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ENHanCE Position Paper #4 - A conceptual framework for non-climatic drivers of (future) infectious disease risk –
An application of integrated scenario analysis
Outline Page 1. Introduction 1 2. Literature review: Non-climatic drivers of infectious disease risk 2 3. A conceptual framework for non-climatic drivers of (future) infectious disease risk 10 4. The road ahead: Developing European scenarios on infectious disease risk 13 References 14 Appendix A: Overview of global scenarios studies (since 2000) 17
1. Introduction
Nowadays, a wide array of global changes is taking place at an unprecedented rate, which can give rise to unexpected infectious disease risks (Sutherst, 2004; McMichael, 2004; Cohen, 2000; Huynen, Hollander, & Martens, 2008; Huynen, 2008; Morse, 1995). Global changes such as declining public health infrastructures, climate change, travel behavior, urbanization, agricultural intensification, and medical practices have all contributed to the notable recent surge in infectious disease incidence (Sutherst, 2004; McMichael, 2004; Morse, 1995; Cohen, 2000; Patz et al., 2008). The ENHanCE project aims to assess the impact of (future) climate change on infectious disease risk, and its outcomes for human health and well-being in Europe. However, when studying infectious disease risk, attention should also be paid to the effects of non-climatic factors. Both climatic and non-climatic factors are relevant for infectious disease outcomes. As climatic and non-climatic factors of global change work together, they can multiply risks in some cases, or cancel out some of each others’ impacts in other cases. The relative importance of each of the factors in a particular case is often difficult to assess and therefore much insight in this still needs to be acquired (Sutherst, 2004; McMichael, 2004; Patz, Campbell-Lendrum, Holloway, & Foley, 2005; McMichael & Martens, 2002; Cohen, 2000; Patz & Wolfe, 2002; Huynen, de Hollander, Martens, & Mackenbach, 2008; Semenza & Menne, 2009; Patz, Olson, Uejio, Gibbs, 2008; Huynen & van Vliet, 2009; IPCC, 2007; Cohen, 2000; Lier, van, 2006; EEA, 2008). The past decade has witnessed a growing recognition of the multidimensional and multilevel causation of population health, including infectious disease risk (Albrecht et al., 1998; Colwell, 2004; McMichael, 2005; Pearce & Merletti, 2006; Wilcox & Colwell, 2005; Parkes et al., 2005). Hence, a clear conceptualization of the system under investigation is required. This position paper seeks to indentify and describe non-climatic drivers of infectious disease risk, leading to a proposed conceptual framework. The insights gained from this will be used for the development of scenarios for future infectious disease risk. It should be noted that the ENHanCE project focuses on Europe as a geographical region. Thus, where appropriate, the relevance of non-climatic drivers within a European context will be stressed. In addition, the focus on human as well as animal health taken on in the ENhanCE project is respected for this position paper.
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2. Literature review: non-climatic drivers of infectious disease risk
There is a broad base of literature available discussing which factors contribute to changes in infectious disease risk. In this section, an effort is made to structure the non-climatic drivers according to broad domains of global change: ecological context, economic development, technological development, socio-cultural context, and institutional context.1 This approach attempts to capture the complexity surrounding infectious disease risk by placing it within an integrative contextual framework (McMichael & Martens, 2002). Many scholars have used similar domains or categories and articulate the significance of the interrelationships between such domains as being responsible for changing infectious disease patterns (McMichael, 2004; Morse, 1995; Cohen, 2000; Sutherst, 2004)2. For the interpretation of the described relationships between non-climatic drivers and their respective effects on disease risk, it should be taken into account that drivers and their disease outcomes vary across geographical locations, across different pathogens, and interactive effects can mediate outcomes (either by multiplying or balancing out effects) (Cohen, 2000; Sutherst, 2004; IPCC, 2007).
a. Impacts of ecological change
Ecological change is a commonly recognized to give rise to infectious disease risk, with high relevance for the European context (Morse, 1995; Sutherst, 2004, McMichael, 2004; McMichael & Martens, 2002; EEA, 2008; Huynen et al., 2008; Patz et al., 2008; Lier, van et al., 2006; Cohen, 2000; Foley, Defried, Asner, et al., 2005; Semenza et al., 2009; EEA, 2008). There are many types of changes that can occur within the ecological context which are all potential drivers of infectious disease risk: land use change, habitat change, climate change3, hydrological change, biodiversity change, vegetation change, microbial change and adaptation (Lier, van et al., 2006; McMichael, 2004; EEA, 2008; Parry, Canziani, Palutikof, et al., 2007; Sutherst, 2004; Cohen, 2000; Patz et al., 2008; Foley, Defries, Asner, et al., 2005; Morse, 1995). Some ecological changes occur naturally, but many ecological changes are human-induced. The latter includes: water management (irrigation, distribution, and storage); expansion of infrastructure (roads, dams); pollution; economic development; globalization; agricultural development (and related deforestation activities); industrial expansion; and urbanization (Lier, van et al., 2006; Huynen et al., 2008; Patz et al., 2008; Sutherst, 2004; Morse, 1995; Cohen, 2000; Rahamat-Langendoen, van Vliet, & van Lier, 2008; Parry et al., 2007; McMichael, 2004; Foley et al., 2005; Morse, 1995). It can be seen that many of the ecological changes show interrelations with the other domains described in this paper. Relating ecological changes to disease risk outcomes is extremely complex, and the existing broad base of findings cannot be generalized easily across cases at a global level (Sutherst, 2004; McMichael, 2004)4.
1 These domains will also serve as a base for the proposed framework in section 3.
2 Therefore, it should be noted that structuring non-climatic drivers according to predefined domains is somewhat
arbitrary (Morse, 1995). 3 Climate change as a driver for infectious disease risk will not be discussed in further detail as this goes beyond the
aims of this position paper. 4 Sutherst (2004) stresses the importance of taking into account the non-linear nature of the relationship between
ecological changes and resulting biological responses. This non-linearity arises from several characteristics inherent to biological systems: “*…+ including thresholds such as developmental or behavioral temperature thresholds,
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Humans have always influenced their environments, but today the scale and scope of our interventions have increased, resulting in increased changes in infectious disease patterns (McMichael, 2004). One of the large man-made drivers of ecological change is expansion and intensification of agriculture and the accompanying land use changes (e.g. deforestation, and changes in hydrological systems) (Sutherst, 2004; Morse, 1995; Cohen, 2000; Lier, van et al., 2006; Rahamat-Langendoen et al., 2008; Patz et al., 2008; Foley, Defries, & Asner et al., 2005; Patz et al., 2008; Parry et al., 2007). Some of the commonly cited impacts of these agriculture-induced changes are alteration of natural vegetation, habitat and biodiversity changes (Sutherst, 2004; Lier, van et al., 2006; Cohen, 200; Foley, Defries, & Asner, et al., 2005; Patz et al., 2008; Parry et al., 2007). With respect to infectious diseases, this implies that the environment of pathogens, vectors, and hosts changes (e.g. change in breeding sites), which will cause changes in the vector-host-pathogen relationships and thus a resulting alteration in infectious disease patterns (Sutherst, 2004; Patz et al., 2008). Many of the ecological changes discussed are in essence anthropogenic, but there are also natural ecological changes responsible for infectious disease impacts. Microbes change and adapt constantly. Selection for antibiotic-resistant bacteria and drug-resistant parasites happens frequently; either due to natural processes of selection, the inappropriate use of antimicrobial drugs, or sometimes other less clear causes (Morse, 1996; Cohen, 2000). Overall, many infectious diseases show a high rate of change and adaptation, thus new variants of diseases can evolve rapidly (Morse, 1995).
b. Impacts of economic development
Within the economic arena, many global changes are taking place which determine infectious disease outcomes. Global changes relevant for the economic context are economic globalization; trade liberalization; globalization of transportation; and the development of the agricultural sector (Huynen et al., 2008; Lier van, et al., 2006; Patz et al., 2008; McMichael, 2004; Sutherst, 2004; IPCC, 2007). The accelerated and globalized movement of goods caused by changes in the economic context can lead to an increased spread of diseases into new areas (Sutherst, 2004; EEA, 2008; Cohen, 2000; McMichael, 2004). In particular, the food industry creates such disease risks, as microbial resistance genes are transported along with disease microbes (McMichael, 2004; Cohen, 2000). These infectious disease risks brought about by the movement of goods shows high relevance within a European context (EEA, 2008). With economic globalization and agricultural development, pollution and contamination play a large role for human health in general, and infectious disease patterns in particular (Sutherst, 2004; McMichael, 2004; Huynen et al., 2008; Parry et al., 2007). Pollutants can degrade immunological functioning, which poses a risk to humans’ ability to naturally tackle disease stresses (Suhterst, 2004; Patz et al., 2008). On a local scale, pollutants can also impact
discontinuities at the edges of the ranges of species, nonlinear responses to temperature and moisture, multiplicative effects of population growth in vectors with multiple generations each year, negative feedback associated with competition or predation as population densities increase, interactions between variables resulting in nonadditive effects, and the disproportionate effects of changes in the frequency of extreme events with small changes in the value of the mean (Sutherst, 2004, p.143)”.
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pathogens and the patterns of infectious disease occurrence (McMichael, 2004; Sutherst, 2004). For farmers, negative health effects from pesticide use and other chemicals have devastating health implications (Patz et al., 2008). Other agricultural developments relevant for the European context, influencing infectious disease risk are farm scale and scope increases; a move towards organic farming; and the increased use of antibiotics (Rahamat-Langendoen et al., 2008). Agricultural developments in particular show close interlinkages with ecological developments (as explained earlier).
c. Impacts of technological development
Technology is recognized by many as a significant driver for disease outcomes, and a region’s vulnerability to infectious diseases (Morse, 1995; McMichael, 2004; Cohen, 2000; IPCC, 2007; Parry et al., 2007). Technological development within the medical sector and in other sectors can have infectious disease impacts, both positive and negative. Advances in medical technology have helped to diagnose new infectious diseases, leading to the development of new methods to control the respective diseases (Morse, 1995; McMichael, 2004). However, medical technology poses additional infectious disease risks. Due to medical advancements, the portion of a country’s population that is most susceptible to infectious diseases, such as the elderly and people suffering from chronic diseases, has grown immensely (Cohen, 2000). Organ transplantations, blood transfusions, and other medical practices are another topic of concern, as they can all contribute to the risk of infectious diseases (e.g. nosocomial disease spread) (Morse 1995; McMichael 2004; Cohen, 2000). Technology also plays an important role in the developments taking place in the other domains discussed. Within the economic context for instance, the transformation of production and transportation, as well as the resulting global scale of commerce, have all been facilitated by technological development. These technology-induced changes all show implications for infectious disease risk (Morse, 1995; Cohen, 2000).
d. Impacts of socio-cultural developments
The social-cultural context includes different drivers of possible infectious disease change: the movement of people (encompassing migration, urbanization, refugee trends, encroachment on new environments, and travel); human behavior/lifestyles (e.g. human-animal relationship, social exclusion, sexual behavior, intravenous drug use, consumptive behaviors, culinary culture); demographic characteristics (increasing vulnerable groups in population e.g. ageing population, level of education); and host conditions (e.g. malnutrition, diabetes, immune status, incidence of (chronic) diseases) (Sutherst, 2004; McMichael, 2004; Morse, 1995; EEA, 2008; IPCC, 2007; Cohen, 2000; Huynen, 2008; Patz et al., 2008; Lier van, et al., 2006; Martens & Hall, 2000). People move because they are exposed to different pressures, such as social unrest and conflict; economic circumstances (positive or negative); demand for skilled and unskilled labor; agricultural development (and the related land use changes discussed previously); population growth; climate change and environmental deterioration (incl. natural disasters); but also the rise in opportunities to travel at an increasingly larger scale works to facilitate the movement of people (Sutherst, 2004; Morse, 1995; McMichael, 2004; Cohen, 2000; Martens & Hall, 2000).
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Increased movement of people can result in the spread of disease pathogens and their respective vectors over large distances, and can maintain disease persistence (Sutherst, 2004; Martens & Hall, 2000; Cosner, Beier, Cantrell, et al., 2009; Morse, 1995; Lier, van et al., 2006; Cohen, 2000; McMichael, 2004). In Europe, the movement of people has important outcomes for current and future infectious disease patterns (EEA, 2008). Human behaviors and lifestyle choices have significant impacts for infectious disease risk, since they create opportunities for exposure to and emergence of (new) diseases. Relevant here are: sexual behavior; (intravenous) drug use; hospital procedures; alcohol and tobacco use; dietary habits and culinary culture; recreational activities; and the use of antimicrobial agents (McMichael, 2004; Morse, 1995; Cohen, 2000; Huynen, 2008). Finally, relevant within the socio-cultural context are demographics and personal risk factors. Personal risk factors and demographical characteristics relate to the susceptibility to infectious diseases, or in other words, the status of the immune system. Susceptibility can be interpreted for an individual or at a national level (Cohen, 2000; Sutherst, 2004; EEA, 2008). Some of the personal risk factors influencing susceptibility are (chronic/infectious) disease incidence, resistance to antimicrobial agents (either genetic or acquired immunity), and malnutrition (IPCC, 2007; Sutherst, 2004; Cohen, 2000). Demographic factors that can impact susceptibility are: changes in population such as an increased portion of the population with enhanced susceptibility (e.g. ageing populations in Europe); increase in two-income households, increase in single-parent families, and level of education particularly concerning knowledge and awareness about personal hygiene (Cohen, 2000; IPCC, 2007).
e. Impacts of institutional developments
The institutional context in a country encompasses the public health infrastructure in place as well as the management of health drivers and health outcomes, which can include public health initiatives, health care, control and immunization strategies. The quality of the health infrastructure has great impacts on health and infectious disease risks (Cohen, 2000; IPCC, 2007; McMichael, 2004; Morse, 1995; Sutherst, 2004). Many point to a recent breakdown of public health structures in many countries as a main factor in exacerbating health problems and specifically infectious disease risk (Sutherst, 2004; Morse, 1995; McMichael, 2004; Cohen, 2000). For infectious diseases, elements of the public health system such as vector-control measures, immunization, (international) surveillance, collaboration between veterinary and health services, and raising public awareness are of high significance for changes in disease patterns (Morse, 1995; EEA, 2008; Cohen, 2000). However, also additional factors, like sanitation and water management, poverty reduction, access to resources, environmental management, migration policies, integration of health and social services, food security, peace and national security play just as much of a role for infectious diseases, and all of these are influenced by the institutional context (Cohen, 2000; EEA, 2008; IPCC, 2007; Sutherst, 2004; McMichael, 2004; Huynen et al., 2008). Thus, it can be discerned that the institutional context can work to mediate the effects of all other non-climatic drivers for infectious disease risk. Below in Table 2.1 a summary of the literature review conducted for this paper is provided, emphasizing the causal chain of events leading to changes in infectious disease risk.
Table 2.1 Non-climatic drivers of infectious disease risk: Summarized overview of literature review
Line of reasoning in literature --------------------------------------------------------------------------------------------
Ecological change5 *Land use (change)
*Land cover (change)
*Habitat conversion: e.g.
deforestation/reforestation
*Habitat fragmentation
*Biodiversity (change/loss)
*Floods/droughts
*Increased human entry into
forests
*Increased surface water (from
soils exposed by logging or new
agriculture); changes in water
ecosystems
*More vector breeding sites and
new breeding sites (due to
deforestation)
*Increased microbe or natural host
populations
*Increased contact/proximity
between humans and
vectors/hosts
*Impact on vector distribution
*Host species imbalance due to
loss of predators
*Microbial adaptation and
change
*Microbial evolution
*Response to processes of
selection in environment
*Selection for drug-resistant
bacteria (i.e. antibiotic-resistant)
*Emergence of new disease
variants
*Pollution (e.g. Endocrine
Disrupting Chemicals,
fertilizers, pesticides,
herbicides, industrial toxins
*Degradation of immunological
function
*Contamination of habitats (incl.
groundwater)
*Effect on vector distribution and
host density
Economic
development &
agricultural
development
*(Need for) irrigation
*(Need for) infrastructure
(incl. storage & distribution of
water)
*Habitat conversion
*Disturbances in vegetation
*Habitat fragmentation
*Biodiversity loss/change
*Water storage
*Sanitation issues
*Surface water increases
*Prevention of seasonal flooding
*Increased use of antibiotics
*Increased farm scale
*More (and greater diversity of)
vector breeding sites
*Reduced predation of vectors
*Higher chance of micro-organisms
in cattle developing resistance
(humans can become infected with
resistance micro-organisms
through food or direct contact with
cattle)
*Increased risk of introduction and
5 Climate change as a driver for infectious disease risk would be a part of the ecological domain. However, this factor is not included as this analysis focuses on non-climatic
drivers for infectious disease risk.
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*Increased farm scope (with
sideline activities)
*Increase in organic agriculture
*Use of antibiotics
*Use of pesticides
*Animal husbandry
*Increased free-range farming
the spread of micro-organisms
among the animals on the farm
(this leads to potential spread to
humans)
*More contact between humans
and animals
*More contact between animals
and the natural environment as
was usual in the past (thus
increasing the risk of certain
infectious diseases, influence on
vector distribution, host density
can change impacts vector
distribution)
*Reduced flushing of snails and
mosquitoes
*Trade & movement of goods
*Development of
infrastructure (logistics)
* Increased volume of goods
transported worldwide (in
particular, fruits and vegetables)
*Increased transport of vectors
leading to ‘homogenization’ of
vectors in receptive areas
*Movement of pathogens from one
region to another
*Redistribution of microbial
resistance genes along with the
microbes
Technological
development
*Globalization of food supply
chains
*Changes in food production,
processing, and packaging
*Medical technologies
*Widespread use of antibiotics
*Organ and tissue
transplantation
*Drugs causing
immunosuppression
*Hospital procedures
*Global movement of processed
foods
*Capacity to detect, prevent and
treat diseases
*Increased risk of exposure
*Increased opportunity to
recognize and treat/prevent
infectious diseases
*Movement of microbial resistance
genes and diseases
*Increased susceptibility to
infectious diseases
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Socio-cultural
development
*Movement of people: travel,
migration, displacement,
urbanization, human
settlements’ encroachment on
new environments (e.g.
suburban sprawl into forested
areas)
*Greater number of people move
at a more global scale (incl.
increase in air travel)
*Stress on drainage & water
supplies (lack of infrastructure
due to poverty)
*Urban decay
*Spread of pathogens & vectors
across large distances
*Increased disease incidence, due
to increased density of human
hosts
*Change in patterns of disease
(higher degree of disease
transmission rates)
*More vector breeding sites
*Increased transfer of pathogens
between regions of endemicity and
disease-free regions
* Increase exposure of visitors to
regions of endemicity
*Human populations closer to
hosts & vectors
*Increased contact between
humans and vectors
*Boost of old infectious diseases
and spread of emerging diseases
simultaneously
*Demographics and
population/individual
characteristics
*Education
*Vulnerable groups in population
(e.g. ageing population groups)
*Incidence of (chronic/infectious)
diseases
*Malnutrition
*Diabetes
*Immune status
*Heightened vulnerability of
human hosts (individuals but also
as a population)
*Human behavior
*Culture & religion
*Sexual behavior
*Intravenous drug use
*Human-Animal relationship
(domestication or animal
companionship/pets)
*Culinary practices and dietary
*Increased transmission of (new)
infectious diseases
*Increased disease transmission
between animal and human
*Increased risk of food-borne
infectious diseases
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habits
Institutional
development
*Public health infrastructures
(deterioration)
*(Breakdown of) public health
policies and measures
*Other relevant policies (e.g.
relating to sanitation)
*Exacerbation of health
problems
*Limitations to and reduction in
prevention programs
*Control measures (incl.
monitoring)
*Inadequate sanitation and
vector control measures
*Reemergence of pathogens
3. A conceptual framework for non-climatic drivers of (future) infectious disease risk
The causality of human health is multi-factorial and many population health problems are invariably embedded within a global context. McMichael (1999), for example, argues that a global approach towards population health and epidemiology should not ignore the importance of individual-level direct risk factors, but should indicate the importance of studying these direct causes in their broader context. As our attention moves upstream in the causal chain of health determinants, there is an increasing interest in multilevel- and systems-approaches (McMichael, 1995, 1999; Pearce, 2004; Pearce & Merletti, 2006). Hence, a growing number of health researchers (Albrecht et al., 1998; Colwell, 2004; McMichael, 2005; Pearce & Merletti, 2006; Wilcox & Colwell, 2005) argue that the health of a population can- or must- be viewed within a broader system of health determinants. Risk factors for disease do not operate in isolation, but occur in a particular population context. Upstream forces play an important role in global health research (Sreenivasan & Benatar, 2006). These upstream or contextual factors may have large impacts, but their effects are non-linear and less-predictable (Philippe & Mansi, 1998). Various terms have been used to describe such broader approaches to population health, such as eco-epidemiology (Ladd & Soskolne, 2008; Martens, 1998; Soskolne & Broemling, 2002; Susser & Susser, 1996), ecological perspective on health (McLaren & Hawe, 2005), social-ecological systems perspective on health (McMichael, 1999), and biocomplexity approach to health (Colwell, 2004; Wilcox & Colwell, 2005). The majority of literature addressing population health as an interacting system of many different factors concerns research into communicable diseases. Disease transmission depends on multiple factors such as environmental change and cultural practices affecting landscapes, communities and population densities. These factors, in turn, interact with host-pathogen biology via evolutionary ecological processes to contribute to the (re)emergence of communicable diseases (Kapan et al., 2006). Parkes et al. (2005), among others, plea for new system-based approaches to address communicable diseases. They argue that the worldwide (re)emergence of infectious diseases (e.g., SARS, Nipah virus, Lyme disease, HIV/AIDS, and malaria) demonstrates that ‘the rate and scale of global change in agriculture, trade, demographics, species translocations and invasions, microbial adaptation, and other complex factors have outstripped our ability to understand and respond to emerging infectious diseases’, and ‘expose serious limitations of approaches that fail to engage with the wider contexts from which infectious diseases emerge’. For example, the risk of highland malaria moving to higher altitudes depends on the interplay between regional climate change, land use change, population movement, agricultural practices (e.g., pesticide use, irrigation systems), public health programs (e.g., monitoring and treatment) and socio-economic status (Hales & Woodward, 2003; McMichael & Woodruff, 2005). The dynamic interaction of these various factors is just one of the many examples of the broader population context in which infectious diseases develop (Albrecht et al., 1998; Kapan et al., 2006). In line with the above, the literature review (summarized in section 2 and Table 2.1) shows very clearly that changes in infectious disease risk are the integrated outcome of multiple factors,
which operate at different levels in a causal chain. We propose that the nature of the various determinants and their level of causality can be combined into a basic framework that conceptualizes the complex multi-causality of infectious disease risk6. In
6 Based on Huynen (2008).
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order to differentiate between determinants of a different nature, we will make the traditional distinction between institutional, socio-cultural, technological, economic, and ecological factors. These factors have different positions in the causal chain, and so operate at different hierarchical levels of causality (Figure 3.1). The chain of events leading to a certain health outcome includes both direct and indirect causes- direct factors act directly to cause disease or health gains, and indirect determinants are further back in the causal chain and act via (a number of) intermediary causes (WHO, 2002). In addition, Figure 3.1 also distinguishes contextual determinants. These are the macro-level conditions that form the context in which the indirect and direct factors operate and develop. Determinants with different positions in the causal chain probably also differ in their temporal dimensions. Individual-level direct health risks can be altered relatively quickly, for example by a change in personal behavior; for disease rates in whole populations to change slower and more structural changes in contextual factors are required, often over the course of a few decades.
Figure 3.1 Hierarchical levels of causality of non-climatic drivers for infectious disease change
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The extensive literature review underlying our conceptual framework reflects the diversity of views abound in various relevant disciplines. The literature review and overview provided in Table 2.1 has served as the base for the development of the conceptual framework proposed in Figure 3.2.
7 Adapted from Huynen (2008, p.85) Figure 4.1: Population health determinants: Different hierarchical levels of
causality.
Contextual drivers
Indirect drivers
Direct drivers
Infectious disease risk
(impact on vector,
pathogen, and host)
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Figure 3.2: Conceptual framework for non-climatic drivers of infectious disease risk
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4. The road ahead: Developing European scenarios on infectious disease risk
The framework provides valuable insights on how to organize the various factors involved in infectious disease risk. It is embedded in a holistic approach towards health determination, stressing the multi-causality of infectious diseases. Therefore, the conceptual framework could give a meaningful contribution to further (empirical) research by serving as a well-structured ‘think-model’ or ‘concept map’. Hence, the conceptual framework proposed in this position paper is considered a useful tool to structure the scenario analysis in the ENHanCE project.8 Two main approaches to develop health scenarios can be distinguished (Huynen, 2003). First, one could develop new integrated health scenarios from scratch. This would be, of course, very challenging, and it would be possible to make use of the expertise already available in the scenario community. The second approach builds on the outcomes of earlier studies and constitutes enriching existing global scenarios with a health component. The inclusion of health in past global scenario exercises has been limited. However, looking at other developments that possibly affect our future health (e.g., food, water, environment, social change, equity, economic growth, technology), we see that many are well addressed in most scenarios. We therefore think that it is possible to explore future developments in infectious disease risk, by building on one or more existing scenarios studies. For the ENHanCE project, we propose to apply the second approach, using the Millennium Ecosystem Assessment (MA) scenarios (Carpenter et al., 2005) as a basis for developing European scenarios focusing on infectious disease risk.9 The MA scenarios address plausible future changes in ecosystems, in the supply and demand for ecosystem services, and in the subsequent changes in human well-being. This scenario study builds on earlier scenarios and modeling efforts. Through a participatory process the following key concerns were identified; globalization, leadership, poverty and inequality, technology, local flexibility, and surprises. Framed in terms of context (increasingly globalised versus increasingly regionalized) and approaches (emphasis economic growth and the promotion of public goods versus emphasis on proactive ecosystem management), the MA scenarios are: Global Orchestration, Order from Strength, Adapting Mosaic and TechnoGarden. These scenarios were further developed in an iterative process of storyline development and modeling. According to the MA, the focus on alternative approaches to sustaining ecosystem services distinguishes these scenarios from previous global scenario exercises. In addition, they give an interesting overview of the circumstances under which a particular scenario can branch into one of the other three scenarios. Contrary to other past scenario exercises, exploring future well-being was one of the initial goals of the MA. In their own words, the MA provides ‘a first order attempt to assess future health’ (Corvalan et al., 2005). Most aspects relevant for human health are more qualitatively explored by means of the four storylines. The MA primarily focuses on the health implications of changing ecosystem functioning (resulting in an imbalance regarding the detailed description of environmental developments on the one side and social and economic factors on the other side) and on the risk of emerging diseases. Additionally, there are some inconsistencies in the MA-reports, which probably arise from the lack of a clear conceptualization of population health and
8 See Huynen (2008) for a first order attempt to use a similar framework to explore future global health.
9 Based on the advice by the ENHanCE Advisory Board; personal communication September 2009.
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population health determination. It is mentioned that in three out of four scenarios global health will broadly improve for both the developed and developing world (Carpenter et al., 2005). However, it is, for example, also stated that ‘ecosystems services are indispensable to the well-being of people throughout the world’ and ‘under the MA scenarios, an increasing number of people may be unable to replace satisfactory, or escape from, the effects of depleted ecosystem services’ (Corvalan et al., 2005). Also, in the Global Orchestration scenario, for example, there is an increasing risk of emerging infectious disease, ecological shocks, environmental pollution, and unhealthy lifestyles. Hence, the finding that health improvements are largest in this scenario is primary based on the (implicit) assumption that other developments (e.g., income growth, education, global governance and improved health services) are able to offset all these negative influences. With regard to the same scenario, one MA-report (Carpenter et al., 2005) claims that there is a slow response to climate change, while a second report (Corvalan et al., 2005) states that the supranational institutions in this scenario are well-placed to deal with global environmental problems such as climate change. Besides building on the MA scenarios, we are-therefore- planning to use additional input from related global scenarios (see Appendix A for an overview), as well as selected European and national (UK, Netherlands, France) scenario studies.10
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Appendix A: Overview of global scenarios studies (since 2000) Selection criteria:
o Scenarios integrated across institutional, economic, social-cultural, technological, and environmental dimensions;
o A long-range time horizon is required, preferably several decades; o Some regional disaggregation; and o Published since 2000.
Table A1. Overview global scenarios
Scenario study - time horizon
Scenario Brief description of storyline
Special Report on Emission Scenarios (SRES)-2100 (IPCC, 2000)
A1 Rapid market-driven growth, with convergence in incomes and culture.
A2 Self-reliance and preservation of local identities; fragmented economic and technological development.
B1 Convergent world with rapid changes in economic structures and emphasis on global solutions to sustainability.
B2 Local solutions to economic, social, and environmental sustainability.
World Water Scenarios- 2025 (Gallopin & Rijsberman, 2000)
Business-as-Usual (BAU)
Current water policies continue high inequity.
Technology, Economics & Private Sector (TEC)
Market-based mechanisms, better technology.
Values and Lifestyles (VAL)
Less water-intensive activities, ecological preservation.
Global environmental outlook (GEO) 3- 2032 (UNEP, 2002)
Markets First A world in which market driven developments converge on the values/expectations that prevail in industrial countries.
Policy First Strong actions are undertaken by governments in an attempt to reach specific goals.
Security First A world of great disparities, where inequality and conflict prevail, brought about by socio-economic and environmental stresses.
Sustainability First
A new development paradigm emerges in response to the challenge of sustainability, supported by new, more equitable values and institutions.
Millennium Ecosystem Assessment (MA) scenarios- 2050 (Carpenter et al., 2005)
Global Orchestration
Globalised, with emphasis on economic growth and public goods. Global economic and social approach to sustainability.
Order from Strength
Regionalised, with emphasis on national security and economic growth. Protection through boundaries.
Adapting Mosaic
Regionalised, with emphasis on local adaptation and flexible governance. Local and regional approach to sustainability.
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TechnoGarden Globalised, with emphasis on green technology. Potential role of technology in providing and improving ecosystem services.
1. Special Report on Emission Scenarios (SRES) by the International Panel on Climate Change (IPCC, 2000) The most recent scenario effort of the Intergovernmental Panel on Climate Change (IPCC) was developed, via a broad consultative process, for estimating emissions of greenhouse gases over the coming century, taking into account input and perspectives from a wide, interdisciplinary research community. The resulting Special Report on Emission Scenarios (SRES) explores the global and regional dynamics that may result from changes regarding population, economy, technology, energy use, and agriculture (land use). The scenarios are intended to exclude catastrophic futures. The distinction between classes of scenarios was broadly structured by defining them ex ante along two dimensions The first dimension relates to both the extent of economic convergence and of social and cultural interactions across regions; the second has to do with the balance between economic objectives and environmental and equity objectives. This resulted in the creation of four scenario ‘families’ or ‘clusters’. Whereas the ‘A’ storylines (A1 and A2) emphasize economic development and leave only a subsidiary role for environmental and social concerns, the ‘B’ storylines (B1 and B2) reverse these priorities. The ‘1’ storylines (A1 and B1) emphasizes successful economic convergence; and social and cultural interaction across regions, while the ‘2’ storylines (A2 and B2) focus on diverse regional developments. A1-scenario The first group of scenarios [A1] is characterized by fast economic growth, low population growth and the accelerated introduction of new, cleaner and more effective technologies. Under this scenario, social concern and the quality of the environment are subsidiary to the principle objective: the development of economic prosperity. Underlying themes combine economic and cultural convergence, and the development of economic capacity with a reduction in the difference between rich and poor, whereby regional differences in per capita income decrease in relative (but not necessary in absolute) terms.
A2-scenario The second group of scenarios [A2] also envisages a future in which economic prosperity is the principal goal, but this prosperity is then expressed in a more heterogeneous world. Underlying themes include the reinforcement of regional identity with an emphasis on family values and local traditions, and strong population growth. Technological changes take place more slowly and in a more fragmented fashion than in the other scenarios. This is a world with greater diversity and more differences across regions. B1-scenario In the third group [B1], striving for economic prosperity is subordinate to the search for solutions to environmental and social problems (including problems of inequity). While the pursuit of global solutions results in a world characterized by increased globalization and fast-changing economic structures, this is accompanied by the rapid introduction of clean technology
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and a shift away from materialism. There is a clear transformation towards a more service and information-based economy. B2-scenario The fourth group [B2] sketches a world that advances local and regional solutions to social, economic and ecological problems. This is a heterogeneous world in which technological development is slower and more varied, and in which considerable emphasis is placed on initiatives and innovation from local communities. Due to above average levels of education and a considerable degree of organization within communities, the pressure on natural systems is greatly reduced.
Table A2. Basic elements of the IPCC SRES scenario families
Population
growth
Economic
growth
Energy
use
Land-use
changes
Technology
development
A1 Low Very high Very high Low-
medium
Rapid
A2 High Medium High Medium-
high
Slow
B1 Low High Low High Medium
B2 Medium Medium Medium Medium medium
2. World Water Scenarios by the World Water Council (Gallopin & Rijsberman, 2000) The approach in the World Water Vision project focused on developing qualitative scenarios to allow incorporation of the many social, economic, environmental and cultural factors that shape the water future. Models were then used to analyze the consistency and coherence of the qualitative scenarios, explore some of the consequences, and fill some of the gaps. The scenarios evolved in four rounds of development, discussion, feedback and subsequent improvement- with interactions among scenario developers, modelers, and groups working on visions for sectors and regions. The main forces affecting the global water scenarios are economic development, demographic developments, technological change, social trends and environmental quality. The three global scenarios that were developed are ‘Business as usual’ (BAU), ‘Technology, economics, and private sector (TEC)’ and ‘Values and lifestyles (VAL)’. Business as usual The Business-as-Usual (BAU) scenario represents the future trajectory if those who do not believe in the crises prevail, and no major policy or lifestyle changes take place; it describes a world in which current policies on water resources management and development are continued in essence unchanged. Under this scenario, developments in the world are largely positive during the first 10–15 years (2005–2015). Water demands increase both absolutely and per capita due to increased affluence and increased per capita food production. Technology improves and water use efficiencies are increased at the rates observed over the last several decades. Water supplies are developed following historical trends and known plans for major water infrastructure get implemented. The world initially develops along the lines of official projections of the UN system concerning population and economic growth. All that time, however, the global system is becoming more and more vulnerable as a result of the increasing scarcity of resources per capita, the diminished quality of water in most of the world, increasing
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conflicts associated to inequality and water scarcity, and the narrower resource base of healthy ecosystems. By the end of the period, the key water problems of today—lack of access to safe drinking water and sanitation, recurrent flood and drought damage, high numbers of deaths from water-related diseases, and so on—do not get resolved in the Business-as-Usual scenario. In the second half of the BAU scenario the regional crises become more pronounced and depending on specific triggers—a widespread, major multi-year drought, a breakdown in the global food trading system—a major global water crisis could develop.
Technology, economics and private sector (TEC) The Technology, Economics, and the Private Sector scenario (TEC) could result from policies favored by those who rely on the market, the involvement of the private sector and mainly technological solutions, and largely nation/local or basin level action. It is characterized by a worldview that is optimistic about the free market system, the potential of new technologies and the possibilities to regulate or limit the undesirable side effects of both. Increased water awareness is manifested predominantly through application of economic principles to the water sector. Increased water awareness is manifested predominantly through application of economic principles to the water sector. Water pricing—or cost recovery for services provided (drinking water collection and distribution, wastewater collection, treatment, and disposal) — leads to rapid diffusion of technologies, increased capital investment and reduced demands. Increased user-participation in, and responsibility for water management, at the basin level through decentralized management structures, balance market forces with social and ecosystem values. This scenario does not invoke drastic value changes. By 2025 there is no widespread water scarcity due to the reduced water intensity of most human activities. This is reached, however, at the cost of social sustainability, since a large section of poorer nations are left out. The ultimate success of this scenario will depend on the strength and effectiveness of governmental and social actions required to correct negative social trends. Values and lifestyles (VAL) The Values and Lifestyles (VAL) scenario could materialize through a revival of human values, strengthened international cooperation, heavy emphasis on education, international mechanisms, international rules, increased solidarity and changes in lifestyles and behavior. It assumes that a strong commitment to avert a water crisis emerges early in the new Century, focused on reaching a set of global and regional targets. The emphasis is on a revival of the fundamental human values and changes in lifestyles in accordance with them. At the national/local levels the key strategic direction is a strong emphasis on education and capacity building as the pathway to establishing sustainable values and lifestyles. Community-level action gains prominence in managing watersheds, harvesting rainwater for agricultural and domestic water use, and protecting ecosystems. Total water withdrawals stabilize at a sustainable level, as a result of cultural, economic and technological changes. Effectively available renewable water resources increase through catchment management and water harvesting that recharges groundwater aquifers. Water intensity reaches an historical minimum. 3. Global Environmental Outlook (GEO3) scenarios by the United Nations Environmental Program (UNEP, 2002) NOTE: Needs to be updated with GEO 4 publication.
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As part of its third Global Environment Outlook (GEO3), the United Nations Environment Programme (UNEP) developed a set of four alternative scenarios depicting developments for the 2002-2032 period. These scenarios were intended to stimulate thinking on different possible trends in the environment at the global and regional level. The GEO3 scenario exercise builds on the earlier work of the Global Scenario Group. It has been a highly participative programme involving experts from all around the world. A core scenario team of global and regional experts designed four global scenarios and, subsequently, regional teams elaborated these at the regional level. A number of models and analytical tools have been used to provide valuable underpinning of the storylines. The scenarios were refined through an iterative process involving the core scenario team, regional teams, modeling groups and external reviewers. The resulting scenarios- Markets First, Policy First, Security First and Sustainability First- describe possible futures based on an interpretation of prevailing driving forces (demography, economic development, human development, science and technology, governance, culture, environment). Market First Most of the world adopts the values and expectations prevailing in today’s industrialized countries. The wealth of nations and the optimal play of market forces dominate social and political agendas. Trust is placed in further globalization and liberalization to enhance corporate wealth, create new enterprises and livelihoods, and so help people and communities afford to insure against- or pay to fix- social and environmental problems. Ethical investors, together with citizen and consumer groups, try to exercise growing corrective influence but are undermined by economic imperatives. The powers of state officials, planners and lawmakers to regulate society, economy and the environment continue to be overwhelmed by expanding demands. Policy First Decisive initiatives are taken by governments in a n attempt to reach specific social and environmental goals. A coordinated pro-environment and anti-poverty drive balances the momentum for economic development at any cost. Environmental and social cost and gains are factored into policy measures, regulatory frameworks and planning processes. All these are reinforced by fiscal levelers or incentives such as carbon taxes and tax breaks. International ‘soft law’ treaties and binding instruments affecting environment and development are integrated into unified blueprints and their status in law is upgraded, though fresh provision is made for open consultation processes to allow for regional and local variants. Security First This scenario assumes a world of striking disparities where inequality and conflict prevail. Socio-economic and environmental stresses give rise to waves of protest and counteraction. As such troubles become increasingly prevalent, the more powerful and wealthy groups focus on self-protection, creating enclaves akin to the present days ‘gated communities’. Such islands of advantage provide a degree of enhances security and economic benefits for dependent communities in their immediate surroundings, but they exclude the disadvantaged mass of outsiders. Welfare and regulatory services fall into disuse but market forces continue to operate outside the walls. Sustainability First A new environment and development paradigm emerges in response to the challenge of sustainability, supported by new, more equitable values and institutions. A more visionary state of affairs prevails, where radical shifts in the way people interact with one another and with the
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world around them stimulates and supports sustainable policy measures and accountable corporate behavior. There is much fuller collaboration between governments, citizens and other stakeholder groups in decision making on issues of close common concern. A consensus is reached on what needs to be done to satisfy basic needs and realize personal goals without beggaring others or spoiling the outlook for prosperity.
4. The Millennium Ecosystem Assessment (MA) scenarios (Carpenter et al., 2005) The Millennium Ecosystem Assessment (MA) scenarios address plausible future changes in ecosystems, in the supply and demand for ecosystem services, and in the consequent changes in human wellbeing. This scenario study builds on earlier scenarios and modeling efforts. Through a participatory process the following key concerns were identified; globalization, leadership, poverty and inequality, technology, local flexibility and surprises. Framed in terms of context (increasingly globalised versus increasingly regionalized) and approaches (emphasis economic growth and the promotion of public goods versus emphasis on proactive ecosystem management), the MA scenarios are: Global Orchestration, Order from Strength, Adapting Mosaic and TechnoGarden. These scenarios were further developed in an iterative process of storyline development and modeling. According to the MA, the focus on alternative approaches to sustaining ecosystem services distinguishes these scenarios from previous global scenario exercises. In addition, they give an interesting overview of the circumstances under which particular scenario can branch into one of the other three scenarios. Global Orchestration The Global Orchestration scenario depicts a worldwide connected society in which global markets are well developed. Supra-national institutions are well placed to deal with global environmental problems, such as climate change and fisheries. However, their reactive approach to ecosystem management makes them vulnerable to surprises arising from delayed action or unexpected regional changes. The scenario is about global cooperation not only to improve the social and economic well-being of all people but also to protect and enhance global public goods and services (such as public education, health, and infrastructure). There is a focus on the individual rather than the state, inclusion of all impacts of development in markets (internalization of externalities), and use of regulation only where appropriate. Environmental problems that threaten human well-being (such as pollution, erosion, and climate change) are dealt with only after they become apparent. Problems that have little apparent or direct impact on human wellbeing are given a low priority in favor of policies that directly improve wellbeing. People are generally confident that the necessary knowledge and technology to address environmental challenges will emerge or can be developed as needed, just as it has in the past. The scenario highlights the risks from ecological surprises under such an approach. Examples are emerging infectious diseases and other slowly emerging problems that are hard to control once they are established. Other benefits and risks also emerge from the inevitable and increasing connections among people and nations at social, economic, and environmental scales. Order from Strength The Order from Strength scenario represents a regionalized and fragmented world concerned with security and protection, emphasizing primarily regional markets, and paying little attention to the common goods, and with an individualistic attitude toward ecosystem management. Nations see looking after their own interests as the best defense against economic insecurity.
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They reluctantly accept the argument that a militarily and economically strong liberal democratic nation could maintain global order and protect the lifestyles of the richer world and provide some benefits for any poorer countries that elect to become allies. Just as the focus of nations turns to protecting their borders and their people, so too their environmental policies focus on securing natural resources seen as critical for human well-being. But, as in Global Orchestration, people in this scenario see the environment as secondary to their other challenges. They believe in the ability of humans to bring technological innovations to bear as solutions to environmental challenges after these challenges emerge. Adapting Mosaic The Adapting Mosaic scenario depicts a fragmented world resulting from discredited global institutions. It sees the rise of local ecosystem management strategies and the strengthening of local institutions. Investments in human and social capital are geared toward improving knowledge about ecosystem functioning and management, resulting in a better understanding of the importance of resilience, fragility, and local flexibility of ecosystems. There is optimism that we can learn, but humility about preparing for surprises and about our ability to know all there is to know about managing socioecological systems. Initially, trade barriers for goods and products are increased, but barriers for information (for those who are motivated to use it) nearly disappear due to improving communication technologies and rapidly decreasing costs of access to information. There is great regional variation in management techniques. Some local areas explore adaptive management, using experimentation, while others manage with command and control or focus on economic measures. Eventually, the focus on local governance leads to failures in managing the global commons. Problems like climate change, marine fisheries, and pollution grow worse, and global environmental surprises become common. Communities slowly realize that they cannot manage their local areas because global problems are infringing, and they begin to develop networks among communities, regions, and even nations to better manage the global commons. The rebuilding is more focused on ecological units, as opposed to the earlier type of management based on political borders that did not necessarily align with ecosystem boundaries. The TechnoGarden scenario depicts a globally connected world relying strongly on technology and on highly managed and often-engineered ecosystems to deliver needed goods and services. Overall, eco-efficiency improves, but it is shadowed by the risks inherent in large-scale human-made solutions. Technology and market-oriented institutional reform are used to achieve solutions to environmental problems. In many cases, reforms and new policy initiatives benefit from the strong feel for international cooperation that is part of this scenario. As a result, conditions are good for finding solutions for global environmental problems such as climate change. These solutions are designed to benefit both the economy and the environment. Technological improvements that reduce the environmental impact of goods and services are combined with improvements in ecological engineering that optimize the production of ecosystem services. These changes co-develop with the expansion and development of property rights to ecosystem services, such as requiring people to pay for pollution they create or paying people for providing key ecosystem services through actions such as preservation of key watersheds. These rights are generally created and allocated following the identification of ecological problems. Because understanding of ecosystem function is high, property rights regimes are usually assigned long before the problem becomes serious. These property rights are assigned to a diversity of individuals, corporations, communal groups, and states that act to optimize the value of their property. We assume that ecological
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management and engineering can be successful, although it does produce some ecological surprises that affect many people due to an over-reliance on highly engineered systems.
