Navigating fundamental tensions towards a decolonial relational vision of planetary health

Theorizing epidemiology, the stories bodies tell, and embodied truths: a status update on contending 21st c CE epidemiological theories of disease distribution

This critical review considers the status of 21st-century epidemiological theories of disease distribution, updating to 2024 prior analyses published up through 2014, and discusses the implications of these theories for research, practice, and pedagogy. Three key trends stand out: (a) the continued dominance of individualistic biomedical and lifestyle theories; (b) growth and elaboration of social epidemiological alternatives; and (c) the ongoing inattention to epidemiologic theories of disease distribution in the training of epidemiologists and public health professionals and in current efforts to improve the rigor of epidemiological research and causal inference. In a context of growing global political polarization, climate crisis, broader environmental and ecological crises, and stubbornly persistent health inequities within and between nations, producing actionable knowledge relevant to improving the people's health and advancing health justice will require much greater engagement with social epidemiologic theories of disease distribution in research, pedagogy, and practice. At issue is critically engaging with the embodied truths manifested in the stories bodies tell in population patterns of health, disease, and well-being.

Policy approaches to decarbonising the transport sector in Aotearoa New Zealand: modelling equity, population health, and health-system effects

BACKGROUND

Health co-benefits are a key potential advantage of transport decarbonisation policy. However, health effects will occur in the context of existing transport-health inequities and decarbonisation policies will themselves affect inequities. This research examines the effects of national decarbonisation pathways for transport on population health, health inequity, and health-system costs in Aotearoa New Zealand.

METHODS

We modelled the health, health-system, and environmental impacts of two pathways to net zero for transport developed by the New Zealand Climate Change Commission using a proportional multistate lifetable model. The behaviour pathway emphasises a mixed approach, including reduced driving, increased cycling and use of public transport, and light vehicle electrification, and the technology pathway focuses on vehicle electrification. We used data from transport, environmental, population health, and health-care sources to populate the model. We simulated changes in health effects through the pathways of physical activity, air pollution (PM2·5 and NO2), and injury for the Aotearoa New Zealand population from 2018 to 2050. We modelled impacts for Māori (the Indigenous People of Aotearoa) and non-Māori. For each pathway to net zero, we calculated changes in overall health-adjusted life-years (HALYs), age-standardised HALYs, and rate ratios for Māori and non-Māori. We also calculated changes in health-system costs and transport greenhouse gas emissions. 95% uncertainty intervals (95% UIs) were derived for all model outputs by use of a Monte Carlo simulation.

FINDINGS

Both pathways show improvements in population health, reductions in health-system costs, and reduced lifecycle greenhouse gas emissions compared with baseline, although health gains were substantially larger in the behaviour pathway. For example, an extra 2100 HALYs (95% UI 1500-3100) were gained in the behaviour scenario compared with baseline. Health gains were 20-30% larger for Māori than non-Māori in both pathways, although more HALYs were gained by Māori in the behaviour pathway. For the cohort aged 0-4 years in 2018, healthy life expectancy differences between Māori and non-Māori reduced by 0·5% in the behaviour pathway over their lifetime. HALYs gained by Māori and non-Māori were altered substantially depending on assumptions about the equity of the implemented pathway.

INTERPRETATION

Decarbonising transport might improve overall population health, save the health system money, and reduce health inequities between Māori and non-Māori. Pathways that increase physical activity have a larger effect on population health than those that rely on low-emission vehicles. The effects on inequity between Māori and non-Māori are larger in the behaviour pathway than in the technology pathway but dependent on how equitably policies supporting decarbonisation are implemented.

FUNDING

Health Research Council of New Zealand and University of Otago.

Advancing the deliberate implementation of the concept of sustainability and its alternatives in physical therapy research, practice, and education

BACKGROUND

Sustainability has become a ubiquitous imperative across all sectors of society, including healthcare. Building on the broader discourse on sustainable development, sustainability is used in relation to social, ecological, and economic concerns with varying degrees of emphasis and often related to a sense of durability.

OBJECTIVE

To provide a detailed analysis of the concept of sustainability in current physical therapy literature and advance its deliberate future implementation.

METHODS

Setting out from a critical exposition of prevalent models of sustainability, we conducted a critical discourse analysis to (1) examine the implementation of the concept of sustainability in physical therapy academic literature and (2) critically evaluate its hitherto use in light of the broader discourse surrounding sustainability.

RESULTS

Our analysis identified a focus on the cost-effectiveness of healthcare interventions, and the use of so-called "weak" and "strong sustainability" models in the physical therapy literature. Other models and the broader critical discourse surrounding sustainability are only gradually finding their way into physical therapy literature.

CONCLUSION

Physical therapy lacks comprehensive exploration of both general and profession-specific understandings of sustainability. Nuanced engagement with sustainability and its alternatives is necessary to ensure its meaningful implementation in physical therapy research, education, and practice.

What we do matters: Supporting anti-racism and decolonisation of public health teaching and practice through the development of Māori public health competencies

OBJECTIVE

This research sought to expand on a set of core Māori hauora ā-iwi/public health competencies initially designed for teaching and to enable their use in workplaces.

METHODS

The research used a kaupapa Māori methodology in four stages including the development of draft levels of competence for all core competencies, consultation hui (meetings), analysis of feedback and redrafting, and respondent validation.

RESULTS

Key themes elicited in relation to the content of the competencies included increasing language expectations, the importance of strength-based approaches and self-determination, and the need for individual responsibility to address structural racism. Reflective practice was identified as a fundamental cross-cutting competency. Participants suggested planetary health and political ideologies be included as additional socio-political determinants of health with equity impacts. Key concerns related to the application of the competency document included the need for cultural safety and ensuring that all public health practitioners are 'seen'.

CONCLUSIONS

The Māori hauora ā-iwi/public health competencies have been published under a Creative Commons licence.

IMPLICATIONS FOR PUBLIC HEALTH

The process of drafting a set of Māori public health competencies elicited key themes potentially relevant for public health practice in other countries and resulted in a competency document for use by universities and workplaces.

Pandemics, intellectual property and 'our economy': A worldview analysis of Canada's role in compromising global access to COVID-19 vaccines

Despite self-congratulatory rhetoric, Canada compromised COVID-19 vaccine equity with policies impeding a proposed global waiver of vaccine intellectual property (IP) rules. To learn from Canada's vaccine nationalism we explore the worldview - a coherent textual picture of the world - in a sample of Government of Canada communications regarding global COVID-19 vaccine sharing. Analysed documents portray risks and disparities as unrelated to the dynamics and power relations of the Canadian and international economies. Against this depoliticised backdrop, economic growth fueled by strict IP rules and free trade is advanced as the solution to inequities. Global vaccine access and distribution are pursued via a charity-focused public-private-partnership approach, with proposals to relax international IP rules dismissed as unhelpful. Rather than a puzzling lapse by a good faith 'middle power', Canada's obstruction of global COVID-19 vaccine equity is a logical and deliberate extension of dominant neoliberal economic policy models. Health sector challenges to such models must prioritise equity in global pandemic governance via politically assertive and less conciliatory stances towards national governments and multilateral organisations. Mobilisation for health equity should transform the overall health-damaging macroeconomic model, complementing efforts based on specific individual health determinants or medical technologies.

Justice, culture, and relationships: Australian Indigenous prescription for planetary health

Indigenous communities shoulder a disproportionate burden of ill health compounded by climate change. In Australia, the oldest surviving cultures have adapted their ecological knowledge over millennia and across climatic ages. However, European colonization has severely curtailed Indigenous peoples' ability to adjust to climate change. An effective response to the climate crisis requires decolonizing processes to reform our relationship with the planet. From an Australian Indigenous perspective, precursors for a self-determined and healthier future are justice, culture, and relationships. We review existing studies on Indigenous-led contemporary climate and health initiatives to assess these precursors. There are examples that highlight the need to attend to issues of restorative justice as the basis for respectful valuing of culture and genuine collaboration to address the climate crisis.

Post-growth economics: a must for planetary health justice

Within the global health field, progress is being made to adopt a justice and sustainability-centred approach by advancing what has been named a planetary health agenda. Meanwhile, an increasing number of global health scholars argue for the decolonisation of the field. Yet, amongst these collective efforts to 'transform' global health thinking, a thorough analysis of political economy dimensions is often missing. 'Growthism', the belief that more production is necessarily good, continues to prevail. Truly committing to a decolonial eco-just global health agenda requires addressing the continuation of colonial arrangements within the structure of the global economy, removing growth dependencies and ushering in post-growth policies.

The relative value of sociocultural and infrastructural adaptations to heat in a very hot climate in northern Australia: a case time series of heat-associated mortality

BACKGROUND

Climate change is increasing heat-associated mortality particularly in hotter parts of the world. The Northern Territory is a large and sparsely populated peri-equatorial state in Australia. The Northern Territory has the highest proportion of Aboriginal and Torres Strait Islander people in Australia (31%), most of whom live in remote communities of over 65 Aboriginal Nations defined by ancient social, cultural, and linguistic heritage. The remainder non-Indigenous population lives mostly within the two urban centres (Darwin in the Top End region and Alice Springs in the Centre region of the Northern Territory). Here we aim to compare non-Indigenous (eg, high income) and Indigenous societies in a tropical environment and explore the relative importance of physiological, sociocultural, and technological and infrastructural adaptations to heat.

METHODS

In this case time series, we matched temperature at the time of death using a modified distributed lag non-linear model for all deaths in the Northern Territory, Australia, from Jan 1, 1980, to Dec 31, 2019. Data on deaths came from the national registry of Births, Deaths and Marriages. Cases were excluded if location or date of death were not recorded or if the person was a non-resident. Daily maximum and minimum temperature were measured and recorded by the Bureau of Meteorology. Hot weather was defined as mean temperature greater than 35°C over a 3-day lag. Socioeconomic status as indicated by Index of Relative Socioeconomic Disadvantage was mapped from location at death.

FINDINGS

During the study period, 34 782 deaths were recorded; after exclusions 31 800 deaths were included in statistical analysis (15 801 Aboriginal and 15 999 non-Indigenous). There was no apparent reduction in heat susceptibility despite infrastructural and technological improvements for the majority non-Indigenous population over the study period with no heat-associated mortality in the first two decades (1980-99; relative risk 1·00 [95% CI 0·87-1·15]) compared with the second two decades (2000-19; 1·14 [1·01-1·29]). Despite marked socioeconomic inequity, Aboriginal people are not more susceptible to heat mortality (1·05, [0·95-1·18]) than non-Indigenous people (1·18 [1·06-1·29]).

INTERPRETATION

It is widely believed that technological and infrastructural adaptations are crucial in preparing for hotter climates; however, this study suggests that social and cultural adaptations to increasing hot weather are potentially powerful mechanisms for protecting human health. Although cool shelters are essential during extreme heat, research is required to determine whether excessive exposure to air-conditioned spaces might impair physiological acclimatisation to the prevailing environment. Understanding sociocultural practices from past and ancient societies provides insight into non-technological adaptation opportunities that are protective of health.

FUNDING

None.

On the possibility of decolonising planetary health: exploring new geographies for collaboration

Decolonial planetary health aspires to centre the diversity and importance of Indigenous thought and stewardship. In this Viewpoint, we explore research in planetary health across holistic worldviews and western scientific approaches. We base our examination of decolonising interventions in planetary health by exploring how global trajectories play out in British Columbia, Canada. A central part of this analysis is highlighting intercultural thinking to promote an anti-colonial, anti-racist, and reciprocal approach to climate change and global health inequities across geographical space and within planetary health discourse. Our perspective encompasses an asset-based examination, which focuses on the Indigenous scholarship in planetary health that is already underway and considers how rigorous engagement with epistemic and geographical diversity can strengthen and advance planetary health. This is a place-based response to planetary health, as British Columbia experiences climate catastrophes that are impacting whole communities, cutting through major transportation systems, disrupting supply chains, and creating a further burden on public health agencies and authorities that are spread thin by COVID-19 response. We argue for a progressive acknowledgment of decolonising work that is pushing research and practice in planetary health forward.

Towards an educational praxis for planetary health: a call for transformative, inclusive, and integrative approaches for learning and relearning in the Anthropocene

Fuelled by the intersecting challenges of climate change, biodiversity loss, pollution, and profound social, economic, and environmental injustices, calls for new ways to work together for a healthy, just, and sustainable future are burgeoning. Consequently, there is a growing imperative and mandate across the higher education space for transformative, inclusive, integrative-and sometimes disruptive-approaches to learning that strengthen our capacity to work towards the goals and imperatives of planetary health. This educational transformation requires attention to pathways of societal, policy, and system change, prioritising different voices and perspectives across jurisdictions, cultures, and learning contexts. This Viewpoint seeks to explore the developing areas of education for planetary health, while additionally reflecting on a praxis for education in the Anthropocene that is rooted within the confluence of diverse knowledges and practice legacies that have paved the way to learning and relearning for planetary health.