Pulse to Planet: The Long Lifeline of Human Health

To the young people of today who have to shape the world of tomorrow

and

For all those who believe in the oneness of humanity and the sanctity of life on this planet

Hitopadesha, 1.3.71:

ayam nijah paroveti ganana laghuchetasam

udaracharitanam tu vasudhaiva kutumbhakam

‘This is my own and that a stranger’—is the calculation of the narrow-minded,

For the magnanimous-hearts, however, the entire earth is but a family.

—The Maha Upanishad

Ancient Mayan Salutation

The Mayan way of greeting a person was to say ‘in lak’ech’, meaning ‘I’m another you’. The response was to say ‘a la k’in’, meaning ‘you’re another me’.

We are reflected in others, as they are in us. Our lives are connected. Especially in health and well-being.

Contents

Foreword by N.R. Narayana Murthy

Foreword by Sir Michael Marmot

Preface

Why This Book?

PART I: What Codes Our Biology?

Is It All in the Genes?

Environment Fine-tunes Our Biology

‘I, Me, Myself’? Not Really!

Gene Expression Is Epigenetically Modulated throughout Life

The Story of Stress

Migration Mash-up: Gene–Environmental Interactions

PART II: Nutrition

Selective Nutrients to Composite Diets

The Many Faces of Malnutrition

Agriculture, Food Systems and Health

PART III: Social, Economic and Commercial Determinants

Water Security and Sanitation Services

Economic Development and Health: Growth and Equity

Education and Health: A Close Relationship

Discrimination Creates Health Inequality

The Commercial Determinants of Health

PART IV: Health System Is More than a Repair Shop

Universal Health Coverage

Our Healthcare Needs Other People Too

Health Promotion Needs Social Policies

On the Wings of Science and Technology

PART V: Environment Is Our Life Support

Progress Should Not Impose Pollution Penalty on Health

Do Humans Trigger Zoonotic Pandemics?

Loss of Biodiversity Harms Human Health

Health Hazards of a Planet in Peril

PART VI: Creating the Future

Vision of a Healthy Society

What Will the Young Persons of 2051 Say?

Acknowledgements

Notes

Index

About the Book

About the Author

Copyright

Foreword by N.R. Narayana Murthy

An ideal citizen is well-informed of his duty to the society and his role in good public governance in bettering his society. He is an expert in an important field relevant to the society. He has his heart in the right place, has idealism in his genes and is positive-minded. He works hard and smart, is disciplined and strives for the betterment of his nation and the world with every one of his actions. Finally, he is deep-rooted in enduring values. Prof. Srinath Reddy, a well-known cardiologist and India’s best-known public health expert, is one such rare citizen of this country. Srinath believes that the only way you can become the global best is by continually working smart and hard every day to become better today than you were yesterday.

I have known Srinath for over twelve years and have, on many occasions, witnessed his leadership from close quarters. He would take up plausibly impossible and aspirational targets. He would inspire his team through his leadership, work hard relentlessly and achieve his goals. No doubt, he earned the plaudits of a vast group of his admirers, of whom I am one. My relationship with him has been illuminated by his deep concern for the health of our citizens and by his unrelenting determination to make public health initiatives in our country a strong force to achieve that objective. A Chinese proverb says that you cannot be a successful shopkeeper unless you can smile easily. I have been an admiring witness to Srinath’s amazing smile in the most trying situations in his bid to sell public health to corporate leaders, government bureaucrats and politicians.

I am happy that Srinath has brought together some of his profound ideas to achieve better health for individuals and to strengthen India’s efforts in public health and India’s commitment to sustainability in this book. This book is very timely and could not have come from a better expert.

Srinath highlights an important point in making this planet and its dwellers healthier and better. He believes that there is a dual responsibility in this task—responsibility of the individual to himself and the society; and the responsibility of the institutions of commerce, of creators of public opinion and of governance in making sure that they make it easy for individuals to fulfil their responsibility. Publilius Syrus, a Syrian philosopher who lived more than 2,000 years ago, wrote that good health and good sense are the two most important blessings in life. Srinath derives legitimacy from Syrus’s view that taking care of one’s health results in energy, enthusiasm and inclination for hard and smart work to make the nation and the world better. He believes that good sense will reduce an individual’s burden on his family members and on the society. He goes further to say that our good sense will ensure that we hand over this planet to our next generation in a better condition than we inherited it from our previous generation.

Jay W. Forrester, the most celebrated father of systems dynamics and the inventor of magnetic core memory, said, ‘In complex systems cause and effect are often not closely related in either time or space. The structure of a complex system is not a simple feedback loop where one system state dominates the behaviour. A complex system has a multiplicity of interacting feedback loops. Its internal rates of flow are controlled by nonlinear relationships.’ Srinath rightly takes a systems dynamic view of our society with public health as an important variable in that complex system. So Srinath views this complex system through the lens of human health. I agree with him that an individual’s health is shaped by the dynamics of interaction among variables like environment, nutrition, agriculture, food systems, tobacco control, urban design and transport, health policy and systems, industrial policy, education, diversity, human rights and sustainable development. He sums up this excellent book with the words: ‘The lifeline of human health truly extends from pulse to planet.’ Of course, every one of us must read it in full to get deeper insights of the author.

Srinath uses his public health expertise to delineate the various factors of the complex system of living well on our planet to its readers with a special focus on the youth of our country. Using his deep expertise in public health, he exhorts his readers to make their lives healthier, joyful and purposeful. These precepts, he believes, will strengthen the future of our country and this world. They will also make this planet a better place for us to live in and pass it on to our next generation in a condition better than we got it from our parents. Like Srinath, I too believe that this is a sacred duty of every one of us. We cannot shirk this responsibility. Srinath’s positivism, hope, confidence and action for this plausible and aspirational marathon rest on the youth of this country and the world. His confidence and hope shine through his words: ‘The amalgam of admirable idealism and amazing energy in young persons can be a formidable force for change.’ I have enjoyed reading this seminal book. Please turn the page over and start reading!

N.R. Narayana Murthy

Founder and Chairman Emeritus, Infosys Limited

Former Chairman, Public Health Foundation of India

Foreword by Sir Michael Marmot

A handbook for improving the planet and its inhabitants.

In 1900, life expectancy in the world was about thirty-one. In 2019, before the COVID-19 pandemic, it was close to seventy-three. Such improvement is quite astonishing. Why has it happened? And will it continue? The answer to the first question may inform speculation about the second.

A simple answer to the first question is that the world has become a better place to live. But that improvement is unequally distributed. Between countries there are great inequalities in the conditions that lead to good health. Within countries, too, such inequalities lead to great inequalities in health.

How are we to understand the phrase, ‘The world has become a better place to live’, and why do great inequalities in health persist? I work in a medical school. Large numbers of medical scientists are devoted to understanding basic biological mechanisms underpinning the biology of health and disease. Others are at the frontiers of medical treatment, developing and evaluating therapy for common and rare conditions. Still others are working in the community in primary care of one form or another. Then, there are my colleagues in epidemiology and public health—looking at the distribution of disease in populations, the causes of that distribution and steps that can be taken to improve health. Across the road, there are psychologists who study human behaviour, specialists in early child development and education, economists and political scientists, agricultural specialists and environmental scientists.

Each of these disciplines is highly relevant to understanding health and disease in populations. Indeed, it is not a takeover bid to argue that measures of health and well-being tell us a great deal about how well society is meeting the needs of its members and creating the conditions for them to flourish. To start to answer our question, of the reasons for remarkable global improvements in health, we need to understand how all of these intersect and interact to influence health and disease. A tall order.

A good place to start is this wonderful book by Srinath Reddy. It is well named: Pulse to Planet. An understanding of biology is valuable but, by itself, will not explain improvements in health over time or inequalities within and between countries. An understanding of social and environmental determinants of health is vital, but it is helpful to understand how they act on human biology and psychology. Someone thinking about commercial determinants of health may not spend much time thinking about the microbiome. That is their loss. Read the relevant chapter in this book and understand better how food and environment act on the body. Need to think why and how changes in the social and economic environment might change health behaviours? Read the psychology chapter on behaviour change.

The insights gained will help address the second question: the future. The big challenges are the climate emergency, growing inequalities and political and social threats to health and well-being. Pulse to Planet gives the reader a way to think about how these might influence health. The book stops short of making predictions, rightly in my view. We shouldn’t sit back and wait for the movie of the future play out before us. We need to act, and ‘we’ will depend heavily on the enthusiasm of young people, the target audience for the book. Given the readability of every chapter, it will be a vital handbook for young people wishing to improve life and health on this fragile planet.

Srinath Reddy’s life work has been and continues to be on strategies to improve the health of individuals and populations. His grasp of the multiple levels of health and its determinants are well in evidence in this special book. Read it and use the knowledge to work together for a better future for the planet and its inhabitants.

Professor Sir Michael Marmot CH

Director of the UCL Institute of Health Equity,

University College London

Chair of the WHO Commission on the Social

Determinants of Health

Author of The Health Gap

Preface

This book is not meant for health experts. It is for everybody who cares about the future of the world, including health professionals. I wrote it especially to inform and assist young persons, who will live in that future but are in danger of being forced to cope with the calamities created by the present models of distorted development. The main driver of the current speeded-up move towards civilizational suicide is a lack of understanding of how the well-being of humans is closely connected, to one another, other occupants of this planet and to our common environment. We cannot provide course corrections unless this inter-dependence is adequately understood and appreciated by humans who are presently driven by ill-conceived individualism that puts them in conflict with the collective well-being of humanity and the sustainability of planetary health. This book looks at human health as the key summative indicator of sustainable global development and highlights the many areas of connectivity that we must recognize and respect if we have to survive and thrive as a species.

In the year in which this book was written (2021–22), much global concern had been voiced about the threats to the environment at COP 26 and COP 27. Human health too has been the dominant theme of media headlines and people’s fears, due to the unrelenting threat of COVID-19. Global economy has been sliding down, even as inequalities have been greatly accentuated by the concentration of wealth and power. All of these have been discussed widely in many scholarly books and sharp media commentaries. What I attempt to do in this book is to present a unifying perspective from the viewpoint of one who sees a healthy life as a common aspiration of all people. It is born out of my belief that health is the best summative indicator of sustainable development as it connects many dimensions of human activity.

I have been fortunate in being exposed to many of those dimensions in my life and career. As a physician and cardiologist, I became familiar not only with the clinical presentations of disease but also with the proximate risk factors and their upstream social, economic, environmental and commercial determinants that create the disease. Clinicians who care for and advise patients emphasize that taking care of one’s health is an individual responsibility. It is right that they do so while advising on the dos and don’ts of individual behaviour that affect health. However, many of those behaviours are shaped by or constrained by economic, social, environmental, cultural and commercial factors that operate at the societal level. Availability, pricing and marketing of food products are examples. Whether we breathe highly polluted air or fill our lungs with clean air is not entirely a matter of our personal choice. Public health recognizes these connections better than clinical medicine.

As I moved to the arena of public health, I could interact with and gain insights from the many groups working on environment, nutrition, agriculture and food systems, tobacco control, urban design and transport, health policy and systems, universal health coverage, education, gender equity, human rights and other components of sustainable development. As I read and listened, I became increasingly aware of how interconnected and interdependent these are and how an individual’s health is shaped by the dynamics of their interaction. The lifeline of human health truly extends from the pulse to the planet.

I have also had the pleasure and privilege of being associated with young people through two youth groups that I helped to found —HRIDAY (Health Related Information Dissemination Amongst Youth) and SHAN (Student Health Action Network). The former means heart and the latter means pride, in Hindi. These groups convened to discuss the pathways and policies by which the health of their generation is enabled or eroded. Their members became informed advocates and enthusiastic campaigners for change. We organized four global youth meets on health around health-friendly policies needed across many sectors, for sustainable development.

The amalgam of admirable idealism and amazing energy in young persons can be a formidable force for change. This book is intended to provide them with a perspective that views sustainable development through the lens of human health. I am greatly inspired by the leadership of young people like Greta Thunberg and Malala Yousufzai. I have seen many others like them at the national and global youth assemblies that HRIDAY and SHAN convened. The voice of Vinisha Umashankar resonated in my ears as she declared at COP26 in Glasgow, ‘I am not just a girl from India, I am a girl from Earth’. I have great hope that the young can rescue the world from the many ills that plague our society today. That will ensure a healthier future for all of humanity. As a doctor, I can wish for nothing more.

However, young people cannot do it on their own. Firmly entrenched business and political interests will resist any change that will not serve them well. Fossil fuels, tobacco, unhealthy foods and beverages, extensive logging and mining leading to deforestation and patent-protected high pricing of essential medicines are among the many threats to human health that have powerful vested interests defending them. I have often wondered what kind of a future those focused on narrow ends wish for their own grandchildren and great-grandchildren who cannot lead isolated lives in an unhealthy world.

The generation that is dictating the patterns of economic and social development of the world today has no right to compromise the natural resources that the coming generation needs or to build destructive models of development that are difficult to dismantle or cause irreversible damage. As Thomas (Tom) Paine, American writer and fighter for independence, wrote,¹ ‘Every age and generation must be as free to act for itself, in all cases, as the ages and generations which preceded it. The vanity and presumption of governing beyond the grave is the most ridiculous and insolent of all tyrannies’. The future generation should not be shackled by the misjudgements and misdeeds of those deciding the fate of the world today.

Unless a majority of global society recognizes the many connections that shape an individual’s health and the need for collective action to positively influence the determinants of health, change will not come