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  • Writer's pictureElena Bouldin

Public Health and the Environment

August 21, 2021

A conversation with Dr. K. Srinath Reddy, President of the Public Health Foundation of India.

Elena Bouldin: You're a most accomplished doctor with a global perspective on health issues, and I'm sure you have plenty of important things to do. So I'm very honored that you accepted to take the time to speak with me today.

Dr. Srinath Reddy: Anybody interested in doing good for the world by protecting the environment, and particularly a young person who's committed time and energy for that, I will always be happy to assist.

Elena Bouldin: Thank you. It really means a lot to hear that, to have the support of people like you. Let's begin: You're the President of the Public Health Foundation of India. Could you explain what this foundation does?

Dr. Srinath Reddy: Given the fact that public health has been a much neglected area within health systems, but also in terms of training public health professionals in India, we believed that it was necessary to start institutions that could offer multidisciplinary education in public health, which could then become multi sectorial implementation programs for changing the various determinants of health, benefitting in this manner the health of populations as well as individuals.

Let me explain that a little more. India has never really invested in public health training institutions. It believed that all public health, if at all, would be taught at medical colleges, and there, it was only doctors teaching about how to manage some elements of general health care and some elements of what was called community medicine. But the broader elements of public health, like epidemiology, health economics, behavioral and social sciences, management sciences, even quantitative sciences like biostatistics and demography, were never really taught in great detail. As such, there was a deficiency of well-trained people able to decide how the various determinants of health could be addressed by way of research, as well as by way of programs.

There are multiple determinants of health. It is not only the biological determinants of health which actually determine whether a person gets sick or not. We fully realize that there are a number of social determinants, like education or housing, but also income levels, the health literacy levels that come with education or directly through other channels of communication and access to those communication channels, for example, digital access.

Dr. Srinath Reddy: Also, we recognize that housing, transportation, and air pollution levels in urban design and transport, all of these matter. Water and sanitation matters. Income levels matter. Poverty matters. And any vulnerability in terms of discrimination also matters. So all of these have an impact on health and on environmental influences on health.

Climate change and air pollution have a tremendous amount of impact on health. We also see the commercial determinants of health influencing what we eat and how we behave. Whether we are going to be smoking tobacco, or vaping, or whether we are eating highly processed foods, all of those are also driven by commercial forces. Even agricultural systems are determined by commercial forces. All of these inevitably impact on health.

Unless we bring all these streams of knowledge together to frame a good public health education and provide channels for action to influence those determinants in a positive manner, we will be failing in our duty. So we must ensure that all of these determinants enable, and not erode, the health of individuals.

But it's not just the health of individuals that we must look at. We must identify the factors that affect the population groups as a whole, and ultimately impact upon individual health. This is where public health comes in. We started several Institutes of Public Health in order to bring that kind of broad public health education, but also with a strong health systems connectivity while also trying to focus on the policies and programs in other sectors. You have to consider whether the urban transport is appropriate to reduce urban pollution levels, whether people's income disparities can be reduced, whether there's clean water and sanitation, whether there is a lot of air pollution, whether the food and agriculture systems are able to give a diverse, balanced diet... All of these things matter.

So the idea of public health is to try and bring health in all of its dimensions throughout the life course of an individual, by acting on these determinants at the broader population level, and the community level, removing the barriers that an individual might face to enjoy good health and wellbeing across his or her life course.

Elena Bouldin: Yes, as I've heard you say before, "health is the best summative indicator of sustainable and equitable development."

Dr. Srinath Reddy: Absolutely. I stand by it. If you can actually get most of these determinants aligned with health, and measure health and well-being, then you can gage whether you succeeded overall in your SDG [Sustainable Development Goals] agenda.

Elena Bouldin: Right. Now, you're a member of the Leadership Council of the Sustainable Development Solutions Network, which assists the United Nations in advancing the Sustainable Development Goals. Could you speak about how exactly this Council assists the United Nations?

Dr. Srinath Reddy: The UN Sustainable Development Goals were framed and adopted in 2015, but a lot of preparatory work went into that. The U.N. Sustainable Development Solutions Network was set up about three years prior to that, in order to assist the United Nations in framing some of those goals. Of course, those goals will have to be ultimately debated in draft form and adopted by the government of each country. But in order to make the drafts, to put in the right elements into those goals, the UN Sustainable Development Solutions Network started working with the office of the Secretary General in the United Nations, who brought in a large number of independent experts from all over the world. The project was coordinated from the Earth Institute in Columbia University by Professor Jeffrey Sachs. But there were people from all over the world who were brought in essentially to contribute ideas.

Twelve thematic streams were set up to provide focused attention to certain areas, such as biodiversity, water security, climate change, education, or health. I am in the health thematic group. Each thematic group, which had membership by several different countries, focused on their particular goal, and provided recommendations of action. But, collectively, all the thematic groups also considered how they connected with each other, like education and health, urban development and health, agriculture and food systems and health, or agriculture and food systems and climate change.

The 17 UN Sustainable Development Goals (SDGs) Source: United Nations

Dr. Srinath Reddy: These connections exist, but are not frequently talked about. And yet, ultimately, sustainable development needs concerted action. So that is where the UN Sustainable Development Solutions Network did the preparatory work before 2015. But after that, it has been continuing its work, it has built up a very large global network of academic institutions as well as action agents, trying to bring in the best of knowledge synthesis, even as we advance towards the implementation of the Sustainable Development Goals.

So how can we do things better? How do we monitor and evaluate the progress? Where do we actually suggest course corrections, and where does technical knowledge need to be continually gathered and passed on to policymakers? How do we do that in an efficient manner, so that the policymakers get a clear message? Those are the kinds of things that we do, essentially bringing in a good deal of evidence into the process of governance where countries are now looking at implementation of the Sustainable Development Goals.

Elena Bouldin: This kind of ties into a question I was going to ask you later, but you've touched on it a little bit. I was going to ask you: as a doctor, what do you think is the role of policy on health?

Dr. Srinath Reddy: Policy is absolutely critical because, as I said, the multiple determinants are there, which need to be influenced. We tackle these determinants at three different levels. One is the level of policy. The second, the level of community action. And the third, the level of individual action. Policy is not directed at individual X, Y or Z, but, because it has a profound impact on the beliefs, the behaviors and the ability of people to address their own goals in life, policies will have a far-reaching effect.

If, as a doctor, I provide health care only to one individual, I'm benefiting that person. On the other hand, if I impose taxes on tobacco, if I regulate that unhealthy, ultra-processed foods should not be sold, or should have food labeling so that consumers know how to avoid unhealthy foods, or if I impose seat belts or helmets, these are all policy measures that are protecting public health. They were not meant for an individual A, B or C, but they benefited millions of people across the world.

But the additional advantage of policy is that it has intergenerational benefits. It is not only protecting and promoting the health of the current generation. Suppose we set up a tobacco-free society where people are not smoking anywhere and particularly not in public places. Suppose we reduce the air pollution levels by our policies. Suppose we slow down climate change. Suppose we frame food and agricultural policy so that we'll get healthy, nutritious food at affordable rates for everybody through crop diversity and dietary diversity. It's not only the current generation that's benefiting, but also future generations.

Source: Accuform

Dr. Srinath Reddy: You build cities which are good for urban transport, with protected pedestrian pathways and cycling lanes. You're protecting the future generation as well. So policy has those intergenerational benefits. Lastly, if you actually impose taxes on tobacco products, on unhealthy food products, on large luxury vehicles which emit a lot of toxic gases, then you are actually collecting money which can be used not only to educate people about how to promote their health, but you may also be able to spend it on health care. For example, some countries have taxed tobacco more, and use the extra earnings to support universal health coverage. So policy has a tremendous impact.

You can use policy even to promote good habits. For example, if you use subsidies for food crops and you reduce the price of healthy food products, then you can actually encourage people, by the pricing mechanism, to choose them, you can make the healthier option the easier option. Policy has tremendous reach.

Elena Bouldin: I completely agree. At the same time, the problem with policy is how difficult it is to implement it. It's hard to get people to accept new policies, especially around public health and the environment.

Dr. Srinath Reddy: Well, it's true that policy should never be automatically imposed from above. There is a bidirectional relationship between policy and public opinion. Policy will be difficult to initiate without public support. It'll be difficult to implement. There will always be people who will oppose it, but if the majority supports it, then it will work.

At the same time, you need policies to make it easier for people, to enable them. Suppose we did not have a rule banning smoking in public places because secondhand smoke hurts others, including children. If the policy was not introduced, then I as a non smoker would not have the right to tell a smoker not to smoke in my presence. Policy gives me the entitlement to law. At the same time, if policy actually reduces the prices of healthy agricultural products, then it makes it easier for me to go and buy fresh vegetables and fruit. Therefore, you will require a bidirectional relationship, you'll need public support, to initiate and implement effectively good policies. But ,at the same time, you need the policy nudge in order to change people's behavior and people's thinking. So we need to move in both directions.

Elena Bouldin: Right. I live in California, and here the extended droughts have been causing an increase in fires in the last few years, with the consequent high levels of smoke in the air at certain times of the year. You live in India, where outdoor air pollution has gone up over 115% since 1990. Of the world's 50 most polluted cities, 35 are in India, and one in every five deaths in the country are attributed to air pollution. That's data from 2019. It seems clear that reducing air pollution would save human lives and obviously also improve the health of our planet and its biodiversity, but what diseases, apart from obvious respiratory diseases, are directly attributable to air pollution?

Air pollution in New Delhi Source: The Guardian

Dr. Srinath Reddy: Yes, air pollution in India is very high. But there are two main forms of air pollution. Most of the world talks about outdoor air pollution, or ambient air pollution, which is a major problem in India, no doubt, but we also have a huge problem with indoor air pollution because a lot of poor families, in rural as well as urban areas, burn biomass fuels for cooking. And that creates a lot of smoke. Part of the solution for indoor air pollution has been to provide cooking gas to poor families so that they switch from biomass fuels to cooking gas. But that is not universal yet, for cooking gas can be costly. We need to implement this change more widely.

Outdoor air pollution has been a huge challenge as well. Now there is an attempt to reduce it by tackling its multiple sources, which are, of course, industrial air pollution, which burns a lot of carbon, dust from construction work sites, vehicular emissions, particularly in high-density urban populations, and noxious gases from garbage burning sites.

But you asked me about the health effects of air pollution. Basically, air pollution, depending on whether it is PM 2.5 or PM 10, has different ways of penetrating the body and causing different types of damage. But ultimately, it causes a huge amount of inflammation in the body. It actually stimulates the body to fight those particles, and, in that process, the inflammation damages multiple areas of the body.

The lungs are, of course, affected. They can suffer from bronchitis, emphysema, or asthma. But it's not just the lungs. In fact, air pollution kills more people due to its effects on the cardiovascular system, for it causes heart attacks, strokes, and blood vessel disease. As I said, air pollution is a source of great inflammation. It has now been found that it also increases the risk of diabetes, the risk of cancers, even the risk of dementia, of having a stillbirth or a small-size baby, because pollutants can cross the placenta. It even causes cataracts. In fact, many of the conditions that are associated with smoking are also associated with air pollution. So air pollution can be extremely damaging. And that's why we believe that we must control both outdoor and indoor air pollution.

Elena Bouldin: You mentioned the transition to other kinds of fuels, especially in the homes, and maybe better ventilation. Is there anything, at a broader scale, that you think is already being done to address the problem?

Dr. Srinath Reddy: Well, we have to reduce our carbon consumption, there's no doubt about it. But there are a number of other sources of air pollution that we must look at, particularly in highly urbanized societies, with high population density. We have to ensure that public transport systems are built so that many people do not need to use cars for commuting. Using public transport is not only better for the planet, it is better for our health too, because, if you are taking a subway, you walk to the subway and then walk from the subway to your office or school, so your level of physical activity increases.

And that brings in the question of urban design. For example, rather than doing a lot of construction in some place at the same time and creating a huge amount of dust, the construction can be spread out. Ventilation becomes a very important area, too. The pandemic has showed us how important ventilation is to prevent Covid transmission.

Dust particles from construction pollute the air Source: Deccan Herald

Elena Bouldin: Since you mentioned Covid, do you think that more Covid-19 type diseases will be appearing if we do not act to reduce deforestation and change our agricultural practices to mitigate climate change on all fronts?

Dr. Srinath Reddy: Absolutely. That danger is very much there. In the past 60 years, about two thirds of all new infections that appeared anywhere in the world were zoonotic, that is, transmitted from animals to humans. That's not because suddenly animals have become malevolent to human beings and have started conspiring against us. It is because we have built the conveyor belts for transporting previously confined microbes and their vectors from the forests into a veterinary population around us.

We create these conveyor belts when we undertake deforestation for mining, for agriculture, for urban growth. We also create them with our large scale livestock breeding, because we deforest for grain feeding the animals. And we do factory farming and industrial-scale meat production, which means that animals are crowded together. With these practices, we are allowing viruses to multiply and mutate pretty fast, and then actually spread to others as well.

So in that sense, we have been ecologically irresponsible and that is the reason why we are seeing many microbial diseases coming in as zoonotic infections. And this will remain, as long as we do not restore the ecological balance, respect biodiversity, and respect the balance that nature has given us by way of ensuring that there is not too much dependance on animal foods.

Elena Bouldin: How does global warming directly affect human health?

Dr. Srinath Reddy: Every one degree rise in temperature, there'll be a 10 percent reduction in the production of staples in South Asia and sub-Saharan Africa, because already we are producing staples, like rice and wheat, almost at the highest level of temperature tolerance. And if there is further rising in heat, the production will go down quantitatively, but qualitatively, too. You will find that the protein content will diminish, the zinc content will diminish, the iron content will diminish. Partly because of water stress, partly because of heat stress. Even air pollution can reduce the nutrient level of crops. So all of this combined together will increase nutritional deficiencies in people by a lot across the world.

Just as the demand for food will rise because of increasing population, increasing urbanization, some reduction in poverty levels across the world, and aging populations, you will find that the availability of food will go down per capita, and you'll have food and nutrition insecurity, with the corresponding impact on health. Plus, with global warming, you're going to see a lot of vector-borne diseases that mosquitoes will breed, such as malaria, chikungunya, or dengue. All of these will spread. As human beings lay listless in the heat, the mosquitoes will become athletic and start climbing up to higher altitudes. So they'll spread faster and farther.

Source: CDC

Dr. Srinath Reddy: The extreme climatic events resulting from global warming will hurt people by causing floods and forest fires too. With floods, water will get contaminated, and water-borne diseases like cholera, typhoid, and so on will spread. Then, you will have direct-heat effects: you'll have people suffering from heat exhaustion, then you'll have people suffering from heat stroke and probably dying because of a complete collapse of the circulation. You'll also have other chronic diseases coming up, because blood pressure goes up with air pollution as well as heat, and you can get heart attacks and strokes, you can have cancers as well. But there is also a mental health effect, which many people do not know. It has been shown that both intra-group conflict and intergroup conflict increase. People not only feel the heat on their bodies, but they also feel it under their collar, in the sense that they get very angry and then they become very quarrelsome.

All of these are side effects that we must expect if we're going to be looking at what the impact of climate change is going to be on human health.

Elena Bouldin: Yes, it's all connected. We destabilize the climate, the balance of nature, and then that obviously affects us, but it also affects the Earth's biodiversity.

Dr. Srinath Reddy: So that's why I say that the lifeline of human health stretches from the pulse to the planet, from the individual, to the entire planet. We are all connected, including the biodiversity.

Elena Bouldin: Yes! Moving on to a different topic now. In one of the talks of yours I heard, you menitoned how the Health and Environmental Leadership Platform in India, with over 6,000 member hospitals aims to transform hospitals into green hospitals. Could you explain what a green hospital is, and why we need green hospitals?

Dr. Srinath Reddy: Outside the health sector, and often inside of it too, people think that hospitals are wonderful places where people get better if they are very sick and go there. But hospitals can also contribute substantially to air pollution and climate change. Because of multiple reasons, they actually have a fair amount of greenhouse gas emissions. In fact, in the United States, 10% of the greenhouse gas emissions come from hospitals.

Hospitals use anesthetic agents, volatile gases that are very similar to chlorofluorocarbons, which can hurt the ozone layer. They also use a lot of disposable equipment, and they do not always follow green procurement processes. We often don't know how equipment has been produced, or what its effects on the environment are. To summarize, hospitals should not hurt the environment, and they should consider what to do to protect it.

Also, doctors are trusted communicators with society. They are people whose voices others listen to. If doctors say "look, we must try and do this to avoid severe climate change and global warming because these are the health consequences and we as doctors are very aware of it", then people will listen and try to change some of those things. If some atmospheric scientists and politicians say that global warming is going to kill x number of people, it would not make much of an impact. However, if your doctor tells you, "look, you better do something about reducing carbon emissions. Don't use your car, because ultimately this is going to make people extremely sick." Then, people are more likely to listen.

Doctors can play a very important role in starting to reduce climate change, using their influence on their patients, and making sure hospitals reduce emissions and wasteful use, and do a green procurement.

Elena Bouldin: So, what exactly does the Health and Environment Leadership Platform do?

Source: Twitter

Dr. Srinath Reddy: We set up the Health and Environment Leadership Platform to bring together people who are running hospitals across India. And we said, "look, as doctors you are to be concerned about the impact of climate change and air pollution. These are the various health effects. Did you not know these effects?".

They just thought it's going to get hotter, that's all. So we had to explain to them all of the health effects, including the effect on food and agricultural systems, on strokes and heart attacks, and on so many other things that matter to them. We helped them understand that, if we don't control climate change, all kinds of sick people would be flooding hospitals. We explained that they have a role to play, and that they can start by becoming a good example themselves and reducing climate change aggravating factors in their hospitals.

And they listened. And then we said, "you also educate people, educate policymakers, join the coalition of those who want to slow down climate change". So that brought about a behavior change in them. They started adopting green procurement practices. Then they started putting air quality monitors on top of their hospitals to monitor air quality. And they started bringing about other changes as well. Laundry, for example. Washing sheets and clothes can be made pretty energy efficient and can use much less water. So there are a number of things that people don't think of, which can actually be altered to protect the environment.

Elena Bouldin: I'm very glad to hear that. Now, as it is, hospitals today use a lot of single-use, disposable equipment. And they also generate a lot of hazardous waste. What do you think is the best way to transition to a greener practice of medicine when basically our whole health system relies on that type of equipment?

Dr. Srinath Reddy: Well, firstly, we must improve our primary healthcare system, improve conditions so that people don't get sick. But if they do get sick, let it be recognized early and treated well in the smaller primary health care area, rather than building a huge number of large hospitals to take care of people whose health care needs were neglected in the first place.

If you actually build a very efficient health system where 90 percent of the problems are taken care of at the primary care level, not at the second level, you don't need huge hospitals, you reduce the amount of disease, as well as the amount of equipment and energy usage. The second thing is recognizing that you still need some big hospitals, but making them as energy efficient as possible in their tasks.

Let's take one more simple example. If people don't get very sick, or if people who get sick are detected very early and treated in primary care, closer to home, they don't have to commute long distances to hospitals. If they can do their blood pressure monitoring and blood sugar monitoring at home, they don't have to go to some hospital to get their checkup done. There are a number of things that we can do to improve the efficiency of our health care by bringing it to home or closer to home.

So the first thing is to prevent disease. The second, is to detect it early and treat it before it gets aggravated. And the third, if people need advanced care, is to make it as energy efficient as possible and to not do unnecessary tests. Do you know how much electricity an MRI machine requires? Each time a doctor orders an unnecessary test, they're also contributing to climate change by wasting energy.

Elena Bouldin: I don't think most people realize all this when they think of climate change. I imagine it's very hard to change the way we do things as we're seeing throughout our whole society, but we can do it if we come together and think about what we need to address to have a greener system.

I want to thank you again for being here and for talking with me for so long. I feel privileged, and honored.

Dr. Srinath Reddy: I'm very happy you've taken so much interest in pursuing something that is of vital importance to all of humanity. If there's any way that we can assist you from India, let me know. And keep me posted about your work. It's of great interest to all of us.

Elena Bouldin: Thank you so much. I will keep you posted.

Dr. Srinath Reddy: Keep the world safe.

Elena Bouldin: We will try. We will try to make sure there's a future.

Dr. Srinath Reddy: Yes, yes. There's a lovely quote from Toni Morrison which says, "If we do not create the future, the present will extend itself."


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