Is the Right to Health Compatible with Sustainability?

Home , Overconsumption

www.jogh.org O Daniel D Reidpath sustainability? compatible with Is the right to health right[7] They went ontodeclare, HASH the for support theirdeclared colleagues and ton In the recent manifesto support less well developed states in achieving tionthewhichextends beyond their borders vision progressivelyto [6]. Furthermore, economically developed states have an obliga would be fully realised for each individual in the world [3].ideally,HASH, time ofperiod a over thatresult the with takestepstowards theprogressive realisation theright,of Article2(1)[3][3]) [5]. That is, States have an obligation to portedby the notion of progressive realisation (cf; ICESCR lyis impossible; and that is why the right to HASH is sup Fully realizing all human rights immediately and complete and occurs in various human rights treaties (cf [4]). [3]; (1966) (ICESCR) Rights Cultural and Social nomic, pearsArticlein theof12International Covenant Ecoon thepreamble to the WHO Constitution (1946) [2]. It ap plify to ‘HASH’ [1]. The HASH right was first articulated in trade–offsthat need tobe confronted and for both HASH and challenges health public fundamental some ever, giving priority to the well being of all” [7]. There are, how planetary and human systems on which health depends by and that “we must conserve, sustain, and make resilient the of unconstrained progress is a dangerous human illusion”, mately cause the collapse of our civilisation”, that “the idea ternsofoverconsumption are unsustainable and will ulti 2 1 Program on Global Health and Human Rights, Institute for Global Health, GlobalUniversity Public of Health,Southern SchoolCalifornia, of Medicine Los Angeles, and Health CA, USAScience, Monash University, Selangor, Malaysia • doi:10.7189/jogh.05.010301 estattainable standard ofhealth, which wesim of every individual to the enjoyment of the high theofnefundamental human rights theisright From public to planetary health, 1 , Sofia Gruskin interalia that “our pat 2 , Pascale Allotey Hor ------1 lto promne bt t os o dtat rm a from detract particular not individual’s does legal it right but to their (unknowable) performance, true ulation 83, thus, potentially provides a policy benchmark for pop age; due, for example, to genetic (dis–)advantages. HASH– may actually be higher or lower than the population aver dividual right to the highest attainable standard of health) (HASH–83) [8]. An individual’s HASH point, (ie, their in expectancy in France, Iceland, Italy, Japan, and Switzerland attainable standard of health was 83 years of life; ie, the life highestaveragereasonablethe benchmarkfora 2013 In sumption. con of levels unsustainable through realised) gressively proachieved(orstandardis thata isstandardhealth of arisebecause, atpopulationa level, the highest attainable trade–offs The compatible. be to agendas sustainability unsustainable levels of consumption. achievedprogressively(or realised)through is that standard a is health of standard able cause, at a population level, the highest attain das to be compatible. The trade–offs arise be standard of health and the sustainability agen fortheachievement thehighestof attainable esand trade–offs that need to be confronted There are fundamental public health challeng 1 June 2015 •Vol. 5No. 1•010301 ------

VIEWPOINTS VIEWPOINTS year [14], we charted the relationship between the per cap and life expectancy data from the World Bank for the same availablelatestecological(2008)footprintWithdatathe run growing ecological deficits” (p.1) [13]. “... about 84% of the world population lives in considerablycountrieshigher GHa/capita thatthanothers andcurrently the sustainability threshold by 50%. Some countries have a The global average GHa/capita is about 2.7; ie,matedsustainable footprintwe about is1.8GHa/capita ‘overshoot’[12]. capita(GHa/capita) [11]. Based thisonindicator, theesti globalhectaresavailableofcommonunitperof theland ison of the per capita ecological footprint of each countryally in available data [10]. Country level data allows a comparityofhuman use ofthe environment using uniform, glob 1990s to create a mechanism for measuring the sustainabil The lations increasing the HASH point [9]. tions achieving the highest standards of health, and popu levels of resource utilisation are the countries with popula NationshighesthighestcapitathethewithperandGDP between resource utilisation and health is well established. individualsustainability.theandHASH right to linkThe ing over the past century. Here in lies the trade–off pectancybetweenwill actually increase, asithas been steadily do HASH–83, we can expect that the current trend in life ex average an progressiveofrealisation the await we While HASH–83. progressivelyto realisablerighta hasindividual selected a population with a life expectancy of 50 years) is that the any randomly selected individual from a population (even adversepre–existingand for guessbest healthstates,the al data about adverse social determinants, favourable genes, HASH. Therefore, and in the absence of specific individu June 2015 •Vol. 5No. 1•010301 EcologicalFootprint indicator was developed in the late

------2 may be even lower than 68 years. nology [15], suggesting that the sustainable life expectancy to populations in low income countries in the form of tech incomehightransferredcountriesfactprintofin is back mons.Unfortunately, ecologicaltheleastsomeofat foot lies on the exploitation of the resources of the global com achieved by those living in the wealthiest countries and re be to likely most is health standardofattainable highest Thesedata suggest that, onaverage, the enjoyment ofthe capita or three times the sustainability threshold. GHa/ 5.5 of footprint ecological mean a with countries, highest average life expectancies (>80) are all high income average life expectancy of 68 years, The countries with the sustainable a suggest line), black (solid curve regression decline slightly) after a GHa/capita of about 6. The median an increasing ecological footprint, and plateau (or perhaps Countries’averageexpectancieslife rapidlyincrease with is the sustainability threshold. (median), 75 nonlinear quantile regression model at the 5 the at modelregression quantile nonlinear 1 (Figure countries ita ecological footprint and average life expectancy in 147 more. dardhealthof andobligationan– taketono stansustainablehighest the to right human of life. At best we should claim a fundamental cus MORE on the quality and not the quantity attainablestandard of health may need to fo The fundamental individual right to the highest th and 95 ). The relationship is plotted with a with plotted is relationship The ). th percentiles. The broken vertical line www.jogh.org available land per capita. GHa/capita – global hectares of expectancy in 147 countries. cal footprint and average life between the per capita ecologi Figure 1. • doi:10.7189/jogh.05.010301

The relationship th , 25 , th , 50 , - - - th - - - - www.jogh.org highest attainable standard of health was stirred by an op The modern origins of the fundamental human right to the life of many plant and animal species. does not auger well for human life on this planet, or for the in absolute consumption is not an unreasonable guess and which the commons we share is the entire planet. Growth in commons the of tragedy the Weface have. currently they than healthgreater to aspire will they and do; they quarter of a century, they will aspire last tothe of consumepeople the morelike are they than if and consume, will health care along with their 7.2 billion companions. They world a century earlier (1950) – will need food, shelter and Those 2.4 billion extra people – the total population of the sic measures of sustainability we completely fail. [21,22]. Now add another 2.4 billion people. On very ba production,the internationaling commitments reducetogreenhouse gas ated with major planetary catastrophes [20]. Notwithstand rates of species extinction in our life time which are associ the natural fish stocks in our oceans [18,19]. We have seen oftheplanet’s rainforests [17]. We have failed topreserve ing to be better off, we have failed to curtail our destructionby one third by 2050. With 7 billion people already striv let us accept that the world’s population is likely to increase achieve their fundamental human will right to everyone HASH. Equally, that idea the hyperbole as accept us Let – at least HASH–83. damentalright tothe progressive realisation ofthe HASH billionby2100 [16]. Each one ofthese people hasfun a risetotaltoa population of9.6billion people and–10.9 increase by one third over the next 35 years (2050), giving world’sprojectionsthe currentwill population On [16]. In 2013 there were 7.2 billion people occupying the world poorest and on average least healthy countries. increasinganpopulationglobal thebyprimarily elled in health will continue to rely on increasing consumption, fu the HASH–83 has not been realised, and improvements in They however still have populations for whom, on average, in lowerlevels of national wealth than others. This is shown resourcelevelslowerofmuch utilisationwith much and Some countries achieve extremely good standards of health Figure 1 • doi:10.7189/jogh.05.010301 by several of the low–middle income countries. rate of production continues to increaseproductiontocontinues of clare no competing interests. icmje.org/coi_disclosure.pdf (available on request from the corresponding author). TheCompeting interests: authors de drafts, and edited and approved the final submission. Authorship declaration: Funding: None. Allauthors havecompleted theUnified Competing Interest form www.at DDR wrote the initial draft. PA, SG, and DDR contributed to subsequent ------3 able can claim a fundamental human right to the highest ityandnot necessarily thequantity ofthat life. Atbest we standard of health may need to focus explicitly on the qual Ourfundamental individual right tothe highest attainable etaryhealth, itwill remain manifestoa ofgood intentions. compromises required to realise sustainable public“call toand arms” plan[7]. However without confronting the critical Theideas behind the opportunity to choose our destiny at all. lessconsumption greaterbut meaning, losemaythenwe but fewer, average) (on hopefully more of dignified and life rewarding years, a and a to life of ourselves oncile ier and wealthier. This is simply untrue. Unless we can rec morrow (or perhaps the day after that) they will be health around the world are promising their populations that to economic growth. Almost without exception, governments centurysolutionsthatina quarterlie last ofthe ancesof pill to swallow, made all the harder by the rhetorical assur tively transferring benefits to the worst off. That is a bitter multaneously reducing the position of the best off and ac simplyby improving the lot of the worst off alone, but si ent. A future just world, a fair world, will be achieved not achievejustaworld. Thereality today markedlyis differ whichinglobal economic growth wasseenthewaytoas timistic vision of human progress and envisioned at a time standard of health – and an obligation to take no more. planetaryhealth manifesto Photo: CourtesyofA.G.Klei,personalcollection June 2015 •Vol. 5No. 1•010301 arecrucial a – sustain ------

VIEWPOINTS VIEWPOINTS June 2015 •Vol. 5No. 1•010301

REFERENCES 18 20 19 22 17 16 11 15 14 13 12 8 9 6 5 4 3 21 7 2 1 10

WorldHealthOrganization registry/App_Main/view_indicator.aspx?iid=65 Lancet Ebener www.ohchr.org/en/professionalinterest/pages/crc.aspx able: dard of health (article 12 of the International Covenant on Economic, Social UNand Economic Cultural and SocialRights), Council. 2000.General Comment No. 14 (2000). The right to the highest attainable stan doi:10.1016/S0140-6736(07)61173-8 Hunt United Nations cember Rights,1966. Nations United line:18016450 Delgado 2011 ence.1244693 Horton Constitution of the World Health Organization 2002;80:981-4. Organ. World Health Bull Organization. World Health the of constitution the of FP.preamble Grad The doi:10.1186/1476-072X-4-5 He 2010 capita at the sub-national level using night-time light imagery. Murawski global markets. Washington, DC: International Food Policy Research Institute, Netherlands Environmental Assessment Agency maps of 21st-century forest cover change. cover forest 21st-century of maps global-co2-emissions-2013-report the 2008-2009 global financial crisis. 2006. with the ecological footprint concept. Olivier Hansen The 2012 revision, highlights and advance tables. New York: UN, United Nations, Department of Economic and Social Affairs, Population Division GlobalFootprint Network Cutler world-development-indicators WorldBank Medline:24223518 Rees Switzerland: World Wide Fund for Nature International, World Wildlife Fund, Global Footprint Network, London Zooological Society GFN/page/footprint_for_nations/ Peters Wackernagel

WE ; ; http://www.unhchr.ch/tbs/doc.nsf/(symbol)/E.C.12.2000.4.En 473 67 Hubbell

Available: . GP DM

S 2014 R 2013

, MC : Right to the highest attainable standard of health. of standard attainable highest the to Right , , CL 1830 , , Janssens-Maenhout :

Wackernagel Murray Marland 368 SA , Beaglehole

Deaton , , . World. developmentDataindicators |

; . . Wada Potapov M 383

- - Available: Rebuilding depleted fish stocks: the good, the bad, and, mostly, the ugly.

SP 71 40 . Convention on the Rights of the Child. New York: UN Human Rights, 1989. doi:10.2105/AJPH.36.11.1315 . International Covenant on Economic, Social and Cultural Rights. New York: UN HumanYork: UNNew Rights. Cultural and Social Economic, on CovenantInternational . , Medline:12571728

http://www.nber.org/papers/w11963 . Onisto

: . . C 847 Medline:21593870 Species-arearelationshipsoverestimatealways loss.habitatfromextinction rates

doi:10.1093/icesjms/fsq125

AS G , doi:10.1371/journal.pbio.1001701 N Tandon ,

, R , . Le Quéré PV Medline:24607088

Rosegrant Lleras-Muney , M

Bonita L http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx , . , Moore . Footprint.nations. for The shoe fits, but the footprint is larger than Earth. Bello . Life expectancyLife.birth (years).at Avaliable at:

A G . Accessed: 22 March 2014). ,

, R

Elvidge

Muntean P , . Accessed: 22 March

R , , MW . Accessed: 23 March 2014. Raeburn , Linares Boden Hancher

Nat Clim Change. , Ecol Econ

doi:10.1038/nature09985 . The determinants of mortality. National Bureau of Economic Research Meijer

CC 4

AC , doi:10.1016/S0140-6736(14)60409-8 J .

, Science .Trends in global CO2 emissions: 2013 report. The Hague: PBL Canadell From wealth to health: modelling the distribution of income per

McKee

M , S . Accessed: 17 March . Falfan [email protected] Malaysiaanya Bandar Sunway, 46150, Selangor DE Jalan Lagoon Selatan Monash University School of Medicine and Heath Sciences Professor of Population Health & Director SEACO Daniel D Reidpath, PhD, HonFRSH Correspondence to: , 2013 , Am J Public Health Nations Health . Ahmed Turubanova 1999 Available: . 2013

M . . Accessed: 17 March 2013

. Accessed: 22 December

JG Available: L ; , 2014 29 ,

Wall ,

2011 Garcia 2012 M . Raupach : 375 ; Available: 342 . Fish to 2020: Supply and demand in changingindemand andSupply2020: to Fish . ).

Int J Health Geogr http://www.footprintnetwork.org/en/index.php/ Lancet. S

; SA . - 2 . : 90

From public to planetary health: a manifesto. :

850 JM http://www.pbl.nl/en/publications/trends-in- 2 , - . Tyukavina 2013

4 MR

doi:10.1016/S0921-8009(98)90063-5 . Accessed: 17 March et alet . -

2014 3 doi:10.1038/nclimate1332 http://data.worldbank.org/data-catalog/ Medline:17679000 2007;370:369-71. . . Medline:24233722 . Rapid growth in CO2 emissions after . www.jogh.org Nationalnatural capital accounting . http://apps.who.int/gho/indicator . Living planet report 2012. Gland, 2014

PLoS Biol . , 2003 2013 . World population prospects: 2005 . et al et • doi:10.7189/jogh.05.010301 . . . 1946 . ; 4 High-resolutionglobal

: ICES J Mar Sci J Cons. 5 . . 2013 Medline:15705196 2014 ; . Accessed:De 22. 36

doi:10.1126/sci Available: : 1315 ; . 11 : e1001701 - 23

Nature

. http:// Med Avail ------. .