Call for emergency action to limit global temperature increases, restore biodiversity and protect health

Atwoli L, et al. Br J Sports Med April 2022 Vol 56 No 8 Call for emergency action to limit global temperature increases, restore biodiversity and protect health Lukoye Atwoli, Abdullah H Baqui, Thomas Benfield, Raffaella Bosurgi, Fiona Godlee, Stephen Hancocks, Richard Horton, Laurie LaybournLangton, Carlos Augusto Monteiro, Ian Norman, Kirsten Patrick, Nigel Praities, Marcel GM Olde Rikkert, Eric J Rubin, Peush Sahni, Richard Smith, Nicholas J Talley, Sue Turale, Damián Vázquez

The United Nations General Assembly in September 2021 will bring countries together at a critical time for marshalling collective action to tackle the global environmental crisis. They will meet again at the biodiversity summit in Kunming, China, and the climate conference (Conference of the Parties (COP)26) in Glasgow, UK. Ahead of these pivotal meetings, we-the editors of health journals worldwide-call for urgent action to keep average global temperature increases below 1.5°C, halt the destruction of nature and protect health.
Health is already being harmed by global temperature increases and the destruction of the natural world, a state of affairs health professionals have been bringing attention to for decades. 1 The science is unequivocal; a global increase of 1.5°C above the preindustrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse. 2 3 Despite the world's necessary preoccupation with COVID-19, we cannot wait for the pandemic to pass to rapidly reduce emissions.
Reflecting the severity of the moment, this editorial appears in health journals across the world. We are united in recognising that only fundamental and equitable changes to societies will reverse our current trajectory.
The risks to health of increases above 1.5°C are now well established. 2 Indeed, no temperature rise is 'safe'. In the past 20 years, heat-related mortality among people aged over 65 has increased by more than 50%. 4 Higher temperatures have brought increased dehydration and renal function loss, dermatological malignancies, tropical infections, adverse mental health outcomes, pregnancy complications, allergies, and cardiovascular and pulmonary morbidity and mortality. 5 6 Harms disproportionately affect the most vulnerable, including children, older populations, ethnic minorities, poorer communities and those with underlying health problems. 2 4 Global heating is also contributing to the decline in global yield potential for major crops, falling by 1.8%-5.6% since 1981; this, together with the effects of extreme weather and soil depletion, is hampering efforts to reduce undernutrition. 4 Thriving ecosystems are essential to human health, and the widespread destruction of nature, including habitats and species, is eroding water and food security and increasing the chance of pandemics. 3 7 8 The consequences of the environmental crisis fall disproportionately on those countries and communities that have contributed least to the problem and are least able to mitigate the harms. Yet no country, no matter how wealthy, can shield itself from these impacts. Allowing the consequences to fall disproportionately on the most vulnerable will breed more conflict, food insecurity, forced displacement and zoonotic disease, with severe implications for all countries and communities. As with the COVID-19 pandemic, we are globally as strong as our weakest member.
Rises above 1.5°C increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state. This would critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change. 9 10 Global tarGets are not enouGh Encouragingly, many governments, financial institutions and businesses are setting targets to reach net-zero emissions, including targets for 2030. The cost of renewable energy is dropping rapidly. Many countries are aiming to protect at least 30% of the world's land and oceans by 2030. 11 These promises are not enough. Targets are easy to set and hard to achieve. They are yet to be matched with credible short-term and longerterm plans to accelerate cleaner technologies and transform societies. Emissions reduction plans do not adequately incorporate health considerations. 12 Concern is growing that temperature rises above 1.5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community. 13 Relatedly, current strategies for reducing emissions to net zero by the middle of the century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere. 14 15 This insufficient action means that temperature increases are likely to be well in excess of 2°C, 16 a catastrophic outcome for health and environmental stability. Critically, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed. 17 This is an overall environmental crisis. 18 Health professionals are united with environmental scientists, businesses and many others in rejecting that this outcome is inevitable. More can and must be done now-in Glasgow and Kunming-and in the immediate years that follow. We join health professionals worldwide who have already supported calls for rapid action. 1 19 Equity must be at the centre of the global response. Contributing a fair share to the global effort means that reduction commitments must account for the cumulative, historical contribution each country has made to emissions, as well as its current emissions and capacity to respond. Wealthier countries will have to cut emissions more quickly, making reductions by 2030 beyond those currently proposed 20 21 and reaching net-zero emissions before 2050. Similar targets and emergency action are needed for biodiversity loss and the wider destruction of the natural world.
To achieve these targets, governments must make fundamental changes to how our societies and economies are organised and how we live. The current strategy of encouraging markets to swap dirty for cleaner technologies is not enough. Governments must intervene to support the redesign of transport systems, cities, production and distribution of food, markets for financial investments, health systems, and much more. Global coordination is needed to ensure that the rush for cleaner technologies does not come at the cost of more environmental destruction and human exploitation.
Many governments met the threat of the COVID-19 pandemic with unprecedented funding. The environmental crisis demands a similar emergency response. Huge investment will be needed, beyond what is being considered or delivered anywhere in the world. But such investments will produce huge positive health and economic outcomes. These include high-quality jobs, reduced air pollution, increased physical activity, and improved housing and diet. Better air quality alone would realise health benefits that easily offset the global costs of emissions reductions. 22 These measures will also improve the social and economic determinants of health, the poor state of which may have made populations more vulnerable to the COVID-19 pandemic. 23 But the changes cannot be achieved through a return to damaging austerity policies or the continuation of the large inequalities of wealth and power within and between countries.

Cooperation hinGes on wealthy nations doinG more
In particular, countries that have disproportionately created the environmental crisis must do more to support lowincome and middle-income countries to build cleaner, healthier and more resilient societies. High-income countries must meet and go beyond their outstanding commitment to provide $100 billion a year, making up for any shortfall in 2020 and increasing contributions to and beyond 2025. Funding must be equally split between mitigation and adaptation, including improving the resilience of health systems.
Financing should be through grants rather than loans, building local capabilities and truly empowering communities, and should come alongside forgiving large debts, which constrain the agency of so many low-income countries. Additional funding must be marshalled to compensate for inevitable loss and damage caused by the consequences of the environmental crisis.
As health professionals, we must do all we can to aid the transition to a sustainable, fairer, resilient and healthier world. Alongside acting to reduce the harm from the environmental crisis, we should proactively contribute to global prevention of further damage and action on the root causes of the crisis. We must hold global leaders to account and continue to educate others about the health risks of the crisis. We must join in the work to achieve environmentally sustainable health systems before 2040, recognising that this will mean changing clinical practice. Health institutions have already divested more than $42 billion of assets from fossil fuels; others should join them. 4 The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature. Urgent, society-wide changes must be made and will lead to a fairer and healthier world. We, as editors of health journals, call for governments and other leaders to act, marking 2021 as the year that the world finally changes course.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors. Digital health has grown from a collection of provocative ideas into a multibilliondollar industry in just over a decade in part because of the promise of this technology for improving physical activity monitoring and promotion strategies. Systematic reviews and meta-analyses of evidence for this technology are beginning to accumulate. 1 2 In this commentary, we offer some important considerations as the field moves towards creating personalised strategies for promoting physical activity. First, apps and wearable trackers are often portrayed as tools for promoting physical activity, but, by themselves, they are not treatments. They are simply vehicles for delivering the psychologically active ingredients of behaviour change, akin to the capsule that encloses pharmacologically active agents in medication. Physicians do not prescribe medication based on the delivery vehicle alone; they consider the mechanism of dysfunction to target, active ingredients in the drug and dosing to inform treatments. It is inappropriate to conclude that digital tools promote positive changes in activity; poorly designed interventions deployed via digital modes are no more than a digital placebo-they lack a defined target or active ingredient but are delivered in a shiny new capsule.

editor's note
Second, between-group differences in treatment and control groups are the sine qua non of randomised clinical trials, but they are not the only important source of evidence. Randomised clinical trial designs are privileged as the gold-standard for causal inferences in evidence-based medicine. Yet they create a vulnerability to the ecological fallacy. Patterns of interindividual variation would only be expected to generalise to intraindividual variation under very stringent conditions that are unlikely to be met in the real world. 3 Behaviour change is fundamentally an intraindividual (within-person) phenomenon. It cannot be properly understood without a clear understanding of within-person processes. Growing interest in ecological momentary assessment and N-of-1 designs for physical activity signals awareness of the need to focus on intraindividual change. 4 5 But this interest has had limited impact on physical activity intervention design. That must change if we are to improve population health and our understanding of behaviour change dynamics.
Third, effect sizes need to be interpreted and communicated carefully to avoid creating hype and unrealistic expectations. One recent review sparked eye-catching international headlines that apps and wearable trackers increased physical activity by 1850 steps/day. 1 A closer look revealed that this estimate was the product of (a) a back-calculated standard deviation from studies that used steps as an outcome and (b) a standardised difference in means from studies using either steps or physical durations as an outcome. Only four of the 21 studies with steps as an outcome reported a difference in means greater than the 1850 steps/day threshold. Three of those four studies had N≤32, and the four samples represented just 3.2% of the overall sample size in the 21 studies. The average difference in group means, 753 steps/day, was less than half what headlines proclaimed. That value is closer to the 950 steps/day difference between groups receiving Fitbit-based interventions and control groups in a similar but independent meta-analysis around the same time. 2 Liberal assumptions based on small studies are not needed to build enthusiasm for digital health. It confuses understanding and will hinder long-term advances.
Fourth, personalisation refers to a type of experience rather than a specific strategy or technique. In their recent review of the effects of apps and wearable trackers on physical activity, Laranjo et al reported that interventions with personalisation features had larger effects than those without those features. 1 In those studies, personalisation was almost entirely based on