Roadmap to a One Health Agenda 2030

Abstract

The current fragmented framework of health governance for humans, animals and environment, together with the conventional linear approach to solving current health problems, is failing to meet today's health challenges and is proving unsustainable. Advances in healthcare depend increasingly on intensive interventions, technological developments and expensive pharmaceuticals. The disconnect grows between human health, animal health and environmental and ecosystems health. Human development gains have come with often unrecognized negative externalities affecting ecosystems. Deterioration in biodiversity and ecosystem services threatens to reverse the health gains of the last century. A paradigm shift is urgently required to de-sectoralize human, animal, plant and ecosystem health and to take a more integrated approach to health, One Health (OH). The Sustainable Development Goals (SDGs) offer a framework and unique opportunity for this. Through analysing individual SDGs, we argue the feasibility of an OH approach towards achieving them. Feasibility assessments and outcome evaluations are often constrained by sectoral politics within a national framework, historic possession of expertise, as well as tried and tested metrics. OH calls for a better understanding, acceptance and use of a broader and transdisciplinary set of assessment metrics. Key objectives of OH are presented: That humans reconnect with our natural past and accept our place in, and dependence on our planet's ecosystems; and that we recognize our dependence on ecosystem services, the impact of our development thereon and accept our responsibility towards future generations to address this. Several action points are proposed to meet these objectives.

Full text

Roadmap to a One Health Agenda 2030
Kevin Queenan
1
*, Julie Garnier
2
, Liza Rosenbaum Nielsen
3
, Sandra Buttigieg
4
, Daniele de Meneghi
5
,
Martin Holmberg
6
, Jakob Zinsstag
7,8
, Simon Rüegg
9
, Barbara Häsler
1
and Richard Kock
1
Address:
1
Depatment of Pathobiology and Population Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hatfield,
Hertfordshire AL9 7TA, UK.
2
Odyssey Conservation Trust: Bakewell, Derbyshire DE45 1LA, UK.
3
Department of Veterinary and
Animal Science, Faculty of Health and Medical Sciences, University of Copenhagen, DK-1870 Frederiksberg, Denmark.
4
Department of
Health Services Management, Faculty of Health Sciences, University of Malta, Msida, Malta.
5
Deptartment Veterinary Science, University
of Turin, L.go P. Braccini 2, 10095-Grugliasco (Torino), Italy.
6
Department of Culture and Media Studies, Umeå University, Umeå,
Sweden.
7
Swiss Tropical and Public Health Institute, Socinstrasse 57, PO Box CH-4002, Basel, Switzerland.
8
University of Basel,
Petersplatz 1, CH-4003 Basel, Switzerland.
9
Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland.
*Correspondence: Kevin Queenan. Email: kqueenan3@rvc.ac.uk
Received: 31 January 2017
Accepted: 23 March 2017
doi: 10.1079/PAVSNNR201712014
The electronic version of this article is the definitive one. It is located here: http://www.cabi.org/cabreviews
© The Author(s) 2017. This article is published under a Creative Commons Attribution 4.0 International License (CC BY 4.0) (Online ISSN 1749-8848)
Abstract
The current fragmented framework of health governance for humans, animals and environment,
together with the conventional linear approach to solving current health problems, is failing to meet
today’s health challenges and is proving unsustainable. Advances in healthcare depend increasingly on
intensive interventions, technological developments and expensive pharmaceuticals. The disconnect
grows between human health, animal health and environmental and ecosystems health. Human
development gains have come with often unrecognized negative externalities affecting ecosystems.
Deterioration in biodiversity and ecosystem services threatens to reverse the health gains of the last
century. A paradigm shift is urgently required to de-sectoralize human, animal, plant and ecosystem
health and to take a more integrated approach to health, One Health (OH). The Sustainable
Development Goals (SDGs) offer a framework and unique opportunity for this. Through analysing
individual SDGs, we argue the feasibility of an OH approach towards achieving them. Feasibility
assessments and outcome evaluations are often constrained by sectoral politics within a national
framework, historic possession of expertise, as well as tried and tested metrics. OH calls for a better
understanding, acceptance and use of a broader and transdisciplinary set of assessment metrics.
Key objectives of OH are presented: that humans reconnect with our natural past and accept our
place in, and dependence on our planet’s ecosystems; and that we recognize our dependence on
ecosystem services, the impact of our development thereon and accept our responsibility towards
future generations to address this. Several action points are proposed to meet these objectives.
Keywords: One Health, Health governance, Health policy, Sustainable development goals, Ecosystems health,
Global health, Planetary Health
Review Methodology: We reviewed academic papers and on line resources for definitions of health for each sector (human, animal,
wildlife, plant and ecosystem health). The 17 Sustainable Development Goals (SDGs) and the official lists of diseases published by WHO
and the OIE were collated and analysed for their suitability for an integrated approach to management. Selected SDGs were chosen as
examples to demonstrate the feasibility of an integrated or one Health approach, which was supported by reviewing the relevant literature
for each.
Introduction
Despite decades of academic appeals for an integrative,
interdisciplinary and transdisciplinary approach to the many
guises of health and disease, the development of human,
animal and environmental or ecosystems health continues
within a highly sectoralized and structural governance
and policy framework [1–4]. Neglect of environmental or
ecosystems health and associated loss of biodiversity is now
at a critical point, threatening ‘Planetary Health’and the
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fundamental processes on which life depends [5]. In
addition, the intensification of and the technological inno-
vation in conventional health systems is proving too expen-
sive to maintain and is further complicated by dependency
on expensive pharmaceuticals. Earlier gains in health are
now looking vulnerable, resulting in global health inequities
and a rise in emerging and re-emerging diseases [6]. Indeed,
many gains in human development, including health,
have been made at a cost to ecosystems, whilst the con-
sequences thereof (climate change, air and water pollution,
chemical exposure, biodiversity loss and ecosystem degra-
dation) are now increasingly the causes for deterioration in
human health [7, 8]. Emphasis to date has been on narrow
perceptions of health and disease, e.g. longevity, human
health burden of disease measures and single species host
pathogen interactions. The influencing drivers and the need
for more preventive health interventions have largely
been neglected in favour of technical fixes including anti-
biotic misuse. A recent contribution from the World Health
Organization (WHO) suggests that on average national
investment in primary preventive health strategies may be
as low as 3% of the countries’total health expenditure [9].
This reactive approach with its rising costs and smaller gains
is proving unsustainable. Furthermore, underinvestment
in the health and productivity of livestock [10] and plants
[11], particularly within the context of vulnerability due
to climate change [12], will result in poorer control of
diseases and reduced productivity, affecting food security
and livelihoods and ultimately impacting on human health.
Houle ([13] p. 401), questioned whether the concepts
upon which we base our understanding of health (within
the disciplines of epidemiology, pathology, etc.) are
themselves ‘unhealthy and maladaptive’. Houle also argues
that the concept of health should acknowledge our
dependency, passivity, weakness and vulnerability as fea-
tures of our human existence. Rook [14] argues that
microbial symbionts and commensals should be seen as a
neglected ecosystem service, essential for the development
of our immune systems and our well-being. Maintaining
individual and public health in the ever changing, complex
adaptive socio-ecological system we form part of, requires
us to think foresightedly and creatively, while remaining
flexible and contributive. The same could be said of
maintaining the health or survival of an individual animal
or single species population. A paradigm shift is needed
towards a fully integrated approach to health; a system(s)
approach with a focus on restoring resilience of biological
systems at all scales, including humans, animals and plants
[6, 15, 16], an approach known as One Health (OH), derived
from the One World One Health concept, which emerged
in the first decade of the twenty-first century [17, 18].
Zinsstag et al. [15] take a narrower view and define OH
as ‘any added value in terms of health of humans and
animals, financial savings or environmental services achiev-
able by the cooperation of human and veterinary medicine
when compared with the concepts of approaches of the
two medicines working separately.’Beyond attempting a
closer cooperation of human and animal health, ‘ecosystem
approaches to health’or ‘eco-health’considers inextricable
linkages between sustainable ecosystems, society and health
of animals and humans [19, 20]. The in-depth understanding
of ecological processes allowed, for example, to show that
mercury poisoning of fish and impeding health risks for
humans in the Amazon basin were not due to upstream
gold mining but to soil erosion following deforestation
[21]. This example and a large body of literature demon-
strate that contemporary complex health problems cannot
be solved by reductionist but rather systems thinking
approaches, such as those promoted by the International
Association of Ecology and Health (www.ecohealth.net)
[22, 23]. One Health and EcoHealth thinking converge
strongly, especially through OH recognizing health as an
outcome of social-ecological systems (SES) and its impli-
cation for sustainability [23–25]. The term OH is used in
this paper because of its high acceptance, whilst clearly
recognizing that ecosystems approaches to health [22]
and health in social-ecological systems (HSES) [23] are
imbedded in the OH approach to complex systems.
The added value resulting from the integration of
relevant sciences in a system(s) approach to health is
the focus of the Network for Evaluation of One Health
(NEOH), a European Union (EU) Cooperation in Science
and Technology (COST) funded initiative (COST TD 1404)
that has developed a framework and protocols for the
evaluation of OH initiatives [26].
This paper stems from work conducted in NEOH.
It describes the current sectoralized health systems,
highlighting the need for integration and presents the
Sustainable Development Agenda 2030 as an opportunity
for a paradigm shift. We outline the interlinkages between
the sustainable development goals (SDGs) and discuss, with
examples, the feasibility and opportunities for achieving
synergies through OH. The challenges in assessing
interventions in complex adaptive systems are discussed
together with the need to adjust our metrics and appraisal
principles. To conclude, key OH objectives and action
points are proposed for an OH agenda towards a more
integrated and accessible health system for all.
Names, Definitions and Their Unintended
Consequences
Human development with all its promise in the twentieth
century is confronted by several uncomfortable truths.
The environment and biodiversity are rapidly declining
and ecosystems are becoming dysfunctional. Ecosystem
services, those benefits that humans derive from dynamic
system of plants, animals and microorganisms, such as clean
air and water, fertile soils and timber as well as recreational
and spiritual benefits [27], are in themselves, metapho-
rically speaking unhealthy [28]. At the same time, earlier
gains in the health of human communities through modern
medicines and technologies, reflected in increasing human
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longevity, are threatened by several emerging multi-
directional health and disease threats including novel patho-
gens, growing mental health issues, obesity and hunger,
micronutrient deficiencies and ecotoxicological risks [29].
We recognize that despite considerable progress in public
health, human health equities across communities and
countries seem more distant than ever. The same inequal-
ities and disparities are noted in animal health service capa-
city and accessibility and in the health of local ecosystems
and their potential impact on human health is generally
ignored. How did these problems and these global dis-
parities emerge despite the growing understanding of and
investment in health across all sectors? To answer this, we
review the definitions of health around which the sector-
alized health systems have developed.
Human Health
When we think of health, we think firstly of the health
of individual humans and communities. The WHO defined
(human) health as ‘a complete state of physical, mental and
social well-being, and not merely the absence of disease
or infirmity’[30]. This understanding of human health
has subsequently evolved to take account of the changing
health needs of an individual in relation to age, culture and
personal responsibility [31] and an individual’s rights [32].
In addition, it is recognized that human health has socio-
ecological determinants and that health underpins devel-
opment [33]. Frankish et al. [34] presented the idea of
population health as ‘the capacity of people to adapt to,
respond to, or control life’s challenges and changes.’The term
Global Health, defined as ‘an area for study, research and
practice that places a priority on improving health and achieving
equity in health for all people worldwide’[35] remains
focussed on human health but is frequently confused with
OH. However, results from the latest assessment of the
burden of diseases from environmental risks clearly show
the need for this wider view, since 23% of global human
premature deaths (and unknown numbers of animal deaths
with consequential financial losses and loss of biodiversity)
can now be attributed to modifiable environmental factors,
representing 12.6 million deaths every year [7]. Even this
assessment is rather narrow in its interpretation of what
‘environment’is, and the figure that could be attributed to
environmental conditions, particularly in relation to social
determinants and behavioural components of health, is
likely to be much higher. There are also other concepts
related to this, such as Universal Health Coverage, which
is more focused on ensuring all members of a particular
society receive equal care throughout life.
Animal Health
Our perception of animal health and its definition in the
sector is much more disintegrated. This is demonstrated by
the fact that notifiable diseases, welfare, terrestrial and
aquatic wild animal health are addressed in separate laws.
For example, recent legislation (Animal Health Act 2014) in
British Columbia, Canada [36] defines it as ‘the health of a
population or subpopulation of animals and includes the
preservation of a population or subpopulation of animals
that is at risk of being exposed to or affected by a notifiable
or reportable disease’. The importance given to infectious
diseases of consequence to domestic animals and to
humans (either directly as zoonotic diseases or indirectly
through economic losses) in relation to the other aspects of
animal health, e.g. in international treaties (WTO-OIE),
reflects the persistence of the somewhat ancient idea that
animals exists solely to satisfy human needs. Only recently,
the World Animal Health Organization (OIE) added wildlife
diseases to its Listed Diseases and now also includes health
as an aspect of its definition of animal welfare. Diseases
(zoonoses), which do not cause any disease in animals,
have been added to the List, accounting for the OIE change
of approach towards animal health and animal disease
reporting. In addition, these aspects since March 2016 are
addressed in EU Animal Health law [37].
Wildlife Health
Wildlife health as a concept is fairly recent without
any formal sectoral responsibility other than generally
through environmental and biodiversity legislation, and in
the context of diseases considered under legislation for
zoonoses in public health and as carriers of diseases of
concern for domestic animal health. A working definition of
wildlife health is needed that recognizes the major threats
to wildlife are not diseases but rather anthropogenic impacts
through the so-called development. Stephen [38] states that
a modern definition of wildlife health should emphasize that
(1) health is the result of interacting biologic, social and
environmental determinants that interact to affect capacity
to cope with change; (2) health cannot be measured solely
by what is absent but rather by characteristics of the
animals and their ecosystem that affect their vulnerability
and resilience; and (3) wildlife health is not a biologic state
but rather a dynamic social construct based on human
expectations and knowledge. Conservationists have recog-
nized and promoted what are known as the ‘Manhattan
Principles’(www.oneworldonehealth.org), that the health
and sustainable maintenance of wildlife in natural reserves
are mutually interdependent with the health of com-
munities and the livestock surrounding them [39].
Plant Health
Plant health, much like animal health, is primarily under-
stood in the context of plants’contribution to the food
sector for humans and to livestock feeds, rather than in the
context of their contribution to biodiversity and overall
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health of the ecosystem. More recently, however, climate
change has drawn attention to global plant population
health as part of the solution to global warming [40].
Recent work combines the provision of plant and human
health services in Uganda [41].
Ecosystems Health to HSES
Ecosystem approaches to health concerns (including
Planetary Health, which is a derivation) is to some extent
embedded in the United Nations Environment Programme
(UNEP). Recently this organization has diverged from static
reports on chemicals, waste, air, water, biodiversity and
soils (with a subset of reporting on ecosystems) to a more
holistic view using the health paradigm (in fact OH) in
reporting the European section of its global environment
outlook titled ‘Healthy Planet Healthy People’[8]. The
theory and practice of understanding and managing human
activities in the context of SES has been well-developed by
members of The Resilience Alliance (www.resalliance.org)
and was used extensively in the Millennium Ecosystem
Assessment, including its work on human well-being out-
comes (www.millenniumassessment.org). It is hence not
difficult to relate human health to SES or so-called human–
environment systems (and similarly the health of animals
too) as HSES [23]. These systems relate outcomes (which
can also be outcomes of health and wellbeing) to systemic
interactions, which are primarily influenced by resources,
governance and users in a given social, economic and
political setting and related ecosystems as part of
‘New institutional economics’[42].
The recent global changes in the SES (urbanization,
globalization, human population growth, increasing con-
sumption, climate change and loss of habitat and bio-
diversity) have created an environment, which favours
the rapid and often global transmission of emerging and
re-emerging pathogens [43]. The complexity of some of
these recent global infectious disease threats (SARS, H5N1,
ZIKA and Ebola) encouraged a lowering of sectoral walls
and a more integrated approach to finding health solutions
at an international level in principle (e.g. tripartite agree-
ment between WHO, OIE and Food and Agriculture
Organization of the United Nations (FAO)). However, at
a national level in almost all countries, ministries remain
separate and sectoralized, with their own budgets and
agendas without integration of health programmes [44].
There are but a few exceptions e.g. the Veterinary Services
in Italy are fully integrated within the Ministry of Health, and
at local level (Local Health Units) public health doctors and
veterinary officials work together. In Denmark, the Food
and Environment are now fused in the Ministry for the
Environment and Food of Denmark [45]. The Canadian
Science Centre in Winnipeg is fully integrated and saves
26% of its running costs compared with separated human
and animal laboratories [46]. The Kenyan Government has,
as one of the first in Africa, an integrated Zoonotic Disease
Unit. Efforts and progress towards OH are still restricted
by the inertia of long established divisions, institutional
and logistical barriers to sharing data and information
across institutions [47], power and leadership struggles
with failure to agree on task and resource allocation issues
[48]. Besides a few studies on joint health service delivery
[49], brucellosis [50], rabies control [51] and laboratory
infrastructure [46], there is a lack of economic evidence and
metrics to measure OH gains [52].
Beyond the paradigm shift called for by OH, namely the
reuniting of human, animal, plant and ecosystem health to
deal with the current and future health challenges of a
complex nature, Wallace et al. [53] reinvigorate the notion
of specifically focusing on the wider context, which lies
behind emerging health problems, including the geo-
political, economic and societal global crises and the un-
sustainability of natural resource use and current global
economic systems. Structural OH is said to ‘empirically
formalize the connections among capital-led changes in
the landscape and shifts in wildlife, agricultural and human
health’[51]. It requires a shift from linear thinking and
simplistic medicalization of health, to systemic transdisci-
plinary approaches with contributions from a wide range of
professionals such as ecologists, agriculturalists, engineers,
architects and also social scientists, including economists,
anthropologists and behavioural scientists, as well as from
the stakeholder community and its representatives [15].
The United Nations (UN) community continues to
develop policy and political instruments to drive change.
In 2015, the 2030 Agenda for Sustainable Development set
new goals (SDGs) to guide global development over the
15 years to 2030. Seen as the daughter of the Millennium
Development Goals (MDGs), the SDGs explore health
concepts further, in terms of universal human health
coverage, the continuum of care, the life-course approach
to health services provision integration and the con-
vergence towards minimum global standards in absolute
terms, everywhere. They cover the social, economic
and environmental pillars of sustainable development,
with a strong focus on equity, and are described as being
‘integrated and indivisible, global in nature and universally
applicable’[54]. The new 2030 Agenda calls for a new
cooperative paradigm based on the concept of ‘full global
partnership’. The need to ‘think differently’to address the
deep systemic changes required by this new Agenda has
also been recognized at intergovernmental level [55]. We
see this as a unique opportunity to propose a roadmap for
an OH Agenda for 2030.
The SDGs: Opportunities for Change
The latest WHO assessment of health in the SDGs
acknowledges ‘that the SDGs, by contrast to the MDGs,
reflect a far wider range of environmental, economic and
societal concerns. All SDGs are designed to be cross-
cutting and the inter-linkages and networks within the
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SDGs are as important as the individual goals themselves’
[56]. Health, instead of being based as in the MDGs on
three narrow targets in isolation from the other goals,
is now recognized as a precondition, an outcome and an
indicator of sustainable development [8], and is now one
target embedded in the others. There is at least a current
acceptance that health depends on many factors outside of
human control and that only by attending to the health of
other biological and physical elements of the planet, will this
be sustained [5, 57].
The Interactive Web of SDGs
Waage et al. [58] noted that total sustainable development
is more than the sum of its parts and ‘is an outcome
of positive synergies between multiple elements and may
be undermined by negative trade-offs between them’. They
go on to criticize the SDGs for being developed within
different sectors and presented by the UN without
recognizing the interactions, both positive and negative,
between them. To demonstrate, they positioned the
SDGs in a framework of three concentric levels depending
on their intended outcomes but argued that ‘governance
within silos is no longer tenable’. The inner level of
Well-Being, which includes ‘people-centred’goals such as
health, education and nutrition (SDGs 1, 3, 4, 5, 10 & 16),
were noted as providing opportunities for synergies. The
middle level, Infrastructure relate to those goals perceived as
essential for a modern society to function (SDGs 2, 6, 7, 8,
9, 11 & 12) and are closely linked with those in the inner
level. The outer level, Environment contains goals which
relate to the management of natural resources and the
provision of ecosystem services and life-supporting systems
(SDGs 13, 14 & 15) were noted as having been largely
ignored and seriously compromised. Achieving the goals
in the infrastructure level must be done so without com-
promising those in the outer and inner levels. We have
adapted this framework further (Figure 1) to highlight three
of the infrastructure goals relating to economic growth,
industrialization and production and consumption (SDGs 8,
9 & 12). These goals have an antagonistic relationship with
other goals, especially under current political economies
(see structural OH above). A comprehensive effort to
apply principles of New Institutional Economics, postulated
among others by Elinor Ostrom [42] could provide a global
shift from the current political economy to link economic
performance with sustainable practices sometimes
described as decoupling [8] in recognition that the only
resource available into the future is a renewable one
to build greener economies. We have added a further
all-inclusive level of OH, which extends to include the SDG
17 for global partnerships, a cornerstone of the SDGs
and of OH.
Figure 1 A framework grouping the SDGs based on their intended outcomes, highlighting goals (in yellow) with antagonistic
relationships with other goals. Adapted from Waage et al. [58].
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The SDGs provide a key entry point for the OH
approach to drive a paradigm shift in policy and practice
towards a fully integrated approach to HSES [23]. Due to
the political consensus and momentum behind the SDGs
as well as the recent frequent global reports on health
concerns this is a historic opportunity.
With this in mind, we explored the feasibility of an
OH approach to play a strong role in successfully attaining
a selection of individual and interlinked SDGs, and provide
examples here as evidence of the success of such an ap-
proach, theoretical arguments in support thereof or argu-
ments against a narrow targeted and segregated approach.
SDG 1 –To end poverty in all its forms
Poverty, entailing poor housing, lack of food and animal
feed, unsafe water supplies and lack of human, animal and
plant healthcare lead to an unequal burden of disease.
In this context, diarrhoeal diseases, tuberculosis, HIV and
malaria are among the top causes of poverty-linked human
deaths. In addition, the most marginalized populations are
characteristically dependent on livestock and also carry the
heaviest burden from diseases that infect both humans and
animals [59].
Diarrhoeal disease caused by viral, bacterial and parasitic
microorganisms cause around 30 million cases a year [56].
Diarrhoeal diseases are listed among the top ten causes
of deaths globally; 1.5 million deaths a year, more than half
(842 000) attributable to unsafe water supplies and a lack
of sanitation and hygiene [56]. Together with inadequate
provision of health care, poverty is the root cause beneath
these poor living conditions of humans and their livestock.
There are also environmental and agricultural contributing
factors, notably poor and contaminated water supplies, and
food borne infections, many of which are derived from the
livestock and food processing systems and passed on to
consumers [60].
Campylobacteriosis ironically although not strictly a
disease of poverty is a product of industrialization of food
to provide cheap meat, and therefore is likely to affect the
less well-off disproportionately. This disease presents
an opportunity for a broader, yet integrated OH approach.
As an important zoonotic human disease (commonly asso-
ciated with contamination of poultry meat during proces-
sing), public health authorities often instigate high levels of
biosecurity in the poultry processing industry. However,
being normal gut commensal bacteria of poultry, little
attention is paid to it at source by the poultry farmers and
veterinarians. An additional concern is the rising trend
of antimicrobial resistant campylobacteriosis cases, likely
to be driven by use of antibiotics in poultry production
both prophylactically and as growth promoters [61, 62].
Concerted action by veterinary and human health auth-
orities and the agricultural sector could potentially alleviate
this problem and mobilize the necessary economic support
for sustainable solutions [63, 64].
SDG 2: To attain food security and improved nutrition
through sustainable agriculture
Whilst the focus (and rightly so) of agricultural develop-
ment has been on improving food security and providing
sufficient caloric intake for the starving, there is growing
awareness that the food systems created to address this, are
not only unsustainable but are malfunctioning [65–67].
More intensive, modernized agriculture has improved food
security in developing countries, but it has ignored the sig-
nificance of dietary diversity and the micronutrient defici-
encies, which result from a reliance on starch heavy diets
[66]. In addition, industrialized agriculture has focused
on producing three main crops (rice, wheat and maize) and
has come at the cost of soil fertility loss and reduced bio-
diversity, whilst losing the dietary diversity (including
related micronutrients) needed for children’s physical and
cognitive growth and well-being [8, 68, 69].
At the other extreme, worldwide obesity prevalence
has more than doubled since 1980 and its prevalence
in European countries ranges from 45 to 67% [70]. This
seems ironic, that the need to address undernutrition in
developing countries is used to promote clearance of land
for intensive agriculture (dependant as it is on fossil fuels,
fertilizer and pesticides), whilst the unintended conse-
quence is low-cost food on supermarket shelves in high-
income countries. This trend along with the consolidation
of agriculture and intensification of agricultural systems has
had profound consequences on diet. Although there is no
single food system that can solve all the problems of both
food security and nutrition security without damaging the
environment [71], the current dominance of industrial
agriculture in the development paradigm is concerning [65].
The unintended consequences are best illustrated by
the penetration of corn products into the diet in North
America with all its negative health impacts. The situation
in Europe is hardly any better with up to 40% of Europe’s
food being imported [72], requiring four times the land area
per head of population in Europe to achieve sufficiency
[73]. To make matters worse, 30–50% of food produced
globally is wasted, much of it in the food miles involved [74]
which in itself is responsible for 3.3 billion tonnes of
greenhouse gas emissions, equivalent to the third highest
emitting country [75].
There is also a mismatch between current modern,
high-income country lifestyles and diets and the evolution of
our physiological and metabolic processes [76]. Increasingly
sedentary lifestyles mixed with easy access to highly pro-
cessed diets that are fat, sugar and calorie dense, result in
an increase in obesity, cardiovascular disease and other
non-communicable diseases (NCDs) such as diabetes,
which are the cause of four out of every five deaths in
the European Region [70]. Companion animals share many
of the same risk factors for obesity and related diseases as
their human owners [77] whilst a strong correlation has
been shown between overweight dogs and the Body Mass
Index of their owners [78]. An integrated OH approach can
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reconnect communities with small scale and diverse,
low-intensity agricultural systems with low-carbon foot-
prints in high-income countries, whilst in low-income
regions, small-scale farming continues to provide the
majority of the nutritious food and employment and has
contributed massively to food security [79]. Food culture,
which promotes dietary diversity, seasonality, nutritional
quality rather than quantity, local and moderate consump-
tion, with a higher ratio of fruit and vegetable to meats
(the latter derived from rangeland use) and a system, which
shuns processing and food profiting, puts the proper
value on food and encourages slow, communal eating.
These principles are promoted in conservation agriculture,
the organic and slow food movements, pastoral systems and
wildlife harvesting, and are exemplified in the traditional
Mediterranean diet, where populations suffer the lowest
levels of NCDs in Europe [80]. Sustaining these traditional
agriculture and organic food systems in both low-
and high-income countries is a challenge and even in
the Mediterranean region, the traditional diet is deterio-
rating. These countries remain under pressure from
consolidation and food industry with cash crops increas-
ingly forced on communities by economic circumstances
(poverty). Some supporting efforts continue, for example
through the integrated approach towards organic/
sustainable agriculture in the Mediterranean carried out
by CIHEAM –International Center for Advanced
Mediterranean Agronomic Studies. A further consideration
is that whilst poor quality, cheap processed fast foods
remain available, NCDs will continue to be socially deter-
mined as poorer communities, which are separated from
the land through urbanization or consolidation of agricul-
ture, find healthier diets unaffordable [81]. Although inten-
sification and agriculture technology are now embedded in
agricultural practice, they need not always be applied at an
industrial scale and much of the philosophy of sustainable
intensification looks to fill yield gaps without fundamentally
changing more conserving agricultural practices [82, 83].
The sustainable agriculture SDG is also linked to SDG 5
on gender equality and SDG 3 on health for all. Although
comprising 43% of developing country agricultural labour
force, women do not have equal access to productive
resources, yet they are responsible for 60–80% of the
food production [75]. Closing the gender gap in access
to land, extension services and other inputs could lift
100–150 million people out of hunger [84] and would
also impact on SDG 1 on ending poverty.
SDG 3: Ensure healthy lives and promote well-being
for all at all ages:
Urban development (SDG 11) not only creates job
opportunities (SDG 8) and wealth (SDG 1) for its citizens,
but also presents multifaceted and interactive environment
and health interactions and often increases their disease
risk and health inequalities [8]. Equally, similar health risks
increase for urban populations of companion animals and
for wildlife, which adapt to urban living.
Nearly 50% of premature deaths in Europe are attribu-
table to cardiovascular and heart disease [70] and the
concentration of one species, the human, inevitably has
consequences on infectious diseases such as tuberculosis
which is both a disease of poverty and urbanization in
the modern age. This figure is expected to rise given the
increases in obesity, increasing urbanization, sedentariza-
tion and longevity of human population.
Air pollution results in a significant burden of disease in
Europe, with an estimated 600 000 premature deaths from
both indoor and outdoor pollution in 2012 [85]. There are
also chronic effects, including lung cancer [86], cardio-
vascular disease [87, 88], decreased lung function in
children [89, 90], respiratory infections during childhood
[91] and low birth weight [92]. Furthermore, evidence is
emerging for a role of air pollution also in other diseases
of multifactorial aetiology, for example diabetes [93].
Again this tends to be a problem of poverty and relative
poverty in the old and young. Thus, there is a clear link
between health of urban populations with SDGs 9 and 11.
Urban development without the provision of natural green
space, exacerbates air pollution, reduces opportunities
to exercise and produces subtle negative effects on physical
and mental health [94–97].
Current health systems appear to lack an integrated
approach to health issues related to environment and
activity. The lack of ecological understanding in public
health has led to the adoption of ‘Green Space’policies
without a true ecological restoration of the domestic
environment [98]. The benefits of urban green space are
multiple, in stress and noise reduction, social cohesion,
physical activity, heat stress mitigation and cleaner air but
are dependent on access [99–107]. These policies can also
result in artificially sustained green spaces with little
ecosystem function or biodiversity [108]. If these natural
elements were additional to the spatial element, this could
significantly enhance the opportunity for the effects of
improved well-being and reduced air pollution, and con-
tribute to improved mental health. A current EU project
(RESPIRIT) is looking into the links between plant diversity
in cities and respiratory health. Therefore, an integrated
approach to the heath of urban populations (humans,
animals and ecosystems) would foresee professionals
from public health, veterinary and ecological sciences
collaborating with town planners, architects and landscape
designers, in the allocation and design of green spaces,
ensuring that self-sustaining and resilient ecosystems
remain at their core [109].
SDG 6: Ensure availability and sustainable
management of water and sanitation for all
Globally, approximately 663 million people lack access to
safe drinking water and 2.4 billion have no access to
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improved sanitation facilities; 80 and 70% of people who
lack access to safe water and sanitation respectively live in
rural areas, the majority in Sub-Saharan Africa [110].
Providing sustainable water management is closely linked
to SDGs 2, 9 & 12. Recycling of nutrients from human and
animal waste saves the use of chemical fertilizers but
requires the understanding of material flows and health
risks [111]. Agricultural development of natural landscapes
can result in deforestation of mountain catchment areas
and drainage of marshes and wetlands (for cropping and
livestock grazing), interruption or redirection of natural
water flow through dams, reservoirs and canals (for power
and irrigation purposes) and lagoon and delta dredging for
navigational access. Freshwater quantity and quality are
dependent on healthy water ecosystems, including catch-
ment areas, river systems, natural water bodies, wetlands
and deltas. Restoring and maintaining healthy freshwater
ecosystems is a cost-effective way to improve water quality,
biodiversity and human health [8, 112]. At a local level, the
integration of education (SDG 4) and a gender perspective
(SDG 5) are also important to consider in water
programmes, as the increased scarcity of water affects
mainly poor women and children in rural communities who
have then less time and energy for tending crops, cooking
meals or attending schools [112].
Human schistosomiasis is a related public health threat,
listed as a WHO neglected tropical disease (NTD). It is
typically targeted with mass drug administration pro-
grammes, provision of safe water and sanitation, mollusci-
cide use and education programmes to highlight risks [113].
However, recent changes in the species evolution and
changing transmission ecology, including zoonotic spill
overs and multi-host pathogenicity and hybridization have
been demonstrated [114–117]. Thus, in the ever changing
world of human and animal population growth, anthro-
pogenic environmental changes, globalized movements
of livestock and humans, the previous narrow, anthro-
pocentric or disjointed sectoral approach to the control of
schistosomiasis in humans will now require a paradigm shift,
taking a wider view through an OH approach.
SDG 13: Take urgent action to combat climate change
and its impacts
Climate change affects human and animal health directly
and indirectly through its impact on biodiversity [8, 112].
Whilst hosts and pathogens have evolved together in a
relatively stable climate for tens of thousands of years, that
equilibrium is now changing [118] and having an effect on
vector distribution and behaviour as well as the rate of
evolution of pathogens, which is much slower in the larger
host species. This mismatch in rate of adaptive change
between pathogen and host is creating opportunities for
emergence and re-emergence of disease, e.g. current Zika
virus outbreaks in humans associated with establishment
and proliferation of Aedes aegypti mosquitos in the
Americas; the close to 100% fatality rate from Pasteurella
multocida infections in the Saiga antelope in recent die-off
events in Kazakhstan with possible climate associations
[119] and anthrax outbreaks in Siberian arctic reindeer
on the Yamal Peninsula, the latter epidemic associated with
the hottest summer on record in the peninsula in 2016.
Linkages between climate change and the Infrastructure
SDGs (2, 7, 8, 11 & 12) are clear. However, with respect to
the recent Ebola outbreak in West Africa, investment in
intensive agriculture, urbanization and infrastructure such
as roads and vehicles with the resultant forest destruction,
disturbance of reservoirs and creation of pathways of infec-
tion, were not considered important factors despite grow-
ing evidence [120–122]. The Emerging Pandemic Threats
programme (EPT) of USAID, despite half a billion dollars
of investment, failed to predict the Ebola epidemic and
the extent of the outbreak represents a massive failure
of modern health systems [120]. The EPT had three
main investment targets; improved prediction, response
and identification of pathogens (laboratory capacity), but it
failed to consider the socio-ecological systems in which
pathogens emerge. Clearly, a more integrated, OH under-
standing of the health impacts of climate and other change
arising from development is needed, with input from
multiple sectors and disciplines.
SDG 14: Conserve and sustainably use oceans, seas and
marine environments and SDG 15: protect, restore and
promote sustainable use of terrestrial ecosystems
The links between these two SDGs and freshwater manage-
ment and sanitation (SDG 6) and sustainable agriculture
(SDG 2), together with the links to climate change
(SDG 13) are clear.
Biodiversity loss occurs due to intensification of crop
agriculture and industrial livestock production, urbaniza-
tion, over exploitation of natural resources (overfishing,
unsustainable harvesting and poaching), pollution, invasive
species and climate change. Biodiversity loss can impact
health through a variety of mechanisms such as increased
likelihood of communicable diseases (wider vector distri-
bution across fewer species) and NCDs (reduced crop
yields and food diversity, contributing to increasing reliance
on fewer unhealthy foods) [8].
The biodiversity within the world’s oceans and seas has
been changed by human activities both in and on them and
indirectly through activities on land and river systems. The
link between oceanic ecosystem health and human health
is complex [123]. ‘Sustainable use’requires an integrated,
ecosystems based management strategy, which permits
the use of the ecosystem services, whilst fostering the
natural capital of the oceans. It should also recognize the
link between biodiversity and the health of ecosystems
through resilience [124]. Oceanic ecosystem services
include natural biological resources, food, carbon dioxide
absorption, detoxification of waste water, energy provision
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(oil and gas, but also wave energy and providing a location
for wind turbines), raw materials of sand and gravel for
construction and opportunities for recreation. An inte-
grated approach is required to protect terrestrial natural
ecosystems and freshwater ecosystems through sustainable
agricultural practices (such as conservation agriculture
and with broader consideration of food demand, supply,
waste and lifestyle) and to indirectly minimize the impact
of estuary and river outputs on the associated coastal
ecosystems.
Europe’s increasing urbanization and intensive agri-
cultural development (Green Revolution) since 1945 has
impacted on the Danube River, which drains water from
approximately 817 000 km
2
of land across 19 countries,
and consequently caused eutrophication and dead-zoning
of approximately 40 000 km
2
of the Black Sea in the 1990s
[125]. Globally, eutrophication has contributed to approxi-
mately 245 000 km
2
of oceanic dead zones [75]. It is
an example of how interconnected terrestrial and aquatic
ecosystems are and how disjointed governance and how-
ever well-meant, narrow environmental policies in one area
can negatively impact on other. An integrated, collective
response from multiple countries, agencies and stake-
holders is necessary to ensure a sustained management
approach, with a focus on maintaining the health of eco-
systems including humans. Sustaining terrestrial ecosystems
also connects back to the discussion of sustainable agri-
culture (SDG 2). The sustainability and productivity
of agroecosystems is dependent on the conservation,
enhancement and utilization of biodiversity especially at
the level of the soil but also in terms of pollinators, pest
control, water and nutrient cycles and overall resilience
[8, 40]. Agriculture now covers half of the EU’s land area
and the current pattern of use is leading to the deterio-
ration of soil and surface water, food conservation and
diversity. The main concern in food conservation is the loss
of quality of the food during the long transport and storage
times in the modern globalized system and associated
waste, which is well above the global average in Europe
[126]. Despite the importance of agriculture for food and
natural land for health and well-being and ecosystems
services, soils are being lost in Europe at an alarming rate of
275 hectares/day to soil sealing or land take [8]. Agriculture
is estimated to be responsible for 70% of the projected
terrestrial biodiversity loss, whilst 52% of land used for
agriculture worldwide today is moderately or severely
affected by land degradation and desertification [75]. The
need for a transition towards ‘ecological intensification’,a
process involving management strategies that integrate and
enhance ecosystems functions associated with crop pro-
duction, for instance increasing the diversity of plants and
animals to increase the resilience of producing systems, has
been suggested [127]. In addition, the different movements
of conservation agriculture (CA) [128], organic farming
[129], fermented food, etc. are all relevant. Europe is
lagging behind many other regions of the world in CA and
this is a perverse outcome of the Common Agriculture
Policy of the EU to date, with considerable benefits from
subsidies to consolidated agriculture. However, CA is now
taking a bigger role in the reform process [130].
Forested areas cover 30% of the earth’s land surface yet
contain 80% of terrestrial biomass and are home to more
than 50% of known terrestrial plants and animal species
[131]. Despite efforts to increase the protected forest
areas, the total global forest area and primary forest areas
are still declining, with associated loss of diversity in vege-
tation and wildlife [132]. In some regions re-afforestation
is going ahead but largely in the form of commercial
plantations, as seen in Europe, with little contribution to
biodiversity recovery (UNEP/UNECE 2016). Corporate
agriculture within a neoliberal trade system is the main
driver for deforestation [133] and until the drivers of
our current unsustainable food system are addressed, the
benefits humanity draws from ecosystems will be ignored
and potentially lost completely.
Conservation and protection of natural ecosystems
has since colonial times often relied on the establish-
ment of national parks, fully fenced and patrolled to
exclude (sometimes after forcibly expelling) human and
domestic animal populations. This fortunately has been
recognized as unsustainable, having to rely on unpopular
measures such as culling for population control and
the expensive relocation of animals to diversify gene
pools. In southern Africa, the recent establishment of
Transfrontier Conservation Areas (TFCAs), aimed at
restoring the ecological connectivity of contiguous con-
servation areas between different countries, is attempting
to redress this issue. However, it will also require an
integrated and multiple-use landscape management
approach to deliver the goal of sustainable socio-economic
development [134]. Management of zoonotic diseases at
the human-wildlife-environment interface in such areas
clearly requires an OH approach in its broadest sense. In
the semi-arid rangelands of East Africa, reconciling the
interests of pastoralist communities and wildlife conserva-
tion and empowering communities to manage their wildlife
has shown some local success through the development
of an integrated approach [135].
The burden of diseases associated with biodiversity
and ecosystem changes is difficult to quantify since we are
considering the loss of a protective service as opposed to
the presence of a specific disease risk, and furthermore the
burden of ecosystem alteration may be disproportionately
experienced by future generations [136]. There is great
disparity in the way people experience health impacts from
the degradation of ecosystems and it is often the remote
and poorest populations, still reliant on their dwindling
local terrestrial and marine resources, who will suffer the
most. The recognition by Steffen et al. [137] that climate
change and biodiversity integrity are two core planetary
boundaries through which other natural systems operate,
(and ultimately our health and existence depends) empha-
sizes the fundamental need to integrate natural ecosystems
in our understanding of health.
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What Have Health Assessments Taught us?
Current health governance remains segregated in local,
national and international institutions, which lack the
authority and tools to prevent emerging health threats
at various scales. Recent global threats like Ebola in
West Africa and Zika in South America provided valuable
lessons, whilst the implementation of International Health
Regulations has improved coordination and internationali-
zation of interventions [138–140]. In addition, governance
is no longer dominated by health organizations but
influenced by many actors, including UN agencies (WHO,
UNICEF) and multinational agencies (World Bank), national
governments, civil society organizations, multinational
corporations and academic institutions, etc. [29]. Animal
health and environmental health governance are in a similar
state. With a better acceptance of the interconnectedness
of health and the multiple determinants and different
sectors and actors involved, Frenk and Moon [29] suggest
using ‘global governance for health’as a more inclusive
term, rather than restricting health governance to health
professionals.
As part of governance, priority setting and
budget allocation are based on priority disease lists
regularly provided by the WHO and OIE. These are
sometimes elaborated at regional or national levels such as
at the European Centre for Disease Prevention and
Control (ECDC), which is quite active in early detection
of communicable disease/zoonoses threats/rapid risk
assessment, i.e. recent report of Rift Valley fever in
Niger –Risk for the EU [141].
These lack an OH assessment, despite the obvious
linkages with the zoonotic diseases and less obvious
environmental, socio-economic or structural drivers.
For example, the WHO’s‘Top emerging diseases likely
to cause major epidemics’includes diseases described
as serious and requiring immediate action [142]. Despite
all six diseases being zoonoses, with arguably strong
environmental and socio-economic drivers, the list
of experts responsible for prioritizing these does not
include veterinarians, ecologists, social scientists or other
stakeholders. Although WHO and OIE are advocating
a transdisciplinary approach, there is little evidence yet of
this in practice.
Our analysis of the drivers and risk factors for prioritized
diseases listed by the WHO (NTDs, Neglected Zoonotic
Diseases (NZD), Pandemic and Epidemic Diseases (PED)
and the top ten causes of death globally), showed 98% of
them could be classified as benefitting from an OH, systems
thinking approach. A similar analysis of the OIEs listed
diseases was performed. Global governance of animal
health, the remit of the OIE, has a focus on economically
significant livestock diseases. More recently their disease list
includes wildlife diseases, including those of insects and
amphibians. The diseases were assessed as to whether they
had either a significant impact on producers’livelihoods
(mass losses, culls or trade restrictions), on farmed and
wild species populations, had a vector distribution affected
by climate change, was zoonotic or caused biodiversity loss
within natural ecosystems. On this basis, we advocate an
OH approach for all 118 listed diseases.
Feasibility studies for policy making in society are
frequently based on five elements; technical, economic,
legal, operational and scheduling, with the economic
element (cost–benefit analysis) often having the most
leverage. This is often not the case in human or animal
health where political and technical considerations are
primary. However, complex problems, such as new
emerging diseases, climate change and antimicrobial resist-
ance create new challenges when assessing their feasibility
for control. Current commonly used economic models,
metrics and analyses often fail to capture the full extent of
costs and benefits produced by health interventions. A
sound assessment must be based on scientific evaluation
and must combine economic, social and ecological aspects
[52, 143]. Predictions in complex problems are heavily
dependent on modelling, whilst benefits may take many
years to accrue, which increases confounding and makes a
traditional cost–benefit analysis difficult. Predicting human
behaviour and how it may change over time is an additional
challenge. An OH approach, based on complex or wicked
problem solving methods [144] with transdisciplinary
collaboration, warrants a better understanding, acceptance,
integration and use of a broader set of assessment metrics,
as promoted by NEOH [26].
But is There Proof of Concept for an
OH Approach and its Added Value?
Policy decisions under challenging economic conditions
rely not only on sound scientific evidence but on economic
evidence too. Several authors have presented evidence of
the feasibility and argued for the added value of an OH
approach compared to isolated and linear approaches to
disease prediction and control [3, 6, 21, 46, 48, 49, 51,
145–149]. The World Bank [46] estimated the annual
funding required to build capacity of human and
animal health systems in developing countries (with high
risk of zoonotic disease prevalence) to WHO and OIE
standards was approximately US$3.4 billion. They estimate
that such annual investment would expect global benefits
of US$30 billion each year. However, many examples lack
the consideration of environment, ecosystems and struc-
tural elements of health in the interventions and benefit
assessments.
Parallels between OH and sustainability (built on
the pillars of Society, Environment and Economy) have
been identified and can be used to broaden the assess-
ment of the added value of OH [150]. In particular, the
economic dimensions require a wide assessment beyond
the obvious cost benefit analysis to include the less tangible
benefits to human and animal health and welfare [148,
150, 151].
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The objective of NEOH has been to provide guidance on
metrics and assessment of OH for use into the future.
Once established they will help to build confidence in the
approach with a scientific method to assess the benefits to
individuals up to planetary systems.
Pathway to an OH Agenda 2030
This paper has described the current definitions of health
and the segregation of health systems. We propose that
considering animal, human and environmental or eco-
systems health separately within narrow perspectives is
no longer valid. This is based on the increasing evidence
of deterioration in biodiversity, ecosystem services and
function, and trends towards a reversal in human and animal
health gains of the past century. ‘Business as usual’will
continue to achieve some apparent gains in human and
domestic animal health through high-cost technological
advancements, whilst failing to adopt integrated approaches
to address the broader socioeconomic and capital
driven structural issues will prove to be unsustainable.
The continuously rising health costs are already on the
political agenda in many developed countries. For example,
the UK is financially burdened with a National Health
Service, which is the fifth largest global employer account-
ing for approximately 8% of GDP [152]. Although there is
much to commend this valuable asset (for example, it is
relatively more efficient than nearly half OECD countries),
is it not also an indication of the parlous state of human
health and the focus of health systems on reaction rather
than prevention? Whatever the theoretical foundations
to implement this change, there is a need to demonstrate
the added value of an integrated approach, something
which NEOH aims to help achieve through developing
better tools for evaluation. Clearly, we need to shift our
current focus to a more balanced health investment with
more global benefits to all species. This is encapsulated in
the movements for OH, Ecohealth, Planetary Health and
Ecological public health, which are essentially converging
towards a paradigm shift for a more integrated approach to
health.
The two key OH objectives, which must pave the
pathway forward to achieving the 2030 Agenda are as
follows:
•We, as humans must accept we are not the ultimate and
superior product of the complex and adaptive ecosystem
we find ourselves in; we are a component thereof and
our health is directly related to the health of the system.
Therefore, we must respect and reconnect with our
natural past and work within the limitations of our
ecological niche.
•We must recognize our dependence on ecosystem ser-
vices, recognize the consequences and negative impacts
and externalities of our previous development on the
ecosystem and accept responsibility to address, mitigate
and where necessary reverse these impacts to restore
ecological processes and function. This is not a return
to some past historical points but to work with evol-
utionary and ecological processes to enhance life not
degrade it.
Key areas for action to achieve these objectives are laid
out in Figure 2 above.
Within the 2030 Agenda for Sustainable Development
and associated goals, there are a number of objectives
relating to OH. The recognition that most SDGs are
interconnected and that deep systemic changes are needed
in order to develop new paradigms (based on the integrat-
ion of environmental, economic and societal drivers and on
inter-sectoral collaborations), provides a unique opportu-
nity to shift into the OH paradigm. However, the reality of
claimed OH initiatives will have to be critically evaluated.
Figure 2 Key One Health (OH) objectives and action points to achieve them.
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This assessment proposes the following as a pathway
(timeframe in brackets):
(1) Exchange and sharing of the current movements,
which share common principles (EcoHealth, One
Health, Ecosystems Health, Planetary Health,
Conservation Medicine, Ecological Public Health)
under one umbrella (3 years).
(2) Consolidate the position of an OH approach outside
of the academic environment where it is currently
languishing. Political support is vital for this and
although considerable political momentum was given
to the One World One Health principles a decade
ago this needs to be sustained and across a broader
constituency (5 years).
(3) Build evidence for the added value of an OH approach
through developing the necessary methodological
framework and metrics for evaluation of OH inter-
ventions; the objective of NEOH (5 years).
(4) Establish capacity and protocols for operationalizing OH
within the main agencies (International and National)
addressing health policies at the nexus of humans,
animals and environment. Promote systemic thinking
in health professionals (10 years).
(5) Initiate educational processes at an academic level,
government level and ultimately at all levels of
society to help the process of change and acceptance
of necessary changes in the health paradigm and
how society addresses modern health challenges
(e.g. established curriculum across medical, veterin-
ary, public health, engineering, architecture, agri-
culture, land management, economic, social and
political science, conservation/wildlife science, etc.
faculties). A common OH curriculum could be a
goal across all key disciplines and be extended to
continuing professional development and government
training programmes (ongoing with a common curri-
culum in 10 years).
(6) Foster transdisciplinary research activities to understand
better the drivers of emerging and prioritized diseases
and level and degree of change in human (develop-
ment) activities and behaviour, which will prevent
or reduce risk and restore systems resilience
(ongoing).
(7) Continue to mitigate effects of emerging diseases at the
interface through conventional but environmentally
neutral approaches (surveillance, early warning,
medical technologies and pharma), reduce trans-
mission risks through appropriate biosecurity and
use integrated approaches to disease management.
Devise public awareness actions on health protection
measures and risk mitigation in the face of crises
(ongoing).
(8) Science policy interface to incorporate research out-
comes on OH disease drivers including development
activities (in land use, agriculture, settlement, trans-
port systems etc.) likely to precipitate disease
emergence and models for prevention of risks
(ongoing).
(9) Participatory political approach to reach consensus on
adoption of proposed OH interventions –a funda-
mental shift from reactive sectoralized medicine to
preventive actions at social, ecological, economic and
biological levels of society. OH provides a framework
for the application of principles and in itself need not
necessarily be institutionalized (10 years).
(10) Create communication and exchange platforms for the
OH stakeholders at national, regional and inter-
national scale (ongoing).
Conclusion
The SDGs are intertwined and have health embedded
within them. We argue that attempting to achieve the
SDGs, whilst working within the currently defined and
segregated health systems (and their often linear approach
to solving health challenges), whilst ignoring the linkages of
health to ecosystems services and biodiversity, will increase
antagonistic tensions between SDGs thereby undermining
overall progress. The SDGs provide a unique opportunity
for a move towards a more integrated approach to the
future health of all. Our suggested pathway to achieving the
2030 Agenda is built upon the recognition that humans are
but a component of an ecosystem upon, which we depend
and within which we are called to support rather than
undermine the services upon which we and other com-
ponents depend. In addition, by taking a broader and more
inclusive view in evaluating the benefits of OH, we believe
enough evidence can be found to demonstrate the added
value of an OH approach. We call for an integration of the
current movements who share these principles to stren-
gthen and deliver a OH approach with agreed protocols
and capacity building within international and national
agencies. In addition, we advocate the initiation of an edu-
cational programme to mobilize the process of change
throughout the education system, creating buy-in from the
whole of society through the school curriculum and creat-
ing a common OH curriculum for all the tertiary education
disciplines with a key role in OH. This will provide a foun-
dation for increased transdisciplinary research activities and
mutual understanding in the future and a framework for a
shift towards integrated and preventive health measures
rather than sectoralized reactive medicine. Furthermore,
this integrated approach requires open communication and
exchange platforms for all OH stakeholders to encourage
participation and to maintain momentum and trust.
Acknowledgements
This paper is based upon work from COST Action
TD1404 –Network for Evaluation of One Health
(NEOH), supported by COST (European Cooperation in
Science and Technology).
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