Local Health Plans: Value and Structure

Any health plan ultimate goal is to improve health and to reduce health inequities, with minimum resources, based on a value for health approach. A local health plan should follow strategic orientations from European, national and regional levels in order to achieve the sustainable development goals established by the World Health Organization. This idea of top-bottom guidelines is fundamental, although the usual short time frame may affect the evaluation of its implementation in terms of outcomes and impact.

Building Local health plans is responsibility of the public health team and health planning is its cornerstone. Also, it represents a social commitment, since it involves collaboration between stakeholders and individuals of a community in all of its phases. These interested parties are numerous actors that play a role in the community, taking direct or indirectly action in the health of the population. Their interventions should contribute to Health in All Politics (no longer policies) concept, and represent a stronger and empowered view of the results that all actions can have on community’s health and well-being. The plan should have a strategic format to provide all stakeholders with the right tools to take it into action; always in a whole-of-government and whole-of-society point of view. They should be diverse in their activities, in order to reach all citizens in different life settings. However, family, school, workplace, healthcare institutions and social environment are priority contexts and require the most adequate interventions.

Figure 1 – Health planning cycle (Adapted from Imperatori and Giraldes 1982, Metodologia do Planeamento da Saúde, Lisbon)

Local health plans are based on the stages of the health planning cycle (figure 1) and start with an analysis of the local health situation assessment, withdrawn from the local health observatory. This information allows the drawing of the first list of health problems and their determinants, which, subsequently, are prioritized. The next step involves the setting of objectives and selection of strategies in collaboration with all stakeholders, taking into account the main health problems identified. During and after the implementation of the plan, it should be monitored and evaluated, as these are important components to ensure its fulfillment, using core indicators.

The health planning cycle should never be interpreted in a two dimensional (2D) perspective. Its structure allows transforming all outputs from evaluation phase to inputs used in the next step. Therefore, from a 3D analysis, the health planning cycle is a spiral which ends in an ideal health condition (utopian perception). It may be considered an iteration cycle, a process used to make anything better over time.

Therefore, a local health plan is a fundamental tool to implement the best practices available and improve population health. Its use must be encouraged and widespread. The importance of stakeholders in all course of action is their multisectoral response and their ability to build bridges between them, centered on population health and well-being. Thus, the interested parties should cover all society sectors based on Health in All Politics approach, leading decision makers to innovate and going beyond an ordinary policy plan.



  1. World Health Organization. National health policies, strategies, and plans. http://www.who.int/nationalpolicies/resources/resources_tools/en/ [Online]
  2. Manual Orientador dos Planos Locais de Saúde. Direção-Geral da Saúde – Plano Nacional de Saúde. Lisboa. Janeiro, 2017
  3. Metodologia do Planeamento da Saúde. Imperatori and Giraldes. Lisboa. 1982
  4. La Planification Sanitaria. Pineault and Daveluy. Barcelona. 1994


João Paulo Magalhães
Public Health Resident
Community Health Center Group of Porto Oriental, Public Health Unit

Vaccine hesitancy: how to communicate with hesitant parents: the C.A.S.E. approach

The SAGE Working Group on Vaccine Hesitancy concluded that vaccine hesitancy refers to delay in acceptance or refusal of vaccination despite availability of vaccination services. It is characterized by different factors in different contexts (political, ideological, social, etc.). Vaccine hesitancy is complex and context-specific, varying across time, place and vaccines. [1]

When approaching a hesitant parent, one must never forget that all his doubts are dictated by a strong perception of risk and by the consequent concern for the safety of his offspring. In this context, information concerning the “danger” or the factor considered as such, is connected and elaborated not only at the cortical level, but also in the limbic system which, thanks to its connections with the pre-frontal cortex, comes into play in the decision-making process, based on emotional reactions.

For this reason, any information you want to transmit to the defaulting mother or father, this must be simple, immediate and preferably proposed using the visual means (eg: simple graphs or sample images that can visually reproduce what you intend to explain), according to the rules of cognitive ergonomics. [2]

In the United States in 2010 Dr. Singer developed a communication model that, referring to Aristotelian rhetoric, provides an effective and efficient approach to communicate with the hesitant parents (C.A.S.E. approach). C.A.S.E. is an acronym that identifies the four phases of the communicative approach, Corroborate, About me, Science, Explain / advise (Fig.1). [2,3]

The first phase, Corroboration, which coincides with the Aristotelian technique of pathos, consists in proving emphatic towards parents who do not want to vaccinate their children, that is to listen, welcome and understand their doubts and their fears. Parents must perceive that who they are in front of is not an enemy whose purpose is to oppose them and impose on them a different way of thinking and acting, but it is a person who shares their primary interest, the health of the child. To achieve this, it is very important to find a point of agreement from which to start. [3,4]

In the second phase, About me, or ethos according to Aristotle’s rhetoric, the health worker should explain to parents what is his working mission (e. g. to advance the health of all people, the children’s sake) and what path he has taken to realize it (the studies, conferences or courses in which he participated, various studies). [3,4] The objective is to qualify the speaker, increasing its credibility and making it an authoritative source of information.

The logos of Aristotle is taken up again in the Science phase of Dr. Singer, in which the scientific evidence about the vaccines is presented to the parents. [3,4] It is in this phase when the cognitive ergonomics, mentioned above, comes into play strongly. To make the interview less dispersive, it is advisable for the doctor, already in the corroboration phase, to let the parents express the factors of greatest concern. This on one hand allows to partially reduce the anxiety of mothers and fathers, on the other hand allows the doctor to focus only on some aspects related to the vaccines and not on all the knowledge about the subject.

Fig. 1 Example of C.A.S.E. approach proposed by dr. Singer (2010)

Finally, to conclude the interview, the explain / advise phase should allow to sum up what has been said and give advice to the hesitant parents based on scientific evidence. [4]

The effectiveness of the C.A.S.E. method against hesitant parents has not yet been evaluated in any study. Therefore, assessing effectiveness in the field would be appropriate.



  1. Mac Donald N, the SAGE Working Group on Vaccine Hesitancy. Vaccine hesitancy: Definition, scope and determinants. Vaccine 33(2015) 4161-4164 2)
  2. Pezzullo L. “The psychological mechanisms underlying the fear of the vaccine”. From the Congress “Vaccines, how to embrace and dispel parents’ doubts”. Treviso, 3rd February 2018
  3. Singer A. Making the CASE for vaccines: A new model for talking to parents about vaccines. NJP CORE VFC Conference 2010. Retrieved from http://www.aapnj.org/uploadfiles/documents/f73.pd
  4. Stevens JC. The C.A.S.E. approach (Corroboration, About me, Science, Explain/advise): improving communication with vaccine-hesitant parent. https://arizona.openrepository.com/ ,2016


Davide Pezzato
School of Specialization in Hygiene and Preventive Medicine – University of Padua, Italy

Stefania Bellio
School of Specialization in Hygiene and Preventive Medicine – University of Padua, Italy

Drinking Water: A Public Health Issue

The access to safe drinking water is essential to health and a basic human right, as well as a structural part of an effective policy for health protection. (1)

Since 1958, aiming primarily to protect public health, the WHO has published several editions of a document, currently called WHO Guidelines for drinking-water quality, which has been regularly updated through rolling revision. This document establishes the principles and guidelines that are the base for the national programs of the United Nations members. (1)

The model for regulating water quality in Portugal has been progressively consolidated through regular legislation revisions that reflect scientific and technical progress. The consequences have been globally positive and are evidenced in a favourable evolution of the indicator on “safe water”, which builds on the fulfilment of sampling frequency and the observance of parametric values (e.g. microbiological and chemical). Figure 1 shows the evolution of the quality level of drinking water; nowadays 99% of water is guaranteed to be controlled and of good quality (in 1993 this indicator was at a mere 50%). (2) (3) (4)

Fig. 1 – Evolution of the “Safe Water” indicator between 1993 and 2016 (3)

This excellence level is supported by strictly monitoring the stakeholders in this process, among them health authorities that may be integrated in Public Health Units (PHU). (3)

The Activity Plan of the ACeS Alto Ave PHU includes a program of sanitary surveillance for drinking water systems with public distribution. These systems undergo annual characterization as a way to promote risk analysis and management for health. I have recently followed my unit’s environmental health technician on his visits to the drinking water systems in the Fafe area.

These visits started at a Water Treatment Station, where water undergoes a complex treatment process after catchment and is then sent to several reservoirs in the area, which then distribute the water to consumers. Besides verifying the maintenance, hygiene and safety parameters, the process also identifies the treatment types for water (e.g. pre-oxidation, decantation and filtration).

We have then visited all the storage reservoirs in the area where special care is given to the inner lining of tanks/cells, vent protection and latest sanitation date.

Some locations, due to their position and/or demographic rate, benefit from local water capture (e.g. water holes, water springs or wellheads). These Dispersed Systems have their own device for water purification with sodium hypochlorite and sometimes pH correction with caustic soda.

Fig. 2 – Reservoir in Revelhe, Fafe

These visits allow us to promote the conservation and maintenance of several infrastructures of the public water supply systems by the appropriate authorities. But they also allow Public Health physicians (as Health Authorities) to intervene in a stricter and more appropriate way in the case of potential infringements of the chemical or microbiological parameters reported. It may therefore be necessary to establish measures to minimize health hazards to the population. (2)



  1. World Health Organization. Guidelines for drinking-water quality: four edition incorporating first addendum. Geneva, 2017.
  2. República Portuguesa. Diário da República, 1.ª série-N.º 164-27 de Agosto de 2007. Decreto-Lei n.º 306/2007. 2007.
  3. Entidade Reguladora dos Serviços de Águas e Resíduos (ERSAR). Relatório anual dos serviços de águas e resíduos em Portugal – 2017. 2017. Vols. Volume 2 – Controlo da qualidade da água para consumo humano.
  4. República Portuguesa. Diário da República, 1.ª série-N.º 235-7 de dezembro de 2017. Decreto-Lei n.º 152/2017. 2017.


José Miguel Fernandes
Public Health Resident, Public Health Unit ACeS Alto Ave – Fafe

Pertussis vaccination in pregnancy in Ireland

Between 2011-2017, pertussis notifications in Ireland were most commonly notified in infants and young children. The age specific incidence rate among the 0-5 month age group peaked in 2012 (ASIR 395/100,000) with smaller peaks in 2016 (235/100,000) and 2017 (225/100,000) Between 2012-2017, of all infant cases, 67% were hospitalised and several infant deaths due to pertussis were notified. None of the mothers of these fatal cases were vaccinated during pregnancy.

Vaccination of pregnant women has been shown to be safe and effective in preventing pertussis in infants. Evidence from data published in England1and Spain2 indicates that protection against pertussis is as high as 90% or more in infants whose mothers were vaccinated in pregnancy.

Antenatal care in Ireland is delivered in three ways: either private care through a maternity unity, free public care through a maternity unit or as free combined care between maternity units and general practitioners (GP). Since 2012, pertussis vaccination in pregnancy has been recommended in Ireland and is available free of charge to maternity units and general practitioners.

However, though the vaccine itself is free, all patients still incur a fee for administration. There is also no clarity or definition regarding where the vaccine should be administered, whether by a GP or in the maternity units. This is thought to contribute to the very low vaccine uptake seen. An audit of maternity units conducted in 2013 showed an uptake rate of 6.2% amongst pregnant women in Ireland. This is far lower than the uptake rate in the UK (73%) where pertussis vaccine is available to pregnant women free of charge.

The lack of a defined pathway for administration and full funding of pertussis vaccination in pregnancy represents a key barrier to increasing uptake. Clarifying a pathway of vaccine delivery and reimbursement should be a priority issue for the Irish health service to ensure that vulnerable infants are protected. Pertussis is a vaccine preventable disease and, as such, every effort should be made to prevent further infant morbidity and mortality.



1 – https://www.ncbi.nlm.nih.gov/pubmed/25037990

2 – http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=22809


Fiona Cianci
Specialist Registrar in Public Health Medicine
Department of Public Health, HSE East, Dublin (Ireland)

Training experience in the UK – Haelo & Salford Royal NHS Foundation Trust

I am at the end of the fifth year of the school of Hygiene and Preventive Medicine at the University of Pisa and just before the end I wanted to taste some examples of the best european infection control. Thanks to a precious man, professor Peter Lachman, pediatrician and CEO of the ISQua, I was connected with Haelo that is a quality improvement agency collaborating with many hospitals, one of which is the Salford Royal Hospital. At Haelo they planned for me one-day full immersion on the programs they run routinely with professionals and academics, their methodology and strategies for QI. The next day I was directly into the hospital visiting the amazing A&E Village that is the result of a recent renovation structurally and organizationally: the workflow is designed to let the patient get out of the unit in less than 4 hours unless complications, major injuries or frailty and they normally obtain the >90% patients target! I spent the next days with the Infection Control Team, visiting wards, receiving explanations for every question I posed them, participating to a part of the Induction Package that every new employee must pass before beginning the job. I visited the lab too, talked to a clinical microbiologist about his occupation there and sharing the differences with my country hospital system. I followed a specialist nurse of the IV team in her activity and it was very impressive in matter of competence! Finally two running projects they showed me were the NAAS and CAAS (Nurse and Community Assessment and Accreditation System), examples for how to fix chronic problems like nurses’ professional update and the link between hospital and local health authorities. Outstanding!

Among the other things, have to flag an excellent restaurant inside the hospital, very nice meals consumed during my stay.

Outside I visited the city of Manchester in occasion of the Chinese New Year, the Salford University swimming pool, very nice indeed and the surroundings of Salford, in particular it is worth of remark the most modern area that is MediaCity.

In conclusion, it has been an intense and intensive experience, deep into the world of Infection Control to lean and bring back home a different way to tackle the antimicrobial resistance and the infection transmission in the hospital setting not to mention many ready-to-use tools for my hospital!


Giulio Pieve
Public Health Resident, University of Pisa

Reflections of a Public Health Resident

I’ve been an internal Public Health doctor since January, and I’m taking my first steps in the wide-ranging medical specialty of Public Health. My unit of work covers a wide area including two small-sized cities, Santa Maria da Feira and Arouca, located approximately 40 kms south of Porto. As the first year of an internship in Portugal is focused on Community Health, my daily work is based on 5 major areas: Prevention and Health Promotion, Environmental Health, Health Authority, Epidemiological Surveillance and Health Planning.

In addition to having a particular interest in Global Health, I attend traveller’s consultations in the International Vaccination Center of Porto whenever I possibly can. I grasped the opportunity to attend the World Health Summit Regional Meeting, which took place in Coimbra on the 19th and 20th of April. The congress was held at the San Francisco Convent in a space that gathered around 600 participants and 120 speakers from more than 40 countries to discuss Global Health. A special focus was paid to the health problems faced within countries of the Community of Portuguese Language Countries (CPLC).


Europarque at Santa Maria da Feira

Besides the excellent exhibits, interesting debates and networking, which was essential for both professional and personal enrichment, it has also brought many concerns and a feeling that change is essential.

The task of countries considered underdeveloped is increasingly seen as a utopia. The high rates of maternal and child mortality in addition to the high burden of communicable diseases, these countries are facing a growing increase in noncommunicable diseases that until very recently were confined to developed countries. Conversely, developed countries are facing the resurgence of some vaccine preventable communicable diseases, such as Measles in Europe, as a result of a drop in vaccination rates due to the growing anti-vaccine movements we have witnessed. Climate change is a fertile ground for migrations of certain vectors, which may facilitate one of the greatest Public Health problems in countries considered underdeveloped, the vector-borne diseases.

Taking into consideration the future problems resulting from the constant increase of the world population with a prediction of 8.5 billion people in 2030… will there be clean water for all?

We’re a time bomb, and time is counting.

According to various experts in many different areas, even if all efforts were put into practice it would be difficult to achieve the 17 sustainable development goals by 2030. The strategies and measures adopted have been scarce in dealing with the many problems that exist.

We can’t continue to focus solely on the health of our communities, knowing what is happening in the rest of the world.

We can’t all live in Sweden (Ranked 1st the SDG’s rankings), but we can replicate 157 Swedens.

Through the history of Public Health, we have a duty to try to change the world for the better, because anything is possible if someone dreams about it.



1. World Health Summit Regional Meeting 2018, Coimbra – Portugal. Available: <https://www.worldhealthsummit.org/regional-meeting.html>
2. SDG Index and Dashboards Report 2017 – SGD Index & Dashboards


Davy Fernandes
Public Health Resident, Feira-Arouca Public Health Unit, Portugal.

Health and migration – A public health residents project

The 15th Conference of the Italian Society for Migration Medicine took place in Catania from April 18th to April 22th. The title was “Dynamics of health and migration: between continuity and new needs”. The conference program was rich in contents and stimuli, and was a multidisciplinary and multiprofessional platform to exchange practices, ideas and field experiences. It was an opportunity for health workers, researchers and academics, operators and educators working with immigrants, activists, volunteers and common citizens, to come together, reflect and learn about “the health of immigrants” and engage in its promotion and  protection.

The title of the conference encouraged to move beyond the “emergency approach”, which often leads to consider simply the emergency dimension of migration, while forgetting the 5 millions of immigrants that have been living and working for years in our country. It is necessary, on the contrary, to understand the “new needs” and move away from a debate centred on the emergency, as a starting point and an opportunity to rethink the organization of the whole health systems and models of care, towards a new definition of the concept of health, centred on PHC, on health promotion and on territorial and community dimensions, with attention to migration as well as to marginality and inequality.

Together with some residents in public health from different Italian universities, we created a working group on migration medicine to address the gaps we perceived in our knowledge on the subject. The group was established as a subgroup of the Inequality Working group of the Italian Hygiene Society Committee of Residents, in collaboration with the Regional Immigration and Health Groups (GrIS) of the Italian Society for Migration Medicine (SIMM). We share the belief that, as future public health professionals, we cannot afford to lack the competences which are necessary to face and interpret this phenomenon, which is central in the current Italian and global debate.

Asylum seekers are refugees who have left their country of origin and have applied for asylum. Italy recognizes and guarantees international protection and healthcare coverage for asylum seekers. The process to apply for and be granted a residence permit may require months, and in both phases they could potentially find themselves without healthcare coverage. Each region has its autonomy in the application of national protocols. This regional autonomy is associated with different waiting times for the acceptance and formalization of the request for international protection, and this leads to discrepancy and discretion in healthcare access for asylum seekers between their arrival and the formalization of the asylum application.

We are realizing a study that we presented at SIMM conference. We wanted to describe the policies (law, regulations…) of the different Italian regions and the gaps between policy and practice, and to map the different practices, in order to highlight similarities and differences. Our goal is to investigate any inequalities between protocols and daily practices, and to deepen our understanding of the issues related to the assistance paths activated immediately after the arrival of the asylum seekers. Preliminary results show differences among regions and single Local Health Units (LHUs) as well as fragmentation of the pathways of care following the first contact with the health system.

It would certainly be useful and interesting to extend the study outside of Italy, to the European context, thus including other countries. Migration must necessarily be read as a complex, interconnected and global issue, and consequently also the analysis of policies and practices can not be limited to a small geographical area.

In this, the quality and strength of the work, as well as the potential transformative power, would be positively affected by the possibility of creating a European network of resident students, who deal with the issue of migration medicine to compare approaches and identify new ways to interpret the complex reality we are trying to describe.

Through the history of Public Health, we have a duty to try to change the world for the better, because anything is possible if someone dreams about it.



Società Italiana di Medicina delle Migrazioni – https://www.simmweb.it/


Chiara Milani
Public Health Resident
University of Firenze

Getting to know the Global Health Next Generation Network

Multidisciplinary work is part of everyday life of any resident; living among Medical Doctors in training for Public Health could isolate us from the different perspectives that exist out there. One of the efforts of Euronet is to connect the residents of the member countries, but also to build bridges between other groups, teams and associations related to Public Health. One example is the Global Health Next Generation Network (GHNGN), which in a short time has created a network of working groups, some with common objectives with Euronet, such as empowering young professionals in trainee with practical tools.

“As the voice of the next generation of Global Health professionals, GHNGN focuses on bringing people together and foster discussion around Global Health through formal (conferences) and informal events (global health hangouts) as well as mentorship opportunities (Global Health Mentorships and Peer to Peer sessions).”

The network was created in Barcelona, with students of the Master of Global Health at the University of Barcelona, with the aim of having a platform so that young professionals from different cultures and backgrounds can network and exchange Global Health expertise and skills; to promote trans-disciplinary teamwork, to help each other out in the transition from academic to professional careers in global health, to initiate and foster dialogue on Global Health education and to support engagement of young professionals in Global Health initiatives and projects worldwide. Currently, there are approximately 30 people in the team, working from 15 different countries.

There have been some attempts to bridge in the last years. But it was this 2018 winter, when members of Euronet and GHNGN gathered in Barcelona and pushed forward on partnering. Some ideas flew on our first exchange of emails like ‘Social media visibility’, ‘Inviting speakers from Euronet for the Global Health Forum‘, ‘nominating a Global Health Ambassador’, ‘Writing a blog/career story about people on each organization’, ‘Exchange of expertise’, ‘Internships´, etc.

The official presentation of the GHNGN to Euronet members was made in March, at the meeting of Nancy. In the assembly there was general approval to draft an agreement for the next meeting. This beautiful story has the next date next July in Valencia, where some members of the GHNGN will visit us to make a formal presentation of their network, pitch some ideas and party with us at our meeting organize by Euronet Spain.



Twitter: twitter.com/globalhealthngn
Facebook: www.facebook.com/GHstudentnetwork/
Website: http://ghnetwork.org/


Efrain Pantoja
MRPH at Hospital Clinic de Barcelona and ‘Mr Pantoja’ at EURONET

Elena Marban
Pre doctoral fellow at ISGLOBAL and GHNGN board member

The Ethical side of Public Health

Nowadays, we still deal with the ethical side of every public health program or initiative using concepts or ideas based on Kantianism or even Utilitarism. We overlight and quote Rose’s paradox(1), as if the population and the individual interests were the only ones that mattered on the difficult path of deciding whether a public health measure, law or policy must be implemented or not. We sometimes strive to achieve a middle point between the population’s best interest and the individual freedom. None of this is unfamiliar, however, the importance of public health as a tool to ensure the compliance of human rights is still rarely discussed.

“In the absence of action, human rights are mere words on paper”(2). This, is one of the most important critics to the human rights approach (the most common approach related to human development). It states that human rights must be associated to measures that assure to genuinely safeguard human development. Nevertheless, political agendas and public health policies around the globe do not actively direct their efforts to assure human development or human rights on the grounds that if freedom is guaranteed, human rights will be guaranteed.

No more than a year ago I met an amazingly intelligent, successful, and wonderful woman that explained to me that the human rights approach is not all. That public health is not only screening, mental health, surveillance, health promotion or Antonovsky’s view for health and illness. She explained that a theoretical negative freedom does not safeguard anything; that social justice could give more answers than questions, problems or debates. She recommended me a book in order for me to get the bigger picture, to be able to see with other eyes the ethical (or unethical) part of public health, to think public health. I’ve been reading and re-reading it ever since.

The capabilities approach (2,3) offers a list of indicators of human development. We could consider 10 central capabilities that may ensure human development (but there are other perspectives of the capabilities approach(3)). Central capabilities, or capabilities in general, are meant to be understood as a common doctrine to be considered in every policy, and more specifically in every public health policy.

Lots of public health programs focus on the power of informing the population, promoting health by every kind of activity imaginable or limiting access implicitly or explicitly to products understood as harmful. Some would define this road as a form of “desired welfarism” and not as a path to achieve human health or human development. Every piece of information, every activity, is full of ethical principles that could affect people’s preferences – and these people’s preferences affect the population’s health results. The Kantian’s idea of community of equals, the Adam Smith’s theory of the impartial spectator or even the Hampton assumption of how preferences should be examined, do not reflect that people’s preferences do not consider social justice. It is not possible to identify the preferences that are the result of unfair and hierarchical circumstances without an independent ethics theory that thinks carefully about social justice.

However, it is not my role to explain to you the theory, the book, or someone’s opinion. My goal is to make us all think and re-think, read and re-read, have another view for every initiative, program or plan. Let’s envision every project with another approach. Let’s try to make something meaningful.



  1. Rose G. The strategy of preventive medicine. The strategy of preventive medicine. University Press; 1992.
  2. Nussbaum MC. Creating capabilities: the human development approach. Harvard University Press. 2011. 256 p.
  3. Sen A. Development as freedom. Oxford New. 2001. 366 p.


Laura de la Torre Pérez
Public Health Resident
Servei de Medicina Preventiva i Epidemiologia – Hospital Clínic de Barcelona

Environmental Health – climate change and impact

Climate change is not a new issue in global agenda, as well as environmental adverse effects on health. Climate consequences are not limited to low and middle-income countries, and Europe will not be spared in such global threat. It is expected that climate change will cause over 250000 additional deaths per year between 2030 and 2050. (1) Globally it is urgent to include a new ecological public health attitude, in which sustainability becomes part of daily practice. (2) Quality evidence is required to mitigate through inclusive strategies undeniable climate outcomes. One health through a cohesive concept, addresses environment and human health sinergically with animal welfare and veterinary medicine. By moderating consequences through multiple tactics, it is possible to achieve objectives in their whole dimension. (3)

Besides total environmental related deaths have been constant, in the last decades a shift from infectious diseases to non-communicable diseases was seen both in environmental fraction and burden, translating years of development in water safety and sanitation in low and middle-income countries. By estimating burden of disease that can be attributable to environmental risks, we can predict how measures can have impact on safeguarding people’s health – population attributable fraction. The acknowledgment of which factors can be amendable is crucial to support evidence in order to locate resources in actions that have a quantifiable benefit. (4) (5)

To monitor these changes, a surveillance system that include both ecological and human health impacts is essential. It is not possible to address these issues without giving health systems an essential role on moderating climate impact on populations’ health and societies. By decreasing their not minor footprint, the sector can be an example that transformations are accessible to all, even in segments as complex as health systems. Second and more appealing to managers and business associates is that these changes can have a serious impact on systems budgets and expenses.

Remarkably, health sector can improve public health and reduce costs simultaneously. (6)



  1. Hales, S, et al. Quantitative risk assessment of the effects of climate change on selected causes of death, 2030s and 2050s. Geneva : World Health Organization, 2014. ISBN 978 92 4 150769 1.
  2. Brousselle, Astrid e Butzbach, Camille. Redesigning public health for planetary health. The Lancet Planetary Health. May 2018, Vols. 2, Issue 5 , e188 – e189.
  3. One Health Initiative. One Health Initiative. About One Health. [Online] [Citação: 3 de May de 2018.] http://www.onehealthinitiative.com/about.php.
  4. Prüss-Ustün, A, et al. Preventing disease through healthy environments: A global assessment of the burden of disease from environmental risks. s.l. : World Health Organization, 2016.
  5. World Health Organization. Preventing noncommunicable diseases (NCDs) by reducing environmental risk factors. Geneva : s.n., 2017 (WHO/FWC/EPE/17.1). Licence: CC BY-NC-SA 3.0 IGO.
  6. WHO’s Department of Public Health and Environment and Health Care Without Harm. Healthy Hospitals – Healthy Planet – Healthy People | Addressing climate change in health care settings – discussion draft . s.l. : World Health Organization, 2008.


Mariana Perez Duque
Public Health Resident
Public Health Unit ACeS Porto Ocidental, ARS Norte, Portugal