The New Primary Health Care

[MUSIC PLAYING] MICHAEL KLAG: Good afternoon, everybody Thanks for coming to this afternoon’s Dean’s Lecture And today we’re honoring Peter Winch And I remember the first time I met Peter I don’t know if he remembers It’s probably not the first time– it was the first time I remember meeting you And it was when, early in my deanship, he came with a group of students in the African Student Network and met with me And I was impressed, at that brief encounter, about how passionate he was about both students and about teaching And since then, I’ve come to learn that he really is a Renaissance man He has incredibly broad interests And as I say at every one of these, it’s not easy to get on the faculty here at Hopkins, but it’s especially not easy to be promoted professor You know, it’s a very high bar And we don’t make the decision, our chairs don’t make a decision The decision is made by people outside the school– peers who write in and give us their unvarnished opinions about what the accomplishments of the nominee are So it’s very hard to get promoted here We congratulate you But it’s especially hard to win the respect and admiration of your peers, which you’ve done And I’m just going to say, I know that everybody in this room knows you better than I know you People come because they admire you, and know you, and respect you and their colleagues Well, I’m going to talk about you a little bit, OK? So I think you all know he’s professor of International Health and director of the Social and Behavioral Interventions Program And he has joint appointments reflecting his broad interests in health, behavior, and society, and in MMI He’s taught in the Department of International Health since 1989 and teaches courses– teaches both qualitative methods, courses on health behavior change, and applied medical anthropology And it’s hard to encapsulate in a brief statement what Peter’s research interests are, but at least one focus is improving the health of mothers, newborns, and young children in areas where access to health facilities is poor or nonexistent and how social, cultural, and economic factors affect the introduction of new treatments and therapies to improve maternal and child health He’s had experience conducting research, doing interventional studies, and evaluating interventional studies around the world And we could talk about all the countries that he’s worked in, but we only have an hour, so I won’t And currently, he’s working in Ghana evaluating a program to promote malaria treatment and evaluating an integrated maternal, newborn, child health program there in Tanzania, rather And he’s designing and evaluating behavior change interventions to promote water and sanitation related behaviors in Bangladesh He’s a passionate teacher, and he’s been honored with a Golden Apple in 2006 for his online version of Introduction to International Health And three times he’s won an AMTRA Award, and it seems every time he becomes eligible, he wins one He is from Canada And since we now have a president of the university from Canada, his stock has risen considerably But he did his undergraduate work in chemistry at McMaster in Hamilton, and received his MD from Queens University in Kingston, and received his MPH degree here from the Bloomberg School So Peter, I think your title says a lot about the broad range of your interests– that you are in fact a Renaissance man, so we look forward to your talk [APPLAUSE] PETER WINCH: Thank you This is going to be a challenging talk for me to give because I’ve been told I have to stay at the lectern MICHAEL KLAG: Oh, I forgot to announce that PETER WINCH: Yeah, it’s being videotaped If any of you know me, when I teach, I like to wander back to the class And that’s useful because I can see what shoes are on sale or what music is popular MICHAEL KLAG: –the problem is that if you say anything, you have to speak into a mic so that it goes on the web capture PETER WINCH: Yeah, this will be on Fox News tonight [LAUGHTER] So actually, this was scheduled for the fall, and the deans couldn’t be present because of travel and other obligations

And actually, it’s turned out well because I realized I couldn’t have been ready to talk about what I want to talk about today if it had happened in the fall And I thought I was ready in January, but I really wasn’t I thought I was ready in February It’s April I still feel I could use another year to get ready for this topic because it’s a huge topic But I’m going to try to bring the different pieces together, and I think these are pieces that we have to be working on very hard I’ve been told I can’t point the pointer at the screen I have to use the mouse here so that it’s recorded So this talk is actually summarizing two manuscripts One of them in American Journal of Public Health has just been accepted, actually, last week And it’ll be coming out in September in a special issue on peak oil and health that Brian Schwartz, and Cindy Parker, and some others are editing And I had a lot of help from Melissa Poulsen and Rebecca Stepnitz putting together those two manuscripts And then, since I was getting into topics that– some of them– I didn’t know that much about, I didn’t want to totally wing it, so I was sending this out for feedback from people And these are some of the people who have been sending me numerous emails correcting deficiencies and factual errors So actually, I think it’s getting close to being fairly truthful now So the overview, I’m going to talk about three global environmental threats I’m going to talk about the general categories of responses to these– mitigation and adaptation And then, it’s hard to go right for mitigation and adaptation to running a program So what principles are going to help us figure out how to run programs? And I’m going to talk about four principles that have been around for a long time We have some people like Henry [? Perry ?] in the audience who have been wrestling with these principles for a long time I won’t say how long And then I’m going to talk about what we need to do in terms of taking action I think there’s a lot we need to do, and the agenda is huge– you might even say onerous But I also think we’re up to the task because we’ve done greater things before So before I get into bad news, I’m going to start with some good news to try to get you into a better mood And then heavy news is going to come So the good news is we’re making a lot of gains in mortality right now We still have a lot of unnecessary death happening– estimated 7.7 million deaths in children under five every year Somewhere around 340,000 maternal deaths every year– totally preventable, in addition to preventable deaths from HIV/AIDS, TB, malnutrition, and many other problems But we’re making a lot of progress, and here’s an example the progress You can see under-five mortality for globally and for Sub-Saharan Africa, and both are going down steadily A lot of people didn’t think this was possible for Sub-Saharan Africa, dealing with the HIV/AIDS epidemic, dealing with malaria, but despite all the challenges– bad roads, health facilities that aren’t quite working– under-five mortality is coming down And many people in this room have contributed to that– making advances in control of diarrhea, pneumonia, malaria, vaccine, preventable diseases So that’s all the good news to get you happy The bad news is I think things are happening in the global environment that’s going to make this difficult to sustain and could undermine a lot of what we’ve accomplished And the three big problems I’m going to talk about– each one could be an entire course, and I’m really just doing a few sides on each one– ecosystem degradation, climate change, and energy scarcity And these could reverse gains in different ways They could change disease patterns, causing increased infectious or non-infectious disease A big one that all of them have in common is they could lead to food scarcity, and we’re already seeing an increase in food prices globally that many people are deeply concerned about Water shortages, or problems with quality of water, and decrease in availability of health services– so for each of these environmental problems, I’m going to talk about how they might affect these different areas of health So starting with ecosystem degradation– again, this could be an entire course It’s extremely complex And we often don’t pay attention to ecosystems or maybe only when we’re on vacation or something, but ecosystems are important, and they provide a lot of services They do things that we need, and they do things that we couldn’t pay for or buy Sustenance– they provide our food They protect us from extreme weather events And when they aren’t there to protect us from extreme weather

events, the weather events are more severe than they would be otherwise They can protect us from disease They help to regulate climate For example, in an urban area, if there’s a lot of trees, the heat waves aren’t as bad in the summer If there aren’t many trees, the heat waves are much worse, and Baltimore, unfortunately, is a bit of an example of that Filtration of wastes and pollutants– it’s good to have water treatment plants, but swamps, marshes, forests are also good ways of filtering water, and regeneration of clean air, water, and soil So in 2005, there was a very important assessment, a landmark assessment– the Millennium Ecosystem Assessment– where they were surveying ecosystems right around the world and seeing, are they getting better? Are they getting worse? Are they providing the services they’re supposed to be providing? And the news wasn’t good 60% are degraded or used in unsustainable ways An example is mangrove forests You know, when you have a storm, if you have the forest there, it can protect the population from the storm If you don’t have the forest, the storm can come right in and wipe out communities And we’ve been seeing that in many areas A lot of this degradation is happening in the last 50 years and a lot of evidence that it’s accelerating So I’m going to be showing these arrows a few times now Big arrow means, in my own subjective opinion, it’s a bigger impact So I think ecosystem degradation is having a very big impact on clean air and water, and it’s going to have a very big impact on food insecurity There’s also going to be changes in disease patterns and health services, but those aren’t the biggest impacts for ecosystem degradation Talking specifically air and water– when you have ecosystem degradation, it can contribute to water shortages, contamination of water, chemical or microbiological Air– we’re seeing that air from the Sahel in Africa reaches Florida Dust, I mean, really travels So if we’re concerned about Florida, we have to be doing reforestation in the Sahel region of Africa Food is a really critical area I don’t know how I can emphasize it enough Overfishing– I mean, any time I go into a supermarket and I see a fish, it’s a real struggle Should I buy that fish or not? Or am I really contributing to the end of fish as we know it? Habitat destruction, pollution, and in terrestrial ecosystems, soil, and– One of my doctoral students, Julia [? DeBruicker, ?] is looking at doing qualitative research with farm workers in Indiana, and one of the main things they mention is soil– first thing I mean, we’re asking them about chemicals in the food, we’re asking them about all sorts of other things, and they’re bringing up soil And they’re very concerned about peak soil– whether we’re degrading soil so much that it’s not going to able to produce what we need to continue to eat Now climate change– Al Gore, of course, could do a whole week on this And I could do a whole week on this I’m going to do this fairly quickly And I’m not going to talk about carbon dioxide concentrations, but they’re definitely part of the story So first, what is changing? Three main things are changing– temperature, precipitation, and extreme weather events Temperature, we’re seeing a global rise in surface temperatures, and we’re seeing warming of the oceans, and both are very serious We, as humans who are more on land than in the ocean, notice the surface temperatures more, but the marine life is noticing the warming And it’s killing corals, it’s killing fish, it’s causing change of range of distribution of fish Precipitation– there’s something you can notice right here in the United States this week– changes in the amount, intensity, frequency, and type of precipitation So it’s not just drought Some areas are getting drought, some areas are getting more rain And then extreme weather events, and we’ve had many examples of that this week Here’s a complicated graph It’s a scary graph This is annual global mean temperatures And there are four little lines here So this line is the slope of increasing temperature over the past 150 years And that itself looks a bit alarming Then this line is a slope over the past hundred years and which is a bit steeper This line is a slope over the past 50 years– steeper still

And this yellow line is the slope over the past 25 years, and it’s quite steep So we are heading towards a warming planet, and that’s going to have a lot of implications for us I could talk a lot about precipitation These are trends in precipitation, 1900 to 2002 And I don’t know what color this is because I’m red-green color blind, but it’s some color And I think this color, whatever it is, is similar to that color And this brings up a fundamental issue of equity You notice the people who are emitting carbon dioxide are like up here and up here, but the people who are suffering from drought aren’t the people who are emitting the carbon dioxide And that’s a fundamental injustice in the world today And we’re going to have to think long and hard about how to address that This scary slide comes to us courtesy of Cindy Parker And down here, you have maybe bad, but not so bad, effects of climate change, and as you go up, you get to worse and worse effects until, up at the top, you have terrible things And what we– in public health, we tend to work more on these things– greater risk of infectious diseases, more heat-related illness But when you get up to the top, there’s a lot of truly scary things that could happen, like collapse of ecosystems or some agricultural systems may totally stop producing food for us And it’s a lot more comforting and manageable to be looking here at the bottom But we also need to be looking at the top, and planning for that, and thinking what we’re going to do about it So again, I have the problem, and I have the four boxes Climate change contributes fairly actively to all four boxes Changes in disease patterns, for example, more malaria in the highlands of Kenya and Ethiopia Access to clean water and air, food insecurity, and hunger– this is a huge, huge effect of climate change And availability and quality of health services, for example, when roads and hospitals are destroyed by climate events So now I’m going to move into the one that I think, maybe, worries me the most, but it’s also one I find people aren’t as familiar with So I’m going to have a bit more graphics So think about energy scarcity When you think, well, what is the foundation of modern economic life? A lot of us, when they think, well, what really drives the economic engine of the world? We think of stuff like this, right? We think of gadgets, and technology, and all sorts of machines we’ve made That’s really what is driving the economic engines on this planet But I would argue– and colleagues in this building such as Brian Schwartz and [? Stuart ?] [? Chaikin ?] argue fairly convincingly– that actually, this isn’t what drives modern economic life This is what drives economic life– fossils We are extraordinarily dependent on fossil fuels And basically, iPads are not driving the economy because the iPads, to run, need electricity And where does the electricity come from? It comes from fossils, ultimately And how does it come from fossils? Well, millions of years ago, they sank to the bottom of some lake or some ocean, and then they had to decompose anaerobically, because if they decompose aerobically, they aren’t going to store that carbon for us And then they had to undergo years and years of compression and folding until they form deposits of fossil fuels So I would argue that fossil fuels are the foundation of a modern economy, not this stuff, even though this is the stuff that’s visible And I find that scary– quite scary that we’re so dependent on fossils I know to kids it may be interesting that we’re dependent on fossils, but I think it’s scary So in environmental sustainability, the F-word is fossil fuel And it’s the F-word because we’re dependent on fossil fuels, and it’s the F-word because producing fossil fuels has all sorts noxious effects on the environment So here are the three F-things We have petroleum, natural gas, and coal And we also have the N-thing– nuclear And a lot of you all think, well, isn’t nuclear energy renewable? Because if you think about the universe, there’s a lot of atoms and molecules out there And aren’t there enough atoms and molecules that we can keep doing nuclear energy forever? And certainly in science fiction movies, we can

And you have spaceships that have been traveling for a thousand years And typically, they have some little thing about this size that’s driving the whole spaceship and is going magically But here on Earth, to produce nuclear energy, we need high-grade uranium and thorium And we’re actually– although there’s still a lot of uranium around, it’s not always the right kind of uranium to be good for making nuclear energy And some people think that around 2030, 2040, we’re actually going to be passing the peak of availability of the high-grade uranium we need to run nuclear reactors Maybe it won’t make as much difference the United States We’re less dependent on nuclear energy It’ll make a big difference in France But they have wine, maybe they won’t notice it as much So here we are breaking it up again So again, we have petroleum, natural gas, coal Those are the big three, right? And in a way, I mean, if we consider ourselves to have a modern economy here, it’s too bad that that’s what– those are the legs of the modern economy And then we have nuclear, which we wish was sustainable, but actually, it’s not that sustainable either Now here, under biomass, I put a little question mark And you might say, well, isn’t biomass renewable, like ethanol? Well, some kinds of biomass take a lot of fossil fuels to produce So to produce ethanol from corn, we have to grow the corn The way we grow corn now is to pump a lot of fossil fuels into every aspect of the production The fertilizers, the machinery, all that needs fossil fuel So some people would say some forms of biomass are quite renewable, but others aren’t so renewable, so I’m putting a little question mark here Overall, if you look at this pie, you can see the renewable part isn’t that big Actually, I had to put wind and solar together so it would be visible to you because we really have not made any serious investments in wind and solar Politicians will put up a windmill maybe just before an election and then say, look, we’re doing something But if you look at where the power is coming from in this country, it’s not coming from wind and solar Although I hear off the coast of Maryland, there’s huge wind potential But people are concerned that maybe they’d be taking a vacation on the beach, and they’d see a windmill, and they’d be uncomfortable, and so– and I’m not being facetious For that reason, we can’t put up windmills, because people– you know, their vacation homes You might see a windmill in the distance, and the value of the home might go down So a tragic thing about non-renewal energy, and something a lot of people don’t realize, is that every non-renewable energy source eventually exhibits declines in production If it’s non-renewable, it’s– I mean, when you first start tapping into it, production goes up, and everybody’s euphoric, and the stock market’s going up, and everybody wants to invest in that But every non-renewable source– eventually, the production has to go down because it’s non-renewable And we’re specifically very concerned about global petroleum production right now It seems to be peaking right now So by peaking, I mean that, for a long time, global petroleum production has been going up But now we’re somewhere around here, and now it’s going to start going down And our economies are extraordinarily dependent on petroleum, and so that’s going to be bad news I did my MPH here in ’87, ’88 And at that time, I took the health economics course, and Alan Sorkin explained that when demand exceeds supply, the price goes up And that’s been true most of the time since it depends on which president’s been in power But anyway, you can see that this gap is going to lead to increased oil prices There’s no way out of it Demand continues to increase because we have expanding economies in India, China, and other places But the supply is not matching the demand Now, I could talk a whole hour and show you different projections And there are others, like [? Stuart ?] [? Chaikin, ?] who are better at that, so I’m not going to even try to do it I would say that there are disagreements There are more optimistic projections that say, well, maybe we’re here, and maybe supply still can rise a little bit more, especially applying new technology And then there’s more pessimistic projections that say, well, maybe we’re just past the peak And then there’s really ridiculous, unrealistic projections that say oil supply is still going up, and so the party should go on But really, nobody with any knowledge is saying this, although some politicians might be saying it Really, maybe we’re here

I doubt it A lot of people think it’s more likely that we’re here So we’re at the peak or we’re past the peak, and that’s going to change almost everything in public health because, arguably, fossil fuels, along with vaccines and antibiotics, are some of the key public health interventions that have reduced mortality So what are some of the reasons for the peak? Well, oil is finite, and it’s made from fossils And you might notice– if you go to BWI, you’re going to see airplanes taking off every minute But if you go to a swamp and watch fossil fuels being produced, the action is a lot slower, right? And most people would rather spend time watching airplanes take off than to watch fossil fuels being created Basically, we’re using it up much faster than are being produced Conventional oil production is declining globally, so in 45 of 64 oil-producing nations, we’re now seeing declines in production In 15 of the 23 top oil-producing nations– and this is not taking into account Libya and other situations So we’re really in a squeeze And of course, the ones who are still seeing increased oil production aren’t always the most stable countries or the ones that we really have much influence over People are searching for oil The discoveries aren’t keeping up with consumption, and unconventional oil is not going to close the gap For any of the unconventional oil, it takes more time, effort, money, and fuel to get the oil out So no matter what we do, we’re facing a decline in global petroleum production Now, I’m going to talk a little bit about the curve Going down is different from going up We all like going up We all like when stock market prices are going up We all like when housing prices are going up And going down is harder We’ve seen that with housing prices It’s not pleasant when things are going down For fossil fuels, a big difference between up and down is, when you’re going up, you have more conventional sources, like, say, Beverly Hillbillies when the oil is coming out of the ground, and it’s at the surface, and it’s easy to extract Or you can think of oil derricks in a field in Texas That’s more conventional sources But as the conventional sources start to run out, then we start getting into non-conventional sources, such as offshore drilling, oil sands, oil shale, and fracking Fracking is short for hydraulic fracturing, where we pump at high pressure, a mixture of water and chemicals into oil shale deposits to crack the layers of rock and release gas But it also can pollute the groundwater, making it undrinkable or worse, and I’ll show you an example of that in a minute So here is for the United States A lot of this is probably familiar to you, although maybe haven’t seen it graphically So Hubbert, in 1956, predicted that US oil production, domestic production, would peak in the early 1970s And at the time, things were still going up, and so a lot of people called him an idiot or worse They were saying, how are things going to go down because everything is going up? But strangely enough, what he said was totally correct, and US domestic petroleum production has been dropping since that time And whatever politicians– politicians can talk a lot, and they do But politicians can’t change the geology through talking There’s either stuff in the ground or there isn’t, and it’s either easy to get out or it isn’t And if it’s hard to get out, no matter how much you talk, it’s still going to be hard to get out So you can see things are easier back when oil was in Pennsylvania It’s close to the population centers, not much transport, close to the surface So we went from Pennsylvania, to Texas, Oklahoma– you see we’re moving west Then we got to the Pacific Ocean We couldn’t go farther Then we go up to Alaska And then we’ve kind of done as much as we could do on land, so we started going into the water We started the Gulf of Mexico, shallow, then we went deep And then we said, well, even the Gulf of Mexico is getting to be a bit troublesome So now people are talking with oil shale in Colorado, Utah, and Wyoming But oil shale– tragically, it takes a lot of energy to get energy out of oil shale You have to invest energy in cracking up the rocks, and steam, and stuff like that So it’s not the best way to be producing energy So as we go down that curve, the environmental impact

of fossil fuel production increases That’s why it’s a public health crisis when we’re going down the curve It’s polluting our water, it’s polluting our air And the energy invested to produce and transport fossil fuels goes up as we go down that curve And here– here are examples of what it looks like So this is how– this building is largely powered by electricity, and a lot of that electricity comes from coal And a lot of that coal comes from West Virginia So we’re sitting here in comfort today, but this is where it comes from So energy scarcity– I put a smaller arrow for clean air and water because the impact on clean air and water really depends on if you’re close to where the energy is being produced And if you’re in Pennsylvania in the Marcellus Shale area, you’re going to have big impacts, but if you’re away from that, you live under the illusion of clean natural gas And it is clean, right? I mean, you turn on your stove, you don’t smell anything You see buses saying powered by clean natural gas And it feels kind of comfortable for us to imagine that using natural gas is clean But then if you think the people who live in areas where the gas is being extracted, what is life like for them? This is from a movie called Gasland, and if you want to know about modern natural gas production, this is a good movie to look at And you can also see water lights on fire And I haven’t taken all of Kellogg’s courses, but I think that’s contraindicated– you don’t want your water to light on fire So the effects on air and water, the effect on food insecurity– modern industrial agriculture is heavily dependent on fossil fuels And then effects on the availability and quality of health services, and I’m going to give you an extended example of that in a second As far as energy and water– I’m not just saying this to make Kellogg happy, it’s also true Energy is crucial for pumping and transporting water, for desalinating seawater or brackish water There are 13,000 desalination plants in the world, and they all mostly run on fossil fuels– purifying water, and then treating, transporting, and discharging sewage So as fossil fuels become more scarce, especially low-income countries are going to have trouble providing clean water And then food insecurity– fossil fuels are key ingredients for fertilizers, various agricultural chemicals like pesticides, and they power irrigation systems– pumps, farm machinery And finally, they transport agricultural produce So if we eat kiwis today from New Zealand, those kiwis came here thanks to petroleum or natural gas And then, health services– the entire modern health sector is heavily dependent on fossil fuels– all this disposable stuff we have My younger son, a year and a half ago, broke his leg jumping off playground equipment And it seemed like the right thing to do at the time to him But what I notice is, sitting in the pediatric emergency, how much garbage is being produced every hour About every 20 minutes, you see a guy dragging a huge bag of garbage out of that pediatric emergency We just produced a ton of trash, and a lot of it is stuff made from fossil fuels– syringes, gloves, you name it A lot of the pharmaceuticals are made from fossil fuels And then the health facilities themselves need power And then we need transport to get stuff back and forth So how can we apply this to a real world example? I’m going to look at maternal health for a minute Maternal health has been slow to improve It’s been one of our more intractable problems, and we have many people in the audience today who’ve been working to improve maternal health We still have an obscene number of deaths from maternal health every year– somewhere close to 340,000 a year In the high-mortality countries, most of the death occurs at home, without a skilled birth attendant And a lot of the interventions that can save lives have to be administered in a health facility You can’t do a cesarean section in the home You can’t do a blood transfusion in the home We have to get women to the facilities So the maternal health community has focused, for a long time, on how to get women to facilities, and they’ve come up with a Three Delays model And they say one delay is in the decision to seek care Then once people decide to seek care, there’s a delay in reaching the health facility And once they reach the health facility, there can be a delay in receiving care

For example, you can get to the facility at night, and the doctor isn’t there, or the doctor’s asleep And actually, the security guard is also asleep, so you have to wake up the security guard, and then get the security guard to tell you where the doctor is And then you’ve got to go get the doctor And then the doctor has to get dressed, and come back, and then has to turn on the generator to get the facility working So all that time, the woman could die because it’s a slow process, depending on how sleepy a doctor you have And there are a lot of factors that affect this, like recognition and understanding of health problems We do a lot of education of families to make them more aware of maternal health problems, try to get them to seek care earlier Countries where you improve the road network, maternal mortality drops Countries where the road network is bad, especially in the rainy season, maternal mortality goes up Roads are very important And the condition of the roads affects the decision to seek care and also how fast people– how long it takes people to reach the health facility Quality of care in the referral facility and family economic status– access to cash and loans If people don’t have money, they aren’t going to seek care People are very worried about going to a health facility because they may incur a lot of debt, and they don’t know how they’re going to discharge that debt So how does peak oil energy scarcity affect this? Well, peak oil is going to lead to reduced availability of medical supplies That’s going to affect quality of care It’s going to make the cost and availability of transport more problematic It’s going to lead to a shortage of energy to run health facilities You need to have the lights on to do a cesarean section Food insecurity is going to affect people’s economic status, and if people have less money, they’re less willing to leave the home and incur expenses And then economic growth– unemployment, in general, is affecting this, and this affects this and this So maternal health is something where we’ve made very slow progress, but it’s an area where we could see a reversal of progress with peak oil So here on one side is everything I’ve said so far I’ve talked about how these three things all cause these three things And so what can we do about it? In the climate change literature, we talk about mitigation and adaptation And mitigation means trying to reduce greenhouse gas emissions or maybe, say, reforestations of the trees can gobble up some of that carbon dioxide And adaptation means, well, given that the climate is changing, how can we help people adapt to the changing climate? How can we help people adapt to the rising temperatures, or to the shortages of water, or other changes? To take into account all three threats, I think we need to extend the definitions So besides thinking about climate, we also have to reduce ecosystem degradation, we have to promote restoration, we’ve got to work on greenhouse gases, but we also have to reduce fossil fuel consumption And that’s everywhere, here and there Adaptation– we need to help people adapt, not only to climate change, but also the ecosystem degradation, and energy scarcity, and build resilience so that people can continue living despite these changes The health sector mostly works on adaptation because adaptation seems closer to the health outcomes that we hold so dearly to our hearts and spend so much time trying to measure But the health sector also has to work on mitigation because all these threats can have big impacts on health And if we don’t do some mitigation, then the changes are going to be too large for us to be able to effectively adapt to And also, you might say, well, the health sector isn’t as important as the transport sector or the agriculture sector But first, we consume a lot more than maybe you were aware of And second, we’re a role model For better or worse, people look to the health sector as people who know what’s going on And if they see us taking sustainability seriously, they think, oh, maybe I should take it seriously, too And if they see us not taking it seriously, they say, well, it can’t be that bad because those guys– and gals, but often guys– aren’t taking it seriously So how do we go from all this to putting together a new generation of programs? What’s the way forward? Are we going to make mitigation and adaptation part of routine practice? What do we need to be doing differently? What are implications for global health practice and programs? First, I’d say the entire health sector

has to be engaged in this We can’t say, OK, the environmental people need to work on this, and the rest of us are going to do what we’ve always done, like everybody Everybody in this room, everybody in this school, everybody in the health sector has to be doing something about this And we need to have core principles that we apply to every project, program, and study As I thought about this more and more, I think a lot of what we need to do is go back to the future A lot of the principles in the Alma Ata Declaration are actually very applicable to global environmental sustainability There’s places where they need to be tweaked or updated, but I think they give us a roadmap or a framework for thinking about what needs to be done So I’m going to talk about four principles briefly– equity, integration, decentralization, and sustainability Equity– we’re all very interested in equity It’s one thing that drives our involvement in public health A lot of you are in this building because you’re committed to equity It’s a core tenant of primary health care, from the beginning And when Carl Taylor was with us, you could never have a conversation with him without equity coming up And towards the end of his life, sometimes he’d get a bit sleepy, but if you said equity, he’d wake up because he was so committed to equity as a concept There’s sort of two parallel universes of equity In health, we’re concerned with decreasing disparities We’re concerned with fighting injustice We’re saying in some patterns of health, inequity are fundamentally unjust We have to rectify those injustices But there’s a whole other field that we don’t think about that much, a lot of time, is environmental equity The fact that the poor are the ones who are likely to live next to a garbage dump– they’re the ones who are likely to be next to the railroad track, and the trains are transporting toxic waste They’re the ones that are likely to be next to the power plant, and the rich aren’t The rich are living in leafy suburbia far from these hazards And so in the United States, environmental equity is a huge field in really looking at how racial and ethnic minorities are continuously subject to environmental hazards, and what can we do about this? And the driving idea that specific social groups shouldn’t be disproportionately affected by environmental hazards But to practice equity, we have to practice it at the global level and at the local level Globally, the problem is the people who are consuming and polluting are often people in North America, people in Western Europe, and they aren’t the ones necessarily going to be so much affected So equity means it’s not enough to work there, we have to work here and change what we’re doing At the local level, it’s an extension of what we do already We have to pay attention to the poorest, the most vulnerable And extending it to environmental concerns, we have to try to address the needs of the people most affected by ecosystem degradation, people living on flood plains in low lying areas Here’s an example of an equity problem This is an equity problem I have trouble appreciating because I can’t see green And I’ve been told that these two things are different colors, but I don’t know Maybe it’s true Well, you can see this color, or whatever it is, is a bad color And you see this bad color is a lot right along the Sahel These are countries with the lowest per capita income in the world They’re in the worst position to adapt to the changes They don’t have the resources to effectively adapt to the changes You see some of this bad stuff is happening here, too, but this is happening in an area where there are more resources and technology available to adapt But basically, you see a lot of the problems are occurring in countries with lower income, whereas some of the benefits– Dean Klag mentioned I’m from Canada, so Canada is an area that’s going to benefit Tragically, ironically, Canada is producing a lot of greenhouse gases through the Alberta tar sands, and it’s going to witness improved agricultural productivity, whereas countries here that aren’t tapping into such resources are going to see their agricultural productivity going down So that’s fundamental inequity that we have to be aware of and we have to act on At the local level, we need to keep doing what we have been doing here, but maybe do more of it Maybe we pay lip service to involving local communities in decision making, but since they’re the ones being affected, we have to reinforce that But we have to also expand We have to– in our health programs, we have to be thinking about ecosystems

We need to be thinking about how to help communities adapt to energy scarcity Now, integration– this is always a focus in primary health care A lot of the early research done in my department on primary health care was looking at integration, like how to integrate health and family planning programs A lot of that work being done in a Narangwal project in India When I say internal integration, I mean integration within the health system For example, if you type in integration on PubMed, you get a lot of articles about integrating HIV/AIDS and TB, or integrating maternal health and child health And sometimes I see that and I say, well, so what? Like, isn’t it obvious you have to integrate HIV/AIDS and TB? But people are still writing articles about it But I think in the original scope was integrating these things to improve coverage and effectiveness The expanded scope for internal integration is, we’re integrating not only to improve coverage, but we’re also integrating to optimize use of increasingly scarce fossil fuels and minimize the impact on the environment So it’s still integration, but maybe integration with a slightly different purpose External integration is something we talk about and rarely do It was right there, clearly, in the Alma Ata Declaration We need to be working on food We need to be working on population, environment, water, sanitation But then in practice, we’ve kind of ignored that because it’s easier, it’s more expedient to just work in the health sector But now, given these threats, we can’t ignore that anymore Health has to be working like this, with agriculture, with education So we had this original scope which, again, was there, but we sort of ignored it So the expanded scope, we have to reinforce that, but we also have to bring in environmental threats in a bigger way We need to form partnerships with other sectors, and in our preparedness and adaptation plans, we need to have all these sectors around the table working on these issues Now population growth– Stan Becker gently reminded me that if I don’t talk about population, he was going to kill me, although I didn’t feel that threatened because Stan is nonviolent and has all these stop war buttons, so I wasn’t that worried about it Environmental concerns can’t be reduced to population growth And you still hear some people say, oh, if those people started having fewer kids, environmental problems would go away And that isn’t true because the highest rates of consumption are in the low-fertility countries But environmental concerns can’t be addressed without addressing population growth, especially since some of the countries most affected have very high total fertility rates Total fertility rates have come down in many countries, and these are some of the countries where they’ve come down markedly Bangladesh is now almost at replacement fertility, something that people thought would be impossible at one point in time Even Iran– people think of Iran Oh, conservative, Muslim country But no, they have a great family planning program, very high rates of contraceptive prevalence But a lot of countries, total fertility rate remains very high, and these are some of the countries For example, ironically, Niger, which is one country that might be most affected in the whole world by climate change, has one of the world’s highest fertility rates So we have to be working on population Now, who’s paying attention to population? Well, what I find also interesting, maybe even disturbing, is I’m finding environmental and conservation groups, like the World Wildlife Fund, these days are often paying more attention to population than the health people So here’s a slide, a graphic I stole on purpose and kept the logo on purpose because I wanted to show– so this is a slide created by the World Wildlife Fund, and it’s showing the amount of unmet need for family planning by district in areas that are conservation priorities in Africa Now, the amazing thing about this slide is I haven’t seen the same thing produced by PEPFAR or anybody else I mean, the health programs are less concerned with population– addressing population less, a lot of the time, than the conservation programs So that tells me there’s something wrong with us that we aren’t taking population this seriously We’re leaving it to the World Wildlife Fund It’s not right OK, two more principles to go– decentralization and re-localization

Decentralization is a key principle in health systems and primary health care And a lot of it has to do with– you have all these bureaucrats in the capital city, and why don’t you get them– take the spending authority away from them Take decision making authority away from them Push it out to the district level, to the community level They’re the people who should be making decisions But we have another, related, different kind of thing, which is the idea of localization or re-localization A lot of the specialization in economic activity on this planet has been driven by cheap fossil fuels So we can have kiwis produced in New Zealand, and something else produced in Brazil, and something else produced in South Africa, and fly it all here because fossil fuels have been very cheap But as they go up in price, we can’t do that anymore We can’t do it for food, we can’t do it for water, we can’t do it for energy We have to have local systems that are able to support themselves more, be less dependent on importing everything from a long distance away So we have decentralization We have localization In the literature, they’re two parallel universes, and they never meet The people talking about this– the people talking about this don’t even know the other literature exists Take energy generation as an example We’re going to have more energy generated locally, even at the household level– household level wind generation, household level solar power generation So decentralization is going to change We’re going to keep this kind of stuff about working with community health workers, about providing services where people are rather than centrally, about training local people more and more to provide care, but we have to add this stuff And this stuff is talking about making the local area more self-sufficient in terms of energy, water, and food This is good, but it’s not going to be enough We’re going to have to add this other panel Last principle– sustainability Here is where we really have the problem of parallel universes And the universes are so parallel, I don’t even know if quantum physics can really address it In the health literature, it’s all about programmatic sustainability, financial sustainability After the World Bank stops paying for this, is it still going to keep going on? The main consideration has been preparing for the eventual end of external funding And we’re going to have to– I mean, that’s still something good to worry about But we also have to add to this programmatic and financial sustainability an expanded scope that talks about innovation with low environmental impact, decreasing the environmental footprint of health services Two years ago, I was visiting a health facility in Tanzania, and I was sitting in an office, and it was adequately lighted, and there was a good breeze It took me a while to realize that there was no electricity in that health facility They had designed it so it didn’t need electricity They had skylights so light could come in You didn’t need to turn on lights during the day And they had a ventilation system so that, naturally, it would be ventilated What we’ve done, in our foolishness, is take those kind of facilities, bulldoze them, build new facilities with air conditioners, and all that kind of thing, and windows that don’t open And then, of course, any of you who work in a low-income country, you know the electricity is going out all the time Why? Because the dam is low It didn’t rain enough this year, whatever And so then you have this window that won’t open, and it’s dark, and you can’t get anything done And so you take your laptop, and you go– if you want to get something done and the electricity is out, you always go to a bar because you know the bar will have a generator, and they’ll have wireless And sometimes I’m trying to Skype with my students, and they’re in a bar, and all I hear is cheering for the football game and yelling But shouldn’t we be able to work in our health facilities? Well, we’ve designed health facilities that don’t work unless we have electricity on So applying these principles in practice– it’s 5:00 I could talk about this for two to three hours It’s going to be difficult to apply it in practice A lot of innovation is going to be needed Every program has to be thinking about mitigation, and adaptation, and– as well as the four principles I talked about– equity, integration, decentralization slash re localization, and sustainability

There are a few examples I worked with Melissa Poulsen scouring the literature, and honestly, we found very little These are some examples And I’m not going to describe these, but these are the ways that we saw them putting some of these guiding principles into practice In terms of equity, they’re focusing on the most vulnerable– in this case, people living with AIDS They’re focusing on people most affected by climate change, who themselves produce few greenhouse gas emissions They were integrating things like water, food, food security, population into the program Both of these programs are trying to address the needs of people living with AIDS As well as addressing the AIDS disease itself, they were trying to improve food production, improve access to water, really strengthen local self-reliance And then us, here in this building, Hopkins I met Dean Klag just about 5:00, and we walked down the hall And I’m not criticizing the dean He’s really tried to get people to not drink bottled water He’s really tried He’s sent out emails that might have been captured by the junk mail filter He’s done everything he can to get people to not drink, but as soon as we’re coming past the [INAUDIBLE] room, what do we see? Bottle of water It’s really hard, and it’s not because of lack of trying on the part of our dean It’s very hard to apply these principles MICHAEL KLAG: That was in internal– or that was an international health conference PETER WINCH: Yeah Yes, even I have no control over this [LAUGHTER] So same with recycling, but I think of recycling as harm reduction because there is still harm to the environment, even if you recycle because the only– if you want to really get rid of the harm, you have to not consume But once you’re consuming, it takes energy to recycle materials, and materials like plastics can’t be fully recycled The recycled plastics aren’t as good as the original plastics In calendar year 2010, we produced 850,000 pounds of refuse– so almost a million pounds, a lot And if you think about all that material had to be created with energy brought here from somewhere, so we have a fairly big footprint on this planet Well, we’re making a lot of demands on the planet– we in this building So we’re trying to promote recycling, and you can see in calendar year 2010, we recycled 34% So that’s good That’s better than it was For a long time, we were having trouble cracking 20%, but we can do better To kind of get you in a happy mood, we started doing better in February because we introduced composting, and we started it with the priority species– rodents in the labs And the rodents in the labs here produce a lot of compost And I know because we have guinea pigs at home They produce a lot of compost And then we started using it for food scraps in the kitchens, and now it’s getting out of there into the general public And the general public is having difficulty getting used to it, and I see people putting the wrong things– or a lot of people just don’t even look They just– I want to get rid of this So we’re making progress, but even getting up to 50% diversion rate is not good enough We need to be doing way better than this We need to be recycling millions at a time And– [LAUGHTER] –it is an inconvenience, but if we’re going to set an example for life on this planet, we have to be doing it Now in Congress, both parties are trying to balance a budget without doing anything about Social Security, Medicare, Medicaid, or defense That’s the ideal scenario But you can’t balance a budget without taking those things into account Similarly, you can’t really decrease carbon dioxide emissions without doing something about electricity from coal, and something about transport based on petroleum You know, those are the– that’s the Social Security and Medicare of the environmental sustainability area, and nobody wants to talk about it If you talk about, well, maybe we should decrease air travel, everybody looks the other way, and they’re uncomfortable, and shifting in their seats But if we’re serious about decreasing greenhouse gases, we have to do something about that It’s a huge– now, here’s an example A lot of us use electricity at our home, and electricity is clean, and it doesn’t smell, and how could it be causing any problem?

But most electricity in this country is produced from coal And there’s a huge coal lobby, and that’s why– now when people think about coal, they think of clean That’s the first thing that comes to their mind due to all the advertising we’ve had about coal But coal is not clean The way coal is produced is profoundly damaging to the environment So you can see this is an average family of four, and they’re producing– they’re using up 1,140 pounds of coal a month, and that’s resulting in 3,369 pounds of carbon dioxide emissions And if you were to pile the coal up, that’s what it’d look like Well, most of us, we don’t see the coal We just see– we turn on our wireless router, and everything’s fine But if you leave your wireless on all day, you’re just burning through a few more boxes of coal every month We’re doing a lot in this building on energy conservation I could spend the next hour talking about each of these things We’re changing the air handling units We’re switching them off at night We’re switching to energy-efficient bulbs We’re turning the lights out at night, which had been a rude shock to some of the students who work here all night We’re doing all this stuff We’re putting hibernation software on computers It’s all good, and we’re actually one of a few units of the university that is seeing a decrease in emissions There was a 5.4 decrease from FY ’09 to FY ’10 And the university as a whole has an ambitious goals in emission reduction, and a lot of this comes from this, which is a cogeneration plant where they would be capturing some of the heat that is lost in energy production, and capturing it, and making more energy out of it But you’ll notice that most of this doesn’t actually include cars and air travel because our greenhouse gas emission plan doesn’t really take those into account that much because it’s sort of rude to ask people about air travel, but it’s a big thing Talking about cars for a minute The proportion of people who drive to work has increased steadily in this country, and it’s heading towards 100% It may even pass 100% I don’t know that statistically possible, but if it is possible, it’s going to happen in this country And air travel is the fastest growing contributor to global warming and particularly short-haul flights– you know, the kind that Southwest does, because it’s the takeoff and landing that uses the most fuel And there’s a lot of other stuff we need to do Better than recycling is not using paper, because to recycle paper takes energy and causes pollution and all sorts of other bad stuff Better than recycling plastics is not using plastics It’s better to bring your own mug It’s better to locally source food, if possible We need to do more on urban forestry We have beautiful windows in this building, and you look out on an unforested landscape We could be planting more trees near the school So really, all these principles– I think one core idea in the new primary health care is it’s not just in Narangwal now, it’s also here We have to decrease our own impact because it’s part of equity The people who are responsible for greenhouse gases need to be reducing their own greenhouse gas emissions We, ourselves, need to integrate We need to bring together different approaches We need to have facilities management people talking to researchers, talking to students We also need to be re-localizing We need to be working more on local purchasing of food, promote living closer to the school, and I know that easier said than done And I live in Charles Village, and there’s many challenges to living in the city And I won’t mention them all Some are hair-raising, but what we need to– and then sustainability And a lot of the sustainability things are really win-win We can save money, and we can also save the environment through application of some of the software Academics– we, the faculty, need to be role models We need to practice what we preach Sustainability can’t be a stand-alone course It needs to be in every course in some way We need to have methods courses in this area because we’re really a palace of methods People come to us for methods, and so if we’re teaching epi methods, and biostats methods, and qualitative methods, we also need to be teaching methods related to sustainability The demand for doctoral study on sustainability is huge The amount of support is minimal And we also need to be looking at global training programs on sustainability Now, a lot of people are doing things I’m going to show you two slides here,

and it’s going to get me into trouble because I’m sure I’m going to miss some group because there are many groups I’ve avoided mentioning departments by name because that’s a great recipe for suicide You always miss somebody University-wide, we have the– what we call E2SHI– Environment, Energy, Sustainability, and Health Institute Public health, engineering, arts and science, and essential university administration have all put seed money into this to get it going, and we’re trying to get collaboration going across divisions And I’ve been participating in this, and I learned that people at APL and engineering are doing things I’m interested in So it’s already paying off There’s our Office of Sustainability, and they’re the ones driving a lot of this stuff They’re guiding that idea Then there’s the Applied Physics Laboratory, and you probably think of them as people who used to fight communists and now fight terrorists, but they do a lot more than that And they have a lot of technology that can be very helpful to us Bayview Hospital and our friends across the street have Green Teams who are fighting against enormous obstacles but have made a lot of progress lately And then there’s groups and centers here with the Environmental Stewardship Committee We have a Green Student Group that sprouted this year and in a very short time has done a lot of stuff And a Social Science and Sustainability Working Group, which is a group– mostly doctoral students who are all doing dissertation work related to sustainability And then we have centers, and here I’m sure I’m missing 10 or 20 other centers who are doing things– but Center for a Livable Future, Program on Global Environmental Sustainability and Health, and Center for Water and Health So this is my last slide We’re trying to have a zero-waste reception today This may be the first dean’s lecture ever where we’re going to have composting But for composting to work, you have to recognize what is compostable We’re going to have composting assistance, and they’re going to be wearing these shirts, so if you see somebody in this shirt, first it means you should be careful because if you do something wrong, they’re going to get at you But that single string, recycling, composting, and waste– so the guidelines for what to put where are right on this shirt So if you see somebody with this shirt and you don’t know what to do with your refuse, you can read the shirt So I’m done, and I’d be happy to take questions [APPLAUSE] And I’m sure our dean is going to say right now, if you ask a question, you have to use that microphone MICHAEL KLAG: You have to use a microphone You can use that one over there, too So put your hands up, and we’ll get you the microphone So you set me up really nicely because we met beforehand and he was saying, well, so how do you think the school is doing on sustainability? What do you think we’re doing well or not? So let me ask you, so if– well, obviously we talked about water, and recycling, and the need for education about what people put in what bin But what else do you think we could do better in terms of sustainability at the school? PETER WINCH: Well first, I think where we’ve made the most progress is in some of the areas that are at least visible Like facilities management, we sort of just take for granted You know, we come into the building, and the water is running, and the rooms are the right temperature, but behind the scenes, they’ve been tinkering with technology and trying different bulbs And I learned those bulbs are expensive, but also they pay off But I think it’s not enough to have a few people behind the scenes We have to make it more of a school-wide thing, and I think a lot of people are just hoping that somebody else is going to somehow solve the problem At the risk of creating dissension, I think at some point, we have to think about commuting And we can’t yank people out of their cars, but I think we can set up incentives for commuting less and maybe making it easier to work at home, maybe making it easier to carpool And we might also need to think about– I hate to say the word shuttle bus, but that comes up And I know the shuttle bus system is in evolution, but I would also say it’s not optimal And there are days it’s a trying experience, and it really drives people back into cars, trying to get to work on time in the shuttle bus And I also think we might need to eventually think about whether we have enough bus routes, given

where people work We need to make it easier for people to get here without cars, and right now, we haven’t made it that easy for people to get here without cars But I think a lot of people have thought, well, I don’t even want to talk about cars because it’s like the third rail You know, you’re going to get– people don’t want to have the car issue brought up, but if you look at where the greenhouse gas emissions are coming from, they’re coming from electricity generated from coal and transport that’s using petroleum And also, I think we need to look at alternatives to air travel When I go to a place like Gates Foundation in Seattle, I’m amazed at how good their teleconferencing facilities are They have these big, wide, big screens And I know we have some facilities here, but it’s really not at the same level Those facilities they have at Gates Foundation, you feel like you’re right next to the person In fact, you can see the hairs on their nose I mean, you can see too much [LAUGHTER] If you’re on that camera, you have to be very careful what you’re doing with your hands because everybody can see exactly what you’re doing And if we had facilities of that caliber, it would allow people to travel less by plane But we aren’t at that level right now, and I think people feel, if I’m really going to communicate with people and get things done, I’m going to have to hop on the plane And speaking for the faculty, I think most of us would rather travel by plane a little bit less anyway because it’s wearing, and there’s only so many things you can buy in Dubai There’s only so much chocolate you can eat before something bad happens MICHAEL KLAG: All right, thanks So comments, questions, comments, questions? So maybe I’ll start– Kellogg, you had your hand up first, and maybe go up and pick up that mic up there AUDIENCE: Thanks for that great talk It was really inspiring Every time we Google out here, we use the energy for a match strike, too, on our computers My question to you, perhaps, is– because there’s so much to arrange here, and we have only about eight more hours to go And with one thing about the decentralization, what do you think about the entrepreneur side of this? Can we bring in market incentives that would help maybe start driving some of this change? Because a lot of the things are done by economic reasons And is there a way for us to perhaps figure out solutions that were decentralizing– water for what I work with, but others– but it actually gives an economic incentive to it that could start driving some of this change, and then the benefits of public health and all that can kind of bring along there? PETER WINCH: Well, my understanding of the literature on environmental economics is that the environmental economists think the whole problem is due to perverse economic incentives, that– water is offered to Americans almost free of charge, even though there’s a lot of expense that goes into building dams and transporting the water And so there’s no incentive to conserve water because you’re almost paying nothing for it And we don’t pay for the externalities For example, if I drive my car to New York City, I pay for the gas in the tank But the tax on that gas is almost negligible It’s almost laughable I’m not paying for the greenhouse gases that are being produced when I drive my car in New York City I’m not paying for the destruction of the environment under the car and beside the car I’m not paying for injuries that happened on the highway All I’m really paying for is the gas, and I’m paying the absolute minimum price But the political feasibility of raising gas prices, it’s almost impossible in this country at this time And that’s the challenge Maybe for individual business people, if we can create incentives that are a bit less controversial But I think a lot of these problems would be attenuated if we could get the prices right And the prices for water aren’t right, the prices for fuel aren’t right If you look at what– now eventually, the prices will become right because fuel is going to get much more scarce, but it’s better to act now rather than waiting for us to be strangled by a scarcity of energy AUDIENCE: So thank you very much for the very collective lecture, and that corresponds to the idea of the think globally and act locally But let me be individual in arguing one issue of the stickiness to the sustainability So I think that the earth has had

a lot of species on its history and a lot of extinctions ever So think about the biological diversity It is very natural And wisdom will let you know nothing will be permanent And that’s the kind of proposition of the hyper thermodynamics will tell you the increasing of the entropy Then what brings you to stick onto the sustainability, which means not accepting the natural consequence that may be the end of the civilization? [LAUGHTER] MICHAEL KLAG: Relax and enjoy it PETER WINCH: Well, although humans don’t live up to their potential a lot of the time, I think we can And I think we bring something to the planet, even though we also bring a lot of problems to the planet There’s a lot of– several books have been written lately about what’s going to happen when humans become extinct– you know, the world after us, and showing how the New York subway system is going to fill up with water almost the next day, and buildings are gradually going to fall apart But I think we can do better than that And rather than waiting for mass starvation, I think we can act now to make the planet more sustainable But there’s so much to be done, it can’t just be left to the environmentalists It needs to be like– we need to have all hands on deck You need everybody work on, everybody making their own little changes, which they might feel are insignificant, but they’re needed, really, if we’re going to turn things around MICHAEL KLAG: Jim, could you handle that question? AUDIENCE: Thank you so much That was wonderful Any comments about what seems like a very low-hanging fruit kind of concept that would be right up the school’s alley– I know there’s a little bit of work on it now, but the potential is so great, and that is research on making stoves in low-income areas more fuel efficient and producing less smoke? The benefit on the environment is enormous And the benefit on health is enormous, too PETER WINCH: Well, I can’t argue against that And I have Jim Tielsch here in the front row, and if I did want to argue against it, I’d lose Jim is part of a group that just got a seed grant from E2SHI to do some more innovative work in this area, and that’s definitely part of the solution, using energy we have more efficiently You brought up the R-word, research And there’s actually a lot of money for research on sustainability, but most of it is in technology Ben Hobbs at Homewood campus was telling me that there’s a billion dollars in the National Science Foundation budget for sustainability research, but most of it is in engineering, like coming up with new technologies And there’s not that much yet on the behavior change side, or the program side, or health So I think the research agenda has been narrowly focused I think we need a broader research agenda And there seems to be support for that, but we also have to articulate what that agenda is and what will be gained by doing research in those areas Jim, I don’t know if you want to say anything about, briefly, what you’re doing in Nepal with this E2SHI support JIM TIELSCH: I won’t go over what we’re doing, but all I can say is, I think the stove story– the improved stove story– is a great example of where advocacy has gotten so far ahead of the science that the nonsense and the absolutely unsustainable statements and claims that are being made are actually outrageous And some of that’s driven by this attempt to make things economically viable for companies that want to try to do a little bit of good but make a profit at the same time So all I can say is, don’t believe everything you read about improved stoves, that the advocacy is just decades ahead of the science And that I think there’s a long way to go in terms of actually applying science and making sure science is at the table when we start to make claims and think about interventions and approaches that actually will improve the situation MICHAEL KLAG: So why don’t we take one more question, and then I think we’re going to have to end AUDIENCE: Hello I have a small proposal For the last year, I’m living with my roommate, and I’m trying to change him sometimes You know that it’s difficult stuff, yeah But we know from the good subject here that half of the all solid waste in cities all around the United States is paper and cellulose

So I see a bad habit, like he’s using, all the time, paper towels I personally propose, let’s take an old shirt, like T-shirt, to use instead of paper So my proposal here, to start from your own perspective, and to change habits, because the most difficult to change is habits of people who– on another side, to talk about government Yes, scientists told a lot that, currently, modern time, the government is just burn it It’s just burn it, it’s not use it efficiently But I want to say that in about 20 years, we will have very sustainable sources of energy I personally know one physicist There is an international collaborative, and they try to use atomic conditioner to create individual resources By that, they create individual resource of energy for each separate house, for example This can be done also for the vehicles So thank you very much PETER WINCH: So I hear several things there One thing I hear is it’s important to intervene at the household level, and in energy production, we’ve often– the current system is very centralized, and that benefits the energy companies And the energy companies don’t like the idea of people starting to generate energy at their household level, but that’s absolutely, absolutely necessary if we’re going to make progress in the energy front, to decentralize energy But we also have to decentralize food production Food production has become extremely centralized, so we have tens of thousands of pigs in one small area The pigs, the cows, chickens, they’re all going to need to be decentralized somehow, rather than just having them on very small areas It’s bad for the environment, and that kind of animal production uses a lot of fossil fuels, and it’s just not sustainable Now, whether anybody in the audience wants to have a cow in their backyard again, well we’ll discuss that But that intervention at the household level is the cornerstone of re-localization, and we need to work on it MICHAEL KLAG: OK, well, you can tell, this was about a half an hour longer than our usual Dean’s Lecture, and everybody stayed And it was a riveting talk, and the discussion, I’m sure, is going to continue outside as we compost, so– PETER WINCH: Some of them stayed because they’re in classes this term, and they don’t want to lose marks [LAUGHTER] MICHAEL KLAG: OK, so a cynic You’re a cynic, too Peter, great talk Thank you [APPLAUSE]