Connecting & Developing Synergy between Health & Sustainable Development Agendas

Key Concepts and Terms

It is increasingly being argued that public health, sustainable development and climate change agendas are so inextricably linked that they need to be considered as one broad overarching system that can catalyse action and policy change (UKPHA, 2007; Griffiths and Stewart, 2008; Griffiths et al, 2009).

Public health is commonly defined as ‘the science and art of preventing disease, prolonging life and promoting health through the organised efforts of society’ (Acheson, 1988), whilst health promotion has been defined as ‘the process of enabling people to increase control over, and to improve, their health’(WHO, 1986). It is widely acknowledged that health is determined by a complex web of environmental, economic, social, cultural and lifestyle influences acting at many different levels – as illustrated by Barton and Grant (2006) in their health map (Fig. 1).

Sustainable development remains a contested concept, often used interchangeably with Sustainability. For the purposes of this guidance package, the term sustainable development is used as the overarching term, reflecting its use by the Higher Education Funding Council for England (HEFCE). It is commonly understood to be ‘development which meets the needs of the present without compromising the ability of future generations to meet their own needs’ – a definition that was popularised following the publication of the Brundland Report (World Commission on Environment and Development, 1987). Subsequent to this, the 1992 Rio Earth Summit on Environment and Development was important in establishing an international policy framework for sustainable development. Significant outputs included:

• Rio Declaration (United Nations, 1992), which, as its first principle, affirmed that ‘human beings are at the centre of concerns for sustainable development, they are entitled to a healthy and productive life in harmony with nature’
• Agenda 21 (United Nations, 1993), which in Para 6.1 stated that ‘health and development are intimately interconnected’
• United Nations Framework Convention on Climate Change, which has been pivotal in the development of a growing consensus that climate change is happening, that it is largely the result of human activity and that it poses an enormous threat to the environment and human health (IPCC, 2001, 2007; WHO, 2005).

Figure 1: A Health Map for the Local Human Habitat

Source: Barton, H. and Grant, M. (2006) A health map for the local human habitat. The Journal for the Royal Society for the Promotion of Health, 126 (6). pp. 252-253. ISSN 1466-4240 developed from the model by Dahlgren and Whitehead, 1991.

Dahlgren G, Whitehead M (1991). “The main determinants of health” model, version accessible in: Dahlgren G, and Whitehead M. (2007) European strategies for tackling social inequities in health: Levelling up Part 2. Copenhagen: WHO Regional Office for Europe.

Sustainable development is presented in various ways, often presenting the economy, environment and society as three themes – for instance as a ‘triple bottom line’, a ‘three-legged stool’, or as ‘three-pillars’, or three circles of a Venn diagram.  The trouble with such analogies is they encourage the three themes to be considered separately, as though sustainability can be achieved merely be working on each in isolation, or with some aspects of overlap rather than by truly integrating them.  It is more helpful to consider the relationships between these themes, recognising the environment as the system which creates conditions in which society and economy can operate.  Barton and Grant present such a nested, systems-thinking approach, tailoring it to a health perspective showing how the health of individuals depends on the health of the systems in which they find themselves – from community, to local environment to global environment (see Figure 1).

A whole system perspective underpins the settings approach to health promotion and public health (Dooris 2005; Dooris et al. 2007), which adopts an ecological model of health and is based on the premise that ‘health is created and lived by people within the settings of their everyday life; where they learn, work, play and love’ (World Health Organization, 1986). Healthy Universities is one application of this approach, which is explored further in a parallel Guidance Package on Leading and Developing the Whole System Healthy Universities Approach.

Wider Context and Evidence Base

Nationally, the Coalition Government has articulated its vision for sustainable development, which highlights the connections between economic, social and environmental dimensions; draws on the previous Government’s 2005 Sustainable Development Strategy; and emphasises the centrality of wellbeing and quality of life:

‘The coalition Government is committed to sustainable development…This refreshed vision and our commitments build on the principles that underpinned the UK’s 2005 Sustainable Development strategy, by recognising the needs of the economy, society and the natural environment, alongside the use of good governance and sound science.

‘Sustainable development recognises that the three ‘pillars’ of the economy, society and the environment are interconnected. The Government has initiated a series of growth reviews to put the UK on a path to strong, sustainable and balanced growth. Our long term economic growth relies on protecting and enhancing the environmental resources that underpin it, and paying due regard to social needs. As part of our commitment to enhance wellbeing, we will start measuring our progress as a country, not just by how our economy is growing, but by how our lives are improving; not just by our standard of living, but by our quality of life.’

The 2005 UK Sustainable Development Strategy has five guiding principles, as illustrated by the model in Fig. 3 (H.M. Government, 2005). Importantly, this model sets out the related aims of ‘a strong, fair and just society’, ‘within environmental limits’.  These aims are to be supported by three means of ‘a sustainable economy’, ‘sound science’ and ‘good governance’ – which should be pursued in ways that support the overarching aims.

Source: H.M Government, 2005

Locally, ensuring a strong, healthy and just society requires a commitment to supporting people’s capacity to meet their fundamental human needs, and tackling economic, social, health and environmental inequalities. Sustainable development provides a logical starting point and an essential analytical framework for finding ways to reduce health inequalities (Marmot et al, 2010) – through seeking to minimise both illness and environmental damage across social and ethnic groups. Universities are key players in local strategic partnerships and it will be important that action for health and sustainable development is aligned with and contributes to the delivery of sustainable community strategies.

There is now a substantial body of policy and evidence advocating an integrated approach to promoting sustainable development and public health (e.g. WHO, 2005; Butland et al, 2007; UK Public Health Association, 2007). This is supported by work within particular sectors such as the NHS, demonstrating the enormous contribution to both agendas that can be made through concerted institutional action with a particular focus on climate change mitigation and adaptation (e.g. Griffiths and Stewart, 2008; Griffiths et al, 2009). Whilst there are obvious differences between health and social care and higher education sectors, there is much transferable learning in relation to institutional policy and practice.

It is not difficult to find illustrations of how environmental and social factors interact with health.  For instance, the World Health Organisation estimates over 140,000 ‘excess deaths’ occur each year due to climate change.  These figures relate to indirect impacts such as changes in disease patterns, and do not include direct impacts such as mortality from droughts, floods and storms (WHO, 2009).   On a positive note, there is considerable evidence that contact with non-threatening natural environments confers a range of health benefits from stress reduction, increased socialising, to faster recovery from illness (Maller et al., 2006).

Useful links:
Sustainable Development Unit
Good Corporate Citizen Scheme

University Context

‘Higher education has a unique contribution to make towards sustainable development. University researchers were the first to alert the world to global warming, and researchers worldwide are working to help society find social and technical solutions to environmental challenges.

Today’s graduates will occupy future management and leadership roles, and will need the knowledge and skills to make informed decisions, taking account of the complex social, economic and environmental issues that exist in the twenty-first century.’

A Shared Vision for Sustainable Development in Higher Education

The importance of sustainable development as a driver and focus for universities has been highlighted by HEFCE’s strategic work in the field. This has been reinforced by the findings from a Higher Education Academy research study conducted with more than 5,700 first-year students – which revealed that:

• sustainability concerns are significant in students’ university choices
• first-year students indicate a willingness to take jobs with a small remuneration sacrifice in order to work in a socially and ethically responsible company
• 80% of respondents believe that sustainability skills will be important to their future employers and the majority believe that it is the role of universities and courses to prepare them for graduate employment.

Higher education is one large and influential sector that has the potential to develop an integrated approach and make a substantial contribution to the promotion of sustainable development and public health – which are among the most critical issues facing global society and look set to increase in importance for this and future generations. Furthermore, these issues are closely interlinked in a number of ways (Orme and Dooris, 2010):

• Firstly, the concept of sustainable development embraces environmental, social and economic dimensions and aspires to health-enhancing communities, societies and environments (H.M. Government, 2005). This highlights the importance of ensuring that action for sustainable development within higher education goes beyond traditional focus on energy and environmental performance to engage with and address health and wellbeing.
• Secondly, it is widely recognized that health is determined by a range of environmental, social and economic influences and that the health of people, places and the planet are interdependent (see Fig. 2). It is widely acknowledged that the world is facing an environmental ‘triple threat’ from environmental degradation, climate change and peak oil/resource depletion – and that this threat is closely linked to and contributes to growing socio-economic inequalities, poor health status and increasing inequities in health. Universities have important roles to play – both as large scale organisations with significant corporate leverage and as influential leaders in society.
• Thirdly, the causes and manifestations of both unsustainable development and poor health are interrelated and frequently pose further interconnected challenges . For example, poorly planned living environments and transport infrastructures can result in increased carbon emissions (thereby contributing to climate change) and decreased physical activity (thereby contributing to increasing rates of obesity). Universities can ensure that their own campus planning takes account of these interconnections and use their influence as stakeholders in local partnerships.

Whilst it can be argued that health and sustainable development are strongly linked in terms of the co-benefits of reducing carbon and improving health, the existence of a national-level strategic statement and action plan on sustainable development in higher education (HEFCE, 2008) has prioritised sustainable development as an important driver for HEIs in a way that has not happened for public health:

‘We want to make sustainable development a central part of our strategy for the future development of the higher education (HE) sector. Our vision is that, within the next 10 years, the HE sector in England will be recognised as a major contributor to society’s efforts to achieve sustainability – through the skills and knowledge that its graduates learn and put into practice, its research and exchange of knowledge through business, community and public policy engagement, and through its own strategies and operations.’

In many institutions, sustainable development has therefore become the overarching ‘umbrella’ for addressing health issues. This can offer a sensible and strategic way forward and has the potential to achieve significant improvement in health and wellbeing in higher education. However, the overriding emphasis remains on environmental sustainability, meaning that the social aspects – including a focus on personal health and wellbeing – tend to be marginalised. It would therefore be misleading to argue that the natural integration of sustainability and health is sufficient to be driving a whole system Healthy Universities approach, and it is crucial that higher education institutions (HEIs)  consider the visibility and overall embeddedness of health and wellbeing within their structures and processes. As Orme and Dooris (2010) argue:

‘Public health, sustainability and climate change agendas are so inextricably linked that they need to be considered as one broad overarching system… Higher education is a large, distinctive and hugely influential sector that has both the potential and the responsibility to lead for change regionally, nationally and globally, thereby catalysing integrated policy and practice responses.’

This leadership needs to involve a number of mechanisms:

• Evidence-informed communication and advocacy for a ‘joined-up’ understanding and integrated approach that clearly connects public health and sustainable development.
• Corporate social responsibility – using leverage and ‘corporate muscle’ at institutional and sectoral levels, thereby contributing to public health and sustainable development and demonstrating inter-connectedness.
• Development of values, knowledge and understanding among students and staff, shaping the views of future citizens, leaders and policy makers – thereby impacting on longer term public health and sustainability in families, communities, workplaces and society as a whole.

One of the drivers for positive change in the HE sector is the student group, People and Planet, who publish a well-known ‘green league’ which assesses universities on some of the environmental aspects of sustainable development.  Their criteria provide a useful reference point when embarking on the development of a university sustainability strategy.

High energy-consuming universities may be required to register for the Carbon Reduction Commitment – a national programme to orchestrate the reduction of emissions in the tranche of organisations whose emissions fall below those involved in the EU Emissions Trading Scheme (see EAUC, 2009).

Useful links:

HEFCE’s Sustainable Development Framework

Environmental Association for Universities and Colleges

Higher Education Academy

People and Planet Green League

Planning and Implementation

‘In engaging with sustainable development, climate change and carbon reduction represent a key focus for institutional practice. Through the 2008 Climate Change Act the UK Government has set a goal to cut greenhouse gas emissions by 80% by 2050, and the higher education sector can clearly contribute significantly to this agenda. There are mechanisms for calculating improvements in areas such as energy efficiency, water usage and waste recycling – and with a particular focus on reducing emissions in vehicle fleets and academic, accommodation and leisure buildings, the Higher Education Carbon Management Programme run by the Carbon Trust is designed to help universities manage their carbon emissions better. There remains, however, a real challenge for institutions to calculate an overall carbon footprint for such large and complex organisations. The University of the West of England, Bristol and other universities are doing some innovative work on this which will be disseminated in due course.

HEFCE has recently funded 11 sustainable development projects under a special funding initiative Leading Sustainable Development in Higher Education. The projects have addressed a variety of issues – including renewable energy generation, carbon management, curriculum development, leadership and good practice exchange.

More widely, guidance on the rationale for and operationalisation of Healthy Universities is set out in a parallel Guidance Package on Leading and Developing the Whole System Healthy Universities Approach. Systems thinking underpins this approach, offering a framework for seeing interrelationships between component parts. With regard to the interrelationships between health and sustainable development, Barton’s and Grant’s health map (Fig. 1) can be particularly useful as a tool for discussion and consultation – highlighting opportunities for integration and synergy.

There are a number of ways in which HEIs can develop synergistic approaches that explicitly connect health and sustainable development. Perhaps the three best developed focus areas are travel, food and curriculum development. Case studies have been developed to demonstrate the work that has been achieved or is in progress at a range of universities in England.

Travel

Sustainable and active transport policies are increasingly being developed and championed across the higher education sector. These contribute to action on climate change by reducing carbon emissions and help tackle obesity and other chronic diseases by promoting physical activity.

UWE’s case study highlights a range of achievements to date which demonstrate an holistic approach to travel planning but also indicates the work that still needs to be done and the challenges to progressing such an important agenda for health and wellbeing.

Food

Food is an issue that clearly highlights the interconnectedness of health and sustainable development agendas. It is evident that the personal and economic costs of food-related ill-health are huge, a particular concern being the year-on-year rise in obesity, which in turn is linked to increases in diabetes and heart disease. At the same time, there is growing understanding of the environmental and social impacts of food through how it is grown, processed, transported and disposed of and issues such as Fair Trade, food miles and local sourcing are now firmly on the public and political agendas.

Recognising the important place that they occupy within the food system, both UWE and UCLan have developed a whole system approach through their procurement, catering, retail, education and research roles. UWE’s case study highlights what has been achieved, what is still to do and the challenges a comprehensive food and health strategy presents for universities. UCLan’s case study describes how it has established a Healthy and Sustainable Food Working Group to oversee the joint implementation by the university and its students’ union of an integrated framework that seeks to influence the delivery of a range of core strategies.

Curriculum Development

Universities can also embed health and sustainable development into their core business through means of curriculum development linked to research and knowledge exchange. The growing literature on education for sustainable development acknowledges that sustainability is about systemic change within higher education that allows for transformative learning to take place. This means that these issues can be viewed from a range of disciplinary angles together with cultural perspectives, different time perspectives and a range of spatial perspectives.

As part of UWE’s commitment to ensuring that the university supports the global sustainability agenda for a strong, healthy and just society living within environmental limits, its Institute for Sustainability, Health and Environment has established a Knowledge Exchange for Sustainability Education.

Useful links:

Higher Education Carbon Management Programme

Active Travel Case Study

Health and Sustainable Food @ UWE Case Study 

Health and Sustainable Food Working Group Case Study

Knowledge Exchange for Sustainability Education 

Higher Education Academy – Education for Sustainable Development

Leading Sustainable Development in Higher Education

Consultation and Partnerships

Developing a whole system understanding of health and sustainable development can be challenging. Consultation across a higher education setting can be a useful process in illuminating and supporting engagement and participation from different groups within a university.

The need to forge partnerships internally can often be overlooked, particularly when there is a strong drive to be outward facing and to engage with a range of sectors, organisations and businesses. However, a commitment to gain widespread ownership of joined-up health and sustainable development agendas, to take people with you and to mobilise for change across services and disciplines is a sound premise from which to work. As such, organised approaches will often be required in order to build good relationships and effective partnerships – bringing together faculties, schools, services and the students’ union. Many people are passionate about the environment and sustainable development – and harnessing their energy and enthusiasm can be extremely helpful. Working with and through existing alliances can be a good way forward – for example, Degrees Cooler, which is an NUS-led collaboration that promotes sustainable living on campus, using a range of approaches including peer-to-peer persuasion to engage and mobilise students and staff.

The Healthy Universities model tends to use informal networking to engage and connect people across boundaries and harness their energy, enthusiasm and resources. However, alongside this, it engages with more formal institutional structures and processes in order to ensure alignment with strategic planning and organisational change.

Alongside internal partnership building, it is important that HEIs remain active and influential players within wider strategic and operational partnerships at local, sub-national and national levels – engaging and working in collaboration with external public, private, voluntary and community sector partners. This in turn highlights the importance of aligning their institutional commitment to integrated action for health and sustainable development with sustainable community strategies and other multi-sectoral initiatives.

A commitment to integrating health and sustainable development within higher education settings requires time, energy, commitment and skills. Effective leadership will prioritise consultative and participative approaches and take time to build effective partnerships. Whilst the scale of the health and sustainability challenges facing our society and our planet point to the need for whole system transformational change, smaller-scale projects are often an important means of engaging people, stimulating ideas and action, and developing tools for dealing with uncertainty and building alliances.

Useful links:

Degrees Cooler

Evaluation and Impact

Evaluation is a key dimension of a Healthy Universities approach, helping to build evidence of effectiveness and develop understanding of what works and why. It is widely acknowledged that evaluation should be pluralistic, incorporating a focus on both process and impact, and action-focused, informing future policy and planning and contributing to the sharing of good practice (for further information, see the Evaluation Section of the main website).

Whilst it is relatively straightforward to evaluate individual interventions and activities, it is much more challenging to evaluate the effectiveness and added value of a whole system approach. This is partly due to the availability of funding and to how the public health ‘evidence system’ is constructed, but it is also because it is much easier to focus on relatively small-scale projects and apply linear thinking than it is to engage with complexity and map and understand interrelationships, interactions and synergies (Dooris, 2005).

With regard to sustainable development, a key initiative that supports HEIs in assessing the impact of their work is Universities that Count, which is co-ordinated by the Environmental Association for Universities and Colleges, Business in the Community (BITC), CSR Consultancy Ltd and the University of Gloucestershire. Drawing on BITC’s Corporate Responsibility Index and Environment Index, it provides a common benchmarking platform for HEIs, allowing them to measure and compare their environmental and social impact.

Resources

Health and Sustainable Development PowerPoint Presentation

References

Acheson, D. (1988) Committee of Inquiry into the Future Development of the Public Health Function. London: HMSO.

Barton, H. and Grant, M. (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Health 126: 6252–61.

Butland B, Jebb S, Kopelman P et al (2007) Tackling Obesity: Future Choices – Project Report. London: Department of Innovation, Universities and Skills.

Dooris, M. (2005) Healthy settings: challenges to generating evidence of effectiveness. Health Promotion International 21: 55–65.

Dooris, M., Poland, B., Kolbe, L. et al. Healthy settings: building evidence for the effectiveness of whole system health promotion – challenges and future directions. In: McQueen, D. and Jones, C. (eds). Global Perspectives on Health Promotion Effectiveness. New York: Springer Science and Business Media, 2007.

The Environmental Association for Universities and Colleges (EUAC) (2009).  EAUC Insight 4:  Carbon Reduction Commitment.  Downloaded from: www.eauc.org.uk/file_uploads/insight_4.pdf

Griffiths, J. and Stewart, L. (2008) Sustaining a Healthy Future. London: Faculty of Public Health. [Internet accessed on 13 August 2014]

Griffiths, J., Rao, M., Adshead, F. and Thorpe A. (eds) (2009) The Health Practitioner’s Guide to Climate Change. Diagnosis and Cure. London: Earthscan.

Hancock, T. (1996) Planning and creating healthy and sustainable citied: The challenge for the 21st century. In: Price, C. and Tsouros, A. (Eds.) Our Cities, Our Future: Policies and Action Plans for Health and Sustainable Development. Copenhagen: WHO Regional Office for Europe.

Higher Education Funding Council for England (HEFCE) (2008) Sustainable Development in Higher Education: 2008 Update to Strategic Statement and Action Plan. Bristol: HEFCE.  [Internet accessed on 13 August 2014]

H.M. Government (2005) Securing the Future: Delivering UK Sustainable Development Strategy. London: TSO.

Intergovernmental Panel on Climate Change (IPCC) (2001) Synthesis Report, Third Assessment Report. Cambridge: Cambridge University Press.

Intergovernmental Panel on Climate Change (IPCC) (2007) Climate Change: Assessment Report. Cambridge: Cambridge University Press.

Maller,C., Townsend, M., Pryor, A., Brown, P., St Leger,L. (2006).  Healthy nature healthy people: ‘contact with nature’ as an upstream health promotion intervention for populations.  Health Promotion International: 21, 1, 45-54

Marmot, M. (2009) Strategic Review of Health Inequalities in England Post 2010 (Marmot Review). [Internet accessed on 13 August 2014]

Orme, J. and Dooris, M. (2010) Integrating health and sustainability: the higher education sector as a timely catalyst.Health Education Research 25(3): 425-437.

Orme, J., Powell, J., Taylor, P. et al. (2007) Mapping public health. In: Orme, J., Powell, J., Taylor, P., Grey, M. (eds). Public Health for the 21st Century: New Perspectives on Policy, Participation and Practice, 2nd edn. Maidenhead: McGraw-Hill Education/Open University Press.

United Nations (1992) Rio Declaration on Environment and Development. UN: New York.

United Nations (1993) Earth Summit – Agenda 21. UN: New York.

World Commission on Environment and Development (1987) Our Common Future: The Brundtland Report. Oxford: Oxford University Press.

World Health Organization (WHO) (1986) Ottawa Charter for Health Promotion. Geneva, Switzerland: WHO. [Internet accessed on 13 August 2014]

World Health Organization (WHO) (2005) Climate and Health: Fact Sheet. Geneva, Switzerland: WHO. [Internet accessed on 13 August 2014]

World Health Organization (WHO) (2009), Mortality and Burden of Disease Attributable to Selected Major Risks.  [Internet accessed on 13 August 2014]

Useful Links

Climate Change Act, Department for Environment, Farming and Rural Affairs, 2008

Commissioning for Sustainable Development – How to Guide and Healthy Futures, NHS Sustainable Development Unit, 2010

CRC Energy Efficiency Scheme, Department of Energy and Climate Change

Good Corporate Citizen Scheme

Making the case for sustainable procurement: the NHS as a Good Corporate Citizen, NICE, 2005

Procuring the Future: Sustainable Procurement Action Plan, Department for Environment, Farming and Rural Affairs/Sustainable Procurement Task Force, 2006