> [!NOTE] Formative Assignment GHM103 > *The following is my Formative Assignment of GHM103 Environmental Change and Global Health Policy*. I chose the question/topic area of: How can setting health as a political priority help to address trade-offs between the desire for economic progress and the need for environmental sustainability? Discuss with reference to examples where appropriate. Grade awarded: 4/5 # Health first: reimagining how health can converge economic development and environmental sustainability ## Introduction _“Investment in health is key to boosting wealth,”_ The Lancet editorial argued. (The Lancet, 2019) What does it mean? What does health even mean? In 1946, WHO sets a high standard of health by defining it as “a state of complete physical, me dntal and social well-being and not merely the absence of disease or infirmity.” (WHO, 1946, p.1) From this holistic definition to today’s world, where economic progress dominates, health often becomes a compromise. Investing in health means prioritizing people’s well-being to boost productivity and spur economic growth. The tension between development, where health plays a major role, and economics, which defines progress, has been ongoing for decades. Since 2000, while the causal link from wealth to health is well-known, the reverse—health driving wealth—has been debated. (Bloom and Canning, 2000) Though the dust seems to have settled between health and wealth in the global arena, dispute on diminishing return remain, as illustrated by the Preston, which suggests rising GDP does not always improve health. (Balabanova et al., 2012; Preston, 2003) The global focus is shifting. In the last decade, balancing economic progress with environmental sustainability has gained urgency, yet the health sector has been slow to enter this battle. WHO has worked to amplify health’s role in climate action, from side events at COP26 to increased recognition in COP29. WHO’s annual Special Report on Climate and Health continues to push for climate strategies that improve global health. (World Health Organization, 2024) Despite repeated appeals at conferences and high-level meetings, global governance remains stagnant, failing climate commitments, eroding planetary boundaries, and endangering human activity. The link between health and economic well-being is evident. Bloom’s 1999 study on Africa’s AIDS epidemic highlighted that 8% of African adults were HIV positive, with 56% of Sub-Saharan Africans unlikely to reach age 60, making human capital a key economic barrier. (Bloom and Canning, 2000) In Indonesia’s 2017 Kulon Progo district election, public health improvements were a decisive factor in garnering votes, demonstrating health’s immediate impact even in areas of high poverty and low economic development. (Power, 2024) Strong political will and effective delivery enabled health to drive broader goals rather than be an end in itself. When health services improve, the adage “health is wealth” holds true. One can only wonder: if health and economic well-being are interconnected, why are they still framed as a zero-sum trade-off with environmental sustainability? Can we, as in Kulon Progo, reassess the assumption that progress requires sacrifice? This essay aims to explore the interplay, correlations, and tensions, as well as how health can drive policy coherence in this pursuit. ## I. Economic growth and environmental sustainability: tension or problem? Economic progress and the pursuit of higher income dominate our screens, as they enable governments and people to afford goods, services, and better lives. It is an unspoken, widely accepted norm to expect economic progress from our leaders. Like the norm that extreme poverty is morally unacceptable, this expectation has been contested—and won. (Ottersen et al., 2014) The debate over balancing economic growth and environmental sustainability has been ongoing, gaining traction since 2012 when Oxford economist Kate Raworth introduced Doughnut Economics. This concept features two concentric rings: a social foundation and an ecological ceiling, ensuring humanity does not exceed planetary boundaries that sustain life. (Raworth, 2022, 2017) Raworth’s work highlights the importance of balancing economic growth and long-term sustainability. While the 20th century economics is all about increasing GDP, she argues that the 21st century thinking must be shifted to uphold social and ecological safe boundaries for humanity to thrive. ![[Doughnut Economy.png]] Figure 1. Doughnut economics (Raworth, 2017) The idea that human well-being depends on planetary health is well established, but transforming global governance to embrace this thinking still lacks a cohesive thread to ease tensions and align development. Historically, health has played a key role in linking economic progress with environmental well-being. For example, pneumonia was the leading cause of mortality among children under five in rural areas with energy poverty due to reliance on wood, dung, and biomass, which generate indoor air pollution. (Wilkinson et al., 2007) Framing this as a health issue enables solutions that not only reduce pollution but also increase access to clean energy, extend life expectancy, and create a healthier, more productive workforce for economic growth. Indonesia’s primary energy sources in 2022 were fossil fuels, with coal (36.4%) and oil (28.1%) leading the mix. (IEA, 2022) The rest comprised natural gas, biofuels and waste, and hydro the least utilized. It was interesting to note that the trends over time since 2000 was focused on oil and coal, with coal production up 693% from 2000 to 2020, and oil production relatively stable until coal production ramped out around the COVID-19 pandemic time and took over the number one spot. The rationale behind the decision between the 2020-2022 timeframe especially has been influenced by China's energy crisis (and restriction on Australian coal imports due to political tensions, so Indonesia became the alternative supplier. Compared to 2020, coal export from Indonesia to China in 2021 rose over 50%. (MEMR, 2022). This crisis was also exacerbated by Russia-Ukraine conflict's impact on energy supply and demand. The combination of geopolitical tensions, national policies, and alluring short-term economic gains have outweighed Indonesia’s commitment to safeguard its people from coal harmful life cycle and advancing environmental sustainability. (Epstein et al., 2011) The decision was not made in a vacuum and must be understood from a political standpoint. Governments, especially in middle- and low-income countries, seek opportunities for economic advancement. In Indonesia, captive coal power projects are allowed if they add value to natural resources, create jobs, and drive economic growth. (Resosudarmo et al., 2023) On a supranational level, international law has largely served power wielders. In the recent Israel-Palestine war, with its excessive death toll (Checci and Spiegel, 2024), a single country was powerful enough to veto a UN Security Council ceasefire resolution. The systemic destruction of Palestinian healthcare infrastructure in Gaza, with little regard for international law or human lives, reinforces the notion that global health governance is rooted in neocolonialism. In this context, it is understandable that leaders in the Global South prioritize national interests. The West capitalized on post-WWII industrialization, driving economic growth while damaging the environment through fossil fuel use. Now, it seeks to impose policies on economic progress and sustainability on others. A 30-year report on global carbon inequality (1990–2019) highlights that the bottom 50% of the world contributed only 12% of global emissions, while the top 10% emitted 48%, yet the lowest emitters suffer the worst climate impacts. (Chancel, 2022) It is unsurprising that developing countries disregard “global” goals, especially when patronized by wealthy nations. During COP29, Least Developed Countries (LDC) expressed strong disappointment, stating in their press that the failure “mocks the spirit of global solidarity,” as rich nations failed to uphold their commitments, leaving LICs victimized with no recourse. (LDC, 2024) This situation echoes Robert Dahl’s argument that power is the ability to influence outcomes, further developed by Lukes as the first face of power—and, to some extent, the second face of power—where dominant nations set the climate agenda for LDCs while manipulating it to align with their own interests. (Rushton and Williams, 2012) ## II. What does it mean to prioritize health politically? Health as a political priority extends beyond the health sector to non-health sectors like water and sanitation and should not be viewed as an auxiliary concern. Over the last decades, research has highlighted the indirect health effects of social, economic, and environmental policies, with numerous commissions exploring determinants of health. (Buse et al., n.d.; Di Cesare et al., 2013; Marmot and Bell, 2009; McKee et al., 2014; Ottersen et al., 2014) In GHM 104 Session 4 Global Health Policy responses to the NCD pandemic lecture notes, there is a statement: _global health governance in the 21st century looks very different from governance and international politics just three decades ago at the end of the Cold War_. We can catch a glimpse of how much more complex today’s global health governance compared to decades, if not, centuries ago, as argued by (Fidler, 2001) and (Kickbusch and Szabo, 2014). Some scholars even suggest that economic institutions will increasingly dictate global health governance, prioritizing market liberalization over health. (Ottersen et al., 2014; Smith and Hanefeld, 2018) A century ago, states did not contend with genetic engineering, corporate influence, inequitable medicine access, migration, or health data privacy. For some, prioritizing health means winning the technology arms race, securing onshore essential medicine production, or simply providing basic services to improve living standards—without treating biomedical advancements as public goods. Prioritizing health as political priority means integrating equity into all priorities. The “Health for All” concept, coined by WHO in 1970s, leverage health as a fundamental right and is an integral part of the national development.(Gorik Ooms and Hammonds, 2020; Whitmee et al., 2015) As noted in GHM103 Session 12 on Sustainable Development Policy, during the Rio+20 Summit (2012), WHO lobbied for co-benefit targets to measure social, environmental, and health gains from climate action. (Kickbusch and Szabo, 2014) To prevent health governance from being dominated by economic institutions, we must decouple "human" from "human resource." Every individual deserves to be treated with dignity and the highest quality of services to achieve optimal health as a fundamental right. A strong example of solidarity and fairness is Norway. It introduced decentralization in the 1960s, shifting health system responsibilities to local authorities to balance central power and reduce financial strain. (Calltorp, 1999) Despite rising healthcare costs, Norway upheld its principles. In 2016, it established clear health priority criteria—evaluating benefits, required resources, and potential lifetime health loss without intervention—while distributing responsibilities across government levels to maintain an open and fair system for all. (Ottersen et al., 2016) ## III. Health as a medium to bridge economic and environmental goals We have established clear links between health, economic progress, and environmental sustainability. This section explores how prioritizing health can align economic growth with planetary boundaries. After World War II, the U.S. experienced rapid urbanization and industrial growth, increasing automobile use and pollution, severely impacting public health and the environment. In “All Health Politics is Local”, Chowkwanyun (2022) details how community activism and local political dynamics in Los Angeles led to federal policy initiatives to combat smog and air pollution. This advocacy contributed to the creation of the California Air Resources Board (CARB), which was granted authority to set stricter emission standards than the federal level, reflecting the state's commitment to addressing its unique environmental challenges. (CARB, 2025) Three years later, in 1970, the U.S. Congress passed the Clean Air Act, granting the newly formed EPA legal authority to regulate pollution. This led to systemic changes in transportation, reducing emissions from vehicles, engines, and fuels while supporting economic growth and cleaner air for Americans. ![[Comparison of Growth Areas and Declining Emissions 1970-2023.png]] Figure 2. Comparison of Growith Areas and Declining Emissions 1970-2023 (“California Air Resources Board,” 2025, Figure 2) The Los Angeles case exemplifies prioritizing health in politics, balancing economic progress and environmental sustainability while creating a multiplier effect. In All Health Politics is Local, a supervisor noted, “The cost in injured lungs and mucous membranes is apparent on health and actual death... those factors present another side, equally, perhaps, if not greater in its financial totals, and certainly the cost in aesthetic values.” (Chowkwanyun, 2022, p. 63) The impact of air pollution extends beyond health to business climate and tourism. In January 2024, China adopted targets for 2027 and 2035 under the “Beautiful China” initiative, integrating environmental objectives into all social and economic policies—including PM2.5 reduction, with health as a key co-benefit. (Danting, 2024) This top-down approach links health, environment, and economic growth, fostering policy coherence across sectors. While extensive research exist on air pollution’s health effects, the implications of emerging economic ventures remain unclear. Instead of reinventing the wheel, we should integrate Health in All Policies (HiAP) and use health impact assessments (HIA) to inform national policies, prioritizing health considerations. As argued by (Kovats et al., 2014) in the case of fracking, HIA-generated data can guide policy and reduce health effects from such endeavor. (Lu et al., 2020) Policy could drive technological advancement that are friendly for the environment. On the contrary, technology could also be weaponized by the current capitalism structure to increase efficiency in industrial production but producing pollutants and waste products. Therefore, Health inequity stems not only from technical limitations but also from issues of fairness and justice. Thus, health impact must be assessed across the entire economic lifecycle—from pollution and waste disposal to long-term emissions. (Hutchinson and Kovats, 2016; Kovats et al., 2014; Ottersen et al., 2014) ## IV. Conclusion While there is no one size fits all approach in global health, understanding health co-benefits and trade-offs between economic progress and environmental sustainability can drive policy reform. I propose four key recommendations: First, dismantle neocolonial mindsets in global health. Understanding global, national, and local health politics and power dynamics is not an act of resistance but a necessity for engagement. Economic institutions increasingly dictate health governance, prioritizing market liberalization over public well-being. If health remains subordinate to economic interests, inequality will deepen, and global health efforts will be dictated by power rather than need. Second, adopt alternative growth measures beyond GDP. Investing in health means prioritizing people over profit. Health in All Policies (HiAP) should be expanded, and Human Development Index (HDI) should be treated as a national strategy, on par with GDP. However, this shift requires resisting the dominance of profit-driven economic institutions that view health as a commodity rather than a right. Third, increase access to clean energy through innovation. Investing in clean technology reduces pollution, improves health outcomes, and fosters economic growth. However, technological advancements must be regulated to prevent their exploitation under the current capitalist model, where efficiency and profit often come at the expense of public health. The system must prioritize technological solutions that reduce health inequities rather than deepen them. Fourth, use health impact assessments (HIA) to guide policymaking. Industrial policies must consider health implications at every stage of the economic lifecycle—from resource extraction to waste disposal. Without this, economic growth will continue to come at the expense of public health. If health remains an afterthought rather than a primary factor, industries will exploit environmental resources, leading to long-term public health crises. Los Angeles’ air pollution policies, Norway’s equitable health system, China’s top-down environmental strategy, and WHO’s Health in All Policies framework all demonstrate that a win-win-win approach is possible when health is central to policy decisions. Let us not forget COVID-19 pandemic easily, that a health catastrophe could wreak a havoc to the global system of governance, enormous economic impact and setback years, even decades, of development work. The lesson is clear: neglecting health risks leads to economic collapse. Future policies must internalize this lesson, ensuring health is prioritized in political and economic decision-making, rather than treated as an afterthought. ## References Balabanova, D., McKee, M., Mills, A., 2012. Good Health at Low Cost’: 25 years on. What makes a successful health system? London School of Hygiene and Tropical Medicine. Bloom, D.E., Canning, D., 2000. The Health and Wealth of Nations. Science 287, 1207–1209. https://doi.org/10.1126/science.287.5456.1207 Buse, K., Mays, N., Colombini, M., Fraser, A., Khan, M.S., Walls, H., n.d. Health Policy Chapter 1 Frameworks.pdf, in: Making Health Policy. McGraw-Hill UK Higher Ed. Calltorp, J., 1999. 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