Daniel Reidpath - ORCID: 0000-0002-8796-0420 https://orcid.org/0000-0002-8796-0420http://jogha.org/documents/issue201501/jogh-05-010301.pdf5pubpub

Allotey, Pascale

Gruskin, Sofia

Reidpath, Daniel

Journal of Global Health

Queen Margaret University eResearch

VIEWPOINTSOne of the fundamental human rights is the right of every individual to the enjoyment of the high-est attainable standard of health, which we sim-plify to ‘HASH’ [1]. The HASH right was first articulated in the preamble to the WHO Constitution (1946) [2]. It ap-pears in Article 12 of the International Covenant on Eco-nomic, Social and Cultural Rights (ICESCR) (1966) [3]; and occurs in various human rights treaties (cf [4]).Fully realizing all human rights immediately and complete-ly is impossible; and that is why the right to HASH is sup-ported by the notion of progressive realisation (cf; ICESCR Article 2(1)[3][3]) [5]. That is, States have an obligation to take steps towards the progressive realisation of the right, with the result that over a period of time HASH, ideally, would be fully realised for each individual in the world [3]. Furthermore, economically developed states have an obliga-tion which extends beyond their borders to progressively support less well developed states in achieving the vision [6].In the recent manifesto From public to planetary health, Hor-ton and colleagues declared their support for the HASH right [7] They went on to declare, inter alia that “our pat-terns of overconsumption are unsustainable and will ulti-mately cause the collapse of our civilisation”, that “the idea of unconstrained progress is a dangerous human illusion”, and that “we must conserve, sustain, and make resilient the planetary and human systems on which health depends by giving priority to the well being of all” [7]. There are, how-ever, some fundamental public health challenges and trade–offs that need to be confronted for both HASH and Is the right to health compatible with sustainability?Daniel D Reidpath1, Sofia Gruskin2, Pascale Allotey1sustainability agendas to be compatible. The trade–offs arise because, at a population level, the highest attainable standard of health is a standard that is achieved (or pro-gressively realised) through unsustainable levels of con-sumption.In 2013 a reasonable benchmark for the average highest attainable standard of health was 83 years of life; ie, the life expectancy in France, Iceland, Italy, Japan, and Switzerland (HASH–83) [8]. An individual’s HASH point, (ie, their in-dividual right to the highest attainable standard of health) may actually be higher or lower than the population aver-age; due, for example, to genetic (dis–)advantages. HASH–83, thus, potentially provides a policy benchmark for pop-ulation performance, but it does not detract from a particular individual’s legal right to their (unknowable) true There are fundamental public health challeng-es and trade–offs that need to be confronted for the achievement of the highest attainable standard of health and the sustainability agen-das to be compatible. The trade–offs arise be-cause, at a population level, the highest attain-able standard of health is a standard that is achieved (or progressively realised) through unsustainable levels of consumption.1 Global Public Health, School of Medicine and Health Science, Monash University, Selangor, Malaysia2 Program on Global Health and Human Rights, Institute for Global Health, University of Southern California, Los Angeles, CA, USAwww.jogh.org •  doi: 10.7189/jogh.05.010301	 1	 June 2015  •  Vol. 5 No. 1 •  010301VIEWPOINTSHASH. Therefore, and in the absence of specific individu-al data about adverse social determinants, favourable genes, and adverse pre–existing health states, the best guess for any randomly selected individual from a population (even a population with a life expectancy of 50 years) is that the selected individual has a progressively realisable right to HASH–83.While we await the progressive realisation of an average HASH–83, we can expect that the current trend in life ex-pectancy will actually increase, as it has been steadily do-ing over the past century. Here in lies the trade–off between the individual right to HASH and sustainability. The link between resource utilisation and health is well established. Nations with the highest GDP per capita and the highest levels of resource utilisation are the countries with popula-tions achieving the highest standards of health, and popu-lations increasing the HASH point [9].The Ecological Footprint indicator was developed in the late 1990s to create a mechanism for measuring the sustainabil-ity of human use of the environment using uniform, glob-ally available data [10]. Country level data allows a compar-ison of the per capita ecological footprint of each country in the common unit of global hectares of available land per capita (GHa/capita) [11]. Based on this indicator, the esti-mated sustainable footprint is about 1.8 GHa/capita [12]. The global average GHa/capita is about 2.7; ie, we ‘overshoot’ the sustainability threshold by 50%. Some countries have a considerably higher GHa/capita than others and currently “... about 84% of the world population lives in countries that run growing ecological deficits” (p.1) [13].With the latest available ecological footprint data (2008) and life expectancy data from the World Bank for the same year [14], we charted the relationship between the per cap-ita ecological footprint and average life expectancy in 147 countries (Figure 1). The relationship is plotted with a nonlinear quantile regression model at the 5th, 25th, 50th (median), 75th and 95th percentiles. The broken vertical line is the sustainability threshold.Countries’ average life expectancies rapidly increase with an increasing ecological footprint, and plateau (or perhaps decline slightly) after a GHa/capita of about 6. The median regression curve (solid black line), suggest a sustainable average life expectancy of 68 years, The countries with the highest average life expectancies (>80) are all high income countries, with a mean ecological footprint of 5.5 GHa/capita or three times the sustainability threshold.These data suggest that, on average, the enjoyment of the highest attainable standard of health is most likely to be achieved by those living in the wealthiest countries and re-lies on the exploitation of the resources of the global com-mons. Unfortunately, at least some of the ecological foot-print of high income countries is in fact transferred back to populations in low income countries in the form of tech-nology [15], suggesting that the sustainable life expectancy may be even lower than 68 years.The fundamental individual right to the highest attainable standard of health may need to fo-cus MORE on the quality and not the quantity of life. At best we should claim a fundamental human right to the highest sustainable stan-dard of health – and an obligation to take no more.Figure 1. The relationship between the per capita ecologi-cal footprint and average life expectancy in 147 countries. GHa/capita – global hectares of available land per capita.June 2015  •  Vol. 5 No. 1 •  010301	 2	 www.jogh.org •  doi: 10.7189/jogh.05.010301VIEWPOINTSSome countries achieve extremely good standards of health with much lower levels of resource utilisation and much lower levels of national wealth than others. This is shown in Figure 1 by several of the low–middle income countries. They however still have populations for whom, on average, the HASH–83 has not been realised, and improvements in health will continue to rely on increasing consumption, fu-elled by an increasing global population primarily in the poorest and on average least healthy countries.In 2013 there were 7.2 billion people occupying the world [16]. On current projections the world’s population will increase by one third over the next 35 years (2050), giving rise to a total population of 9.6 billion people – and 10.9 billion by 2100 [16]. Each one of these people has a fun-damental right to the progressive realisation of the HASH – at least HASH–83.Let us accept as hyperbole the idea that everyone will achieve their fundamental human right to HASH. Equally, let us accept that the world’s population is likely to increase by one third by 2050. With 7 billion people already striv-ing to be better off, we have failed to curtail our destruction of the planet’s rainforests [17]. We have failed to preserve the natural fish stocks in our oceans [18,19]. We have seen rates of species extinction in our life time which are associ-ated with major planetary catastrophes [20]. Notwithstand-ing international commitments to reduce greenhouse gas production, the rate of production continues to increase [21,22]. Now add another 2.4 billion people. On very ba-sic measures of sustainability we completely fail.Those 2.4 billion extra people – the total population of the world a century earlier (1950) – will need food, shelter and health care along with their 7.2 billion companions. They will consume, and if they are like the people of the last quarter of a century, they will aspire to consume more than they do; and they will aspire to greater health than they currently have. We face the tragedy of the commons in which the commons we share is the entire planet. Growth in absolute consumption is not an unreasonable guess and does not auger well for human life on this planet, or for the life of many plant and animal species.The modern origins of the fundamental human right to the highest attainable standard of health was stirred by an op-timistic vision of human progress and envisioned at a time in which global economic growth was seen as the way to achieve a just world. The reality today is markedly differ-ent. A future just world, a fair world, will be achieved not simply by improving the lot of the worst off alone, but si-multaneously reducing the position of the best off and ac-tively transferring benefits to the worst off. That is a bitter pill to swallow, made all the harder by the rhetorical assur-ances of the last quarter of a century that solutions lie in economic growth. Almost without exception, governments around the world are promising their populations that to-morrow (or perhaps the day after that) they will be health-ier and wealthier. This is simply untrue. Unless we can rec-oncile ourselves to a life of (on average) fewer, but hopefully more dignified and rewarding years, and a life of less consumption but greater meaning, then we may lose the opportunity to choose our destiny at all.The ideas behind planetary health manifesto are crucial – a “call to arms” [7]. However without confronting the critical compromises required to realise sustainable public and plan-etary health, it will remain a manifesto of good intentions. Our fundamental individual right to the highest attainable standard of health may need to focus explicitly on the qual-ity and not necessarily the quantity of that life. At best we can claim a fundamental human right to the highest sustain-able standard of health – and an obligation to take no more.Photo: Courtesy of A. G. Klei, personal collectionwww.jogh.org •  doi: 10.7189/jogh.05.010301	 3	 June 2015  •  Vol. 5 No. 1 •  010301Funding: None.Authorship declaration: DDR wrote the initial draft. PA, SG, and DDR contributed to subsequent drafts, and edited and approved the final submission. Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author). The authors de-clare no competing interests.VIEWPOINTSREFERENCES  1  Grad FP. The preamble of the constitution of the World Health Organization. Bull World Health Organ. 2002;80:981-4. Medline:12571728  2  Constitution of the World Health Organization. Am J Public Health Nations Health. 1946;36:1315-23. Med-line:18016450 doi:10.2105/AJPH.36.11.1315  3  United Nations. International Covenant on Economic, Social and Cultural Rights. New York: UN Human Rights, 1966. Available: http://www.ohchr.org/EN/ProfessionalInterest/Pages/CESCR.aspx. Accessed: 22 De-cember 2013.  4  United Nations. Convention on the Rights of the Child. New York: UN Human Rights, 1989. Available: http://www.ohchr.org/en/professionalinterest/pages/crc.aspx. Accessed: 22 December 2013.  5  Hunt P. Right to the highest attainable standard of health. Lancet. 2007;370:369-71. Medline:17679000 doi:10.1016/S0140-6736(07)61173-8  6  UN Economic and Social Council. General Comment No. 14 (2000). 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Medline:21593870 doi:10.1038/nature0998521  Peters GP, Marland G, Le Quéré C, Boden T, Canadell JG, Raupach MR. Rapid growth in CO2 emissions after the 2008-2009 global financial crisis. Nat Clim Change. 2011;2:2-4. doi:10.1038/nclimate133222  Olivier J, Janssens-Maenhout G, Muntean M. Trends in global CO2 emissions: 2013 report. The Hague: PBL Netherlands Environmental Assessment Agency 2013. Available: http://www.pbl.nl/en/publications/trends-in-global-co2-emissions-2013-report. Accessed: 23 March 2014.June 2015  •  Vol. 5 No. 1 •  010301	 4	 www.jogh.org •  doi: 10.7189/jogh.05.010301Correspondence to:Daniel D Reidpath, PhD, HonFRSH Professor of Population Health & Director SEACO School of Medicine and Heath Sciences Monash University Jalan Lagoon Selatan Bandar Sunway, 46150, Selangor DE Malaysiaanya daniel.reidpath@monash.edu

Is the right to health compatible with sustainability?

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Is the right to health compatible with sustainability?

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