-ordination requests to efforts or, perhaps more precisely, neglect to put whole-of-society or health/environment in all poli- it on the agenda, separately or jointly. The period cies. Whereas the epistemic regimes of wholeness when environmental policy integration was at the as sustainable development and health promotion forefront was the period when sustainability and have had their historical momentums, a number of environmental politics were strong, but these have strategic initiatives have evolved to initiate network since withered away. A current healthy policies governance, impact assessments, focused areas of development in Europe may give us a window of joined coordination, and so on, among a diverse understanding into the lack of coordinating efforts. field of societal players to fulfil multi-layered and This could be derived from scrutinising formulations integrative goals. This is fuelled by the reports on about ‘governance for health’ in recent international new environmental health problems and a profound policy documents. institutional build-up of knowledge and institutions on environmental health in the EU and the WHO. Today, the WHO’s plea for governance for health So far, the agenda of environmental health has draws on the Adelaide statement of ‘Health in All succeeded in being on the political agenda and in Policies’ to invoke the health sector’s special key role influencing the EU’s environmental directives, and in placing public health issues on the agenda in the most recently, the UN’s sustainable development policies of other sectors. The governance for health goals of 2015 (UN, 2015). perspective deals with approaches to collaboration and the co-production of health across the health The stark lack of strong coordination between public sector and other sectors, and across the state and health policies and environmental protection poli- the society. The governance for health perspective cies challenges the underlying assumption that the is closely linked to whole-of-society approaches public health sector and the environmental protec- concerned with involving stakeholders from civil tion sector need strong support from each other society and the private sector to find innovative or from other sectors to contribute to sustainable solutions. Whole-of-society approaches are seen as development. From a sustainable development per- key to giving public health a more prominent posi- spective coordinating efforts are not merely about tion in the policies of other sectors. ‘Health in All integrating a health-oriented perspective into envi- Policies’ is about how the health sector can reach out ronmental policies, nor are they about integrating to other sectors and help them perform new roles in an environment-oriented perspective into public shaping policies to promote health and well-being. health policies. But we are in spite of this kind of It builds on the recognition that the most important knowledge and e.g. UN sustainability goals, witness- determinants of health are found outside the health ing a genuine lack of coordinating efforts, when we sector and outside the reach of government. But take a closer look at policies of public health and the health sector is not the only sector requiring or environmental protection. That said, we have to calling for actions in other sectors for support, and acknowledge that coordinating efforts do take place it may not be the case that the health sector is so within certain states and periods, as was the case in attractive to contribute to as other policy sectors. Switzerland for 10 years, and in a number of selected Political and economic sectors, may only gain power projects, such as the healthy cities projects and local or profit from integrating health and environmental Agenda 21, although below the level of policy sector concern, under certain conditions. Insisting on coordination. playing a key role in formulating the agenda for shaping other sectors’ policies, may be an obstacle Exploring the reasons for the lack of coordinating to further coordinating efforts across public health efforts may not be a simple endeavour and the fol- and environmental protection. lowing may be seen as a tentative attempt to explore

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A simple reason for hesitant cooperation could Notes be that 15 to 20% of all deaths in the European 1. The literature is not clear on this, but we may analytically region, as mentioned earlier in this article, are at- differentiate between integration as fully merged policy tributable to environment-related diseases. Although sectors, and coordination and co-operation as various environmental risks are attributed a larger role in forms of combining, co-operating etc. (see section 3). environment-related diseases, environment-related We use all the concepts to articulate the wide spread of risks play a more minor role than diseases related to coordinative efforts; in general, the literature uses the the social determinants of health. Vice versa, health term integration. impacts are only a side-aspect of the concern of environmental policy. But currently, the governance 2. There are of course a vast number of other types of social for health perspective appropriates, or at least des- approaches to integrating environmental and health ignates/assigns, the environmental sector as a means concerns, but here we only pay attention to the political for public health policies and the public health sector efforts and conditions. as the overarching coordinator. In the 1970´s the 3. The Information Centre 2006–2010, then labeled Con- situation was opposite. In any case, it may politi- sumerchemicals 2010–13, then closed, currently trans- cally be problematic for sector co-ordination among ferred into a semi-private information center (Danish functionally differentiated sectors, to perform such Consumer Council THINK chemicals). subordination strategies. 4. We will not describe the many specific rules and regula- Perhaps only governmental hegemonic projects on tions that, to some degree, underline the environmental sustainable health or environmental health promo- health path, such as REACH that is aimed at improving tion, assisted by research, institutions and strong the protection of human health and the environment from local innovation programmes on chosen areas of the risks of chemicals. importance to citizens, public authorities and business — such as joint efforts towards environmental health inequality — could deeply combine social and References environmental factors and allow a more permanent Adger, W. N. & Jordan, A. (2009) Sustainability: Exploring sector marriage. The UN Declaration Transforming the processes and outcomes of governance. In: Adger, W. our world: the 2030 Agenda for Sustainable Develop- N. & Jordan, A. (eds.) Governing sustainability, Cambridge ment is deeply rooted in an integrated and indivis- University Press, London, pp. 3–30. ible approach to health and environment, but will it materialise? Breck, T. (2001) Dialog om det Usikre: Nye Veje i Risikokom- munikation. København, Akademisk Forlag. Christiansen, P. M. (1988) Teknologi Mellem Stat og Marked. Dansk Teknologipolitik 1970-1987. Århus, Forlaget Politica. Conklin, J. (2005) Dialogue Mapping: Building Shared Under- standing of Wicked Problems. New York, John Wiley & Sons. CSDH. (2008) Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission in Social Determinants of health. Geneva, World Health Organization. Danish Health and Medical Authority. (2010) Tænk Sund- hed ind i Miljøet. Et Prioriteringsværktøj og Inspiration til Kommuners Forebyggende Indsats. København, Sundheds- styrelsen. Danish Health Protection Agency. (2007) Miljø og Sundhed Hænger Sammen. København, Miljøstyrelsen.

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