Resilience - public health white paper

Resilience is mentioned several times in the recent public health white paper 'Healthy Lives, Healthy People' (england and wales). What does resilience mean and is it linked with sustainability?

The white paper uses resilience in refering to mental health, but also in connection with emergency preparedness. There will even be Local and National Resilience Forums.

I was intrigued whether we're talking about the same thing in sustainability discussions. For example Rob Hopkin's Blog, at Transition Culture (co-founder of Transition Towns), recently reviewed a film 'ResilientCity' dir. Gregory Greene. I haven't seen the film, but I guess resilience here means community resilience. This has some implications of self-reliance, localisation and some degree of redunancy of roles and systems (compared to modernist specialism).

To find out a little more about the public health sense of resilience I watched a very good youtube panel interview from US government public health emergency dept. This discussion is mainly from the perspective of emergency planning, but it covers a range of perspectives:

• Personal resilience - related to physical health & managing chronic conditions
• Personal resilience - related to mental wellbeing (maybe interpersonal?)
• Community resilience - a preparedness of the community for emergency
• Institutional resilience - non-governmental (NGO) and state organisations - especially how they coordinate

In the discussion there was an opinion that resilience is more positive approach, compared to emergency response. Which would fit with sustainability discussions. Another opinion from a public health professional was that an indicator of resilience was whether NGO's were communicating with local government. I may be reading too much into this, but I detected a power imbalace here - that onus was on the community groups to 'report' to statutory bodies.

These two points are an interesting reflection on UK thinking. Local government is moving towards 'asset-based' approaches, which are intended to be a more positive way of working with community than 'needs-based'. The second point reflects on many unknowns within the white paper - how much capacity do community groups have to deliver public health? How much freedom will they have in how they deliver and how and to whom will they report?

The youtube film was mainly talking about emergency preparedness,and this is indeed an interesting perspective from which to look at the impacts of peak oil on community and public health. However the slow-burn nature of the emergency may limit this approach. On the other hand the economic situation, job losses and potential social unrest may be much more of an emergency situation, both personally and for communities. Will this white paper help us weather the storm?

Waste medicines

I've just come across a report on waste medicines by York Health Economics Consortium and the School of Pharmacy, University of London. They seem to be saying that we've done the easy bit in reducing wasted drugs. Now it's likely to be more expensive to reduce the waste than it's worth - just £300million! This is the economic argument. This is based on clinicians and pharmacists time (£25-100 per hour) required to reduce waste.

Can environmental sustainability have a different view on this. Viewing wasted drugs from an environmental impact rather than just a cost. This includes C-footprint of manufacture, shipping and disposal.

The authors do come up with some recommendations to reduce waste. It would be great if bringing sustainability into the argument could strengthen their case and encourage action. I found the report through commentry on Pharmaceutical Services Negotiating Committee it would be great to find out if anyone in that organisation is championing sustainability?

Health chapter of Post Carbon Reader by Brian Schwartz and Cindy Parker

See following chapter, available from Post Carbon Institute as pdf:

HEALTH: Human Health and Well-Being in an Era of Energy Scarcity and Climate Change Brian Schwartz Cindy Parker (Published Oct 12, 2010)
Also interview with author.

I'm not going to write anymore, cos I've just become a Dad! So it's his health and wellbeing (current and future) that I have to think about now!

Travel survey in Eastham

The Merseyside Transport Partnership is currently consulting with the public on it's preferred strategy for transport for the next 14years (and short term targets for 2015). The straplines that they have come up with include 'creating a new mobility culture' for a 'thriving international city'. I would argue that we shouldn't be emphasising 'mobility' as it has nuances of driving freedom, but rather 'accessibility'. Having goods and services at convenient locations within our community is a better approach than improving 'mobility' for people to get to large shopping and entertainment centres (which generally favour out of town supermarkets and commerce parks).

Transition Town West Kirby have started their own mini-survey to find out whether people would prefer investment in car infrastructure or investment in walking and cycling. We repeated the idea at 3 Transition Village Eastham and Bromborough events and had 50 responses. People attached a sticker to a chart indicating whether they would like to see more investment in car infrastructure or cycling and walking. The colours correspond to age categories (data not shown here). It is evident that a majority of people would like more investment in infrastructure for cycling and walking. But there are many balanced opinions - wanting 60% investment in cycling, or 80%, unlike my own view of 100% !

Transition Hospital

Just been listening to Podcast from Andy Williamson who has realised through his medical treatment for kidney disease the resource needs of healthcare and hospitals. He suggests that hospitals could see themselves as communities and become Transition Hospitals, to help find positive approaches to the transition to low carbon healthcare.

He gave this podcast to a medical meeting of kidney doctors run by Campaign for Greener Healthcare. In the questions he talks about the benefits of getting data over the internet (information communication technology, ICT) for accessing data. Also the support of social networking to communicate with fellow patients.

Land access

I'm writing this in response to Rob Hopkins Transition Culture blog which asks whether Transition Towns groups can access land. Here in north west UK we have some opportunities for accessing land, although we are facing the usual obstacles:

Green Infrastructure  - it seems the north west have been leading in developing a regional green infrastructure. Commission for Architecture and the Built Environment (CABE) have been involved with this, as well as local organisations such as Mersey Forest, and local council organisations (eg Liverpool Vision). Amongst the motivations for such a project of course are the usual suspects, to tackle dereliction and enhance economic growth, but climate change (mitigation and adaptation) and biodiversity (green corridors) also do get a mention.

Health benefits have also been highlighted - not only physical activity in greenspace, but also mental wellbeing from being in the natural environment, or even the therapeutic effect of seeing 'greenery' out of the hospital window (see NHS forest).

All of these initiatives are opportunities for community groups to get involved in growing food, medicinal herbs or to create relaxing places. An exciting development in Liverpool is the Greater Liverpool Food Alliance. A social enterprise: UrbanAg have been involved in linking together: people with land, people who want to grow, and people who want to sell with customers in Liverpool. The local health people, Liverpool Primary Care Trust have also expressed an interest in working with the alliance to improve people's access to fresh food (as I mention Liverpool PCT - they also support allotment growing in the city - so it may be worth linking with your local PCT). Transition Livepool's allotment could well be one of the suppliers to this food alliance, and there are plans to set up food co-ops.

Although I believe these are great possibilities, there are still the usual hurdles. I have recently heard how a community project that Transition Liverpool is working with to create a community growing space is having difficulty accessing the land. The project has been successful with funding, but now is in danger of stalling due to contractual wrangles over access to council-owned land. Issues such as security, liability etc can be sticking points for such projects, which require technical expertise and sensitive management. I've just seen a response to Rob's blog which describes toolkits that Community Council of Devon have created to tackle some of these issues.

Finally, my local transition initiative; Transition Village Eastham and Bromborough, has recently been working with the local adult day centre; Eastham Centre. Many great growing programmes have been run at the centre previously and they have several greenhouses on site! However, due to lack of capacity, these have mostly been stopped. The management are now keen for community groups, like ours, to get involved and use the facilities! So this is a great opportunity, and if some of our projects can also include clients at the centre - then everyone's a winner! The centre also links with local country parks, so we have even more growing opportunities.

Finally, finally, I just want to add something about connection with the earth. I remember some reference about connection with the earth being important for social structure in developing countries and growing cities. For transition in (small) towns food projects are relatively easy first 'hands-on' success stories. City transition finds it a little more difficult. But maybe it's even more important to regain that connection to the earth for dwellers in the concrete jungle and suburbia. The contraction of cities like Liverpool creates redundant spaces, however although we may dream of turning these into green oases, the obstacles can seem insurmountable. However, hopefully by linking different programmes, working with councils and private companies we can make progress and everyone can get a handful of earth on a regular basis!

Eco-Schools, Healthy-Schools

It's really exciting to see so many eco-projects or health-projects going on in primary schools around Liverpool! I'm just starting to recruit schools for a research study looking whether Year 6 (age10/11) children 'engage' with my message of 'Low Carbon Healthy Lifestyles'. Two simple examples are:

•  walking to school - reduces pollution & improves health and fitness.
• eating local veg & growing their own - reduces food miles, avoids potentially nasty ingredients like palm oil (linked with deforestation) & improves diet

But these are just my examples - I'm hoping to find out what young people are thinking about and interested in. So looking at their schools websites there's all sorts of projects including school gardens, projects in the park, even a project where they've linked up with schools in Nigeria and Zimbabwe and made a video!

I'm also linking up with 2010 Year of Health and Wellbeing in Liverpool city region:

Contact me for more details on this project.

Quango cull affects health and environment most

No surprise, but Conservative voices in the coalition government (UK) have no doubt influenced choice of quangos (QUasi-Autonomous Non-Governmental Organisations) to have their funding cut.
The figure shows in grey the current proportion of quangos linked to each government department (so for example Dept for International Development and Government Equalities Office only had 2 quangos to these will be relatively unimportant in this analysis).

Departments which have seen the greatest loss of quangos (red bars) include health, communities and local government, environment farming and rural affairs, transport and education.

Departments which have seen the most quangos retained include defence, home office and justice.

It is noticeable that departments with the greatest amount of dithering (green - 'under consideration') are education and foreign and commonwealth office. Education may be particularly sensitive after previous cuts and reinstatements...

Is there a pattern here? Is this evidence of a move towards a 'secure' state and away from egalitarianism?

Good news is that Department for Energy and Climate Change and Department for Culture Media and Sport have survived relatively well.

Similarity between global antibiotics resistance and peak oil

A new type of antibiotic resistance (called NDM-1) has recently been discovered which could become the next global health crisis. Sarah Bosely in her global health blog in the Guardian, recently drew a parallel with peak oil. The following is my explanation / exploration of these ideas.

In a recent editorial in British Medical Journal, Angela Raffle, a public health consultant at Bristol and also a member of Transition Town Bristol, clearly described the impact of peak oil on health and healthcare. I’ll try to use this as a basis for finding parallels with antibiotic resistance.

 

Discovery

• Looking at the frequency of discovery of new oil wells, the global peak was mid-20th century. The frequency of productive wells follows discovery with approx 40yr lag time (due to economics etc). Oil which is easiest to extract is the most economical (and has the highest net energy). Once they become uneconomical the wells close. Many countries’ oil production is now in decline (USA, UK). This doesn’t mean the wells are empty (although we know the resource has to be finite) it’s just uneconomical (and may become negative net energy to extract).
• Once Alexander Flemming had discovered the effectiveness of penicillium as an antibiotic (1928), this enabled researchers to find variations on a theme, and also to investigate antibiotics which could work through novel mechanisms. Now it would be ideal to show a graph of antibiotic discovery here... but presumably it increased rapidly through the latter half of the 20th century. Unfortunately microbes become resistant to certain antibiotics, through a process assumed to be natural selection. Many antibiotics don’t actually kill bacteria (germs) they just slow them down to give our natural immune system a chance to clear the infection. This means that there’s a chance that some bacteria, through genetic mutation, will find ways of surviving in the presence of the antibiotic and become resistant. Once that happens the progeny of that bacteria (strain) cannot be successfully treated with that antibiotic – i.e. the infection will fester. What’s worse is that this resistance can spread between different strains and even types of bacteria by genetic transfer (eg. Plasmids). This means that antibiotics can gradually become ineffective due to increasing frequency of resistance. Like the oil wells, antibiotics may have a finite lifespan, due to the spread of resistance. However if an antibiotic’s use was curtailed bacteria could, in time, lose resistance thereby increasing effectiveness of the antibiotic again. Unlike oil, antibiotics are not a finite resource. Development of new ones however takes an uncertain amount of time and investment. This could be called a technology gap and is similar to the gap between using fossil fuels and developing renewable power.

Demand

• Oil (energy) demand seems to increase constantly, with economic growth, and especially with rapid industrialisation of ‘developing’ countries. The increasing demand, combined with limits to production is expected to start to produce oscillations in the market – price rises until it’s no longer affordable, followed by economic ‘crunch’ and decrease in price, followed by gradual recovery and price increase again. These cycles of price rises and falls could be more damaging to the economy than anything else.
• Whenever there are scares of antibiotic resistance there are concerns about unnecessary use or lack of compliance. The theory is that the more bacteria are exposed to low levels of antibiotics, or incomplete treatments, the faster they will adapt and become resistant. It could be said that ‘western’ societies use of antibiotics has matched it’s profligate use of oil. Examples would include including antibiotics in household soaps, or giving healthy farm animals antibiotics. Both of these are prophylactic uses of antibiotics, which is a new approach to using antibiotics, normally used as a treatment, with specific instructions to follow the full course of medication. The problems arising from patients who don’t complete the course as well as the increased use in our home and farm environment is that these low dose or constant exposures produce the environment which is likely to give rise to antibiotic resistance. I’m not suggesting that either of these practices has caused the new antibiotic resistance (NDM-1), but that profligate use of antibiotics will increase likelihood of future resistance problems.

Economics

• Sarah Boseley refers to the economics of antibiotic research and development. While production of antibiotics is very economical, research and development has become less favourable. Pharmaceutical companies have to justify investment in research by the impact of the potential therapeutic. This raises many difficult questions. As the price of antibiotics fall, due to increasing production efficiency and patents running out, the potential financial return on a new product also decreases. Also, from a population perspective, there is little demand, because existing antibiotics are, for the most part, doing the job. This may be the strongest link with peak oil: whilst there is little financial impact currently, the economics does not support investment in new technologies (renewable in the case of peak oil).

Affected population

• Peak oil will affect the poorest most harshly. I don't think it is possible to define an at risk population any further, apart from maybe; those are most dependent on consumables now will be most affected
• For antibiotics, the other question about the health economics is who will be affected. If a small population are likely to be affected, pharmaceutical companies will lack incentive to develop new drugs. If the likely population are poor or live in a developing country, then again there is low incentive. From initial reports (lancet) NDM-1 resistance has been found in India and Pakistan, with only sporadic incidences in UK, mostly thought to have been contracted whilst in Asia. From a pharmaceutical company’s perspective investing in research and development does not look like a sound financial choice.

Risk perception
The difficulty in tackling these issues will be in risk perception. Both peak oil and peak antibiotics appear to the mainstream as low risk, distant future issues. The people who discuss the issues are labelled doomsayers. It seems the issue is likely not to be taken seriously until it affects people in the ‘western’ world and creates an impact on the ‘market’. However, due to the lag time in developing new technologies, it will certainly be too late.

International Health Aid

Although Department of International Development funding is ringfenced for now, there are cuts on the table.
http://www.guardian.co.uk/society/sarah-boseley-global-health/2010/aug/13/international-aid-and-development-globalrecession
originally from:
http://www.leftfootforward.org/

A leaked document indicates that spending on health services and systems (£6bn up to 2015, exluding HIV/AIDS, TB and Malaria) may be cut. When this was spending was proposed back in 2008 it included climate change in it's scope. Also included were aspects of fairer trade and improving use of evidence in practice.

We are increasingly aware of how global health has become. Despite the controversies surrounding the swine flu pandemic, it did highlight the risks that a health problem the other side of the world can very soon be a health problem here.

Just when climate change is getting on the health agenda, or the other way round, it's future seems uncertain. We'll have to wait to see how tough that ring-fence is, in this 'greenest ever' government.

Introduction

I hope to cover three broad areas of interest in this blog:

1. Health impacts of mitigation and adaptation to climate change (especially inequalities)
2. Encouraging health professionals to take action
3. Developing community action to deliver health co-benefits of taking action on climate change

I aim to develop an approach that mirrors health economics - how do we factor in decisions which relate to the natural and social environment into clinical or public health decision making.

Is carbon-footprint labelling of medicines and treatments worthwhile?

How do we get the 'triple bottom-line' of (natural) environmental, social as well as economic capital into the board-room budgeting conversations?

My aim is to inform research and develop educational material for everyone (some focused for professionals) within UK primarily.