# Review sessions ## Review Session 1-4 Building Blocks WHO definition of health opened up dimension beyond good healthcare, but also situation that shapes health status, such as social, cultural, economic, and environment circumstances. Researchers complement each other in defining environment, for example, Frum (2005) defined it as all external, non-genetic factors while Pruss-Ustun and Corvalan (2006) extended it further that environment exclude those natural environments that cannot be reasonably modified. Meanwhile, WHO defined environmental health comprises those aspects of human health, including quality of life, that are determined by external factors (non genetic) that are in the environment. Moreover, it also refers to theory and practice of assessing, correcting, controlling and preventing these factors in the environment that can potentially affect adversely the health of present and future generations. Hazard is a source of danger while risk the probability that an event will occur, e.g., that an individual will become ill or die within a stated period of time. As economies develop, health hazard change as well. With population demographic and epidemiological transition. From traditional hazards that are dominated by factors related to infectious disease, to a modern hazards related to urbanization and industrialization, such as inadequate housing and poor water quality and drinking water and sanitations, transport hazards, pollutions from industry, climate change, unbalanced diet due to unchecked trade. Health inequalities is differences in health experience and health status between countries, regions, and socioeconomic groups, while health inequities are avoidable ("unfair") inequalities, which relate to lack of equity in opportunity, access, use, provision or outcome of healthcare as well as unfair differences in health status arising from inequalities. Paradigms of environment and health has changed throughout time. From occupational and environmental health in mid-19th CE that were focused on health impacts of environmental and occupational hazards, to planetary health in 21st century shifted the approach to understanding and living within planetary/ecologial limits under which modern civilization can flourish. Due to our new understanding of planetary health, the [[Sustainable Development Goals (SDGs)]] was developed, aligned with the idea from Alan Thomas in "Meanings and Views of Development" that development is deliberate efforts and actions from multiple actors. Sustainable Development popularized the term "health co-benefits" to put health at the centre of social, environment, and economic goals. The SDGs were able to streamline and give voice to health in other sectors' strategic planning and policymaking. For example, the detrimental effect of fossil fuel pollution to health can be weaved by health actors to promote health benefits of retiring coal plants from improved air quality, shifting to renewable energy may also avoid children deaths from pneumonia if houses are using clean energy, health co-benefits of active transport to prevent deaths linked to physical inactivity while reducing CO2 emission at the same time. The WHO has narrowed down three major risk factors (tobacco use, poor diet, and physical inactivity) that contributed to four major chronic diseases (coronary heart disease, type 2 diabetes, lung disease, and cancers) ## Review Session 5-9 Building Blocks: case studies of environmental quality and health (5-8) and policy challenges and responses (9) [[GHM103 Session 05 Energy and health]] Based on the International Energy Agency statistics (IEA, 2021), approximately 70% of global energy supply in 1973 were sourced from oil. Despite exponential growth of energy demand, in 2023, where the energy source share has shifted, oil and coal still contributed more than a half of global energy demand. There are three ways energy influences human health: 1. The amount of energy available to use: energy per capita is correlated with better health up until a point. 2. Type of fuel that is used: renewables tend to be cleaner than fossil fuels and biofuels 3. Where the fuel is burned compared to where people live/work: separating production and consumption reduces exposure ![[@wilkinsonGlobalPerspectiveEnergy2007#Conclusion]] ### Fossil fuel - [[@epsteinFullCostAccounting2011]] Fossil fuels are natural resources like coal, oil, and natural gas, formed from ancient plant and animal remains over millions of years. It has been used as the primary energy source since the industrial revolution. Despite propelling the economic growth through trade, transportation, and overall human activity, the usage is not without its negative consequences. Fossil fuel exposure differs from other type of energy sources, such as hydroelectric and biofuel and renewables. Fossil fuel produces high air pollution, which majorly contributes to anthropogenic climate change. Epstein et al. (2011) estimated that the life cycle effects of coal, from extraction, transport, processiong, combustion, and the waste stream generated are costing the U.S. public a third to over one-half of a trillion dollars annually. In Indonesia, the primary energy sources are coal (36.4%) and oil (28.1%) in 2022. The rest are followed by natural gas, biofuels and waste, and a tiny bit of hydro. The trends over time focused on oil and coal, with oil production relatively stable until coal production ramped out around the COVID-19 pandemic time and took over the number one spot. The renewable energy sources were relatively small, only 10%. In 2022, geothermal, solar, wind slowly increased over the years and approaching natural gas's energy supply. The condition happened because Indonesia's coal mines are vast, and thus, one of the world's largest coal producers and exporters. It's low-cost production makes it competitive in the global market. Moreover, coal industry are owned by politicians. The 2020-2022 timeframe especially has been influenced by China's energy crisis (shortages) and restriction on Australian coal imports due to political tensions, so Indonesia became the alternative supplier. This crisis was also exacerbated by Russia-Ukraine conflict's impact on energy supply and demand. In short, it's a combination of political, economic, and geographical factors. Global shift to renewable energy will benefit the global community. However, despite clear benefit to health and the climate, it is not a straightforward decision. For example, In 2023, Indonesia's enery transition began to gain momentum by launching Just Energy Transition Program (JETP), with the co-leadership of US and Japan, to phase out coal power plants, along with other coal-reliant economies such as South Africa and Vietnam. However, US withdraw its leadership in 2025 to focus on coal power projects abroad. These changes then would incentivize Indonesia to keep producing and depend on fossil fuel, deterioriate health, worsen climate change only for a short-term economic gain, such as seen during the 2020-2022 timeframe. Beware of [[Energy poverty]]. Take into account energy policy. Energy sustainability and efficiency has become an agreed goal in SDG number 7, to ensure access to affordable, reliable, sustainable, and modern energy for all by 2030. [[GHM103 Session 06 Outdoor air pollution, road transport and health]] [[GHM103 Session 07 The urban environment and health]] [[GHM103 Session 08 Biodiversity, Ecosystem Services and Human Health]] [[GHM103 Session 09 Climate change and global response]] # Past exams ## Q1. Outline TWO climate change mitigation opportunities, their possible health benefits, and implications for sustainable development. Select ONE of these opportunities and evaluate the benefits and challenges for health and sustainable development in ONE country of your choice. ### Commentary Students were expected to define ‘climate change mitigation’ and ‘sustainable development’. Climate change mitigation opportunities include active transportation, energy efficient and sustainable building stock, dietary changes, and switching from non-renewable energy sources (e.g. coal) to renewable energy sources (e.g. solar). Answers should also include possible health benefits and implications for sustainable development arising out of these climate change mitigation opportunities and for one of these opportunities, discuss benefits and shortcomings for health and sustainable development, in the context of one country of your choice. For higher grades, students were expected to explain how the chosen opportunity could contribute to the mitigation of global climate change, and then illustrate their answer with references to any scientific estimates. Essays could also focus on a discussion of disaster management in the case of L/MIC, which may have an increase vulnerability to natural disasters.  Discussion on the chosen climate change mitigation opportunity can cover health benefits of the chosen mitigation opportunity for current and future generations, referring to health impacts of climate change and short-term co-benefits of mitigation actions as well as any scientific estimates on the potential magnitude of these benefits in the country of choice; potential benefits of the chosen opportunity for sustainable development, making reference to inter-generational and intra-generational equity and to the relevant SDGs; any potential negative consequences of the chosen climate change mitigation opportunity for health and sustainability; any synergies and tensions between positive health and sustainability outcomes and consider the effectiveness or feasibility of applying the chosen mitigation opportunity in practice. ### Practice ## Q2. Describe how the environmental effects of the transport sector impact human health in urban settings. Critically discuss TWO transport and urban planning strategies that could be implemented to promote health and involve sustainable transport solutions. Illustrate your argument with relevant examples. ### Commentary The question intended to evaluate students’ critical knowledge of the main health consequences of the transport sector. Students were expected to define the key concepts as outlined below and to describe transport sector and urban planning’s consequences for health. Finally, the question aimed to evaluate students’ knowledge of relevant policies/strategies to improve health and sustainable transport, drawing on relevant examples were possible. Students were expected to demonstrate understanding by describing the role of the transport sector in promoting adverse health and environmental outcomes, and to use examples to illustrate this description, including transport-related pollution, noise and vibration can pose serious threats to human health and wellbeing; air pollution caused by fossil fuel powered transport can cause cardiovascular/pulmonary and respiratory disease, as well as contributing negatively to climate change; exposure to lead can cause increased blood pressure, liver and kidney damage, impaired fertility, comas, convulsions, and death. Occupational health issues includes a focus on jobs where exposure to benzenes can have an increased risk of hematologic diseases and cancers. Traffic jams/congestion and thus slower mobility along roads, as well as increased air pollution (e.g. lead, CO, pm 2.5, nitrogen oxide), and environmental consequences (e.g. contaminates water and soils, contributes to climate change). The construction and expansion of roads and railways at the expense of green spaces can reduce active mobility and create obesogenic environments. Transport (such as cars, lorries and other large vehicles) can contribute to adverse mental health, including from noise pollution. Benefits and drawbacks of TWO transport sector and urban planning strategies can include a shift in investment and urban development patterns so as to integrate land-use and transport planning to enable more localised work, production and consumption e.g. 15 minute cities; reducing accidents requires a systematic approach incorporating elements of better infrastructure, vehicle inspection, and education and enforcement of control speed and alcohol consumption; regulation of fuels and/or vehicles on the road, as well as improving vehicles and fuels to reduce urban air pollution and greenhouse gas emissions; investment in green and low carbon transport systems can reduce greenhouse gas emissions substantially without major additional investment; hybrid and electric vehicles reduce air pollution and also reduces noise pollution; improved urban mobility can help people to access social spaces and connect with each other and reduce social isolation and loneliness e.g. attempts to develop green corridors; introducing low emission zones to discourage use of personal vehicles in centre or particular parts of urban setting, so as to reduce air pollution and traffic congestion; encouraging active mobility. Although reducing motor vehicle use would decrease the injury risk for existing pedestrians and cyclists, if many more people walked and cycled there might be an increase in the number of pedestrian and cycle injuries. For higher grades, students were expected to engage with examples in greater depth and nuance, such as discussing specific examples and how they tied to questions of socioeconomic disparities and changes; lobbying by fossil fuel companies and transport companies; climate change (e.g. change in rainfall patterns or temperatures at higher altitudes) and globalisation. ### Practice ## Q3. Critically discuss the role of biodiversity in the origins, emergence, and human impacts of infectious disease outbreaks with reference to examples of specific infectious disease outbreaks. Discuss ONE biodiversity-relevant policy for controlling and preventing such outbreaks with potential global or multi-country impacts ### Commentary The question intended to evaluate students’ understanding of biodiversity and its relevance to the emergence of infectious disease outbreaks. Students were expected to define key concepts as outlined below and to describe biodiversity’s relationship to infectious diseases outbreaks. Finally, the question aimed to evaluate students’ knowledge of biodiversity relevant policy options to prevent / control infectious disease outbreaks, drawing on relevant examples were possible. For a passing grade, students were expected to define key concepts, including biodiversity and infectious disease outbreaks such as the COVID-19 (pandemic), H1N5, Ebola (epidemic), Lyme’s disease, Malaria etc. Policies for controlling/preventing infectious disease outbreaks that might have global or multi-country impacts, include prevention and control of wildlife trade, particularly for consumption via investment in conservation and human resources to monitor and stop illegal wildlife hunting and/or more control and monitoring to ensure at risk ‘wild meats’ are safe where they are legally hunted; policies to reduce deforestation and conserve at risk ecosystems, as well as incentivise reforestation and wildlife preservation; invest in alternative livelihoods to encourage people to stop commercial wildlife hunting and trade; and education of consumers and provision of alternative diets to wild meats and medicines. For higher grades, students were expected to provide more detailed definitions of key concepts, demonstrating critical thinking skills by discussing the strengths of weaknesses of particular conceptualisations, such as biodiversity – e.g. not all aspects of biodiversity are good/healthy for humans (e.g. mosquitoes as vectors for malaria and dengue or animals like bats or chimpanzees which may act as reservoirs for infectious agents). Responses could also include a discussion and definition of ecosystem services or One Health and a discussion of concepts such as zoonosis, pandemics and/or epidemics. Students were also expected to engage with examples in greater depth and nuance - this might include, discussing Ebola, Lymes disease or Malaria and how their emergence, spread and control were tied to questions of socioeconomic disparities and changes in livelihoods. Broader market demands for land and products may lead to, increased deforestation and changes in ecosystems composition (e.g.  increased water and presence of natural reservoirs), which leads to increasing human exposure to vectors and hence disease, such as malaria or schistosomiasis etc. Recognising the shortcomings of contemporary discourses on ecosystem services framing includes turning ‘nature’ into a resource that can and must be managed economically and hence capitalised on, which means questions of zoonoses might not be weighed against profits from deforestation, or challenges of biodiversity discourse; i.e. not all biodiversity is beneficial for human health, e.g. malaria parasites, coronaviruses etc. ### Practice ## Q1. Describe the sources and health effects of ONE air pollutant. Critically discuss ONE policy option that can tackle the air pollutant you have described to improve air quality. What co-benefits for health does this policy produce and does it reduce health inequities? Illustrate your argument with examples. ### Commentary The question intended to evaluate students’ knowledge of the components and sources of air pollution of public health concern, and their acute and long-term health effects. Students were expected to define the key concepts (health inequity and co-benefits) and to briefly describe their relationship to health. Finally, the question aims to evaluate students’ knowledge of policy options to address air pollution and evaluate the trade-offs between health benefits and harms in policies. For a passing grade, students were expected to describe the sources and health effects of ONE air pollutant and to select a policy to address this pollutant. Using appropriate examples, students were expected to illustrate how this approach would improve air quality, improve health outcomes and help address health inequities. Policy examples include setting ambient air quality standards or emission standards; technological controls and policies implemented through market-based and voluntary approaches. Critical analysis of their impact on health inequities and co-benefits may include that health inequities arise both through differences in exposure to environmental hazards (as a result of living conditions) and through differences in people’s ability to respond to, or protect themselves from, those hazards (because more affluent communities can pay to improve their environment, or move to a better one, whereas poorer communities are less likely to afford to do so). The stage of economic development can also have differential effects on health. For a higher grade, students were expected to deliver a more nuanced discussion touching on the need for inclusive policies that address the needs of vulnerable population groups, and show how policies can be implemented in deprived communities in order to reduce health inequities. Offer more detailed definitions of key concepts, demonstrating critical thinking skills by discussing the strengths and weaknesses of particular conceptualisations. For example, students could discuss both acute and long-term health effects of air pollutants or link broader (sectoral) policy approaches to the pollutants. ### Practice ## Q2. Effectively addressing climate change requires attending to issues of environmental justice and economic inequalities. Critically discuss the merits of this claim with reference to TWO relevant sustainable development policies. ### Commentary The question intended to evaluate knowledge of climate change and critically discusses, using examples, whether its emergence and solutions are related to social justice and economic inequalities. Students are expected to define key concepts (climate change, environmental justice and sustainable development), as well critically engage with them using examples to support their arguments. Finally, the question aims to evaluate knowledge of sustainable development policy options to address climate change and their effectiveness for jointly addressing social justice and economic inequalities. For a passing grade, students were expected to demonstrate the merits (or otherwise) of effectively addressing climate change whilst addressing issues of social justice and economic inequities. This discussion needs to be supported with references to relevant examples. Examples might include historical differences in socioeconomic ‘development’ and improvements in health outcomes; questions of colonialism, land appropriation and resource extraction and related pollution; differential health outcomes related to either the history of environmental change or present climate change. Students may provide some brief comparison / contrast of countries’ or populations’ experiences of climate change and their contributions to its drivers and provide some discussion of TWO relevant sustainable development policies. For higher grades, students were expected to offer more detailed definitions of key concepts, demonstrating critical thinking skills by discussing the strengths of weaknesses of particular conceptualisations, such as engagement with notions of power. Any potential shortcomings of sustainable development, including sustainable development with relation to economic growth, consumption and production. ### Practice ## Q3. Outline ONE example of a bottom-up local policy, project or programme focused on addressing the links between health and an environmental issue of your choice. Critically discuss how the concept of power may affect the policy, project, or programme’s development and its implementation ### Commentary The question intended to evaluate students’ critical knowledge of how local policy development and implementation for a specific health/environmental issue. Students were expected to define the key concepts, describe the particularities of how their environmental issue impacts health and provide a critical outline of a relevant local policy to address it. Finally, the question aimed to evaluate students’ knowledge of how power shaped the development and implementation of their chosen local policy, including through critical discussion of national and global actors/policies etc. For a passing grade, students were expected to define and/or accurately engage with key concepts, including stakeholders; local governance; and a bottom-up policy approach. There are many different conceptualisations of power. Students were expected to demonstrate understanding of the links between health and environmental issues, and discuss relevant local policy response(s), through the lens of a specific example. Students were expected to connect the issue to and outline an example of a bottom-up/grassroot local policy, project or programme, include discussion of power (i.e. power dynamics between different stakeholders), and some mention of relevant stakeholders and notion of local governance. These might include advocacy and social movements or attempts to solve environmental/health issues. Include some mention of local governance, with some critical discussion of these actors and power dynamics. For higher grades, students were required to provide more detailed definitions of key concepts, demonstrating critical thinking skills by discussing the strengths and weaknesses of particular conceptualisations, such as in relation to local governance and stakeholders, they might discuss the challenges of separating local, national and global stakeholders, there interconnectivity, including discussing in more detail questions of power. ### Practice ## Q1. The EAT-Lancet Commission report on healthy diets from sustainable food systems (Willett et al, 2019) describes how the planetary boundaries framework can guide a Great Food Transformation for sustainable food systems. With reference to ONE of the five strategies from the EAT-Lancet Commission critically evaluate policy implementation challenges to achieving a Great Food Transformation in accordance with the planetary boundaries framework. Illustrate your argument with examples from particular country contexts. ### Commentary In answering this question, students were expected to draw on study materials from Session 2 (Introduction to environmental public health), Session 3 (Introduction to global health policy), and Session 13 (Planetary boundaries and planetary health: The case of sustainable food systems) as well as the integrating activity in session 13. Some of the key points expected in responses include - definitions of terms such as food system, planetary boundaries framework, and Great Food Transformation. Students needed to use the EAT-Lancet Commission report to discuss how the global food system can be transformed to promote sustainable diets and sustainable food production. Students were also expected to discuss the key concepts in relation to the policy and implementation challenges related to one of the Commission’s strategies, for example contradictory policies, difficulty of achieving the radical changes, interactions and conflicts at the policy level, diverse actors and their opposing views. There were several additional points of discussion that could be included – for example, a more in-depth discussion of the chosen strategy, including challenges to monitoring and evaluation of policy changes; illustrations of how the student’s chosen strategy would lead to a ‘win-win’ scenario by producing co-benefits for health and the environment within a given country; a critical discussion to link food and the food system in relation to some of the other concepts and frameworks, such as the SDGs, the precautionary principle, planetary health, equity and the Health in All Policies framework and the planetary boundaries framework; references to other ‘successful examples of systems change’; limitations in the EAT-Lancet report. ### Practice ## Q2. Explain how changes caused by rapid urbanisation and the environment risk transition contribute to the rise of obesogenic environments. Critically discuss ONE policy option to tackle obesogenic environments to promote healthy and sustainable communities ### Commentary Students were expected to draw on materials from Session 1 (Introduction to health and the environment), Session 2 (Introduction to environmental public health), Session 7 (Urban environment and health), Session 10 (Local initiatives), and Session 11 (Global initiatives). Definitions of key terms included urbanisation, environmental risk transition, and obesogenic environments. Students were expected to put forward a clear argument explaining the how rapid urbanisation and environmental risk transition contributed to the rise of obesogenic environments - e.g., systemic/structural factors related to the four aspects of urbanisation (physical, social/cultural, psychosocial and economic), urbanisation brings economies of scale and proximity to infrastructure and services, increases in population in urban areas (esp. in LMIC) will add to environmental pressures, reducing access to open spaces and exercise opportunities, health issues that arise when risk transitions are not well managed. Students were also expected to discuss ONE policy option to tackle obesogenic environments, which could have been a transport-related policy (e.g., increasing the use of public transport, introduction of cycle lanes) or an urban/city planning policy (e.g., access to health and other services, development of initiatives promoting urban agriculture). Additional points of discussion included: - Wider discussion of food systems and food systems challenges – for example: - Increased density of fast-food outlets linked to higher prevalence of obesity - Urban agriculture initiatives and projects that can help improve access to healthy foods - Community participation in such projects is also beneficial as it improves people’s awareness of healthy eating, food production and food hygiene and affordability of fresh food - The central role of local government in implementing and supporting local and policy initiatives - Discussion of examples of additional policy options to address obesogenic environments that make a distinction between low/middle and high-income countries - In-depth discussion of other policies - The development of public policies at the local level to create physical, cultural, economic, and social environments that support good dietary and physical activity choices and strengthen community action for health - Health promotion strategies in relation to diet, food, and exercise - Provision of jobs (improve income) and education (e.g., strengthen education around food, physical activity and health at an early age; compulsory ‘home economics’ for all children etc) ### Practice ## Q3. Critically discuss the implications of energy production from fossil fuels versus renewable sources for environmental justice and human health ### Commentary Students were expected to draw on materials from Session 5 (Energy & health), Session 6 (particularly with relation to outdoor air pollution), and Sessions 9 to 12, particularly when discussing policy suggestions. Students were expected to provide accurate and detailed definitions of key terms - fossil fuels, renewable energy, and environmental justice. Students were expected to critically discuss the relationships between energy, environmental justice, and human health, which could include a discussion of the negative consequences for environments and human health for different energy sources. Students were also expected to provide relevant examples from their study materials, e.g., specific countries or companies’ pursuit of continued fossil fuel extraction (e.g. Australia and China), oil pipeline conflict with indigenous peoples in North America, fracking and its relation to environment (and human) health, renewables and their relatively better environmental and health consequences. Additional points that could be discussed for higher grades included: ·      References to key texts to support arguments for green-based energy policies, e.g., IPCC reports (e.g., 2019 report Global warming of 1.5C), UNEP 2021 Gap report, COP26 goals etc ·      An recognition that renewables may not necessarily be better in justice terms, if affected people are not involved (e.g., if a large wind- or solar-farm was built on traditional hunting grounds) ·      Original formulations or critical insights, like connecting to questions around decolonisation, racial (in)justice, as well as questioning notions of sustainable growth and proposals around degrowth (i.e., reducing energy consumption) ·      Critical reflections on the traditional development model/growth paradigm ·      Discussion of how green-based energy policies can promote social equity and sustainability which improves population health. ### Practice