Comment
Health and climate change: the end of the beginning?
www.thelancet.com Vol 384 December 13, 2014
benefits will be. The final message is that countries can achieve both climate protection and health gains, while also increasing the prosperity and wellbeing of their citizens, and promoting international solidarity. Gro Harlem Brundtland, a UN Special Envoy and former Prime Minister of Norway, described how Norway has taxed its fossil fuel consumption and production, investing the revenues in domestic health and education, overseas development assistance, and sufficient reforestation to offset its greenhouse gas emissions many times over. She also mentioned Indonesia as a country that had taken steps in the same direction. These messages are now starting to be taken up beyond the health community. The economic analysis released at the summit showed that countries such as China are losing about 10% of their GDP to the effects of poor air quality on health, and have most to gain from low-carbon development.7 The International Monetary Fund has released a report8 showing that if the top twenty greenhouse-gas-emitting countries put a price on the (mainly air pollution) cobenefits of climate change mitigation at a level that would directly benefit their own populations, carbon emissions would be cut by 13·5%. Valuation of immediate and local health gains can therefore give an important head start to mitigation, even before the essential but difficult business of international climate negotiations. However, much progress is yet to be made. Few countries are already factoring health into their climate
Susan McCartney/Science Photo Library
Health and climate change have entered a new phase. In August, WHO hosted the first worldwide conference on health and climate in Geneva, Switzerland.1 The conference brought together 400 participants from more than 90 countries, including 25 ministers and four UN agency heads. It was also WHO’s first carbonneutral meeting. The conference substantiated the growing leadership of countries around the world in connecting health to climate change. It concluded with a strong statement—warning that, in the absence of mitigation and adaptation, climate change poses unacceptable risks to health; defining a scaled-up, systematic approach to increase health resilience to the climate risks that countries are now experiencing; and recognising that health needs to support and help define climate change mitigation policies, not least to help reduce the 7 million worldwide annual deaths from air pollution.2 In September, the Climate Summit3 hosted by UN Secretary General Ban Ki-moon brought together 125 heads of state in New York, USA to make commitments to ease the path to a planned international climate change agreement in Paris, France in 2015. By contrast with most previous climate meetings, health was well represented, not only in civil society side events, but also as one of the main thematic discussions within the summit itself, on climate, health, and jobs. This discussion moved beyond the now well-known health risks presented by climate change towards emphasis on health opportunities that could be realised through sustainable choices in sectors such as transport, electricity generation, and food and nutrition.4 A series of clear messages emerged from the summit. The first is that we need not be hesitant to place health centrally within climate change discussions. The policy initiatives that have been most effective at addressing environmental issues, such as the Montreal Protocol5 to protect the ozone layer and the Clean Air Act6 in the USA, have health as their main justification and protection of the natural environment as the cobenefit, rather than vice versa. Second, the main solutions that are being advocated within climate discussions, such as ending of fossil fuel subsidies and putting a price on carbon, would also bring health benefits—the more that health is incorporated into policy design, the greater these
2085
Comment
change mitigation and adaptation policies, and large vested interests make the transition to low carbon and sustainable development paths difficult. Sustained mechanisms are needed to continue to mobilise the strength of the health community. The WHO conference committed to establishment of a platform to support engagement of the full range of actors to both increase health resilience to climate change and gain health benefits, while greenhouse-gas emissions are cut. Moreover, although agendas need to be defined, they also need to be implemented, and appropriate mechanisms should ensure that what gets measured gets done. Health and climate change are not standalone issues, but link to every aspect of development. They should therefore be fully integrated into the new Sustainable Development Goals. WHO Director-General Margaret Chan and UN Framework Convention on Climate Change Executive Secretary Cristiana Figueres agreed at the conference on health and climate to provide specific country data to assess and monitor progress on health and climate. This agreement could draw on the highly successful experiences of tracking progress towards health-related Millennium Development Goals, such as provision of improved water and sanitation services, and reduction of maternal, newborn, and child mortality. This same approach that has been used to address the unfinished
health business of the 20th century can also be applied to climate change as the defining public health challenge of the 21st century.9 *Maria Neira, Diarmid Campbell-Lendrum, Marina Maiero, Carlos Dora, Flavia Bustreo Family, Women’s and Children’s Health, World Health Organization, CH-1211 Geneva, Switzerland [email protected] We declare no competing interests. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2
3 4
5
6 7
8
9
WHO. WHO conference on health and climate; Geneva, Switzerland; Aug 27–29, 2014. WHO. Burden of disease from household air pollution for 2012. Summary of results. http://www.who.int/phe/health_topics/outdoorair/databases/ FINAL_HAP_AAP_BoD_24March2014.pdf?ua=1 (accessed Nov 5, 2014). Climate Summit 2014; New York, USA; Sept 23, 2014. Climate Summit 2014. Climate, health and jobs. http://www.un.org/ climatechange/summit/2014/08/climate-health-jobs (accessed Nov 5, 2014). van Dijk A, Slaper H, den Outer PN, et al. Skin cancer risks avoided by the Montreal Protocol—worldwide modeling integrating coupled climatechemistry models with a risk model for UV. Photochem Photobiol 2013; 89: 234–46. United States Environmental Protection Agency. Air pollution and the Clean Air Act. http://www.epa.gov/air/caa (accessed Nov 5, 2014). The Global Commission on the Economy and Climate. Better Growth, Better Climate. The new climate economy report. Washington, DC: World Resources Institute, 2014. Parry IW, Veung C, Heine D. How much carbon pricing is in countries’ own interests? The critical role of co-benefits. Washington, DC: International Monetary Fund, 2014. Chan M. Climate change and health: preparing for unprecedented challenges. Dec 10, 2007. http://www.who.int/dg/speeches/2007/ 20071211_maryland/en (accessed Nov 5, 2014).
Science Photo Library
Revisiting the BIOSCIENCE of drug-eluting stent technology
Published Online September 1, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61415-X See Articles page 2111
2086
Of the coronary stents, the thin-strut, cobalt-chromium, fluoropolymer-based everolimus-eluting stent has become the epitome of clinical performance. However, the permanent presence of fluoropolymer in contact with the vessel wall increases the potential for impaired vascular healing, which can lead to late stent thrombosis and neoatherosclerosis.1,2 Biodegradable polymers have the potential to abolish these late adverse outcomes. In comprehensive network meta-analyses, however, a higher risk of stent thrombosis was noted with earlygeneration, biodegradable polymer-based drug-eluting stents, compared with polymer-based everolimuseluting stents (rate ratio [RR] 2·04, 95% CI 1·27–3·35).1 In addition to the polymer, mechanical features of stent platforms seem to play an important part in
thrombogenicity associated with drug-eluting stents. Data from bench tests show that thrombogenicity is 1·5 times higher with thick-strutted stents compared with thin-strutted stents.3 The strut thickness of the earlygeneration, biodegradable polymer-based drug-eluting stents is also much higher than that of polymer-based everolimus-eluting stents, with a polymer-drug matrix of 150 μm versus 96 μm. This might explain the findings of increased thrombogenicity with drug-eluting stents. In The Lancet, Thomas Pilgrim and colleagues4 report results from the BIOSCIENCE randomised trial that compared the performance of the new ultrathin-strut, biodegradable polymer-based sirolimus-eluting stent with the standard durable, thin-strut, polymer-based everolimus-eluting stent. The primary endpoint was www.thelancet.com Vol 384 December 13, 2014
Health and climate change: the end of the beginning?
www.thelancet.com Vol 384 December 13, 2014
benefits will be. The final message is that countries can achieve both climate protection and health gains, while also increasing the prosperity and wellbeing of their citizens, and promoting international solidarity. Gro Harlem Brundtland, a UN Special Envoy and former Prime Minister of Norway, described how Norway has taxed its fossil fuel consumption and production, investing the revenues in domestic health and education, overseas development assistance, and sufficient reforestation to offset its greenhouse gas emissions many times over. She also mentioned Indonesia as a country that had taken steps in the same direction. These messages are now starting to be taken up beyond the health community. The economic analysis released at the summit showed that countries such as China are losing about 10% of their GDP to the effects of poor air quality on health, and have most to gain from low-carbon development.7 The International Monetary Fund has released a report8 showing that if the top twenty greenhouse-gas-emitting countries put a price on the (mainly air pollution) cobenefits of climate change mitigation at a level that would directly benefit their own populations, carbon emissions would be cut by 13·5%. Valuation of immediate and local health gains can therefore give an important head start to mitigation, even before the essential but difficult business of international climate negotiations. However, much progress is yet to be made. Few countries are already factoring health into their climate
Susan McCartney/Science Photo Library
Health and climate change have entered a new phase. In August, WHO hosted the first worldwide conference on health and climate in Geneva, Switzerland.1 The conference brought together 400 participants from more than 90 countries, including 25 ministers and four UN agency heads. It was also WHO’s first carbonneutral meeting. The conference substantiated the growing leadership of countries around the world in connecting health to climate change. It concluded with a strong statement—warning that, in the absence of mitigation and adaptation, climate change poses unacceptable risks to health; defining a scaled-up, systematic approach to increase health resilience to the climate risks that countries are now experiencing; and recognising that health needs to support and help define climate change mitigation policies, not least to help reduce the 7 million worldwide annual deaths from air pollution.2 In September, the Climate Summit3 hosted by UN Secretary General Ban Ki-moon brought together 125 heads of state in New York, USA to make commitments to ease the path to a planned international climate change agreement in Paris, France in 2015. By contrast with most previous climate meetings, health was well represented, not only in civil society side events, but also as one of the main thematic discussions within the summit itself, on climate, health, and jobs. This discussion moved beyond the now well-known health risks presented by climate change towards emphasis on health opportunities that could be realised through sustainable choices in sectors such as transport, electricity generation, and food and nutrition.4 A series of clear messages emerged from the summit. The first is that we need not be hesitant to place health centrally within climate change discussions. The policy initiatives that have been most effective at addressing environmental issues, such as the Montreal Protocol5 to protect the ozone layer and the Clean Air Act6 in the USA, have health as their main justification and protection of the natural environment as the cobenefit, rather than vice versa. Second, the main solutions that are being advocated within climate discussions, such as ending of fossil fuel subsidies and putting a price on carbon, would also bring health benefits—the more that health is incorporated into policy design, the greater these
2085
Comment
change mitigation and adaptation policies, and large vested interests make the transition to low carbon and sustainable development paths difficult. Sustained mechanisms are needed to continue to mobilise the strength of the health community. The WHO conference committed to establishment of a platform to support engagement of the full range of actors to both increase health resilience to climate change and gain health benefits, while greenhouse-gas emissions are cut. Moreover, although agendas need to be defined, they also need to be implemented, and appropriate mechanisms should ensure that what gets measured gets done. Health and climate change are not standalone issues, but link to every aspect of development. They should therefore be fully integrated into the new Sustainable Development Goals. WHO Director-General Margaret Chan and UN Framework Convention on Climate Change Executive Secretary Cristiana Figueres agreed at the conference on health and climate to provide specific country data to assess and monitor progress on health and climate. This agreement could draw on the highly successful experiences of tracking progress towards health-related Millennium Development Goals, such as provision of improved water and sanitation services, and reduction of maternal, newborn, and child mortality. This same approach that has been used to address the unfinished
health business of the 20th century can also be applied to climate change as the defining public health challenge of the 21st century.9 *Maria Neira, Diarmid Campbell-Lendrum, Marina Maiero, Carlos Dora, Flavia Bustreo Family, Women’s and Children’s Health, World Health Organization, CH-1211 Geneva, Switzerland [email protected] We declare no competing interests. © 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved. 1 2
3 4
5
6 7
8
9
WHO. WHO conference on health and climate; Geneva, Switzerland; Aug 27–29, 2014. WHO. Burden of disease from household air pollution for 2012. Summary of results. http://www.who.int/phe/health_topics/outdoorair/databases/ FINAL_HAP_AAP_BoD_24March2014.pdf?ua=1 (accessed Nov 5, 2014). Climate Summit 2014; New York, USA; Sept 23, 2014. Climate Summit 2014. Climate, health and jobs. http://www.un.org/ climatechange/summit/2014/08/climate-health-jobs (accessed Nov 5, 2014). van Dijk A, Slaper H, den Outer PN, et al. Skin cancer risks avoided by the Montreal Protocol—worldwide modeling integrating coupled climatechemistry models with a risk model for UV. Photochem Photobiol 2013; 89: 234–46. United States Environmental Protection Agency. Air pollution and the Clean Air Act. http://www.epa.gov/air/caa (accessed Nov 5, 2014). The Global Commission on the Economy and Climate. Better Growth, Better Climate. The new climate economy report. Washington, DC: World Resources Institute, 2014. Parry IW, Veung C, Heine D. How much carbon pricing is in countries’ own interests? The critical role of co-benefits. Washington, DC: International Monetary Fund, 2014. Chan M. Climate change and health: preparing for unprecedented challenges. Dec 10, 2007. http://www.who.int/dg/speeches/2007/ 20071211_maryland/en (accessed Nov 5, 2014).
Science Photo Library
Revisiting the BIOSCIENCE of drug-eluting stent technology
Published Online September 1, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)61415-X See Articles page 2111
2086
Of the coronary stents, the thin-strut, cobalt-chromium, fluoropolymer-based everolimus-eluting stent has become the epitome of clinical performance. However, the permanent presence of fluoropolymer in contact with the vessel wall increases the potential for impaired vascular healing, which can lead to late stent thrombosis and neoatherosclerosis.1,2 Biodegradable polymers have the potential to abolish these late adverse outcomes. In comprehensive network meta-analyses, however, a higher risk of stent thrombosis was noted with earlygeneration, biodegradable polymer-based drug-eluting stents, compared with polymer-based everolimuseluting stents (rate ratio [RR] 2·04, 95% CI 1·27–3·35).1 In addition to the polymer, mechanical features of stent platforms seem to play an important part in
thrombogenicity associated with drug-eluting stents. Data from bench tests show that thrombogenicity is 1·5 times higher with thick-strutted stents compared with thin-strutted stents.3 The strut thickness of the earlygeneration, biodegradable polymer-based drug-eluting stents is also much higher than that of polymer-based everolimus-eluting stents, with a polymer-drug matrix of 150 μm versus 96 μm. This might explain the findings of increased thrombogenicity with drug-eluting stents. In The Lancet, Thomas Pilgrim and colleagues4 report results from the BIOSCIENCE randomised trial that compared the performance of the new ultrathin-strut, biodegradable polymer-based sirolimus-eluting stent with the standard durable, thin-strut, polymer-based everolimus-eluting stent. The primary endpoint was www.thelancet.com Vol 384 December 13, 2014
