Vital Connections: Science, Society and Sustaining Health

Meteos is a not-for-profit company that undertakes cross-sector, multi-stakeholder dialogues to accelerate solutions to a range of systemic social and environmental challenges. Meteos uses a highly consultative, research-based approach to facilitation. Our dialogues provide a forum for senior figures in the corporate sector, civil society, public sector and investment worlds to share different perspectives on the major trends that will shape market, regulatory and societal outcomes in coming years. The dialogues analyse the speed and direction of these trends and provide an opportunity for those who will determine future outcomes to work together to achieve an alignment of interests.

The Wellcome Trust is a global charitable foundation dedicated to improving health. Our Strategic Plan sets out five major challenges that we committed to address within the overall mission and charitable objectives of the Trust. Challenge 5 is “Connecting Environment, Nutrition and Health”.

It is recognised in the Strategic Plan that this is an emerging area for Wellcome that will need to be developed further in order for us to make a significant contribution to the global response, given the magnitude of the issues at stake. A “Sustaining Health”

team was created to lead on this development. To support their work, the team commissioned Meteos to provide Wellcome with an independent perspective.

This report is a key output of that commission and it will be considered by an advisory panel to the Wellcome Trust Board of Governors during Q1 2015. It will inform our developing agenda as we decide how Wellcome can have an impact in this field. We also think it important to share the report with the wider community, as we believe it can inform the work of others looking to play their part in tackling these challenges.

We would like to take this opportunity to thank Sophia, Becky, Marloes, Zoe, Constance and all of the participants in the Sustaining Health Dialogue for their thoughtful insight, support and valuable counsel.

Sarah Molton & Ted Bianco Sustaining Health Team, Strategy DivisionThe Wellcome Trust

Foreword

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In 2009, Connecting Environment, Nutrition and Health was introduced as one of the Wellcome Trust’s five challenges in its Strategic Plan 2010-2020. The Trust’s Sustaining Health team, created to lead on this area of work, commissioned the think tank, Meteos, to provide an external perspective on whether and how the Wellcome Trust could scale up its grant-making and policy work in this area. Meteos sought this perspective by running the Sustaining Health Dialogue with a Core Group of experts from academia, NGOs, social enterprise, business and government. The focus of the Dialogue was on how scientific and technological advances could contribute to Sustaining Health. This report presents its findings.

Ecological Overreach: Health, Nutrition and EnvironmentAdvances in medicine, medical devices, diagnostics, surgery and disease management over the past 70 years have contributed to a belief in the inexorable progress towards longer, healthier lives. But there is worrying evidence that this forward trajectory is halting, or even reversing. The spread and virulence of infectious diseases is increasing, obesity has reached epidemic proportions, and there has been a rapid (poorly understood) rise in immune dysfunctions.

Advances in understanding of the complex and interdependent determinants of health underline the importance not only of social and physiological factors, but also of the physical environment.

It is apparent that if the complex global systems we rely on for clean air, fresh water, healthy soil, biodiversity and a stable climate are threatened, so too is nutrition, health and, ultimately, life. There is currently a poor ecological fit between what we are asking of the planet and its capacity to provide for current and future generations. The number of people in the world is placing severe pressure on food, water, climate and biodiversity systems. As the population increases, net global food demand – and demand for animal protein in particular – is set to accelerate rapidly. At the same time, half the world’s population is either undernourished or obese/overweight. Approximately 840 million people remain inadequately nourished, while obesity rates have doubled

Executive Summary

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since 1980, increasing the risk of type 2 diabetes, hypertension, coronary heart disease and various cancers. Nor do we eat all the food we produce: one in three kilograms of food is wasted. Eliminating food waste would feed hungry people and reduce CO2 emissions and land use.

Our oceans are also under threat. Poor management, over-fishing and lack of regulation have left 75% of the world’s marine fish stocks fully exploited or over-exploited. In this already stressed system, higher levels of CO2 absorption are leading to ocean acidification, which is happening faster than at any other time in the last 65 million years.

The demands of humanity extend to the air we breathe and the atmosphere that supports life. Air pollution exposure is today the world’s greatest single environmental health risk. In future, high ambient temperatures associated with climate change are likely to lead to significant health impacts due to shifting patterns of disease vectors, social responses such as migration, and the potentially wide-ranging effects of heat waves, droughts, floods and fires.

The spread and virulence of many infectious diseases are being encouraged by population growth, urbanisation, mega-agriculture and deforestation. Intensive agro-industry comes with risks of cross-contamination, as does the dramatic increase

in the movement of people. This increased risk of infectious disease is taking place against a backdrop of rising antibiotic resistance, raising fears that previously curable or treatable infectious diseases are once again becoming untreatable. These concerns are compounded by the use of antibiotics in veterinary medicine and in agriculture, aquaculture and horticulture.

In the future these challenges will intensify. Land and water scarcity – already demanding for seven billion of us – will be more so when there are up to four billion more mouths to feed and bodies to shelter, and when the direct and indirect impacts of climate change and biodiversity loss on health become more pronounced.

Despite the extent of the challenges, we live in an era of extraordinary technological advance. New discoveries can now be distributed at speed and scale, not just across the globe but far into space. Somehow we must find the resources – financial, social, political and ethical – to harness these sophisticated tools and capabilities to overcome the health, nutrition and environmental challenges before us.

Science and Technology: Saboteur and Salvation

We live in an era of unprecedented knowledge about how to use technology to promote health. Advances

in biomedical science are combining with social sciences to yield new insights into prospects for improving health. We also live in an era of unparalleled generation and collection of data, which can be analysed to provide findings of extraordinary scope and complexity.

Science and technology are already at the heart of our complex relationship with food, health and the environment; the Haber-Bosch process has been the keystone of industrialised food production for decades. More recently, genetic selection has transformed animal husbandry and crop production. Our challenge is to ensure that scientific and technological advances become part of the solution rather than the problem.

Bench science will be vital. There have been major advances in nutrition science, which, though a young discipline, holds great promise for improving our diets. But to reverse obesity it will need to harness knowledge from other disciplines such as behavioural psychology, psychobiology and behavioural neuroscience, to help us understand human behaviours relevant to food consumption.

Meanwhile, we still have a malnutrition problem. Crop biofortification seeks to deal with micronutrient deficiencies in the developing world, and has made big advances. But crop fortification is unlikely to be enough in the face of far greater environmental change. Scientific research is therefore seeking

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to decipher genetic codes to enhance crop resilience against the threat of rising temperatures, lower rainfall, and violent extremes of drought, flooding and storms.

Advances in high-level bench science will need to be accompanied by cross-disciplinary learning and research into the relationship between environment and health. Interdisciplinary research, however, is not easy and will have to tackle a number of difficult issues – such as standardisation of methodologies and agreement of research approaches – to achieve its goals.

Scientific advances are of limited value without application. Extraordinary examples abound of enabling technologies with the potential to make a major contribution to environmental management and nutritional and health outcomes. Most striking is the rise of digital health, which is now big business. In the developing world, efforts to improve digital healthcare are focused most heavily on the growing use of mobile phones.

Technology is also transforming agricultural production, allowing producers to be more efficient in their use of water, land and fertiliser. Advanced technologies

are being used in urban planning, and remote sensing and satellite imagery is being used to measure rainfall patterns, fire risk, crop production, terrestrial ecosystems and coastal-zone ecosystems, and to help us understand the links between air quality and disease. The cost of these advanced technologies, however, remain beyond the reach of most people.

What Needs to Happen?The scale of ecological overreach and its impacts on health requires immediate and urgent action. The original version of this report for the Wellcome Trust outlined a number of specific options for the Trust to consider. It is nevertheless clear that the agenda is highly relevant to us all. For science and technology to be (re)directed to address issues such as under-nutrition, biodiversity loss and climate change, the report concludes, five things need to happen.

First, we need to break down boundaries that exist between academic disciplines and across institutions, and bring different skill sets to the problem. Second, we all need to extend our timeframes to think not just of short-term gains, but also of the longer-term implications of our actions. Third, we need to commit to a new, collaborative leadership to create a compelling

shared vision of the future that we want to work towards. Fourth, this future can no longer tolerate the exclusion of marginalised and younger people. Finally, we need to agree on a new ethical framework to underpin our aspirations to achieve a sustainable future.

This report is written as a contribution to wider efforts to address Sustaining Health challenges. It is written in an important year. In December 2015, governments from across the world will meet in Paris at the 21st Conference of Parties (COP) in another attempt to come to agreement on climate change. The COP provides the most immediate opportunity to weave together multi-disciplinary understanding, collaborative leadership and justice in a binding long-term commitment to drastically reduce carbon emissions. Given the projected impact of climate change on health, if achieved, this would be the most significant step imaginable for the Sustaining Health agenda.

Even if this goal is reached it will be a beginning not an end. Ongoing commitment from all stakeholders to take their part in this multifaceted challenge will be essential to making significant progress on Sustaining Health.

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Introduction to the Sustaining Health Dialogue

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Faced with a burgeoning human population and environmental pressures ranging from biodiversity loss to climate change, there is a growing call for cross-disciplinary, multi-sector approaches to understand and address such complex challenges. The interaction between health and the environment is of particular interest. Many climate and health events took place around the UN Secretary General’s Climate Summit in September 2014 and the World Health Organization (WHO) Climate and Health conference, two weeks before. Foundations, academics, researchers and public-private partnerships are driving a growing number of initiatives linking climate change, biodiversity, water availability and agricultural production with human and animal health.

As a contribution to this work, the Wellcome Trust commissioned Meteos, a non-profit think tank that specialises in research-based facilitation, to provide an external perspective on whether and how the Trust could scale up its work on Sustaining Health. Meteos sought this perspective by running the Sustaining Health Dialogue, a structured consultation with a Core Group of experts from academia, NGOs, social enterprise, business and government. The group was selected to represent the multidisciplinary, partnership and global ambitions of the

Trust, as well as its focus on high quality research and tangible outcomes in the real world. The Dialogue ran from October 2013 to November 2014. Its conclusions are the result of two face-to-face workshops, substantial desk research, the academic submissions of many of the Core Group members, and a multi-stakeholder consultation held in New York to coincide with the UN Secretary General’s Climate Summit and Climate Week.

The Dialogue was designed to contribute to the Wellcome Trust’s thinking about Sustaining Health: the interface between health, nutrition and the environment. Given the Wellcome Trust’s focus on research and its application to improve human and animal health, the Dialogue concentrated on the role of science and technology and was intended for a particular audience. Despite this, the quality of inputs, extensive research, and the diversity and brilliance of the Core Group led the Trust to ask Meteos to ensure that the Dialogue’s findings and their implications be made available to others working in related fields. This public version of the report is therefore written as a contribution to wider debates about the steps we might take to address health, nutrition and environmental challenges in holistic, equitable and successful ways.

“ The biggest threat we

face is the non-linearity

of environmental systems.

We’re basing expectations

on previous experiences.

Environmental systems are

so complex though, and there

might be unexpected non-

linear changes which mean

the system will change at

a faster pace.” *

“ People need to start

getting into their brains

that they have to take

responsibility for health

and wellbeing, which means

living in environments that

don’t threaten physical and

mental health. Government

must provide information

and put in place measures

to prevent people getting

sick in the first place.”

* All italicised quotes are from interviews conducted with Core Group participants during the Sustaining Health Dialogue.

Ecological Overreach: Health, Nutrition and Environment

Advances in medicine, medical devices, diagnostics, surgery and disease management over the past 70 years have contributed to a belief in the inexorable progress towards longer, healthier lives. Child mortality rates are falling, stunting is decreasing, successful smoking prevention has reduced cardiovascular disease and lung cancers in some places, and we are living much longer. However, there is worrying evidence that this forward trajectory is halting, or even reversing. Infectious diseases continue to account for over a fifth of human deaths and a quarter of morbidity, and multiple factors look set to accentuate their spread and virulence.1 Obesity has now reached epidemic proportions, with all the implications that brings for heart disease, diabetes and cancers. At the same time there is a rapid, but poorly understood, rise in immune dysfunctions – allergies, asthma, autoimmune diabetes and inflammatory bowel disease. The massive health gains of the past 70 years for much of the world’s population risk being undermined; no sooner

has one health challenge been successfully tackled than another emerges to take its place.

Advances in our understanding of the complex and inter-dependent determinants of health are reminding us of the importance not just of the social and physiological factors, but also of the vital role the physical environment plays in health. Immediate local factors, such as air pollution or the availability of clean water, matter hugely. But so too do the complex global systems we rely on for clean air, fresh water, healthy soil, biodiversity and a stable climate. And we are increasingly coming to realise that if they are threatened, so too is nutrition, health and, ultimately, life.

The more we understand about the interactions between humanity’s reliance – and impact – on natural resources, the more we realise that there is a poor ecological fit between what we

are asking of the planet and its capacity to provide for current and future generations.

Viewed positively, we live in an era of extraordinary technological advance. New discoveries can now be distributed at speed and scale not just across the globe but far into space. In recent years humanity has successfully landed the rover, Curiosity, on Mars after a 570 million km journey from Earth, manoeuvring reduction of entry speed from 20,000 km per hour to 0.6 miles per second; Internet and satellite technologies have transformed communications, reshaping not just personal and professional interactions, but also political processes. And the cost of technology is falling; the fastest available supercomputer in 1975 cost US$5m, while in 2013 an iPhone 4 with the same performance cost US$400.2 Somehow, we must find the resources – financial, social, political and ethical – to harness these sophisticated tools and capabilities to overcome the health, nutrition and environmental challenges before us. A major part of the problem we face is that many people don’t know - or can’t afford to – care about the damage our current systems and lifestyles are inflicting. Yet our attitudes,

“ There’s been a lot of progress on health. Child mortality

is declining rapidly, the AIDS pandemic is subsiding, life

expectancy is increasing. All these are good signs. But at the

same time, the sustainability dimension is getting worse and

this includes environmental threats to health. We don’t know

what the consequences of the overuse of resources will be.

That’s the scary part.”

“ The environment has more impact than we ever expected.

We are creatures of our environment. We construct our beliefs

given our environment.”

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expectations and understanding of health (our own and that of the planet) will be key to defining whether and how we successfully address the Sustaining Health challenge. There are signs of a dangerous attitude of resignation to and acceptance of some of these health trends that will need to be overcome.

Food, Food Everywhere… Yet Not Enough Nutrients

Already, nearly half the world’s population is either undernourished or obese/overweight. Approximately 840 million people are

affected by inadequate nutrition, which still causes 45% of deaths in children under five (about three million per year).3 One-third of the global population receives inadequate iron, vitamin A, iodine and zinc from their diet – macronutrients essential for growth and development.4

At the same time, obesity rates have doubled since 1980, affecting over 40 million children under the age of five today.5

Obesity is a prime risk factor for type 2 diabetes, and increases the risk of hypertension, coronary heart disease and various cancers.6 Its consequences – financial, health, wellbeing and societal – are now among the most significant challenges facing both Western and a growing number of developing countries. In an ironic twist, there is dismaying evidence that it takes just two generations for a family to move from malnutrition caused by having too little to eat, to malnutrition from too much of the wrong food.7

“ We need to address the amount of money put into

maintaining health, which is miniscule compared to the

money put into treating disease. The nutrition community

has so far made a poor argument about prevention.

I want to see dieticians in doctors’ offices.”

“ We need a new model for conducting human research

that produces results faster; the outcomes of which can be

used to implement change.”

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The High Cost of High-Protein Diets

Global food demand is set to accelerate, with some estimates of demand-increase as high as 70% on today’s production by 2050.8 Nor is it just about quantity. Economic development has been accompanied by a “nutrition transition”, where subsistence on vegetables is making way for an increasing demand for animal proteins.9

The number of people regularly eating eggs, meat and dairy products could reach three or four billion by 2050.

To grow more food without increasing agricultural land is a huge challenge. To do so in a way that does not further degrade the natural environment, even more so. Agricultural production already eats into rainforests, swallows vast quantities of water, and – with forestry and other land use – belches out a quarter of the world’s greenhouse gases.10 Poorly-used fertiliser can result in excess nitrogen running down rivers and into seas, reducing available oxygen and leading

to algae bloom and damaged ecosystems. Given all this, it is especially scandalous that an estimated one in three kilograms of food is then wasted.11 Eliminating food waste would not only feed the needlessly high numbers of people who go to bed hungry; it would also reduce CO2 emissions by 10% and the amount of land used for agriculture by 30%.12

The Sea, the Sea

Until recently, despite its vital role in food security and economic stability, the ocean has been relatively overlooked in debates about food.13 Demand for fish – already an essential source of protein for three billion people – is projected to rise by 50% by 2050.14 Poor management, over-fishing and lack of regulation have left 75% of the world’s marine fish stocks fully exploited or over-exploited.15 Recent fishing moves into deeper, less regulated, high seas are creating huge pressure at the very heart of the ocean’s ecosystem.16 In this already-stressed system, higher levels of CO2 absorption are

leading to ocean acidification, a phenomenon that is happening ten times faster than at any other time in the last 65 million years.17

“ Systemic change happens

when social change happens

[…] What will bring lasting

change is an attitude that

food is simply too precious

to waste.”Pollution and the Air We Breathe

The demands of humanity on land and oceans extend to the air we breathe and the atmosphere that supports life. Since the Industrial Revolution we have grappled with the noxious impacts of industrial and urban pollution on air quality. Today, although indoor air contamination from cooking with solid fuels and smoking remains hugely problematic in developing countries, it is traffic and industrial-related outdoor air pollution that is the greater challenge – forcing policy makers to respond to growing public protest at the resulting stinging eyes, scorched throats and burning lungs. It was in part the (publicly demonstrated) concern about local air pollution that prompted the Chinese government to introduce mandatory cuts in sulphur dioxide and nitrogen dioxide emissions from coal-fired plants in its 12th Five-Year Plan (2011-15).18 In the US, too, the Environmental Protection Agency (EPA) Clean Power Plan of 2014 set the first-ever national carbon

“ There’s an urgent need to build awareness among people

under 35, who can then put pressure on others to make change.

Polls show that food is an issue they care about. After all, it’s

them who are changing their diets.”

“ The association between economic wealth and social

class is what is driving a huge amount of disease. COPD and

cardiovascular disease are pretty much accepted in Scotland

as an inevitable part of ageing if you are a 50-year-old male.

A fatalistic approach to disease means there is no motivation

to change diet or stop smoking.”

pollution limits for America’s existing power plants, citing direct health benefits as a main reason for the regulation.19

A 2013 WHO report declared air pollution exposure to be the world’s greatest single environmental health risk. It has come to account for one in eight of total global deaths – a doubling of previous estimates.20

This ambient air pollution, particularly in and around cities, is directly linked to the rise in respiratory diseases and some cardiovascular conditions. By 2030, chronic respiratory conditions,21 particularly asthma and COPD, will have overtaken their infectious counterparts as a leading cause of death everywhere except Africa.22

Infectious Diseases

“ We thought we had

it covered. I’m concerned

though that we haven’t fully

grasped the re-emergence

of infectious diseases.”Nor is the battle to overcome infectious disease won. The human population is predicted to rise to ten billion by 2050. Ninety-five percent of this increase is predicted to take place in cities in the developing world, where lack of water and sanitation, and poor infrastructure, creates

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“ Although we thought asthma had plateaued, it seems that

PM 2.5 may double its incidence. Are there things we can

do today – more sunshine and exercise, less smoking and

pollution? What happens if we research all those things at

the same time?”

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“ There’s more awareness, but it hasn’t yet been translated

into real, significant changes in the physical environment for the

people who are affected most. In the south Bronx, asthma rates

are 11 times higher than the US norm, and there are 12,000 diesel

trucks that go in and out each day. So it seems like a no-brainer

to make those trucks less pollutant, but it means tackling the

power of the financier and cross-sector restructuring.”fertile ground for the spread of infectious disease.23 Pneumonia, bronchitis and tuberculosis have been persistent entries on mortality and morbidity charts since they began, and stretch back long before then. Infectious respiratory disease is a particular risk in lower-income countries and disproportionately affects children. Infectious diseases are the number-one cause of childhood deaths worldwide (after premature births).24 They also plague the elderly, who account for nearly half of infectious respiratory deaths.

“ We need to get to

grips with global ecology;

both with the development

of resistant bacteria

and viruses, and also

the impact on vectors

of new antibiotics and

new antivirals.”This all takes place against a backdrop of rising antibiotic resistance. Many of the medical breakthroughs of the last century could be severely affected by the loss of prophylactic antibiotics. Similarly, previously

curable or treatable infectious diseases could once again become untreatable. This has already started to happen. And concerns about antimicrobial resistance are compounded by growth in the use of antibiotics in veterinary medicine and for growth promotion and disease prevention in agriculture,aquaculture and horticulture.25

Infectious Diseases and Intensive AgricultureThe spread and virulence of many infectious diseases are being encouraged by population growth and the resulting urbanisation, mega-agriculture and deforestation. Intensive agro-industry to produce food quickly and cheaply comes with serious risks. Concentrated animal-farming methods, often near urban centres or forests, provide havens for communicable zoonotic diseases (diseases that originate in animals). Since many countries

lack the necessary public health infrastructure and/or education to combat disease, it spreads further and becomes deadlier. Zoonotic diseases account for 75% of the emerging infectious diseases.

Migration and the Spread of Infectious Disease

The dramatic increase in the movement of people – both within and between nations – is already setting off alarm bells for those who understand the well-established links between migration and the introduction of disease.26 Migratory movements are complex and multiple, involving various age groups and socio-economic profiles, and may be seasonal or permanent. They are driven by economic factors, political upheaval and possibly by climate change, aided by the tailwinds of improving transport and communication infrastructure. Refugee camps and extensive informal urban settlements – with poor access to water and sanitation – are often hotspots for disease.

Migration provides ideal conditions for the rapid spread and re-emergence of infectious diseases. Aircraft have been described as “petri dishes” for microbial growth – the

“ The issue of population growth is key. It puts huge pressure

on health, environment and nutrition. The human and animal

interface fuels diseases, increases costs, causes environmental

damage and puts pressure on food production.”

re-emergence of dengue fever in the US during the 2000s was thought to be due to traveller-imported viruses transmitted via local mosquitos.27 The spread of Ebola into the US and EU (so far a handful of contained, isolated cases as a result of returning healthcare workers) also demonstrates the ease of transmission.

Precisely how these factors, individually and by interaction, increase the risk of infectious disease is not fully understood. But there is a clear need for global strategies both to fight the spread of disease and control the risk factors that appear to promote it. It has been underlined most recently by the Ebola outbreak, but also by the SARS crises of the mid-2000s, the 2009 swine flu pandemic, the threat of various strains of avian

influenza, the re-emergence of drug-resistant tuberculosis and vigorous growth of dengue fever cases.

More Intense Challenges AheadLooking to the future, the challenges associated with the links between environment, nutrition and health will intensify. Land and water scarcity – already demanding for seven billion of us – will be more so when there are up to four billion more mouths to feed and bodies to shelter,28 and when the direct and indirect impacts of urbanisation, climate change, water scarcity and biodiversity loss on health become more pronounced.29

Climate change is a particular concern. Although in its Fifth Assessment Report of 2014

the Intergovernmental Panel on Climate Change (IPCC) found that climate change is more likely to exacerbate existing health challenges than create new ones, this is only for now. In future it predicts that climate change impacts on agricultural productivity will be net negative. Under-nutrition is known to have a direct and immediate impact on children’s development and adults’ susceptibility to disease. Therefore, as the number of places that are food-insecure increases, so too does the number of vulnerable people. At the other end of the malnourishment spectrum, as temperatures rise, the IPCC predicts that health impacts will be borne disproportionately by overweight/obese people with poor heat tolerance. Chronic diseases associated with these conditions, such as diabetes and ischemic heart disease, magnify the risk of death or severe illness associated with a hotter world. Climate change also affects respiratory health by exacerbating the existing acute and chronic impacts of particulate matter (PM). It is also likely to lead to other significant health impacts due to shifting patterns of disease vectors, social responses such as migration, and the potentially wide-ranging effects of heat waves, droughts, floods and fires.30

“ We tend to look at climate change as a factor in

isolation, but what you have to do is look at climate change

plus ocean acidification, because that’s going to affect all

of the marine food chain, plus the thermal stress of labour

productivity, as that will probably prevent subsistence

farmers from working anyway. Nobody’s really looked

at the combined effect of all these and how one might

ameliorate it all.”

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“ In China and India alone, there will be around

a billion people moving to cities from the country.

There are 70 million in India with no access to clean

water or sanitation, and we’re talking about 100 million

more in the next ten years.”

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The Speed of ChangeDespite the scope of the challenge, the speed of change today – largely driven by the exponential speed of change in technology – could be a positive factor. Moore’s Law, which dictates that computer-processing speed doubles every 18 months, comes with the risk of accelerating runaway problems but also provides opportunities to speed up the introduction of solutions. As one participant in the Dialogue put it, “technology has a habit of solving the problems it creates”. The next section explores the potential role of science and technology in addressing Sustaining Health challenges.

“ Change is a process

that moves from awareness

to consensus to strategic

focus. We are still at the

awareness phase, with lots

of competition for that

awareness. There are an

awful lot of attitudes that

are not well-founded or

grounded. We need more

awareness with a scientific

base to move discussion

forward.”

Science and Technology: Saboteur and Salvation

We live in an era of unprecedented knowledge about how to use technology to promote health. Advances in biomedical science from molecular, cellular and structural biology are combining with other disciplines – anthropology, social science, philosophy and economics – to yield new insights into prospects for the prevention, management, treatment and cure of a wide range of diseases. We also live in an era of unparalleled data generation and collection. The world’s technological per-capita capacity to store information has roughly doubled every 40 months since the 1980s; it is now estimated that 2.3 trillion gigabytes of data are created each day.31 This data, particularly when aggregated as “Big Data” – digital data gathered from multiple computer-generated sources and crowd-sources – can be analysed to provide findings of extraordinary scope and complexity. Little wonder therefore that the Sustaining Health Dialogue, with its focus on science and technology, spent considerable time discussing the potential of these different knowledge-sources to meet Sustaining Health challenges.

Building the Science for Solutions

Science and technology are already at the heart of our complex relationship with food, health and the environment. Since its discovery a hundred years ago, the Haber-Bosch process, which “fixes” atmospheric nitrogen – converts it into some bioavailable form – has been the keystone of industrialised food production. An estimated 50% of protein in humans is made of nitrogen converted into ammonia in this way.32 Fertilisers and synthetic chemicals underpin intensive agriculture, which produces the bulk of the most frequently traded agricultural commodities: maize, wheat, rice, soybeans and potatoes. Genetic selection has transformed animal husbandry to ensure that chickens, for example, grow bigger and faster – ready for slaughter in five to seven weeks, instead of their natural growth span of twelve weeks.33 Science and technology are helping to feed us all, and to feed many of us rather too much. Our challenge is to ensure that scientific and technological advances become part of the solution rather than the problem.

Bench science will be vital. There have been major advances in understanding of micro- and macro-nutrient absorption in the human body, as well as early understanding of nutrient-nutrient interactions. Imaging and -omics (fields of biological study, such as genomics, proteomics and metabolomics) research has given us epigenetics (understanding of heritable changes in gene expression) and understanding of how gene function may be influenced by environment. It has provided cellular and molecular disease models and understanding of how nutritional interventions may influence them; and finally, it is leading to more sophisticated studies to determine nutrient status and evaluate how different populations respond to the same dietary intervention. Although nutrition is a very young science, which has yielded few actual outcomes, it holds great promise.

This promise will be invaluable to attempts to improve our diets. But to reverse obesity, it will need to be accompanied by knowledge from other disciplines as well. Behavioural psychology can help us understand how to influence the way people think and act in response to information and incentives, while psychobiology is starting to uncover the influence of contextual cues on eating, as well as the neural and physiological pathways underlying certain food-related behaviours.34 This can then

“ Our challenge is to shift to farming nutrients and using

scarce resources to have better diets rather than producing

crops for fuels or cows. Instead of focusing on increasing

productivity in corn, companies should look at how to put

more nutrients into crops that are already productive.”

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be combined with behavioural neuroscience, which is helping us understand the subtle, often illogical realities of human behaviours relevant to food consumption: the tendency to fear losses relatively more than enjoying gains, and to live for today at the expense of tomorrow. Fresh at the cutting edge is neuroeconomics, which seeks to integrate economic theories of decision-making and psychological insights into behaviour with actual neural

function in the brain.35 The extent to which this science can be applied to help us understand attitudes and habits will make an important contribution to determining how changes in behaviour can be incentivised and consolidated.

Meanwhile, scientific advances haven’t solved the globe’s malnutrition problem. Crop biofortification is an attempt to breed crops to enhance their nutritional value and provide an important means of dealing

with micronutrient deficiencies in the developing world. Many such efforts, public and private, are underway to fortify a variety of crops including wheat, sweet potato, maize, beans, cassava, rice, bananas and millet. Typically they are enhanced with vitamin A, iron, zinc or protein. But fortified crops face regulatory and commercialisation hurdles (Golden Rice is 15 years old and still not approved).36 And even if these hurdles are removed, fortification is unlikely to be enough in the face of far greater environmental change, where crops will need to be able to withstand not just gradually rising temperatures or lower rainfall, but violent extremes of drought, flooding and storms. As a result, there has been a burgeoning

“ It’s very difficult to get customers to change behaviour,

unless there is a shock. We’re more successful if we look at

what people already eat and make that healthier, rather than

persuading people to eat different stuff. But, getting 22 million

customers a week to drive a health change, no.”

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of scientific research seeking to decipher genetic codes to enhance resilience. Wheat and potato genomes have both been unravelled in recent years, providing scope for nutritional improvement as well as resistance-related enhancement to allow varieties to be grown at different latitudes.37

Non-genomic technologies are important too: high-intensity, focused x-ray beams can be used to determine where and how each mineral is present in wheat grains, potentially allowing strains with low nutritional value to be screened out, while zapping potatoes with electricity can enhance their nutritional value.38

Simply selecting different crops to grow can also help. Legume crops, such as peas, pulses, chickpeas and the common bean, contain as much as twice the micronutrients of cereals, don’t require nitrogen-based fertilisers and are highly nutritious (protein, starch, fibre, low-fat). There is still some concern about the long-term impacts of genetic modification, but even for those who do not share those concerns there is a strong case for growing and eating more legumes.39

As impressive as advances in high-level bench science are, the crop biofortification story shows how they are a necessary part of the solution but insufficient in themselves. Science needs to be accompanied by political commitment and appropriate incentives to guarantee its selection, application and widespread use. And just as science on its own can’t solve Sustaining Health without technology and application, nor can one discipline on its own find the most effective solution.

Moves to Inter-disciplinary Science For this reason, the increased appetite for cross-disciplinary learning is particularly evident in nutritional science (though is by no means confined to it). It is fascinating to see how, in the process, findings and insights are leaching into other therapeutic areas (and back again). Nutritional research is leading to respiratory findings,

and respiratory research is leading to the gut. Obesity has long been known to increase the risk of cardiovascular disease, type 2 diabetes and certain forms of cancer. Recent studies show it is also associated with an increased risk of a variety of respiratory disorders, including obstructive sleep apnoea, obesity-hyperventilation syndrome and asthma. Respiratory research has moved on from the lungs to study how interventions in the gut can reset the body’s immune balance by triggering innate responses – involving lungworms and faecal matter in the process. And recently, at least one school of thought is attributing the rapid rise of autoimmune dysfunctions to changes in gut bacteria resulting from the use of antibiotics.40

Beyond the medical, interdisciplinary research is exploring the relationship between environment and health; recent publications in this area have looked at the effects in Europe of air pollution on cerebrovascular events, and on blood pressure.41 There is growing interest, too, in how reduced contact with natural biodiversity might affect human microbiota (gut flora) and its

“ The real challenge is how do you mine big data in a way

that is directional to identify the next set of issues we have to

manage. We don’t know how to think about big data, much

less know how to use and harness it. It’s like inventing a fire

without a fireplace.”

“ There are very interesting data on probiotic protection

against asthma. By affecting the mucosal lining of the gut

you can drive a phenotypic response to asthma. It’s all very

interesting and unexpected. But we really do need rigorous

scientific research to avoid the muck and the magic.”

immunomodulatory capacity.42 Multi-institutional projects like these are matched by the growth of interdisciplinary research faculties at universities. The European Centre for Environment and Human Health at Exeter University supports interdisciplinary research initiatives into connections between the environment and human health, while Vermont Center on Behavior and Health, funded by the National Institute of Health, applies knowledge from behavioural economics and behavioural pharmacology to investigate links between behaviours and the risk of chronic disease and premature death.

Initiatives like these will be crucial to understanding the links between nutrition, health and environment, but it is important to note that interdisciplinary research is not easy and will have to tackle a number of difficult issues – standardisation of methodologies, development of appropriate incentive and reward structures, agreement of research approaches – to achieve its goals.

Applying Science and Directing Technology to Sustain Health Scientific advances would, of course, be of limited value without application. Extraordinary examples abound of enabling technologies with the potential to make a major contribution to environmental management and nutritional and health outcomes.

In the medical field they range from breakthroughs in pharmacology, such as the so-called “checkpoint inhibitors” which disable a mechanism that cancer cells use to escape the immune system (effectively galvanising it to attack the cancer), to novel diagnostic devices such as a “smart” contact lens that can monitor blood-sugar levels via tear fluid.43 This particular technology is still a way off every day application, but plenty of already-available wearable gadgets and monitors are part of the revolution in healthcare driven by new digital capabilities.

Digital health is now big business. Investment in digital-health firms has doubled to almost $2bn in the US since 2011.44 IT products and services

range from electronic health (or medical) records (EHR), used to monitor large-scale clinical workflow; analytics and Big Data; digital medical devices; wearables/sensors; population health management; “digital medicines” (which put ingestible sensors into pharmaceuticals to monitor compliance); and healthcare consumer engagement around the “quantified self” through the use of healthcare apps, designed to be fun and informative. Since 2012, digital-health investment is up 40%, compared with traditional biotech (8% growth in investment) and non-health-related software investment (up 27%).45

In the developing world, many efforts to improve digital healthcare centre on the growing use of mobile phones, to which nearly 50% of people have access.46 Such efforts, which combine resources from mobile phone companies with those of international aid organisations and charities, include attempts to improve patient medication adherence and epidemiological monitoring. In addition, cameras and laptops are being used to capture and send images of rural patients to specialists in cities or other countries as a way of addressing the shortage of trained experts.

Technology is also transforming agricultural production, and “precision farming” could play

“ There’s a boom in apps for self-monitoring – and

theoretically, the consumer is empowered to measure

everything they want. How do I sleep? How do I run?

But the science behind them isn’t great. Lots of apps

are quick and dirty.”

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a huge part in addressing hunger and improving sustainable agricultural production. It allows producers to be much more efficient in their use of water, land and fertiliser, by providing site-specific irrigation and sensors to monitor soil electrical conductivity, ground elevation, acidity and organic-matter content. Farmers can use telematics (“robot tractors”) or high-flex tyres to reduce soil impaction. In the future, drones are likely to be used widely to map field use, take multi-spectral images to monitor plant health, expose irrigation problems and infections, and survey crop damage.47

Advanced technologies are also being used in urban planning in cities where the majority of us live.48 The global market for smart city technology is set to grow from US$6.1bn in annual revenue in 2012 to US$20bn by 2020 – growth of 16% a year.49 Smart energy management, smart water management and smart transport management are the key drivers of this growth

(with smart buildings and smart government coming in behind).

Remote sensing and satellite imagery is another new and evolving technology. It has particular use in agriculture and food production as it can measure and demonstrate climate change effects on different regions. These techniques can also measure rainfall patterns, fire risk, crop production, terrestrial ecosystems and coastal-zone ecosystems. A better understanding of the effects of climate and geophysical effects on agriculture enhances our ability to undertake seasonal forecasting, investigate the correlation between geophysical features and nutrition/health, and even underpin insurance. It can also help us understand the links between air quality and

disease. Satellite-generated weather forecasts can be combined with digitally enabled crowd-sourced medical data and sensor-provided air-quality data to manage disease symptoms and improve air quality.50

Balancing Private and Public GoodTechnology is all very good in theory, but of course, we face huge challenges in making it available where it is most needed. The advances of digital health and precision farming, for example, disproportionately end up in the hands of those who can afford to pay for them. Unless we successfully address the question of affordable access to new technologies, inequality will continue to rise. At the same time, we need to acknowledge and overcome the other barriers to disseminating all these new technologies all over the world, including limited market incentives, poor infrastructure and transport systems, insecurity and conflict.

“ There’s huge potential for Big Data to help. Take a 3G data

network, combine with a simple device in the river, add a flow

meter, and you create a mesh network of those devices that

can identify everything from illegal dumping, hydration, and

predict flash flooding hours before it’s a problem.”

“ It’s quite possible to create a network to monitor airborne

pollutants that can be collected hour by hour and correlated

with public health, cancer, lung info. From a data-analysis

perspective it would be easy to look at correlations between

spikes in public health and air-quality data.”

What needs to happen?

Breaking Down BoundariesOne big challenge – and urgent area of research – is to understand how health and nutrition interact with agriculture, climate/environment, behaviour, education, economics, social policy and politics. We need a greater understanding of the linkages in the enviro-income-nutrition-health pathway that are most critical to improve outcomes, and most amenable to intervention.

That requires knitting together the reductionist science of cellular, molecular and structural biology with the insights of social anthropologists, behavioural psychologists and economists, to explore how and why people are likely to respond to health threats and opportunities. Collaborating across disciplinary boundaries within and outside of science is challenging, and requires ongoing facilitation. It requires specialists from different sectors to speak a common language and respect common datapoints and methodologies. It requires the right incentives to share knowledge to achieve a common cause.

Such interdisciplinary arrangements are already emerging in thriving collaborations across institutional boundaries: between for-profit corporations, NGOs, governments, academics and local communities, each with complementary skills to achieve that common cause. A number of participants in the

Sustaining Health Dialogue are experimenting with these new approaches, including Mobile Metrix’s data-gathering collaboration between companies and shanty-town communities, PATH’s public-private technology partnerships, the Food and Climate Research Network, and the Nestlé Research Institute’s work with governments and communities to better understand genotype responses to nutrients.

Extending Timeframes Crossing institutional boundaries will not alone be enough; other political, social and economic conditions will be needed as well. At the heart of the Sustaining Health challenge is the need to address short-termism. This is nowhere more evident than in markets, which need to be reshaped to better reflect the social and environmental impacts of the companies in them. To be sure, market forces, together with science and technology, have sparked innovation and fuelled the speed, extent and global reach of today’s food, healthcare, energy and financial markets. But they have also magnified and exacerbated underlying trends and imbalances in how we manage our resources. In particular, they have contributed to accelerating inequalities and the concentration of wealth and power.

The successful revolution in farming and food processing, for example, has led to intense

competition to sell the high-volume, low-cost outputs and created a situation in which cheap food winks out at you wherever you go. This has made a major contribution to the obesity epidemic. This immensely powerful driver of change must be redirected to tackle our growing understanding of the long-term implications of climate change, obesity, air pollution and biodiversity loss.

There is a groundswell of initiatives to reshape market forces in this way. Some, like the Institutional Investors Group on Climate Change (IIGCC) and the UNEP FI Inquiry into the Design of a Sustainable Financial System,51 focus on creating the right policy frameworks to support long-term investment and business behaviours. Others like social impact funds or ethical or responsible investment offerings attempt to channel funds directly towards sustainability-linked outcomes. The ultimate prize is, of course, for mainstream investment flows also to be deployed to these ends. A first step to achieve this would be for investors to cross-fertilise research findings between asset classes and over longer timeframes. Greater understanding of the risks to investment opportunities presented by climate change, healthcare burdens and pollution would allow them to understand their likely impact on long-term value creation, and to invest accordingly.

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Short-termism is not restricted to markets. Governments and multilateral donor agencies also have important roles to play. They can not only influence investors’ behaviour by incentivising more desirable market outcomes; they can also get their own houses in order by making related commitments to long-term sustainability. Governments must think about – and verbalise – how the regulatory environment and public investment in infrastructure and services will contribute to (or detract from) Sustaining Health outcomes. And they can work with experts to provide an appropriate balance between regulation and public awareness-raising to help individuals understand the

long-term health impacts of the choices they make today and act appropriately.

Private funders, too, need to fund more cross-sector work, and to plan for longer time horizons and greater flexibility to adjust programmes as knowledge is generated and real-world results become clear. As such moves gather momentum they should generate longer-term rewards, both financial and non-financial.

New, Collaborative Leadership

The Dialogue returned repeatedly to the question of which levers are able to catalyse change for the

Sustaining Health agenda, and where they lie. They are held by powerful individuals and institutions – politicians and governments, top executives in large corporations, influential big-city councils, NGOs, specialist academics, donors and investors – and increasingly with the power of ordinary citizens, mediated by social media and cyber activists.

Pulling the levers isn’t trivial: it involves changing incentive structures, challenging the status quo and daring to set new, ambitious objectives. It requires leadership, boldness and vision – yet that leadership cannot be one-man/woman or one-organisation leadership; it has to be collaborative leadership.

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Collaborative, visionary leadership focused on these goals won’t be created overnight: it emerges as increasing numbers of players demonstrate their commitment to a vision that many can share, and to a narrative that is clearly communicated and which makes sense to different organisations and individuals from different sectors. The arts and culture sector, with its capacity for cultural commentary, for critique, and expression of public mood, should be brought in to play a central role in shaping that narrative.

Addressing Marginalisation and Intergenerational Equity

The Sustaining Health Dialogue identified two constituencies who are often poorly consulted or not consulted at all: namely young people and people in marginalised communities. Younger people have very different perceptions of the role, potential and dangers of new technologies, and these perceptions – which will continue to evolve – will be increasingly important. Today’s working-age adults need to involve younger people in the design

of technology-harnessing infrastructure suitable for future generations, to reflect their different priorities and world-views. The speed and extent to which technology is changing younger generations’ lifestyles and attitudes already provides strong, positive evidence of how traditional boundaries can, and are, being redrawn all the time. For tomorrow’s generation, the interlinking of health, environment and nutrition must be second nature.

This is also true of marginalised communities. Technology and data may have already connected and improved the lives of millions of people who were previously isolated, but for huge swathes of the population – communities and countries – who remain off-grid, this is yet to happen. By one estimate, 90% of data available in the world was created in the past two years.52 For those who know how to access and interpret it, this is providing unprecedented opportunities. For those who are excluded, it is exacerbating the divide. There is also a growing gap between those who are holders of knowledge, and practitioners on the ground who could apply it to the benefit of their communities.53 Ongoing engagement and

the development of new social infrastructure to build the capacity and voice of these constituencies are extremely important.

A New EthicsThe links between health and poverty are well established. One has only to look to West Africa and the spread of Ebola to realise how strong these links are and how bad things can get. Likewise, in richer countries there is evidence that the lower a person’s social position, the worse his or her health is likely to be.54 Because health inequalities result from social inequalities, we need a commitment to equity and solidarity to ensure that policy, market and behavioural solutions address this imbalance.

Second, there is a growing gap between what science and technology make it possible to do and what it is ethical to do. There is an urgent need for public debate and a new consensus about how we manage the dilemmas created by technical advances in health, such as the balance between data access and privacy, ownership of and access to genetic information, and the nature of end-of-life care.

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Conclusion

The scale of ecological overreach and its impacts on health requires immediate and urgent action. Developments in digital health, precision farming, smart cities and remote satellite imagery all illustrate the growing potential of science and technology – and Big Data in particular – to help us address the Sustaining Health agenda. But it will not happen in a vacuum. For developments like these to be (re)directed to address issues such as under-nutrition, biodiversity loss and climate change, an explicit commitment is needed from governments, companies, researchers, entrepreneurs and communities.

We need to break down boundaries that exist between academic disciplines and across institutions. We all need to extend our timeframes to think

not just of short-term gains, but the longer-term implications of our actions. We need to commit to a new, collaborative leadership to create a compelling shared vision of the future that we want to work towards – a future that no longer tolerates the exclusion of marginalised and younger people. And finally, we need to agree on a new ethical framework to underpin our aspirations to achieve a sustainable and healthy future.

Things won’t change all at once, and they won’t change overnight. But a commitment from all stakeholders to take their part in this multifaceted challenge will make a huge difference to Sustaining Health.

This report is written as a contribution to wider efforts to address Sustaining Health challenges. It is written in an

important year. In December 2015, governments from across the world will meet in Paris at the 21st Conference of Parties (COP) in another attempt come to agreement on climate change. The COP provides the most immediate opportunity to weave together multi-disciplinary understanding, collaborative leadership and justice in a binding long-term commitment to drastically reduce carbon emissions. Given the projected impact of climate change on health, if achieved, this would be the most significant step imaginable for the Sustaining Health agenda.

Even if this goal is reached it will be a beginning not an end. Ongoing commitment from all stakeholders to take their part in this multifaceted challenge will be essential to making significant progress on Sustaining Health.

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This report is the result of collaboration between all participants in the Sustaining Health Dialogue. Meteos would like to thank all those who contributed to this process, particularly the members of the Core Group, who were so generous with their ideas, engagement and, crucially, their very precious time. Without their commitment to the process and its outputs, this report would not have been possible.

This report is a team effort. It was written by Sophia Tickell, with additional writing and editorial input from Melanie Senior. Additional research and editorial support was provided by Marloes Nicholls, Becky Buell, Cassie Tickell-Painter, Gbola Amusa, Brett Scott, Constance Mackworth-Young,

Zoe Scabbiolo, Sarah Cassidy and Alexa Clay. It is also the result of the expert facilitation of the Dialogue, led by Becky Buell and supported by others in the team. Any errors or omissions in the report, however, are the author’s alone.

We would like to thank Sarah Molton, Saskia Heijnen and Ted Bianco, who somehow managed to find the perfect balance between being closely engaged with the project and allowing us full independence to come to our own conclusions. It was a real pleasure to work with them, as they combine intellectual rigour with being incredibly good fun.

Madeleine Thomson at Columbia University’s International Research Institute for Climate and Society also

deserves a special mention for her role in helping to develop, organise and deliver an exceptionally interesting and helpful event during New York Climate Week. Inputs from that event helped shape this report. And again, it was a pleasure to work with Madeleine. I would also like to thank readers, James Painter, Alison Tickell and Susan Carstairs who provided thoughtful insights into drafts of the report.

Finally, we are very grateful to the Wellcome Trust for the privilege of being asked to do this work.

Sophia Tickell March 2015

Acknowledgements

Appendix One: ParticipantsJustin Adams Global Managing Director of Lands The Nature ConservancyDave Allen* Head of Respiratory Theory Area GlaxoSmithKlineGbola Amusa Financial analyst IndependentTom Armour* Leader of Global Landscape Architecture ArupRichard Ashcroft Professor of Bioethics Queen Mary University of LondonMolly Brown Research Scientist University of MarylandMichael Bull* Director/Global Environmental Arup Consulting Skills Leader Alexa Clay Economic historian, author, Independent innovation strategist Jason Clay Senior Vice President, Market Transformation WWFRachel Crossley Senior Advisor Access to Nutrition IndexSteve Davis CEO PATHMichael Depledge Professor, Environment and Human Health University of ExeterMelanie Edwards CEO Mobile MetrixVladimir Eskin CEO PrognozSharon Friel* Professor of Health Equity Australian National UniversityRicardo Fuentes Head of Research Oxfam GB Nieva Tara Garnett Food and Climate Research Network Environmental Change Institute, University of OxfordPeng Gong Professor Tsinghua UniversityRachel Gordon Strategy Director DigitasLBiDavid Green Social entrepreneur IndependentBeth Hart Head of Product Development J Sainsbury plc and Technology, Fresh and Frozen Foods Alison Hill* Deputy Chief Knowledge Officer Public Health EnglandClaire Hughes Company Nutritionist Marks & SpencerJim Kaput Head, Systems Nutrition and Health Unit Nestlé Institute of Health SciencesHeidi Larson Senior Lecturer London School of Hygiene and Tropical Medicine Jeremy Nettle Director, Global Client Advisor for Healthcare OracleBenet Northcote* Head of Corporate Social Responsibility John Lewis PartnershipNick Osborne* Senior Research Fellow University of Exeter (Epidemiology and Toxicology) Thulasiraj Ravilla Executive Director Lions Aravind Institute of Community OphthalmologyMark Rhodes VP Sustainability, Environmental GlaxoSmithKline Sustainability Centre for Excellence Vladimir Savic Senior Banker, Agribusiness European Bank for Reconstruction and DevelopmentHoward Shapiro* Chief Agricultural Officer Mars, Inc.Jason Payne* Philanthropy Engineering Team Lead PalantirTristram Stuart Founder FeedbackRaj Thamotheram CEO Preventable SurprisesPhil Thompson Associate Professor of Urban Politics Massachusetts Institute of TechnologyIvo Vlaev Senior Lecturer in Behavioural Sciences Imperial College London

* Indicates that this person was interviewed and provided research inputs but did not attend a workshop23

24

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2. James Manyika et al., ‘Disruptive technologies: Advances that will transform life, business, and the global economy’, McKinsey Global Institute (2013), p. 5

3. WHO Fact Sheet No. 178, ‘Children: Reducing Mortality’, September 2013. Accessed on 8 November 2014 at: http://www.who.int/mediacentre/factsheets/fs178/en/; Food and Agriculture Organisation, International Fund for Agricultural Development and World Food Programme, ‘The State of Food Insecurity in the World’, FAO, IFAD and WFP (2013). Accessed on 8 November 2014 at: http://www.fao.org/docrep/018/i3434e/i3434e.pdf

4. UNICEF, ‘Vitamin and Mineral Deficiency: A global damage assessment report’ (2004). Accessed on 15 September 2014 at: http://www.weforum.org/pdf/Initiatives/GHI_2004_UNICEF_MI.pdf

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47. Neil Munshi, ‘Farming advances with appliance of science to tractor technology’, Financial Times, 24 October 2013. Accessed on 19 January at: http://www.ft.com/cms/s/0/a48ad98c-36c7-11e3-aaf1-00144feab7de.html#axzz31ANPz33y

48. The Global Commission on the Economy and Climate, ‘Better Growth, Better Climate’ (2014). Accessed at: http://newclimateeconomy.report/TheNewClimateEconomyReport.pdf

49. Environmental Leader News Release, ‘IBM, Cisco, “Top Smart City Technology Vendors”’, 12 July 2013. Accessed at: http://www.environmentalleader.com/2013/07/12/ibm-cisco-top-smart-city-technology-vendors/

50. United States Environmental Protection Agency (EPA), ‘Integrated Earth Observations: Application to Air Quality and Human Health’ (2007). Accessed on 19 January at: http://www.epa.gov/geoss/pdf/ieo-workshop.pdf

51. http://www.unep.org/newscentre/Default.aspx?DocumentId=2758&ArticleId=10698

52. The United Nations Secretary General’s Independent Expert Advisory Group on a Data Revolution for Sustainable Development, ‘A World that Counts: Mobilising the Data Revolution for Sustainable Development’, IEAG (2014). Accessed on 20 November 2014 at: http://www.undatarevolution.org/wp-content/uploads/2014/11/A-World-That-Counts.pdf

53. Ibid.

54. The Marmot Review, ‘Fair Society, Healthy Lives. Strategic Review of Health Inequalities in England, Post 2010’ (2010). Accessed at: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review

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PhotographsCover: Fluorescent microscope image of an osteoblast cell line. © Wellcome Images/Kevin McKenzie

Page ii: Zambian football pitch. © Constance Mackworth-Young

Page 1: Micrograph showing the surface morphology of the polycrystalline compound copper indium gallium diselenide, a material used in solar energy. © Wellcome Trust/Eberhardt Josué Friedrich Kernahan and Enrique Rodríguez Cañas

Page 3: Agricultural sludge sample used to verify the contamination of fuels and soils. © Wellcome Trust/Eberhardt Josué Friedrich Kernahan and Enrique Rodríguez Cañas

Page 5: Bait net from below. © Hani Amir

Page 7: Ebola virus particles. © National Institute of Allergy and Infectious Diseases (NIAID)

Page 11: Smart contact lens. © Google

Page 13: Aerial view of irrigated soya fields in Goias State Brazil. © Alamy/ Edward Parker

Page 17: Soundwaves. © Wikimedia Commons/Luis Lima89989

Page 19: Children eat a meal as part of ‘Feeding The 5000’ campaign. © Feedback

Page 21: PATH, an organisation which specialises in global health innovations, carry out a community survey on tetanus toxoid vaccination. © PATH/Vu Minh Huong

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