Richard Horton, Editor-in-Chief of The Lancet, “Planetary Health”

By | September 11, 2019

– I’m delighted to welcome you to this lecture by Richard Horton, who will speak on Planetary Health: Perils and Possibilities
for Human Civilization. For those of you who
haven’t been here all day, and let me thank all those who have been for sticking with us, this is the culmination of this year’s Strauss Symposium. The Strauss Symposium, or
more formally known as the Leila and Melville Strauss
Class of 1960 Family Symposium, is the leading conference
that the Dickey Center puts on every year, and we rotate it between our different
core areas of activity. Mickey Strauss was a admired and beloved member
of our Board of Visitors, who established this
symposium in a bequest several years ago, and I want to thank again Leila Strauss, his wife and his son, Scott Strauss, who is a member of our board now, and a member of the faculty
at the University of Wisconsin and couldn’t be here today. But they’ve been engaged all along and they’re wonderful supporters of this event. This is our third Strauss Symposium. I’m happy to say the inaugural one was held in 2015, and dealt with exploring new methods and technologies for early warning of mass atrocities, including genocide and other large-scale crimes against humanity. It supported another project that we’ve had
here at the Dickey Center, together with the United
States Holocaust Museum, the Early Warning Project, which is a terrific portal on the internet where you can model and study mass atrocities and
crimes against humanity and try to figure out what are the factors that lead to such events. We also had, last year, an outstanding Strauss
Symposium that was devoted to lessons learned and best
practices for the future after the Nepal earthquake. And that was a really successful event and I think that this year’s, this year’s symposium on
global health in an era of de-globalization has
been a fitting successor to those two events. Our various panelists
have been saying all day that they don’t like that title, so I’m just going to abuse the
prerogative of the microphone to say that it is none-the-less, it was wonderful to hear all
the defenses of globalization and I remain one of its great fans, but it is a time when
many of us are worried about the engagement of
governments around the world and the financial resources of the major international organizations
and foundations to maintain the kind of
progress that we have seen in the last 25 years. And it’s all the more reason
why we’re delighted that Richard Horton is here today to discuss these issues. But it does not fall to me
to introduce Richard Horton, instead that falls to
President Phil Hanlon, so I’m gonna ask him to
come up and do the honors. (audience applauding) – Good afternoon, welcome everyone. I am Phil Hanlon, the
president of Dartmouth College and it is an honor and
a privilege to introduce your keynote speaker this afternoon. Though I’m certain for
those of you in the room who are more into this field, he needs no introduction whatsoever. For more than 20 years,
Richard Horton has served as Editor in Chief of the Lancet, one of the world’s most
respected medical journals. Richard joined the Lancet in 1990 after qualifying in
physiology and medicine with honors from the
University of Birmingham four years prior to that. In 1993 he moved to New York
as the North American editor and two years later returned to the UK to assume the role of Editor in Chief. Under his leadership the
Lancet has played a critical role in shaping the global health agenda and become an authoritative
global health publication. It’s catalyzed scholarship
and shaped global policy around the emerging health challenges from the rising tide of
non-communicable diseases in low and middle income
countries to the links between climate change and
health and the devastating effects of conflict and the
resulting mass migration on health. In 2013 Richard launched
the Lancet Global Health, an open source journal
focused specifically on disadvantaged populations. Richard was the first president
of the World Association of Medical Editors and
is the past president of the U.S. Council of Science Editors. He’s written two reports for the Royal College of Physicians, Doctors in Society in 2005 and Innovating for Health in 2009. In 2003 he authored the book
Health Wars about contemporary issues in medicine and health and is a regular contributor
to the New York review of books and the Times
literary supplement. In 2011, Richard was elected
as a foreign associate of the U.S. Institute of Medicine. Please join me in welcoming
to the stage, Richard Horton. (audience applauding) – Thank you very much indeed. Thank you, thank you. President Hanlon, Ambassador
Benjamin thank you very much indeed for your kind words
and it’s a great pleasure to be here with you today. We’ve had a great day in this symposium and first of all we
have a little bit of fun with another ambassador Nils Daulaire, who was as you know representative in the Department of
Health and Human Services in the United States
government in a previous era under a different president
and represented the United States on the executive board of the World Health Organization. We had a little bit of
fun because this man, Sir Henry Wotton once
said an Ambassador is an honest man sent abroad
to lie for his country. We tease Nils a little
bit about that today. But what’s often not quoted
is the part that follows that. A news writer is a dishonest
man who lies at home for himself. So that’s me. So I started off as a medical doctor and now work at a medical journal. So you’ll have to take
what I say in the context of what Sir Henry Wotton said
way back, 3-400 years ago. It’s gonna be an, I hope,
challenging tale about the predicament that we face as a species. Who would have believed
that Time magazine would have ever put a quote like
this on its front cover just a few weeks ago? Who would have believed that this country could have put as a
leader of what is actually a major public health agency, a man who does not believe
in the relationship between carbon dioxide and climate change? Who would have believed
that a country that has led the world in discovery
science would submit a budget that promises to eliminate $5.8 billion from that science budget? Let alone take out the Fogarty Center, one of the foremost advocacy
and delivery organizations that we have in global
health in the United States? Who would have believed that
it wasn’t just NIH that was being attacked in this
unprecedented assault on science, but a whole series of
institutions that not only lead in America but lead in
the world in terms of your soft power, your scientific
power, your contribution to global humanity? Who would have believed that
we are living at a moment where there is a rage against the global. Where trust and belief in
multilateral organizations such as the United Nations feels that it’s at an all time low? Who would have believed
that we would be alive at this moment today? Who would have believed it
because we have an opportunity that’s unprecedented in
the history of humanity? And that opportunity is
expressed in 17 sustainable development goals. Those goals, in a sense,
articulate a manifesto of hope for what we can do
as a species in improving the lives of our fellow
citizens on this planet. I’m not gonna test you on the goals, but basically the first six
are goals that were embedded in the millennium development goals and have been transferred
into our vision out 2030. And then we move into
a really remarkable set of commitment on energy for
all, promoting economic growth, infrastructure, addressing inequality, resilient cities, and
sustainable consumption. And then the pivot point is
SDG13 which is addressing climate change, which
links, of course perfectly. Whoop, which links of course
perfectly with the Paris Climate Agenda. Which was, despite what you might hear, one of the most remarkable
multilateral agreements I think that has been made
in the history of human kind. It wasn’t a legally binding document, but it set the world on a course, which even this country
is going to find difficult to divert us from. Conserving oceans, protecting ecosystems. Promoting peace and
revitalizing partnerships. It sounds very utopian. John Rawls, your great
philosopher did write, indeed, in his theory of justice
the notion of a realistic utopia. And I think the sustainable
development goals do set out a realistic utopia about
what we could achieve. That’s the opportunity, that’s the prize for us to grasp. For those of us working in health, we have our marching orders. And that’s what we in our sector have to achieve over
the next 14 years or so. And it’s a big set of asks around maternal mortality,
child mortality, infectious diseases,
non-communicable diseases, various substance abuse
and alcohol, injuries, sexual reproductive health,
universal health coverage, the big one. Because if you can achieve
universal health coverage, many of these will fall into place. And pollution and various
other focal points for us to address. But those goals don’t
actually tell us what sustainable development
is really all about. Sustainable development is not 17 goals. Or a whole bunch of targets. It’s about something
much deeper than that. So what is it? The idea of sustainable development, unlike the millennium
development goals is that it’s a universal concept. It’s not about people who are
living in extreme poverty. It’s about everybody on this planet. You and me and everybody. And it’s about our essential
interconnectedness, our essential interdependence,
one with another. That is an inspiring idea, that we are related to one
another in terms of our futures, our future trajectories. It’s not only about us, it’s also about the next generation. We can’t make decisions
about our future without taking account of the
futures of our children and our grand children. Equity is a defining
idea in global health. But inter-generational
equity is the defining idea of sustainable development. It’s not only about our species. It’s about all species and
the dependence of all species on each other for our collective future. The oneness of all life. It’s also about not just
life, but the relationship, indeed the symbiosis
between life and the planet that we inhabit. But it’s also a warning. And it’s a warning that says this, the threat that we face
is not carbon dioxide. The threat that we face is
the challenge to the systems that we have created as a species. The political, economic, social systems that govern our lives in this world. The challenge is to those
system as to whether we can diagnose the problems that we face. Whether we can understand
the challenges that we face and whether we have the
courage, the capacity, the will to act. Let’s look briefly, very
very briefly at progress with the sustainable
development goals so far. This is actually looking
at progress during the course of the millennium development goals and where are we? We can see that we’ve made
really quite substantial progress in universal health
coverage where we are today. This summary report card
was published towards the end of last year. We’ve made some progress in
access to modern contraception but it could be better. We’ve made some progress
in access too clean water, but it could be better. And we know where we’re
doing not very well, alcohol consumption and childhood obesity. So we have a report card on our current progress. And we’re working in
collaboration with Chris Murray’s group at the Institute for
Health Metrics and Evaluation at the University of
Washington in Seattle to try and track progress over
the next 14 or 15 years to see how we are progressing
towards the sustainable development goals. But again, there’s a
concern that we should have. Our target for those of
us in the health community cannot just be SDG3, which
is insuring healthy lives for all. We will not achieve healthy lives for all unless we work at the interface between the sustainable development goals. There can be no health
unless we address education. Education is absolutely critical. There’s no point saving
children’s lives if we can’t deliver those children to
a strong educational system that can fulfill their
full potential in society. There’s no point in
saving children’s lives if we don’t also achieve
gender equity and equality. If we don’t count women,
reward women, give women the opportunity for political
participation in society. If we do none of that, saving
lives is not going to achieve or realize the hopes that we have. We will not be able to
achieve healthy lives for all unless we create the fiscal
space to invest in our health systems. And therefore we need to
create economic growth. This picture, this
slightly strange picture of Francois Hollande and President
Zuma, I took when I was chairing an expo group
reporting into a commission on, as you can see here, health,
employment and economic growth. It reported to the United
Nations last September at their general assembly. And the essential idea
is a very simple one. To drive economic growth, one doesn’t just invest in health, but one should be investing
in health workers. Investing in jobs and
skills in the health sector. The health sector is often
seen as a cost to an economy because we don’t produce anything. But in fact, the latest
economic evidence shows us exactly the opposite. That investing in the health sector and I’m not talking about doctors here, I’m talking about nurses, midwives, community based health
workers, pharmacists, a whole array of different
cadres of health work in the system can drive economic growth. So health is an engine for the economy. And we can’t achieve healthy lives for all unless we invest in the rule of law. Unless we invest in governance, unless we invest in accountability, unless we provide
opportunities for the state to intervene, but also limit
the powers of the state through the rule of law, we will not be fully able to
achieve healthy lives for all. Indeed when you look in plots
measures of the rule of law against various health
outcomes you see some very interesting correlations and
that’s why we are running a commission with Georgetown
University in Washington D.C. looking at the relationship
between health and the law. So let’s just stop and summarize
where we’ve got to so far. The threats to our future are
real and they’re existential. Our successes, and there
have been successes, but they hide serious failures. The SDGs are inspiring and
they’re deeply motivating to all of us to act, but
our predicaments are not static, they’re dynamic. Global health science
can give us solutions, but it also reveals the terrifying extent of our uncertainty and
the challenges ahead. And we are living at a moment, a moment that just a few
years ago we would not have predicted. We are living at a moment
when science is under attack and the vital partnerships that it’s taken a decade or more to
development are under threat. So is that it? We could perhaps stop there. Or is something missing from this story? There was an essay
written by Thomas Nagel, a philosopher in 2005 in
Philosophy and Public Affairs called The Problem of Global Justice. Global justice is a great phrase and I’ve, many times,
stood on stages and said, human rights, equity,
global justice, this is what we’re fighting for, and global health. These are the values that we believe in. But then Thomas Nagel
unfortunately wrote this essay that punctured my slightly
idealistic naivete. There can be no global justice. Why can there be no global justice? His argument is justice as
a concept can only originate within entities where
there is sovereign power. And the only entities that
our species has created where there is sovereign
power are things we call nation states. Justice can exist within a nation state if the sovereign power so wills it. But we have no sovereign
power over the world. There is no world government
so the concept of global justice is just simply impossible. It logically cannot exist. So his conclusion in his
final paragraph to this rather bleak and depressing essay is this. The path from anarchy to justice
must go through injustice. And what he’s saying in
a rather eloquent way is things have to get really bad
before they go to get better. And boy things are gonna get really bad. So prepare yourselves. We’re living in a different age. And global health has not
yet begun to get to grips with the seriousness of
this epochal transition that we are already in
the early stages of. And if the global health community, if our universities and
colleges like Dartmouth do not embrace the magnitude
of this transition, we are going to miss one
of the most important challenges that our
species faces or has faced in several hundred years. How many of you have
seen the films Ice Age? Yeah, they’re great movies,
I’ve taken my daughter, who’s 16 and wouldn’t go with me now, but when she was smaller she did. And they’re great movies. But when I watched the Ice
Age films, I hadn’t really understood that we were
talking about 2.5 million years ago, so this was the Pleistocene, that’s the setting for those movies and that takes us up to
about 11,700 years ago. And that’s the beginning of
what we have thought about as our era. The Holocene. A lot actually did happen in the Holocene and although these graphs
look a little bit bumpy and sometimes flat, that
conceals a lot of activity in terms of these various measures. Ice cores, temperatures,
carbon dioxide and methane parts per billion. But it’s when you get to
here at the very very edge that things really start to happen. So what is happening? So let’s got from 1750 up to 1950. Here you start seeing carbon
dioxide concentrations increasing, we’ll come
to plutonium in a moment. And then we just start
producing lots of stuff. We’re really good at manufacturing things. Whether their concrete, plastics
or measures of pollution such as black carbon. But then it was around 1950, the point that we now call
the moment of the great acceleration that things
really really take off. Now people have been arguing
for the last 10 years or so, maybe a little bit more
about when does this new era, the Anthropocene really begin. The moment when you can
actually measure the impact of human activity on the planet,
and not just on the planet but changing the directory
of travel for the planet. Some people put it back into
the industrial revolution. Some say there isn’t such a
thing as the Anthropocene, this is just a continuation
of the Holocene. But the time when most people
think that we should be considering is a very specific moment. And that specific moment
happened in the deserts of New Mexico, July 16th, 1945. Trinity. It was trinity that led to this
rise in radiogenic fall out. As being perhaps the
critical stratigraphic marker of the Anthropocene. Plutonium started to
be detected in the soil around 1951 and it’s
that stratum of plutonium that the geophysical
community are considering as the moment that we
should be thinking that we truly are in a new era. So, here we are, Pleistocene, Holocene and now we’re in the Anthropocene. Let’s take a very good
measure of the kinds of issue that we’re talking about
in the Anthropocene. Pollution. We were talking earlier in
the symposium about the fact that climate change can
sometimes seem a very abstract entity, doesn’t feel that
it’s having an impact on human lives. That actually climate change
can seem very very distant. But it is having an impact on human lives. If you think about it more
broadly in terms of the ecological crisis that we are facing. So this is looking, this is work that has just
recently been published, just two days ago, in our journal. Looking at from 1990 to 2015
and looking at PM two point, less than 2.5 micrometers. And what you can see of course
is the story of the world in terms of its human development. You can see a collection
of countries here, the United States in a
very welcome position, right at the bottom in
terms of output of PM 2.5, but then what you see are
countries such as Bangladesh, India dramatically, China
more slowly, Pakistan, seeing an increase arise in
their levels of pollution. A crude but never-the-less
reasonable markup for human development. As you see industrialization,
consumption, population growth, technological
change, taking a grip of these nations. When you then look at the
contribution of pollution, this particulate matter
to deaths then you can see measurable increases over time. Again this is 1990 from 2015
and this is work from the Global Burden of Disease Study
again from IHME in Seattle. Looking at deaths attributable
to PM 2.5 in millions. And you can see this gradual
increase over the last 20 years or so. And then you can see the
hotspots in the world where this is already happening. So when you look at this legend here, there are some red areas
are where you’re seeing very high levels of
pollution related mortality and so you’re seeing them
across South Asia, China, parts of the Middle East
here, parts of Europe. This is happening right now. These are measures of the
ecological degradation. The collapse in our ecosystem
services that we are seeing as a result of one particular
measure of pollution. But this measure gives
a slightly false view about the threat that pollution has. This work was published in
Nature just a few weeks ago. And what it shows is the
importance of transnational pollution. Pollution produced in
one part of the world and its effect on another
part of the world. So let’s take, let’s take an example. This is looking at the
region where deaths occurred and here the region where
pollution was produced. So let’s take here. A big part of East Asia and we go up here, there’s 76,000 deaths in
this region of East Asia. And over half of those
deaths have taken place in, let me see here, sorry, 40% of
those deaths have taken place because of pollution
which drifted from China. Or take this part, again,
another part of this more South Asia, 26% of deaths in
other regions of South Asia from pollution in India. And this is around 400, this is 26% of around 276,000 deaths. Or take here, more closer to home. A smaller number, in Canada,
8000, just over 8000 deaths from pollution and about 47%
of those deaths attributable to pollution that’s come
from the United States. So this is the important
part about interdependence. And that when we blame certain countries, we have to look at our
responsibilities as well in terms of, in this case, the
pollutants we are producing and the effects that they have. I’m giving you examples from middle and high income countries. But let’s now look at some
of the parts of the world which are facing
particularly acute threats. UNICEF put out this warning
just a few weeks ago about 1.4 million children
across four countries in Africa and the Arab world who are at imminent risk
of death from famine. From famine. Why are they at risk of death from famine? Because not only are they
facing poor governance, economic collapse, disease,
they’re also seeing a prolonged period of
drought which is exacerbating the risks for these communities. It’s certainly true that if
you read the intergovernmental panel on climate change,
then the impacts of climate change on human health
are currently small. But that’s the wrong measure to look at. Sustainable development is
about the oneness of life. And so we need to be looking
at the impact of climate change not only on our
species, but on all species to get a real sense of what is happening and what will happen eventually to us. And when you look at, in
this particular case the rate of vertebrate extinctions
you see over the course of 400 years or so, a dramatic
increase in the number of extinctions. And it’s these data which
tell us that we are passing through a planetary moment
which can be called the sixth mass extinction. What do we need to do? We can lay out the problem,
but what do we need to do? Johan Rockström who leads the
Stockholm Resilience Center just two weeks ago published
a road map for what we need to do over the next
40 years to meet the goal of 1.5 degrees, two degrees
increase in global temperatures which fits with the Paris Agreement. And we need to recognize
that we are going to have to achieve, if we really
want to achieve the objective of Paris, this is going to
require a dramatic change in our behavior. And this is why I say,
talk about human systems. Are we ready for it? Can we do it? There’s never been a test
of human kind like this. Here’s what we’re gonna have to do. We’re here. By 2020 we are going to
have to see a peak in human carbon emissions. That’s just in three years time. After 2020 carbon emissions
have to turn down. If we’re going to meet that
1.5 to two degrees temperature. By 2030 we need to have eliminated
coal from our energy mix. By 2040 we need to have eliminated
oil from our energy mix. By 2050 we need to have
put in place technologies which we have yet to discover
that will begin to extract carbon dioxide from our atmosphere. In other words, right now,
we have consistently passed a threshold hitherto unpassed
that is 400 parts per million of atmospheric carbon dioxide. But by 2050, we need
to have put into place carbon extraction technologies
to bring that figure down from 400 to around
380 parts per million. This is a big ask, but
that’s what’s needed if we’re going to achieve Paris. Our two biggest emitters
of carbon dioxide, China and the United States. We see strong leadership
from President Xi Jinping. I won’t make a comment about this country. This book is in your
bookshop on main street. And I would encourage,
there were two copies. And I would encourage
you to run and buy it. This is the silent
spring of our generation. This is Rachel Carson’s the
Silent Spring but written for us. Tony McMichael, an Australian
epidemiologist who became intensely concerned about
climate and ecological collapse. And he wrote what is a
manifesto of the evidence and for public action
on climate and health. Famines, fevers and the
fate of populations. He finished the manuscript in early 2014. And very tragically passed
away later that year. But two colleagues of his
plus his family discovered the manuscript and put it together finally so it was published
for the very first time just a few months ago this year. Two copies in your book store, I guess your book store, it’s still open, it’s only 5:19, if I see
two people leave the lecture I won’t be upset. In that, he absolutely correctly pinpoints the challenge that we face. This is not just a climate
crisis or an ecological crisis. The great undercurrents
that shape the fates of civilizations, their
cultures, ideologies and power structures. That’s his subject. The fates of civilizations. That’s the unit of analysis we have. I trained as a medical doctor. What that meant was that I
sat in front of a patient, took a history, did a
physical examination. My unit of concern was the
patient in front of me. And then I grew up and
discovered something called public health and then my unit
of concern was the community. What should be our unit of concern today? Our civilization. Our civilization because
it’s within our civilization that the systems exist for
us to diagnose, understand, act upon the threats we face. So what should be the
response of you and I, the scholarly community
to this new human epoch? A couple of years ago we
wrote about the idea of an urgent transformation
required in our values and practices based on recognition
of that interdependence I talked about and the
interconnectedness of the risks we face. And we spoke about a move from
public health to planetary health. We are very grateful to
the Rockefeller Foundation for giving us a grant so
that we could investigate this idea a little further, a commission on planetary health. And the definition of
planetary health is a very straight forward one. It’s the health of human
civilizations and the ecosystems on which they depend. Two important ideas at least there, one, the notion of the
civilization as the unit of our concern and second,
the fact you cannot talk about human existence without
thinking about our existence in the context of broader ecology. Because we face a challenge
of massive ecological proportions. In fact, three challenges we
laid out in the commission. The first is a challenge
to our imagination. What do we mean when we
talk about prosperity? Prosperity is not only GDP. It is not only financial objectives. It is the notion of a double bottom line that is to say thinking
about something more than just the money. Thinking about the notion
of prosperity in terms of our human relationships. About the connections we
have with the land and sea around us and how we
measure that prosperity. A challenge about knowledge. We created universities
and colleges like this one that function on the basis of schools. Schools of engineering,
schools of medicine, schools of business. They live in their little worlds. They often have walls around them. They have faculty that
live in those little worlds with walls around them
and often don’t interact much across those walls. Sometimes the incentives aren’t
in place for interaction. But if we are really going to
generate the kind of knowledge that we must have to address these complex predicaments that we
face, we have to tear down these walls to quote a
past American president. And who would have
believed now a much loved past American president. Seriously, we have to
tear down those walls. How do we do that in an
institution such as this? Maybe you’re already doing
it, so I shouldn’t say that. At an institution like most of ours back in the United Kingdom. And the third challenge is
it’s all very well generating the knowledge, but publishing
papers in a medical journal for example isn’t much use
if we don’t do something about it. So what’s our responsibility to act? This idea of planetary
health seems to have caught a little bit of imagination. There are now symposia,
meetings on planetary health, those of you in the
Consortium of Universities for Global Health just a
few days ago in Washington saw planetary health discussed
across several symposia. There’s a planetary health alliance which is meeting in Boston
in just a few weeks’ time. Led by Sam Myres at the
School of Public Health. This was a group of us
meeting at the Rockefeller Foundation last month in New York because the Rockefeller is
investing further grants in supporting planetary health. The very first professor
of planetary health, Tony Capon is now installed
at the University of Sidney. Planetary health programs
are springing up around the world. There’s even a journal, Planetary Health, about which I will say nothing more. (audience laughing) What does it really mean to
talk about planetary health? Great, another abstract idea. What does it really mean? It means looking at our
problems in a different way. This is something WHO did recently, just a few weeks ago which
gives an example of it. We know that about six
million children under five die every year. We know the causes of those deaths. Infectious diseases being one example. Newborn mortality being another big cause. Those of us in the maternal
child health community and I include myself in
that because we publish work from that community for
the last decade or so, have a very fixed view about the causes and therefore the responses
we need for addressing child mortality. But there’s another way of looking at it. What about if you shine child
mortality through the lens of the environment? Then you get a completely
different picture which those of us in women’s
and children’s health have never talked about before. Not seriously. About a quarter of all under
five deaths can be explained through environmental causes. But we just have never
thought about child health in terms of environmental causes. So it’s changing our frame of reference. It’s changing the coordinates
with which we see a problem. That’s the front cover
of this week’s issue of the Lancet. If you still read paper. This is another example
of planetary health. Because planetary health
is asking us, remember, to look at the questions of the politics, the economics and the social
systems that we’ve created in our society to address
particular problems. This is what you see
from 1910 through to 2015 in terms of the share of
the total income received by the top 1% of earners in the U.S.. And you can see from about the mid 1970s we’ve seen this gradual increase in terms of that proportion. And this is a series of five
papers looking at inequality in the United States. Not only do we have an
income in equality problem, but we are seeing greater
stress on particular communities and of course you know
this better than I do, because you’ve been living
through these debates about patient protection
and affordable care act. But as we’ve seen, worker’s
earnings have a very very gentle slope of increase,
we’ve seen deductibles and premiums increase such
that the gap between these two lines is increasing. Increasingly, the costs
of health care become more unaffordable. If you then look at that
issue a different way, this is now looking at debt. And what are the main
contributors to personal debt in the United States? Oil companies, credit
unions, check guarantees, automotive, educational,
personal services, insurance, financial government, rental,
banking, retail, utilities, cable, unclassified and the
leader, medical and health care. Which drives that
catastrophic expenditure. But there’s also a social
crisis that exacerbates these inequalities and this figure
particularly blew me away. So this is looking at
incarceration in 21 democracies in our world. From 1980 to 2015, and you can see that
most of these lines are, they might be slightly different levels, but most of these lines are broadly flat. You can see that some have seen increases, but look at this one. Is this the kind of society that we want? In one of our great democracies? I consider myself an
American citizen even though I’m not one. Because everything that
happens here it affects me and my family and all my friends. So, I want to be an American
citizen for the purposes of this discussion. That can’t be something we’re happy with. Look at it a different way. This is inflation
adjusted household income. Across selected percentiles. I talked strata earlier and
you can see the stratums, the strata of American
life in this picture. Again going back from 1970 to 2015 and you can see these deciles that this is looking at
annual household income. The flat here, and rising here. Again, the inequality
really quite dramatically increasing and for this particular group which is the top 1% in terms of income. Again escape velocity taking
place for this particular group in our population. Now that’s only one part of the story. This is work that was published
by the Brookings Institution again just a week ago. You may well be familiar with
some of their earlier work, Angus Deaton and Anne Case at Princeton. Looking at what they
call diseases of despair. And their particular
concern was this group, white non-Hispanic Americans
with a high school diploma or less. And their observation is
that over the last 15 years, if you’re African American,
you’ve seen your total mortality, all-cause mortality decline, but you see for white,
non-Hispanic Americans with a high school diploma or less, you’ve seen that increase. And that increase is
what has driven the white non-Hispanics total to have increased. Now their argument of course is this is the group of people
who are not just suffering lower incomes but their
seeing their family structures and their marriages challenged. They’re seeing their
health systems destroyed, their education systems destroyed. No employment, no skills training. They’re seeing the institutions,
including the church for example, that normally
bound their communities together falling apart. And these are the diseases of despair often driven by new epidemics,
for example opioid drug use for chronic pain. And their particular analysis
is somewhat controversial, because it’s focusing on
this particular group, a group that the current
president here has tapped into in terms of his popular support. Bernie Sanders wrote an
editorial to accompany the series we published this week. And, wonder what life
would have been like with him as president. And he wrote about an
agenda to fight inequality. And he said this, “Making
sure that every citizen “has the right to child
care, health care, a college “education and a secure
retirement is not a radical idea. “It is as American as apple pie.” We should be careful. Mary Bassett also wrote
and she’s the New York Health Commissioner, also
wrote in this weeks issue of the Lancet this, “A
narrative that sees black and “Latino individuals as on track, “and white individuals as now off track, “possibly due to neglect,
will not yield a successful “public health response.” And there’s an important
warning here that while we separate out different groups
and we do pay attention to white non-Hispanic Americans,
don’t forget this point about interdependence. Don’t forget this point about communities. About social solidarity. And that’s what’s Mary is
identifying here as so critical if we’re really going to build
a response to the threats that we face. Now I can’t come to you
and say all this stuff about America without mentioning Brexit. I’ve got one slide only on Brexit. So that was a bad day. For those of us who
thought we were Europeans. We made a mistake, it was our mistake. The 48% who lost, it was our mistake. And it was our mistake
because we didn’t understand the schism that had taken
place in British society, particularly England, English society. We thought that everybody had
benefited from globalization. Everybody had benefited
from being in Europe. And we didn’t understand
that 52% of our population actually didn’t agree with us. Not only did they not agree with us, but they didn’t like the fact
that we had open borders. And they weren’t comfortable
as many of us were, sitting on tubes in London with
every different nationality you could possibly think
of, half a dozen different languages being spoken at the same time. That celebration of globalization,
of multiculturalism, something that I want my
children to enjoy and embrace, but for 52% of our population,
they saw that as a threat. There’s an interesting
historical parallel here because this is a crisis that
Britain has faced in the past. And it is this notion of
isolation and how we address it. So I went back and I
looked in my history books. I’m old, I’m 55 years old. So I went back to when I was about 15, so 40 years ago. And I discovered this
page from my history book. Slightly childish writing,
so apologies for that. But I had a section in my
history book from class I actually headed “Splendid Isolation”. And this is what the British really think. This is the problem about being an island. Britain, from around 1875 onwards, under the influence of Lord
Salsbury pursued a policy of going it alone in
which it held no alliances or commitments to foreign powers. This was called splendid isolation. In the 1890s Britain, on her
own, elevated I think it was meant to be, my spelling
was never very good. Elevated herself from a
tight situation with France over the Sudan. Both claimed Sudan although
the French only wanted it for prestige. In the end Britain got Sudan
and took away even more prestige from France. This the British education. We’re taught, we’re taught to hate Europe from the age of 15 onwards. This showed how successful
splendid isolation was. The splendid isolation
policy was also tested by the Boer War and once
again, we came out triumphant. I was horrified when I read this. Education is indoctrination. And I bought the whole lot. It’s just an example of
how an education system has a particular conception of the history of a nation and then transmits
it to the next generation. I have no idea what you teach. I’m sure it’s not as bad as
my history was taught then. But this is an existential
crisis about Britain as a country in the
world, anxious and fearful about it’s direction of travel. 40 years ago, I was taught
that splendid isolation in the 19th century was
a solution to the threats we faced in Europe and
elsewhere in the world. In 2017, that’s the cause of Brexit. How do we get out of that? Question to you, if planetary
health is so important, Mr. President, (audience laughing) You’re the man with the budget. You can write any check for anybody. – [Phil Hanlon] You got the job! (audience laughing) – I want to know when the next professor of planetary health is gonna
be, the first professor of planetary health will
be appointed at Dartmouth. It’ll be a great day and
I’ll come and celebrate with him or her. I’m gonna close now. I’m gonna close with one
anxiety and two further thoughts and they’re optimistic
thoughts, don’t worry. The anxiety though first. And that is, it’s an
anxiety about our systems, it’s about our democracies. Are they capable of finding solutions? You know the great thing about democracy is I can write an editorial
and demand on A, B, C, D, or E institution to do that, fantastic. That’s the great thing
about freedom of speech. The problem is that it’s
rather harder to deliver responses. Not only that but we’ve created
systems in our democracies where power is fragmented
and we tend to disagree with one another which paralyzes congress or paralyzes the British parliament. Wouldn’t it be so much
nicer to live in China? Well, actually, don’t knock it. We do a lot of work in China
and when they understand that they have to act, boy do they act. And they don’t let
anybody get in their way. Which raises issues in and of itself. But there is a balance between
autocracy and democracy. And there is a question
about whether our democracies really can deliver. We have to build
extraordinary new coalitions if we’re going to address
the challenges we face. And the quality of our lives is going to depend upon
the quality of the way we communicate with one another. So, lemme give you two examples. This is the man Khalid
Masood who drove his car into tourists crossing Westminster Bridge, who jumped out of his car
and then fatally stabbed a policeman standing outside
the House of Commons. His photograph was on
the front page of every British newspaper, was
on television screens and it led to another wave of Islamophobia in the United Kingdom
and attacks on migrants. Shortly after this event took place, a young, Iranian asylum seeker
was attacked in South London by a gang of 20 young
people, men and women. His head was kicked like a football and he’s still lying
in hospital in London, almost certainly with
permanent brain injury. Every year for the past eight years we’ve held a meeting in
the Arab world called the Lancet Palestinian Health Alliance. It’s a meeting where
we bring together about 100-150 young male and
female Palestinian scientists from around the region to
present their abstracts. Research abstracts that we
then publish in the Lancet to tell the story of their life, their health predicaments, their nation. This is a picture taken from an abstract that this young woman presented just a month ago in March this year, at the meeting we held
in Birzeit University just outside of Ramallah in the West Bank. She’s happy, she’s happy
and smiling because she got her abstract accepted
and she’s been telling me about it, she’s a pharmacist. She’s proud of her work. She’s confident in what she’s doing. She’s free to do this work, and she’s encouraged to do this work. She is an empowered young Muslim woman doing great things in her great country. So you compare the stories
of these two people and the images that we think of. Khalid Masood the terrorist murderer or this young lady who
is presenting her work at our research meeting. It depends which image
you show that tells you a very different story about Islam. We see this image all
the time in our media. We rarely see this kind of image. This is our responsibility. Science, medicine, scholarship, building relationships
between institutions like this or journals like ours with
communities in other parts of the world can build
peace, understanding and a different story that can give hope and opportunity and shape the public mind. Last week, just a few days ago
now, April fourth and fifth, we held another meeting, this time in Rome in a building,
an unbelievable building, literally overlooking the Roman forum. We were discussing the
future of civilization in the ruins of a past civilization. The goal of this, with
somebody who directs the institutes Mario Negri in Bergamo was to heal the wounds between science and the Catholic church. And the idea was that we
would look at the future of humanity not only through
the lens of medical science, but also through the lens
of the Catholic church. We worked with Cardinal
Ravasi who has the Pontifical Council of Culture in the Vatican. And we even managed to get
the Pope to come along, there’s Mario Capecchi who
discovered knockout mice one of our speakers at the
meeting, meeting the Pope. That’s Alison Abbott from Nature magazine. Again, if you’d asked me a few years ago, would the Lancet have ever
worked with the Catholic church, 1.5 billion people on the
planet to try and address issues around planetary
health, I think I might not have agreed that that
would be a likely outcome. But we have to build
extraordinary coalitions. Across faiths, across
different communities. In three weeks time, I’ll
be in Israel for a week presenting with my colleagues in Israel a series looking at the
Israeli health system and the contribution of Israeli academics, both Jewish and Arab to an
international conversation about health. My goal is to try and
build a linkage between our work in Israel now and the
Lancet Palestinian Health Alliance. I’m not saying that I’m
gonna be Jared Kushner (audience laughing) That’s not what I’m trying to do. All I’m trying to say is
that the one great thing that we have in our world is scholarship, science and medicine is
the opportunity to create extraordinary coalitions
if we choose to do so. This is what one person
presented at this conference in the Vatican, John Sweeney. And I just want to leave
you with these words. “There are two decades
left to achieve the large scale decarbonisation
necessary to avoid dangerous climate change and the
dangerous increase in health problems it will be accompanied by. Two decades is one generation. Two decades is one generation. That’s how long we’ve got. Last slide. This painting is by Gustav Klimt. It was completed in 1901. It’s a compositional sketch,
you’ll find it in the Israel museum in Jerusalem. Klimt was invited by
the University of Vienna to paint three paintings,
medicine, philosophy and jurisprudence for
the great hall in the University of Vienna. And the idea was to celebrate
the great contributions of the university to
the world of learning. Klimt was smart and he wanted to editorialize on this great contribution. So this is medicine. Here, a figure, a naked
woman floating in the air represents life. And she’s connected with
arms and here the arm of a man to another group,
again of human figures which is the river of life,
containing this skeleton, in a black robe, Death. Life and Death, that’s medicine. This is the Goddess Hygieia. The problem is that when
he presented this painting, the faculty in the University
of Vienna were furious. They called it pornography and perversion. Why? Because Hygieia has turned
her back on humanity. She’s not facing, whoops,
sorry, sorry, sorry. She’s not facing, she’s not
facing the symbol of life or the river of life
and the threat of death. She’s turned her back
on those very things. Through her arrogance,
through her indifference, through her narcissism,
through her love of her own achievements, she’s ignored
the predicaments that face her world. The painting was never shown. It was locked away in
a castle for 40 years. And when the Nazi’s raked
their way through Austria, they burned the paintings, all that’s left is this
compositional sketch in the Israel museum. That’s the challenge,
that’s the predicament. Let’s not turn our back on humanity. Thank you. (audience applauding) As are the United Nations. Based in the UN building. – Do you want to take some questions? – [Richard] If you’ve got
time, I know it’s a bit late. – Okay, if you haven’t already left, – [Richard] To get those books. (laughter) – Offered to take a few
questions for aren’t really floored already. Actually, I’ll ask one. – Okay. – I’ll abuse the prerogative. – Okay. – As an aspirational
American who gets to watch us from the perfect
Archimedean point in London, why are we having this war on science? – Oh boy. Ya know, it’s so hard to get into the head of Steve Bannon (laughter) and understand where that comes from. I mean, I couldn’t believe that uh, is it Robert Kennedy Jr. or
one of the Kennedy family when soon-to-be president
Trump was holed up in Trump Tower in New York,
apparently saw this man, thinking that he’s going to
have a review of the safety of vaccines. It is difficult to understand
where this comes from. I honestly don’t know. I don’t know. And again I would reflect this back on us. What have we done, what
have we failed to do to communicate the contribution
science makes to society? Something has gone wrong
in that conv, I mean, it would be very easy to blame Trump, blame Steve Bannon, blame
that group, you know, however many percent
of people voted of him who were skeptical of the elites, of which we presumably are. But I think instead of
blaming those people who voted for him, we need to look at ourselves. And one of the reasons I think,
why we’ve not come across sometimes as the public good
that we hope that we would be is that we’ve not focused
enough on how we communicate our ideas and our
contributions to society. Science should be in
the service of society. We know that it is, we know medicine is, but sometimes the way we present ourselves is too much about us,
is too much about money that we want from sources
of government or wherever to support what we do and we don’t go out and make a strong case
about what our achievements have been for communities. And I think we need to
do a better job of that. I do think this is a
moment for us while we need to advocate to support and
protect our institutions of science and science funding, we also have to do a little
bit of inward reflection about where we’ve gone wrong. ‘Cause I do think we’ve
taken some mistaken turns. (participant’s words obscured
due to lack of microphone) Of course. – I just want to add to
this that we have been pretentious enough to
be far from the people. As much as there are no
dialog inside university and it’s so shocking. As much there was no dialog
with the people we pretend to serve. We pretend only. We are, I love this painting. We have turned the back. They don’t understand what
we do that means we don’t talk to them. And your president talk
to them in the wrong way. People have the sense
that they have been seen after long time of talking
to pretentious people. Secondly, all people who want to do or plan to do bad thing,
because I don’t believe that the men who run this
environmental institution doesn’t know what he’s
doing, he just wants money. He doesn’t work for his own. He work for many people like him. They know what they’re going to do, but they need that money. So there are two dialog there. We need to be near the
people we pretend to serve and we need to fight for
science and do it differently. And there is also, when
we see the big institution who give the money for the
science, it’s for hard science that can bring hard things,
that we produce a lot of money. Not health. Implementation science
is totally neglected. Try to find a grant for
implementation science. While if I, I can continue hours. (laughter) – Hello.
– Hi. – Again.
– Hello again. Thank you for giving your talk. I have a question that’s
related to what I believe to be a political presentation
of science in your lecture. And so my question to you
is simply, do you think that science is apolitical? – Absolutely. Science is about choices. It’s the choices that you
make if you’re a funder and what you fund. It’s the choices we make
as journals and what we do, it’s the choices that
scientists make in terms of what they choose to work on. Those are all political choices. Sometimes we’ve made
decisions to publish certain items which get us into trouble and we’re told that we are
being overly political. But when we published a
paper looking at civilian mortality in Iraq after
the March 2003 opening of the war in Iraq, yeah,
we were deluged with angry hate mail from the
United States telling us that we shouldn’t have
published that paper because it was a political
attack on George Bush. What was funny was that
that was the paper in 2003 when it was mission accomplished. In 2006 we published another
paper from the same group. When things didn’t look
quite so positive in Iraq after those initial months. When we published that paper
we got a lot of supportive letters from the United
States saying thank God you published this paper
because that’s the message we need to hear. And that tells me that the
interpretation of a piece of work including science is governed
by the political context in which you publish it. Everything’s political, nothing is not. I don’t know who’s moderating
this, so I don’t know whether I should just, – In conversations about global health and global responsibility
for civilization, we talk about how it’s
all of our responsibility. I wanted to ask what your
thoughts are on whose responsibility it was in
the context of authoritarian regimes such as the situation
in Syria and other countries. – Oh my goodness me. (laughter) You want me to make a comment on Syria? Yeah, well, I’ll tell you
what we’re doing there. We’ve set up a commission
on Syria and global health. The global consequences of
the Syrian conflict for global health. Syria is not just a
conflict within a country or even within a region. As we’re all seeing it’s
having global implications. So we’re working with a team
at the American University of Beirut and Harvard, Jennifer Leaning, to investigate these consequences. We published an interim
product from that work just a few weeks ago looking
at attacks on medical personnel in Syria and we
are, the work will continue during the course of this year. So that’s a slightly
diversionary way of not answering your question but to say
that I fully recognize that the subject you’re
raising has deep consequences for health, medicine, global health. I don’t want to pre-judge the commission but I can promise you that
we will give you an answer to that in the fullness of time. – I just wanted to ask–
– Hello. – Brief question, hi. My question is, just for
context, I was in Malawi not long ago and the
Malawian doctors that we were working with, we were
talking about WHO protocols and they were talking about
how important they are, they’ve been using them, wonderful. And they said, well, how do
you implement the WHO protocols in America? And they were shocked to
believe and to recognize and to understand that
America doesn’t say follow the WHO protocol for pneumonia treatment or doesn’t follow the WHO
protocol for heart failure, you get the idea. For the SDG’s same thing. We are somehow functioning
outside of these global norms or these global
commitments and we continue to do it which is why
I applaud you so loudly and strongly for the series
you did on inequity in America which most people really don’t know about. So my question is,
considering all of that, how do you think that we as citizens, how would you advise us to, in what ways would you
suggest we hold our government more accountable to these global norms and are there ways to do that
without using a framework around racism and health in America? – Thank you for the question. So I really do think that
the scholarly community can play a very important
role in holding governments or any power to account. I think the very act of
measurement, assessment, interpretation and then publication, it was said earlier, you know, publication we should move on from
that it’s not a big deal. Publication is an important
part of accountability because it puts on the
record in a formal sense, a judgment, not just a
description but a judgment about the success or failure
of a particular program. So the science community
has a critical part in political accountability. It’s just that we don’t
think about it like that. The direction of travel
we’ve taken the Lancet is to use the journal as
a platform for political accountability. In a non-partisan way, in our
science part of the journal, but never-the-less, as a tool
for political accountability. Because political accountability
is about measurement, it’s about providing a forum
for transparent participatory review of that work,
publication in the journal and then it’s about
mobilizing people to act. Which we can’t do on our
own, but through coalitions we can. So I completely, I completely
share the sentiment of your question. But it’s, I want to see the
New England Journal do that. I want to see other journals do that. Because it seems to me in
this country they can be far more powerful than we can since
we’re not fully based here. – [Phil] Okay, one last question? – Thank you. My question’s related to your
idea of forming coalitions amongst different
organizations across the world. And especially regarding the
fact that different countries are producing a lot of um,
countries, especially countries like India and China
which developing countries are producing huge amounts of pollution. How do you form coalitions
with countries like these when there is an argument
to be made that due to factors like colonialism and
erasure they’ve been held back for such a long time
that to reach development now they have to go through
this whole process of, which other developing
countries, developed countries, have already done in the past. How do you like, and I do
know as an Indian myself, that we are taking steps
to reduce our pollution and everything, but how do
you strongly form coalitions? – No, I fully agree with that. And it can’t be done by people like me, or anybody in the west
telling countries what to do. It has to come from the country. Lemme give you an example,
it won’t be from India but it’ll be from China. Two years ago, we went
to see Chen Zhu who’s the vice chair of the
National People’s Congress in the Great Hall of the
People in Tiananmen Square. And we went to him and we said, “What can the Lancet do to
assist you, your government in terms of its progress
in health and development in China?” And he identified two
issues, one, how do we build a primary health care system? Because hospitals dominate too much. And two, how do we produce healthy cities. Because they recognize the
challenge of pollution. So these two commissions
are currently ongoing. They’re not led by the Lancet. They’re not led by western scientists. The one on pollution is led
by somebody who’s a professor of earth sciences at Tsinghua
University, Pon Gong, he’s assembled an amazing team
including some internationals to produce a first draft of their report. I was in Beijing a month ago with him, looking at that report,
we’ll be publishing it in October of this year. It will be a report for
the Chinese government written and led by
Chinese earth scientists and health scientists
to guide China in terms of its policy options. So I think the answer is
we provide the platform. We can provide the convening
point, the catalyst I hope, but what we have to do is
to give it to scientists in the country who then
write their futures for themselves. And India, absolutely, we
should be doing that too. – [Participant] Thank you, I
look forward to reading that. – Thank you. – On that note I hope you’ll
all join me in thanking Richard for, (audience applauding) – Thank you very much. – I think uh,

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