While we were launching the OECD Environmental Outlook to 2050, a German TV crew was heading for the zoo in Limbach-Oberfrohna to film an earless rabbit, announced as the Next Big Thing after Paul the Psychic Octopus and Knut the polar bear cub. But the poor bunny turned out to be luckless too, since the cameraman stood on it and killed it. We shouldn’t try to read too much into this, but we will since it sums up so neatly the message of the latest Outlook: humans are causing serious and in some cases irreversible harm to nature.
The Scottish poet Robert Burns was prompted to think about these things when he destroyed the nest of a field mouse with his plough. The most famous part of To a mouse is when he talks about what can happen to “the best laid schemes of mice and men”. But he also regrets that “man’s dominion/Has broken Nature’s social union” justifying the ill-opinion that other creatures have of us.
One rabbit or mouse more or less may be no big deal, but the Outlook paints a depressing picture of what’s happening to life on Earth under our dominion. Terrestrial biodiversity is projected to decrease by a further 10% by 2050, with significant losses in Asia, Europe and Southern Africa. Globally, mature forest areas are projected to shrink by 13%. About one-third of global freshwater biodiversity has already been lost, and further loss is projected to 2050.
Climate change will replace agriculture as the fastest growing driver of biodiversity loss to 2050. Without a significant change in policies, global greenhouse gas (GHG) emissions are projected to increase by 50%, primarily due to a 70% growth in energy-related CO2 emissions. Global average temperature is projected to be 3C to 6C above pre-industrial levels by the end of the century, exceeding the internationally agreed goal of limiting it to 2 degrees.
The GHG mitigation actions pledged by countries in the 2010 Cancún Agreements at the UN Climate Change Conference will not be enough to prevent the global average temperature from exceeding the 2C threshold, unless very rapid and costly emission reductions are realised after 2020.
Projections like these are probably familiar to most people interested in environmental issues, but other figures in the book may prove more of a shock, notably concerning health. We may be damaging the environment, but it’s killing us. Today, unsafe water kills more people than all forms of violence, but air pollution is set to become the world’s top environmental cause of premature mortality, overtaking dirty water and lack of sanitation. The number of premature deaths from exposure to particulate matter (which leads to respiratory failures) is projected to triple from just over 1 million today to nearly 3.6 million per year in 2050, with most deaths occurring in China and India.
The absolute number of premature deaths from exposure to ground-level ozone will more than double worldwide (from 385,000 to nearly 800,000). More than 40% of the world’s ozone-linked premature deaths in 2050 are expected to occur in China and India. However, OECD countries with their ageing and urbanised populations are likely to have one of the highest rates of premature death from ground-level ozone, second only to India when the figures are adjusted for population size.
The subtitle of the Outlook is “The Consequences of Inaction”, but the authors show that actions to protect the environment make economic sense too. For instance, global carbon pricing sufficient to lower GHG emissions by nearly 70% in 2050 compared to the Baseline scenario and limit GHG concentrations to 450 ppm (the level that keeps warming below 2 degrees) would slow economic growth by only 0.2 percentage points per year on average. The potential cost of inaction on climate change could be as high as 14% of average world consumption per capita.
As the international media noted, the data and trends the report sets out are grim. But the Outlook also proposes policies, and strategies for coordinating them, across all the domains it covers. The question is whether we will take the actions required. Too often we give the impression that we’re like skydivers whose only plan is to jump from the plane and hope they’ll find a parachute somewhere on the way down.
OECD Environment Ministerial Meeting 29 March to 30 March 2012
OECD Environment Ministers will meet in Paris under the theme of Making Green Growth Deliver. They will discuss future priorities for action based on the OECD Environmental Outlook to 2050, which makes a strong case for green growth policies.
Kieron Smith, Boy by James Kellman describes life in Glasgow in the 1960s as seen by a child from ages four to almost thirteen. Nothing is presented other than Kieron’s thoughts, so what we are told directly is what he finds interesting and what he thinks about it. Indirectly, the novel describes a number of social and other situations that were starting to change, including this: “There was a fat boy in our street. People called him fatso.” At the time, obesity was unusual enough to draw attention. Yet now more than a third of Scottish 12-year-olds are considered to be overweight, a fifth to be obese and over one in ten severely obese. The statistics for adults are even worse, with almost two-thirds of men and more than half of women.
The situation is better in the other OECD countries, apart from the United States, but overweight is a concern almost everywhere. Obesity is one of the few cases where the popular perception that things were better in the old days is supported by a range of objective evidence. The facts also suggest that people are right in blaming the problem on changes in lifestyle and diet. Kellman’s hero is outside as much as possible, and is usually involved in highly physical pastimes like football, climbing or running. He hardly ever has any pocket money and can rarely afford to buy snacks or a soda. Indeed, another boy is remarkable because he can buy chips once a week on the way home from a youth group.
That doesn’t mean his diet was particularly healthy, but hours of physical activity and no income to buy junk food compensated for all the carbohydrates. Diets for lower socio-economic groups have remained just as poor, or have got worse in some respects, at the same time the amount of exercise has declined.
The result is that overweight and obesity rates have been increasing relentlessly worldwide, Obesity-related problems, such as diabetes, now account for 2% to 6% of health care costs in most countries. Even lower-income countries are affected, with some of them actually having problems of obesity and under nutrition simultaneously.
The causes and consequences of obesity and how to tackle it are analysed in Fit not Fat: Obesity and the Economics of Prevention. The book asks how to trigger meaningful changes in obesity trends. The short answer is by wide-ranging prevention strategies addressing multiple determinants of health. The reality is that every step of the process is conditioned not just by public health concerns, but by history, culture, the economic situation, political factors, social inertia and enthusiasm, and the particularities of the groups targeted.
Authors Franco Sassi and Michele Cecchini of the OECD’s Health Division also contributed to a series of articles on obesity in The Lancet, the latest of which are published today. The Lancet’s conclusions are similar to the OECD’s: the changes needed are likely to require many sustained interventions at several levels, and national governments should take the lead.
That includes tougher action – including taxing junk food – but the food industry will resist such changes. Speaking to the BBC about the reports, Terry Jones, of the UK Food and Drink Federation, said “The Lancet fails to recognise the lengths to which the UK food and drink industry has gone to help improve the health of the nation, particularly in relation to rising obesity levels.”
Professor Boyd Swinburn (author of a paper on what’s driving the obesity epidemic), doesn’t agree. In fact he compares the tactics of the food industry – in terms of getting people addicted to their products and in blocking attempts to discourage consumption – to those of tobacco firms in previous decades.
Health is one of the topics included in the OECD Better Life Index. The Index allows you to put different weights on each of the topics, and therefore to decide for yourself what contributes most to well-being.
You can create your own index on the BLI site and share it on social media and other platforms.
Would you eat animal excrement if the flavour was right? Mayu Yamamoto of the International Medical Center of Japan thinks you might, and won the 2007 Ig Nobel for chemistry for developing a way to extract vanilla fragrance from cow dung.
The Japanese team were looking for ways to tackle a major environmental problem in the country. Livestock produce 50 million tons of excrement each year, and almost all farms are located close to residential areas in Japan, increasing the dangers of pollution – bacteria like E. coli are one of the most widely used indicators of faecal contamination of water.
The case in Germany is only the latest in a long list of deadly outbreaks. However, although it is a particularly nasty variant, there are no signs that E. o104 (the present strain of E. coli) is the mutant superbug epidemiologists have nightmares about.
It is though a warning about drug resistance.
Microbes resistant to penicillin appeared within a few years of the drug’s introduction, and since then medical science has been fighting an increasingly serious battle against microbial resistance to cheap and effective first-choice, or “first-line” drugs.
Bacterial infections which contribute most to human disease are also the most resistant: diarrhoeal diseases, respiratory tract infections, meningitis, sexually transmitted infections, and hospital-acquired infections.
Resistance is becoming more serious due to a number of trends.
Urbanisation facilitates the spread of typhoid, tuberculosis, respiratory infections, and pneumonia.
Pollution, environmental degradation, and changing weather patterns affect incidence and distribution, especially those spread by insects and other vectors.
A growing proportion of elderly people need hospital care and thus are at risk of exposure to highly resistant pathogens found in hospitals.
AIDS has enlarged the population of patients at risk from many previously rare infections.
The resurgence of diseases such as malaria and tuberculosis plus greater global mobility increases the speed and facility with which diseases and resistant micro-organisms can spread.
Irrational use of antibiotics is also promoting resistance. This is due to their being prescribed when not needed or in self-medication, or because patients do not complete courses for financial or other reasons.
Antibiotics use in agriculture is another factor. In North America and Europe, half of all antimicrobial production by weight is used in farm animals and poultry, notably as regular supplements for prophylaxis or growth promotion, exposing even healthy animals to antimicrobials.
As ever, the impacts are worse in poorer countries. In South Asia, one newborn baby dies every two minutes due to treatment failure caused by antibiotic resistance. Treating multidrug-resistant tuberculosis in South Africa costs around $4300, compared with $35 if first-choice or “first-line” drugs are effective.
It’s a problem in rich countries too. As Harvey Rubin recalls in his paper on pandemics for the OECD Future Global Shocks Project, the direct costs to the US healthcare system from antibiotic resistant infections runs into the tens of billions of dollars. He quotes a study by the Infectious Diseases Society of America which found that more than 70% of the 90,000 deaths from bacterial infections were attributable to antibiotic resistant strains, and that “For many patients, there simply are no drugs that work…”.
Moreover, the pipeline of new treatments is practically empty, with only two new classes of antibiotics brought to the market in the past 30 years. Rubin argues that major pharmaceutical companies have stopped developing new agents because antibiotics are not as profitable as drugs that treat chronic (long-term) conditions and lifestyle issues.
Fans of TV medical shows know the procedure: In a chaotic emergency room, Dr. McDreamy examines a feverish patient, furrows his brow, shouts out a diagnosis and – before you know it – a dozen or so suspiciously attractive doctors and nurses are running around, subjecting the poor patient to a bamboozling array of medical tests and scans. All very impressive.
But, in the real world, it’s also all rather expensive – and getting more so by the year. In OECD countries, for instance, the amount governments spend per person on healthcare has risen by more than 70% in real terms since the early 1990s. That spending has brought big benefits, not the least of which is that people are living longer: Over the past two decades, life expectancy – a widely used indicator for national health levels – has been rising by about a year every four years.
Increased healthcare spending isn’t the only reason for that – factors like diet and poverty also play a big role in determining life expectancy. For example, Japan spends less than the OECD average on healthcare and has just 2.2 practising physicians for every 1,000 people – well below the OECD average of 3.2 per 1,000. Nevertheless, it has the highest life expectancy in the OECD area – just under 83 years – and very low rates of infant mortality, due in part to the fact that it’s a wealthy country with a relatively healthy diet.
Still, the increased spending on healthcare since the 1990s has undoubtedly helped to improve health standards in OECD countries. But there’s a downside: spending probably can’t go on rising at its current rate. In 1995, it accounted for $12 out of every $100 spent by OECD governments. Twelve years later, that had risen to $15 out of every $100. In the wake of the financial crisis, when many governments are tightening their budgets, health spending may well come under the scalpel.
But that might hurt less than you’d expect. Why? Simply because governments don’t always get great value for money in healthcare – many could spend less and still get the same results. A report released by the OECD this week suggests that efficiencies could lead to substantial savings in health spending: Without reducing health outcomes, Ireland could make savings on healthcare equivalent to almost 5% of GDP by 2017, the OECD calculates, with Greece and the United Kingdom not far behind on almost 4%.
But even if countries don’t reduce spending, they could still gain substantial health benefits from spending more efficiently, says the OECD. For example, if all countries equalled the performance of the most efficient spenders, life expectancy at birth could be increased by another two years across the OECD area.
Staying with health, the OECD has also been looking recently at sickness and disability benefits, which is another major budget area for governments – it accounts for about 10% of public social spending in OECD countries. Before the recession struck, more people in OECD countries were receiving disability benefits than unemployment benefits – just over 30 million compared with just under 28 million.
A disproportionate number of people with disabilities in OECD countries live in poverty – around 22% compared with about 14% of non-disabled people. Helping them to go out to work could lower that number, but in many cases there are real obstacles to doing that: people with disabilities may have relatively lower levels of education and may face prejudice when applying for jobs. The OECD report suggests addressing these barriers by a partial shift from “passive” to “active” spending. That means that, instead of simply making payments to people with disabilities, more should be spent on things like providing them with training and offering subsidies to employers to hire them.
This post is contributed by Harvey Rubin, a member of the steering group of the OECD Future Global Shocks project and Director of the Univerity of Pennsylvania Institute for Strategic Threat Analysis and Response, and Nicholas Saidel, a Research Specialist at ISTAR.
Thinking about certain aspects of public health and infectious diseases as “existential threats” to human security arguably began as early as December 10, 1948, when the General Assembly of the United Nations adopted and proclaimed the Universal Declaration of Human Rights, in which Article 3 states: “Everyone has the right to life, liberty and security of person.” This was reaffirmed in the United Nations Development Programme (UNDP) of 1994 and again in the 2003 UN Commission on Human Security. These efforts conceptualize security as human-centric rather than the traditional state-centric and include protection from the shocks that affect human safety and welfare – such as disease, hunger, unemployment, crime, social conflict, political repression and environmental hazards. In this formulation, the nature of an existential threat depends in part on the particular threatened sector.
The traditional national security threat is understood to be the threat to the survival of the sovereignty, territory and physical condition of the nation. To the medical community in general, and especially to the public health and infectious diseases sectors, survival clearly refers to taking every action to minimize morbidity and mortality as well as to minimize the effect of disease on the economic, social and political stability of communities, nations and transnational organizations. HIV/AIDS is frequently discussed in the context of securitizing public health issues. This discussion originated with the UN Security Council Resolution 1308 (2000), which placed HIV/AIDS squarely in the cross-hairs of the security debate by stating: “Stressing that the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security.” More recently, obesity has been identified as a national security issue by retired generals and admirals in the report Too Fat to Fight, concluding: “If we don’t take steps now to build a strong, healthy foundation for our young people, then it won’t just be our military that pays the price – our nation as a whole will suffer also.” Even Michelle Obama identified obesity as a national security issue in the announcement of her ‘Let’s Move’ campaign.
Where will the securitizaton of medicine and the medicalization of security lead with regard to the future of public health, and conversely, with regard to the future of national security? These issues are generally addressed in the literature of the political scientists. For example, Stefan Elbe’s new book, “Security and Public Health,” analyzes the framing of health problems as security concerns and whether this framing helps or hinders controlling these problems in national and international political, social and economic venues. Elbe convincingly uses HIV/AIDS, SARS, and H5N1 influenza and bioterrorism as case studies of the effect of medicalizing security. Much like traditional security issues formulated in military language, a responsible reaction to threats is the development of countermeasures. Widening the security gambit to include an “inflated list of possible medical threats to security (Elbe)” can lead to a corresponding extension in funding for medical countermeasures – new vaccines and therapeutics. From our point of view—why is this bad?
The controversy over sovereignty rights concerning epidemiological data and, more specifically, on influenza sequence data that continues to engage the international community, is fascinating. This issue crystallizes many of the concerns of the national security community, including potentially weakening the traditional military agenda by widening the spectrum of security threats, removing the discussion of policy issues from the biomedical and public health practitioners and placing it in the hands of the diplomats, the military and possibly even the intelligence community, and focusing attention on the needs of the economically and militarily stronger countries and not on global health.
Understanding and dealing with the interdependencies of public health and national security spans widely divergent disciplines of clinical medicine, public health, basic biomedical science, economics, political science and international relations and deserves a deep and broad analysis by the interested parties. In this respect, Dr. Lincoln Chen’s comments in his address to the Helsinki Process Track on Human Security are instructive.
Given the perpetual tension between the demands of national security and the need to protect civil liberties, a balance must be struck whereby states can deal with national emergencies efficiently but without an unreasonable erosion of citizens’ privacy rights. Moreover, an international system that fosters, rather than inhibits, cooperation between states in terms of data sharing and bio-surveillance is required. For these reasons, we propose the implementation of a Global Compact for Infectious Diseases.
In 2005, scientists announced that they’d sequenced the DNA of a chimp called Clint and that it was practically the same as that of a man called Clint, or any other human being.
As far as DNA is concerned, our two species are 96% identical, and the number of genetic differences between chimps and us is ten times smaller than that between mice and rats.
The genomes of any two persons (apart from identical twins) vary by 0.1%. However, given that there are 3 billion DNA molecules (or “base-pairs”) in the genome, that represents around 6 million differences, contributing to the great variety of height, skin colour, morphology and other traits, while the 4% human-chimp gap represents 40 million base-pair differences.
When the human genome was first sequenced, there was talk of a flood of revolutionary medicines exploiting the new data. That hasn’t happened because the science is far more complicated than the optimistic forecasts suggested.
However, there has been considerable progress, and genetic medicine is one of the themes of the HUGO-OECD McLaughlin-Rotman Centre for Global Health symposium on genomics and the bioeconomy being held today, May 17th, in Montpellier, France.
One of the most innovative aspects on the agenda is the potential for genomic medicine in the developing world, with reports from institutions that have initiated large-scale genotyping initiatives to improve the health of their populations as well as to promote a knowledge-based economy.
The technology isn’t the only thing that’s changing. Dr Samir K Brahmachari, Secretary to the Government of India, calls for an open-source approach to drug development, claiming that the Indian-led Open Source Drug Discovery project could do for health care what the Web and Linux did for IT.
Apart from human health, the symposium will also be looking at the possibility of harnessing living processes for bioenergy, environmental remediation, and food production.
The Bioeconomy to 2030 (OECD publication, 2009)
This week the Insights blog will be focusing on health care issues. In this second post, we introduce evidence-based care.
My grandmother believed that tar fumes stopped kids catching colds, so if she saw road menders at work, she’d march me, my sisters and brothers and our friends over to breathe in the vapours.
We’d then have to huddle around a steaming dollop of bitumen, arms flapping to help the lungs pump the goodness into our ventricles, like a flock of baby seagulls stuck in an oil slick.
A woman who thought that pigs could see the wind probably wasn’t the best source of advice on health (or anything else), and a carcinogenic mixture of 10,000 chemicals, half of them unidentified, probably not the best prophylactic around, but the wisdom of the ancients is not the only knowledge that seems bonkers in retrospect. Mainstream medicine has had its share of dubious treatments too.
Not just dubious. The aptly named To Err is Human report from the US Institute of Medicine in 2000 estimated that medical errors killed more people than traffic accidents in the US.
Of course, with millions going to see the doctor every day, even a tiny fraction of mistakes soon adds up to a startling sum, but the problem isn’t just a slip of the scalpel or an illegible prescription. Another report estimated that up to a third of treatments had no real clinical effectiveness.
To the layperson, this is astonishing. How on Earth were the doctors deciding on treatments? Rolling dice? In fact, they were applying what they’d learned at medical school and best practice as it evolved. (more…)