Ask the Expert: Q&A with Dr. Carlos Dora | Global collaboration and communication as the keys to reducing the environment’s impact on health

carlos-dora-shotIn our second installment in our Place & Health series we are speaking with Dr. Carlos Dora, Coordinator of Public Health, Environmental and Social Determinants of Health Department at the World Health Organization.

In his role at the WHO, Dr. Dora strives to turn scientific evidence into local action through providing recommendations on urban environmental policies that serve to benefit the health of citizens across the world.  We spoke with Dr. Dora to get his views on this global collaborative effort, in a conversation on March 2, 2016.

Tell us about yourself and your work.
I’m a medical epidemiologist, and I work as a health policy expert at the WHO where I coordinate a unit that provides guidance on the health impacts of different sectors’ policies. We work with housing, transport, energy, and extractive industries such as oil and mining; and we also work on environmental health risks – such as air pollution, radiation, occupational health, etc.

I focus mostly on innovation, and my role has been to generate new knowledge and tools including for cities. We are working to define a model that will build the strength and capacity of the health sector to work with other sectors to prevent disease through encouraging investments to reduce air pollution and mitigate climate change. Our focus is on public policies, private investments, and how they influence health.

How that model is shaping up and what it looks like?
For many years there has been a lot of discussion about the need and importance of working across sectors for public health, but there has been relatively less effort on the knowledge base, skill set and tool set. We are now focusing on how the health sector can be equipped to do that. I think that the skills set of Healthy Cities has done some of that on the process part, but we need to have the knowledge — to know the interventions of the other sectors that have worked for health, how to compare those interventions, and do scenario analyses to know what works best so we can plan for investments.  If you are a transportation operator or if you are in energy utility — how is it that they can put value and identify which policies will get more health benefit? It is the role of the health sector to inform those other sectors.

Your work focuses on preventing disease by promoting a healthier environment. Often in the public discourse when people think of the main culprit posting a threat to urban health, they think of air pollution and that seems to take up a lot of the attention. Can you speak to other factors that affect urban populations?
I think they’re right to focus on air pollution because it causes 7 million deaths a year — that’s a lot of death. In terms of environmental factors, this is the largest single environmental health risk. So the focus on air pollution globally is very appropriate. Especially in countries in Southeast Asia, parts of Africa, and the Middle East, where there are very high levels of air pollution.

Attention to certain environmental issues depends where you are. In having a profile of risk in your city, it is important to identify not just the risks but the sources as well. If you know the source, you work to address the environmental risk and can also see the policy options available to address that risk source, equally you can map the health benefits expected from the same policy options and find out which provides more overall value. We are interested in all the synergies and efficiencies that come from certain policy options; and we use a model that identifies those synergies for overall health benefits through health impact assessments. For example you can reduce air pollution from transport by using better engines or cleaner fuels, but if you want more health from transport, then you need to switch to public transport, walking and cycling, as besides reducing pollution, those policies also reduce noise, traffic injuries and physical inactivity – all important health determinants.

To your point, the focus on certain environmental issues tends to depend on where you are. What elements create an enabling environment where certain issues can rise, in terms of the policy agenda?
I think there are various elements that go into governance, and communication is one of them. I think people tend to focus on the law and regulations part — which of course is very important — but I see it as equally important as access to information and the engagement and understanding of private actors. Localizing the whole information chain is very empowering. The people in municipalities are motivated to use local information to inform local policy choices for local benefits. This is a more direct link between policy decisions and those who benefit from such decision and there are more chances of engaging stakeholders by using information that affects them directly. That is what we are trying to attempt in our urban interventions.

In your work in bringing together these core sectors — housing, transportation, and those working in the natural environment — what are some of the challenges that you face in creating these collaborative efforts? What are some take-home messages that you can give in terms of the success factors in bringing together multiple types of sectors to drive change?
I think as the WHO, people look to us to know if something is true. Why do they look to us? Because we have possibly one of the most rigorous mechanisms to issue any recommendation based on science. For us that scientific rigor is what builds our base for being able to be heard about issues. For example, we’ve done guidance on household energy — how you cook, heat, and light your home. We’ve evaluated this energy technology to understand what’s best for health. It took us four years and a lot of effort, but the results have the ability to change the way people think, invest, and act. I think that is our preferred way as a technical agency, because it is a solid basis for action.

The other part is that we contribute our knowledge of the health sector. The guidelines can be taken from Geneva to other locations around the world. I used to work as a doctor in a village in the south of Brazil, in the outskirts of a large city. I used to use WHO guidance for the ways I was dealing with my patients. That is also something unique in the health sector. We have this cohesive and coherent way of operating globally. And it is an advantage of the profession, so the WHO uses that to the benefit of public and environmental health.

The 2016 International Conference on Urban Health is an opportunity for different professions and sectors to come together to advance the understanding of actions needed to improve urban health in cities worldwide. Based on your many years of experience in this field, what do you see as game changing innovations and promising practices in the areas you oversee?
There are a lot of multi-city initiatives, like UCLG or C40, that are looking for examples of good practice. I’ve been reflecting on this and analyzing what’s being done in the city space; and I think what is missing is not so much the good practice, but being able to relate this to the thousands and thousands of cities that do not participate. The vast majority of citizens do not get to benefit from these new innovations and practices. So here at the WHO, one of the reflections that we are having is how to use what exists in good practice to create mechanisms that can translate to the rest of the world. This is something that concerns us primarily, because we are in charge of advising the world’s population — all of the cities. So, that is something that has been very much on my mind and I think we do need that rigor of comparison so that we can learn the best from good practices and leadership that exists today.

In terms of the work that you do around partnership building what are the opportunities?
There are lots of opportunities. For example, I worked for 10 years in academia in London and then WHO Europe. What we developed then between transportation and health, for example, has really impacted the way people see transportation, health, and environment in Europe. Today cycling, walking, and public transport are highly regarded in European cities. When we started this in the mid 90’s, that was not the case. People used to laugh at us when we used to talk about cycling as a mean of transport, but in the period of 20 years there has been a massive change in Europe.

I think we are about to see other signs of change in access to clean air, green space, and access to public space. In housing there’s now much more evidence, and in energy we are seeing a lot of transformation. I’m absolutely optimistic about the kinds of changes that we can enact. In my experience at the WHO, whenever we come up with some solid facts and some good evidence, the other sectors listen. That’s why engagement and communication are so important. The moment facts get to a large enough groups of people, and you start using them and experimenting in different places, it has the potential for massive change.

Whenever you’re out at conventions like COP 21 you see a lot of people doing excellent work. So I think the challenge is more with synthesizing the information and getting it to people who do not have the chance to be in COP21. The health sector exists in all cities, in poor countries, rich countries, and villages. Our guidance needs to go beyond using medicines or vaccines, we need to give them more tools. There is a lot of ground that has been covered, for example with Healthy Cities, so I see that as excellent material for us to take stock in and take it to a new level of rigorousness, communication and outreach that empowers the health sector and really equip them with the right tools to do their job. Health workers have a very influential role in creating a better urban environment.

Is it fair to say your call to action is to gather the rigorous evidence, communicate it in a compelling way to local people, engage people in change, and make the information regarding change transparent?
I think you have summarized it very well. One may have a very good technical program, but what is needed is a sufficient number of people to be informed and engaged in order for change to happen. A third of our resources are going to go into communications, dissemination, and outreach. Communication is just as important as the technical tools for the capacity of the individuals in the cities to take action.

I did some research on health communications when I was put in charge of mad cow disease in the 90s. I found that communication was the greatest of all problems. We monitored media and looked at perceptions — how people communicated and framed different things, and I learned a great deal about its importance. [Communication] is not something you do at the end of your work. The whole framing of your work has to take into consideration how you’re going to engage, who you are going to engage, and what mechanisms you are going to use. I find that to be an integral part of our technical work, even our scientific work. If you want to be thinking of influencing policies, you have to think about the way you frame.