This anthology is a project of the Planetary Health Alliance

(planetaryhealthalliance.org). The Planetary Health

Alliance is a consortium of over 200 partners from around
the world committed to understanding and addressing the
human health impacts of global environmental change.

Case studies were written and photographed by Hilary

Duff with editing and support from Amalia Almada,
Christopher Golden, and Sam Myers. Teaching guides
were written by Carlos A. Faerron Guzmán.

Please cite this introductory chapter as Myers, S., Duff, H.,

and Faerron, C. "Introduction." in Planetary Health Case
Studies: An Anthology of Solutions." 2020.

Please cite this Anthology as “Duff H., Faerron Guzmán,

C., Almada, A., Golden, C., and Myers, S. “Planetary Health
Case Studies: An Anthology of Solutions”
2020; https://doi.org/10.5822/phanth9678”

Please note this work is licensed under a Creative

Commons Attribution-NonCommercial-NoDerivatives
4.0 International License. To view a copy of the license,
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To access the full Planetary Health Case Studies: An

Anthology of Solutions, please visit https://www.
planetaryhealthalliance.org/case-studies
 Acknowledgements Introduction
p.8 p.10

01 Health and Haze 02 Dams and Disease 03 Medical Clinics 04 Going Circular
for Planetary Health
A Science-Driven Policy An Ecological Solution The Surprising Link Between How Restoring a River Ecosystem
Approach to Southeast Asia’s to Schistosomiasis in Senegal Logging and Healthcare in Chile’s Capital City has Benefited
Annual Occurrence in Indonesia Human Health and Economics

p.32 p.82 p.130 p.176

05 Putting Food 06 Typhoid and Torrents 07 Today’s Solutions 08 Family Planning

Needs First for the Future of Food for People and Planet
How Alternative Proteins Could The Link Between Downstream A Population, Health, Environment
Save Madagascar’s Endangered Health and Upstream Actions Approach in the Lake Victoria
Biodiversity Basin

p.220 p.268 p.314 p.360

09 Coastal Conservation 10 The Interconnectedness

Takes Root of People and Planet
Education and Economic Learning from Māori Worldviews
Agency as a Way to Protect
Sri Lanka’s Mangroves

p.408 p.466
Case Study Indonesia Senegal Indonesia Chile Madagascar Fiji Germany, Guatemala, Europe Uganda, Kenya Sri Lanka New Zealand

Ecosystem Peatland River basin Rainforest Urban center Rainforest River basin/coastal Urban, highlands Lake basin Mangrove Country-wide

Project Lead Government agency; academic Academic researchers; NGO NGO Private sector Academic researchers; NGO Academic researchers; NGO NGO; private sector NGO; private sector NGO Indigenous iwi (tribes)
researchers
Topics
Land use and land cover Infectious disease; food security; Land use and land cover Circular economy; climate change; Biodiversity shifts; food security; Water quality, infectious disease; Food security; food waste; Biodiversity shifts; food security; Land use and land cover change Indigenous knowledge;
change (peatland fires and biodiversity shifts; land use and change (peatland fires and infectious disease; urbanization; land use and land cover change land use and land cover change circular economy; climate change; gender lens; climate change; (mangrove loss); food security; mental health and well-being;
deforestation); climate change; land cover change; water security; deforestation); climate change; water security; local solution; (deforestation); zoonotic/ (deforestation and farming); non-communicable disease; infectious disease; water quality; local solution; policy link; climate nutrition; climate change; non-
non-communicable disease; local local solution; social determinants non-communicable disease; local scaling up solutions infectious disease; demographic food security; climate change; gender lens; local solution; social demographic shifts; local solution; change; gender lens; Indigenous communicable disease; water
solution; social determinants of of health; scaling up solutions solution; social determinants of shifts; local solution; Indigenous Indigenous knowledge; social determinants of health; policy link social determinants of health; knowledge; social determinants quality; local solution; social
health; policy link; scaling up health; policy link; scaling up knowledge determinants of health; policy link policy link; scaling up solutions of health determinants of health; policy link
solutions solutions
Author, Case Studies - Hilary Duff Co-Editor Christopher D. Golden Thank you to the sponsors of this case study anthology, specifically the
Hilary Duff is a multimedia journalist who has worked and Dr. Golden is an Assistant Professor of Nutrition and Planetary
Garfield Weston Foundation, Green Park Foundation, and the Rockefeller
reported from six continents. She is interested in solution- Health at the Harvard T.H. Chan School of Public Health. Dr. Foundation.
based storytelling—amplifying the positive changes being Golden is an ecologist and epidemiologist interested in the
driven at every level, from young social innovators in sub- interface of ecosystems and human health, specifically in the
Saharan Africa to national governments in Asia. Prior context of global trends in biodiversity loss and ecosystem Thank you to our partners at Brunel University, particularly Dr. Mary
to creating this case study anthology, Hilary reported transformation. Dr. Golden conducts research on a breadth
extensively on social and environmental entrepreneurship in of topics under the umbrella of planetary health, focusing Richards and Anne Smith, for their critical support of this project.
sub-Saharan Africa and the MENA region for both Canadian on the future of food systems and sustainable nutrition. His
NGOs and international projects run by the European Union long-term, multi-decadal research in Madagascar and more
and the United Nations Environmental Programme. Her recent research in the South Pacific serve as the grounding for A special thanks to case study partners, without whom we would not
website is http://www.hilaryduff.work/ his perspective on planetary health issues. In 2017, Dr. Golden have these case studies: Alam Sehat Lestari, Health In Harmony, Badan
developed a multi-disciplinary undergraduate fellowship
program to receive hands-on experience in planetary health Restorasi Gambut (BRG), Pathfinder International, Watershed Integrations
Author, Learning Guides - Carlos A. research in Madagascar, and co-developed and led Harvard for Systems Health, MealFlour, Seacology, Sudeesa, Too Good To Go,
University’s first undergraduate course in planetary health.
Faerron Guzmán ProVeg International, Madagascar Health and Environmental Research
(MAHERY), The Upstream Alliance, and Aguas Andinas.
Dr. Faerron is the Associate Director of the Planetary Health Co-Editor Samuel Myers
Alliance. He also is the co-founder and current director of
the InterAmerican Center for Global Health (CISG). CISG
is the first global health hub in Central America and seeks
Dr. Myers is the Director of the Planetary Health Alliance and A warm thank you to the other members of the Planetary Health Alliance
is a Principal Research Scientist of Planetary Health at the
to redefine the meaning of leadership and global health
Harvard T.H. Chan School of Public Health. Dr. Myers works
staff team who have contributed to the development of this anthology,
through innovative educational approaches. Dr. Faerron is
adjunct faculty at the Department of Oral Health Policy and
at the intersection of human health and global environmental specifically Sara Stone, Emma Pollack, Perri Sheinbaum, Erika Veidis,
change and is currently the principal investigator on several
Epidemiology at Harvard University and at the University
transdisciplinary research projects based at the Harvard T.H. Max Zimberg, Darya Minovi, Angela Shields, Hannah Nash, Jeremy Pivor,
of Maryland Graduate School. From his different roles, Dr.
Faerron leads efforts to innovate in program and curricular
Chan School of Public Health. Dr. Myers is a Commissioner Simone Wahnschafft, Joanna Wagner and Mahaa Amhed.
on the Rockefeller Foundation—Lancet Commission on
design as well as providing strategic leadership in the
Planetary Health and member of the Lead Expert Group
administration and implementation of different academic
programs in the field of public, planetary, and global health.
on Agriculture and Food Systems for Nutrition. In 2015, he Thank you to the Lancet Planetary Health for hosting our original call
received the Prince Albert II of Monaco—Institut Pasteur
Award 2015 for “outstanding contributions to the field of for case study ideas as well as the Planetary Health Alliance network for
global environmental and climatic changes and their impacts contributing countless ideas and feedback throughout this project.
Co-Editor Amalia Almada on human health,” and in 2019, he was the inaugural recipient
of the Arrell Global Food Innovation Prize. With Howard
Dr. Almada is a Research and Policy Fellow at the University Frumkin, he has just completed a first text book in planetary The case study author would personally like to thank Chris Golden,
of Southern California, supporting research that advances health: Planetary Health: Protecting Nature to Protect
governance frameworks for sustainable marine aquaculture Ourselves. Amalia Almada, Mary Richards, and Sam Myers for their support over
industries in the United States. Dr. Almada was the Senior the course of this 18-month project. Family and friends were my rock on
Program Manager of the Planetary Health Alliance from
the time of the PHA’s launch in early 2016 through mid days when travel was long, interviews difficult, and writing arduous—my
2020, overseeing the strategic visioning, external relations, special thanks to dad, mom, Pat Alps, Bill Mavin, Sarah Eisman, Sanne
and program operations for the PHA. Dr. Almada led
the development of the GeoHealth Journal’s inaugural Wesselman, Anisha Mohil, Benjamin David, and Chris Bailey. Finally, thank
publication, “A Case for Planetary Health/GeoHealth” with you to the more than 150 individuals across six continents who took the
colleagues from the PHA and has authored several peer-
reviewed scientific articles. She received a Ph.D. in Biological time to speak with me for this anthology. This project would not have been
Oceanography from the MIT/Woods Hole Oceanographic possible without your knowledge, patience, and generosity.
Joint Program.

8 9
 A group of young girls in Senegal inspect
Introduction This anthology is a collection of stories about how we can create the snails that host schistosomiasis,
a healthier future by rewriting the relationship we have with a parasitic, water-borne disease.
Samuel Myers, MD, MPH, Director
of the Planetary Health Alliance and our Earth. The cases in this anthology introduce a range of
Principal Research Scientist at the environmental challenges perpetuated by people worldwide:
Harvard T.H. Chan School of Public deforestation in the Indonesian Borneo, contaminated river
Health
systems in Fiji, bushmeat hunting as a driver for species-loss in
Hilary Duff, Multimedia Journalist and Madagascar—just to name a few. Each of these environmental
Case Study Writer with the Planetary
Health Alliance
challenges, in turn, contribute to a variety of human health
outcomes, including cardiorespiratory disease, food insecurity,
Carlos Faerron Guzman, MD, MSc, water-borne diseases like schistosomiasis and typhoid, and
Associate Director of the Planetary
Health Alliance and Director General
concerns related to mental health and cultural identity. At their
of the InterAmerican Center for Global core, these stories illustrate how human health and well-being are
Health, Costa Rica inextricably linked to the status of our natural environment.

Importantly, these cases go beyond simply identifying urgent,

interconnected problems. This anthology is inherently solutions-
based, and each story highlights a concrete example of how groups of
actors worldwide are using planetary health approaches to address
problems in their communities: from millions of Europeans using
a phone app to reduce food waste; to villages reducing pressure
on wildlife populations; to private sector innovation in wastewater
treatment; to women’s groups working in partnership with the Sri
Lankan navy to replant mangroves. What they share in common is We find ourselves at an extraordinary, even unique, moment in
action fueled by commitment to bring people and planet back into human history. By most metrics, there has never been a better
balance to ensure the health and well-being of future generations. time to be a human being. The last 70 years have been marked
by almost unimaginable improvements in global wealth, health,
and education. The percentage of the global population living in
extreme poverty dropped from 63% to less than 10%, despite a near
tripling of the human population.1 Average global life expectancy
climbed by nearly 30 years,2 while child mortality dropped by a
factor of four worldwide.3 The percent of the adult population able
to read and write has doubled.4

But the 70 year period that has delivered these enormous human
development gains has not come without sacrifice. The economic
growth and scientific and technological developments that fueled
these improvements have driven an extraordinary ballooning of
humanity’s ecological footprint. It is hard to overstate the scale
of human impacts across our planet’s natural systems. We have
converted 40% of Earth’s land surface into croplands and pasture
in order to feed ourselves.5 We use about half the accessible fresh
Rainforests in Borneo have faced
substantial deforestation in recent water on the planet, mostly to irrigate our crops,6 and we exploit a
decades due to community-based logging third of monitored fisheries beyond maximum sustainable limits.7
and conversion for oil palm concessions.
10 11
 A mangrove replanting session in northern Sri Lanka.
12 13
A fishing site on Lake Victoria, one of
East Africa’s most important fisheries. The scale of human activity now exceeds our planet’s capacity
to absorb the wastes we produce or regenerate the resources we
use. As a result, we are transforming and disrupting most of
Earth’s natural systems at by far the fastest rates since humans
arrived on Earth. These changes in the conditions of our lives
ultimately impact every dimension of our health and well-being as
illustrated in Figure 1. Planetary health focuses on understanding
and quantifying the human health impacts of these global
environmental disruptions, and focuses on developing solutions
that will allow humanity and the natural systems we depend on to
thrive now and in the future.

We have cut down roughly half the world’s temperate and tropical
forests5 and dammed over 60% of the world’s rivers,8 with proposed
dams expected to increase this figure to 93%.9 These and other
activities are crowding out the rest of life on our planet. In May
2019, 145 authors from 50 countries released the Global Assessment
of the Intergovernmental Panel on Biodiversity and Ecosystem
Services. They concluded that roughly one million species face
extinction, many within decades.10 Already, we have halved the
population of birds, mammals, reptiles, amphibians, and fishes
since 1970.11 Extraordinary improvements in human well-being
have come on the groaning back of a crumbling biosphere.

A bamboo lemur near Andasibe-

Mantadia National Park in eastern
Madagascar. Bamboo lemurs are one of
the world’s most critically endangered
species.
Figure 1: Schematic illustrating the
impacts of anthropogenic change on
human health. Underlying drivers include
rapid population growth, additional
increases in consumption, and the use of
technologies with large environmental
impacts. These drivers occur at such
a scale that they are transforming
our natural systems and changing
fundamental conditions for human
health and well-being. Ultimately, nearly
every dimension of human health is
affected.
14 15
Much has been written recently about the science of planetary
health and its theoretical foundations,12 13 including a new
textbook that serves as a companion to this anthology:
Planetary Health: Protecting Nature to Protect Ourselves
https://islandpress.org/books/planetary-health. However, there are
few resources to describe planetary health practice in action. How
do we do planetary health? And what best practices and values do
these actions share across scales (local, regional, national, etc.) and
regions of the world?

This anthology of case studies is an attempt to begin filling that

gap. Over a year and a half, journalist and photographer Hilary
Duff travelled around the world interviewing practitioners,
community members, government officials, business leaders, and
other stakeholders on the front lines of environmental change.
Combining their experiences and knowledge with existing
scientific research, the resulting case studies tell the stories of
planetary health in practice. Together with the new textbook, these
case studies support the goal of growing the next generation of
planetary health scholars and practitioners. These new resources
promote classroom education and provide the foundation for
further efforts to communicate complex, interdisciplinary
planetary health science and solutions to policy makers, funders,
government agencies, students, and NGOs.

Achieving planetary health will require a broad societal

transformation. Some have described it as the “Great Transition”14
where we learn to do nearly everything differently: how we produce
and consume food, manufacture products and energy; how
we construct and live in our cities; how we manage our natural
landscapes and resources. The changes needed are not only in the
physical world. The Great Transition demands a mindset shift—a
rewriting of the stories we tell about our place in the world, our
relationship with Nature, how we compensate for and address the
significant inequalities that exist, and what it means to live a good
life. The cases in this anthology are by no means representative
of all the kinds of change that will be needed or all the types of
practitioners whose contributions will be critical. But we do hope
they illustrate the breadth of approaches that will be relevant and
necessary to achieving planetary health.
Hilary Duff, the case study author,
during her case study reporting in the
Senegal River Basin.

16 17
 Farmland in Senegal relies on irrigation
Overarching themes As you read through these cases, we hope you will begin to water redirected from a dam that was
recognize a group of overarching themes that run through many constructed in the mid-1980s.
of them and are central to the field of planetary health.

Listening
Several stories in this anthology take place at the level of
communities living in or near threatened natural systems: the
rainforests of Kalimantan, a protected area in northeastern
Madagascar, the shores of Lake Victoria, the islands of Fiji, or the
mangrove forests of Sri Lanka. More often than not, local people
are well aware that their use of natural resources is not sustainable,
but they have few other options. If local people are cutting trees
as a way to pay for urgent medical costs (Kalimantan), or hunting
wildlife because it is the only available source of nutritious diets
for their families (Madagascar), then efforts aimed at curbing
these activities must directly address those needs and limitations.
Meaningful relationship-building and reciprocity are necessary people who reap the rewards are often categorically different
for sustainable planetary health interventions. That requires from the people who pay the greatest health tolls. This divide is
practitioners carefully listen to understand local needs, ideas, and commonly illustrated among key lines: Global North and Global
priorities—and then take action to craft community-proposed South, rural and urban communities, Indigenous and settler
solutions alongside these new partners. This crucial element— groups, and socioeconomic status. Quantifying the health
what one project describes as “radical listening”—should be the externalities of projects like dam building or biomass burning is
foundation underlying the initial approach, and guide course an important step in ensuring that certain groups aren’t forced
corrections along the way. to pay the costs of other people’s economic gain. Planetary health
practitioners and scholars can also use their power and privilege to
These case studies also deconstruct a problematic international advocate for those communities whose health is most affected, but
development paradigm: that “developed” countries are the ones whose voices often go unheard.
best positioned to bring “solutions” to “developing” countries.
While countries in the Global North often have greater financial These case studies also force students to question the barriers
resources available to fund planetary health interventions, “radical that exist in concepts of universality and access. Though certain
listening” recognizes the agency of communities to identify the sexual and reproductive health services are freely available for
needed solutions. In listening to communities, planetary health women in Uganda, gender norms, culture, and geography can
practitioners and scholars must respect that knowledge and focus limit them from accessing these rights. While Indonesia has an
on creating programs that are community-centric as opposed to ambitious universal healthcare program, people living in remote
prescriptive. villages may need to travel over land and sea to access medical
facilities. Though international aid organizations may provide
Equity and Justice nutritional supplements to a country like Guatemala, corruption
People generally disrupt natural systems for a purpose. Dams and systemic racism can prevent those supplements from reaching
in West Africa generate electricity, create much needed arable the families who need them most. And though some Senegal River
farmland, and provide reliable water to irrigate crops. Fire is an Basin villages can access tapped water and improved sanitation
effective and inexpensive way to clear land for agriculture in many facilities, financial, educational, and cultural barriers commonly
parts of the world. Shrimp farms constructed atop mangrove prevent people from utilizing this infrastructure that could reduce
ecosystems are a lucrative business opportunity. However, the schistosomiasis transmission.
18 19
 Problems Rooted in Power Addressing Livelihoods
Research and technological innovations can, to an extent, solve Many of the cases illustrate the need to consider livelihoods
important problems. But some problems are rooted in power when crafting planetary health solutions. Providing access
inequalities and can’t be solved without movement building, social to microloans (Sri Lanka, Kalimantan) or other development
action, and system change. Structural racism and intergenerational support (Madagascar, Senegal, Lake Victoria) can help jumpstart
trauma prevent many Māori from accessing health care in New income-generating activities. Poverty is an urgent determinant of
Zealand. In this case, improving health equity demands a paradigm environmental destruction. Income-generating activities can help
shift to create a health system that reflects Māori cultural values, families overcome cycles of poverty that perpetuate the feedback
ways of knowing, and relationship with the natural world. In loops between environmentally-destructive behaviors and human
Indonesia, although better science was necessary to quantify the health concerns.
true health burdens associated with biomass burning, success
came in part by organizing restoration efforts at a grassroots level. Further, several of the cases emphasize the role women must play
Mangrove protection in Sri Lanka would not have been possible in livelihood activities. Much of our world is still a patriarchy, and
without recognizing the agency of local fisherfolk communities planetary health interventions are an opportunity to elevate the
and elevating the role of women in households. The stories shared role of women in society to the benefit of all. This is most clear in
in this anthology demonstrate the ability for planetary health the stories shared from Kalimantan, Guatemala, Sri Lanka, and
interventions to correct for these historical power imbalances. the Lake Victoria region.

Unique Context, Unique Solution

The cases included in this anthology are at varying stages in their
solution-finding process. While there are many best practices that
can be adapted in other parts of the world, each context requires
a unique solution. The stories in this anthology demonstrate that
solutions must closely consider the cultural, governance, economic,
and social realms—the mediating factors outlined in Figure 1.
Each of these layers influences the way a solution is implemented
and perceived in any one community.

Indeed, there’s not even a single solution for any one context.
Many of these cases caution against a “silver bullet” solution that
can easily solve all the problems at hand. In Senegal, for instance,
planetary health practitioners are looking at prawns as one option
in an ever-evolving “portfolio of solutions.” Similarly, the project
highlighted in the Fiji case is looking at the many interventions
that need to take place at various scales in order to restore river
catchment health and reduce water-borne disease.

Circular Economy
A key element of the Great Transition will be a significant
reduction in waste flows and the reuse and recycling of materials.
An impactful example can be found in Santiago, Chile, where the
wastewater agency is turning sewage into a source of clean energy,
Women in northern Sri Lanka sign off to receive a microloan from the Sri Lanka Mangrove Conservation Project. fresh water, and fertilizer for surrounding fields. Similarly, the
20 21
 MealFlour is an NGO in Guatemala that
use of a popular phone app in Europe allows tens of millions of is improving local food security using
consumers and tens of thousands of retailers to divert healthy edible mealworms.
food from landfill, redirecting it to a new customer base. This,
in turn, saves money for consumers, provides new revenue for
business owners, and reduces pressure on the planet. Across
manufacturing, food systems, the built environment, and other
domains, rethinking practices to dramatically reduce waste and
encourage reuse and recycling of materials is a critical tenet of
planetary health.
Matthew Bannister, a Too Good To Go
waste warrior uses the food waste app to
buy lunch in central London.

Innovation, Technology, and Knowledge

Scientific and technological innovation is critical in achieving
planetary health. Innovative use of biofactories in Chile’s capital
city has turned sewage treatment into a source of energy, clean
water, and fertilizer for surrounding farms. Use of a mobile phone
app in Europe is reducing food waste at a retail and consumer
level. Research on river prawns in the Senegal River Basin led to
an intervention to control schistosomiasis while simultaneously
providing a new source of income and nutritious food for
communities. All three innovations have the ability to be scaled
and replicated in other parts of the world.

Behavior Change But these case studies also urge readers to expand their views
The Great Transition will also require behavior change as of what constitutes innovation, technology, and knowledge.
people around the globe learn new ways of living. Whether it is Innovation doesn’t always mean building something from
loggers transitioning to new livelihoods (Kalimantan) or school nothing, nor does it need to be high-tech. In Sri Lanka, traditional
children learning to cook plant-based meals (Germany), the Great brushpark fishing techniques have been passed down through
Transition will require investment in education and training. In generations. This practice was refined around the sustainable use
some cases, behavior change requires engaging traditional habits of mangrove ecosystems and the behavior of local fish species,
in a new way (farming mealworms in Guatemala as a source of confirming the immense environmental knowledge held by local
nutrients), creating technologies (Too Good To Go app in Europe), communities. Local customs and protocols in Madagascar, Fiji, and
and elevating collective action to build power (Māori action around New Zealand have also guided the interactions people have with
creating a healthcare system that incorporates their cultural their surroundings, and often it is the breakdown of traditional
values and needs). Further, the cases emphasize that planetary knowledge or practices that leads to unsustainable relationships.
health practitioners must understand the motivators that are Innovations in support of planetary health include precision
driving environmentally-harmful activities. It’s only when these agriculture with the use of artificial intelligence and robotics, but
root causes are identified that solutions can change behaviors and they also include novel applications of agro-ecological techniques
be truly responsive to community need. that have been used for centuries.
22 23
Dodoely, a traditional healer in Gertrude, a young mother on Bussi
Antaravato, Madagascar. She produces Island in the Ugandan portion of Lake
remedies based on her knowledge of local Victoria.
medicinal plants.

A goal of these cases is to help the next generation of planetary The Anthology Beyond immersing readers in inspiring stories from around
health practitioners and scholars recognize the many linkages as a Teaching and the world, this anthology aspires to create structured learning
between human health and changes to Earth’s natural systems. Learning Resource opportunities to ensure readers effectively connect theory with
But another aim is to have readers begin to reflect on the humility, practice, knowledge with reality. In conjunction, the anthology
compassion, and care we must have for one another—skills that seeks to impart the knowledge, skills, and attitudes relevant to
aren’t always taught in the classroom. Some of these stories planetary health practice that students will need in order to
may be difficult to read. They demand people question their integrate these competencies into solution-driven actions in the
own assumptions about “good” and “bad” and acknowledge the near future.
privileges they may hold. The cases require readers enter the
murky grey area to understand the true complexities of peoples’ As a method, case studies are transformative learning
lives. By combining scientific research and storytelling, we hope opportunities, and they are part of a well-established practice
this anthology sparks a journey driven by a sense of understanding of teaching and learning about complex situations. The case
and empathy as well as informed by data and academic rigor. study technique involves representing complexity in real-life
situations in a way that can invoke a multiplicity of perspectives
in the evaluation/analysis of the case and a creative generation/
application of solutions from the learners. The case studies in this
anthology also reflect real-life uncertainty and illustrate practical
24 25
 Cornelia Lemke, a teacher in Berlin,
and pragmatic approaches to diverse situations around the globe. Germany, has adjusted her curriculum to
As an additional layer, the cases encourage critical thinking and include greater discussion of plant-based
reflection as an essential component of the learning process, foods.
enabling the reader to acknowledge their position concerning the
geographical, historical, cultural, epistemological perspectives of
each case, and future actions based on these considerations. We
further hope to foster curiosity and the development of lifelong
learning, in addition to allowing the reader to feel empowered,
responsible, and an active part of the learning process.

Using the cases as teaching tools

Each case is supplemented with a set of assets that allows them to
become effective teaching resources. It is important to highlight
that the cases do not seek to provide definitive solutions to
planetary health challenges, but rather train learners to generate
them as a group through collaborative work and team decision-
making. To achieve this, cases are accompanied by –

For Learners:
Connections to explore further theoretical concepts within the
“Planetary Health: Protecting Nature to Protect Ourselves” textbook.
Questions and side notes that are designed to promote reflection and
further exploration of contextual and theoretical factors. Links to
resources of interest designed to promote curiosity and provide insights
for further group discussions. Objectives that allow the learner to clearly For educators:
understand the expected outcomes of the learning process. Structured teaching guides for each case study provide:
An overview of the main themes covered in each case study. Learning
objectives that can be modified according to learner levels and other
Monitoring the water level of peatlands contextual factors. Guidance on appropriately positioning each case
in Central Kalimantan, Indonesia.
within curriculum. Optional assignments or suggested background
readings for learners. Ice-breakers or similar dynamic exercises to
start each case group discussion. Questions to lead group discussions.
Recommendations to guide board plan and group discussion. Suggested
concluding remarks for group discussion.

A note for learners:

Case study methodology requires the learner become a protagonist
and take charge of their learning process. Learners are expected to
read with retention each case study, solving the reader questions,
and preparing any background readings or assignments suggested
by the facilitator. Active participation and motivation are expected
from all students during the group discussion. In addition, learners
are expected to:
26 27
Become familiar with using the case method approach, including its
objectives and limitations. Connect previous knowledge and personal
experiences with each case study. Synthesize perspectives in a way that
is understandable to others. Listen comprehensively, critically analyze,
and evaluate the conclusions and opinions of others. Motivate others
to speak up and present their ideas, as well as be respectful if they
choose not to do so. Respectfully rebut opposing views of their peers or
instructor. Analyze situations from multiple perspectives and propose
solutions based on complex analysis. Work collaboratively in groups
when required.

A note for educators:

The case study method requires the educator become a facilitator.
In preparing for the case discussion, the facilitator must review each
case and the subject matter in detail until they feel comfortable
leading the discussion. Once leading the group discussion, they
must actively influence the learning process by encouraging
critical thinking, reflection, synthesizing students’ perspectives,
accommodating divergent understanding, and negotiating within
multiple frameworks of knowledge. The instructor must be aware
not to impose their views and should allow for learners to reach
a consensus within the group discussion. Facilitators are also
expected to:

Establish guidelines for appropriate group discussion. Urge learners

to strive for comprehensive, nuanced, and critical answers, and avoid
simplistic positions. Connect theoretical underpinnings with emerging
themes and perspectives from the group. Embrace and capitalize on
the diversity of opinions and new ways of thinking about the challenge
being addressed. Motivate participation and balance distinct voices
from within the group. Keep a cordial environment for debate and the evaluation of a variety of other essential learning outcomes Andy Chamberlin and Dr. Susanne
divergent perspectives. Maintain a dynamic and engaging discussion relevant to liberal and civic education, and those particularly Sokolow with Stanford University use a
drone to map water access points in the
with appropriate timekeeping. Maintain a cordial and egalitarian relevant to planetary health practice. We suggest the facilitator Senegal River Basin.
relationship with students. Prepare for uncertainty and acknowledge also evaluate students on the following domains: critical
what is not known. Seek opportunities to bring out broader themes thinking, creative thinking, problem-solving, inquiry and analysis,
related to planetary health (like those described above) that run through intercultural knowledge and competence, ethical reasoning,
several cases oral communication, quantitative and information literacy, and
teamwork. The Association of American Colleges & Universities
A note for evaluating student performance: has developed adaptable rubrics for each of these domains: VALUE
As with other aspects of the learning process, students should be (Valid Assessment of Learning in Undergraduate Education)15.
evaluated based on clear criteria established beforehand by the The VALUE rubrics enable educators to evaluate students in
instructors. It is important to highlight that beyond theoretical a transparent and adaptable fashion and may be useful as an
knowledge and participation, the case study method allows for assessment tool.
28 29
 Bibliography

1 Roser M, Ortiz-Ospina E. Our World in Data Extreme Foundation&#x2013;<em>Lancet</em> Commission on

Poverty. 2018; https://ourworldindata.org/extreme-poverty. planetary health. The Lancet. 2015;386(10007):1973-2028.
Accessed April 2020.
14 Raskin P. Journey to Earthland: the Great Transition to
2 Roser M. Our World in Data Life Expectancy. 2018; https:// Planetary Civilisation. Cambridge, Massachusetts: Tellus
ourworldindata.org/life-expectancy. Accessed April, 2020. Institute; 2016.

3 Roser M, Ritchie H. Our World in Data Child Mortality. 15 Rhodes, Terrel. Assessing Outcomes and Improving
2018; https://ourworldindata.org/child-mortality. Accessed Achievement: Tips and Tools for Using Rubrics. Washington,
April 2020, DC: Association of American Colleges and Universities. 2010.

4 Roser M, Ortiz-Ospina E. Our World in Data Literacy. 2018;

https://ourworldindata.org/literacy. Accessed April 2020.

5 Foley JA, Defries R, Asner GP, et al. Global consequences of

land use. Science. 2005;309(5734):570-574.

6 Postel SL, Daily GC, Ehrlich PR. Human Appropriation of

Renewable Fresh Water. Science. 1996;271(5250):785-788.

7 FAO. The state of world fi sheries and aquaculture—

opportunities and challenges. Rome: Food and Agriculture
Organization;2014.

8 Dams and Development: A New Framework for Decision-

Making. London: World Commission on Dams; November
2000.

9 Barbarossa V, Schmitt R, Huijbregts M, Zarfl C, King

H, Schipper A. Impacts of current and future large dams
on the geographic range connectivity of freshwater fish
worldwide. Proceedings of the National Academy of Sciences.
2020;117(7):3648-3655.
Three residents of Naqarawai village in Finally, we acknowledge that this anthology and its teaching
the highlands of Viti Levu, Fiji. 10 IPBES. Summary for policymakers of the global
notes are neither exhaustive nor definitive; nor are they a perfect
assessment report on biodiversity and ecosystem services
representation of every situation or perspective. These cases were of the Intergovernmental Science-Policy Platform on
written based on interviews conducted in 2018-2019, and certain Biodiversity and Ecosystem Services. . Bonn, Germany: IPBES
situations and approaches will likely shift with the passage of time. secretariat;2019.
Innovation is meant to be challenged and revised. We encourage 11 WWF. Living planet report 2014: species and spaces,
anyone using this anthology to adapt it to their unique situations people and places. Gland, Switzerland: World Wide Fund for
or objectives, as well as to provide the Planetary Health Alliance Nature;2014.
with timely feedback for future editions. The anthology should be
12 Myers SS. Planetary health: protecting human health on a
a starting point for anyone looking to engage in any of the many rapidly changing planet. The Lancet. 2017;390(10114):2860-
fields that represent planetary health and as part of a continuum 2868.
for the creation of the next generation of planetary health scholars
13 Whitmee S, Haines A, Beyrer C, et al. Safeguarding human
and practitioners. health in the Anthropocene epoch: report of The Rockefeller

30 31
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
01
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Health
Duff H., Faerron Guzmán, C., Almada, A., Golden, C.,
and Myers, S. “Health and Haze: A Science-Driven Policy
Approach to Southeast Asia’s Annual Occurrence.”
Planetary Health Case Studies: An Anthology of Solutions.
2020; https://doi.org/10.5822/phanth9678_1

Please note this work is licensed under a Creative Commons

Attribution-NonCommercial-NoDerivatives 4.0 International

and Haze
License. To view a copy of the license, visit https://
creativecommons.org/licenses/by-nc-nd/4.0/

To access the full Planetary Health Case Studies: An

Anthology of Solutions, please visit https://www.
planetaryhealthalliance.org/case-studies

A SCIENCE-DRIVEN POLICY APPROACH

TO SOUTHEAST ASIA’S ANNUAL OCCURRENCE
 Executive Summary This case study explores how an anthropogenic haze episode
Themes from this case study are
in September and October 2015 contributed to 100,300 excess
explored in greater detail in the land premature cardiopulmonary disease-related deaths in Southeast
use section of chapter 4 and the Asia, with a focus on Indonesia, Singapore, and Malaysia. It will
non-communicable disease chapter
7 as well as the discussion of air
look at how historical and present-day land use and land cover
pollution in the energy chapter 12 of change (LULCC) practices on peatland areas altered ecosystems
↘ Planetary Health: Protecting Nature and influenced the vulnerability and severity of the 2015 event.
to Protect Ourselves.

The case study will also outline how the Indonesian government
Learning Objectives has addressed this issue: with the creation of new policies and
After examining this case, students the establishment of a government agency to manage and restore
should be able to: peatlands. Collaborating with groups across the country, as well
as with international researchers, that government agency is
➀ Analyze the underlying driving
forces of haze events. using a multi-tiered approach to address the complex drivers that
contribute to peatland fires. Included in that approach is the use
➁ Appraise the short- and long-term of a new tool that allows policymakers to link land use scenarios,
health effects of haze events.
associated fire emissions, and long-term health consequences into
➂ Explain the importance of the foreseeable future.
multidisciplinary and multi-sectoral
actions when facing planetary health
This case study is based on interviews conducted in Jakarta and communities across
challenges, specifically haze events
prevention and peatland restoration.
Central Kalimantan in August 2018.

➃ Evaluate how determinants of

health frameworks can guide problem
analysis and the solution design
process.

➄ Apply principles of good

governance, equity, and evidence-
informed policy in the face of
planetary health challenges.

35
Introduction On this humid day in August 2018, the Badan Restorasi Gambut Hanging in the BRG office is a photo of President Joko Widodo,
(BRG) office in Central Jakarta is buzzing with activity. If the BRG Indonesia’s leader since 2014. President Jokowi, as he’s commonly
(the Peatland Restoration Agency in English), had a busy season, referred, established the BRG as his first presidential decree of
this would be it. August is the mid-way point in Indonesia’s 2016, and the agency is overseen by his office. Its establishment was
dry season, a period that stretches from June to October each a bold statement marking the political seriousness with which the
year. With those months comes a history of haze—the dense air issue is now regarded—and the international pressure that urged
pollution that drifts over much of Indonesia and other Southeast its creation.
Asian countries as a result of smoldering, human-caused peatland
fires. In 2015, that international pressure was intense. Photos of
Indonesia’s red-and-yellow tinged skies captured headlines
BRG’s mission is to reduce haze by facilitating the restoration worldwide. “Southeast Asia, Choking on Haze, Struggles for
of more than 20,000 square kilometers of peatland. They also a Solution,” proclaimed The New York Times. “Indonesia’s fires
coordinate the sustainable management of those ecosystems labelled a ‘crime against humanity’ as 500,000 suffer,” declared The
with many levels of government, organizations, and communities Guardian. Images captured by NASA satellites show a dense cloud
across Indonesia. of smoke blanketing the region during September and October
2015,1 the period in which 68% of all active fires were detected.2
Today, that mission is still a work in progress. A newspaper
headline announces the number of hot spot fire areas in Central Dense clouds of smoke seen over the
Kalimantan, one of Indonesia’s most fire-prone provinces. Along island of Borneo in September 2015.
Photo via NASA Earth Observatory.
the capital city’s notoriously traffic clogged streets, every other
person riding an ojek motorbike taxi has their face covered by a
mask. While caused by vehicle pollution rather than peatland
fires, today’s hazy scene is a small glimpse into what thousands
in the country face year-after-year. In both cases, face masks offer
inadequate protection.

A family riding a motorcycle through the

thick air and smoke from peat fires in
October 2015. Outside Palangka Raya,
Central Kalimantan. Photo by Aulia
Erlangga, CIFOR; cifor.org

36 37
 Pak Budi is the Deputy Head of
What is striking about these satellite images is that the smoke hangs Planning and Coordination with Badan
heaviest not over the burning areas, but those regions downwind Restorasi Gambut (BRG), Indonesia’s
in Indonesia and, to a lesser extent, in neighboring countries. In Peatland Restoration Agency. That
agency was created in response to 2015’s
Malaysia, Members of Parliament called for the government to
transboundary haze event.
adopt regulations that could be used to take legal action against
companies responsible for creating the haze3 —similar regulations
had already been passed in Singapore. Indonesia’s environmental
crisis was the plight of the region and the talk of the world.

This was the media and political climate that surrounded President
Jokowi in December 2015 as he attended the United Nations Climate
Change Conference, COP21, in Paris. The fires of the previous
three months were finally being extinguished by monsoon season
downpours, but not before they had scorched through 26,000
square kilometers of Indonesian land. The cause had already
been identified: human-triggered fires set as an inexpensive way
to clear land for agriculture. A 2015 World Bank report laid out
the short-term impacts of the event: the haze had forced weeks of
school closures, grounded airplanes, and caused thousands to fall
sick across the region.4 Early estimates placed the initial economic Using their diverse backgrounds, the team more recently combined
i A detailed breakdown of this cost of that year’s haze at US $16 billioni —twice the amount that fire emissions inventories, satellite monitoring, chemical transport
estimate is included in the full World it took the country to clean-up the devastating 2004 tsunami.5 models, and epidemiological data. The result was a framework
Bank report (see above). It includes
losses of US $399 million in the This estimate does not account for the long-term health costs of to determine which peatland areas should be prioritized for
tourism sector, US $372 million in sustained haze exposure nor the loss of biodiversity and ecosystem management in order to prevent the greatest number of downwind
the transportation sector (including services. health effects in the future. Another takeaway was that preventing
shipping), and US $151 million in
immediate health costs. Overall, the haze-related deaths demanded more than a reactionary response.
costs represented 1.9% of Indonesia’s “The creation of BRG was the response of the president to stop The team concluded that an effective long-term solution would
2015 Gross Domestic Product.
and prevent fire, haze, and further peatland degradation. It was require shifts in land use management in order to target the root
also because of the international concerns to the republic,” says cause of the haze.
Pak Budi Wardhana, the agency’s Deputy Head of Planning and
Coordination. “During the Paris COP21 [in December 2015], the This long-term view of prevention and mitigation resonates with
President made a commitment to the international community the BRG. “The World Bank study only covered five months of the
that Indonesia will take every measure, and will set up an agency disaster. It wasn’t really looking into the long-term effect of the
that focuses on peatland restoration. That was the seed of health problems,” says Pak Budi of the 2015 report. “Those health
establishing the BRG.” effects will add more cost to the government, so with [the SMOKE
Team’s studies] we can provide the government with a compelling
The need for peatland restoration became more apparent the argument that the sustainable management of peatlands is much
following year. Research published by Harvard and Columbia more important, rather than just restoring it.”
University researchers linked the haze exposure in September and
October 2015 to 100,300 excess deaths in Indonesia and neighboring Addressing the causes of the 2015 haze event demanded Indonesia
ii How are excess deaths calculated? countries of Malaysia and Singapore.6ii That research was conducted take a dive into its long history of fires. While the public health
Why is this measure useful? ↘ Learn by a multidisciplinary group of scientists, medical professionals, toll of the 2015 dry season was the first to be carefully quantified,
more here
and policymakers who called themselves The SMOKE Team. similar episodes have been occurring for decades.
38 39
 The waterlogged appearance of a
healthy peatland forest in Central
Kalimantan. Photo by Nanang Sujana,
CIFOR; cifor.org
40 41
Southeast Asia and With a land area of 1.9 million square kilometers, the Republic of Peatlands: The World’s Carbon Bank
a History of Haze Indonesia is the largest country in Southeast Asia. It’s the fourth Peatlands are a wetland ecosystem created when trees and other
most populous country in the world, and its 264 million inhabitants organic matter have partially decomposed in a water-logged,
live across a sprawling archipelago of more than 17,000 islands. oxygen-poor environment.iv The result is a thick layer of wet, iv Are there peatlands in your country
organic material, ranging from half a meter to 20 meters in of origin? Are they protected or
sustainably managed? What policies
Seasonal haze is an annual problem in Indonesia and across the depth.9 Having existed on our planet for around 360 million years, surround these ecosystems in your
region, although severity varies from year to year. So common is the the oldest peatlands store carbon captured thousands of years country?
issue that it’s looked at as an inevitable event expected every year ago.10 ↘ Watch: An introduction to peatland ecosystems video from
around the dry season. The past two decades alone have provided the BRG
plenty of cause for concern, with severe fires in 1997-98, 2006, and
2013 making headlines long before the events that transpired in Despite covering just 3% of the Earth’s surface,11 peatlands store
2015. Fire activity has historically been most severe on the islands of more carbon than all other ecosystems combined.v The majority is v What other ecosystems store large
Sumatra and Kalimantan, the Indonesian portion of Borneo island. stored in tropical peatlands, most of which are found in Indonesia amount of carbon compared to their
total surface? ↘ Find out here
Fires that burned through the Indonesian and Malaysian Borneo in and Southeast Asia.12
1982-83 remain the largest on record, with 50,000 square kilometers
iii Roughly the size of Costa Rica, or scorched.7iii Primary, logged, and secondary forests contributed to Peatlands store carbon through a process called carbon
Alabama. As reference, the Amazon more than half of the total area burned in these years.8 sequestration. Rather than allowing decaying vegetation to release
fires of 2019 burned around 10,000
square kilometers carbon into the atmosphere, peatlands contain and hold this
Experts say the government response to these fires has historically carbon over the long-term, reducing the amount of carbon dioxide
been underwhelming. “When the cases happen then the (CO2) circulating in the atmosphere. The release of CO2 into the vi Which countries emit more net total
government is very busy and concerned about this situation, but atmosphere is the main contributor to climate change. This can carbon dioxide and other greenhouse
gases? How about per capita
after the haze passes then it’s business as usual,” says Dr. Budi happen from the combustion of fossil fuels, and also through the emissions? What is surprising about
Haryanto, an environmental epidemiologist at the University of burning of carbon rich ecosystems such as peatlands.vi this data? ↘ Find out more here
Indonesia’s Research Center for Climate Change. “The Indonesian
government was in denial when the [2015 SMOKE Team] study
came out, but for me, I believed it because I have been looking at
the health findings associated with haze and air pollutants for The Issues Beyond Burning
many years.” Burning peatlands emit large amounts of carbon dioxide (CO2). But even non-burning peatlands emit CO2
through a process called oxidation. Peatland oxidation happens when dried peatland is exposed to the sun,
While the miniscule particles that cause haze can be generated by releasing the carbon that’s been previously sequestered in the form of CO2.
coal burning factory emissions, traffic pollution, and road dust,
the haze events that so frequently occur in Southeast Asia are Oxidation will continue unless peatlands are rewetted to ground surface level, says Marcel Silvius, a peatlands
produced by vast, human-triggered fires. What made the 2015 fires expert with the Global Green Growth Institute in Indonesia. Current regulation classifies peatlands as rewetted
so harmful to public health was not only that a large area burned— when the water table sits no more than 40 centimeters below ground surface level.
but the length of time that the fires smoldered, and the material
that was set ablaze: peat. Paired with the issue of oxidation is the risk that comes when peatlands subside—organic matter that had been
previously propped up by natural water levels sinks once that water has been drained. Peatland subsidence
is a significant issue in the Netherlands, Silvius’ home country, where water has been pumped from the
peatlands for several centuries to allow for continued agricultural development. “Half of the Netherlands lies
below sea level as a result of the oxidation of peatlands over the centuries,” says Silvius. In 2016, the country’s
Environmental Assessment Agency found that the continued subsidence of peatlands in the Netherlands will
cost taxpayers between €1.7 billion and €5.2 billion from the date of publishing until 2050.13

42 43
 “In the Netherlands, dykes have been built along the coast and the rivers, and we let farmers continue their Water-logged peatlands must be drained in order to be used for
unsustainable business even though it costs society huge amounts of money,” expands Silvius. “[One hundred farming—an act that dramatically increases the land’s susceptibility
thousand square kilometers] of peatland in Indonesia is going to face the same problem and subside. In the to fire.18 Draining is most easily done by digging a series of deep
Netherlands, the rate of subsidence is 1-2 centimeters a year. It happens much faster in tropical locations, canals beneath the peatland. Once drained, remaining peatland
at a rate of 3-6 centimeters annually.” The long-term risk, Silvius says, is when the ground level subsides to vegetation is cleared by setting fires—the fastest and most cost
sea-water level: “Indonesia would have to build thousands of kilometers of coastal and river dykes to prevent effective way to prepare land for new growth. This method is
flooding and keep that land arable and livable. It’s an issue of huge financial, economic, and social proportions.” referred to as slash and burn agriculture. The ash cover that
settles after burning provides a nutrient-rich layer for new crops
which offers short-term benefits for farmers.19 Those nutrients,
An area of peatland near the Trans-
Kalimantan Highway in Central however, are short-lasting, and slash and burn agriculture leads
Kalimantan—this area was scorched to detrimental long-term effects, including soil degradation, loss
during the 2015 fires. of habitat, soil erosion, water contamination, and, in the case of
peatlands, deadly haze. Slash and burn is the traditional method
used by Indonesian farmers annually to prepare their land for the
approaching rainy season. While these slash and burn fires are
deliberate and their area planned, blazes can sometimes burn out
of control, and “escape fires” create damage on neighboring land.x x Is slash and burn used in your
country? Are there sustainable ways
of doing slash and burn? Why or why
In their natural state, peatlands are moist and non-flammable. not? Are there policies in your country
Once drained, however, they become tinderboxes of organic in this regard?
material. Fires that spread from slash and burn sites to areas of
surrounding dried peat become virtually impossible to extinguish.
As they burn, centuries worth of CO2 and other greenhouse gas
emissions are released into the atmosphere—10 times more CO2
than the amount released by forest fires.20 The depth of peatlands
means that while fire crews can tame surface-level fires, the thick
carpet beneath can continue to smolder for weeks until monsoon
While providing valuable ecosystem services like carbon rains finally dampen the blaze. The effect is eerie: tracts of land
sequestration, water storage and regulation, habitat for biodiversity, where you see no fire, only the huge clouds of smoke that billow
and nutrient cycling,14 tropical peatlands have experienced decades from within.
vii Kalimantan is the name for the of land use and land cover change (LULCC). This is especially true
Indonesian portion of Borneo island. in Sumatra, Kalimantan,vii and Papua, the three Indonesian islands
Borneo is shared by three countries,
including Malaysia (an area known as with the greatest peatland area.15 Human activity on Indonesia’s
the Malaysian Borneo) and Brunei. peatlands began in the 1980s, with extensive land conversion
by large-scale concessions and small-holder farmers leading to
viii Another case study in this
anthology focuses on deforestation deforestationviii and peatland degradation. Between 1990 and 2015,
and illegal logging in Kalimantan, Sumatra, Borneo, and Peninsular Malaysia experienced a 47%
with a focus on the lowland rainforest decline in peat swamp forest area.ix There was a growing demand
around Gunung Palung National Park
in West Kalimantan. for arable land and the flat topography of peatlands made them
an easy target for production.16 As of 2015, industrial plantations
ix Peatlands that have not been and small-holder farms cover half of all former peatland areas in
drained and deforested. Sumatra, Borneo, and Peninsular Malaysia.17

44 45
 The contrast between an area of burnt
peatland (left) and regrown peatland
(right). Though a valuable carbon bank,
peatlands are often perceived as wasted
space and are cleared and drained
to make way for more “productive”
activities.
46 47
The Burning of 2015 This was the scene in much of Indonesia during the 2015 haze mile away, and it became more of a question of what people on the
event. ground were supposed to do with that information,” says Koplitz.
Both meteorological phenomena are associated with reduced
In Gohong Village, Central Kalimantan province, village secretary dry season precipitation and exacerbate the risk of drought in
Pak Anang Sogito remembers not being able to see beyond two landscapes that have become highly flammable because of human
meters. If he had been able to see, he would have witnessed alteration.
devastation—village records say the 2015 fires burned through
more than 150 square kilometers of land. “We lost our sources of
food and our economy was totally damaged. The income decreased When Meteorological Systems Meet
for all of the villagers,” Pak Anang says.
Two meteorological systems played a role in creating the ideal setting for 2015’s haze events: the coupling of the
At the time, the residents of Gohong Village took the only action El Niño Southern Oscillation (ENSO) phenomena and a positive Indian Ocean dipole.
they could: they attempted to extinguish the fires using traditional El Niño conditions* occur in the Pacific Ocean basin, and mean less rain on the western side of the basin,
methods. Those methods involved isolating fire areas by digging including in Indonesia. The El Niño phenomenon in 2015 was the strongest on record since 1997.21 These dry
four-meter-deep wells into the ground to limit their spread, just as conditions increase the flammability of landscapes as plants lose their leaves and lower their moisture content.22
firefighters may clear cut part of a forest to prevent the growth of
a wildfire. This method worked to contain some blazes, but many The Indian Ocean dipole operates in the ocean basin of the same name. Like the Pacific Ocean, the Indian Ocean
more times the depth of peat meant fires would spread unseen has a variance in temperature, with warmer sea surface temperatures around Indonesia typically leading to more
beneath the surface. “We all fought until we reached our limit, precipitation. A positive Indian Ocean dipole, like the one in 2015, brings less precipitation.
using big cans of water to make the peatland wet,” Pak Anang
describes. “But it didn’t solve the problem because it was just the “When you have both of those systems operating in unison it is a double whammy for drought, and that’s what
top of the peatland that was wet.” happened in 2015, 2006, and 1997,” says Koplitz. Scientists are still actively looking into how the ENSO and dipole
systems interact with one another, as well as the effect climate change could have on these systems.
Gohong Village is located in Pulang Pisau, a priority area for the
BRG. More than half of the region is peatland, and the regency was
particularly affected by the 2015 fires. Draining of the peatlands in Unlike other places where fires are a natural part of the ecosystem, *The Pacific Ocean is where the El
Niño Southern Oscillation (ENSO)
this area began in the 1980s when the government constructed the the ecology and climate of Indonesia rule out meteorological system occurs. The ENSO controls
3,900-kilometer Trans-Kalimantan Highway that runs across the conditions alone as the cause of the 2015 fires. “In the humid tropics much of the year-to-year variability
in the areas surrounding the Pacific
island. The drainage canals that were built created transportation like Southeast Asia, fires don’t generally occur unless there are Ocean, including precipitation
channels allowing villagers to reach once inaccessible parts of people setting them,” explains Dr. Ruth DeFries, an environmental patterns, winds, and storm systems.
the island. As a result of this practicality, more canals were made, geographer at Columbia University. A member of The SMOKE The Pacific Ocean basin has a
variance in temperature, an in non-El
further drying peatlands. “At first it helped us reach new land, but Team, DeFries has worked at the intersection of fire, deforestation, Niño years, the eastern side of the
after a lot of canals were built it affected us, especially during the and air quality for the better part of three decades. In 2015, it was basin is cooler than the western
long dry season,” Pak Anang explains. the combination of meteorological systems and individual and side. This is why the western United
States experiences dryer weather,
industrial land use that created the setting for a destructive fire and countries in Southeast Asia
At a global scale, atmospheric scientists knew 2015 would be a season. By September and October 2015, the height of the year’s experience more rain. During an El
problem. “Everyone who was paying attention to fires knew it burning season, the Global Fire Emissions Databasexi had detected Niño system, that gradient in ocean
temperature lessens, leading to less
was going to be a bad year by late July, August,” says Dr. Shannon more than 100,000 active fires across Indonesia.23 precipitation on the western side of
Koplitz, an atmospheric scientist on The SMOKE Team. For one the basin.
thing, 2015’s dry season followed a similar pattern to previous
xi Check out real time data on global
fire years. “We were watching that El Niño index creep up, and a fire emissions ↘ here. What can you
positive Indian Ocean dipole index creep up, too. You could see it a conclude from this map?

48 49
 The emissions produced by those fires was intense. For a three According to the 2016 research published by The SMOKE Team,
week stretch, Indonesia’s peatland fires produced more daily CO2 the 2015 haze accounted for 91,600 excess deaths in Indonesia.
xii 15.95 mega tons is the U.S. than the average daily emissions of the entire United States.xii Neighboring countries of Malaysia and Singapore faced 6,500
daily average. The United States
is the world’s largest producer of By the end of the 2015 fire season, 4 teragrams (4 million tons) of and 2,200 excess deaths respectively. That’s because haze is a
greenhouse gas emissions. emissions had been emitted between July and October.24 After just transboundary environmental issue,30 meaning the pollution
a few months, Indonesia’s CO2 emissions were on par with the is so thick and dense that its concentration downwind remains
amount of fossil fuel-attributed emissions generated by countries high enough to create health impacts. That includes in densely
xiii What is a GHG equivalency? Why like Japan and India over the course of an entire year.25xiii More populated urban centers such as Singapore and Kuala Lumpur,
is it useful? ↘ Explore more here than three quarters of all emissions came from Kalimantan and Malaysia.
South Sumatra, the islands most badly burned.26
Ultimately, it was those living in close proximity to the peatland
xiv Do you think your actions might be
affecting the severity of haze events in While the impact on the global climate was concerning, more dire fires who experienced the worst health effects. That includes Pak
Indonesia? Why or why not? still were the serious health effects being faced by millions.xiv Tuberyono and his 45-day-old granddaughter, and other people
living in Central Kalimantan province. Dr. Mual Bobby had been
working as a pulmonologist at RSUD Doris Sylvanus the largest
The Health Toll of Haze It’s a beautiful clear day in Palangka Raya, the capital city of Central state-run hospital in the province, for six years when the 2015 haze
Kalimantan province. The windows and front door are wide open began. During a normal shift he would see around 100 patients,
on Pak Tuberyono’s home, a very different sight from 2015. That but in 2015 he was treating up to 500 a day. The hospital faced so
year, he and his family were trying to make their house as airtight much demand for treatment that it turned away patients for three
as possible to prevent haze from seeping in. “Where the wind could weeks in September and October, admitting only those who would
come in, the haze could also come in,” Tuberyono remembers. The receive treatment while sitting on the floor.
average Indonesian home is rarely airtight, and outside air and
pollutants can waft in through gaps in floorboards and ventilation “It was especially bad for people with asthma and elderly people
Dr. Mual Bobby is a pulmonologist in
slots above windows. with chronic obstructive pulmonary disease (COPD),” says Dr. Palangka Raya, Central Kalimantan.
Bobby. “Every day their lung function decreased, and this happened He would see as many as 500 patients a
The birth of Tuberyono’s third grandchild, Ratu Agnesia, had faster during the haze situation. They were in terrible condition. day during the haze events in September
and October 2015 — sometimes treating
aligned with the start of 2015’s haze season. A healthy baby girl, I was giving them the anti-inflammatory medication [for asthma people lying on the ward floor when all
Ratu Agnesia’s life was cut devastatingly short when she developed and COPD] and oxygen but that didn’t change their condition.” the beds were occupied.
an acute respiratory tract infection, an ailment the hospital
confirms was caused by the haze. “It was very fast. It started with it Like homes, hospital buildings in tropical climates are rarely
being hard for her to breathe, then we asked for medicine from the airtight. Open architecture allows for natural ventilation, but in
midwife,” Tuberyono recalls, staring out the window. “We brought 2015 it meant the haze could drift in and hang above the wards
her to the hospital but it wasn’t long before she passed away.” Ratu where patients were being treated in the beds below.
Agnesia was just 45-days-old.
It was a similar scene in the local puskesmas clinics, the community-
Tuberyono and his family weren’t the only ones who sought health units that provide first-response primary care for outlying
medical help during the 2015 haze. Indonesia-wide data found urban areas and rural villages in Indonesia. “We started from 8
that the percent of children under five diagnosed with pneumonia a.m. and would usually end at 10:30 a.m., because our vision would
during a hospital visit jumped from a baseline that had historically be blurred if we worked earlier or later in the morning. I remember
ranged from 23-29% to 63% that year.27 Global data indicates that that breathing made us weak,” says Dr. Yulitha Christiana, who
xv Why are children most affected by children under the age of five and adults over 60 are the groups worked in a puskesmas location at the edge of Palangka Raya. Dr.
haze? most impacted by air pollution.28xv Pollution-related mortality Christiana also saw patients in her home clinic. “Here I had oxygen
disproportionately occurs in low and middle income countries, of available for patients. I blocked the door with a wet towel, but it
which Indonesia is one.29
50 51
 could still not free us from the haze,” she recalls, adding that it
was virtually impossible to find oxygen canisters in September and
October. They were sold out across the city.

So bad was the haze that Stefani Koseanto and her mother left their
home in Palangaka Raya for Jakarta. Prior to leaving, Koseanto
had been going through a morning ritual: waking up in a day dark
as night and posting photos on her Facebook page. Those photos
included screenshots of the city’s Pollutant Standards Index (PSI)
and the color of the sky outside her window, shades that shifted
from a sepia yellow to an alarming red. On many days the PSI was
higher than 2,000. A healthy figure is 0-50, with anything beyond
301 considered hazardous.

Koseanto has asthma, and had been taking five times the normal
dosage from her inhaler. Her father, a doctor in the city, eventually
suggested she evacuate. “The air was so thick in my room. I used
an air purifier but it didn’t help,” she said. Despite growing up in
Palangka Raya, Koseanto had never seen haze so bad. “In the past
it was white smoke, it wasn’t a yellow and red sky, and it would only
stay for a few days,” Koseanto recalled.

For Pak Tuberyono and his ailing granddaughter, the scale of the
haze made evacuation seem fruitless. “The smoke was all over the
province and in the next province—where would we go? All the
peatland was burning,” he says. Turns out the question was moot.
Tuberyono and his family wouldn’t have been able to afford to
leave even if they had wanted to.

The impact haze has on human health and well-being is a growing

field of research. A 2016 review of epidemiological studies highlights
the role automobile exhaust, haze from burning biomass, and
wildfire smoke has in COPD risk and incidence. Both short-term
and chronic exposure to haze cause respiratory symptoms, reduce
lung function, and lead to the development of COPD.31 Increased
xvi What is the global burden of risk depends on a number of factors, including the chemical
disease due to air pollution? Who is composition of the haze and the concentration to which people
more affected? ↘ Read more, and
check the status of the air you breathe are exposed. In most cases, the fine particulate matter component A student goes to school wearing a
on the State of Global Air here of haze presents the gravest health concern.xvi mask to protect him from the smoke
that blankets the city of Palangka Raya,
Central Kalimantan. October 2015.
Photo by Aulia Erlangga, CIFOR; cifor.
org

52 53
Referred to as PM2.5 because particles are less than 2.5 micrometers (μm)
in diameter, you could fit 20 fine particulate matter particles across the
width of a single human hair. “PM2.5 in particular is a health concern
because it’s so small it can go deep into our lungs,” explains Jonathan
Buonocore, a Harvard University-based epidemiologist, environmental
health expert, and member of the multidisciplinary SMOKE Team. From
there it can cross the lung-blood barrier and get into the bloodstream.
Samples taken from the September 2015 peatland fires in Indonesia
found that 81.6% of all particulate matter was less than 2.5 μm in size.
That size, combined with the chemicals that composed the particulate
matter, made the episode particularly harmful to people’s health.32
According to the WHO, fine particulate matter is the most harmful form
of air pollutants, a broad category accounting for the anthropogenic
chemicals generated by industry, transportation, and households.33

Peatland fires in Indonesia are particularly hazardous, emitting

a cocktail of up to 90 chemicals, including toxic gases such as
formaldehyde, carbon monoxide, and ammonia.34 These chemicals
are invisible to the naked eye until the fine particulate matter binds
together to create haze. Research is currently underway to differentiate
the chemicals that come from Indonesia’s peatland fires versus other
types of urban air pollution.

Despite the global literature establishing the health impacts of air

pollution and haze, local governments still seek ‘local data’—in this
case, research gathered and published in Indonesia. To address the
desire for local data, UNICEF commissioned a 10-year epidemiological
time-series study to look at seasonal spikes in air pollution and health
outcomes in the country. Based on data from health facilities and air
quality monitoring devices in affected areas, the study demonstrated the
impact of haze on respiratory health. It also highlighted the limitations
that come with relying on public health data.

“We found that the cases recorded at health centers did not reflect
the true caseload or the long-term burden of disease,” says Richard
Wecker, a Risk Reduction Specialist in UNICEF Indonesia’s Disaster
In 2015, activists in Palangka Raya,
Management, Climate Change Adaptation & Mitigation portfolio. He Central Kalimantan put masks on city
says collecting data for the 10-year study was costly time-wise and statues as a symbol of protest against
financially, and that the satellite data and modelling methods used by peatland fires. Photo by Aulia Erlangga,
CIFOR; cifor.org
The SMOKE Team may be more accurate and cost-effective. “However,
this information is not always as compelling to stakeholders, so we
need a balance,” Wecker says, referring again to the need for local data
to show Indonesian policymakers.
54 55
 Attempted Health Interventions The Role of Land Use The role individuals versus industry play in Indonesia’s peatland
Various health-focused interventions were implemented with little Management fires is a contentious topic. On one side is the large oil palm,
success during the 2015 haze. “During the peak of the fires, most timber, and logging companies that have shaped the landscape
agencies including the government were helpless to do anything of Southeast Asia for decades. Fly over many Indonesian islands,
beyond band-aid measures to protect the health of people,” says but especially Kalimantan and Sumatra, and you’ll notice the
Richard Wecker. “You could not possibly evacuate the tens of unmistakable patchwork of oil palm plantations: palm trees in
millions of people affected by transboundary haze. At that stage xvii What other countries produce orderly grids the size of dozens of city blocks. Trucks carrying the
harm reduction measures were necessary, but most were not palm oil? At what scale? Why valuable fruit rumble down the highway, precious cargo secured
has there been a rise in palm oil
appropriate and offered limited overall coverage.” production globally? in place by canvas tarps. The commodity is the country’s largest
↘ Read more here agricultural export.xvii
The first of those harm reduction measures was the distribution of
masks. In Palangka Raya, the provincial Ministry of Health also set In control of large areas and with a vested interest in preparing land
up airtight, air-conditioned tents where people could seek refuge for rows of palm trees, oil palm plantations are the most common
from the haze. Even government offices became mini hospitals scapegoat for the destruction of Indonesia’s peatlands. However, a
where people could stay in an air conditioned and well-ventilated study looking at a decade of manmade fire ignitions in Kalimantan
space. “We also asked cooperation from parents to restrict the between 2000 and 2010 found that only 17 to 19% of man-made
outside activities of their children,” says Erna Parida Susanti, a fires originated on palm oil concessions.35 Satellite data showed
midwife at a local puskesmas. With school suspended for as much the majority of fires came from a mosaic of non-forested areas—
as three weeks, she admits this was a near impossible ask. land composed of small-scale, independent oil palm producers,
farmers, and swatches of degraded and drained peatlands. This
Back in Dr. Bobby’s office at RSUD Doris Sylvanus hospital in came as a surprise to Dr. Ruth DeFries of Columbia University,
Central Kalimantan, the brightness of the day has been spoiled who co-authored the research with other members of The SMOKE
by conversation of the haze. “I don’t want to talk because what Team. “We went into this thinking we would find that the big
happened in 2015 is a kind of trauma for us pulmonologists. We oil palm concessions are the root cause of the fires and the haze
opened our eyes and we could not see in front of us. For three problem. The oil palm industry is what everyone loves to hate. […]
months we had this situation. Maybe if you don’t have a healthy That’s lesson number one: challenge your assumptions.”
mind you could go crazy. Every day I went to the hospital and saw
people die.” DeFries says this revelation both simplified and complicated the
land use scenario. While it shed light on the true source of fires, it
meant the haze issue could not be solved by targeting a single player.
Midwife Erna Parida Susanty, Dr. Yulitha
Christiana, and nurse Nurul Hafizhah “To have a policy that targeted big oil palm producers would have
were on the frontline of care during the been easier because there’s less of them, but at the same time more
2015 haze. Employed at a puskesmas, challenging since they’re a large industry and they have lobbies
a community health clinic, the three
women saw patients throughout the
and lots of profit at stake,” she says. Meanwhile, most of the fires
course of the fires. were occurring on a mosaic of degraded land that had thousands
of users. It became increasingly apparent that preventing fires
required a paradigm shift in how that land was used, protected,
and restored. Only once all three were addressed could a group
address the root cause of the haze.

It was within this context that The SMOKE Team set out to build
a tool to help policymakers prioritize restoration areas that would
yield the greatest benefits to human health.
56 57
A common scene on roadsides in
much of Indonesia. Palm oil is one
of the country’s largest industries,
and individual households often
get involved by threshing the
fruit from the spiked bunches.
Be it rainforest or peatlands, the
creation of oil palm plantations is
a main driver of land use change in
the country.

58 59
 The SMOKE Policy Tool in Indonesia, with similar reductions in Malaysia and Singapore
While The SMOKE Team’s 2016 paper focused on quantifying (73% and 70% respectively).37
the public health effects of the 2015 haze, their latest research is
forward-looking. Published in July 2019 with BRG’s Pak Budi as a The SMOKE Team’s tool enables policymakers to better consider
co-author, the paper outlines a framework policymakers can use to public health consequences when making land use decisions. These
maximize the health benefits from peatland restoration. policy-level approaches are complemented by more community-
oriented, grassroots interventions spearheaded by BRG and the
The paper documents the future health outcomes for five land use Government of Indonesia. With varying levels of success, these
scenarios. It does this by synthesizing historical data: looking at bottom-up efforts are an attempt to consider not only the public
land use and land cover change, where fires have originated and the health outcomes of haze, but also the complex social, economic,
resulting smoke traveled, and the public health outcomes. Over the and cultural reasons behind why peatlands are burned.
next several decades, a business-as-usual (BAU) land use scenario
would lead to an average of 36,000 premature adult deaths each year
across Indonesia, Malaysia, and Singapore. Additionally, the model
forecasts an average of 1,100 annual deaths of children under the
age of five due to acute lower respiratory infections.36 These figures
are averages, and the team acknowledges mortality numbers could
range from <100 to 80,000 annual deaths, depending on the year.

The scientific framework outlined in the paper is publicly

available through the SMOKE Policy Tool, a free online decision
support tool that allows stakeholders to forecast public health
effects in a way that would have previously been prohibitive. “For
policymakers to run 30 years of five different land use scenarios—
that would be a lot of expensive computer hours and would require
xviii ↘ Take a moment to visit the knowledge of complicated tools,” explains Shannon Koplitz of
policy tool here and change the
different settings to achieve different The SMOKE Team.xviii
scenarios.
Policymakers can use the tool to toggle between land use scenarios.
That includes a BAU scenario, and others demonstrating what
would happen if fires were blocked on all industrial oil palm, wood
pulp, and logging concessions; in existing conservation areas; and
on BRG priority sites which involve peatlands in both concession
and non-concession areas.

Pak Budi of the BRG notes that the areas identified by the SMOKE
Policy Tool as having the greatest potential health impact generally
align with the agency’s priority areas. He says the tool adds two
Palm Oil becomes the main source of
other useful elements: honing in further still on specific priority income for many villagers in Indonesia.
protection sites, and quantifying the downwind health concerns of
possible haze events. The most ideal land use scenario for human
health involves the blocking of all fire in peatland areas. In this
scenario, mortality from haze exposure decreases by 65% annually
60 61
National and Regional Experts say it’s only recently that the Government of Indonesia Mapping Indonesia’s Peatlands
Responses to Peatland started to change its stance towards degraded peatlands—
Management something that was long overdue. “In 2006 Wetlands International Mapping—or a lack thereof—has presented one of the greatest challenges to peatland protection and
came out with a report on peat carbon dioxide which showed huge restoration in Indonesia, and has fueled historic conflicts around property rights. One of the first tasks of the
emissions from peatland degradation in Indonesia and Malaysia. newly-established BRG was to work with partners such as the World Resources Institute to put together a more
That was not welcome from either government, and the first comprehensive map of the country’s landscapes. The government calls this the One Map Initiative. The map,
reaction was to deny the issue and ban discussions on it,” says Marcel which will feature peatland area and depth, will become the basis for future restoration planning.
Silvius, who has been working on the issue of peatland restoration
worldwide, first with Wetlands International and now with the In 2016, Indonesia’s Geospatial Information Agency (Badan Informasi Geospasial, or BIG) launched the million
Indonesian branch of the Global Green Growth Institute (GGGI). dollar Indonesian Peat Prize in order to more comprehensively map the area and depth of the country’s
“It took Indonesia several years to acknowledge the problem, and peatlands. Two years and 44 teams later, the winners of the Indonesian Peat Prize were announced on World
the major fires that have occurred repeatedly contributed to that Wetlands Day in February 2018.
level of awareness raising,” Silvius says in neighboring Malaysia,
peatland degradation and its related consequences are still not
being seriously discussed by the government. Pak Budi says the “breakthrough” moment came in late 2016. That’s
when the Government of Indonesia updated a previous regulation,xxii xxii The original regulation was
Pak Budi, BRG’s Deputy Head of Planning and Coordination, proactively protecting peatlands by banning the use of peat Government Regulation ↘ No.
71/2014 Concerning Protection and
worked with the World Wildlife Fund before joining the agency. areas with a depth of more than three meters, even on existing Management of Peatland Ecosystems
He says policy around peatland restoration didn’t exist before 2015, industrial concessions. The regulation also stipulates the water
despite the annual effects of peatland fires. Restoration involves table of peatland areas be no lower than 40 centimeters as a way to
restricting the development on a piece of land while also taking prevent the deep smoldering that occurred during the 2015 fires.xxiii xxiii The 40 centimeter figure was
active measures to improve its integrity. “Before [2015] it was just a The World Resources Institute (WRI) notes that primary forest determined by Susilo et al (2013) to be
the ideal depth as to prevent the risk
matter of protecting peatlands, monitoring the [fire] hotspots, and loss on Indonesia’s protected peat areas declined by 88% between of peat fires.
responding to those without really taking into account the larger 2016 and 2017, and attributes part of the change to this updated
policy,” he expands. regulation.39

The first inkling of policy around peatland restoration came in May The private sector bears the brunt of this updated regulation.
2011 when the central government led by then-President Susilo More than half of the peatland area prioritized for restoration is
Bambang Yudhoyono instated a two-year moratorium on issuing industrial concession land. If a company is found to be burning
new concession licenses on areas of primary forest and peatland. their land or operating on deep peat areas, it can face warnings or
That moratorium has since been extended on three occasions, the civil and criminal sanctions.
latest in May 2017 by President Jokowi.38 That moratorium will be
in place at least until the government has mapped which peatland Pak Budi admits the private sector reaction to the 2016 regulation
xix Can you think of some unintended
consequences a moratorium like this areas could be appropriate for production, and those which must was quite negative. “They saw this regulation as adding more
might have? be conserved.xix complications to the bureaucracy. We made several consultations
with forestry and oil palm groups to provide data around which
In direct response to the 2015 fires, Jokowi also issued a permanent, areas were and were not peatland, and provided them with
national zero burning decree for industry and individuals, banning restoration activities,” he says of the BRG’s attempts to cushion
xx ↘ Explore the RSPO website, and
take a look at some of their criteria for the use of fire to clear peatland areas. Not using fire, and taking the the initial negativity. Since then, two-way communication has
sustainable palm oil production means to prevent and monitor flames proactively, is also one of the been key, and companies can come forward if an area has been
criteria oil palm companies must meet to comply with Roundtable mistakenly identified as peat. Each company is responsible for
xxi Which countries or regions
purchase most of Indonesia’s palm oil? on Sustainable Palm Oil (RSPO)xx criteria, though standards are producing a restoration plan, with the BRG planning to verify the
↘ Explore the chart here voluntary and still permit planting on peatlands.xxi
62 63
 impact of those activities in the coming years. A land-swap plan cost between $1.62-2.7 billion.42 “The costs of smoke haze pollution
has also been introduced as a means of compromise with forestry were in the range of $674-799 million, and probably higher because
xxv What are some challenges in the
companies that have more than 40% of their land on protected implementation of international legal estimates for the economic impacts on Indonesian business
peat areas (those with a depth greater than three meters), though mechanisms such as this one? activities were not available,” says a CIFOR report.xxv
it has received criticism from NGOs and private sector companies
alike.40 However, the agreement was virtually powerless until 2014
xxvi The first use of that act was when Indonesia, the largest producer of haze, finally ratified the
While the private sector thought the 2016 regulation went too far, in 2014 when six lawsuits against agreement. That set the stage for the next iteration of the policy, the
others felt it was only scratching the surface of what was needed. Indonesian companies were filed. The Transboundary Haze Pollution Act of 2014. Since then, Singapore
largest was filed against Indonesian
“The Minister [of Environment and Forestry] stuck her neck out plantation company Sampoerna Agro, has levied fines on Indonesian companies in each subsequent
in doing this, so it’s a daring step, but it is still not sufficient to at a fine of US $81.62 million. year.xxvi
address all the peatland degradation related issues,” says GGGI’s
Marcel Silvius of the 40 centimeter regulation. Silvius advocates But as Ruth DeFries and others found in their research, policies and
for full peatland rewetting, which would restore peatlands to near- regulations that consider only the actions of large companies failed
natural hydrological conditions. That would stop emissions and to address the millions of small-scale farmers using traditional fire
xxiv What other policies would have
to be in place to make this regulation soil subsidence, reduce fire risk, and offer an environment to grow methods to clear land—and the economic practicalities of why
overall successful? commercially interesting local species.xxiv they were choosing that method. While the national and regional
response was important, peatland protection and restoration
Striking a balance of restoration buy-in from a wide spectrum demanded the involvement of people at every level.
of partners is necessary for the BRG to achieve its ambitious
restoration goals. “One of the reasons a lot of people are interested
Pak Ardiansyah is a Fire Guard with the
in this issue is because we all realize restoring [25,000 square Ministry of Environment and Forestry.
kilometers] is a humongous task, and BRG knows it’s impossible Along with other members of Gohong
if they do it alone,” says Satrio Wicaksono, the World Resource Village in Central Kalimantan, he has
received firefighting training since 2015.
Institute’s former Forest and Landscape Restoration Manager in
Indonesia. For its part, WRI is helping BRG map peatland areas in
three priority provinces and create restoration action plans. The
institute also oversees the upkeep of Pantau Gambut, an interactive
watchdog tool people can use to hold the BRG accountable to its
commitments.41 “It’s been working out quite well. BRG is seen
as easier to work with than the Ministry of the Environment
and Forestry,” Wicaksono says. “If you look at who the people
are in BRG, they used to be in NGOs and academia. It’s not like
they’re long-time government bureaucrats, [many of whom can
stereotypically] be averse to working with partners.”

At a regional level, policies from other Southeast Asian countries

have also taken aim at addressing Indonesia’s peatland fires. In
2002, the Government of Singapore tabled the ASEAN Agreement
on Transboundary Haze. That environmental agreement came
in response to large-scale forested peatland fires that occurred in
1997. The Center for International Forestry Research estimates
the degradation and deforestation that resulted from those fires
64 65
Community-based The sun is low in the sky by the time Pak Anang Sogito from focused more on grassroots activities and behavior change. The
Solutions: The BRG’s 3 R’s Gohong Village reaches his destination: a rickety, four-story fire goal is to shift perceptions around the usefulness of peatlands,
tower constructed a few meters from the highway. The view from and provide affordable alternatives to traditional land clearing
the top is spectacular: green shrubs and small trees sprouting methods using fire.
from peatland as far as the eye can see—except in one direction
where it reaches the boundary of a rubber tree forest and oil “We needed to have interventions in activities that were really
palm plantation, an inescapable reminder of the delicate state of important to people, and found that economic activities were
Kalimantan’s peatlands. central,” says Dr. Myrna Safitri, the BRG’s Deputy of Education,
Socialization and Participation. After these activities, people
This peatland is slowly experiencing regrowth after being scorched gradually change their perception that peatland restoration is
in 2015. Had this fire tower been standing that year, it too would something harmful to their lives. They see it can improve their
have burned. An inconspicuous white pipe—picture a simplified household.”
fire hydrant—protrudes from the ground at the base of the tower.
It’s one of 300 pumps found across the hotspot area near Gohong The first R intervention is rewetting, in order to accelerate the
Village, installed since 2015 by the BRG and USAID funded project, recovery and restoration of the hydrological functions of the Pak Anang stands next to one of the
Lestari. As of mid-2018, the BRG had installed more than 23,000 of peatland. Rewetting efforts include installing grids of deep water deep water wells at the edge of Gohong
Village.
these deep water wells across its seven priority provinces. wells like the ones in Gohong Village, in addition to supporting
community firefighting efforts. It also involves the construction of
In heavily peated fire-risk areas like this, pumps sit in a 400 meter dams to block the canals historically used to drain peatlands. The
by 200 meter grid. They wouldn’t offer full coverage if a hotspot goal is for rainwater to eventually re-saturate the dried areas to
were to become a full-blown fire, but Pak Anang says they’re a prevent further oxidation. Rewetting success depends on natural
start. Plus its presence means villagers wouldn’t need to rely on precipitation, but also the education and understanding of people
traditional extinguishing methods: the aforementioned buckets living near those canals. Safitri says some communities resisted
of water thrown fruitlessly over smoldering fires. Expanding local the dams at first, particularly because the canals had been used as
firefighting capacity and community response has been one of the illegal logging access points.
main mitigation efforts introduced since 2015, and is the focus of
both the Ministry of the Environment and Forestry’s Manggala Agni Sensitizing people about interventions like canal dams is two-fold.
fire brigade and the UN Environment Programme’s Gambut project. “We use language that people easily understand,” explains Safitri.
“When we talk about what peatland restoration means, we tell
The installation of deep well water pipes is one of the BRG’s people it’s like a hospital. We’re in the emergency room now where
interventions to proactively restore Indonesia’s peatlands. we’re facing very serious degradation of peatland ecosystems. If we
The agency has a double mandate: facilitate the restoration of do nothing it will get worse, and we tell people they will be the first
degraded peatlands, and coordinate the sustainable management victims. Many children get sick because of the haze, and peoples’
of those ecosystems. That work is the responsibility of a National agricultural land burns. If our ecosystem can be saved then lives
Coordination Team, a body consisting of 17 government agencies, can be saved.”
10 ministries, and governors in the seven priority provinces, each of
whom play a role in supervising restoration efforts by individuals,
communities, and private sector.

Notable are the interventions that make up BRG’s community

restoration efforts. These interventions take what the agency calls
a “3-R” approach. While the national government has focused
on several top-down policies regulating peatland use, the BRG is
66 67
Pak Charles overlooks a peatland
canal constructed on his land. With
support and funding from the Peatland
Restoration Agency, he and others have
built the canal blocking dam that he
now stands on.

68 69
Canal dams have been constructed in nearly 20,000 locations across An Indigenous Youth-led Movement Addressing the Haze
Indonesia. Two of them are in Tumbang Nusa Village in Central
Kalimantan province. That’s where Pak Charles stands squinting Emmanuela Shinta is a young Dayak leader from Central Kalimantan, Borneo. She recently spoke at the 2019
in the midday sun, observing a wooden canal block on his property. planetary health conference hosted by Stanford University. During a panel session on Mobilizing a Planetary
It was constructed by his farming group, with money and support Health Movement, Shinta introduced the Youth Act Campaign that she and other Indigenous youth started in
from the provincial government, who in turn received funding and 2016 in response to the fires and haze that had been occurring since 1997.
guidance from the BRG. In addition to rewetting the peatland, when
filled with water the blocked canal makes it easier for Pak Charles The Youth Act Campaign organized many activities to get young people politically engaged, including creating
to reach his property far from the road. “After we make the canal haze shelters and training them as firefighters to help extinguish peatland fires. “They put all of their energy and
blocking the land surrounding is good for farming,” adds Pak Charles. time to protect their own people, their family, and our beloved homeland: our beautiful forest which is part of
our identity,” Shinta said on the panel, recognizing her people as the guardians of the forest.
The canal water is also used by the Ministry of the Environment
and Forestry’s Manggala Agni fire brigade. Even with efforts to rewet Shinta is an advocate for bottom-up approaches to land management—this starts, she says, by consulting
peatlands, the project is a work in progress and the ground’s dryness is Indigenous communities who best know the land. “If you want to know how to manage the land and preserve
evidently dire. Pak Imade, the Chief of Manggala Agni for this district, the forest ask the Indigenous communities because they have been doing that for thousands of years,” Shinta
prods at a piece of wood that has been warped and dehydrated by explained.
heat and a lack of peatland saturation. It crumbles easily in his palm,
the perfect fire tinder. Each day, Pak Imade’s joint squad of army, Shinta also compels people internationally to take individual action to reduce the large-scale clearing of land:
police, and Manggala Agni officials monitor the peatlands around the “I would like to urge everyone here to mind your palm oil consumption. There is a lot of suffering behind the
village. They use two satellite monitoring applications to look for fire products that you consume.”
hotspots, before investigating in-person. “It wasn’t until after 2015
that we started our joint patrol, and to do door-to-door socialization
about the new government rule forbidding people to burn their land,” To further emphasize the value of peatlands, BRG has created more
explains Pak Imade. than 200 Peat Care Villages across their seven priority provinces.
In these villages, the agency supports the creation of farming
Revegetation is BRG’s next “R” intervention. This planting of new demonstration plots, farmer groups, and village development plans
tree and shrub species is especially important in peatland areas that integrate peatland restoration. Villagers also receive legal
that were previously burned or degraded. Not only can agroforestry training so they can advocate for their land rights around peatlands
projects provide livelihoods for community members, but the new and beyond. Land boundary issues remain one of the largest
vegetation can also provide biomass that helps peat form. conflicts, both among neighboring villages and with large concession
companies.
Community involvement is key for BRG, especially for the third
“R”: revitalization. This intervention involves the introduction of Safitri says it’s never the agency’s aim to introduce something
alternative livelihood activities conducted without burning. That completely new, since BRG’s mandate and capacity are ultimately
includes farming peatland-appropriate crops, livestock rearing, limited. “We analyze existing initiatives and see how we can
creating ecotourism destinations, and social forestry projects. support improvement,” she explains.
Anything that helps villagers benefit economically from healthy
peatlands. Another of BRG’s community involvement approaches is One example of BRG supporting existing initiatives is in Anjir
to help individuals understand that their actions are part of a bigger Kalampan, where village chief, Pak Yanir, has become somewhat of
picture. Often, that involves inviting a farmer to talk about their a celebrity for his success growing fire-free crops on peatland. While
activities at an international event. “This helps farmers know what Pak Yanir had been experimenting with non-burning methods of
they do in their village is not only impacting their communities, but opening land since 2011, his efforts ramped up following 2015, and
has a global impact,” says Dr. Myrna Safitri with BRG. with support from BRG. “I considered the haze accident as the
70 71
 important moment. It became the urgent thing to do,” he explains, He says it’s a misconception that opening land with fire is less
sitting on the floor of the village office. expensive, though admits his method does require some start-
up resources such as the ducks and the manual labor to create
Pak Yanir, 52, has lived in Anjir Kalampan his entire life. Over the raised garden beds. It took a handful of failures and years of
last decade he has developed a specific technique to grow vegetables experimentation for Pak Yanir to master this burning-free method
in the highly acidic peatland environment. His method involves but it’s one that has today been adopted by the village’s farmers.
creating raised rows of soil so plant roots don’t reach the acidic The combination of producing his own manure, carefully selecting
groundwater, even during rainy season. Unlike rice paddy fields, his crops, and raising his garden beds has proven productive.
a traditional crop in the region that requires the flooding of land, Importantly, this method is also affordable for subsistence farmers.
Pak Yanir plants crops with shallow roots such as watermelon,
chili, and onions. His method is also entirely organic. Instead of Proposing affordable and culturally acceptable alternatives to
buying expensive pesticides and creating nutrients on the land clearing land without fire is key for BRG. “At the beginning
through burning, Pak Yanir mixes the feces of ducks that have villagers were reluctant of the no fire rule,” confesses Pak Yanir.
been provided by BRG with decomposing grass. The result is a “They blamed the government for making a rule without any
nutrient-rich manure. solution, and refused to follow it because they could not afford
anything other than burning.” Pak Yanir says people eventually
Pak Yanir, a resident of Anjir Kalampan came around as the result of training sessions—and the threat of
village. prosecution.

Using demonstration plots and field schools as learning sites,

BRG’s proposed land clearing methods involve training farmers to
manually prepare farmland using machetes and other tools. The
slashed organic material is then combined with animal feces and
other ingredients and left to decompose for several months. The
resulting manure mixture minimizes the need for fires.

However, this method isn’t perfect. For one, it’s a substantially

longer process than lighting a fire and watching it burn, and it’s
one that can attract pests and diseases. That’s what a team from
the Centre for International Forestry Research (CIFOR) found
when they looked into the effect the government’s zero-burning
policy had on small farmers in Riau province. In Riau and other
provinces across Indonesia, fire has been a part of traditional land
clearing methods for generations. “There is a need for flexibility in
implementing the policy on the ground,” wrote CIFOR Researcher
Dede Rohadi in a 2017 opinion piece.43 “Genuine farmers should
be allowed to implement controlled land burning. Traditional
community wisdom makes it possible to apply the technique with
the guidance of government officials in the field.” Rohadi argues
that without this needed flexibility smallholder farmers may be
forced to abandon their land because the cost of fire-free clearing
is higher than what they’re able to earn through their harvest.

72 73
Restoring Russia’s Peatlands Back in Anjir Kalampan village, one of Pak Yanir’s farm helpers,
Wasis, proudly recalls a week earlier when he harvested five tons of
Southeast Asia is not the only region that has experienced the health effects of haze. Like Indonesia, Russia is juicy red, orange, and yellow watermelon—a bounty, he notes, was
home to a considerable area of peat—it makes up 8% of the world’s largest country. The similarities do not end promptly sold. The watermelon was grown on peatland that had
there. The country’s peatlands have also fallen victim to short-term economic gain, particularly in the 1970s and been prepared and fertilized by hand, using the raised bed method
1980s when peatlands were drained for agriculture, forestry, and use as fuel. These actions were supported by the explained earlier by Pak Yanir.
Soviet state, and Russian engineers also bolstered the draining of peatlands in Indonesia by providing calculations,
surveys, and designs. With the fall of the Soviet Union in 1990, hundreds of thousands of square kilometers of Wasis says villagers now look at peatlands differently, including
drained peatland were abandoned. Similar to in Indonesia, these drained layers of peat provided the ideal kindling seeing the value of protecting peatlands beyond the purely
for hazy fires, and are located upwind from many large population centers. economic: “They understand that when the peatland burns it
affects their health. But education still needs to happen, because
In 2010, peat fires smoldering around the Moscow Region contributed to 11,000 premature excess deaths.44 ultimately burning remains the easiest way [to clear the land].”
Resulting from that crisis was a bilateral project between Russia and Germany. Working with the Russian branch
of international NGO Wetlands International, as well as a team of lawyers, scientists, sociologists, and engineers,
the ongoing project has rewet 950 square kilometers of drained peatland, and is one of the largest peatland
ecosystem restoration projects worldwide. About a third of that restoration has occurred using an ecological
restoration approach.

The goal of ecological restoration is to not only rewet areas, but also to restore natural ecosystems. In order to
do this, natural dams are constructed along the man-made canals formerly used to drain the peat areas. Rainfall
remains trapped within the dammed areas, and resaturates the dry peat, leading to the slow restoration of its
original water-logged state and biodiversity. With dams created using vegetation native to the area and filled
solely by natural rainfall, this form of ecological rewetting has been found to be 10 times cheaper than other
rewetting methods.
According to Dr. Tatiana Minayeva, a peatland restoration expert with Wetlands International, a major challenge
of the project has been convincing Russian stakeholders of the importance of peatlands. Similar to BRG’s work in
Indonesia, the approach in Russia recognizes that it’s not possible to simply demand people act differently. “The
attitude is that peat is an obstacle for your development. Draining it was positive for them. We have learned that
you need to have different models and schemes,” says Dr. Minayeva.

Those models are different based on each community—as are the barriers faced. Some communities,
Dr. Minayeva says, demand proof of profit upfront. Some want direction from the highest level of government,
and others want to see how rewetting has benefited nearby villages. The introduction of paludiculture—a form of
agriculture that happens atop healthy peatlands—is one of the ways Wetlands International and its partners are
Wasis moved from the populous island
hoping to convince Russian partners that there is value to be gained from maintaining peatlands. of Java to Central Kalimantan in search
of agricultural land. What he found was
While policy changes have not been put into place by the Russian government, this ecological restoration project plenty of open peatland—an ecosystem
that is typically challenging for growing
is an example of what can happen when behavior change, economic benefit, and the health of the planet and
given its high soil acidity level. The
humans is combined. Peatland Restoration Agency works
alongside farmers like Wasis, conducting
agricultural trainings to demonstrate
that it is possible to have a viable
livelihood on healthy peatlands.

74 75
Institutionalizing Peatland Indonesia has not conclusively shaken its pattern of dry season
Restoration for the Future fires. “There was lower fire incidence in 2016-2017 overall, and
we now know that those areas did not burn because of our
activities, socialization, education, and stronger law enforcement,”
confirms BRG’s Pak Budi of the progress that has been made,
though says the interventions are still too nascent to fully assess
their effectiveness. Pak Budi points out that climate-wise, 2016-
2017 were drier compared to the previous three years, including
2015. In 2017, NASA satellites detected 1,927 hotspots during the
July to October dry season months—a fraction of the 130,000 fire
hotspots during the same period in 2015, and a new record low.45

However, 2019 saw the return of the transboundary haze crisis.

The worst fire and haze season since 2015, nearly 16,000 square
kilometers of land burned in Indonesia, particularly on the islands
of Sumatra and Borneo.46 Nazir Foead, head of the BRG, told
Mongabay the agency’s monitoring had detected the overly-dry
peatlands in as early as May 2019. He acknowledged the need to
re-check the canal blocks and deep wells that had been installed
in previous years, but added that “fires are flaring up in areas that
seldom burned [in the past] and indeed they weren’t monitored.”47
Other BRG officials have pointed to the lack of maintenance
budgets for rewetting infrastructure, while certain Indonesian
NGOs say the agency isn’t being transparent enough about progress
being made in peatland restoration.48

A suite of solutions for this annual environmental crisis is still

underway. The BRG’s Pak Budi says it’s important to ensure the
issue maintains the political support and funding it needs. For
that, he stresses the importance of having the agency’s work
backed by science and public health data. That’s one of the
reasons he joined The SMOKE Team to co-author their 2019 paper
connecting peatland restoration areas with their long-term health
benefits. “That paper gives us an argument that regional policy
and coordinated work are important, not only to suppress the fires,
but to prevent health concerns from happening,” Pak Budi says.
xxvi What are other examples in which “We always need more data and studies that the health effect isn’t
scientific research has informed policy only in the five months of the dry season, but can have a long-term
decision at a large scale?
effect, too.”xxvi

Peatland forest in Central Kalimantan.

Photo by Nanang Sujana, CIFOR;
cifor.org
76 77
Keeping Track of Who’s Dr. Mual Bobby Jonathan Buonocore Pak Charles Dr. Yulitha Christiana Dr. Ruth DeFries
Who
Pulmonologist at RSUD Doris Sylvanus Research Associate, Environmental Resident of Tumbang Nusa village in doctor at a puskesmas in Palangaka Environmental geographer at Columbia
hospital in Palangka Raya, Central Health, Harvard T. H. Chan School Central Kalimantan Raya, Central Kalimantan University and member of The SMOKE
Kalimantan of Public Health and member of THE Team
SMOKE Team

Dr. Budi Haryanto Dr. Shannon Koplitz Stefani Koseanto Dr. Myrna Safitri Marcel Silvius
Environmental epidemiologist, Atmospheric scientist and member of The Resident of Palangka Raya, Central Deputy of Education, Socialization and Indonesia Country Representative with
University of Indonesia’s Research Center SMOKE Team Kalimantan Participation, Badan Restorasi Gambut the Global Green Growth Institute in
for Climate Change (Peatland Restoration Agency) Jakarta

Pak Anang Sogito Erna Parida Susanti Pak Tuberyono Pak Budi Wardhana Richard Wecker
Village Secretary, Gohong village in Midwife at a puskesmas in Palangaka Resident of Palangka Raya in Central Deputy Head of Planning and Risk Reduction Specialist with UNICEF
Central Kalimantan Raya, Central Kalimantan Kalimantan, grandfather of Ratu Coordination, Badan Restorasi Gambut Indonesia’s Disaster Management,
Agnesia (Peatland Restoration Agency) Climate Change Adaptation & Mitigation
portfolio in Jakarta

Satrio Wicaksono Pak Yanir

Forest and Landscape Restoration Chief of Anjir Kalampan village and
Manager, World Resources Institute peatland farmer

Acknowledgements Thank you to all those interviewed and quoted in this case. Ibu Erna
Ika Rahayu was my behind-the-scenes contact at Badan Restorasi
Gambut, and coordinated interviews both in Jakarta and Central
Kalimantan. Pak Agus Susanto from the Indonesian Society of
Respirology helped me get in touch with medical professionals in
Palangaka Raya. Richard Wecker from UNICEF provided helpful
feedback on drafts of this case and put me in touch with colleagues
across Indonesia. Thanks to the entirety of The SMOKE Team,
but especially Dr. Samuel Myers, Pak Budi Wardhana, Dr. Ruth
DeFries, Dr. Miriam Marlier, Dr. Shannon Koplitz, and Jonathan
Buonocore for your time speaking with me and reviewing drafts
of this case. Finally, thank you to Imam, my interpreter during a
week of interviews in Central Kalimantan.

Several preventative measures are being used to reduce the risk of new peatland fires. That includes regular monitoring
by a group called Manggala Agni.

78 79
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rising%20costs_Findings.pdf doi.org/10.1071/WF17084

80 81
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
02
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Dams and
Please cite this case study as “Duff H., Faerron Guzmán, C.,
Almada, A., Golden, C., and Myers, S. "Dams and Disease:
An Ecological Solution to Schistosomiasis in Senegal."
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planetaryhealthalliance.org/case-studies

AN ECOLOGICAL SOLUTION
TO SCHISTOSOMIASIS IN SENEGAL
 Executive Summary This case study is about the effects dam building and land use
Many of the ideas and themes in this
change have had on schistosomiasis, a parasitic disease, in the
case study are explored in depth in Senegal River Basin in West Africa. Construction of the Diama Dam
chapter 6 on infectious disease in at the mouth of the Senegal River was intended to bring various
↘ Planetary Health: Protecting Nature
to Protect Ourselves. human health and economic benefits. While there were some
positive impacts, the dam also had unintended consequences. For
one, it affected the life cycle of a native river prawn, hindering its
essential migration to the mixed fresh and saltwater estuary near
the Atlantic Ocean. An important predator in the river ecosystem,
the local extinction of prawns led to an upstream explosion in the
Learning Objectives snail species that serve as a reservoir for schistosomiasis. Disease
rates spiked and schistosomiasis has been endemic in Senegal since
After the case discussion, in relation
to the Senegal River Basin and the
the dam was completed in 1986. As similar human infrastructure
construction of the Diama Dam, projects are proposed worldwide, it is key to understand the effect
students should be able to: these developments could have not only on the environment but
➀ Understand the short- and long-
also on human health.
term positive and negative outcomes
of large dams. Past interventions addressing schistosomiasis have focused on
➁ Appraise the unintended
the distribution of therapeutic drugs. These campaigns have been
health consequences of large unsuccessful in countries like Senegal. One reason is because they
dams, particularly in relation to fail to consider how social, ecological, economic, cultural, and
schistosomiasis.
health access factors affect the transmission of disease. A team
➂ Analyze social and environmental of researchers and civilians called The Upstream Alliance are
factors that influence schistosomiasis mindful of these complexities and the original ecosystem balance
transmission.
that kept snail populations in check. The group proposes re-
➃ Assess the challenges associated introducing the native prawn species as an ecological intervention
with scaling and sustaining to complement drug therapy. This intervention has been found
solutions to planetary health
challenges, especially in relation to to reduce schistosomiasis rates and, if successful and sustainable,
schistosomiasis. could provide food and livelihood security for people living in the
➄ Apply systems thinking principles
Senegal River Basin.
to the analysis and solution-
seeking process of planetary health This case study is based on interviews conducted in the Senegal River Basin and Dakar,
challenges. Senegal in April 2019.

85
Introduction “Look how beautiful they are, I love them!” Dr. Susanne Sokolow When interventions do occur, mass drug administration campaigns
is gushing as she peers into a large basin, roughly the size of a have been the public health community’s control method of choice.
backyard swimming pool. She’s referring to the 300-some prawns The Upstream Alliance’s complementary contribution is prawns, a
skittering around the base of the tank. Sokolow’s enthusiasm for predator of the snails that serve as the reservoir host for the parasite
these crustaceans, and the prawn hatchery that houses them, is that causes schistosomiasis. Research has shown that restoration
understandable. These prawns are in many ways the culmination of of native river prawns can reduce the number of snails—and as a
the decade-long efforts of Sokolow and others in the West African result, the prevalence of disease—in the Senegal River Basin.7 It’s
country of Senegal. Sokolow is a disease ecologist and veterinarian one part of an ecological solution that, if scalable in the way The
at Stanford University, and a co-founder of The Upstream Alliance, Upstream Alliance envisions, could be a triple-win for human
a partnership of scientists and citizens from four continents, all health, restoring the ecosystem, and alleviating poverty.
equally dedicated to the promise of these particular prawns.

Not far from this prawn hatchery lies the Senegal River, the
1,800-kilometer-long band of water that traces the border between
the countries of Senegal and Mauritania. The Senegal River Basin’s
landscape is arid desert that extends from the Sahara and stretches
across much of the region. The river and its tributaries are the
water source for the 3.5 million people in four countries who live,
farm, and fish within the basin.1

The prawns in this hatchery are being raised to support the health
of nearby villagers in surprising ways. The crustaceans could reduce
rates of schistosomiasis, a parasitic disease that infects an estimated
240 million people worldwide and puts more than 700 million at
risk.2 The World Health Organization estimates 200,000 people die
from schistosomiasis each year.3 Over 90% of the people infected
i Which countries are affected
the most by schistosomiasis? live in sub-Saharan Africa, and schistosomiasis is second only to
↘ Learn more here malaria as the most burdensome parasitic disease globally.4i

ii Other than the new number of cases Senegal is one of 52 countries where the disease is endemic5, meaning
(i.e., incidence), how else would you
measure the burden of this disease?
levels of infection are consistently maintained. This is especially
true in the Senegal River Basin, where there has been a high and
iii What other diseases fall under continued incidence of schistosomiasis since the late 1980s.6ii
this category of neglected tropical
diseases? ↘ Learn about NTDs here
Regional inequity is to blame. Schistosomiasis is a disease of
*For context, the World Health poverty, disproportionately affecting people who live in low-income
Organization estimates there were
228 million malaria cases worldwide in settings without access to safe drinking water and sanitation. It has
2018, and 405,000 deaths. It reports been deemed a neglected tropical diseaseiii as a result of the people
that US $2.7 billion was available for it affects and the comparative lack of attention it receives from
global malaria control and elimination
programming that year. Meanwhile, funders*, governments, media, and researchers alike. Worldwide,
the WHO says the total amount spent less than half of people infected receive drug treatment.
on all 18 Neglected Tropical Diseases Aquaculture engineer Papa Demba Ndao
(including schistosomiasis) amounted gestures at the prawns at the hatchery
to between $200 million and $300 outside of Saint-Louis.
million a year between 2012 and 2014.
86 87
Senegal: The Gateway Located at the westernmost point of the African continent, Senegal rather than through insurance, with individual patients paying
to West Africa is known as the “Gateway to Africa.” The country’s economy is one for care and medication at healthcare facilities12, similar to other
of the strongest in sub-Saharan Africa, with economic growth parts of the world without universal healthcare. This figure is
exceeding 6% every year since 2015.⁸ Macky Sall was re-elected as high in a country where, on last measure in 2011, 46.7% of the
President in February 2019, and is implementing the second phase population lived below the national poverty line.13 The Senegalese
of “Emerging Senegal,” his economic and social development plan government has made strides in improving healthcare access for
that started in 2014. That plan includes a focus on agriculture some demographics and diseases. For example, free healthcare is
and aquaculture, the practice of farming fish, prawns, and other provided to newborns under the age of one and people over 60, and
aquatic species. the country has a comprehensive tuberculosis treatment program.

Agriculture is Senegal’s most important industry. Farming, fishing, Small health posts overseen by a nurse or midwife are the first
livestock rearing, and other livelihoods employ an estimated 60% point of care for most Senegalese, and represent 90% of the
of the labor force.⁹ The fishing industry is evident from the large country’s public healthcare facilities.14 There are also 14 regional
wooden boats that line the oceanside of coastal cities like Saint- hospitals across Senegal, though these are found in the regional
Louis—what’s less outwardly visible is the farmland. Main highways capital cities which are still commonly inaccessible due to cost or
in the north of the country cut through sandy desert landscapes, travel time. More serious health cases are referred to one of the
clustering most agricultural land around the Senegal River Basin, national hospitals in Dakar.
its tributaries, and the large Lac de Guiers. With a growing
iv How does population growth in populationiv and changing climatic patterns, development projects These barriers in reaching and affording healthcare treatment
Senegal compare to that of your such as dams and irrigation schemes have been expanding to have become more urgent in the last 30 years as new infrastructure
country of origin?
support farming and livestock husbandry by providing year-round projects have increased the prevalence of schistosomiasis in the
access to freshwater. While these developments were designed Senegal River Basin.
to increase available land for agriculture and the generation of
clean energy, they can also alter ecosystems and cause unintended
A Senegal River Basin village seen in
human health consequences. proximity to the river—and the desert
landscape. (photo courtesy of Andy
Those negative health effects disproportionately affect people Chamberlin, The Upstream Alliance)
living in rural regions where healthcare access can be limited. Over
half of Senegal’s population of 15.4 million people live in urban
centers, including the capital city of Dakar.10 While wealthier
Dakar residents have geographic and economic access to medical
care, there are significant inconsistencies in accessing health
services in peri-urban and rural areas, including the Senegal River
Basin. This is partly due to decentralization of health services,
and the fact that each of the country’s 14 regions independently
decide how to spend their healthcare budget. However, it has been
v Do you know how your health care is reported that local governments contribute less towards local
funded? healthcare services than they’re legislated to do.11v

This gap in funding means people often need to pay for health
costs out of pocket, including medication to treat diseases like
schistosomiasis. It’s estimated that more than a third of national
health spending comes from the wallets of everyday Senegalese
88 89
The Diama Dam and the A herd of cows strolls lazily alongside the irrigation canal that making of a food crisis, and national governments feared the
Dynamics of Land Use connects the Senegal River with Maguette Diop’s family land. With political and social instability that could come if prices were raised
Change the dust and dry of the surrounding environment, arable farmland and basic food needs unmet.
is an unexpected sight. Diop lives in Maka Diama, a village about
seven kilometers from this property. His daily commute is via All the while, low precipitation levels meant a drop in groundwater
the horse-drawn cart that sits at the edge of the field. He and his supply. This allowed saltwater from the Atlantic Ocean to seep
family alternate what they grow on this land—half of the time it’s into freshwater aquifers and flow up the Senegal River, reaching
flooded as a rice paddy field and the other half, like now, it’s filled 250 kilometers inland. Salinity in groundwater stores increased
with small green onion sprouts. Both are essential sources of food and further limited the land suitable for agriculture and the water
and revenue for the family. available for household use.vi This shortage of arable land led to vi How does this process of
actions that stressed the environment but were necessary to meet salinization happen? How will
Maguette Diop in his family field. increasing temperatures affect this
food production demands. This included the cutting of trees to process? Who is most at risk?
create more inland farming areas and planting farm plots year
after year, preventing nutrients from being restored.17

In response to these freshwater access challenges, the West African

countries of Senegal, Mauritania, and Mali came together in 1972
to form the Organisation pour la mise en valeur du fleuve Sénégal
(Organization for the Development of the Senegal River, OMVS).vii vii The West African country of Guinea
OMVS’s first act was to propose a technological solution: two dams joined the alliance in 2006.

to be installed in the river basin.

Expectations for the dams were high. Objectives included ending

the basin’s food shortage crisis by expanding the area for irrigated
farmland, producing hydroelectric power, and maintaining river
water levels to allow for navigation and use by irrigation canals.18
The primary purpose of the Diama Dam was to block saltwater
Year-round agriculture hasn’t always been possible in the Senegal from further intruding into upstream groundwater supplies and
River Basin. The region faced two pressing challenges by the turn soil. Saltwater intrusion is expected to become a greater problem
of the 1970s: persisting drought and a growing population. Located worldwide as sea levels rise, precipitation patterns shift, and a
in the Sahel region where the Sahara Desert transitions into the greater demand for freshwater stresses groundwater supplies to
tropical ecosystems of sub-Saharan Africa, climatic variability is the point where seawater begins to seep into the source.19
dramatic and precipitation scarce. This was especially true during
the 1970s and 1980s—average rainfall in the Sahel had decreased Envisioned as a fix-all solution for the region’s challenges,
by more than 30% when compared to 1950 levels.15 This put the construction of the Manantali and Diama Dams were enough to
predominantly agricultural region in a precarious state. temporarily band the member states together towards a shared
purpose. Senegal, Mauritania, and Mali handed control of their
Drought resistant crops such as sorghum and millet were not new, land and river works over to OMVS in order for the pair of dams to
and their production was increasing at a rate of 1% a year. However, be constructed.20 The Diama Dam opened in 1986, approximately
this agricultural yield was outpaced by a 2.5% annual population 30 kilometers inland from the coastal city of Saint-Louis, Senegal.
growth.16 Further, governments in the region prioritized the The Manantali dam opened two years later, a further 1,150
cultivation of cash crops such as cotton and peanuts for export, kilometers upstream along the Bafing River in Mali.
neglecting the food needs of the growing population. It was the
90 91
Amadou Mbodji waters his green
onions in the arid landscape of
northern Senegal. The water used
on his farm and others would not
have been available without the
construction of the Diama Dam.
92 93
 The project received ample criticism. “The worst possible More detailed cost benefit analyses have revealed the true value of the
solution,” said one critic.21 There were concerns that OMVS’s dam infrastructure 30 years after construction. Despite the initial
intentions might be misleading. “Once more, peasant farmers are financial revenue that came from increased agricultural activity,
being used as an alibi. In theory, all this is being done for their it’s calculated that the dams cost the region approximately US
benefit,” proclaimed a French agronomist in a 1982 publication.22 $572.1 million over 20 years due to lost productivity, environmental
He continued: “if one looks more closely, one notes that the dams ix How do you think this is estimated? degradation, costs to human health, and other social impacts.28 ix
have already benefited: the consultancy firms that have already
earned several thousand million francs in fees, and hope to earn
much more; [and] the bureaucracy of OMVS and its counterparts
in each of the three member States.” Disrupting the The Diama Dam altered the upstream ecology of the Senegal River.
Predator-Prey Just as the dam blocked saltwater from reaching upstream, it also
Criticism wasn’t unfounded. A British consulting firm hired to do Relationship prevented the flow of aquatic species in the opposite direction from
a pre-construction evaluation of the project deemed the need for river to sea. That had devastating effects on the river’s population
two dams unnecessary, stating that one would have likely been of Macrobrachium vollenhoveni, a native species of giant river prawn
fine without the other.23 OMVS ignored these recommendations, that needed to travel up and downstream to complete its lifecycle.
constructing the two dams as planned. Survival of the species requires that female prawns migrate to the
brackish water of the estuary in order to lay their eggs and raise
The Diama Dam achieved its mission in some ways. Protection x This has been described in other larvae. Once the larvae reach adulthood, prawns would normally
parts of the world, but with other
against saltwater intrusion and a new series of irrigation canals species. Has it happened in your migrate back upstream to the freshwater environment. The dam
led to a higher availability of freshwater. Land with access to country or region? Why or why not? trapped them on one side of an impassable concrete structure.x
irrigated agriculture grew over 24-fold.24 That benefited farmers
like Maguette Diop, whose original family land in Maka Diama
was flooded and covered with aquatic vegetation following the
construction of the dam. Like many other farming families, Diop
had to shift where his land was located and adopt new methods Trophic Cascades
of agriculture. The initial impact of this was challenging: not
only is tending an irrigated field different than relying on annual Trophic cascades involve the addition or removal of an ecosystem’s top carnivorous predator. Present worldwide,
patterns of flooding and precipitation, but the displacement and trophic cascades send complex ripples through food webs.
reassignment of new farmland led to land tenure conflicts across
the basin.25 One of the most well-known trophic cascades was the local extinction of wolves from Yellowstone National Park.
Killed off in the early 20th century as part of predator control programs meant to protect domestic livestock29,
Still, Diop admits the Diama Dam brought his family more benefits the absence of wolves saw an increase in deer in the park. The deer population had previously been kept in check
than setbacks. “Before the dam was constructed we couldn’t do because of predation from wolves. Liberated from predatory pressure, the deer grazed leisurely through the park’s
farming activities during the dry season but now farming is possible flora, decimating plant species to the detriment of other species in the park. Since the reintroduction of wolves to
through the whole year,” he says, gesturing to the nearby irrigation Yellowstone in 1995, the deer population has been re-regulated, erosion decreased, and species of all kinds, from
viii The distribution of irrigation water canal.viii “If we weren’t able to water our fields it might get complicated beavers to songbirds to fish, have benefited from the natural restoration of order in the ecosystem.30
in Senegal is overseen by a number for us because farming is the main activity in this region.” While the
of groups, including organizations
operating at arms-length from the construction of the dam allowed for year-round freshwater access from Trophic cascades don’t always have positive endings. Another case study in this anthology details the trophic
government and NGOs. irrigation canals, it also contributed to a 50% decline in the Senegal cascade triggered when the non-native Nile perch was introduced to Lake Victoria for sport fishing purposes.
River Basin’s fishery.26 Certain species in the river fishery required That introduction had devastating implications on the ecology of Africa’s largest lake and continues to affect people
a mix of salt and freshwater to complete their life cycles, conditions living on its shores today—including possibly increasing the risk of schistosomiasis as the non-native perch out-
that were not possible after the construction of the Diama Dam.27 compete native cichlid species that kept snail populations in check.

94 95
 Not only an important food source for Senegal River villages, the
prawns played a key role in the ecosystem’s food web.xi They served xi Before moving forward, can you
as a natural predator for the many small snail species that existed find out what the food web in Senegal
might have looked like before the
within the river. With no predator and blooms of aquatic vegetation dams were built?
caused by newly stagnant water, the snail population thrived. That
wasn’t good news for human health: the more snails, the more
parasitic reservoirs. Two years later, people living upstream from
the dam started urinating bloodxii and displaying other symptoms xii This is known as hematuria.
of schistosomiasis. It was a turning point for the health of people
living in the Senegal River Basin.

Recognizing the surprising consequences of dams on disease is

an urgent problem worldwide. Only one-third of the world’s long
rivers remain free of man-made dams and other infrastructure.31
The number of similar infrastructure projects is expected to
continue to grow as countries transition from fossil fuel derived
energy to cleaner sources, and as freshwater supply decreases with
climatic variability.

Worldwide, nearly 400 million people are at a higher risk of

contracting schistosomiasis, partly because dams have blocked
the migration of snail-eating river prawns.32 Though prawns are
not the only predator for snails, they are a significant regulating
force. Additionally, dams bring increased human migration due to
xiii Start thinking of all the
the agricultural or industrial development they support — a social determinants of health that are at play
driver that can increase risk of schistosomiasis.xiii in the context of schistosomiasis.

Take, for example, northern Egypt, where schistosomiasis

prevalencexiv increased from less than 20% to 75% in some areas after xiv It is unspecified whether this was
a new dam was constructed in the 1930s.33 This was attributed to an increase in intestinal or urinary
schistosomiasis.
an increase in the snails that serve as a host for the disease. Today,
people in sub-Saharan Africa living within five kilometers of dam
reservoirs are at increased schistosomiasis risk, as are people living
closer to dam-supported irrigation systems.34 New dams are still
being constructed worldwide without the necessary consideration
of not only their environmental effects but also their public health
implications.
One of the water access points where
Senegal River Basin village residents
get much of their water for drinking,
cooking, and other daily activities.
(photo courtesy of Andy Chamberlin,
The Upstream Alliance)

96 97
Origins of an Outbreak January 13, 1988. Dr. Idrissa Talla recalls the date without a been described in the Senegal River Basin in 1908, and by the 1960s
moment’s hesitation. He’s sitting in his office at the Universite the disease was found across the country.35 Cases of intestinal
Amadou Hampathe Ba in Dakar, where he serves as head of the schistosomiasis, however, were rare in the region. In 1988, only
Community Health Programme in the public health department. 1.9% of stool samples collected from Richard Toll residents tested
In 1988 Talla was in a very different position, geographically and positive for intestinal schistosomiasis. By the end of 1989, 71.5% of
seniority-wise. stool samples showed evidence of these parasitic eggs.36

Four years into his career, Talla was appointed as the medical Acute symptoms of intestinal or urinary schistosomiasis
doctor in charge of the health district of Richard Toll, a rapidly- can include fever, chills, cough, and muscle aches. Chronic
growing town in the Senegal River Basin known for its sugarcane schistosomiasis can cause abdominal pain, an increased risk of
xv Sugarcane in Senegal is produced production.xv The factory was big business, and people were flocking liver fibrosis and bladder cancer, and bloody diarrhea (for intestinal
by the Compagnie Sucrière from across the country and West Africa to seek employment. schistosomiasis) and painful urination and blood in the urine (for
Sénégalaise (CSS), which basically
acts like a state-owned monopoly for The population boom soon put a strain on freshwater resources, urinary schistosomiasis). According to the Centers for Disease
sugar production. and the town’s small reservoir was insufficient for the expanding Control and Prevention, repeated infection in children can lead
community. The dam had provided increased freshwater for to anemia, malnutrition, and learning difficulties, as cognitive
agriculture, but not for the growing population. People spent growth is affected by parasitic eggs reaching the brain.37
their days centered around the network of irrigation canals that
channeled water from the river into the sugarcane fields. They’d Talla and his team were shocked by the discovery of intestinal
work in them during the day and, as a result of the limited reservoir, schistosomiasis. The environmental impact assessment performed
use the same water for domestic purposes like cleaning, bathing, before the dam’s construction had suggested there would be
and drinking. “People were very closely in touch with the water,” an increase in urinary schistosomiasis, but said intestinal
Talla describes. schistosomiasis wouldn’t be possible because of the environmental
conditions.
That intimate relationship between people and their limited
water resources had human health consequences. “A colleague, Contrary to all that was suggested, the Richard Toll health center
the only microscopist at the district laboratory, knocked on my had an outbreak on its hands. Talla published the findings in
door and said ‘Dr. Talla, I saw something very bizarre and I don’t an international journal without seeking permission from the
know what it is,’” recalls Talla of the January day in 1988. Initially national Ministry of Health, fearing they’d try to downplay
brushing off the concerns, his colleague persisted. Eventually, the findings. The study attributed the outbreak to two factors:
Dr. Idrissa Talla outside of his office in Talla and two other doctors went to the laboratory. Looking in the construction of the Diama Dam which introduced environmental
Dakar, Senegal’s capital city. microscope, they were perplexed by what they thought they saw: alterations and the demographic shifts that came as people migrated
the eggs of Schistosoma mansoni, the parasite that causes intestinal to Richard Toll from countries where intestinal schistosomiasis
schistosomiasis. was persistent.38

Talla and his team requested another stool sample from the patient. The paper was widely read, and an international contingent of
And then another. “We put the slides under the microscope and it schistosomiasis scientists soon converged on Richard Toll. “I was
became more and more clear—this thing is schisto.” Talla quickly very tiny at the time, just around 30-years-old. I think they wondered
ordered a meeting with the nurses and midwives, demanding stool ‘who is this small bush doctor talking about schistosomiasis?’” Talla
samples be collected from all patients. “We were surprised. Almost laughs. He took them to the irrigation canals to see the snails. “We
every single person was infected,” Talla says. took them from the water, went to the lab, and heated them with
a lamp. When we exposed them to the heat the cercariaexvi came xvi Cercariae are the larval stage of
The outbreak happened virtually overnight. Schistosoma out. Everybody looked at that incredulously and said ‘ah, now we the parasite.

haematobium, which causes urinary schistosomiasis, had first are convinced!’”

98 99
 A young girl in Mbarigo village washes
The cercariae that Talla and the team of scientists saw under her family’s lunch dishes. This is just
the microscope are central to understanding the life cycle of the one of the many activities that happen
parasite and the transmission from snail to human. As for the at these water access points. These
water outlets are as much a community
place of transmission itself—you just need to find the water. gathering spot as they are a bathtub,
kitchen sink, and toilet for local villages.

A disease with an There are two very different types of activity happening along the
environmental reservoir shores of Mbarigo village. The village of 600 sits on a tributary of
the Senegal River. This shallow watering hole is one of three points
where residents have direct access to fresh water.

The water is a cloudy mix of sediment and soap. It surrounds a

group of young girls doing their afternoon chores, including
16-year-old Nafissatou Diagne. Knee-deep in the water, Nafissatou
is scrubbing her family’s colorful woven mat. She stops occasionally Director of The Upstream Alliance. Environmental changes like
to adjust her pink skirt, gingerly lifting the bottom seam from the warming, deforestation, or introduction of new species can increase
water’s surface. or decrease the persistence of parasites in the environment. That
xvii Do you know of other examples
includes boosting the population of river snails by installing a dam where something similar has
On either side of Nafissatou, Dr. Susanne Sokolow and Souleyman at one end of an ecosystem.xvii happened?
are wearing a slightly different uniform. Donning the high
waterproof boots often worn when fishing, their movements are
surprisingly agile as they scoop vegetation from the river bottom. Typha Taking Over
Mossy vegetation undulates gently around their legs.
Prawns and snails were two species impacted by construction of the Diama Dam. Another ecological effect of
Raising her scoop from the water, Sokolow picks through the the dam was an increased abundance of typhaxviii, an invasive wetland reed that thrives along the riverbanks of
knotted vegetation searching for snails. “The bulinus snails are freshwater ecosystems.
super attracted to this plant, probably because of all its surface
area. They get to eat all the algae on here,” she says. She extends a In no place is this altered river ecology more apparent than at the Diama Dam itself. Standing along the land
gloved hand to reveal the miniscule snails she’s extracted from the barrier that separates the dam and the Mauritania side of the Senegal River, one can easily see the difference
vegetation. between the natural and altered ecology.

Schistosomiasis is a vector-borne parasitic disease. It relies on an On one side, the bank of the river is still visible and bare of vegetation; on the other, a dense mat of healthy
environmental reservoir, meaning its transmission cycle includes a typha fringes the river’s edge. Its increased abundance is both a nuisance and a public health risk. For one, its
significant component in the environment outside a human host. overgrowth restricts the ability of villagers to reach their water access points.39 Typha can also clog pumping
This is the case for many of the world’s most prevalent diseases: stations used to supply water to irrigated agriculture.
malaria, typhoid fever, and zoonotic diseases such as Ebola and
Nipah virus, just to name a few. In the case of schistosomiasis, Typha has also been connected with the presence of schistosomiasis. In Zimbabwe, an increased number of
the environmental component is the time the parasite spends in snails has been found to correlate with the presence of typha reeds,40 and the same is suspected in the Senegal
snails, as well as in the water in search of a human host. “Because River Basin. Typha is common in each of the water access points studied by The Upstream Alliance in the Senegal
the pathogen of these diseases stays in the environment for a River Basin.41
considerable amount of time, there is the obvious opportunity
xviii Pronounced TEA-fuh. Goes by the
for a wide range of environmental drivers to affect their survival,” common name cattail.
says Dr. Giulio De Leo, a Stanford University biologist and Science
100 101
Raphael Ndione from the Senegalese
biomedical research centre Espoir The health and environmental consequences weren’t of particular
pour la Santé (EPLS) works with Andy surprise to OMVS, the group behind the Senegal River dams.
Chamberlin and Dr. Susanne Sokolow “We knew that we were going to face many problems after the
from Stanford University to collect snails
from the shore of the Senegal River. These
construction of the [Diama] dam, but when we compared the
snails will later be dissected and examined drawbacks and the advantages we realized there were more
for the microscopic parasite that causes advantages,” says Adama Cheibany, technical manager of the
schistosomiasis. Diama Dam. He again references the increase in irrigated
agricultural land, the availability of freshwater, and the generation xxi If you were to weigh the pros and
of clean energy provided by the Diama Dam’s sister project, the the cons of the large infrastructure
project, what things would be most
Manantali dam. “Now we are trying to minimize the negative important to you when making a final
impacts,” Cheibany says.xxi decision on whether to build it or not?

Schistosomiasis is caused by a parasitic organism that lives either

on or in a reservoir host. In Senegal, there are three common
species (and a few other less common species42) of snails that serve
as the intermediate reservoir host for the schistosomes that infect
humans43, though other mammals like livestock can also be hosts.
Infection happens when people come in contact with parasite
infested waters.

Driven by warm temperatures to leave the snail’s shell, the

parasite propels itself through the water in search of a human or
mammalian host. This is why, at the water access point in Mbarigo
village, Sokolow and Souleyman are wearing wader boots. It’s
also why the group of girls, including Nafissatou, are at risk of
contracting schistosomiasis.

Once the parasites have found a human host, they burrow through
the skin and live as adult worms in the veins surrounding the
xix Schistosomiasis has a specific bladder (for urinary schistosomiasis)xix or intestines (for intestinal
tissue tropism to these organs. What schistosomiasis). Female worms can lay as many as 300 eggs per
other parasites have a particular
affinity for certain organs? Why do day.44 Bearing a sharp barb on their side, eggs become lodged in
you think this happens? human tissue. This deposition of eggs and their exit from the
↘ Learn more here body can cause severe tissue damage and is the cause of blood in a
person’s urine or stool. ↘ Appendix 1: CDC schistosomiasis diagram

A person infected with schistosomiasis is immediately at risk of

Tapped water is available in some
spreading the disease to others by urinating or defecating the eggs Senegal River Basin villages, but it costs
xx How many people in your country into or nearby a water source. The eggs hatch into larvae which money to access. Despite understanding
do not have access to improved find a new snail host, completing the life cycle. More snails, more the connection between the water and
sanitation facilities? How about in schistosomiasis, poverty means that
Senegal? And in the world? schistosomes, and an increased likelihood of people coming into many people have no choice but to
↘ Learn more here contact with the disease.xx continue using the river.
102 103
Past Interventions: Mass There have been several unsuccessful attempts to reduce or High costs and an inability to distribute praziquantel more
Drug Administration and eliminate schistosomiasis rates in the Senegal River Basin. A frequently are two of the challenges and limitations to MDA
Sanitation reason for that failure is that interventions typically target only campaigns, says Dr. Gilles Riveau, CEO of the Biomedical
one arm of transmission, focusing on the reduction of disease Research Center Espoir Pour La Santé (BRC EPLS), a Senegalese
xxi These approaches are known as
reductionist approaches. Do you know in humans while ignoring that the problem is also mitigated by institution based in Saint-Louis. BRC EPLS has been addressing
what the opposite approach is called? environmental conditions.xxi schistosomiasis and other parasitic diseases in the Senegal River
Basin since 1991, and the institution’s research helped influence
A decade before the first cases of intestinal schistosomiasis the methodology of the country’s MDA campaigns. “You have
were discovered in Richard Toll, another medical discovery to find a way to use [praziquantel] that meets the economic and
was made. The innovation was praziquantel, a new therapeutic access issues in a country,” Riveau says. ‘How can you reach the
drug to treat parasitic worm diseases, including intestinal and people with the products? What methods will you use? Who will
urinary schistosomiasis. By the mid-1980s an estimated one give the drugs? You develop an incredibly long list of questions and
million patients had been treated safely and successfully on three you have to find the way to be the most efficient.”
continents45 and the global health community was optimistic that
praziquantel could be a means to treat schistosomiasis.
Schistosomiasis Vaccine: A Work in Progress
By 2001, the distribution of praziquantel through mass drug
administration (MDA) campaigns had become the key control Researchers around the world, including in Senegal, have spent the past several decades working towards a
strategy for schistosomiasis worldwide. MDA is the treatment of schistosomiasis vaccine. It was under the pretense of developing a vaccine that Biomedical Research Center
xxii Have you ever been exposed to an targeted populations without individual diagnoses.xxii In the case Espoir Pour La Santé (BRC EPLS), a Senegalese research hub and NGO was founded in 1995 by Dr Gilles Riveau.
MDA campaign?
of schistosomiasis in Senegal, the campaigns targeted school-age BRC EPLS is The Upstream Alliance’s scientific and community partner in Senegal.
children between the ages of 5 and 14-years-old. This demographic
has the highest risk of schistosomiasis infection and faces the Bilhvax (Sh28GST), a vaccine for urinary schistosomiasis, showed promise when trialed on non-human primates
longest-term health implications due to their young age. and cattle. However, human clinical trials have yet to show efficacy.47 The most recent phase III of clinical
trials involved 250 school-aged children in the Senegal River Basin. The vaccine was administered alongside
Praziquantel is highly effective under certain circumstances. A praziquantel to see if together they could delay reinfection of the disease. Follow-up assessments over the
trial from the 1990s found that two treatments of 40 mg/kg given course of three years found there was no significant difference between the half of children who had gotten the
40 days apart “cured” three out of four individuals—meaning they Bilhvax vaccination versus those who were injected with a placebo.
had “worm burdens below the detection level.”46 Double doses of
praziquantel given in this schedule also reduced the intensity of Another vaccine currently in clinical trials is the Brazilian-developed SM14/GLA-SE. The next trial phase will
schistosomiasis by 88%, which is to say individuals had a lower involve 95 school children living in areas of the Senegal River Basin. BRC EPLS is overseeing this trial and
burden of worms in their system. supervised the one performed for Bilhvax. While vaccine development and testing is underway, BRC EPLS relies
on other interventions to lessen the burden of disease in the basin. That includes working with The Upstream
However, most Senegal River Basin residents are not able to get Alliance on the prawn project, and also supporting government MDA campaigns for praziquantel.
two doses of praziquantel treatment. This is usually because of the
cost of the medication and an inability to reach a health post to “We wanted a tool to fight the pressure of the disease, and praziquantel leaves people in relatively good shape
purchase the drug. Since 2009, annual large-scale MDA campaigns even if they will be reinfected one day after,” says Gilles Riveau, Executive Director of BRC EPLS. “It wasn’t
have aimed to address schistosomiasis in Senegal. During those logical for us to think we could only focus on the vaccine if you remember that we are at the service of the
campaigns, doses of praziquantel are distributed to school-age population. In the short term we have to use praziquantel and in the far future we have to work on a vaccine.”
children and at-risk adults. Funding for Senegal’s National Control
Program currently depends on the World Bank. Like the prawn intervention, there is the possibility that a successful vaccine be incorporated into control
programs for schistosomiasis alongside existing interventions like praziquantel rather than being seen as a
standalone “silver bullet” solution.

104 105
 Dr. Idrissa Talla later became head of the National Control Program “The pills work great, it’s just that in a zone of transmission that’s
of Schistosomiasis. He agrees that the logistics of praziquantel as high as this, kids end up being almost on a treadmill where
distribution were the greatest obstacle. “The medicine was they’re treated and they get re-infected at such a rate that it negates
there, people were trained, and the populations were aware of the treatment,” explains Dr. Susanne Sokolow. “If it were a low risk
the necessity of the medication. But you still had logistics. The area where you wouldn’t acquire new worms so rapidly after going
government needed to give us cars, but we had to ask for money back in the water, then you could march towards elimination
outside of the country instead. That was a weakness, and I think through drugs alone.” Today, prevalence rates of urinary and
that it hasn’t much changed,” he says. intestinal schistosomiasis among children in the Senegal River
Basin are estimated at between 90 and 100%.50
MDA campaigns have another catch: even if there was a way to
regularly treat those at risk of contracting schistosomiasis, it
still wouldn’t be enough. The drug kills only the adult worms in The Socioeconomics of Schistosomiasis transmission is also exacerbated by social and
humans, and doesn’t address the environmental reservoir—the Disease Transmission economic factors, variables that can’t be addressed by drugs.
snails. That means a child treated as part of an MDA program can Transmission of disease requires exposure to infected water, and the
go back into the water an hour later and not only get new worms, water access points of villages and murky rice paddy fields provide
but release eggs into the water if they urinate or defecate nearby. an ideal environment. In theory, improved sanitation and drinking
The cycle continues. water infrastructure could reduce the risk of transmission, but that
hypothesis is imperfect in real-world application.

From Corsica, With Love A 2004 study investigated the hygiene practices of children and
mothers with infants in Northern Senegal. It found that more
Schistosomiasis has recently made the news in unexpected places. A popular tourist destination in the than two-thirds of children rarely or never used latrines, and that
middle of the Mediterranean Sea, the French island of Corsica experienced an outbreak of over 120 cases of a quarter of kids defecate in or near water,51 releasing parasitic eggs
urinary schistosomiasis in the summer of 2013. Tourists and locals, some of whom had never left Europe, were as a result. Disease transmission is also common among adults who
exhibiting symptoms of schistosomiasis after swimming in the island’s Cavu River. use rivers for bathing purposes following defecation. While some
latrines are available, particularly in schools, many are not used or
Interestingly, the cases in Corsica were caused by a hybrid of two schistosome parasites. Just as travel are deemed too dirty.
contributes to the spread of parasites worldwide, studies suggested the schistosome culprits in this outbreak
could have been introduced by a person who was either infected in or visiting from Senegal.48 Hoping to reduce rates of schistosomiasis through infrastructure
alone also neglects the importance of the river in people’s identities
Ultimately, it’s not enough for an infected individual to urinate or defecate near a water source—there also and livelihoods. “We could not imagine life without the existence
needs to be the correct species of snail to serve as a reservoir for the disease. While the implications of of the river,” says Alassane dit Baye Ndiaye, a resident of Lampsar, a
precipitation, climate, and land use change on snail populations and schistosomiasis prevalence are still being village upstream from Mbarigo. “Every family here has a fisherman,
determined, initial research suggests snail survival rate is affected by temperature.49 Further data show that a farmer, or someone who is breeding animals. For all those activities
deforestation in some areas can favor transmission of schistosomiasis and other vector-borne diseases by you need water.” Standing near one of Lampsar village’s water access
allowing more sunlight and warmth to reach water bodies. Overall, changes to the Earth’s natural systems could points, Ndiaye is surrounded by activity. A group of young boys
eventually lead to high rates of schistosomiasis in some areas and a reduced risk in others. splash joyfully; large silver platters bob just below the surface of the
water waiting to be washed by a pair of girls; a mother prepares to
According to Dr. Giulio De Leo, it’s important to remember that there will be people who win and lose with bathe her infant son.
these environmental changes. “An increase in temperature might actually remove a disease in places that
become unsuitable for the parasite to complete its life cycle because it’s too hot,” he says. “Given the level of While Ndiaye says there are families who try to only use tap water,
climate change expected and the extent of land use change through agriculture and urbanization, we know we this ultimately isn’t realistic. “You can sensitize children and tell
are going to be dealing with these new challenges in the future to come.” them to only use taps, but you can’t prevent them from coming
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here,” Ndiaye says of the river. As if on cue, the gaggle of young boys Awa Diop stands with three of her
shriek in a splashing frenzy. “Even if children do not come here they nine children outside their home
are obliged to go to the fields and help water the gardens, so they in Lampsar village.
need to be in contact with water. Many people have no other choice.”

Maguette Diop, the farmer from Maka Diama, has been infected
with schistosomiasis twice. Both times he has had to purchase
praziquantel treatment in the nearby village. He suspects he
contracted the disease while in his rice field. Despite these suspicions,
Diop wasn’t able to change his behavior: “it couldn’t prevent me
from coming to work every day,” he says.

Awa Diop, unrelated to Maguette, lives in Lampsar village with her

nine children. She’s tried to change the behavior of her kids since
two of her daughters contracted schistosomiasis after what she
suspects was a post-lunch bath. While she was able to afford the
cost of praziquantel for her children, she says this might not always
be the case. As a result, she’s limited her kids access to the river,
encouraging them instead to use the tap and well water on their
property for chores. That means they could avoid all contact with
the river—technically. “If they had the choice they would rather do
laundry in the river since it’s easier and cooler,” Diop shrugs. And
unlike tap water, the river is free. “With the river you don’t need to
collect water or change the water in your bucket. It’s a bit complicated
when they can’t go there.”

Tap and well water isn’t an option for other families living in the
Senegal River Basin, despite its proximity to Lac de Guiers. That lake
is the most important freshwater reservoir in Senegal, and is the
primary water source for Dakar, located 160 kilometers southwest
of the lake. While Senegal’s urban areas have water coverage and
sanitation rates sitting at 93% and 89% respectively, this drops to
71% for water coverage and 43% for sanitation in rural areas.52 These
disparities put rural communities at a higher risk of waterborne
diseases like schistosomiasis.

The socioeconomic barriers faced by families combined with the cost

and logistical limitations of MDA campaigns mean actors battling
schistosomiasis have had to turn their gaze in new directions. To
The Upstream Alliance, that pluralization of ‘directions’ is key.
Prawns could be the missing piece in a suite of solutions that address
the complex layers of environmental, social, and economic factors.

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More Prawns, Fewer Before the advent of praziquantel, the public health community had Over the course of the pilot study, thousands of snails were collected
Snails, Less Disease no choice but to consider how changing environmental conditions from the two village water access points, dissected, and analyzed
could reduce or eliminate schistosomiasis. This approach has for signs of infection from schistosomes. The study also looked at
had success in a number of countries worldwide. Japan drained whether praziquantel, the drug used in MDA campaigns, could be
xxiii Molluscicides are pesticides used its wetlands, used chemical molluscicidesxxiii, and cemented its more effective when combined with a prawn intervention. Midway
to kill mollusks, including snails. While irrigation canals, reducing weeds and snail habitat as a result.53 By through the study, participants were given two consecutive doses
they often accomplish this mission,
they can also affect other species. 1994, schistosomiasis had been eliminated from the country. In of praziquantel three weeks apart.
the past century, countries and territories from Iran to Morocco
to Puerto Rico have used snail control to completely eliminate the By the end of the pilot study, the abundance of infected snails
disease. Nearly a dozen others have used snail control methods to had dropped by 80% in Lampsar, the prawn-stocked village.55
reduce prevalence of the disease by more than 90%.54 The global Importantly, there were also fewer schistosome eggs found in the
evidence supports that environmental controls can also address stool of villagers, meaning the intensity of infection in people
schistosomiasis, rather than relying on drug administration alone. had been reduced to a rate where praziquantel could cure in the
long-run, rather than simply treat. There were more prawns, fewer
For The Upstream Alliance focused on the Senegal River Basin, snails, and less disease.
prawns are one potential environmental control method. With
increased risk of schistosomiasis attributed to dammed river Expanded studies across 16 villages support that finding. An Dr. Susanne Sokolow dissects snails in
catchments, a decline in the native river prawn population, and epidemiological model developed from those observations the Espoir Pour La Santé laboratory in
Saint-Louis.
an increase in snail hosts—as well as the limitations of MDA demonstrates that continued MDA campaigns alongside a prawn
campaigns in high-risk regions like Senegal—the next step was intervention offers the most rapid reduction in the burden of
for the team to prove that reintroducing wild river prawns into the schistosomiasis.56 This emphasizes The Upstream Alliance’s
could reduce the burden of disease. argument that it’s not about finding one right answer. “If you give
the drug and control the environmental risks at the same time,
To do that, the Stanford team joined with Espoir Pour La Santé whether that’s through improved WASH standards, molluscicides,
(BRC EPLS), the Saint-Louis based biomedical research center, to or prawns, it’s going to be synergistic,” says Dr. Susanne Sokolow.
run their first trial stocking of native prawns in villages. Scientific “You’re balancing the equation so the worms you’re getting rid of
expertise came from both groups. The collaboration with EPLS are not being replaced rapidly. You end this perpetual cycle.”
was key in making it possible to test the prawn intervention in
Malacologist and Lampsar village
resident Alassane dit Baye Ndiaye partnership with affected communities. EPLS had been working ↘ Appendix 2: Figure 4A from 2019 Hoover et al paper
holds one of the snails that serves as an with Senegal River Basin villages for more than 20 years. “[EPLS] is
intermediate reservoir for the parasite not using the local population as a guinea pig, but they’re working In scientific principle, The Upstream Alliance has proven its reduced
causing schistosomiasis. Ndiaye has led
sensitization and education workshops
with them to try and solve environmental and public health snails-reduced disease intervention in Senegal. But challenges still
with community members, but notes that challenges that are taking a big toll on people locally. They really exist in getting enough prawns into the villages where they could
it can be difficult to ask people to stay were our eyes and ears in the field,” says Dr. Giulio De Leo. affect the prevalence of disease. The adult prawns used in the pilot
away from water access points. trials were either imported from Cameroon or fished out of nearby
In 2012, the project reintroduced native M. vollenhoveni river prawns estuaries. What’s next for this planetary health intervention is
into Lampsar, one Senegal River Basin village. The prawns were put determining how to get a steady, locally-sourced stock of prawns.
in a mesh net enclosure spread across the village water access point. To do that, The Upstream Alliance needs to focus on expanding a
The prawns were able to prey on snails that entered the enclosure. nascent industry.
Another nearby village served as the control site for the study. The
water point in this second village was not stocked with prawns,
allowing researchers to compare and determine if the presence of
prawns did, in fact, impact schistosomiasis transmission.
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Putting Prawns Back Re-introducing prawns to Senegal River Basin villages could have
on the Table a positive impact on public health—and that’s not all they could
do. If sustainably managed, the prawns could restore the Senegal
River’s fishery which had been disrupted by the construction of the
Diama Dam. The domestic breeding of prawns could also support
the growth of the aquaculture industry, a priority for the Senegalese
government. Finally, prawns could provide an important source of
xxiv Aquaculture is an increasingly food and protein for people living in the region.xxiv
“popular” technique to combat
poverty and food security challenges.
Can you find global trends on what Senegal’s aquaculture industry has grown steadily over the last
types of species predominately are decade, and production expanded by 46 fold between 2007 and
fished, what countries predominate 2016.57 The growth in Senegalese aquaculture is consistent with
in the industry, and the benefits and
challenges of various types (coastal, global trends—especially important as marine fisheries decline
offshore) or species type (algae, worldwide.58 Globally, the Food and Agriculture Organization of the
shellfish, finfish)?
United Nations (FAO) acknowledges that sustainable intensification
of aquaculture could fill the gap of livelihood creation and food
xxv What are the negative security. There’s a long way to go.xxv As of 2016, sub-Saharan Africa
consequences of the intensification of contributed less than 1% to the global production of aquaculture.59
aquaculture?
Aquaculture is still a nascent sector in the region, and this figure is
perhaps not surprising given the region’s limitations in freshwater
access, technology, governance, energy supply, and technical capacity.

Aquaculture and the Blue Economy

Aquaculture constitutes nearly half of the world’s fish production and provides 53% of fish for human
consumption.60 Not limited to fish species, aquaculture production also involves the production mollusks,
crustaceans, and aquatic plants and algae. In its 2018 State of the World Fisheries and Aquaculture Report, the
FAO notes aquaculture is growing faster than any major food production sector worldwide. With the world’s
population expected to grow to 10 billion by 2050, sustainable intensification of aquaculture could be key in
ensuring everyone has access to nutritious diets.

The majority of aquaculture production (90%) occurs in Asia. China is the leading producer, with production
rates nearly four times higher than the world’s second top producer, Indonesia. India, Vietnam, and Bangladesh
round out the top five list in terms of aquaculture production.61 While the earliest forms of aquaculture have been
around since the Neolithic period (some estimate 4,000 B.C.), the industry is less than a century old on the African The fledgling hub of Senegal’s prawn aquaculture industry is a large A group of men prepare to catch pond-
continent.62 hatchery warehouse on the property of Gaston Berger University, a grown prawns that are being bred as part
of SIA breeding trials.
30 minute drive from Saint-Louis. Papa Demba Ndao rolls back the
There are a number of aquaculture methods, with operations taking place on land, in the ocean, and in large metal door to reveal the operation that, if and when it reaches
freshwater. These techniques vary in productivity and environmental impact. For example, tilapia and shrimp are capacity, could produce one million prawns a year for up to 1,000
typically farmed using a pond method. If not treated and filtered, wastewater from these ponds can pollute the villages in the Senegal River Basin. There’s not much happening
surrounding environment. This is what we saw in the Sri Lanka case study, where shrimps farmed using intensive during this time of the year — Wjust Ndao and a colleague amidst
pond aquaculture had a devastating effect on mangrove ecosystems. Contained systems typically have a lower the droning whir of one of the prawn tank filters.
environmental impact, as wastewater is managed and species are prevented from escaping into the surrounding
ecosystem. SeaChoice outlines the many types of aquaculture methods on its website.

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 Ndao is an aquaculture engineer with Station d’Innovation Aquacole ventures worldwide have 80% larval survival. “So we have a long
(SIA), an arm of The Upstream Alliance that runs this operation. way to go,” says Dr. Susanne Sokolow. “The biology is challenging.
The hatchery is headed by Nicolas Jouanard, Executive Board We have the world’s experts on it, both in Senegal and outside.”
Member of The Upstream Alliance. He also works for Espoir Pour One of the options is to potentially import an all-male cohort of a
La Santé. non-native freshwater prawn, Macrobrachium rosenbergii, in place xxvi Introducing non-native species
might have negative consequences.
of the native prawn (see textbox 5 for more information about the What are they? What are some
In the Senegal River Basin, this hatchery is an essential piece of implications of this introduction).xxvi examples from around the world?
infrastructure needed to make a prawn intervention possible. With
the Diama Dam still impeding the ability for prawns to migrate up “Any species is complicated to breed in a context where the
and downstream, aquaculturists need to imitate the reproduction aquaculture sector is embryonic,” adds Nicolas Jouanard, CEO
cycle that existed naturally in the basin’s environment. That of Station d’Innovation Aquacole. Successfully domesticating the
requires the regular adjustment of water temperature and quality, prawns in the hatchery is one piece in the puzzle. The other is
salt water content, and food sources to ensure prawns and new getting the adult prawns to survive the precarious conditions of
larvae have the ideal conditions to survive and reproduce. village water access points. To-date, the ability for prawns to eat
the snails and reduce disease has been challenged by the fact that
However, a key challenge has obstructed progress so far: M. the enclosure is not durable enough to survive the demanding
vollenhoveni, the native African river prawn that The Upstream environment of these water sites. The prawns either die or are
Alliance used for its pilot prawn interventions, has never been collected before they can serve their public health purpose.
successfully domesticated.

Aquaculture ventures that currently exist in Senegal focus on tilapia Next Steps for Prawn Progress
and catfish, two fast-growing species that are low-maintenance
Papa Demba Ndao holds two M.
vollenhoveni prawns at the Station when it comes to water quality and the food needed for survival. The Upstream Alliance has considered three options for raising the prawns needed to make any future venture
d’Innovation Aquacole (SIA) prawn While tilapia and catfish can go from fingerling to fish in just six a success. The first was the attempted domestication of Macrobrachium vollenhovenii, the native river prawn
hatchery. This is one of the locations months, the process of prawn reproduction and raising larvae can from West Africa. The team is looking at what comes next after pilot attempts to domesticate the prawn yielded
where The Upstream Alliance has raised
the prawns needed for its intervention,
take four months alone, with another minimum of seven months a maximum of 5% survival rate during the larval rearing phase.
and it will continue to be a central hub for the prawns to grow to their adult size.
for future research and development. One option is to fish M. vollenhovenii prawns from estuaries in Senegal and other parts of West Africa, growing
“Prawns are very demanding and expensive because they need a them to size in an outdoor pond before transporting them to villages or selling them to the market.
lot of attention,” says Ndao, scooping one up off the bottom of the
tank and holding it in his hand. Its exoskeleton is delicate and soft A third option may provide faster prawn growth and, as a result, more commercial and public health gain.
to the touch—it has just gone through a molting stage. “Compare That option involves introducing Macrobrachium rosenbergii, the variety of giant river prawn commonly used
this prawn with catfish which can almost grow in a tank without for aquaculture ventures worldwide. However, there’s a catch: as a non-native species to Senegal there is the
air. That’s not okay for prawns. You must have aeration and that concern of how an alien species could affect existing biodiversity. The Upstream Alliance is working with Ben
needs electricity,” Ndao says. Unfortunately, consistency of power Gurion University in Israel to trial the introduction of transgender female prawns —changing the sex of M.
supply isn’t always a given in Senegal. rosenbergii from female to male ensures that only male offspring are produced. Laboratory tests have found
no evidence of cross fertilization between the local and single-sex species.63 This means introduced all-male
Unlike the adult M. vollenhoveni prawns that were used for The prawns could be bred for aquaculture purposes without a risk of the population exploding out of control.
Upstream Alliance’s pilot studies, the long-term sustainability of
this intervention depends on raising prawns from larval stage. So The Upstream Alliance received a permit from Senegal’s Ministry of Environment in order to import M.
far, SIA’s breeding trials report a maximum of 5% survival during rosenbergii from Israel. That importation of 15,000 M. rosenbergii post larvae will allow the team to begin
the larval stage. Successfully creating a new business venture would to understand the challenges of growing the species using the resources and conditions available in Senegal.
require at least 20% survival, and more developed aquaculture
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“[The enclosure is] just a net, and everything can happen in the Beyond the Ivory Tower: In the future, The Upstream Alliance aspires to grow Station
village. It’s a public space and people do their laundry, dishes, and A Business Case for d’Innovation Aquacole (SIA) into a for-profit social enterprise.
wash themselves and their animals. It’s basically the worst place in Prawns Social entrepreneurship fuses the for-profit mentality of the
terms of water quality,” says Jouanard. “If I were a prawn I would business world with the social impact more commonly associated
also do everything I could to escape.” Ultimately, he doesn’t see the with non-profits—demonstrating that financial success and
enclosure nets, which were designed for research purposes, as a positive impact are not mutually exclusive ambitions. Some dots
translatable solution for prawn aquaculture. need to be connected between The Upstream Alliance’s current
work and investors before that can happen.
Alassane dit Baye Ndiaye, a resident of Lampsar village, saw this
problem firsthand. Ndiaye was responsible for maintaining the SIA’s business model is to use aquaculture to eliminate
prawn enclosure in his village during The Upstream Alliance’s pilot schistosomiasis in the Senegal River Basin. A percentage of the
study. At first, he says there were some struggles with the enclosure prawns domesticated at the SIA hatchery would go directly free-of-
because people didn’t know its purpose, and kids and fishermen charge to villages where they could be stocked in nets, rice fields,
alike tried to cross the net to reach the other side of the river. By or another location as a way to lessen the number of snails and, as
the end of the trial period, though, he says people in the village proven by pilot studies, reduce schistosomiasis alongside strategic
understood the role the prawn could play in their health. “Even administration of praziquantel. Once prawns reach maturity, they
when people saw a dead prawn they would come to my house and could be harvested and sold or eaten by villagers, improving food
tell me. So they knew the importance of the prawns,” Ndiaye says. security and providing a new livelihood opportunity.
“We would be pleased to again see them back in the village.”
The remaining prawns from the hatchery would be sold to high-end
The Upstream Alliance is investigating ways to introduce prawns restaurants and hotels, with the revenue from those sales funding
in villages without the need for a net enclosure. There’s been the continued restocking of prawns in Senegal River Basin villages.
discussion that adding prawns to rice paddy fields could provide The sale of prawns to these restaurants and hotels means market
a more hospitable environment while limiting the frequent public demand would fund schistosomiasis interventions, allowing SIA
visits and household pollution of water access points. Another goal to generate its own revenue and be financially sustainable.
would be to encourage the company that manages the Diama Dam
to construct a prawn ladder—a piece of infrastructure that would If successful, this for-profit model would allow The Upstream
again allow prawns to naturally migrate up and down the river. Alliance to escape the time and focus constraints of traditional
The original species collapse may have been avoided had this cost- research grants or donor funding. Typically funded for just a few
effective measure been taken in 1986. years, the short-term cycles of these forms of financing aren’t
necessarily well suited for the longer timeline needed to establish
The Upstream Alliance team has also calculated the prime stocking an aquaculture venture in an emerging market. Further, grants
density of both the native M. vollenhoveni and the non-native are often limited to one discipline—funding research related to
M. rosenbergii prawns in order to effectively complement MDA human health or ecology or aquaculture. The Upstream Alliance
campaigns. Those calculations include the optimal harvest time is concerned this restricted scope may not be a good fit for the
of prawns as well as the economic and food benefits each harvest multidisciplinary nature of its work.
would yield. For example, the non-native M. rosenbergii would be
optimally harvested every 165 days, yielding about 1,560 prawns each The feasibility study and business plan for SIA’s for-profit model
time. That would bring in a 10-year average of US $5,400 with every was developed by a team from the Middlebury Institute of
harvest.64 These economic calculations may seem outside the realm International Studies at Monterey, California. The Upstream
of The Upstream Alliance’s original public health mission, but the Alliance had reached out to the institute, wanting to prove to
team believes that if the prawn project is going to have sustainable potential investors that they weren’t only biologists, ecologists,
long-term health effects there also need to be economic benefits. international development practitioners, and epidemiologists
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A prawn from the SIA facility. —but savvy business people, too. They enlisted the help of
Middlebury MBA students Tyler Higginson and Matthew Salyer,
alongside economics professor Constantin Gurdgiev. Higginson
visited Senegal to do market research and complete the feasibility
study while Gurdgiev designed the venture’s funding model.

While The Upstream Alliance has proof of concept for its health
intervention, the business feasibility of the project is still only
theoretical. This means the project remains in the research and
development stage, and the business is looking for investment that
could be used to start producing prawns and test the Minimum
Viable Product (MVP) model. Gurdgiev estimates it would take US
$60,000 to launch the MVP for the prawn venture. This start-up
capital would fund upgrades to the current hatchery and allow for
a first round of prawn breeding to fully assess market demand.
Launching a new venture in addition to the existing pilot hatchery
would require an additional ~$335,000 in capital expenditure.
Based on Gurdgiev’s market analysis, it would take 10 to 12 months
from securing funding to produce the first commercially-viable
batch of prawns.

According to Higginson’s feasibility study, there is a market for

prawns, both in Senegal River Basin villages and among high-end
restaurants and hotels. “People are eager for it. They really enjoyed
them in the past, almost to a nostalgic level, and they truly want
the prawns,” he says.

As well as supplying the market with an in-demand product, SIA’s

mission would also accomplish two desires of the Senegalese
government: helping the country accomplish its priority of
growing the aquaculture industry all while addressing a persisting
public health concern. As a result, Higginson says SIA could
possibly introduce something like a social impact bond—where
the government pays the venture to expand the social impact
side of its business (the stocking of prawns in villages to reduce
schistosomiasis). “For example, the government could help
subsidize the lost revenue of the prawns that go to impact rather
than to market,” Higginson says. “I think we will find a certain
level of cooperation because we are addressing that social and
health need.”

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Epilogue In the end, SIA and The Upstream Alliance need more time.
Time to import the all-male M. rosenbergii prawns. Time to see
whether they can be domesticated in Senegal. Time to create a new
solution for how the prawns should be stocked in villages. Time
(and funding) to establish whether its for-profit model could be a
success in the first place.

Those many waiting periods and paced progress illustrate what

Dr. Giulio De Leo from Stanford says is one of the key learnings
of planetary health interventions: the need for endurance and
patience when dealing with projects and teams that are complex
and multidisciplinary. He admits that this longer time scale can
sometimes seem exasperating, particularly when dealing with
challenges as urgent as the ones currently facing the world.

The story is far from finished in Senegal. Members of The

Upstream Alliance team from the University of South Florida will
be continuing their work looking into the effects of agricultural
fertilizer on the spread of schistosomiasis. Generally, as well as
through their work in Senegal, The Upstream Alliance team
is hoping the planetary health community can develop a suite
of tools so decision makers are better equipped to consider the
environmental and public health implications of a development
project—before it happens. Finally, they’d like to eventually take
the prawn intervention on the road, applying it in countries like
Brazil where there are increasing rates of schistosomiasis, native
river prawns, and a more robust aquaculture industry.

It is tempting to simplify and point to prawns alone as the ideal

intervention to eradicating schistosomiasis. But as The Upstream
Alliance and those responding to the disease worldwide have
learned, there is no one-size-fits-all answer. Instead, it takes
a portfolio of tools developed from years of multidisciplinary
expertise, consideration of the dynamic variables that affect a
person’s health, and sometimes, a business case to drive it all home.
As Dr. Susanne Sokolow puts it: “complex problems, complex
solutions.”

120 121
Keeping Track Adama Cheibany Dr. Giulio De Leo Nafissatou Diagne Awa Diop Maguette Diop
of Who’s Who
Technical manager of the Diama Dam Professor of Biology and Senior Fellow at Resident of Mbarigo village Resident of Lampsar village Farmer and resident of Maka Diama
with Société de Gestion et d'Exploitation the Woods Institute for the Environment,
de Diama (SOGED) Stanford University; Science Director
with The Upstream Alliance

Alassane dit Baye Ndiaye Constantin Gurdgiev Tyler Higginson Nicolas Jouanard Papa Demba Ndao
Malacologist and resident of Lampsar Economics professor at the Middlebury Former MBA student at the Middlebury CEO of Station d’Innovation Aquacole; Aquaculture engineer with Station
village Institute for International Studies at Institute for International Studies at Executive Board Member with The d’Innovation Aquacole
Monterey; Member of the business Monterey; Member of the business Upstream Alliance
development team for The Upstream development team for The Upstream
Alliance Alliance

Dr. Gilles Riveau Matthew Salyer Dr. Susanne Sokolow Dr. Idrissa Talla
CEO of Espoir Pour La Santé; Science Former MBA student at the Middlebury Disease epidemiologist and veterinarian Epidemiologist and Head of the
Director (Senegal) with The Upstream Institute for International Studies at at Stanford University; Executive Community Health Programme in the
Alliance Monterey; Member of the business Director of The Upstream Alliance public health department at the Universite
development team for The Upstream Amadou Hampathe Ba; former head
Alliance of the National Control Program of
Schistosomiasis

Acknowledgements To everyone directly quoted in this case study: thank you for taking
the time to speak with me about your work, lives, and livelihoods.
Coordinating my time in Senegal would not have been possible
without Nicolas Jouanard, Simon Senghor, and the entirety of
the Espoir Pour La Santé team. To Andy Chamberlin, Dr. Giulio
De Leo, and Dr. Susanne Sokolow: thanks for your work and for
sharing many an adventurous truck or car ride. Today, I’m happy
to consider you all friends. Constantin Gurdgiev, Tyler Higginson,
and Matthew Salyer from Middlebury Institute for International
Studies at Monterey helped with the financial section of this case
study. Tapha was my star interpreter in the Senegal River Basin,
and to him I extend the utmost thanks.

A water access point in Lampsar, one of

the Senegal River Basin villages where
The Upstream Alliance is working.

122 123
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Appendix 1: CDC schistosomiasis diagram ↘ Back to page Appendix 2: Figure 4A from 2019 Hoover et al paper ↘ Back to page

126 127
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
03
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Medical
Please cite this case study as “Duff H., Faerron Guzmán, C.,
Almada, A., Golden, C., and Myers, S. “Medical Clinics for
Planetary Health: The Surprising Link Between Logging and
Healthcare in Indonesia.” Planetary Health Case Studies:
An Anthology of Solutions. 2020; https://doi.org/10.5822/
phanth9678_3

Please note this work is licensed under a Creative Commons

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Planetary
Health
THE SURPRISING LINK BETWEEN
LOGGING AND HEALTHCARE IN INDONESIA
 Executive Summary This case study examines a connection between rainforest
conservation and affordable healthcare access in communities
surrounding Gunung Palung National Park (GPNP) in West
Themes of land use change and
deforestation are explored in the land
Kalimantan, Indonesia. It emphasizes that human and
use section of chapter 4 of environmental well-being cannot be seen as separate from one
↘ Planetary Health: Protecting Nature another. Specifically, it explores how deforestation impacts human
to Protect Ourselves. Environmental
determinants of infectious disease health and well-being, and how implementing co-beneficial
exposure are explored in chapter 6. solutions can improve human health while protecting natural
Developing business and economics ecosystems. Finally, this case study highlights the importance of
models more consistent with
planetary health are explored in collaboration to achieve planetary health, both within communities
chapters 15 and 16. and within organizational teams.

Learning Objectives Featuring the work of U.S.-based NGO Health In Harmony and
After examining this case, in relation
its Indonesian partner organization, Alam Sehat Lestari (ASRI),
to the communities surrounding GPNP, this case study details how a planetary health intervention that
students should be able to: integrates medical care, conservation education, reforestation,
➀ Understand the interlinkages
and livelihoods training has had positive benefits on human health
between deforestation and health. and the surrounding ecosystem. These benefits include a decrease
in deforestation between 2008 and 2018 around the GPNP, and the
➁ Analyze the push and pull factors of
deforestation. opening of a medical clinic, which has served over 33,000 patients
in that same time period.1
➂ Describe common barriers to
access healthcare services. This case study was developed based on interviews conducted in West Kalimantan,
Indonesia, in July 2018.
➃ Appraise the utility of bottom-up
approaches in the face of planetary
health challenges.

131
Introduction When Kinari Webb visited Borneo in 1993, the orangutans were After searching for an appropriate site to set up the program,
her first love. “It was said at the time that an orangutan could go Webb moved to Kalimantan with her husband Cam Webb who she
from coast to coast to coast on the third largest island in the world had originally met in Gunung Palung National Park when he was
without touching the ground,” Webb recalls in a 2016 TEDx talk. doing his PhD in rainforest ecology. In 2007, alongside Dr. Hotlin
“But even back then, you could hear that hated sound: the sound Ompusunggu and ecologist Antonia Gorog, they created partner
of a chainsaw. The trees they were cutting were so enormous that organization Alam Sehat Lestari (ASRI). ASRI is a dual community
when they hit the ground you could literally feel the Earth shake medical clinic and conservation organization in Sukadana, West
in your feet.” Kalimantan, Indonesia. A planetary health organization before
the term existed, ASRI provides people living in and around
In the beginning, Webb hated not only that sound, but also the Gunung Palung with the access and means to a livelihood outside
men wielding the weapon. But over the course of her year in the of logging.
rainforest, she met some of the loggers—and she started to listen
to what they had to say. What she heard were stories of impossibly
large responsibility, men who had to pay for their family’s needs,
including medication and emergency healthcare, while living in
subsistence conditions. From her conversations and follow-up
research, Webb learned families would spend approximately a
year’s income on medical emergencies like surgeries, caesarean
sections, wounds, and serious malaria cases. Those medical bills
would leave most in debt, and as it happened, illegal logging was
one of the best ways to get fast cash.

Near the end of her time in Borneo, Webb felt herself staring down
diverging paths. “I remember writing a list of the pros and cons
of doing conservation work versus health, and not being able to
decide between the two,” she describes. “This intersection wasn’t
on anyone’s radar, but I could see it from my own experience
talking to people. I had this real desire to focus on human health
and the protection of the rainforest.”

Instead of continuing orangutan research and working for a

traditional single-sector NGO, Webb decided to tackle one of
the root causes contributing to the loss of the species: the illegal
logging that was occurring to pay for emergency healthcare.
Finishing medical school in 2005, Webb—now with an MD after
her name—founded Health In Harmony. The organization started
with the understanding that human and environmental health are Gunung Palung National Park as seen
inextricably intertwined, and that the best way to save the forest is above ASRI's clinic. Photo courtesy of
to ask communities what solutions they think would work. Jocelyn Stokes.

132 133
 Gunung Palung National Park in West
Borneo and Gunung Pa- The close interaction between nature and people is evident even
Kalimantan, Indonesia, is home to
lung National Park: Biodi- before reaching Sukadana. The road into town is mercilessly 10% of the remaining wild Bornean
versity Hotspots bumpy, an amusement park ride through rainforest vegetation. orangutan population. The name
Just beyond, the distinctive branchless-trunks of giant dipterocarp orangutan comes from two Bahasa
trees extend a hundred meters into the sky, exploding into a dense Indonesian words: orang and hutan.
canopy shading the road from the afternoon sun. The translation, “person of the forest,” is
an indication of the connection people
Gunung Palung National Park (GPNP) and Sukadana are found feel to that species.
on Borneo in the Indonesian province of West Kalimantan. As an
island, Borneo is shared between Indonesia, Malaysia, and the tiny
nation of Brunei. The Indonesian portion of the island goes by the
name Kalimantan.

↘ Appendix 1: Three maps featuring the area where ASRI operates

One of the thousands of islands that compose Indonesia’s 5,000

kilometer archipelago, Kalimantan is home to eight national
parks. Gunung Palung National Park has tripled in size since it was
first protected as a forest nature reserve in 1937, and is considered
one of the best maintained examples of the primary lowland forest
that once characterized the island.2 Recognized as a national
park in 1990, GPNP now covers 1,080 square kilometers along
i Based on a map drafted by the park Kalimantan’s western coast.i
in 2014.

The area holds a special place in the hearts of many conservationists.

“Borneo as an island has one of the richest biodiversity levels in
the world,” says Mahardika Putra Purba, ASRI’s Conservation
Manager. “Some of the flora and fauna can also be found in
Sumatra (another of Indonesia’s islands) or Malaysia, but they were
originally from here. That’s what makes Borneo unique.”

Putra Purba further explains that 80% of that biodiversity can be

found within GPNP’s boundaries. That includes 2,500 critically-
endangered Bornean orangutans (Pongo pygmaeus), and the
park remains one of the last remaining places where orangutans
thrive in the wild. Other unique species join this list: endangered
proboscis monkeys with their peculiar long noses, vulnerable
clouded leopard and sun bear populations, and hundreds of species
of birds, mammals, and other primate groups, several endemic
to Borneo.3 Much of the region’s flora is also on the endangered
species list, including many trees within the dipterocarpus
genus—valuable tropical hardwood trees that form the foundation
of Kalimantan’s lowland forests.
134 135
The Intertwined Nature Rainforests provide invaluable health benefits for those living The ability of Gunung Palung’s forests to regulate pollutants
of Human Health and around them.ii There’s often a misconception that the people was tested by unseasonably high rainfall in 2017, which caused
Forest Health who exploit nature fail to understand the connection between flooding in and around Sukadana. Many people blamed this event
ii Before moving ahead, what do you environmental well-being and the health of their families. In many on the logged forests. The effect that land use and land cover
think these benefits are? cases, this couldn’t be further from the truth. change has on flooding in Indonesian Borneo was the focus of a
2016 study. It acknowledged that a major rainfall event can lead
iii “Pak” is the respectful honorific Early on a Sunday morning, Pak Sahmadiiii stands on the beach in to flooding even in ecosystems that have not undergone land use
used to refer to an adult man, the Sukadana. He’s preparing his boat for a fishing expedition, but for and land cover change—the clearing of land through logging, for
equivalent of saying “Mr.” in English.
Many Indonesians only use one name, now he’s marooned on the shore, a pool of muddy water reflecting example.9 However, the authors noted that natural land conversion
in this case, Sahmadi. his blue and red craft, and the towering rainforest beyond. The can result in increased flooding risk. These risks originate from
morning is quiet, but Sahmadi says it wasn’t always that way. a loss of groundwater storage in deforested areas, erosion and
sedimentation, and the role that man-made roads and footpaths
“Before, I heard the sound of many chainsaws here,” Sahmadi play in channeling the direction and speed of water.10
remembers. “Usually in the morning I would see trees falling from
where I stood.” The effects of logging became even more apparent When forests are intact, trees regulate heavy rainfall using their
when he would go to the rainforest to gather water. In the past, canopy and root systems. The canopy above prevents heavy rain
he says the number of drinking sources were declining, and many from falling directly to the ground. When rain filters through the
children were getting sick because of poor water quality. The water leaves, it reaches the soil at a rate in which it can be absorbed and
flowing into the villages around GPNP draws its source from three stored by root systems. This helps prevent flooding. The 2016 study
upstream watersheds.4 The watershed supplying Sukadana and reported that flood frequency was less likely in watersheds with a
other coastal communities is facing an acute human-caused loss greater level of intact forest, while villages within five kilometers of
of its lowland dipterocarp forest, despite being classified as an area a logged forest recorded higher-than-average recent flood activity.
of High Conservation Value.5
Past publications have directly and indirectly linked flooding to
Sahmadi’s observations linking the health of children in his village multiple health problems, including diarrhea, acute respiratory
with water quality are not purely anecdotal. Research conducted infections, skin infections, and non-communicable diseases.11vi vi What are the mechanisms at play
in 35 countries, including on the Indonesian island of Flores, has Dr. Nurmilia Afriliani, a General Practitioner and former Clinic here?

verified that link, finding a higher level of upstream tree cover Director at ASRI says this was reflected in the clinic’s patient
associated with a lower probability of downstream diarrheal diagnoses after the 2017 flooding event: “there were cases of
disease for children under five.6 The World Health Organization diarrhea and many bacterial skin infections because the water
iv What microbes are primarily (WHO) lists diarrheal disease as the second leading cause of death contained everything,” she remembers.
responsible for this high burden for children in this age group, killing around 525,000 children
of disease and mortality? You will
probably be surprised. annually. In total, there are an estimated 1.7 billion childhood The services provided by forest ecosystems have added importance
↘ Read more here cases globally each year.7iv in rural, lower income communities where people are more
vulnerable to the impacts of upstream tree cover loss.vii The vii Ecosystem services are widely
Preventing diarrheal disease is one of the ways in which forest aforementioned 2016 study of 35 countries found that 93% of discussed in the Chile-Aguas Andinas
Case Study. Make sure you review this
ecosystems safeguard human health. They do this in two ways: people relying on surface water live in rural communities, making concept before moving forward.
“by displacing human activities that can pollute the watershed, or the effects of watershed degradation disproportionately impactful ↘ Learn more here
by filtering or diluting pollutants from areas of human activity.”8 to these populations.
In other words, people are less likely to disrupt a watershed if they
can’t access it, and if they do gain access, tree cover provides a layer
v What do you think are the biological
mechanisms at play here? Does soil of protection so pollutants have a lesser effect on people living
play a role? downstream.v
136 137
 Pak Sahmadi on the beach in
Sukadana, West Kalimantan.
138 139
 In the communities around GPNP, the outcome of past deforestation BPJS health insurance coveragexii does acknowledge some of xii Attracting more patients who are
is already being witnessed: loggers and their families are the ones the socio-economic inequities that exist in the country. Less subscribed to a BPJS scheme is one
of ASRI’s future pathways to financial
most acutely affected by the domino health effects of forest loss. economically-fortunate Indonesians have their health insurance sustainability. As a healthcare
As Mahardika Putra Purba, ASRI’s Conservation Manager, points paid by the central government, which waives the cost of doctor’s provider, ASRI receives a monthly
payment based on the number of BPJS
out, communities and forests can continue functioning after fees, minor procedures, and limited medications. In smaller
patients who have listed the clinic as
the effects of deforestation, but the impact won’t go unnoticed: villages and towns where appointments are available only with a their primary care provider, regardless
“Imagine you cut off one of your arms,” Putra Purba says. “You nurse or general practitioner, patients can be referred to a free- of whether a patient received care
that month. As of time of writing,
can still live, but your activity will be limited. The balance of the of-charge hospital in what Indonesia classifies as a more advanced 1,000 BPJS patients had ASRI listed as
ecosystem is completely disturbed.” Type C, B, or A facility.xiii their primary care provider, and ASRI
aspires to grow that number to 10,000
patients in the next five years.
Although implementing universal health insurance relieves many
of the burdens of healthcare costs, it does not remove them all.
xiii Type D category medical facilities
Community Healthcare The forests surrounding Gunung Palung National Park (GPNP) are For example, the insurance does not account for the expenses of include small community clinics like
Access: A Multi-Layered home to many families. More than 107,200 people in 23 districts accessing healthcare away from home: costs like transportation, ASRI, including ones that aspire to
Challenge live around the park,viii and the population has grown steadily in accommodation, and food for a patient and at least one family reach hospital status.

recent decades. member. “Getting referred to another medical facility is okay in

viii The area around Gunung Palung big cities because everything is in the same area,” says Dr. Afriliani.
National Park is Kayong Utara Economic growth brought by industries such as oil palm and In Sukadana, however, she points out that patients need to travel
Regency. Indonesia is divided
into provinces, and sub-divided forestry have made a difference on the household incomes of rural 80 kilometers to access more advanced medical care. If they still
further into regencies. For example, Indonesian families. Today, 5.8% of the country’s rural population can’t be treated, the next level of care requires either a five-hour
Kalimantan has five provinces,
(nearly 120 million people) live below the international poverty line speedboat or hour-long flight to a larger city. Sometimes patients
including West Kalimantan where
the ASRI clinic is located. West of $1.90 a day. That’s a steep decline from 1984 when 80% of rural are even asked to travel to Jakarta for an appointment with a
Kalimantan is divided into 14 households fell into that category.12 When it comes to healthcare, specialist. “Patients in critical condition sometimes refuse to get
regencies, including Kayong Utara
Regency, of which Sukadana is the
lower rural incomes are compounded by the country’s doctor referred because they cannot pay,” Dr. Afriliani explains.
capital city. Kayong Utara is West shortage. Kalimantan has one doctor for every 2,700 people.
Kalimantan’s newest regency, and was The doctor-to-patient ratio is much lower in the regency around
created by the government in 2007. Dr. Nurmilia Afriliani is the former Clinic
Gunung Palung—approximately one general practitioner for every Director at Alam Sehat Lestari (ASRI).
ix What is the recommended ratio by 10,700 people.13ix She says a number of anthropogenic
the WHO? What is it in your country? environmental changes have affected the
Refer to the ↘ WHO data here health of the clinic’s patients, including
In 2014, seven years after the establishment of Alam Sehat Lestari flooding and haze events.
in Sukadana, the central government introduced a mandatory
National Health Insurance in the aim of making medical care more
accessible. The insurance program is overseen by an agency called
Badan Penyelenggara Jaminan Sosial14 (BPJS, the Social Security
Administration for Health in English) and is slowly being phased
x How many people in your country in for all Indonesians. More than 222 million people15 (about 85%
are covered by health insurance? How
many services are covered? What of the total population) currently hold membership, making the
does this depend on? insurance program one of the largest worldwide.x The government
aspires to have all Indonesians covered, but challenges include
xi Beyond having social insurance,
what other factors determine your government deficits,16 large population numbers, and significant
access to healthcare? regional disparities in accessing resources and care.xi

140 141
 In other cases, physical access to even the first-tier of primary care is Recent government policies indicate a greater shift towards xvii Where is Indonesian wood mainly
nearly impossible. Many villages outside of Sukadana are accessible conservation. A 2002 government regulation divided forests into exported? ↘ Explore the chart here

only via four-wheel-drive, motorbike, boat, or a combination of the three categories: conservation forests, protection forests, and Visit ↘ Global Forest Watch to see
three. Prior to ASRI’s establishment in 2007, residents of Sukadana production forests, with national parks and nature preserves satellite imagery of deforestation in
Indonesia over the last 15 years.
had access only to a government health-clinic (puskesmas) which falling into the first category.19 In 2011 the government also issued
offered sub-par primary care and lacked a general practitioner. This a moratorium on new logging concessions.20 That moratorium
remains the case in many smaller villages around GPNP. couldn’t prevent illegal logging, however, and an estimated half of
all Indonesia’s timber comes from illegal, small-scale sources.21
Pak Sukri Sabar was the head of Pangkalan Jihing sub-village for
12 years. He remembers the story of a woman who experienced Still, the World Resources Institute notes the incredible complexity
complications during childbirth. She was carried from her home and contradictory nature of Indonesia’s forestry laws, with more
and, after a full day of travel aboard two boats, was finally able to than 1,000 bodies and individuals holding the ability to create
see a medical professional. “If we had not brought her to that place, new laws across many levels of government.xviii This complicates xviii To learn more about the various
she probably would have died,” he says. Sabar recalls another time the monitoring and enforcement of illegal logging, including in regulations that govern production,
protection, trade, and taxation of
before the community had cell phone reception. They would bring the area around Gunung Palung.xix The effectiveness of negative Indonesia’s forests, visit the World
a patient to the nearest large village only to discover the midwife incentives in curbing logging rates has not been measured. Resources Institute’s ↘ Risk Tool.
It includes summary descriptions of
wasn’t working that day. Sukri Sabar’s story is one example of how key forestry policy and links to the
universal healthcare is true only in theory. In reality, the burdens of National park regulations state that people living around parks can original regulations.
xiv The issues rural communities physical access and additional travel costs mean many Indonesians use the protected forest to obtain non-timber forest products. This
face in accessing primary health face significant barriers preventing them from utilizing universal includes collection of fruits and vegetables, water, and rattan— xix ↘ Read more about the
care is also discussed in chapter 5 complexities of this issue here
of this anthology in the context of healthcare coverage. Similar limitations affect rural communities pliable palm stems used to create furniture and handicrafts. While
northeastern Madagascar. worldwide.xiv non-timber forest products offer some value, logging has always
been a lucrative activity, and local communities saw an opportunity
For people living in remote, low-income communities like Pangkalan to pay for their basic needs. Many secondary industries around the
Jihing, essential medical care could be attained through either a park, including wood processing and the sale of chainsaws, spare
higher household income or infusions of quick cash. These monetary parts, and gas, were also dependent on the continuation of illegal
gains would help people afford travel to their healthcare provider, and logging.22 Vested interests were everywhere.
pay for subsequent medications or procedures. Illegal logging was the
most reliable way for community members to earn that quick cash. Community surveys conducted around Gunung Palung National
Park found other factors motivating community-based illegal
logging.23 For example, the transition from a bartering system to a
The History and Effects Logging is deeply entrenched in Indonesian culture. Its roots stem cash-based economy meant people who had historically obtained
of Community-Based back to the 17th century when the Dutch East India Company goods through trading suddenly needed access to cash. There
Logging (DEIC) first took control of what is now modern-day Indonesia. was also a movement away from traditional medicine collected in
Forestry policies from the Dutch colonial and post-Independence the forest, in favor of modern medical systems—all of which cost
Indonesian governments favored the exploitation of forestry money. Additionally, the timber concessions that operated around
xv Why do you think post-colonial resources over conservation.xv the park closed by the late 1990s. This meant that villagers—now
governments favored exploitation over with greater access to chainsaws—had free-range to use their
conservation?
Indonesia gained independence from the Netherlands in 1945. Over logging training and knowledge of waterway and road access to
See: 1865 Forest Law and the Basic the next 50 years, the country’s forest cover decreased from 1.62 million pick-up where the concessions left off. Some of the sawmills that
Forestry Law No. 5 1967, for instance. square kilometers to 980,000 square kilometers.17xvi By the 1980s, had once processed wood from legal concessions switched to
xvi Who benefited more from this Indonesia was the world’s largest exporter of tropical hardwood, purchasing illegally logged wood.
exploitation of hardwood? and forests were being unsustainably cleared.18xvii
142 143
 Illegal as it may be, community-based logging had the potential to is Lubuk Baji, a section of park a half hour’s motorbike from
transform the average income of households around GPNP. Though Sukadana. Along the way, the road passes through rice paddies,
logging provided families with quick cash, the supply chain was agricultural fields, and small sub-villages, all of which were
fraught with inequality. The amount individual loggers received— historically forested areas.
around USD $20 per tree—was a fraction of the timber’s high market
value. Logged trees purchased by a middleman were often sold to Pak Muslianto is the park guide for the day. He leads the way
sawmills for twice the price paid to community loggers. From there, through a quiltwork of fields, a handful of which are currently
the timber reached the market where it was priced higher still and being scorched as a cheap and efficient way to prepare land for
sold to meet local and national demand. agricultural purposes.xxiii Pillars of smoke billow into the air, and xxiii Traditional shifting cultivation
the ashy land sits gently smoldering, waiting to be replanted. methods (also known as slash and
burn) are a common practice in
From here, it’s a transition through recovering grassland to reach Indonesia, including in Kalimantan.
Forest Cover Change A study around Gunung Palung from the late 1990s found that the depths of the rainforest. Soon, it’s like someone has dimmed This agricultural preparation method
was a contributor to substantial
Around Gunung Palung 47% of households relied on logging as their primary source of the lights and boosted the humidity. The vegetation underfoot peatland fires in 2015. The haze
National Park income—a 71% increase in the seven years leading up to the time becomes tangled and challenging to navigate—a web of roots, created by this event, and the
of survey.24 When ASRI started its work in 2007, Kinari Webb’s decomposing leaves, and scurrying ant trails. Walking is a slow and subsequent health effects, are the
topic of chapter 1 of this anthology.
xx A logging household is classified as calculations estimated that 1,450 households around GPNP were graceless task, and yet for many years this landscape was expertly
any household where one person has logging as their primary source of income.xx This figure came navigated by men wielding chainsaws.
logged in a month.
through self-reported community surveys, and the ASRI and
Health In Harmony teams suspect the number was higher. When it comes to trees, Lubuk Baji is both a graveyard and the
site of new vegetation growth. Muslianto points out each tree
A bird’s eye view of GPNP offers a sense of the changing landscape. that was illegally downed, using his hands to imitate the act of a
Nurul Ihsan Fawzi sits cross-legged on the floor and opens his chainsaw taking its final blow. The operations that downed these
laptop. ASRI’s Reforestation Program Manager and GIS Remote trees were a far cry from industrial production, and often involved
Sensing Analyst, Fawzi knows the park inside and out. He zooms villagers using traditional tools or chainsaws, transporting their
into the area of Gunung Palung on the satellite layer of Google Maps. timber via motorbike, bicycle, or river floats. Though small-scale
Zoom in enough and you see the orderly blocks that make up the in nature, the cumulative effect was a substantial environmental
unmistakable landscape of oil palm plantations. Move your eyes threat, contributing to the 40% decrease in forest cover that Fawzi
west of the park and you come across rice paddy terraces and other mapped through satellite data.
xxi Landsat is a free collection of gardens, areas cleared for rubber, durian fruit, and chili growth.
satellite imagery that has been
compiled by the U.S. Geological There are bare spots in the dark green patches that represent the As Kinari Webb learned during her first visit to Borneo, logging
Survey and NASA over the course of park’s primary forest—land once covered in towering trees is now isn’t viewed through a simple lens of good or bad. A 2013 study from
four-decades. The images are often bald with anthropogenic grasslands. Fawzi used remote sensing Borneo supports what Health In Harmony learned in 2007. It found
used by agriculture, forestry, geology,
and other sectors to identify land data from Landsatxxi to calculate that the lowland forest in GPNP that nearly half of people on the island approved of small-scale
change over time. More information declined by nearly 40% between 1989 and 2017. The land dedicated forest clearing if it was for their own direct use.26 Interestingly, it
and data sets can be found on the ↘
Landsat website.
to mixed plantations nearly doubled in the same time period, and also noted that 93% of people recognized the forest as either “very
mixed agriculture land use increased 33 fold, though still makes up important” or “quite important” for their health. The seemingly
xxii Mixed plantations include land a small portion of the park.xxii contradictory data illustrates the complex relationship people have
that is converted for use as industrial with the forest: despite the majority wanting it maintained, it was
timber, pulp and paper, or oil palm
concession. Mixed agricultural land ↘ Appendix 2, 3: Land cover change in Gunung Palung National Park also seen as a source of economic value.xxiv xxiv For the case discussion, remember
is composed of areas where food from 1989 to 2017. Table / Maps to look up general socio-economic
crops are grown, including rice and data for Indonesia.
To combat illegal logging, Health In Harmony recognized the
vegetables.
While GIS mapping offers a bird’s eye perspective, hiking through need for an intervention that considered the realities of people
the park also reveals the extent of land use change. Only three who wanted to live in peace with the forest but also use its timber
sections of GPNP are currently accessible by visitors. The nearest to benefit their families.
144 145
 Pak Muslianto appears miniscule
amongst the giant trees in Lubuk
Baji, the only publicly accessible
section of Gunung Palung
National Park.
146 147
Identifying an Interven- That paradox presented an opportunity for Health In Harmony “Radical listening” and a commitment to implement community
tion through “Radical and ASRI. Ask anyone at either organization why their work solutions have been core values of Health In Harmony and ASRI
Listening” has been successful and they’ll say it’s because the community since the very beginning. At the time of the radical listening
proposed the solution that led to their approach. sessions in 2007, ASRI was a lean start-up. The main office was
Webb’s small home, where the team of five gathered each day to
To learn how goes back to ASRI’s founding in 2007, and Kinari discuss which villages to visit. Pak Wilfirmus and his wife, Clara,
Webb’s prior work in Kalimantan. Webb and the other ASRI were two of the original nurses who served as listeners for the first
xxv These techniques fall broadly
in the category of action/research founders knew their end goal was to conserve the rainforest community meetings.
methods called Community-based around the park. What they didn’t fully understand were the
Participatory Research – or CBPR drivers causing logging in the first place. In order to gain greater The approach was different from what Wilfirmus had encountered
for short. Why are these methods
important? Why are they useful? insight, the newly created ASRI team made the choice to “radically in previous NGO work. “We were just doing, never hearing the
When should they be used? listen.”xxv community, or even talking to them,” Wilfirmus describes of past
experiences. “It’s different with ASRI—we are listening to the
“Radical listening” doesn’t look any different than normal listening. community and then we do something. That’s how the community
In practice, 15 to 50 people take part in a radical listening session, approved and trusted ASRI, and we became the best healthcare
and everyone sits in a circle at the same level. There are always two option in this area.”
listeners, who, for trust and gender consideration purposes, are
ideally both women. One of those two listeners should come from The nascent ASRI team spent 10 months systematically listening Pak Wilfurmus and his wife, Clara, were
a religious or cultural background similar to participants, and one to all 23 communities around Gunung Palung National Park. “It’s two of ASRI’s original team members.
with an outsider’s perspective. They ask an open-ended question, possible that in those formal listening sessions there might have
like the one asked by ASRI listeners in 2006: “what would you been bias in the solutions that the communities proposed so that
need as a thank you from the world community so that you could they could protect the national park,” Webb admits, since they
protect this precious rainforest that you all are the guardians of?” introduced themselves as medical professionals opening a clinic.
But from her 10 years working with the communities around
The answers, Webb says, rarely touched on a single sector. “As GPNP, she knew there was truth to the healthcare request. In later
long as you give people a big enough container, they’ll bring all years when they did radical listening in other regions of Indonesia,
the issues: health, conservation, economics.” “Radical listening” is the Philippines, and Madagascar they concealed the fact that they
similar to the Rapid Rural Appraisal (RRA) and Participatory Rural were medical professionals, but still often found radical listening
Appraisal (PRA) approaches that became popular in the 1980s and sessions yielded requests for healthcare.
1990s. Both RRA and PRA were approaches used by outside groups
to learn more about the lives and conditions of people living in After more than 400 hours of radical listening sessions around
rural settings.27 PRA saw outsiders as facilitators, asking questions Gunung Palung, community solutions became clear. The
and learning from the people who lived in a place. consensus was that people could stop logging if they had access
to high quality, affordable healthcare and training in organic
What Health In Harmony says is fundamentally different about farming techniques—a request that surprised the team. With the
its “radical listening” approach is its readiness to implement the community-driven solutions identified and permits secured, the
solutions proposed by community members. “This is a different ASRI clinic opened its doors for service.
paradigm,” says Jonathan Jennings, Health In Harmony’s Executive
Director. “We aren’t just listening to learn and extract, we are
listening to drive solutions which we can then invest in realizing.”
Webb says “radical listening” is inherently solutions-oriented: “It’s
not asking people what the problems are—it’s asking them for the
solutions and getting a consensus, which is a whole other step.”
148 149
A Win-Win for Human Today, ASRI’s operations in Sukadana have grown significantly. Continue down the hallway and you can literally walk into nature—
Health and the Rainforest The program employs a team of 100 staff members, a cohort there is no door. Two hundred meters later you reach the rainforest
that’s entirely Indonesian, the majority of whom are women. The and an unassuming log marks the spot where ASRI property ends
clinic sits along one of the village’s main roads, and the large, and the national park begins.
bright building stands in contrast to the smaller houses and open
shopfronts nearby. This newly-built clinic opened in October 2016,
replacing the makeshift single-family home that housed ASRI for
its first nine years.

Household surveys conducted between 2007 and 2017 exhibit

measurable improvements in the health of people living around
xxvi Fankhauser, Katie. "Health in Gunung Palung National Park.xxvi These surveys were conducted in
Harmony Impact Data." June 17, 2018; villages where ASRI had signed a Memorandum of Understanding
unpublished
agreement. MoU agreements mean ASRI works with those villages
to offer conservation activities, tiered healthcare costs based on
logging activities, education sessions, and livelihood trainings.

Individuals were asked to self-assess their health and well-being

during the surveys. Analysis found there was a decrease in infant
and childhood mortality rates during the 10-year period, and a
drop in disease symptoms such as fever, persistent cough, diarrhea,
xxvii Fankhauser, Katie. "Health in and weight loss symptoms.xxvii Further analysis of this health data
Harmony Impact Data." June 17, 2018; is currently underway in order to determine whether MoU-signing
unpublished.
villages experience a greater improvement in health outcomes.

xxviii What is meant by “primary care” Offering affordable and high-quality primaryxxviii care will remain
and “primary health care”? How are ASRI’s focus in the short-to-midterm period, which includes
these different? Why is this difference
important? partnering with the new district hospital so it can utilize their
expertise to offer more specialized services. A surgeon has recently
completed his ASRI-funded residency and returned to Sukadana
where he has been positioned at the district hospital. “The hospital
has not had a surgeon since July 2019 and it is very hard to get
a specialist who wants to stay in a small town like Sukadana,”
explains Nur Febriani, ASRI’s Executive Director. “It is ASRI’s
contribution to the community.” She adds that the surgeon will
likely spend the afternoons at ASRI serving patients and training
young doctors.
Today, ASRI is in its second home, a custom-
built medical facility where patients can sit
Meanwhile, ASRI continues to incorporate the values of nature among nature. The hallways are open-air and
and conservation into its clinic space. The spine of the building is a gardens dot the property.
long, sunlight-flooded corridor with views onto garden courtyards.
Beyond, the back half of the building houses ASRI’s conservation
office and space for training and volunteer accommodation.
150 151
 Health Levers for Conservation activities. Data found that forest loss decreased in a dose-response
Planetary health examines the ways in which human health is ratio to the level of engagement. According to the team’s paper, a
impacted by human-caused disruptions to the Earth’s natural “casual association between the intervention (including health,
systems. Within that definition is a feedback loop. Anthropogenic livelihood, and conservation programs) and ultimate deforestation
xxix Anthropogenic environmental environmental changes affect the health of people.xxix But the health outcomes is plausible.”
shifts include human-produced air and of people—the ability to be physically, socially, and mentally well,
water pollution, shifts in biodiversity,
land use change, and more. In 2015, in addition to economically secure—also influences the way people Planetary Health in the Clinic
The Rockefeller Foundation and The interact with the natural environment. For ASRI and Health In Harmony, the interplay between human
Lancet released their Commission on
Planetary Health. The Commission
health and conservation exists in daily practice. Collaboration
is the forefront academic resource This loop reiterates the interconnectedness of human health and among ASRI’s multidisciplinary teams is a central value. Each
shedding light on the many ways in environmental systems. It introduces the possibility of designing workday starts with a morning meeting in the clinic’s library.
which human-caused disruptions to
the Earth’s natural systems affect
win-win planetary health solutions that recognize that a change in Medical staff sit next to conservation team members who chat
human health. ↘ The Commission’s one system can trigger positive shifts within another. Ecological levers up the ASRI economist who calls across to the garden landscaper.
documents can be found here. for public health are interventions in the ecosystem or conservation A pen is spun, and whomever it points to is in charge of taking
space that have positive outcomes for human health. notes and leading the meeting. Everyone is given an opportunity to
speak and the day’s activities are coordinated between the health
There are also health levers for conservation, such as Health In and conservation teams.
Harmony and ASRI's intervention. The theory of change was
straightforward enough: by creating a dual conservation-health “It really helps bring people together from a teamwork point
program, the organizations were able to improve human health of view,” says Dr. Monica Nirmala, ASRI’s Executive Director
and reduce deforestation of Gunung Palung’s rainforests. While the between 2014 and 2018. Coming from Jakarta with little exposure
lever-based framework offers a helpful way to envision the interplay to environmental issues, Dr. Nirmala says she was surprised by
between different systems, these links are not easy to prove or what she learned, in part thanks to these meetings. “If we didn’t
quantify. Monitoring impact across its diverse programmatic areas have a morning meeting then maybe someone on the conservation
is one of the greatest challenges flagged by ASRI and Health In team wouldn’t know the nurses. It helps everyone to have the same
Harmony leadership. planetary health perspective,” she says. The morning meeting
also works in a practical sense—staff can disseminate educational
In the case of Health In Harmony and ASRI’s intervention, community information, coordinate travel to pick up planting supplies or
surveys spoke of a 90% decrease in illegal logging households since medicines, and ask questions, knowing that everyone who can
2007, down to a total of an estimated 150 households. However answer them is in the same room and on the same page.
notable, the organizations want to confirm whether there was an
actual decline in deforestation during that time period. Engaging The fusion of conservation and healthcare extends beyond
a team from Stanford University, researchers are using satellite morning meeting. ASRI patients receive their medical check-up
imagery and statistical inference to compare forest change rates in with a side of planetary health education. That includes planetary
GPNP to that in all other national parks across Indonesia, during health presentations delivered by ASRI staff in the waiting room,
the period of 2007 to 2017. The Stanford team is also in the midst of as well as information directly from doctors. “I talk about nature
assessing whether a decrease in deforestation could be attributed to with my patients, and tell them to open the windows on their
community engagement with ASRI activities. home so that the air from outside can enter. And I try to make
them understand how it can be harmful when they burn garbage,”
The next question the Stanford team asked was whether a decrease says Dr. Fitriyani Simangunsong, ASRI’s new Clinic Manager and
in deforestation could be attributed to engagement with ASRI a general practitioner.
activities. Engagement was defined as a person interacting with the
clinic, or participating in conservation, education, and livelihood
152 153
 Clinic art further supports this dual education: photos of Designing an Intervention Creating a planetary health intervention is one thing—
reforestation progress, maps of GPNP’s ecosystems, an illustration for Success: Affordability maintaining its success is another. That’s where affordability and
of a human body outlining what happens when the environment and Positive Incentives positive incentive measures come into play. Health In Harmony
is healthy, versus when it’s not. There’s even a large banner of an and ASRI have initiated a non-cash payment system to ensure
orangutan with puckered lips, a favorite selfie spot for staff and people can always afford the clinic’s medical services. Meanwhile,
visitors alike. the organization also offers a number of positive incentives to
discourage people from logging while accessing care.

Non-Cash Payments
It’s not far from ASRI’s seedling nursery that Pak Sebani sits
waiting for his doctor’s appointment. He’s borrowed his neighbor’s
motorbike to visit the clinic—he makes a modest income as a
farmer, and can’t afford his own mode of transportation. Without
ASRI’s non-cash payments, he wouldn’t be able to afford care,
either.

Sebani is recovering from tuberculosis. Today, he’s suffering

shortness of breath and pains in his stomach. In the past, he would
drive two-hours to buy his medication. “We had a lot of costs when
I did this. My daughter had to take a break from school because I
got sick and we couldn’t afford the books and other school costs,”
Sebani says. “The most important thing is the cost. But expensive
medications are not a problem now because at ASRI you can buy
them with other things.”

Tree seedlings have been Sebani’s payment of choice on two

separate occasions. The seedlings are commonly grown by
patients themselves using seeds foraged in the rainforest. These
young plants are the non-cash payment most encouraged by ASRI,
and carry the highest value. In-demand ironwood and meranti
seedlings earn patients between $0.70 and $1.40, and are brought
to one of ASRI’s reforestation sites. The goal is to have 10,000
seedlings “paid” by patients every year. Figures from 2019 exceeded
that, with 23,146 seedlings received from patient payments.

Today, about one patient a week pays using a non-cash payment,

xxx A small percent of patients pay though these are often the patients with higher bills.xxix The
using non-cash methods, but they options are displayed on a large green poster outside the cashier
constitute a higher percentage of
ASRI’s income. till: requests for fertilizer, manure, rice husks, and egg shells,
The scene from ASRI’s morning meeting.
all of which are used in the ASRI-established organic farming
cooperatives. Patients can even make handicrafts and barter with
Nani Utari, ASRI’s cashier, in exchange for their visit fees. The
average visit ranges from $0.55 and $2, and patients can bank extra
non-cash value for later visits or emergencies. As was demonstrated
154 155
in a shortfall with the national healthcare scheme, high quality spike in prices for bird nests more people try to build the houses to
healthcare can only get patients so far if it’s prohibitively expensive benefit,” says Supianto. Illegal logging is a main source of building
and difficult to access. ASRI’s non-cash payments help reduce some material. Finally, while one village may not exhibit any logging
of these barriers. activity, Supianto admits that could simply be because individuals
are logging outside of the park, their activity undetected by ASRI.
Village-wide Incentives
ASRI has also created an initiative to circumvent the rational
behavior that would tempt families to access high-quality
healthcare while continuing to illegally log. Since 2018, ASRI
has been offering community-wide discounts to incentivize the
curbing of illegal logging.

To begin, villages are color categorized based on the progress

they’ve made towards ending the indicators of illegal logging.
Assessed as either red, yellow, or green, villagers receive between a
30% discount (for red villages) and 70% discount (for green villages)
applied to their healthcare bill. Administration of these discounts
takes regular monitoring, and is overseen by Agus Supianto, ASRI’s
Monitoring Coordinator. Supianto visits villages three times a
year, looking for any of seven negative indicators of illegal logging,
including small sawmills and logging access routes. No indicators,
and the village is green, more than three, and it’s deemed red.

Supianto says the act of implicating an entire village in the actions

of one or two loggers is key. “If we give punishment only to the
logger then maybe the other villagers will not care about the forest
because they have their discount,” he says. “This category system
makes caring for the forest the responsibility of all villagers, and
they are the ones who give social punishment and pressure to the
logger.” This village-wide discount system has been identified by
ASRI patients as the most important incentive to reduce illegal
logging.

Despite being deemed effective, Agus Supiano, ASRI’s Monitoring

Thousands of seedlings are stored behind
Coordinator, says villages regularly go back and forth between red, ASRI’s clinic in Sukadana. In addition to
yellow, and green. He explains: “in the dry season the indicators accepting them as non-cash payments
of forest gardens could increase because people’s crops aren’t from customers, ASRI also receives
seedlings from children and teenagers
growing. In the rainy season the indicators can increase because who participate in their education
the rain makes it easier for loggers to access forest areas, which program. Health In Harmony’s recent
makes transporting wood easier.” Harvesting bird nests is another ↘ carbon offset program also allows
popular industry around West Kalimantan—bird nest soup is people living worldwide to purchase
seedlings and support the organization’s
a delicacy in China. The harvesting is done in the multi-story, replanting efforts.
windowless buildings that line the roads. “Whenever there is a
156 157
Livelihoods to End Seasonal spikes in logging activity meant that providing high The Time for Just Transition
Logging quality healthcare alone wasn’t going to be enough to protect the
rainforest. When asked in 2007 what they needed to put down As the world transitions towards more environmentally sustainable economies and industries, an important
their chainsaws, community members said they wanted affordable mission is to ensure the people whose industries and jobs are being transitioned don’t get left behind. This has
and high-quality healthcare, and training in organic farming been a demand since the 1970s when the Just Transition concept was born during the US labor movement.
practices. The message was clear and reasonable: if loggers were The acknowledged father of the movement, Tony Mazzocchi, was a member of the Oil, Chemical and Atomic
going to permanently give up their main source of income, they Workers’ Union, and he established the movement to ensure the rights of workers were respected through the
needed to replace it with another. environmental and social movements that were taking place in the country.33

This idea references a new framework that was developed by labor Whether it’s men dependent on illegal logging in Indonesia, coal workers in America, or people employed
unions and the environmental justice movement. “Just Transition” by fossil-fuel dependent industries worldwide, the Just Transition movement was created to ensure those people
is the term used to describe the shift between an environmentally- had a voice and a job to turn to when their current position was deemed environmentally-defunct. In a way,
detrimental, extractive industry (such as logging) to more planet- the Just Transition movement draws from the lessons of Participatory Rural Appraisal and “radical listening,”
friendly, regenerative economic activities. The framework was by putting the people who are affected by this transition in a place of power and self-determination.
created in part to protect worker’s rights, ensuring they had Just Transition is becoming a greater part of climate action policy worldwide. COP24 in Poland saw the creation
other meaningful work to turn to when their extractive job was of the Solidarity and Just Transition Silesia Declaration, signed by 50 countries, including Indonesia. That
eliminated. In West Kalimantan, Just Transition demands that an declaration recognizes that developing countries and their citizens are especially vulnerable to the adverse
alternative work solution be introduced so loggers can maintain effects of climate change, and that conditions of poverty would make it more difficult for these communities
their household income and benefit from the transition away from to experience a Just Transition.34
logging.

Dr. Courtney Howard, a Canadian ER doctor and member of

the Health In Harmony board of directors, spent a month in
Sukadana in early 2018. Two months earlier, she had been in a very
different setting, serving as a Canadian delegate to climate change
negotiations at COP23. There, the importance of Just Transition
was brought up in every meeting.

“I was thinking that the health community hadn’t done a good

job in addressing this transition, and I felt quite guilty,” Howard
recalls. “Then, I go from the center of the world conversation to
rural Sukadana, where I’m watching a fisherman sign over his
chainsaw in exchange for a small business loan. I’m sitting there
thinking ‘holy cow, ASRI has a giant Just Transition component in
their community-based project.’ I was blown away.” Howard says
Kalimantan was the first place she saw a Just Transition approach
in practice, rather than in theory.

Pak Iskander and his family outside of their home.

158 159
From Logger to Alternative Livelihood His attitude only recently shifted. For one thing, Iskandar’s 12-year-
Former loggers aren’t using terms like Just Transition, but they old daughter, Ayu, started attending ASRI Kids, the organization’s
do agree that the opportunity to access an alternative source of after school program. There, she learned how cutting down trees
income has helped them put down their chainsaw. could cause floods, fires, and sickness, and about how important
it was to protect wildlife. She brought that message home to her
The afternoon light filters into Pak Iskandar’s home in Penjalaan father, once, twice, many times. Eventually what she was saying
Village, illuminating a faint tinge of smoke and dust. School is out struck a chord.
for the day, and there is a small huddle of children crouched in
the front room. Four of them are Iskandar’s children, and along Ayu’s pressure was paired with a visit from Agus Novianto, ASRI’s
with his wife, Ibu Suryati, and mother, Ibu Amah, there are three Economist and head of the Chainsaw Buyback Program.35 The
generations and seven people living in this modest wood home. Chainsaw Buyback Program is ASRI’s approach to convert “last
mile” loggers. Despite an 90% decline in logging households since
Supporting a family of any size costs money, and this household 2007, the forest guardians counted a remaining 141 loggers in 2017.
is no exception. That’s why in 2000, Iskandar started logging This correlated with the estimated 150 logging households from
the protected rainforest around his home. He had heard from ASRI’s 10 year survey in 2017. At this point, ASRI staff recognized
friends that it was good money. “The money I earned was for the they needed another solution, one that acknowledged the education
daily needs of my family: healthcare, school costs, clothes, food,” level and economic well-being of families. Mindful of these social
Iskandar explains. determinants of health,xxxi ASRI created an alternative livelihood xxxi The World Health Organization
program to help loggers experience a Just Transition away from defines social determinants of health
as “the conditions in which people
While many of his friends were caught and punished for logging, logging. are born, grow, live, work, and age.”
Iskandar never received a warning. The park rangers would often It notes that social determinants of
tell the village office they were planning a visit, and word got out to Introduced in January 2017, the Chainsaw Buyback Program is health are responsible for many health
inequities, as they are shaped by the
the loggers that a “guest” was coming to the forest. On these days, a business development program for families. After five days of distribution of money, power, and
Iskandar would watch from the safety of his home as the rangers entrepreneurship training with Novianto, loggers and their wives resources.
rode by on their motorbikes. have a business plan they can use to start or scale their enterprise,
which is co-owned by ASRI. Including wives in the process is
“I cannot blame the police rangers, and it’s good that they asked deliberate and important. “Usually at home it’s the wife who
us to take a break,” Iskandar admits. “But if they ask us to have a manages the finances, and often even the business,” Novianto
break from cutting the trees then it meant my family would have explains. He says that while men might use the income to buy
a break from food. I didn’t have another job and we still needed to cigarettes, women are more likely to spend that cash on family
cook.” It wasn’t that he didn’t feel guilty. “Even though I did not needs. This fits in with another main principle of Just Transition
steal someone’s money from their house, I bought oil, I bought a framework, which is to use new livelihoods as a way to redistribute
chainsaw, and I knew it was stealing in the forest.” power and transform traditional gender inequities.36

On one occasion, Iskandar remembers being surrounded by park The funds for the new family business come from two sources.
rangers. Like a scene in an action movie, the officials were closing Families are given approximately $275 for selling their chainsaw,
in from all sides. Spotting an escape route, Iskandar threw his and can access another $400 in zero-interest loans to support
chainsaw into the trees and bolted. When the park rangers left the their new business. The entire amount is held by Novianto, who
village the following day, he trekked back, recovered his chainsaw, accompanies families to buy the supplies outlined in their business
and resumed logging. plan. Once the loan is paid off, the business is wholly owned by the
family.

160 161
For Pak Iskandar, the Chainsaw Buyback program has meant Agus Novianto stands carefully among
reconnecting with his former work as a fisherman. ASRI program the chainsaws that have been purchased
data found that the most common livelihoods couples have as part of ASRI’s Chainsaw Buyback
Program. The program creates financial
transitioned to are those in retail, agriculture, and food and drink. incentives for both men and women in
Unlike the forest rangers or police who threaten loggers with arrest a household, supporting them in the
or punishment, Iskandar says he was drawn to ASRI’s proposal of creation of a new livelihood.
a solution. Hanging on the wall in his home are two hand woven
nets awaiting their first use. Beneath is an insulated container
for fish storage, and a box of hooks and lines. Parked outside is
the motorbike he was able to repair with some of the money so
that he could transport his catch. Down the road, the used boat
he purchased has a new coat of paint. Ayu, Iskandar’s daughter,
looks pleased. “She wants to be a policewoman,” Iskandar laughs,
proudly pointing at the trophies she has won for academics and
chess. “Luckily I already stopped being a logger!”

A consistency in income and a desire to transition away from

a risky livelihood are factors former loggers say make ASRI’s
alternative livelihood programs attractive, even if they’re bringing
in less money overall. It’s not just ASRI promoting the program
to loggers—Novianto says forest rangers and police often present
the Chainsaw Buyback Program in order to avoid conflict with the
community.

Nowhere is the initial success of that program more evident than

in a room at the ASRI clinic, where dozens of purchased chainsaws
lie haphazardly on the floor, rusty blades in the air, surrounded by
a dried puddle of oil. The plan is to turn these collected chainsaws
into a number of monuments, as a memorial of sorts to the
thousands of trees that were cut using the tools and as a testament
to the new planetary health future of these communities.

162
Improvement and a Despite successes like the Chainsaw Buyback program, ASRI
Regrowth Approach and Health In Harmony face similar challenges to those of
other organizations. One is the aforementioned difficulty in
quantitatively linking improvements in health outcomes to a
reduction in deforestation, as well as capturing other success
metrics.

Resources are another challenge. A dual medical-conservation

approach means resources have to be spread across a large and
diverse team—positive for programming, but challenging for staff
capacity. “I am the long boat [that travels down the river to monitor
logging sites], I am the drone,” laughs Agus Supianto, referencing
how he is the only ASRI staff member responsible for monitoring
the forest activities in dozens of villages.

ASRI’s Forest Guardians

At the request of community members, ASRI launched its Forest Guardians (Sahabat Hutan) program in 2011
to help monitoring efforts. Based in more than 30 villages surrounding Gunung Palung National Park, Forest
Guardians are the link between clinic and community. They’re responsible for reporting illegal logging activity in
their villages, and help ASRI staff members approach those loggers to discuss an alternative livelihood.
The view from Batu Bulan. The
reforested corridor is visible on the
Many Forest Guardians are former loggers, and believe this makes them better at their job since they right side, connecting Lubuk Baji with
understand the motivations and realities of being a logger. That includes Pak Handayani, who had been logging the main portion of Gunung Palung
National Park. In the next ground-level
the forests around GPNP for 26 years before being nominated to become a Forest Guardian. “At the time we
photo, a concealed camera reveals that
were poor, and we didn’t have other jobs or choices,” he says of his quarter century as an illegal logger. “Now orangutans have again started to use the
we have a lot of jobs through ASRI so we can move from logging to something else.” In addition to working as forest corridor.
a Forest Guardian, Pak Handayani is also a member of his village’s ASRI-coordinated organic farming group.
These farming groups are meant to produce food for family consumption and selling at market.

Pak Muslianto, the guide on the hike through Lubuk Baji, is another Forest Guardian. Before becoming a
guardian, Muslianto was a long-time national park guide. Despite encountering loggers in the forest, Muslianto
says he didn’t have the courage or ability to stop them until he was trained as a Forest Guardian. “I learned how
to approach the community. When I find loggers cutting down trees I’ve learned to not make them upset and
offended. It’s very helpful to persuade them with ASRI’s programs,” he says. Since starting as a Forest Guardian,
Muslianto has persuaded six loggers to put down their chainsaws and adopt an alternative livelihood.

164 165
Lack of staff capacity is also felt by other members of the conservation Funding the Future
team. Despite multiple people working on reforestation efforts, ASRI ASRI’s reforestation work is also a strategic move to access grants. Reforestation is currently a popular funding
needs more data to inform its future strategy. That includes the area—by using conservation grants to buy seedlings from patients for reforestation efforts, ASRI is indirectly using
development of more comprehensive indicators to identify illegal environmentally-oriented grants to fund medical care. The team says it’s a workaround since many grants and
logging, and a forest inventory and map so the team can site-match other traditional funders still dole out money using a single sector approach.xxxii
seedlings with the conditions that support their growth. The latter,
Conservation Manager Mahardika Putra Purba says, can come from
xxxii How can planetary health
improved collaboration with national park staff. ASRI has a long- organizations like ASRI and Health In
running Memorandum of Understanding with GPNP, but Putra Harmony overcome the challenges of
Purba says the organization would benefit from information sharing, single-sector funding? What are ways
foundations and grantors could adapt
as well as potential assistance in accessing government funds. When their system to acknowledge the need
it comes to the indicators and drivers of illegal logging, ASRI is also for holistic approaches?
proposing potential research areas with different organizations and
universities.

A Long-Term Outlook: Beyond Restoration to Reforestation

A main focus of ASRI’s current five-year strategy—just one of the
ways in which the sister organizations are closing the feedback loops
that connect rainforest and human health. Etty Rahmawati speaks to a group
of preteens as part of the ASRI Kids
program. The sessions cover a range of
Back on the hike with Pak Muslianto in the Lubuk Baji portion of
topics, from the effects of climate change
Gunung Palung National Park, the climax of the multi-hour loop is to plant identification to the importance
the Batu Bulan viewpoint. Standing at the cliffside forest clearing of not littering.
offers a dramatic vista across to the primary forest that makes up the
majority of the park. Until recently, the rainforest between Lubuk Education is at least partly responsible for this attitude shift, and
Baji and the rest of the park was disconnected by a band of rice fields. it’s an element that unites Health In Harmony and ASRI’s medical,
Today, one of ASRI’s reforestation sites is dedicated to reconnecting conservation, and livelihoods approach. Community outreach
these two portions of park, creating an orangutan corridor in what is central in that learning campaign. That’s why every second
was previously sparse forest and grasslands. In addition to focusing Wednesday, a handful of team members pile into a car to give a
on key areas like the orangutan corridor, the reforestation projects presentation to a community that may not have had the chance to
also target areas that have been heavily logged and burned to hear about ASRI’s programs.
grassland, places where natural recovery is less likely. Alongside two
other reforestation sites, the organization has replanted 1.6 square Crucial, too, are ASRI Kids and ASRI Teens, after school programs
kilometers of degraded or deforested areas since 2007. It’s aiming for like the one attended by Ayu, the daughter of former logger, Pak
4.8 square kilometers over the next five years. This area is small when Iskandar. While education has been part of Health In Harmony
compared to the huge areas that are deforested each year, but it’s a and ASRI from the beginning, the term “planetary health” has
start. only been actively incorporated in the past few years. “I think the
community is aware of the benefits of the forest, but they don’t get
Community members are in favor of reforestation. In fact, it was that it really affects your health a lot,” says Etty Rahmawati, ASRI’s
what people asked for as part of a 10-year radical listening check-in. Planetary Health Education Manager. “Our outreach is about
One of the reasons for that request, ASRI suspects, is that people now making them draw that connection to the next level.”
better understand that replanting efforts also bring jobs, and that
healthy forests supply fruits for harvest and protect water supply.
166 167
Applying a Planetary ASRI surpassed its 10-year mark in 2017. Now, Health In Harmony Ultimately, Health In Harmony and ASRI’s interventions are unique
Health Model Worldwide is replicating that model worldwide—taking the successes and to this context. In West Kalimantan, the organizations’ “radical
lessons learned from Sukadana and applying them in other similar listening” sessions identified the need for affordable, high quality
contexts. “This means high conservation value areas where human healthcare, alternative livelihoods, conservation education, and
health and well-being barriers are driving ecosystem degradation,” a switch from deforestation to reforestation. The combination of
says Jonathan Jennings, Health In Harmony’s Executive Director. planetary health interventions will most certainly look differently for
In 2018, Bukit Baka Bukit Raya (BBBR) National Park on the those working elsewhere. However, the methodology for effectively
border of Central and West Kalimantan provinces became the working with communities is universal: ask, listen, and act.
organization’s first replication site. The Health In Harmony also
began work in 2019 in rainforests as far away as Madagascar and This co-creation of solutions between outside groups and
will likely begin in the Brazilian Amazon in 2020. In all of these communities is gaining momentum worldwide. While experts
sites, the radical listening methodology is being used to create have found that many of these interventions have yet to eliminate
a community-driven planetary health solution that takes local systemic issues, they note that, they note that co-creation has
challenges into account. the potential to break the status quo of how companies, non-
profits, and other groups serve and collaborate with communities.
Kinari Webb, Health In Harmony’s Founder, acknowledges its Interdisciplinary research in this space has identified five best
interventions will always be multi-sectoral, though they may need practices shared by groups who are changing how they work with
to shift depending on what the team hears. They haven’t yet visited people. They include finding ways to share power, prioritizing Pak Nasir and his daughter outside of
a site where health was not one of the needs. “We have done a first relationships, and legitimizing different ways of knowing.37 their home and storefront.
round of “radical listening” in Madagascar and found that food Utilizing these learnings, planetary health practitioners can
security was a much bigger issue than it is in Indonesia,” she says. partner with community members to identify their needs and
“Health and hunger are clearly both major drivers of logging.” design human-centered innovations that make a real impact. In
doing so, these solutions can further validate Health In Harmony’s
While the intervention in Borneo is an example of a health lever theory of change: that it’s possible to conserve and regenerate the
for conservation, future replication sites could hone in further and world’s most biodiverse ecosystems by respecting the realities of
adopt a ‘livelihoods lever for conservation’ or ‘food security lever for people living within them.
conservation’ approach. This possible adaptation demonstrates the
need to localize even proven planetary health solutions. Regardless
of the lever at play, the value of interconnectedness remains: an
improvement in one system can have co-benefits in many others.

xxxiii ↘ Click here to watch Kinari In Webb’s 2016 TEDx talkxxxiii, she shares the story of Pak Nasir,
Webb's TEDx talk a logger since the age of 12 who once cut down dozens of trees
to pay for a family member’s caesarean section. Some elements
of Nasir’s story remain the same: he still lives in Sukadana, a few
minutes from the ASRI clinic. But outside his home today is a
small storefront. Stocked with packets of instant coffee and shelled
peanuts, Nasir and his wife opened the shop in 2017 in partnership
with ASRI’s Chainsaw Buyback Program. He no longer needs to
log the forest to make quick cash, and in turn gets to spend more
time with his family. Nasir’s story has come full circle.

168 169
Keeping Track Dr. Nurmilia Afriliani Nurul Ihsan Fawzi Nur Febriani Dr. Courtney Howard Pak Iskandar
of Who’s Who
General Practitioner and former Clinic Reforestation Program Manager and GIS Executive Director, ASRI Canadian ER doctor and member of the Farmer and resident of Maka Diama
Director, Alam Sehat Lestari (ASRI); Remote Sensing Analyst, ASRI Health In Harmony board of directors

Dr. Monica Nirmala Agus Novianto Mahardika Putra Purba Pak Muslianto Pak Nasir
Executive Director of ASRI from 2014- Economist, ASRI Conservation Manager, ASRI CEO of Station d’Innovation Aquacole; Former logger and resident of Sukadana,
2018 Executive Board Member with The participant in ASRI’s Chainsaw Buyback
Upstream Alliance program

Pak Sahmadi Pak Sebani Pak Sukri Sabar Pak Wilfirmus Etty Rahmawati
A resident of Sukadana and a Forest Former MBA student at the Middlebury Former head of Pangkalan Jihing sub- A nurse at ASRI and one of the Planetary Health Education Manager,
Guardian with ASRI Institute for International Studies at village, one of the communities where organization’s original team members ASRI
Monterey; Member of the business ASRI operates
development team for The Upstream
Alliance

Dr. Fitriyani Agus Supianto Dr. Kinari Webb

Simangunsong
Monitoring Coordinator, ASRI Founder of Health In Harmony and Co-
General Practitioner and Clinic Manager Founder of ASRI
at ASRI

Acknowledgements A collective thanks to Dr. Kinari Webb and Nur Febriana, the two
women at the helm of Health In Harmony and Alam Sehat Lestari.
The patience, generosity, and expertise of your teams in the U.S.
and Indonesia made this case study possible. I also appreciated the
help of Trina Jones, Ashley Emerson, and Jonathan Jennings from
Health In Harmony. Thank you to all the folks interviewed for this
case—I am privileged to have heard your stories and learned about
your lives. Etty, Dika, and Amat were instrumental in setting up
interviews and helping with interpretation work in Sukadana.
Dr. Monica Nirmala provided information and invaluable editing
support from both Sukadana and Boston. Darya Minovi and
Angela Shields helped with the initial conceptualization of this
case study. Stephanie Gee provided photo and moral support.
Finally, thank you to Isabel Jones, Dr. Susanne Sokolow, and their
colleagues at Stanford University. The concept "health levers for
conservation" was coined by the Science for Nature and People
Partnership (SNAPP) working group ↘ (https://snappartnership.
net/teams/ecological-levers-for-health/), and the group's work was
extremely helpful in the creation of this case.
Pak Muslianto appears miniscule amongst the giant trees in Lubuk Baji, the only publicly accessible section of Gunung
Palung National Park.

170 171
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org/10.1088/1748-9326/11/6/064016 e73008. September 9, 2013; https://doi.org/10.1371/journal.
10 Wells, Jessie A. et al. 2016. pone.0073008
11 Saulnier, Dell D. “The Effect of Seasonal Floods on Health: 27 Chambers, Robert. “The origins and practice of participatory
Analysis of rural appraisal.” World Development. July 1994; https://doi.
Six Years of National Health Data and Flood Maps.” org/10.1016/0305-750X(94)90141-4
International Journal of Environmental Research and 33 Just Transition Research Collaborative. “Mapping Just
Public Health. April 3, 2018; http://www.mdpi.com/1660- Transition(s) to a Low-Carbon World.” United Nations
4601/15/4/665/pdf Research Institute for Social Development. December 2018;
12 The World Bank. “Indonesia - Rural.” PovcalNet. 2020; http://www.unrisd.org/80256B3C005BCCF9/httpNetITFram
http://iresearch.worldbank.org/PovcalNet/povOnDemand. ePDF?ReadForm&parentunid=9B3F4F10301092C7C12583530
aspx 035C2A5&parentdoctype=book&netitpath=80256B3C005BC
13 Mahendradhata et al. “The Republic of Indonesia CF9/(httpAuxPages)/9B3F4F10301092C7C12583530035C2A5/$f
Health System Review.” Health Systems in Transition ile/Report---JTRC-2018.pdf
(7)1. 2017; http://apps.who.int/iris/bitstream/ 34 “Solidarity and Just Transition Silesia Declaration” United
handle/10665/254716/9789290225164-eng.pdf;jsessionid=C5E Nations Climate Change Conference, COP24. 2018; https://
B308630AE1E876BC439E952C38C4C?sequence=1 cop24.gov.pl/fileadmin/user_upload/Solidarity_and_Just_
14 Heriyanto. “Q&A: BPJS Kesehatan, health for all Transition_Silesia_Declaration_2_.pdf
Indonesians.” The Jakarta Post. April 7, 2018; http:// 35 Minovi, Darya. “Introducing: ASRI’s Chainsaw Buyback
www.thejakartapost.com/academia/2018/04/06/qa-bpjs- Entrepreneurship Program.” Health In Harmony. April 20,
kesehatan-health-for-all-indonesians.html 2016; https://healthinharmony.org/2016/04/20/introducing-
15 “Jumlah Faskes dan Peserta.” BPJS Kesehatan. June 13, 2019;
https://bpjs-kesehatan.go.id/bpjs/index.php/jumlahPeserta
Appendix 1 - Three maps featuring the area where ASRI operates ↘ Back to page Appendix 2 - Land cover change in Gunung Palung National Park from 1989 to 2017 - table ↘ Back to page

Appendix 2 - Land cover change in Gunung Palung National Park from 1989 to 2017 - table ↘ Back to page

174 175
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
04
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Going
Please cite this case study as “Duff H., Faerron Guzmán,
C., Almada, A., Golden, C., and Myers, S. “Going Circular:
How Restoring a River Ecosystem in Chile's Capital City has
Benefited Human Health and Economics.” Planetary Health
Case Studies: An Anthology of Solutions. 2020; https://doi.
org/10.5822/phanth9678_4

Please note this work is licensed under a Creative Commons

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Attribution-NonCommercial-NoDerivatives 4.0 International
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Anthology of Solutions, please visit https://www.
planetaryhealthalliance.org/case-studies

HOW RESTORING A RIVER ECOSYSTEM

IN CHILE’S CAPITAL CITY HAS BENEFITED
HUMAN HEALTH AND ECONOMICS
 Executive Summary The Mapocho River running through Santiago, Chile’s capital city,
was a literal sewage dump for decades. The pressures of urbanization
For further detail on themes covered were taking a toll on the city’s water resources. Outbreaks of
in this case study, see the water
section of chapter 4, chapter 6 on typhoid fever, cholera, and hepatitis A were common as Santiago
infectious disease, chapter 9 on residents consumed crops irrigated by river water teeming with
mental health, chapter 13 on healthy household waste. In 1999, less than 3% of Santiago’s wastewater
cities, and chapter 16 on the business
of planetary health of ↘ Planetary was treated. That year, Chile privatized its water resources in order
Health: Protecting Nature to Protect to increase the capacity and efficiency of wastewater management.
Ourselves.
The bid for Santiago’s water services went to Aguas Andinas, now
Chile’s largest water utility company.

Learning Objectives Twenty years later, the Mapocho is unrecognizable. Between 2000
and 2015, Aguas Andinas increased wastewater treatment to 100%,
After examining this case, in the
context of Santiago, Chile, students a change that has contributed to improved health outcomes for
should be able to: the city’s residents, a revival of the river’s aquatic plant and animal
➀ Recognize the challenges of
species, and the creation of new green spaces. In 2017, the company
urbanization in the context of a also adopted a circular economy approach in its operations. This
changing climate with regards to approach is characterized by its cyclical reuse of resources and
water use and wastewater.
byproducts that may otherwise have gone to waste.
➁ Evaluate the linkages between
water, water security, water By turning its two largest wastewater treatment plants into
governance, and health.
“biofactories,” Aguas Andinas has increased its energy self-
➂ Assess how circular economy sufficiency and created a valuable suite of products from treated
principles can be beneficial in the face sewage that would have previously been sent to landfill—all while
of planetary health challenges.
demonstrating that a circular economy model is better for the
➃ Apply co-benefit strategies company’s bottom line and for climate change resilience.
to advocate for planetary health
solutions. This case study is based on interviews conducted in Santiago, Chile, in May and June
2019.

179
Introduction It feels more like a place for a leisurely picnic than the site of a Paulina Vicentela is the Chief of Resource Management of
sewage treatment plant. Paulina Vicentela walks towards the Biofactories at La Farfana. She explains that the biofactories don’t
edge of the lagoon and gestures at the black-necked swans gliding only treat wastewater—they also give it new life. Biofactories use
along its still surface. One of the 170 species of birds found in this a series of biological processes to transform sewage sludge into
lagoon, she notes. It’s autumn in the southern hemisphere, and the useful resources, including biogas to power the plants themselves
air smells faintly of decomposing leaves. and surrounding homes; fertilizer for local farmer’s fields; and
sanitary water that can be safely used for irrigation. This modus
If this serene lagoon seems like an unusual site so close to Santiago, operandi where resources are recycled and reused in order to
Chile’s capital city, more unexpected still is its genesis on this spot extract maximum value and minimize waste is a business model
and the owner of the land. Continue up the road around the lagoon called the circular economy. In addition to reducing Aguas Andinas’
and you reach the property’s main tenant: La Farfana, one of the carbon footprint, the biofactories have demonstrated that the bold
largest wastewater treatment plants in Latin America. Wastewater changes needed to protect planetary health can also be the best
is anything that goes down the drain, from flushed toilets to strategic move for a company’s bottom line.
i Wastewater can also go by the term kitchen dishwater to laundry liquid.i While wastewater treatment
gray water. plants don’t typically attract visitors, two big buses have just pulled Making its operations circular is one of Aguas Andinas’ key
up at La Farfana’s main entrance. The university students starting sustainability strategies for the future. With the scientific
their visit today join the more than 9,000 visitors who have come community predicting increased water insecurity internationally,
to tour the plant since 2018. Through the glass windows of the Aguas Andinas’ circular economy strategy and emphasis on
front reception they can be seen reading colorful information planetary health present a progressive model for private sector
panels and getting a dizzying aerial view of the plant using a set of industries worldwide.
virtual reality goggles.
Paulina Vicentela, Chief of Resource
La Farfana is one of three biofactorias (biofactories) in Santiago. Management of Biofactories at La
This site and La Farfana’s partner biofactories, Mapocho-Trebal and Farfana, stands next to the lagoon
El Rutal, are owned by Aguas Andinas, Chile’s largest wastewater nearby the plant.
company. Aguas Andinas oversees the household water supply for
85% of Santiago’s residents.

Utilizing its three biofactories and a series of 10 other small plants,

Aguas Andinas treats 100% of Santiago’s wastewater. This is a
relatively new accomplishment for the city and the continent. At
the cusp of the new millennium, wastewater treatment levels in
the capital city sat at less than 3%. Raw sewage from household
and industrial waste poured directly into the Mapocho River, the
waterbody that runs through the center of Santiago. That polluted
water came at the detriment of environmental and human health,
ii Enteric diseases are those caused by disrupting the river ecosystem and contributing to outbreaks of
intestinal infections. enteric disease among Santiaguinos.ii

180 181
 An aerial view of the lagoon that was
constructed adjacent to La Farfana
biofactory. Aguas Andinas was required
by legislation to compensate for the land
and ecosystems that would be displaced
by the construction of the wastewater
treatment plant. Instead of purchasing
land elsewhere or opting to buy green
bonds, the company decided it was
important to keep animal species near
their original habitat.

182 183
Santiago: Growing City, Santiago sits in the bowl of a valley, and on a day free of smog
Contaminated River you can see foothills and the Andes Mountains rising from its
outlying neighborhoods. The city is the capital of both Chile and
the Metropolitan Region, one of the country’s 16 administrative
regions. Santiago is the most populous city in the country, and
has grown from 380,000 people in 1907 to 6.5 million in 2019.1
That constitutes over a third of the country’s total population.
Throughout Chile, 90% of the country’s population now lives in
urban centers compared to 58% in 1950.2 Politics have contributed
to this shift from rural to urban, namely the centralization of
services in Santiago as part of a multi-decade military regime that
ended in 1990. Chile has experienced rapid economic growth since
then, and today its economy is one of the fastest growing in Latin
America.3

Chile’s Political Past

Chile’s political past greatly shaped the country, especially the period between 1973 and 1990. In 1973,
Augusto Pinochet became the leader of a military government. One of his priorities was centralizing
the country’s resources. He was assisted by the natural geography of the country—Chile extends 4,270
kilometers from north to south, marginally less than the width of continental U.S. Communities in the north
and south are geographically isolated, with distinctive climatic and industrial conditions. During Pinochet’s
military government, Santiago was the priority for government spending on infrastructure, health, and social
programming. A supporter of neo-liberal policies such as lessened government control and free market
economics, this period in Chile’s political history saw the privatization of many essential services, including Recent events and weather trends support that statement. An 8.8 The skyline of Santiago, Chile, featuring
water. This privatization remains controversial today. magnitude earthquake in 2010 shook Santiago. The quake and the the central placement of the Mapocho
River
tsunami it triggered caused more than 500 fatalities.7 In January
Environmental challenges are imminent threats to this prosperity. 2017, the worst wildfires in Chile’s history scorched through the
In 2017, the Global Climate Risk Index ranked Chile as number 16 country. It drove home the findings of a study from the previous
on its list of countries most likely to be impacted by climate change. year documenting that Chile’s wildfire frequency had been on the
Risk has increased substantially—in the two previous decades, rise since 1985. The authors found that “climate conditions and
Chile’s average ranking on the index was 94.4 At a more local problems of human pressure,” including poor land use management
scale, Santiaguinos have identified the urgency of environmental by forestry companies, were two of the main factors contributing
stressors. A survey conducted as part of the city’s March 2017 to that increase.8
resilience strategy elaborates on citizen concerns such as air
pollution, lack of green space, and the management of solid waste.5 Then, there’s the issue of water—be it too much at once or the
At the time of its release, the governor of the Metropolitan Region threat of future scarcity. Trends have already demonstrated a
went so far as to tell Reuters that “Santiago is a city of disasters – we rise in temperature in the Andes Mountains, where most of the
have had in the last year the worst fires ever, we had two floods in country’s water resources are stored, including for Santiago.9
the city (and) two important water supply cuts.”6 Exacerbated by Higher temperatures in the mountainous regions translates to
inequality and corruption, the city’s resilience strategy was clear: less snow and glaciers to serve as water reserves in dry summer
environmental challenges pose a dire threat to Santiago and its months. Precipitation levels are also projected to decrease, and the
residents. World Resources Institute (WRI) ranked Chile as one of the most
184 185
iii How is water security defined? water stressed countries worldwide.iii Water security is already A Contaminated River
↘ Review the UN Water infographic an issue in present-day Chile, and WRI suggests that stress will Patricia Arroyo Meneses has many childhood memories of the
here
increase further still, reaching extremely high levels by 2040.10 Mapocho River. She remembers the natural flow of the river,
iii ↘ Learn about the WRI and their These challenges pose a threat to Chile’s rapid economic growth, and boats sailing through the city. Then, there were the floods:
work on water here
as an estimated quarter of the country’s GDP is dependent on torrents of water that would surge the banks of the river and sweep
water intensive industries such as mining, agriculture, forestry, through the streets of Bellavista, the neighborhood where Meneses
and manufacturing.11 Water challenges are not faced by Chile was born and raised. “The flood even reached our home two blocks
alone. Global demand for water is expected to outpace supply by from the river. I remember seeing the water. It was black and very
iv What do you think drives increased 40% over the next decade, which will create severe water stress for dirty with a lot of waste from the mountainside,” she says.
water demand globally? nearly half of the world’s population.12iv

Closer to Santiago, conditions are already changing. Droughts in

the Maipo Valley followed by periods of heavy, sudden rainfall have
triggered landslides that have flushed mud into the Maipo River,
the intake source of Santiago’s drinking water supply.13 Ironically,
the increasing occurrence of flash floods is paired with the forecast
of long term water shortages. Studies predict a 12% drop in average
monthly flow in the Maipo River between 2035 and 2065,14 putting
a serious strain on water supply for Santiago’s growing population.
While water supply will be a defining challenge for Santiago in the
coming decades, the city has long had water concerns of another
nature.

A close-up of the Mapocho River in

2019. Much of its original flow has been
diverted upstream.

Now 59-years-old, Meneses has spent the better part of her life Patricia Arroyo Meneses has been
working at La Vega, Santiago’s largest fruit and vegetable market working at La Vega vegetable market
since she was a child in the 1970s.
on the northern bank of the Mapocho River. The Mapocho is a She has witnessed many changes in
tributary of the Maipo River, which rises on the western slopes of Santiago, from shifts in government to
the Andes. An essential source of water, the Maipo supplies up to ones pertaining to the cleanliness of the
river. Like many vendors here, Meneses
90% of the drinking water for Santiago15 as well as irrigation water
remembers a time when they needed to
for surrounding agricultural fields. That has proven problematic rinse vegetables with chloride before they
in the city’s past. could be sold or eaten.

186 187
By the 1980s, rapid urbanization was impacting the cleanliness of are still irrigated with wastewater.20 The difference, however, is
the Mapocho and the health of Santiaguinos. Rivers in this part that higher income countries often treat that wastewater first.v v A study found that as per capita
of Chile are naturally clean, originating high in the mountains Compare that with Chile in the 1980s and 90s when wastewater income increases, a country
progresses from using untreated
and flowing for relatively short distances before emptying into the was being used, untreated and sometimes unplanned, to water water to treated.
Pacific Ocean. This was historically the case with the Mapocho, the crops that would feed a growing population. The public health
says Manuel Contreras, Executive Director of El Centro de Ecología implications were substantial.
Aplicada, a Santiago-based environmental consulting group.
That water purity, Contreras says, was negatively affected by the Tests of irrigation water in 1983-84 found evidence of Salmonella
pressures of rural-urban migration. “When the population grows, enterica serovar typhi in 10% of samples.21 Salmonella typhi is the
particularly in a city like Santiago, the load of contaminants in bacterium causing typhoid fever, an infectious disease contracted
the river increases. That was the situation of the Mapocho River,” through contact with contaminated water and food. Between
Contreras says. “There was a bigger demand on water, and a larger 1977 and 1985 Chile faced the largest typhoid epidemic in Latin
load of materials being disposed in the river. At the beginning it America, despite the country having the best health indicators in
was wastewater and organic material, and then it was industrial the region. This included a higher life expectancy and reduced
contaminant. The water supply was stressed.” rates of maternal and infant mortality.22

Increased contamination of the river was also connected with The highest incidence rates of typhoid were found in the region
Santiago’s efforts to increase household sewage collection. By 1991, that includes Santiago, even though the city had a better sanitation
87% of Santiago homes were connected to a sewage collection system than the rest of the country. At its peak in 1983, typhoid
system16 operated by Empresa Metropolitana de Obras Sanitarias incidence in Santiago was 219 cases per 100,000 people. High
(EMOS), a public utility. Increased sanitation access is an indicator prevalence rates were representative of a broader trend in Latin
of improved health worldwide, but in the case of Santiago, sewage America which, during this decade, experienced some of the
collection did not equate to sewage treatment. One chemist highest rates of typhoid worldwide.23
articulated the problem particularly well: “[sewage collection]
merely removes the bulk of our excreta from our houses to choke Urbanization had led to greater water demand and more waste
our rivers with foul deposits and rot at our neighbors’ door.”17 entering the river—it also increased the number of people in
close proximity who could contract disease.24 Dr. Sandra Cortes,
That chemist was onto something. Soon, the Mapocho River that a public health epidemiologist at the Pontifical Catholic University
market vendor Patricia Arroyo Meneses remembers was no longer, of Chile, says there were other contributors to the high prevalence
and she was presented with another sight and smell: the city’s of disease, including the country’s political climate. “Everything
household waste. Santiago’s wastewater discharged directly into related to environmental control was not a priority from 1973
the river, and the Mapocho became an open sewage dump. Waste to 1990,” says Cortes of the past government. Unemployment
poured in at a rate of 13.3 cubic meters a second,18 an Olympic conditions and a lack of health services intensified the spread
swimming pool worth of sewage every three minutes. EMOS of disease from contaminated irrigation waters. Not limited to
was responsible for producing and distributing clean water and one disease, the typhoid epidemic was compounded by a cholera
vi Beyond infectious diseases, how can
collecting wastewater in Santiago, but treatment was nonexistent. outbreak in 1991 and cases of other enteric infections such as contaminated rivers affect the health
hepatitis A.vi of populations?
The open disposal of sewage was a problem for local irrigation as
well. After flowing through Santiago, the mixture of river water and As Patricia Arroyo Meneses recalls, the connection between the
sewage was used to irrigate 1,300 square kilometers of agricultural spread of disease and agriculture wasn’t good for market business.
land in the Metropolitan Region. This included 70 square kilometers “Customers started asking for sanitary approvals before they
of vegetable crops that would be consumed raw from La Vega and would buy our vegetables,” she says. “We would have to wash our
Santiago’s other markets.19 This isn’t unusual—fields worldwide vegetables with chloride diluted by water.”
188 189
The outbreaks prompted emergency action from the Chilean
Santiago is surrounded by
government. An intervention in 1983-84 involved communication agricultural land, much of which
and education campaigns about hygienic crop preparation and the is irrigated with water from the
administration of an oral vaccine for typhoid. In 1991, emergency Mapocho River. Historically, this
interventions included “increasing the number of prohibited contributed to outbreaks of typhoid
crops; banning restaurants from serving raw vegetables, [...] and other diseases before the river
and construction of new irrigation channels separated from was decontaminated.
sewage discharges”—interventions that one study notes were
more effective at addressing the environmental transmission of
disease rather than person-to-person transmission.25 While these
interventions had a level of success in reducing disease prevalence,
the long-term improvement of public health required addressing
the root cause of the problem: the contaminated Mapocho River.

Wastewater Treatment—A Public Sector Attempt

“There was an awareness of the problem [of wastewater] but it
still led to the huge question of how to solve it.” This is how Yves
Lesty, Circular Economy Manager at Aguas Andinas, describes the
situation in Santiago in the mid-1990s. Despite having identified
irrigation with untreated wastewater as a cause of disease, no
stakeholder had succeeded in removing the sewage from the river.

Santiago’s need for wastewater treatment had first been flagged as

part of a 1984 sewage master plan developed by EMOS, the city’s
public sanitary works company. That plan proposed constructing
more than 200 kilometers of sewers as a way to prevent
contamination in irrigation channels and reduce the incidence of
typhoid fever.26 The sewers would feed into a new plant that would
pilot sewage treatment in the city.

Construction of the sewers was to start two years later with

funding assistance from the World Bank. The goal was sidelined,
however, by budgetary and bureaucratic hold-ups, in addition to
flooding in 1986 that damaged existing water infrastructure. Soon,
the focus of the project shifted from improving sewage coverage
to improving water supply. A project completion report filed by
the World Bank found that the project had not accomplished its
sewerage component but had been successful in increasing water
coverage.27 The construction of infrastructure to intercept and
treat household sewage would have to be managed by another
project at another time. EMOS set a new goal: 100% wastewater
treatment by 2024.28

190
Clean River, New Life: In the end, Santiaguinos didn’t need to wait until 2024. By the
Manuel Contreras stands behind
The Privatization of turn of the new millennium, Santiago’s water supply and sewage
the office of El Centro de Ecología
Chile’s Water Utility infrastructure was primed for another set of upgrades. After Aplicada. One of the only offices
considering the idea for decades, the Chilean government decided in Santiago with what he calls
the task of water supply and sanitation was best managed by the “waterfront property,” Contreras says
private sector. In 1999, the majority stake in EMOS was sold to being located near this small stream
Sociedad Inversiones Aguas Metropolitanas Ltda., owned by Agbar would not have been possible when
and Suez Group, two multinational companies. Two years later the the Mapocho was contaminated.
company was renamed, and Aguas Andinas officially came into
being as a privately-owned, publicly-listed operation. Angel Simon,
who today serves as Executive Vice President of Suez Group in
charge of Spain and Latin America, was the first General Manager
of Aguas Andinas between 1999 and 2002.

Despite being privatized, water services must still comply

with Chile’s regulatory framework set out by a body called the
Superintendencia de Servicio Sanitario (Superintendent of Sanitary
Services). As the regulating body, the Superintendent sets the tariffs
that customers pay and has final approval over any tariff increase,
including ones proposed to build a new piece of infrastructure or
upgrade existing systems.

The complete treatment of wastewater was one of the In its natural state, the Mapocho River had once provided
requirements of the new private utility. This promised to be a Santiaguinos with many services. “People could take a bath, they
substantial undertaking: just 3% of Santiago’s wastewater was fished, they visited and walked around the area, and navigated
being treated in 1999, one of the lowest rates in Chile.29 With by boat,” says Contreras of the river’s past. “In 2003 [before
that requirement, Aguas Andinas launched a new program that decontamination] none of that was happening.” In order to
year: Mapocho Urbano Limpio (MUL, Clean Urban Mapocho) improve the health of the river, Manuel Contreras and his team
in order to decontaminate the river. MUL involved several large offered Aguas Andinas a few recommendations. One echoed the
infrastructure upgrades, including the construction of three new requirement of privatization: the removal of organic matter from
wastewater treatment plants: La Farfana, El Trebal, and Mapocho. the river through the creation of wastewater treatment plants.

Prior to its decontamination efforts, Aguas Andinas commissioned Aguas Andinas got to work. Construction of the first treatment
an environmental baseline study of the Mapocho. “In general plant, El Trebal, started in 2000 and La Farfana began operations
terms, the river was in very poor shape,” says Manuel Contreras in 2003. Over the next 12 years the company eliminated 46
with El Centro de Ecología Aplicada, the agency that authored discharges—places where millions of cubic meters of sewage
the report. The pressures of urbanization on the river had caused previously emptied into the river. Instead, the sewage collection
biodiversity shifts. “There should have been many fish, birds, and pipes spilled into a new 102-kilometer-long interceptor system
aquatic plants. But having the Mapocho River sick meant that the that channeled wastewater directly to one of three new sewage
environment was sick as well,” says Contreras, explaining there treatment plants. With the opening of the Mapocho Sewage
was not enough oxygen in the contaminated ecosystem to support Treatment Plant in 2013, Aguas Andinas had achieved its 100%
life. “Our main conclusion was that the conditions were very poor wastewater treatment obligation in less than 15 years.
and the recovery was going to be a slow process.”
192 193
 Marta Colet, Deputy CEO of Aguas Andinas, notes how this Privatization of Santiago’s water resources impacted the price
timeline compares to other parts of the world: “France and Spain customers were paying for their household water supply. Tariffs
started with water treatment plants in the 1950s and it was a slow rose by 90% in the four years following privatization37 in order
progressive increase because the investment was made through to upgrade the city’s wastewater treatment services. To reduce
public funds. It took 50 to 60 years, and in some parts of Spain, we water access inequities that would come with tariff increases, the
still have areas which do not comply with European regulations,” central government has a water subsidy program that covers the
she says. “So to have 100% [wastewater] treated and returned to first 15 cubic meters used by lower income households monthly.
the environment in good condition in this time period is a record.” Depending on household size and use, this covers between 15 and
85% of water bills, and experts say this safety net has made water
The Chilean Water Code privatization and tariff hikes in Chile less controversial than in viii How is wastewater managed in the
other Latin American countries.38viii places you live and work?
While it had the benefit of accelerating the treatment of Santiago’s wastewater, the neo-liberal system of
privatization has long been a controversial topic in the city and country. It started in 1981 when the military Impacts on Human and Environmental Health
government created the Chilean Water Code, the piece of legislation that to this day governs use and According to Dr. Sandra Cortes from the Pontifical Catholic
management of the resource. The code made water a private commodity that could be bought, sold, or leased University of Chile, it’s difficult to quantify the exact impact
like any other resource. privatization and the decontamination of the river had on the
health of Santiago residents. As noted, incidence of typhoid fever
The idea for free-market privatization came from a group of University of Chicago-educated Chilean economists had already dropped after 1991 with emergency government
nicknamed the Chicago Boys. Their new policies were supported by World Bank recommendations. Both interventions that ordered an end to crop irrigation with sewage-
groups suggested privatization would be a more effective way to manage water coverage and access, and said contaminated water.39 The only Latin American study looking at
privatization would allow for a reduction in state intervention and the encouragement of foreign trade.30 the impacts of privatization on public health found that childhood
mortality rates were lower in communities with privatized
Critics of the existing Water Code challenge its contradictory nature. It establishes water as a national public utilities.40 Overall, a literature review found the verdict is still
good, but also grants ownership in perpetuity to private companies, including Aguas Andinas. In some parts of inconclusive as to whether privatization in the region has been
Chile, this has interfered with people’s access to water, one of the essential human rights set out by the United necessary in achieving better health outcomes.41
Nations General Assembly.31 And while water privatization has improved services like wastewater treatment,
advocates in favor of public ownership have demonstrated that this has come at the cost of customer tariff Cortes says the lowering of enteric disease also correlated with a
hikes, while private companies and utilities continue to expand their profits.32 change in government in 1990. Environmental control and public
health programs had been stalled for the better part of three
The conversation of who to best manage water and other natural resources is playing out in other parts of the decades, and the new government resumed social programming.
world, where research has found that the privatization of services could leave lower income communities more “That’s why it hasn’t been easy to prove that only Aguas Andinas
vulnerable to climate change.33vii did something about [improving the health of Santiago residents]
because that improvement is also a consequence of development,”
says Cortes.
vii Where do you stand on this Globally, wastewater treatment isn’t the norm. An estimated 80%
discussion that’s happening in Chile
and worldwide? of wastewater worldwide is discharged into the environment A decade and a half after its first study, El Centro de Ecología
without ever receiving treatment.34 Latin America does a bit Aplicada performed a follow-up study on the condition of the
better, treating nearly 40% of its wastewater, approximately double Mapocho River. Its findings were more directly linked to the
the global average.35 A report from the International Resource actions taken by Aguas Andinas during its Mapocho Urbano
Panel suggests recycling, reusing, and returning this water to the Limpio program.
environment are three measures that could help countries more
holistically manage their water resources36 and minimize negative “We found a high diversity of aquatic insects, and these are
impacts on local ecosystems. indicators of the quality of the water,” says Manuel Contreras of the
194 195
2016 report. Compare this to 2003 when the river was home only
to worms that could survive in oxygen-poor settings. “This was
proof in ecological terms that the Mapocho River was improving
little by little.” Those aquatic insects were joined by the recurrence
of native fish species, including small catfish, Chilean silverside,
and the mosquito fish. The study also found that aquatic plants
had increased and that mammals and birds were beginning to
reappear along the riverbank.

Cleaning of the Mapocho also led to an increase in the number

of parks along the river. Numerous studies have quantified the
impact of daily greenspace exposure on physical, mental, and
social health. Iván Poduje, an architect and urban planner in
Santiago, points out the parks on Google Earth—new strips of
greenspace lining the river. Some of these spaces, he notes, were
built in the 90s when the Mapocho River was still contaminated.
As a result, they were rarely used. “Then we built the Parque de la
Familia after the water was cleaned,” he says. A key feature of the
park is a calm lagoon with water from the Mapocho River. Walk
through the manicured landscape and visitors can reach a strip of
path that sits next to the river. While there’s still some trash and
pollution in the water, it’s a far cry from the open sewage dump of
the 1980s and 90s.

Poduje adds that the Parque de la Familia is in a lower income part

of Santiago. “When you clean the river and create green area you
break the social segregation of the people with the river,” he says.
“You create a park, land and property values go up. You eliminate
security issues, and people have a beautiful park nearby. When this
happens you forever change the quality of life of the people.”

With improved public health, a cleaner river, and increased green

space all either directly or indirectly linked to its full treatment of
wastewater, Aguas Andinas had reached an operational crossroads
and had the opportunity to ask “what’s next?”
Parque de La Familia, constructed
near the edge of the Mapocho River, is
one of Santiago’s newest greenspaces.
The park features a testament to the
decontaminated river: this lagoon filled
with water from the Mapocho. On the
weekends families stroll through the park
and take paddle boats onto the lagoon.

196 197
La Farfana is one of the largest
wastewater treatment plants in Latin
America. First opened in 2003, the plant
was retrofit as a biofactory after Aguas
Andinas’ strategic change in 2016.
Today, parts of the facility are open for
public tours.
 Carlos Castro holds a biocement brick —
From Sewage to Circular There’s a cement block in the corner of Carlos Castro’s office. made exclusively from dried ash extracted
Castro is the Manager of Biofactories and Sustainable Operations from household wastewater. This could
with Aguas Andinas, and was one of the original supporters of be a future market for the byproducts
that come from Aguas Andinas’ circular
the company’s biofactory project. This cement block is a tangible economy model.
example of the valuable byproducts that can be created from what
is extracted during the process of treating wastewater. This block
was created from the dried ash of what was once household waste.
ix A monofill is a type of temporary “Our dream is that this biocement be produced from the monofillix
landfill. In the case of Aguas Andinas, at El Rutal and then sent to plazas or buildings,” says Castro,
the monofill at El Rutal is a place
where dried sludge is stored until it placing the block on his desk.
can be turned into something useful,
like the biocement in Carlos Castro’s
office.
Having achieved 100% wastewater treatment by 2015, Aguas
Andinas could take one of two paths. The company had met the
requirements established by privatization, and the most straight-
forward next step would have been to maintain its status quo as a them to do so. For me, the company is a biological being. It is alive
traditional water and wastewater utility. The other option was to and it depends on its surrounding environment. It needs to adapt
forge a new business strategy that updated the company’s mission to that environment in order to obtain a license to live,” Berberana
in alignment with the shifting values of society and the changing says.
needs of its clients.
He combined this personal philosophy with the new attitudes of
“What we have now are empowered citizens who require a very clients, pointing to these societal demands to support his argument
different relationship with a utility,” says Narciso Berberana, for a revised strategy: “how could we use the previous paradigm
Aguas Andinas’ Chief Executive Officer, and the person who led its that was not up-to-date? We said that society is changing so we
change in strategy in Chile. He says clients today demand greater must too.” At the same time, Berberana was careful not to criticize
transparency around supply breaks and increased consideration the company’s past approach, mindful that his proposed changes
of environmental responsibility, including ensuring wastewater is could put the board of directors on the defensive.
treated. “Nowadays it would be unthinkable to have sewage in the
middle of the city,” he says. The evolution of the company strategy took time. “Convincing the
board was one of the most difficult things to do,” says Berberana,
The strategy change required new infrastructure, turning Aguas now a board member himself. “It was a traditional board and
Andinas’ La Farfana, Mapocho-Trebal, and El Rutal facilities into they were used to a business environment where profit was only
one of the largest wastewater treatment systems in the world: the economically gained. The point of inflection was when I was able
Gran Santiago Biofactory. The biofactories are one element of the to open them to the vision of how the company could be five years
circular economy model that was suggested by Angel Simon, and into the future. [...] What I proposed was to change Aguas Andinas
has been used by Agbar Group in Barcelona, one of the companies into a services company that had not only an economic focus but
that owns Aguas Andinas. an environmental and social mission, too.”

At the same time, the biofactories demanded the adoption of new The updated corporate strategy was unanimously approved—
mindsets and business models. That wasn’t easy. A long-time almost. Water and quality of life, the final of the seven pillars
environmentalist, Narciso Berberana says it’s key that a company proposed under the new strategy, received pushback. It included
change over time. “I believe in the sayings of a very famous Chilean goals like increased participation in health and water studies and
biologist and philosopher, Humberto Maturana. He said that biodiversity preservation and recovery projects. “The board said
species arise and surge in environments that make it possible for this was outside the strategy of the company,” Berberana explains.
200 201
Biodiversity and Watershed Management "Reaching a consensus on the new corporate strategy took about
nine months. The result of this new project was Santiago Merece
Preserving the biodiversity of ecosystems is one of the objectives of Santiago Merece un 7, Aguas Andinas’ un 7 (Santiago Deserves a 7), the long-term strategy of Aguas
long-term strategy. This includes protection of the Mapocho River and the Maipo watershed from which the Andinas,” says Esteve Clos, Organization and Talent Manager.
river draws its source. Less than 5% of that watershed is currently protected.42 Launched in 2017, its seven pillars include resilience, circular
economy, social legitimacy and water and quality of life—each a
The company’s choice to include biodiversity in its strategy elicited some confusion. “Non-health focused new direction for the established company.
companies [see the inclusion of biodiversity] as exotic,” says Carmen Lacoma, Manager of Sustainable
Development at Aguas Andinas. “However, we find it important to link the two because the preservation ↘ Appendix 1: The seven pillars of Santiago Merece un 7
of biodiversity has a direct impact on the water we capture in the basin.”

The company is in the midst of preparing its first biodiversity strategy. That strategy involves more effective
measuring of the company’s carbon footprint, supporting the release of endangered Tricahue parrots when When Waste Becomes Resource
the Pirque Mega Tanks open, and protecting the birds of prey that have flocked to its Turning La Farfana and Mapocho-Trebal wastewater treatment Narciso Berberana is the CEO of Aguas
El Rutal biosolids monofill. Lacoma notes that these projects will likely be supported by the creation plants into biofactories was an integral part of Aguas Andinas Andinas. He was one of the key people
who led the company’s strategic change
of a new corporate volunteering program. achieving its new vision. “Our difficulty has always been identifying in 2016 following the company achieving
how to connect with general people who don’t have a technical a 100% treatment of wastewater.
In an effort to improve watershed management, Aguas Andinas is a signatory on The Nature Conservancy’s vision,” says Dulcinea Meijide, the Director of Sustainable
Santiago Water Fund. The fund is a public-private partnership to protect nature in the Maipo watershed. This Development with Suez Group Spain, the company that has
includes investigating how nature-based solutions such as river buffer zones and healthy vegetation can improve ownership in Aguas Andinas. “When talking about the circular
water quality and reduce treatment costs. economy and shared value you need to identify examples. We can
point to the biofactories and people say ‘ah yes, I see.’”
Manuel Contreras with Santiago’s El Centro de Ecología Aplicada says collaboration is key in making future
watershed management efforts a success. Environmental activities by industry and non-governmental With the opening of its biofactories, Aguas Andinas now defines
organizations, he says, have previously been limited to the conservation of wetlands, with each stakeholder itself as a “services company.” It provides the traditional service of
considering only its own vested interests. “Education and agreements with these groups would be one strategy drinking water and wastewater treatment, but also produces and
that could change how we view the water, and this is one area where Aguas Andinas could contribute more,” sells the raw materials and resources generated by its biofactories.
Contreras says. He adds that he’d also like to see the company use its influence to urge the Ministry of the
Environment to take greater responsibility of the country’s watersheds. The creation of new products from what would otherwise be
waste is part of the company’s new circular economy model. It’s an
approach that envisions the cyclical reuse of products, resources,
To convince them of this seventh pillar, Berberana played another and waste to extract its maximum value. Compare this with
strategy card: he assigned responsibility of the new strategic plan standard linear economy models, defined by mentalities like “take,
to the director who most opposed it. Suddenly, this director was make, and dispose” and “use it or lose it.”
personally invested and responsible for persuading the rest of the
board to approve and adopt the new strategic direction, quality ↘Appendix 2: Linear and Circular Economy Diagram from the Ellen
of life and all. Broadly, similar strategies could be key in helping MacArthur Foundation
private companies adopt or champion more holistic planetary
health business practices.

202 203
 Circular Economy Initiatives Around the Worldx Yves Lesty, a long-time engineer with Aguas Andinas, became the
company’s first Circular Economy Manager in September 2017.
The European Union has been a global leader on transitioning to a circular economy. In 2015, the European “[The circular economy concept] was little developed in Chile.
Commission, the executive branch of the EU, started its Circular Economy Action Plan. That plan included There are some companies that are more specialized and recycle
54 specific actions that sectors and countries could follow to extend the life of its products and materials.43 plastic and glass products, but these few initiatives are relatively
The action plan was considered fully implemented by 2019. small in size,” Lesty says.

On a common thread, The Switchers, a joint project of the European Union and the United Nations Environment The Aguas Andinas biofactories in Chile aren’t the first of their
Programme, profiles circular economy initiatives in the Mediterranean region. This includes stories of an kind, but they are the largest-scale example worldwide. Suez
innovator finding a way to extend the life of electronic waste in Palestine, an Italian sailor who creates fashionable Group, the company that owns Aguas Andinas, has also adopted
accessories from old sails and sail cloth, and a Moroccan innovator who uses a process called pyrolysis to biofactory models at its wastewater treatment plants in Spain.
transform agricultural waste into a charcoal fertilizer. “[What we are doing in Santiago] is taking the cutting edge
technology from other parts of the world and applying it in Chile,”
x What are some circular economy says Jordi Fontana, the General Manager of Biofactories.
initiatives in the places you live and Jordi Fontana and Paulina Vicentela are
work?
There are a number of secondary products that can be created on the management team at La Farfana
biofactory. The displays behind them are
from the extracts of wastewater. Back in the reception area at La in the entrance of the plant, and explain
Farfana biofactory, Fontana gestures at a placard highlighting the to visitors the process of the biofactories
company’s aspirations in adopting a circular economy approach: and the history of water sanitation in the
capital city.
zero environmental impact through producing zero waste and
zero emissions, and needing no energy consumption from outside
sources. “La Farfana is the biggest plant of its kind and puts all
these pieces together to achieve the goals,” he says.

The specifics of those goals are more technical. When wastewater

enters a traditional treatment plant or biofactory, wastexi is xi The waste extracted from
extracted during the cleaning process. Traditionally, biosolids are wastewater is called biosolids
or sewer sludge. Aguas Andinas
sent to a landfill where utility companies pay for their disposal. Not uses the term biosolids.
only can this be expensive, but landfills are also an environmental
liability, creating smells and unsafe areas. The biofactories, on
the other hand, sanitize and dehydrate the biosolids, giving
them to local farmers free of charge. Already high in nitrogen
and phosphorous, farmers can add potassium in order to use
the biosolids as fertilizer.xii “This allows us to reincorporate the xii What is the difference between
biosolids into the food cycle and continue their lifespan,” says Yves organic and inorganic fertilizers? Are
there downsides to fertilizer use?
Lesty. Today, 70% of the biosolids produced by Aguas Andinas are
distributed as fertilizer and what remains is sent to the monofill at
El Rutal, awaiting a second life. A future goal is to further dry the
The biosolids monofill is located north of biosolids in order to create a more valuable product that could be
Santiago—the piles are household waste
sold rather than given away.
that has been dehydrated and sanitized.
These biosolids are then given a second
life, reducing the amount of waste that
ends up on landfill.

204 205
 The creation of biosolids also helps reduce the company’s
xiii How is a carbon footprint emissions.xiii Before being disposed, biosolids are dried for about 20
calculated? Why is it important to days. This lowers the water content of the sludge by 75%, making it
calculate it? What is your carbon
footprint? more compact and lightweight for transportation. Aguas Andinas
↘ Learn more here estimates it currently produces 850 tons of emissions a day in
biosolid transportation. This could be reduced to 300 tons daily
with proposed further drying techniques.

Finally, the biofactories are key in Aguas Andinas’ aspiration of

reaching carbon neutrality, and the company aspires to be 100%
energy self-sufficient by 2020.44 Water and wastewater plants
demand large amounts of energy to run continuously. The
distribution and treatment of water and wastewater uses about
4% of the world’s total electricity supply, and this energy demand
is expected to double by 2040.45 This creates an opportunity for
companies to be more efficient through the production of their
own energy sources.

xiv Where else can biogas be Biogas is one option.xiv Biogas is a mixture of gases created using
obtained? How is biogas turned into a process called anaerobic digestion. Visualize a giant stomach:
energy? Is burning biogas detrimental
to the environment? bacteria is used to break down the sludge cleaned from wastewater,
and ‘digest’ it in an oxygen-devoid setting. The resulting biogas is
then combusted to create heat or electricity. To date, 85% of the
Mapocho-Trebal biofactory is run on this biogas. An agreement
between the city and La Farfana plant means it’s more cost
effective for Aguas Andinas to use electricity supplied by the city
than to capture its own. Instead, biogas from La Farfana is sold
to Santiago’s natural gas distributor and provides electricity to La Farfana's wastewater cleaning
30,000 households. This could change in the future when Aguas mechanics from above.
Andinas is able to modernize La Farfana to operate on the biogas
that’s produced. The company says this project must be evaluated Biofactories: A Benefit to The ability to create new revenue streams is another benefit of the
on its own merit, and that this process is on track to happen by Business circular economy. Take, for example, the fact that Aguas Andinas
2022. has started accepting industrial waste generated during the
production of soda. This highly concentrated waste would have
“The idea is to recover the greatest portion of energy from the previously been brought by truck to the wastewater treatment plants
sludge,” says Jordi Fontana of the biogas production. “This could at a high cost. The soda company would then pay to have the waste
be electricity, hot water, steam. All of these residual energies could treated. Now for a lower cost, companies can opt to send effluent
be used later in a boiler or to dry more waste.” Aguas Andinas through a discharge pipe to the Mapocho-Trebal biofactory where
sees these diverse energy sources as one of its key climate change it is added to the anaerobic digester and transformed into energy.
mitigation efforts. It decreases reliance on fossil fuels and also Money is saved by both the soda company and Aguas Andinas, and
creates a new source of revenue for the company. a valuable product is produced. Aguas Andinas benefits financially
at both ends of the process: with payment from the soda company
and in the cost-savings it receives from producing biogas.
206 207
 Whether it’s biogas, biocement, fertilizer, or other future
byproducts, each can be sold by Aguas Andinas through its
subsidiary businesses. The requirement is that the income from
these sales be used to reduce and/or mitigate the possible increases
in the rates paid by customers. In other words, the more income
obtained from the sale of biofactory resources, the greater the
likelihood that residents of Santiago could see a stabilization
in their water bills. “Aguas Andinas has the vision to advance
steadily in the search for shared efficiencies,” declares a company’s
statement.

While the biofactories have allowed Aguas Andinas to expand its

environmental and social vision, it’s not all about altruism, but
economics, too. The company must run a careful cost-benefit
analysis of every infrastructure upgrade and biofactory product it
considers producing. This is because of the regulatory environment
in which Aguas Andinas operates. Converting wastewater
treatment plants into biofactories is not an inexpensive task. With
a price tag of US $61.2 million between 2018 and 2020,46 these
infrastructure upgrades are funded by the customer tariffs that
can be updated by the Superintendencia de Servicio Sanitario every
five years.

For better or worse, the Superintendent is notoriously conservative. Tariff increases aren’t the only approach Aguas Andinas is using The view over La Farfana's facility.
“If they were asked about whether or not we could carry out a to fund its upgrades. “The great jump in strategy was when we Educational placards mark the place
where visitors and students come
change they’d simply say no because they associate all that’s issued green and social bonds and the stock market received them each year to learn about Santiago's
traditional with control, even though that’s an incorrect concept,” successfully,” says Berberana. wastewater management system.
says Narciso Berberana, Aguas Andinas’ CEO.
He’s referring to the two rounds of bonds the company issued in 2018
As a result of this conservative regulator, no tariff change can be and 2019, raising US $68 million and US $83 million respectively.xv xvThe payback period on the 2018
made without demonstrating it will bring cost-savings over the While this represented the first time green and social bonds bonds is seven years at an interest
rate of 1.8%. The second round of
long-run. Aguas Andinas needs to prove that its circular economy were issued and sold in Latin America, the approach is becoming green and social bonds will be paid
approach makes more economic sense than the traditional way of increasingly popular worldwide as a way to fund environmental back over the course of 25 years at an
and climate-related projects. The world’s first green bonds were interest rate of 2%.
doing business. For example, say it costs the company $1 to dispose
of its biosolids in a landfill. If distribution of those same biosolids issued by the World Bank in 2008, though the water and wastewater
to farmers cost $1.50, Aguas Andinas would have no choice but sector represents just 10% of green and social bonds commitments
to select the first option. If the circular method is shown to be in 2018.47 New environmental funding streams are key in directing
more cost effective, however, the Superintendent is more likely money to urgently-needed climate change resilience, adaptation,
to approve a tariff increase to raise money for that switch. In the and mitigation measures. As Mami Mizutori, the UN secretary-
xv What are co-benefits of climate
action? Why are they important? Read case of biosolids disposal, Aguas Andinas says it costs 40% less to general’s special representative on disaster risk reduction told The
more here produce biosolids for fertilizer versus sending them to landfill.xv Guardian “resilience needs to become a commodity that people will
pay for.”48 Green and social bonds can offer that investment model.

208 209
 Bonds are long-term, typically lower risk investments that help autonomy when the first flooding event happened in 2008. “After
finance certain projects—in the case of Aguas Andinas, the funds this event we suggested to the Superintendent that we should
will be directed towards projects that make an environmental construct a big emergency tank, but they said ‘no’ because it was
and social impact.49 Berberana says it’s notable that investors are very expensive and nobody thought there would be a bigger event,”
starting to consider these categories of projects as being more says Rodríguez.
secure over time. “You can associate sustainability visions with
more stability. It would have been impossible to speak in these Just as Aguas Andinas needs to demonstrate the economic
terms three years ago,” he says. Demand exceeded the bond amount argument for transitioning to a circular economy model, the
offered in both rounds of issuance, demonstrating that there was same rule applies for the approval of climate change resilience and
an interest in investing in the company’s long-term vision. “The adaptation measures. Basically, the company needs to show that it
xvi What are other examples in which investors validated our strategy and were willing to invest in a would be more costly to do nothing in the face of climate change.
green and social bonds are being company that makes radical changes,” says Berberana. Unlike Two major floods affected Santiago in the first months of 2013.
used? What international agreements the shareholders of Aguas Andinas who are almost exclusively Shortly after, the Superintendent approved the construction of
have incorporated these finance
mechanisms in the past? Were they international, the green and social bonds were available only to the Pirque Mega Tanks, which will store 1.5 million cubic meters
successful? Chileans.xvi of emergency water. It’s Aguas Andinas’ largest climate change-
related resilience project to date, and has increased Santiago’s
water autonomy from 11 to 34 hours. If the Pirque tanks had been
operational in 2013 the company would have avoided that water
A Planetary Health Climate change resilience and adaptation measures are two cut event, notes Alberto Blanco, Director of Engineering and
Approach for Future priorities for the funds raised by Aguas Andinas’ green and social Sustainable Development. Aguas Andinas recently presented a
Development bonds. That includes accounting for an increase in climate- new proposal to raise the autonomy levels further still to 48 hours.
intensified flooding and future water shortages. “We have to
defend our plants,” says Eugenio Rodríguez, Director of Service While new emergency storage tanks help in the case of flooding
Management with Aguas Andinas. At least five events in the last or landslides, they don’t address the drop in water supply that
seven years have forced the company to suspend water services. Santiago is forecast to face.50 “We are working on this,” says
Typically, this happens when sudden, heavy rains trigger landslides Eugenio Rodríguez, the Director of Service Management. “We
which muddy the river and force Aguas Andinas to close its intake talk about resilience and in parallel we have a drought plan that
valve along the Maipo River. considers different alternatives like protecting glaciers, decreasing
losses in our network, and convincing the community to use less
“This has meant one million customers without service for between water.”xvii xvii Take a moment to think if you are
one and three days. It’s very bad for us because our core business doing your share to save water. What
else could you be doing? ↘ Click here
is providing water continuity,” says Rodríguez. “It’s a reputation Community water consumption, conservation, and efficiency are to learn more on where your water
problem because customers don’t understand that the climate is addressed in Aguas Andinas’ sustainability roadmap. A goal is footprint is coming from
producing the event. They see a company stopping service.” These to educate at least 30,000 people each year on sustainable water
water cuts occurred in the summer months, with 30 degree Celsius use. A few years ago, Aguas Andinas launched a summertime
temperatures intensifying the impacts of water shortages. campaign called Plazas del Agua (Water Squares), small community
water parks where children can go to cool off. This is meant to
Increasing emergency water autonomy is one of Aguas Andinas’ decrease one of the company’s most significant water consumption
main climate adaptation measures to address these cuts. Autonomy concerns: kids opening fire hydrants during warm weather months.
is the number of hours in which the company can support the The sustainability roadmap also addresses water and quality of
city with emergency drinking water while normal water intake is life, emphasizing that the creation of healthy environments can
disrupted. This is usually done in the form of large storage tanks improve the quality of life for Santiago’s citizens.
and additional groundwater wells. Santiago had four hours of
210 211
Eventually, another way to address water supply issues could Epilogue In 2018, Aguas Andinas was named one of four winners of a
be treating wastewater to the extent that it could be reused as planetary health Momentum for Change award from the United
potable drinking water. This method is already being used in Nations Framework for the Convention on Climate Change
water-stressed cities around the world, from Perth, Australia, to xviii Two other winners in the (UNFCCC).xviii Former CEO Narciso Berberana says the award
Big Spring, Texas, to Singapore, to Windhoek, Namibia. “This is planetary health category, the Sri represented another milestone for the company’s new direction,
Lanka Mangrove Conservation Project
an eventual goal because of our strong limitation of water in the and the Plant-Powered Pupils/Climate and validated its circular economy model with politicians and
region,” explains Yves Lesty, Circular Economy Manager. Efficient Schools Kitchens projects, other corporations in Chile. It also highlighted to the international
are featured in case studies within this
anthology.
community how the private sector can engage in planetary health
However, the greatest opportunity for curbing water use in efforts.
Santiago and Chile lies not within the purview of Aguas Andinas
and household water consumption, but instead in the adoption of “Planetary health is not about the technical performance of
more efficient technologies within industries such as agriculture, our water networks,” says Berberana. “We would talk to the
mining, manufacturing, and forestry. Industrial water demand environment, treasury board, or financial ministers, and they’d
accounts for more than 90% of all water use in Chile, and demand say ‘wow, your award is not about water issues, it’s about planetary
is forecast to rise in coming years.51 While community education health and a low carbon economy.’ The change is huge for the
and individual household water conservation is important, it’s company. It’s not about only water, it’s about people’s health.”
a drop in the bucket when it comes to the larger issue of water
scarcity in Chile. More effectively communicating its environmental and social
mission is one of the most important next steps for Aguas Andinas.
Be it the opportunity to improve the health of Santiago’s citizens While its corporate strategy has changed greatly in the last five
by improving the health of the Mapocho River system, or through years, company management says this hasn’t yet been recognized
the ability to reduce waste and pollution by embracing circular by the general public. That’s why visits will continue at La Farfana
economy principles, Aguas Andinas presents an example of a large biofactory—so people, especially students, can better understand
private sector company that has adopted a planetary health framing the complexities of the water system and how what goes down
in its business approach. Further, the company has proved that a the drain is connected with their health and the health of their
planetary health model doesn’t come in conflict with economic city. “Students visit and they see this huge area and it’s beautiful
development, but can in fact aid in its behalf. surroundings. They’re impressed that all the wastewater from
Greater Santiago comes here,” says Paulina Vicentela, looking
out at La Farfana’s lagoon. “We tell them that what happens in
Santiago isn’t what happens everywhere in the world, so they leave
this place with a positive point of view and a sense of pride that
commits them to reducing waste and taking care of water as a
resource.”

At a larger scale, Narciso Berberana hopes Aguas Andinas can

be a model for other private sector companies or utilities that
understand the need to step up their environmental efforts but
are concerned about their bottom line or optics among their
investors. “I believe a private company that thinks its only purpose
is to generate profit is wrong,” he says. We have to generate an
environment that’s better, and companies receive money to achieve
that planetary improvement.”

212 213
Keeping Track Narciso Berberana Alberto Blanco Carlos Castro Esteve Clos Marta Colet
of Who’s Who
Former Chief Executive Officer of Aguas Director of Engineering and Sustainable Manager of Biofactories and Sustainable Organization and Talent Manager, Deputy CEO of Aguas Andinas
Andinas, now a member of the board of Development, Aguas Andinas Operations, Aguas Andinas Aguas Andinas
directors

Manuel Contreras Dr. Sandra Cortes

Jordi Fontana Carmen Lacoma Yves Lesty
Executive Director of El Centro de A public health epidemiologist at the
Ecología Aplicada, a Santiago-based Pontifical Catholic University of Chile Manager of Sustainable Development, Circular Economy Manager, Aguas
General Manager of Biofactories, Aguas
environmental consulting group Aguas Andinas Andinas
Andinas

Dulcinea Meijide Patricia Arroyo Meneses Iván Poduje Eugenio Rodríguez Paulina Vicentela
Director of Sustainable Development, A long-time vegetable vendor at An architect and urban planner in Director of Service Management, Aguas Chief of Resource Management of
Suez Group Spain Santiago’s La Vega market Alliance Santiago Andinas Biofactories at La Farfana, Aguas Andinas

Acknowledgements The author and the Planetary Health Alliance would like to thank
Aguas Andinas and its Escuela del Agua Chile for its cooperation
and assistance in the development of this case study. The case was
developed based on interviews and secondary material collected
in May 2019. Saverio Atria, Carlos Castro, and Esteve Clos played
a fundamental role in coordination before, during, and after the
author’s visit. Many thanks also to those interviewed: Dulcinea
Meijide with Suez Spain; from Aguas Andinas: Alexis Araya,
Narciso Berberana, Alberto Blanco, Carlos Castro, Esteve Clos,
Marta Colet, Jordi Fontana, Carmen Lacoma, Yves Lesty, Eugenio
Rodríguez, Jose Saez, and Paulina Vicentela. We’d also like to
extend thanks to Dr. Sandra Cortes, Dr. Catterina Ferreccio,
Manuel Contreras, Elizabeth Araya, Iván Poduje, Arturo Guerrero
Cortes, and Patricia Arroyo Meneses. Finally, this case would not
have been possible without the expertise and interpretation work
of Patricio Gonzalez and Jorge Villegas.

Aguas Andinas’ La Farfana wastewater treatment plant as seen from above. The corridor in the top left is where the treated water from
the plant gets rechanneled back into the Mapocho River.

214 215
Bibliography
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8 Ubeda, Xavier, et al. “Wildfires in Chile: A review.” Global and Emergencia, cúspide y declinación de una enfermedad 41 Mulreany, John P., et al. “Water privatization and public epa.gov/carbon-footprint-calculator/
Planetary Change. October 6, 2016; https://doi.org/10.1016/j. infecciosa en Chile.” Chilean Journal of Infectology. December health in Latin America.” Revista Panamericana Salud Pública.
gloplacha.2016.10.004 2017; http://dx.doi.org/10.4067/S0716-10182007000600001 2006; https://doi.org/10.1590/s1020-49892006000100004 “Water Footprint Calculator: How to Save Water” Grace
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water systems.” OECD. June 2013; https://www.oecd.org/env/ 26 The World Bank. “Implementation Completion Report: Nature Conservancy. https://www.nature.org/en-us/about- https://www.watercalculator.org/how-to-save-water/
resources/Chile.pdf Second Santiago Water Supply and Sewerage Report.” The us/where-we-work/latin-america/chile/stories-in-chile/
10 Maddocks, Andrew, et al. “Ranking the World’s Most Water- World Bank. June 17, 1996; http://documents.worldbank.org/ santiago-water-fund/
Stressed Countries in 2040.” World Resources Institute. curated/en/546701468010508380/pdf/multi-page.pdf 43 European Commission. “Report from the Commission
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11 OECD. 2017. 28 “Priorities in the Water and Wastewater Sector.” Regions on the Implementation of the Circular Economy
12 “Half the World to Face Severe Water Stress by 2030 unless Environmental Technologies Industries. http://web.ita.doc. Action Plan.” European Commission. April 3, 2019; http://
Water Use is "Decoupled" from Economic Growth, Says gov/ete/eteinfo.nsf/1a588f4a83898ad285256892007bca93/7a58 ec.europa.eu/environment/circular-economy/pdf/report_
International Resource Panel.” United Nations Environment 01bff63041a285256610005fb123!OpenDocument implementation_54_actions.pdf
Programme. March 21, 2016; https://www.unenvironment. 29 “Priorities in the Water and Wastewater Sector.” 44 Aguas Andinas. “Application: Santiago Biofactory, UNFCCC
org/news-and-stories/press-release/half-world-face-severe- 30 Burgos, Roberto. “The Current Reform of the Chilean Water Momentum for Change Awards.” Unpublished. 2018.
water-stress-2030-unless-water-use-decoupled Code: An Attempt to Contest the Commoditised Treatment of 45 IEA (International Energy Agency”. “Water-energy nexus.”
13 Ahumada Theoduloz, Gerardo, et al. “Effects of climate Water.” TLI Think! April 28, 2017; https://dx.doi.org/10.2139/ IEA. 2018; https://www.iea.org/weo/water/
change on drinking water supply in Santiago de Chile.” ssrn.3049153 46 “Application: Santiago Biofactory, UNFCCC Momentum
Sciences in Cold and Arid Regions. 2013; https://doi. 31 Larrain, Sara. “Human Rights and Market Rules in Chile's for Change Awards.” 2018.
org/10.3724/SP.J.1226.2013.00027 Water Conflicts: A Call for Structural Changes in Water
14 Ahumada Theoduloz, Gerardo, et al. 2013. Policy.” Environmental Justice. April 24, 2012; https://doi.
org/10.1089/env.2011.0020
Appendix 1 - Santiago Merece un 7 strategic pillars ↘ Back to page Appendix 2 - Linear and Circular Economy Diagram from the Ellen MacArthur Foundation ↘ Back to page

218 219
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
05
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Putting
Please cite this case study as “Duff H., Faerron Guzmán, C.,
Almada, A., Golden, C., and Myers, S. “Putting Food Needs
First: How Alternative Proteins Could Save Madagascar's
Endangered Biodiversity.” Planetary Health Case Studies:
An Anthology of Solutions. 2020; https://doi.org/10.5822/
phanth9678_5”

Please note this work is licensed under a Creative Commons

Food Needs
Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view a copy of the license, visit https://
creativecommons.org/licenses/by-nc-nd/4.0/

To access the full Planetary Health Case Studies: An

Anthology of Solutions, please visit https://www.
planetaryhealthalliance.org/case-studies

First

HOW ALTERNATIVE PROTEINS COULD SAVE

MADAGASCAR’S ENDANGERED BIODIVERSITY
 Executive Summary Madagascar is one of the most biodiverse countries on Earth, and
is home to a variety of endemic animal and plant species, including
more than 100 species of lemur. Traditional conservation policies
For further detail on themes covered
in this case study, see the land use and laws have attempted to safeguard this wildlife for more than a
section of chapter 4 and chapter 5 century, but haven’t always thoughtfully addressed the needs and
on nutrition in ↘ Planetary Health: motivations of people living in these environments.
Protecting Nature to Protect
Ourselves.
Today, humans are impacting wildlife in Madagascar including
its charismatic lemurs in two key ways: through land use change
Learning Objectives
driven by agriculture and energy needs, and through the hunting
After examining this case, students of wildlife for subsistence needs. Both land use change and
should be able to:
hunting can have positive and negative public health implications.
➀ Understand the roles of policy, For example, while the latter provides a critical source of nutrition,
governance, culture, health access, particularly for poor rural communities, hunted wildlife also
malnutrition, and poverty in relation to
Malagasy biodiversity and forests.
increases the risk of exposure to zoonotic disease

➁ Analyze the risks associated with Set in the Maroantsetra region of northeastern Madagascar, this
bushmeat consumption.
case looks at interventions that could dually support wildlife
➂ Describe the role of health systems conservation and promote human health. These interventions
in response to zoonotic diseases. include the possibility of sustainable wildlife harvest as well as
➃ Assess the opportunities and domestic animal rearing. Chickens are one of the desired domestic
challenges associated with the animals, and this case explores efforts to make the switch to
community-based poultry intervention domestic animal rearing possible and sustainable.
applied in this region of Madagascar.

This case study was drafted based on interviews conducted in northeastern Madagascar
and Antananarivo, Madagascar, in March 2019.

223
Introduction Most people are still asleep as Zandrilahy leaves Antaravato to Although satisfying a family’s food needs is essential, hunting wild-
check his lemur snare. Walking along the narrow dirt track that life can have negative public health implications. Around the world,
constitutes the main road of the village, the path continues through terrestrial wildlife hunting has led to transmission of pathogens
knee-deep mud in rice paddy fields and up a 45 degree incline from their original animal hosts to humans—Ebola and HIV in
where only a machete can slash some semblance of a trail through the Congo-Cameroon Basin in continental Africa; Nipah virus,
the brush. After a half hour of bushwhacking, Zandrilahy reaches SARS, and Swine influenza in Malaysia.5 In all cases, scientists and
his destination: a clearing called a fira where he’s constructed the public health officials have connected each outbreak to the hunting,
snare. butchering, and eating of terrestrial wildlife. In Madagascar, where
bubonic plague has recently made a resurgence, the World Health iii Deforestation and an expanding
agricultural frontier can also be a risk
If this do-it-yourself assemblage of twigs, grass, and cord works as Organization has said hunting or other contact with rodents could factor for zoonotic diseases. Has this
planned, it will be used to snare one of the 12 species of lemurs1 lead to increased risk of contracting the disease.6iii happened in your country?
hunted for food around Makira Natural Park, the largest protected
rainforest area in Madagascar. Now, in the middle of the rainforest,
Zandrilahy demonstrates the snare’s effectiveness. Reaching for a
fallen leaf the length of his arm, he skirts it down the branch that
juts into the fira like a diving board over a swimming pool. A bunch
of bananas sit at the end of the branch; in between is a mechanism
constructed of grass and a delicate braid of orange cord. That cord
is attached to another thinner branch that arches over the fira,
creating what’s called laly totoko—a baited bridge. As Zandrilahy
brings the leaf towards the snare, its movements are eerily similar
to the swaying of a lemur’s tail. Into the trap the leaf goes and snap!
It triggers the snare and the leaf is yanked out of Zandrilahy’s hand
and left to dangle above the fira—an imaginary lemur caught in a
tight noose. Zandrilahy smiles.

Scenes like this are a nightmare for conservationists. Hunting

lemurs has been illegal in Madagascar since 1960, and current
consumption rates of the animal in the Makira forest point
towards local extinction.2 Seen through this lens, a complete ban
on hunting would be a logical decision. But a shortcoming of such
an all-or-nothing policy is that it fails to consider the growing body
of research into the complex reasons why men like Zandrilahy
hunt terrestrial wildlife in the first place. In northeastern Madagascar, or in any place where people rely Zandrilahy constructs a snare across a
on terrestrial wildlife as a food source, wildlife conservation and forest clearing in Makira Natural Park in
i The right to food was first recognized
northeastern Madagascar.
in the 1948 Universal Declaration of Food security is a basic human right,i and Zandrilahy and public health efforts must account for the needs of the people living
Human Rights, and later ratified in
the 1966 International Covenant on
his family depend on the forest’s wildlife to survive. They’re in those environments. If governments and organizations are
Economic, Social and Cultural Rights. not alone—hundreds of millions of people worldwide rely on going to demand an end to hunting and, in turn, curb the possible
What else is considered a basic human terrestrial wildlife for food.3 As a result, an estimated 301 mammal spread of zoonotic disease, they also need to ask what other food
right?
species globally are threatened by human hunting pressure. Meat sources can be offered as nutritional, sustainable, and accessible
ii Beyond mammals, what other consumption is the primary purpose of that hunt.4ii alternatives. Plus, those options need to be culturally appropriate
species are hunted for meat and desirable—because as Zandrilahy says, lemur meat makes for
consumption?
a delicious dinner.
224 225
Madagascar: Old World It was approximately 88 million years ago that the island nation of The History of Malagasy Conservation
Biodiversity Meets New Madagascar shifted away from all other landmasses. Now part of Colonial notions of conservation have often prevailed since the
World Challenges the African continent, Madagascar spent more of its geographic first settlers “discovered” new land and established authority over
past attached to India, before tectonic plate activity isolated the areas traditionally managed by Indigenous groups. This is true
country in the middle of the West Indian Ocean, hundreds of worldwide, but especially in Africa where all of the continent’s
kilometers off the coast of mainland Africa. More than twice the wildlife reserves were established during European colonialism.
iv Behind Greenland, New Guinea, and
Borneo, Madagascar is almost as big size of the United Kingdom, Madagascar is the world’s fourth
as Texas! largest island.iv Colonial conservation, also known as fortress colonialism, was
characterized by the expulsion of local populations from the land
The country’s geographic marooning had a remarkable impact in order to protect wildlife and other biodiversity. The expectation
on its biodiversity. More than 90% of Madagascar’s mammal and was that local people would destroy environments and that the
reptile species can only be found in that country.7 That includes only way to protect valuable ecosystems was to exclude all human
59 species of chameleons, more than two dozen species of small, presence other than for tourism and scientific research.10
hedgehog-like tenrecs, and what is perhaps Madagascar’s most
famous resident: the lemur. In Madagascar, colonial conservation policies started after 1894
when the country became a French colony. That style of governance
Scientists believe lemurs crossed the Mozambique Channel from continued following Madagascar’s independence in 1960. Between
mainland Africa on floating mats of vegetation. Encountering 1927 and 1997, 46 protected areas were created across the country.
Madagascar some 62 to 65 million years ago, the species evolved free Protection of species and enhancing opportunities for research
of aggressive primates such as monkeys and chimpanzees, as well were the primary motivations, similar interests to those held by
as the large predators that roam the savannas of mainland Africa. colonial conservationists. The establishment of these protected
Lacking the predator-prey dynamic faced by other primates, lemurs areas did little to consider the communities living on the land—
evolved into a small-bodied, docile species that eat primarily fruits, people who were reliant on the food, livelihoods, and spiritual
insects, and leaves. Today, Madagascar is home to more than 100 sanctuary it provided.
endemic species and sub-species of lemurs, from the pocket-sized
v Around the size of an adult beagle. Madame Berthe's mouse lemur to the 9.5 kilogram indri.v
The indri, known in Malagasy as the
babakoto, is one of Madagascar’s
Though they historically lacked predation, lemur populations most iconic lemur species. Critically
today face many threats. In fact, 94% of species “are under some endangered, the Indri is one of more
than 20 species of lemurs hunted in
level of threat, making lemurs the single most imperiled group of northeastern Madagascar.
mammals on Earth.”8 Though different for each species, lemurs
generally reproduce later in life and have longer intervals between
births, two biological factors that affect the ability for healthy
population growth. Then there are the pressures posed by another
predatory primate: humans.

Humans are one of the more recent mammals to reach

vi Islands were some of the last places Madagascar.9vi Just as the country’s endemic species rely on the
to be populated by humans. Which natural resources of the island nation, so too do the 25.5 million
do you think was the last region of the
world to be populated by humans? people who now share that home.

226 227
 Traditional Malagasy Governance SAPM also saw the creation of Communautés de Base (COBAs),
federations of community members that jointly manage the
Long before these written laws and European colonialism, however, there was the presence of fady—the expanded protected areas. COBAs formalize the process of land
Malagasy taboo system that influences social, moral, and cultural behavior. While fady vary by individual, management and formerly transfer control of the area into the
household, community or ethno-linguistic group, there are many instances of taboos related to the avoidancevii hands of the communities that have held traditional claims to
of certain animal species. These are generally motivated by self-preservation and not by conservation.. Similar the land. COBAs are then responsible for making their own land
to Western conservation laws that have legal implications enforcing morality and action, so too does dina, management plans that balance their livelihood and natural
the Malagasy system of community law. Neither fady nor dina were reflected in the French administration’s resource needs with conservation objectives. These groups also
conservation system. create and enforce dina (local customs and social norms) in these
areas.

vii Avoidance includes staying away, “Ignoring that was a major flaw in getting people to believe in Conservation practitioners in Madagascar say the shift towards
not hunting, and not eating these the value of conservation,” says Dr. Christopher Golden, whose community management is the start in making biodiversity
species.
multi-decade research in northeastern Madagascar sits at the protection more inclusive and attractive to local communities.
intersection of conservation, nutrition, and human health. “If However, they admit that enhancing participation from rural
you are excluding people from land that they have had de facto communities, ensuring financial sustainability of the management
control over for generations and then not providing an incentive programs, securing law enforcement, and alleviating poverty are
to conserve that land, it’s going to create a mixed message where among the principle challenges for Madagascar’s protected areas
conservation is seen as exclusionary and not benefiting them.” going forward.14

viii These targets are expected to be The expansion of protected areas has continued in recent years. Human Needs of the Forest
25% of all land and water protected by In 2003, Madagascar’s President Marc Ravalomanana pledged to While an expanding network of protected areas is seen as aiding
2025 and 30% by 2030.
triple the country’s protected area over the following six years. conservation efforts, it doesn’t bring immediate economic benefit to
Which countries do you think are
protecting more of their terrestrial
The bold plan put Madagascar on the path to achieving a UN most Malagasy. Madagascar is one of the poorest countries in the
and marine territories? Which are Convention on Biological Diversity target: that each nation protect world, and three quarters of the population live in extreme poverty,
protecting less? ↘ Use this map to 17% of its land and freshwater and 10% of its marine and coastal surviving on less than $1.90 a day.15 Over 60% of the country’s
narrow down your assumptions.
ecosystems by the end of 2020.11viii population lives in remote, rural regions, further limiting access to
food markets, healthcare, education, and other basic services.
Madagascar’s protected areas quadrupled between 2003 and
ix It should be noted that while 2016.12ix Managed under the newly-created Madagascar Protected Four out of five Malagasy rely on agriculture as their main
Madagascar’s protected areas did Area System (SAPM), governance of these areas shifted in an effort livelihood,16 the majority of whom are small-scale rice farmers who
grow substantially post-2003, the
World Bank estimates that only 5.9% to better account for the needs of rural communities. “[SAPM grow the country’s staple food. Population pressure contributing to
of terrestrial land in the country is management] parallels global trends in protected area policy, agricultural expansion is the leading cause of land use change in the
protected today. and reflects the realization that most priority sites were home to country, as forest is cleared or burned to create space for agriculture,
significant populations of rural people that depended to varying including rice fields.17 The burning of land and forest for agriculture xi Slash and burn is a practice used
in many parts of the world. What are
extents on natural resources for their subsistence and income,” is called tavy, and it is significant as both an ancestral practicexi and some pros and cons of this practice?
write the authors of one report.13 as the most efficient and inexpensive way to prepare land for new
growth.xii xii Chapter 1 in this anthology looks
at the prevalence, cultural relevance,
Certain areas protected under SAPM have a shared governance and economic necessity of slash-and-
x How is the concept of governance modelx where the central government mandates management Energy demands also contribute to deforestation rates. Only 13% of burn agriculture in Indonesia. There,
different to the concept of to another body. This is often a Malagasy or international Madagascar’s population has access to electricity,18 one of the lowest the practice has increased the risk of
government? fires on peatland ecosystems. This has
non-governmental organization that works closely with local rates worldwide. This furthers the reliance on forests, and up to 99% led to annual haze events that have
communities to create protected area management plans. of the population uses either firewood or charcoal as their cooking significant public health implications.

228 229
xiii What are some health fuel source.xiii More than 90% of Madagascar’s original forests have A Visit to MaMaBay Communities in northeastern Madagascar are illustrative of the
consequences from using charcoal or been lost since humans first came to the island thousands of years intersectional nature of Madagascar’s environmental, social, and
wood as cooking fuel source?
ago.19 Almost half of that deforestation has occurred in the last 70 economic challenges. Reaching these communities is also revealing
In 2012 alone, 63% of the 8000 child years.20 of the isolation faced by many of the country’s rural regions.
deaths due to acute lower respiratory
tract infections were attributable to
household air pollution. ↘ WHO 2012 Deforestation and forest fragmentation have long been considered the Twice a week, a plane flies between Antananarivo, Madagascar’s
main drivers of habitat and subsequent species loss for Madagascar’s capital city, and Maroantsetra, a small market town in the country’s
wildlife.21 But a recent body of evidence points to subsistence hunting northeast. Despite its position on Antongil Bay which connects to
as an equally pressing anthropogenic threat, both in Madagascar the ocean, Maroantsetra is described as landlocked because of the
xiii Make sure to visit Global Forest and other parts of sub-Saharan Africa. In Madagascar, regions in the difficulty residents have in accessing goods and services from other
Watch to understand the extent of the
deforestation process in Madagascar northeast have been a focal point of research into hunting, health, parts of the country. The single road heading south from the town
over the last 20 years. and conservation.* is little more than a mud track, and the 500-kilometer stretch is
impassable at worst and can take days to navigate even during the
dry season.

And so, most visitors arrive by plane, a landing that offers clear
views of Nosy Mangabe, the island reserve that is part of nearby
Masoala National Park. Mainland hillsides are fringed with dark
rainforest canopy stretching as far as the eye can see, the landscapes
of Masoala National Park to the east and Makira Natural Park
in the west. Encapsulating the bay and the two protected areas,
the region is often referred to as MaMaBay. While Masoala
National Park was first created in 1997 and remains governed by
Madagascar National Parks, Makira forest was protected as part
of the post-2003 expansion under the Madagascar Protected
Area System. Management of the park has been mandated to the
Wildlife Conservation Society (WCS), an international NGO with
a regional field office in Maroantsetra.

“Makira Natural Park is the largest protected block of terrestrial

humid rainforest in Madagascar,” explains Andrew Kirkby,
MaMaBay Landscape Coordinator with WCS. “Access to get
from one side to the other can be three to four days. There are
approximately 90,000 people living around the park, many of
whom have very limited access to basic needs. This makes it quite
a complicated landscape to address many of the problems.”

A rice paddy field outside of Antaravato,

northeastern Madagascar.

230 231
 The Limitations in Accessing Healthcare
Traditional ethnomedicinexiv is the first level of healthcare accessed by people living in the Maroantsetra region
in northeastern Madagascar. Here, 241 species of plants have been identified as providing ethnomedical
treatment to 82 categories of illness, demonstrating that traditional medicine is a well-established practice.
Not limited to this region or Madagascar alone, the World Health Organization estimates traditional medicine
is used by 80% of Africa’s population as a way to address a gap in healthcare needs.

A survey looking at medical access and barriers in the Maroantsetra region found that the majority
of adolescent men and women rely first on traditional medicine as a way to address illness.xv This is because
of three key barriers in accessing healthcare in the region:

• Geography: People in Maroantsetra region need to travel between one and eight hours by foot to reach the
nearest Centres de Santé de Base (CSB) I or II clinic, both of which provide different levels of service. River
or sea travel would reduce that time, though safety and the logistics of finding and renting a boat can be
complicated and cost-restrictive.
• Financial: Despite certain healthcare costs covered or subsidized by the government, CSB or hospital visits
involve additional expenses, including transportation to facilities, loss of wages for the patient and the family
member who likely needs to accompany that person, and the cost of any prescribed medication or treatment.
• Expertise: Madagascar has 1 physician per 7,000 people, with most professionals concentrated in urban
centers. Whilexvi CSB I facilities have a healthcare professional, they provide only basic primary care and
vaccinations. Physicians are limited to CSB II facilities. Allopathic (conventional pharmaceutical) medication
is available at the village level in epiceries, pharmacies, and is commonly sold by traveling salespeople with
no specific health-related training.

↘ Watch: MAHERY video on the barriers to healthcare access in Madagascar

Gathered from the forest and distributed by a traditional healer or self-administered, ethnomedicines are lower
cost and more geographically accessible. The value of these plant-based medicines has been compared to that
of local allopathic medications, and are estimated to bring household value equivalent of 43% to 63% of median
household income.22 Dependent on the health of the surrounding environment, ethnomedicine is just one
further illustration of the important ecosystem services provided by the forest.

xiv Often referring to indigenous Sources: Bustamante, N.D., et al. 2018. A qualitative evaluation of health care in the Maroantsetra region
practices, ethnomedicine describes of Madagascar. International Health. https://doi.org/10.1093/inthealth/ihy070; Golden C.D., et al. 2012.
Rainforest Pharmacopeia in Madagascar Provides High Value for Current Local and Prospective Global
the use of plants and animal species
Uses. PLoS ONE 7 (7): e41221.
for medical purposes.

xv Reliance on traditional medicine

was lower for more vulnerable
populations, including children
and elderly.
An area of forest on Nosy Mangabe,
xvi How about in your country a small island reserve in northeastern
or region of origin? What is the
recommended rate of doctors per Madagascar that is part of Masoala
population? National Park.
232 233
 Reaching the villages where those people live requires a trip via a
combination of either motor vehicle, boat, or foot, a journey that
can take from a few hours to days. Scarcity of food, finances, and
healthcare pose an acute threat to these communities, and this
reality has led to an increased dependence on the forest and its
wildlife species.

Across Madagascar, including in the northeast, terrestrial

mammals are commonly hunted as a subsistence food source.23
Also known as bushmeat hunting, terrestrial wildlife hunting
has not always been well studied in Madagascar. Part of the
reason, experts say, was that it was never considered a significant
threat when compared to other causes of species decline such as
deforestation and forest fragmentation.

Another reason bushmeat hunting was not recognized as a threat

was because of its low public visibility. Unlike in West and Central
Africa where wildlife ranging from antelopes to chimpanzees to
forest elephants can appear at local markets, the comparatively
small size of Madagascar’s mammals mean hunts are often
surreptitiously transported from forest to home and consumed
wholly by a single family. While other threats, including the
short and long-term ownership of lemurs as pets24 and the sale
of certain types of bushmeat as a luxury food item,25 are present
in Madagascar, they’re much less common than in other regions
of Africa. For example, in the Congo Basin, a hotspot for illegal
wildlife hunting, an estimated 4.5 million tons of bushmeat enters
the market annually, often for luxury consumption.xvii xvii Read more on the global bushmeat
from ↘ this document of the
Convention on Biological Diversity
Lack of bushmeat visibility in Madagascar is also driven by the and Center for International Forestry
illegality of the action and by stigma. “[Bushmeat] is considered Research (CIFOR)
poor people’s food, and so you’re not broadcasting to people
that you’re eating it,” says Dr. Christopher Golden, who in 2009
published one of the first papers looking at subsistence wildlife
hunting in the Makira forest. The use of bushmeat as a subsistence
food source is also reflected in some central African countries,
including Cameroon where bushmeat can be purchased from
Park Director Hervé Andrianjara the market. Similar to Madagascar, bushmeat consumption is
Amavatra outside the office of generally limited to the poorest of households as opposed to being
Masoala National Park. He
a luxury product.26
says that while the park does
not condone hunting, they can
understand why it’s a necessity for In Masoala National Park, Park Director Hervé Andrianjara
some families. Amavatra says there were 13 lawsuits against lemur hunters in
234 235
 2018, and nine the previous year—though he notes the greater Bushmeat hunting still commonly occurs in northeastern
number was due to an increase in patrols, and not necessarily in Madagascar. A 2009 survey conducted by Dr. Christopher Golden
hunting activity. “I know the sanctions of the penalty are a little bit and his team found that 95% of households had consumed some
tough, but there are some awareness raising activities that we have type of terrestrial mammal in the past year, including 23 species
done so people should not commit infractions,” says Amavatra. He of lemur, bats, tenrecs, and bush pigs. Additionally, over half of
says the park staff doesn’t explicitly see hunters as “bad” people, households had eaten a lemur species even under a hunting ban.
though. Bushmeat hunting can be a crucial food source, but also have
negative implications for human health. Examining the risks
Former bushmeat hunters are often aware of the consequences requires a trip across the Mozambique Channel to mainland Africa.
of their actions. “Almost all the animals have disappeared,” says
xviii Babakoto is the Malagasy name Laurent, who lives in the northeastern village of Antaravato. “We
for the indri, the largest lemur species. can’t hear the voice of the babakotoxviii from our home anymore. I Zoonoses in the Zoonotic disease may not be a mainstream term, but its epidemics
realized that if all the lemurs would disappear there would be no Anthropocene are. The global shutdown caused by the COVID-19 pandemic in
stories for the future generations.” 2020. Ebola in Sierra Leone, Guinea, Liberia, and the Democratic
Republic of Congo. The original emergence of HIV. All are
Moratombo, another former hunter, learned to catch wildlife examples of zoonotic disease—infectious diseases spread from
when he was a child, a skill he attributes to his ancestors. “The animals to humans. Worldwide, 75% of emerging infectious
meat of lemur was so tasty, and that’s the reason I ate it. It made diseases originate from this breaching of the animal-human
me strong,” he explains. “I would bring the meat back to my family, barrier.29 Patient zero—the first human infected by a disease—
normally three times a week. Now the lemurs and the forest are often comes from a location where there are unique or intensified
very far away because people are cutting the trees and others are interactions between humans and animals.
hunting with guns.”
Though transmission varies depending on the infectious disease,
the spread of pathogens generally happens through a few key steps.
The Effects of Social Discounting First, the zoonotic virus or bacterium is transmitted from a wild
animal to humans or domestic animals. In his TED talk about
A concept called social discounting can further the understanding of why people in northeast Madagascar the global emergence of zoonotic disease, virologist Dr. Nathan
hunt, despite seeing the decline of their surrounding natural environment. Social discount rates are the element Wolfe illustrates this first step with photos of hunters in central
of cost-benefit analysis used to “put a present value on costs and benefits that will occur at a later date.”27 For Africa. The images show men with wild game hoisted over their
example, someone with a 5% annual social discount rate may perceive a service offered by an ecosystem as shoulders—a source of either food or income for their families. In
worth $1 today, but just $0.95 a year from now—a 5% loss in value. The higher the social discount rate, the more many cases these animals are bloody.
a group of people is likely to use a resource today in fear that it will diminish in value in the future.
Wolfe says the intimate interaction between hunter and catch
Social discount rates differ greatly based on context, but range in developing countries between 8-15% annually, is an ideal scenario for people to come in contact with the fluids
with developed nations averaging 3-7% each year.28 Early results from studies conducted in the Makira forest and tissues of infected wildlife, exposing them to disease as
show that discount rates are incredibly high, perhaps approaching 50%. When it comes to wildlife hunting, this a result. Cuts and bites from infected animals also present an
translates to an urgency of ‘hunt this animal today because there’s a high likelihood that it will not be there later.’ opportunity for disease exposure. Hunters and butchers of wildlife
are at greatest risk, though risks affect any person overseeing the
transportation, sale, or cooking of an infected animal. In many
cases it’s not possible to know whether an animal is infected in the
first place.

↘ Appendix: Nathan Wolfe’s TED talk – The jungle search for viruses
236 237
 Larger-scale anthropogenic activities can exacerbate the spread In Madagascar specifically, there isn’t yet evidence of the spread
of zoonotic disease. That includes the consumption demands of of zoonotic disease due to bushmeat hunting. General awareness
a growing human population and the globalization of trade. The campaigns do, however, aim to educate people about the real
first has led to rapid land use change to make way for human possibility of the emergence of zoonoses like has been witnessed
settlements and food production. Deforestation is a major cause in many regions around the world. “There are lots of national
of land use change in both Madagascar and across sub-Saharan communications on the radio to say that people who eat wild
Africa. With a population that is expected to double in the next animals, especially bats, need to be careful because they could
three decades, the region’s forests are a valuable source of fuel for bring viruses,” says Johnnah Ranariniaina, Manager of Livelihoods
firewood and land for agricultural expansion. with the Wildlife Conservation Society in Madagascar. Though
discussed, Ranariniaina says people only have a basic awareness at
Madagascar is just one testament to this trend. A lower income best. “It’s still minor because people have not seen a tangible case
country that is rich in national resources, strong evidence has in their village that shows someone died because of a [zoonotic
drawn the connection between greater economic prosperity and a disease] outbreak.”
reduction in forest cover.30 The scale of this threat is substantial—
in pursuit of traditional economic development and a desire to However, research from northeastern Madagascar indicates
improve qualities of life, the motivations behind deforestation in many people have a deeper traditional knowledge of how animal
low and middle income countries are difficult to contest. and plant species affect their health. A study found that more
than three-quarters of social taboos (fady) held by Malagasy
xix The case studies in chapter 3 and Increased risk of disease transmission, zoonotic and otherwise,xix households were linked to spiritual immunity, physical health, and
6 of this anthology examine the effect is an unintended consequence of deforestation. Interestingly, personal security—all elements of human health and well-being.32
deforestation has on water quality and
the spread of diarrheal and water- if looking solely through the lens of preventing zoonoses, a These taboos have been orally passed down through empirical
borne diseases in Indonesia and Fiji. complete clear-cutting of forest would be better for human health, observation, and govern behavior through the prohibition of
particularly when compared to the selective logging that happens certain actions. Says the study: “The local Malagasy stories often
in many parts of central Africa and Madagascar. Selective logging illustrate a sophisticated understanding of germ theory, whereby
is the practice of cutting certain high-value hardwood species microorganisms, too small to be seen by the eye, are believed to be
while choosing to leave the rest—this means wild animal habitat the root of contagion and disease.”
remains, though in a more concentrated area. There is as a result
greater opportunity for humans to come in contact with wild
A critically endangered bamboo lemur
animals and the diseases they may carry.31 in Madagascar's Andasibe-Mantadia
National Park.
Even anthropogenic activities meant to improve human health—
the construction of a road into a rural village in order to provide
improved health services, for example—can increase disease
transmission. Those roads link previously isolated communities
with urban centers, exposing people to diseases from other parts
of the world and vice versa. Making previously inaccessible tracts
of forest reachable by road can also increase the ease and appeal
of bushmeat hunting in those locations. Finally, roads contribute
to the globalization of trade, meaning that diseases once isolated
to small pockets of the world now have greater potential to spread
through traveling products and people.

238 239
People living in Antaravato village talk
outside their homes after a morning
health survey. While some families
live in houses with corrugated metal
roofing and multiple rooms, most people
live in these raised, one-room homes
constructed of reeds and raffia.
240 241
 The Role of Food Taboos on Health and Well-being

Be it for reasons of health, economics, religion, or simply what tastes best, everyone has motivations for
why they eat what they eat. Food taboos are another factor—cultural practices that dictate what people should
and should not hunt and, as a result, eat. “You can’t truly understand why people are hunting or not hunting
certain species without understanding the social system in which hunting behaviors are embedded,”
says Dr. Christopher Golden, who co-authored a study on the potential implication of Malagasy food taboos
on human health and species conservation.

The study documented 1,119 taboo stories in 819 households, with 65% of households having an origin story
for at least one food taboo. While taboos have sometimes been reduced to superstition, the study found certain
taboos were consistent with findings of modern science and medicine. Based more on observation versus
empirical “hard science,” taboos were found to be an invaluable form of Indigenous knowledge that could
be used to advise against the consumption of certain animals that pose a potential threat to a person's health. A
notable 21% of food taboos related to physical health in the form of zoonotic disease, toxins, or allergic reactions.

The hedgehog tenrec is an interesting example of how a food taboo could potentially safeguard human health.
The small ground mammal is an effective reservoir of the bubonic plague,xx a medieval zoonotic disease that
has caused epidemics in Madagascar since 2012. The most common food taboo in the Makira forest region
relates to hedgehog tenrecs and “according to local stories, ancestors would bleed, vomit, and have foamy
mouths following hedgehog tenrec consumption, similar to symptoms of bubonic plague.” While 45% of
households had a food taboo for the hedgehog tenrec, just 3% had a similar taboo for the common tenrec,
a species similar in physical appearance, and yet not an effective host for the plague. In this case, the research
concludes that traditional knowledge of plague and its link to hedgehog tenrecs could have informed the creation
of this food taboo.

Conservation-wise, a quarter of the population has a food taboo related to lemurs. The study hypothesized as to
whether this taboo could have conservation-related impact in a region where nearly half (49%) of the population
hunts lemurs. It found that nearly all households with a lemur taboo abide by that taboo, whereas 42% of the
population complies with local conservation policies. The conclusion was that, while not 100% effective in
accomplishing conservation purposes, food taboos should be understood by conservation-focused organizations
in order to thoughtfully couple these beliefs with more conventional forms of environmental policy-making.xix

Source: Golden, C. D., and J. Comaroff. 2015. The human health and conservation relevance of food taboos
in northeastern Madagascar. Ecology and Society 20(2): 42. http://dx.doi.org/10.5751/ES-07590-200242

xx Curious about the bubonic plague? While taboos are present in Malagasy households, subsistence
↘ Read here. food needs can contradict these beliefs and lead to bushmeant
xxi What are some food taboos from
hunting—a more affordable action families take to improve
your place of origin or current place nutrition and provide other essential health benefits.
of living? A tenrec and a sifaka lemur (photos
courtesy of Dr. Benjamin Rice)

242 243
Bushmeat Hunting: The It’s smoky in the kitchen and the light streaming through the wood found to be severely lacking in calcium and vitamins A, B12, and
Need for Nutritious Diets slat walls is suspended in the haze. Maman’i Aimé is preparing D. Overall, households were found to be consuming an acceptable
lunch. Crouching over the cooking hearth, she adjusts the burning amount of foodxxiv for just over half of the year, though distribution xxiv The study used the World Food
branches and the fire radiates warmly into the small room. of food among family members is inconsistent. Programme’s Food Consumption
Score (FCS) index to determine
whether a household was eating
Picking up an old condensed milk can, Maman’i Aimé measures Micronutrient deficiencies are difficult to visually diagnose, which an acceptable, borderline, or poor
consumption of food. The index
portions of rice—enough for the nine people who will be joining has led to the public health community penning the term ‘hidden outlines the frequency in which eight
her table today. Next to the fire hearth is a metal bowl of cassava hunger.’ The term describes the chronic micronutrient deficiency food groups should be eaten over the
leaves that have been pounded into a coarse grind. With the rice faced by more than two billion people worldwide—more than course of a week. Food groups include
main staples, vegetables, fruit, meat/
cooking, Maman’i Aimé calls out to her son who quickly clambers twice the number who are malnourished due to a lack of calories.33 fish, and milk. More information about
up a palm tree to retrieve a coconut. Her husband, Laurent, chops Hidden hungerxxv can lead to a compromised immune system the FCS index ↘ can be found here.
it in half with a machete and Maman’i Aimé extracts the milk and predisposition to certain diseases, affecting the health of
by squeezing the meaty coconut flesh through the coarse weave individuals, families, and countries for years to come. Economic
of a cloth satchel. Combine these ingredients and you have a dish growth is a major determinant in reducing this burden.34 xxv Is there hidden hunger in your
called ravimbazaha sy voanio—cassava leaves and coconut served part of the world? How is it being
addressed? Check out ↘ this map
over rice. Maman’i Aimé tosses the remaining coconut fibers to her While conventional and higher yield crops like carrots, onions, and to understand where the problem is
chickens who squawk excitedly around the sandy yard. tomatoes can be grown in other parts of Madagascar, year-round worst.
rain and a likelihood of cyclones means farmers in the northeast
The family’s average meal is usually a bit more basic: moringa region are limited to growing rice and a variety of valuable cash
leaves stewed in salty water, perhaps with dried fish. Other staples crops like vanilla, coffee, and cloves.35 Even though vegetables and
include plantain, breadfruit, and ovy dia, a wild yam foraged from other packaged products are shipped to Maroantsetra, the nearest
the surrounding Makira forest. Whatever the accompaniment, it’s market town, those products are expensive and geographically far.
always served alongside a heaping plate of white rice, the likes of Maman’i Aimé makes the multi-hour trip to Maroantsetra just
which is grown in the family’s nearby paddy or hillside field. Rice four times a year. For most people in Antaravato, they’re reliant
is the foundation of Malagasy meals, and paddy field production on what they can grow, gather, and hunt in their surrounding
is particularly high in this part of the country where consistent environment.
rain provides plenty of access to surface water. Eaten for breakfast,
lunch, and dinner, Madagascar has one of the highest rates of rice
Chickens in Antaravato
consumption worldwide.

Maman’i Aimé’s family is not unique in their meal selection.

A nutritional analysis of diets in rainforest communities in
northeastern Madagascar—including Antaravato, the village
where Maman’i Aimé and her family live—tracked the 250 types
of foods eaten over a nine-month period. Research was gathered
and analyzed by Madagascar Health and Environmental Research
(MAHERY), an organization founded by Dr. Christopher Golden.

The study found that cereals like rice, root vegetables, and starchy
xxii Including cassava, yams, taro, and tubers,xxii constitute nearly 80% of the Malagasy diet by weight.
sweet potato.
That translates to a diet that is very high in carbohydrates, has
xxiii Why are micro-nutrients sufficient protein (primarily from rice), and not very much fat.
important? How about others like
iodine, iron, or magnesium? Many of these foods are low in micronutrients,xxiii and diets were
244 245
 Pounded cassava leaves are a common
green in Malagasy cooking

Maman’i Aimé uses a famiaham-banio to extract the milk from coconut shavings. She’s preparing ravimbazaha sy voanio, a delicious dish
of cassava leaves and coconut served over white rice.
246 247
 Why the World Can’t be Vegetarian Animal-source foods, rich in micronutrients, make up around 5% of
the diet by weight in northeast villages with wildlife contributing
What would happen if the world were vegetarian or vegan? It’s a question that’s been posed by various popular 40% of the total. Up to three quarters of hunted terrestrial wildlife
media articles and pondered on global platforms like the World Economic Forum. Research supports the species are classified as endangered41 or critically endangered.
shift. Respected nutritionist and epidemiologist Dr. Walter Willett from the Harvard Chan School of Public Another option for animal-source food is domestic livestock such
Health recently advocated for the benefits of a plant-based diet, including its role in reducing the risk of non- as chickens and zebu, though ownership of these animals is often
communicable diseases like diabetes and heart disease.36 Worldwide, red meat consumption is 288% higher than limited to wealthier households. Studies from eastern Madagascar
the planetary boundary (or 638% higher in North America).37xxvi have shown that domestic animals and fish are the preferred food
among people, demonstrating that bushmeat hunting often occurs
Decreasing consumption of animal-based protein is thought to be one of the most effective individual ways of out of necessity as opposed to preference.42
lessening the effects of climate change. The agricultural industry is the largest producer of methane and nitrous
oxide, which, in addition to carbon dioxide, are two of the most damaging greenhouse gases.38 In fact, recent A family’s bushmeat consumption habits change throughout the
studies estimate the livestock sector (both the rearing of animals and the land use conversion to make space for year. People generally have a higher macro and micronutrient
domestication) could consume between 37% and 49% of the greenhouse gas budget created in order to limit intake during the hot season of September to January, months
global warming between 2°Celsius and 1.5°Celsius by 2030.39 that correspond with peak fishing and rice harvest season. On
the contrary, surveys show a drop in protein, vitamins A and B12,
With evidence mounting, it seems like a moral imperative to become vegetarian. But as the recent EAT-Lancet zinc, and fat between February and September when fishing and
Commission on Food, Planet, Health found, pressing vegetarianism on the world is not feasible for many rice aren’t as readily available.43 During these periods, families
communities and cultures worldwide, especially in sub-Saharan Africa. The region has the highest burden of who cannot afford domestic meat supplement their nutritional
stunting, a condition that prevents the proper growth and cognitive development of children within the first 1,000 intake by hunting lemurs, tenrecs, and other terrestrial mammals.
days of their life.40 Chronic under- or malnutrition is commonly blamed for stunting, and can be linked to a lack This bushmeat is an essential part of diets, especially for children
of the protein and key micronutrients that are particularly rich in animal-source foods. Despite too-high red meat whose growth and development are seriously impacted by a lack of
consumption trends worldwide, access to animal-based protein in sub-Saharan Africa is projected to be lower iron and other micronutrients.
than the healthy reference diet developed by the EAT-Lancet team.xxvii Additionally, there is the need to consider
the taste and cultural preferences of local communities who may be accustomed to eating fish and livestock as ↘ Appendix: Seasons in Madagascar recognized by the local Malagasy
part of indigenous diets. in the Maroantsetra region (from Golden et al 2019)

The conclusion drawn by the EAT-Lancet Commission is contrary to ideas of total vegetarianism: people living Iron-deficient anemia (IDA) is the most common cause of anemia xxviii Anemia is described as a low
in sub-Saharan Africa could benefit from an increase rather than a decrease in animal-source protein, while still worldwide,xxviii and is a hidden hunger that occurs primarily when a hematocrit. That is your body lacks
enough properly functioning red
eating within planetary health boundaries. The commission advocates that, as with other categories of food, person isn’t eating enough iron-rich foods. It's further exacerbated blood cells, and that usually limits the
consumption needs to be considerate of the regional and socioeconomic realities of the people doing the dining. by infectious disease burden, intestinal parasites, or excessive capacity to carry adequate oxygen
blood loss.xxix West and Central parts of sub-Saharan Africa, as to your body's tissues. What then
could be some signs and symptoms of
More context on this topic is offered in a case study looking the need to restructure the present-day food system. well as Madagascar, made little progress when it came to reducing anemias?
anemia rates between 1990 and 2010.44 IDA can lead to longer
xxix What other conditions can cause
term health effects, including cognitive, motor, and emotional iron-deficiency anemia?
xxvi ↘ Here are the countries that
consume the most meat in the world. development issues.
xxvii The healthy reference diet
recommends the consumption of 84 Removing access to wildlife is estimated to lead to a 29% increase
grams of animal-source protein per in the number of children suffering from anemia in northeastern
day, while the availability of animal- Madagascar. In the poorest households where reliance on hunted
source protein in sub-Saharan Africa
is projected to be just 13 grams per wildlife is highest, anemia cases in children would triple.45
day by 2050, given current population
estimates.

248 249
Monitoring Malagasy Health A young boy in Antaravato village stops
snacking on rice in order for Rivo, an
The health of families in Antaravato is well monitored by an organization called Madagascar Health and employee with Madagascar Health and
Environmental Research (MAHERY). Staff with the organization measure the growth and weight patterns of kids Environmental Research (MAHERY), to
aged 12 and under quarterly and conduct dietary intake surveys three times a year.
measure his head circumference. These
anthropometric measurements happen
every three months.
Data is logged using a small offline tablet powered by the Dharma Platform, a health surveillance tool. The
measurements help the MAHERY team track the long-term development and diets of families in northeastern
Madagascar.

MAHERY is working in collaboration with the national Ministry of Public Health, Catholic Relief Services, and
the Dharma Platform to pilot a community-based health surveillance platform. Currently, the main source of
epidemiological data in the country is gathered by the ministry’s Centres Santé de Bases when patients visit the
clinic, says Hervet Randriamady, MAHERY’s National Research Director. However, Randriamady says access to
these clinics is often restrictive—and as a result, the data they can collect is limited and doesn’t always record
the full reality of people living in rural regions. For example, the ministry may never hear about community
illnesses or outbreaks, and as such are unable to appropriately allocate resources or send in medical staff to
address epidemics.

The health surveillance system being trialed by Randriamady and the MAHERY team could bridge the
gap between community and ministry. The paperless platform reduces human error and allows for the
faster transfer of data. If the pilot proves successful, community health workers across Madagascar could
be equipped with a tablet and the health surveillance platform. Not only that, but the health data that’s
collected could be paired with climate and habitat mapping data to get a big picture look at how the health of
communities is affected by changes to the natural environment.

250
 Back in her kitchen in Antaravato, Maman’i Aimé says her family
was one of those households. “We were struggling to find food
because of the difficulty getting money, especially for our first
child,” she says. At the time, the family didn’t have a plantation of
their own to grow crops, and performed small jobs for other people
to make enough income to purchase food.

“When I was working in the faraway field plantations I started

to build some [wildlife] traps so I could eat,” explains Laurent,
Maman’i Aimé’s husband. Flipping over a piece of paper, he
sketches his passive snaring method, identical to the trap set in the
forest by Zandrilahy and similar to the majority of traps set up in
the region.46

The family’s meals were soon supplemented by bushmeat. “In 1992

our second son was born. Since then when I caught lemurs I would
bring them home for all of my family. That was to feed them, and it
related to the fact that I had two young children,” Laurent explains.
“If I did not bring home that lemur we wouldn’t eat meat and we
would just eat greens.”

Laurent stopped hunting in 2005, persuaded by awareness

programs conducted by the Wildlife Conservation Society and the
prompting of a catchy tune from Malagasy artist Clément Mily.
The musical ode to encourage people to protect their natural
environment was widely popular in the nineties, and is called
Mandrora mantsilany. This translates loosely to “if you spit lying
down then your spit will come back to you.” Laurent smiles and
hums a few bars outside of his home.

↘ Appendix: Mandrora Mantsilany on YouTube

Laurent and Maman’i Aimé say it’s easier to put food on the table
today. They started their own agricultural plantation in 2000 and
can now grow more crops. Maman’i Aimé says they eat meat about
once a week—sometimes zebu, but more commonly the scrawny
chickens scurrying around their yard. Still, limitations exist. “We
can eat every day but sometimes we cannot afford expensive meat,”
Maman’i Aimé says. “My favorite meal is freshwater fish from this
area with some greens. I do love lemurs, but they’re very rare today.”

Maman'i Aimé and Laurent outside their home in Antaravato.

253
Sustainable Wildlife Hunted wildlife remains an important part of diets for many in activities planned in the SWM Programme is conducting wildlife
Hunting: A Possibility northeastern Madagascar. As research has shown, reducing a surveys to estimate the population sizes of these species to inform
in Madagascar? reliance on wildlife and conserving biodiversity demands more decision-making at the community level, for them to adopt more
than hunting bans or creating protected areas. Instead, it requires environmentally friendly hunting practices,” says Andrew Kirkby,
a conservation and development intervention that will transition WCS’ MaMaBay Landscape Coordinator.xxx xxx What are some places in which
people away from bushmeat without taking a toll on their “sustainable hunting” is allowed and
working well?
nutritional needs or limited financial resources. Ecologist and founder of MAHERY, Dr. Christopher Golden, agrees
that wild pigs could be a sustainable hunting option, but says they’re
That intervention could take different forms. One option is the an exception. Overall, he’s less certain the terms ‘sustainable’ and
continued hunting of certain wildlife, though done in a way that ‘wildlife hunting’ can go together in Madagascar. This is because
is sustainable and allows for the reproduction and growth of those of the types of species in the country, their reproductive behavior,
populations. But is that possible in Madagascar and other parts of and the size of the human population that relies on them.
the world?
For example, lemur species that reproduce at a later age and
A 2013 review of 750 harvest sustainability evaluations worldwide have longer intervals between births are more susceptible to
found 65% of harvests had been deemed sustainable,47 suggesting overharvesting.49 Research indicates that the season in which
that sustainable hunting could be a possible strategy. However, people hunt has the ability to both positively and negatively
the authors of the review noted that these evaluations may be influence the sustainability of lemur populations.50 Bushmeat
challenged because they relied on indicators gathered once as hunting in northeastern Madagascar is especially common
opposed to over time. As a result, the data may not capture the between March 15 and June 15 because these months correspond
wildlife population trends that could increase or decrease due to with off-peak fish and rice harvest season. It is also the wet
factors such as habitat and climate change. season when fruit-laden trees attract lemurs which increases the
likelihood of hunting success.
In Madagascar, a new global program is taking on this question
of whether hunting can be done sustainably. The European Dr. Christopher Golden says he can’t foresee a solution that is
Commission-funded Sustainable Wildlife Management a triple win for the sustainable hunting of bushmeat, lemur
Programme was launched in July 2018 and is led in Madagascar populations, and food security. That’s why he and the MAHERY
by the Wildlife Conservation Society (WCS) in collaboration team have introduced a solution that involves alternative foods
with various national and international partners. One of the such as chickens. Studies from eastern Madagascar have found
programme’s approaches in Madagascar is to see if there are that people prefer many kinds of domesticated livestock (e.g. pig,
“resilient wildlife and domestic species” that could be used to chicken, zebu, goose, turkey, and duck) over the common brown
transition people away from a reliance on bushmeat48 to achieve lemur, the most desired illegally hunted wildlife.51 This suggests
interlinked objectives of promoting wildlife, conserving the people would be willing to eat chicken as an alternative to
ecosystem, and improving livelihoods and food security. bushmeat—if it were an affordable and viable option.

Lemurs and many other terrestrial mammals are protected by law.

However, “there are other [wildlife] species that are not protected,
which, if hunted sustainably, could provide a sustainable and
healthy source of wild meat for people,” says Charlotte Spira, the
Ecological and Social Research and Monitoring Manager with
WCS. Possible legal, sustainable wildlife, she says, could be wild
pigs, which are not a conservation priority as they are an introduced
species, and certain species of rodents and tenrecs. “One of the
254 255
On Poultry and Planetary “If there was no disease many people would become rich,” says This is the scene that plays out in certain households across
Health Jerome, shaking his head. Another resident of Antaravato, the Antaravato and five other villages every four months. The small
village at the edge of Makira forest in northeastern Madagascar, eye dropper bottle means the vaccine can be administered by
Jerome’s face is barely visible in the little light radiating from his community vaccinators like Josiane. Trial vaccination has been
storefront. His 20 chickens have been brought inside for the night. ongoing since May 2016, and Josiane is one of the volunteers who
Jerome has been rearing poultry for more than three decades. Like was trained by the IMVAVET and MAHERY teams.xxxiv xxxiv In recent years, and thanks to the
many people in Antaravato and villages across Madagascar, he and work of the GAVI Alliance, vaccination
rates for children have actually almost
his chickens have faced their fair share of problems. These trials have shown promising results in six rural villages in doubled! ↘ Read more here.
northeastern Madagascar. Data gathered between 2011 and 2018
Over the years, Jerome estimates he’s lost more than a thousand found that village chicken populations could stabilize and grow
xxxi Care to read more on Newcastle chickens to an infectious bird fever called Newcastle disease. xxxi with moderate, consistent vaccination. However, complete herd
Virus? ↘ Click here He isn’t alone—a Madagascar-based study found the disease immunityxxxv against Newcastle disease would require at least 85% xxxv What is herd immunity?
causes up to 40% mortality in non-vaccinated flock.52 While people of all village chickens be vaccinated, something that is unlikely
consider chicken a delicious food source, viability and consistency with community vaccination alone.
of flock has been an issue because of this disease. Currently,
bushmeat presents a cheaper and more reliable source of much- Even with a thermostable vaccine that can be administered by
needed micronutrients. community members, challenges in raising village chickens
remain. For one, vaccination needs to happen every four months,
There is a vaccine against Newcastle disease, but it can only be otherwise chickens remain at risk of contracting the disease. While
xxxii All these are challenges of many injected by a trained veterinarian.xxxii In a context where people relatively inexpensive per individual dose—100 Ariary, about USD
types of vaccines administered rarely leave the village for pressing health concerns, the likelihood $0.03—Josiane says the cost can add up for large flocks, and is
to humans.
of traveling for a chicken vaccine is slim. This injectable vaccine compounded by the fact that people are skeptical of the vaccine’s
also needs to be refrigerated, a barrier in rural villages where the effectiveness.
nearest fridge may be a day’s walk away.
“They say that their chickens will go blind, or that their chicken
In 2014, MAHERY approached Dr. Ando Miharifetra, head of the died due to vaccination,” says IMVAVET’s Dr. Miharifetra of
Department of Vaccine Production at the Institut Malgache des some of the reasons why people are resistant to the vaccination.
Vaccins Vétérinaires (Malagasy Institute of Veterinary Vaccines, “When they say something like that we’re trained to convince
referred to in short as IMVAVET) in Antananarivo, Madagascar’s them otherwise, but it’s very hard. As of right now we have failed
capital city. With intellectual and financial support from MAHERY 100% of the time.” Increasing acceptability of the vaccine through
and the Wildlife Health Network, the IMVAVET team developed community education and outreach is an important next step for
xxxiii Which is to say it doesn’t require a thermostablexxxiii vaccine that could withstand the challenging MAHERY and IMVAVET.
refrigeration conditions of Malagasy villages like Antaravato.
For Jerome, the long-time poultry farmer, the cost of the vaccine
The newly developed vaccine comes in an inconspicuous eye is a worthwhile investment. “Even if I raised hundreds of chickens
dropper bottle. With a handful of rice tossed to the ground as a I’d still get the vaccine because the cost of one chicken that stays
diversion, a man quickly scoops up one of the chickens dashing alive could cover the cost of the vaccine for me. Since I’ve been
around the yard. Josiane brandishes a small eye dropper bottle part of the vaccination program no chicken has died. It’s been very
and tenderly holds the chicken’s head between her index finger effective,” he says.
and thumb. A droplet lands in its eye and seconds later the bird is
released, left to continue its rice pecking.

256 257
Josiane administers the vaccine
against Newcastle disease. While
administration of this eyedropper
fluid is easier than the previous
injectable vaccine (which could
only be administered by trained
veterinarians), Josiane still faces
other challenges in convincing
community members to vaccinate
their flock.

Dr. Ando Miharifetra from IMVAVET

inspects one of the insulated bags
used to transport the I-2 vaccine to
northeastern Madagascar. The vaccine
must first be transported by plane
from the capital city of Antananarivo
to Maroantsetra, where it is then
driven, boated, or walked into rural
communities.
The Wildlife Conservation Society is looking to chickens and Epilogue There are co-benefits for conservation and human health if
fish farming as an alternative meat source to wean people from MAHERY and WCS’ poultry and alternative protein programs are
bushmeat, though their approach differs from that of MAHERY. successful and sustainable. For example, chicken survival would
WCS plans to establish 150 demonstration farms in the 10 mean families have access to a valuable and preferred source of
Communautés de Base (COBA) where its Sustainable Wildlife micronutrients in their own backyard, which could reduce their
Management Programme operates. The organization will provide reliance on wild bushmeat. In addition to curbing hunting rates
these households with the start-up materials, training, and vaccines for lemurs and other wildlife, chickens are raised in small areas
they need to either maintain a chicken population or start a fish near a family’s home, reducing the amount of forested land that
farm. WCS also plans to train local veterinarians to help provide may need to be cleared to raise livestock or grow crops.
and administer a thermostable chicken vaccine in collaboration
with the Ministry of Agriculture, Livestock and Fisheries. From a human health perspective, healthy chicken flocks could
improve food security, address the challenge of ‘hidden hunger’
This poultry program is the next iteration of the agricultural in children and adults, and limit the contact people make with
livelihood projects WCS has already been operating around wildlife that could be carrying disease.
Makira forest. Only now, MaMaBay Landscape Coordinator
Andrew Kirkby says WCS is framing its programme slightly There are also socio-economic benefits to be gained. Chickens are
differently: “In these 10 selected sites, we want to carry out a very one of the most culturally-appropriate food sources for people.
targeted combination of activities including forest management Unlike lemurs which can be taboo to eat, there are few Malagasy
through good natural resource governance, livestock keeping, cultural taboos that exist against chicken.53 Finally, both WCS and
and sustainable hunting while improving access to veterinary and MAHERY see the potential of poultry not only as a food source,
human health services. We hope that these sites could serve as but also as an income generating opportunity for families who
an example of what is possible and provide guidance and lessons want to sell surplus chickens and eggs.
learned to expand to other sites around the park.”
Back in Antaravato, it’s time for another meal with Maman’i Aimé
and Laurent. This time, it’s perhaps fitting that chicken is being
served. Laurent has owned chickens since he was 10-years-old, and
has had a similar experience to Jerome, raising the birds only to
see them die with Newcastle disease. “Sometimes you think you
don’t want to do that anymore, but when you see the chickens of
your neighbor you say, oh I’m going to do that again because you
get inspired,” he says.

The family eats meat once a week when the chickens are healthy.
Laurent joined the vaccination program at inception and says his
chickens have not been killed by the disease since. He says that
today many people in the village have poultry, and that there are
few people who still hunt lemurs. But it’s hard to know, and local
dietary intake surveys certainly reflect that wildlife is still making
it onto people’s plates. Until an alternative can be successfully
introduced across the entire village, that’s likely to remain true. But
today, in this moment, the family has nutritious food on the table.
And with that, Maman’i Aimé says a prayer and it’s time to eat.

260 261
Keeping Track Maman’i Aimé Hervé Andrianjara Dr. Christopher Golden Jerome Josiane
of Who’s Who Amavatra
Resident of Antaravato, wife of Laurent Park Director, Masoala National Park Ecologist and epidemiologist; Assistant Resident of Antaravato and chicken Volunteer community chicken
Professor of Nutrition and Planetary owner vaccinator; resident of Antaravato
Health with the Harvard T.H. Chan
School of Public Health; Director and
Founder of Madagascar Environmental
Health and Research (MAHERY)

Andrew Kirkby Laurent Dr. Ando Miharifetra Moratombo Johnnah Ranariniaina

RMaMaBay Landscape Coordinator, Resident of Antaravato, husband Head of the Department of Vaccine Former bushmeat hunter and resident Manager of Livelihoods, Wildlife
Wildlife Conservation Society of Maman’i Aimé Production at the Institut Malgache des of Antaravato Conservation Society (Madagascar)
(Madagascar) Vaccins Vétérinaires (Malagasy Institute
of Veterinary Vaccines, IMVAVET)

Charlotte Spira Zandrilahy

Ecological and Social Research Former bushmeat hunter and resident
and Monitoring Manager, Wildlife of Antaravato
Conservation Society (Madagascar)

Acknowledgements Thank you, first, to Dr. Christopher Golden for his support
and guidance around this case. In Madagascar, this case study
would not have been possible without the help and leadership
of Hervet Randriamady and the entire Madagascar Health and
Environmental Research Team. A special thanks to Tata and Dalia
for hosting me in Maroantsetra, and to Maman’i Aimé and Laurent
for doing the same in Antaravato. This case benefited from the
expertise of the Wildlife Conservation Society Madagascar team
in Maroantsetra.

A curious brown lemur in Andasibe-Mantadia National Park in eastern Madagascar. Despite being a protected species, the brown lemur
is commonly eaten in parts of the country.

262 263
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Land-Use Change Program. https://lcluc.umd.edu/hotspot/ harvard.edu/news/hsph-in-the-news/vegan-diet-health- IUCN and UNEP-CMC. The World Database on Protected
deforestation-madagascar environment/ Areas (WDPA). April 2016. https://wdpa.s3.amazonaws.com/
20 Harper, Grady J., et al. “Fifty Years of Deforestation and 37 Willett, Walter, et al. “Food in the Anthropocene: the Files_pp_net/Global_PAs_April_2016_w_logos.png
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S0376892907004262 org/10.1016/S0140-6736(18)31788-4 https://www.cbd.int/
264 265
Appendix - Seasons in Madagascar recognized by the local Malagasy in the Maroantsetra region (from Golden et al 2019) ↘ Back to page

266 267
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
06
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written
by Carlos A. Faerron Guzmán.

Typhoid
Please cite this case study as “Duff H., Faerron Guzmán,
C., Almada, A., Golden, C., and Myers, S. "Typhoid and
Torrents: The Link Between Downstream Health and
Upstream Actions." Planetary Health Case Studies: An
Anthology of Solutions. 2020; https://doi.org/10.5822/
phanth9678_6

Please note this work is licensed under a Creative Commons

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Torrents

THE LINK BETWEEN DOWNSTREAM

HEALTH AND UPSTREAM ACTIONS
 Executive Summary This case study looks at how anthropogenic environmental change
and human behavior at numerous scalesi increases the risk of
This case addresses themes of typhoid fever and the transmission of other waterborne diseases on
land use change, water quality and the Pacific island nation of Fiji. This includes industrial activities
infectious disease exposure which are
also addressed in more detail in the such as upstream deforestation and cattle-farming, poor sanitation
land use and water sections of chapter standards in riverside villages, and poor household practices
4 and the infectious disease chapter around water, sanitation, and hygiene (WASH). The setting for
6 of Planetary Health: ↘ Planetary
Health: Protecting Nature to Protect this case study is rural communities on a small island nation, a
Ourselves. setting where people are particularly dependent on healthy river
catchments for their water, food, and livelihood needs.
Learning Objectives
Further, customary land tenure and vanua (the ways in which
After examining this case, in relation people identify with the land and sea) are deeply important in
to typhoid fever in Fiji, students should Fijian culture. Erosion of these customary rights can have a
be able to:
negative effect on natural resource management and subsequently
➀ Understand the interlinkages increase the spread of disease.
between land-use changes, river
catchment areas, and human health.
In addition to better acknowledging customary rights, reducing
➁ Analyze the role of colonial legacies disease transmission requires interventions at household, village,
and their impact on land tenure and
how these interact with traditional
river basin, and national levels, and the involvement of community
ecological knowledge and natural members and policymakers alike. To that end, the Watershed
resources management. Interventions for Systems Health (WISH) project, led by a
➂ Apply an ecological approach
multidisciplinary team of academic researchers, NGO staff, and
to understanding the individual, government officials, is one example of ongoing work to improve
household, local, regional, and global and restore river catchment health in Fiji.
factors that impact health outcomes.
This case study is based on interviews conducted in Suva, Nadi, Nabukavesi, and
➃ Design interventions that consider
Naqarawai, Fiji, in October and November 2018.
scale and an interdisciplinary
approach to complex issues such
as infectious diseases in rural Fiji.

i Regionally, in river catchments,

at a community level, and within
individual households.

271
Introduction Waisea Naisilisili is talking about the value of the natural world development.iii
when he comes across part of it about to be destroyed. It’s an Those development stressors involve a range of human activities:
October afternoon, and Naisilisili is driving a large black pick-up gravel extraction, mining, and what Naisilisili witnessed today:
truck down from the highlands of Viti Levu, Fiji’s largest island. deforestation to prepare land for agriculture and cattle farming.
Fiji is an archipelago of more than 332 islands in the middle of the These challenges are compounded at a global scale by climate
Pacific Ocean. change and an increase in storm severity and frequency, and at
a local scale by the growing population of riverside communities
He slows the truck to inspect the land-clearing happening near the with inadequate access to water, sanitation, and hygiene (WASH).
riverbank—one man, maybe two, with chainsaws in hand. “This These changes are more than an affront to Naisilisili’s customary
is my family’s customary land, and these guys are clearing it,” he land—research in Fiji has confirmed that these various scales
explains, snapping photos of the scene. “They bought the lease and of environmental change and behaviors can lead to freshwater
now this guy is doing big-scale farming.” Naisilisili sits back in the contamination. As a result, villages like Nabukavesi are increasingly
driver’s seat, shaking his head.

Naisilisili is a Fisheries and Operations Support Officer with the

Fiji branch of the Wildlife Conservation Society. Before he was
interrupted by the scene at hand, he was describing his love of
nature and this land that he and generations of his family have
ii Take a minute to try to write down
what is your relationship with nature? called home: “To me, nature is identity, and to protect nature simply
When did this relationship start? means you’re protecting yourself,” he shares matter-of-factly. He
Can you remember when you became refers to the significance of totems—the trees, animals, and birds
aware that “nature” needed to be
protected? How has this relationship that ground iTaukei (Indigenous Fijians) in their connection to the
with nature changed, and why? Earth.ii

“Our traditional belief is that the totems signify who we are and
where we are from. They’re very sacred,” Naisilisili explains. This
Indigenous wisdom isn’t exclusive to his village or clan alone.
Oral narratives across Fiji speak of how observations of plant and
animal behavior have been used to predict an oncoming cyclone
or tsunami, and offer methods of coping with these risks.1 This
knowledge is important for both the advice it offers and the cultural
identity it supports. Naisilisili’s grandmother was a custodian of
this knowledge, and his family’s connection to nature is a message
Naisilisili is now passing to his own children. He and his family
live in Nabukavasi, a small village located along a river of the same
name.

The relationship between planetary and human well-being is

nothing new to the iTaukei. A connectedness with the Earth is
Waisea Naisilisili during a road trip
iii How do you think each of these what has historically influenced the way in which clans manage break on the way into Viti Levu’s
elements is playing a role as factors and respect their natural resources—though those beliefs are now highlands.
that are causing a disconnection
between the iTaukei’s relationsip with being tested by increased connection to the outside world, loss
nature? of community self-sufficiency,2 and the pressures of economic
272 273
 affected by infectious disease transmission, especially typhoid.3
This is where one of Naisilisili’s colleagues comes into the picture.
Dr. Aaron Jenkins has spent the past several years researching the
effects of anthropogenic activities on river ecosystems and human
health. A fisheries ecologist by training, Jenkins was frustrated by
what he found when he first came to Fiji in 1996: sediment and
nutrients from upstream activities, manure, sewage, and trash
flowing into river basins. This human-produced waste wreaked
environmental havoc along the coast and disturbed coral reefs
and other marine ecosystems. “That’s when I knew I better start
working upstream so I could understand the connection between
what was happening on the reef and what was going on in the
river,” explains Jenkins.

That run-amuck waste was having human health implications

in villages like Nabukavesi where Waisea Naisilisili lives with his
family. The river is an integral part of these rural, often remote
iv Another case in this anthology takes communities, and people depend on it as an essential source of
us to the Senegal River Basin in West water for household consumption.iv “Reading the newspapers, I’d
Africa, where a dependence on the
river puts communities at an increased notice a particular area had been quarantined because of a massive
risk of contracting schistosomiasis, typhoid outbreak and I’d think ‘wow, the outbreak is next to this
a parasitic disease.
really degraded river catchmentv where there were no fish and the
v A river catchment is a low-lying area water quality was crap,’” Jenkins recalls.
where water gathers. Also known as
a river basin or a watershed, a river
catchment is named quite literally While the transmission and prevalence of typhoid fever and other
after its ability to “catch” the water water-borne diseases had been well-researched and documented
flowing into the region, including from in other parts of the world, there was still a question mark around
other smaller bodies of water and
uphill precipitation. River catchments the local risk factors affecting people living in isolated Pacific
are also where pollution, sediment, island countries like Fiji. Not only that, but it was still unclear how
and anything upstream end up. A
subcatchment is the name for a
anthropogenic changes could further impact those risk factors.
segment of a river catchment. These
two terms come up frequently in this Today, a team called Watershed Interventions for Systems Health
case study.
(WISH) is investigating that relationship between the intersection
of environmental change and human health—and is attempting to
mitigate the negative health outcomes for riverside villages and the
river catchments on which they depend.

Aerial views of a river system on

Viti Levu, Fiji’s largest island.
274
A view from Viti Levu’s highlands down
through multiple river catchments and
out to the Pacific Ocean in the distance
A Hub in the Pacific The Republic of Fiji is one tiny piece in the Pacific puzzle that in a prompt 30 minutes. Press your forehead to the window and you’ll
makes up the region of Oceania. Sometimes referred to as the see water systems snaking their way to the coast, the geometrics of
Blue Pacific continent, the region is home to more than a dozen agricultural plots, overgrown logging roads and, as you land into Suva,
island nations, the likes of which appear miniscule and isolated the river delta where the muddy, brackish waters of the Rewa River
when looking at a map of the world. Oceania lies in both northern belch into the Pacific Ocean. The obvious interconnectedness between
and southern hemispheres, and covers an area of 8.5 million interior and coastal ecosystems observed from the air becomes out-of-
square kilometers. Exclude Australia, New Zealand, and Papua sight, out-of-mind as you enter the city.
New Guinea, and you have an ocean area greater than that of
continental USA, with the landmass of small islands composing Fiji’s population is becoming increasingly urban. Located on opposite vi What percentage of people
an area roughly the size of Cuba. coasts of Viti Levu, Nadi and Suva are the country’s major urban centers. where you come from live in
urban areas? What percentage
Consistent with global trends, national census data from 2017 indicate of the world lives in urban
Fiji and other Pacific island nations are often considered a that 55.9% of Fiji’s population6 of 884,887 live in urban areas, up nearly areas? How has this percentage
microcosm for the world. Their isolation, vulnerability to climate 10% from two decades earlier.7vi The country is ethnically diverse, with changed in the last 100 years?
↘ Find out more here
change, and size mean the feedback loops that exist between iTaukei (Indigenous Fijians) making up 56.8% of the population, and
anthropogenic actions and human health are more rapidly apparent Indo-Fijiansvii composing another third. vii Many Indo-Fijians were
than those interactions on continental ecosystems. “Tinker with first brought to the country
as indentured laborers on the
one part of an island system and almost immediately people Those who don’t live in coastal cities often dwell in rural river sugar plantations the British
downstream are having muddy water and getting more diarrhea. I catchment areas in island interiors. That includes in Central Division, administration introduced during
the start of their colonial rule.
think this is what makes small island systems an important place a region in the southeastern part of Viti Levu. Central Division is the
Fiji was a British Crown colony
to do planetary health research,” says Aaron Jenkins. most populous of the country’s four divisions, and is home to 42% of the between 1874 and 1970. The
country’s population. Here, most people live along two river corridors: impacts of colonialism have
had long-lasting impacts on the
Oceania includes groupings of low islands—coral atolls like the the Suva-Nausori corridor near the capital city, and along the Navua country, from the introduction
countries of Kiribati and Tuvalu which sit barely above sea level— River corridor that runs through various subcatchments on its path of capitalism, to the land tenure
to what’s known as high islands. High islands are characterized by from the highlands to the coast.8 Those two river corridors are part of system that affects natural
resource management, to the
steep slopes and rolling hills, a testament to their volcanic origin.4 the 26 river subcatchments that split Central Division into a quilt-work language and culture of modern-
of informal boundaries. day Fiji.
The Pacific high islands are unique beyond their geographic
immensity: their size lends itself to better water resources.5 Surface These 26 subcatchments are the focal point of planetary health research
water comes from freshwater rivers and lakes, and groundwater in Fiji. Aaron Jenkins says he believes these smaller sections of river
spurts from aquifers in highland and coastal areas. These water catchments are the ideal place to look not only at the public health
sources are also replenished by generous precipitation. The effects of upstream land-use change, but also the environmental and
increased water availability in high islands means soil is more socio-economic determinants of health at community and household
fertile than that of low islands, and is better suited for supporting levels.9 Influenced by these many factors, Jenkins is not alone in his
human settlements, agriculture, and mineral extraction. assessment that river catchments—and the water that runs through
them—are the most appropriate place to promote community resilience
The verdant green folds of Fiji’s highlands are a stark contrast to the and prevent the spread of disease.10
turquoise waters that offer a more quintessentially tropical scene.
Fijian islands vary in size, from the largest of Viti Levu where the The health vulnerabilities of downstream communities are significant.
capital city of Suva is located, to more than 500 islets—the name Central Division residents have been exposed to typhoid fever, with 279
for landmasses that are no more than rock or coral protruding cases reported between 2014 and 2017. Of these cases, rural highland
from the ocean. Even Viti Levu is just 146 kilometers from east to villages had the highest incidence rate of disease and nearly as many
viii Peri-urban areas are an
west, and a medium-sized propeller plane will get you from the cases of typhoid fever as urban and peri-urbanviii areas, despite having a intermediary between rural and
country’s main international airport in Nadi to the capital city significantly smaller population.11 urban areas.

278 279
A young girl stands in the doorway of her home in Nabukavesi on Viti Levu. Nabukavesi is just one of many rural
communities that relies on its local river when the reservoir in the village runs dry. It’s also one of the villages that
has faced rising typhoid outbreaks in recent years.
The Nested Nature of “A few years back we had a really difficult time.” These are the Urban-rural disparities have been even more apparent since
Fiji’s Typhoid Outbreaks first words Rosa Batiri shares, sitting cross-legged on the floor of February 20, 2016. That’s when Cyclone Winston made landfall
her home. Batiri lives in Naqarawai village, a community of 54 in Fiji, affecting more than half of the country’s population.19
homes arranged neatly on the grassy plain that runs uphill from The category five tropical storm damaged water supplies in more
the Wainawene River in the highland interior of Central Division. than 500 villages, and caused nearly $1.42 billion in damage and
In 2015, Batiri’s youngest daughter Ruci, then four-years-old, loss, a third of Fiji’s gross domestic product (GDP). As of late 2018
contracted typhoid when visiting her aunt in a village downstream. there are still interior communities whose water and electricity
“She got a fever and was really weak. I was worried,” Batiri says. infrastructure are being rebuilt following the storm.
“Typhoid was one of the main illnesses that was happening at the
time. People were getting sick in all of Fiji because of the disease.”

ix If you were to guess, which part of A serious illness caused by a bacteria called Salmonella typhi,
the world do you think typhoid fever typhoid fever affects an estimated 22 million people worldwide
is more common?
each year.12* Transmission happens in various ways, though
the most common is when miniscule particles of fecal matter
contaminate drinking water and food, making the disease both
waterborne and foodborne.13 In Fiji, the incidence of typhoid fever
has been increasing since the 1990s, and rapidly so since 2005.14

Epidemiological studies have found significant differences between

Fiji’s typhoid outbreaks and those in the rest of the world. Take the
population most at-risk. Globally, the World Health Organization
considers children under five most likely to contract the disease—
kids of Ruci’s age. However, a case-control study in Fiji found
x Another case in this anthology the average age of infection to be 29-years, with Indigenous
is set in Santiago, Chile, where a iTaukei representing 95% of that group.15 Epidemiological surveys
contaminated river led to years of
public health outbreaks. The solution conducted by Fiji’s Ministry of Health between 1995 and 2009 had
that has been proposed for that similar findings, with iTaukei being affected in 82.5% of the 1,509
urban center looks different than cases confirmed during the period.16 iTaukei families are more
the approach in Fiji, but both are
examples of planetary health solutions likely to live in rural and remote communities that depend on
in action. clean river water for consumption and household activities.
Where does the water you use come
from? How is it treated? What is the Access to clean drinking water and household sanitation are two
governing body over the quality of elements that affect disease transmission.xPacific Island countries Fiji’s typhoid outbreaks increase following major storm events An outhouse in Naqarawai village in the
that water? What laws exist in your highlands of Viti Levu.
place of origin regarding the access to
have the lowest coverage of improved drinking water and sanitation like Cyclone Winston.20 They also follow seasonable trends linked
drinking water? worldwide. Between 2000 and 2015 Fiji was one of 10 countries to climatic conditions—rates peak between January and June, xiii The case in Santiago, Chile, also
worldwide where basic drinking water access decreased.17xi following on the heels of the rainy season when the flooding of examines how climate change affects
safe drinking water access in that
xi Do you think clean drinking water is Statistics suggest significant water, sanitation, and hygiene (WASH) rivers and community septic tanks is more likely. Climate change country.
a human right? inequalities between urban and rural communities: 62% of rural and the increased severity and frequency of weather events are
Pacific communities lack access to basic water access (compared to global factors that affect the spread of disease and water quality,
xii What other diseases are higher in
prevalence due to lack of access to 10% of urban communities), and sanitation coverage is below basic not only in Fiji, but worldwide.xiii
safe drinking water? in nearly 80% of rural areas (compared to 29% of urban areas).18xii

282 283
 Oceania’s Vulnerability to Climate Change Mass Typhoid Fever Vaccination—A Potential Solution?

Cyclone Winston was the most severe tropical storm to affect Fiji on record, but it will not be the last. Capturing Mass vaccination against typhoid fever was trialed in Fiji following
international headlines, Cyclone Winston opened the door for Fiji’s climate vulnerability to be discussed category 4 Cyclone Tomas in March 2010. Part of post-disaster
on the world stage. At COP23 in November 2017, the Fijian government released the country’s first climate response involved Fiji and the Pacific Island region’s first-ever large-
vulnerability assessment. Among the sobering highlights: climate change could push an additional 32,400 scale typhoid vaccination program run by the country’s Ministry of
people into poverty each year by 2050,xiv and projected sea level rise would put nearly one-third of the Health with funding from Australian Aid.23 More than 64,000 people
country’s population at-risk.21 were vaccinated as part of that campaign, which also involved some
community-based demonstrations on hand-washing and other
Fiji’s vulnerability to climate change is reflected in Oceania as a whole. Oceania is repeatedly ranked as the sanitation practices. The campaign was most effective in three disaster-
highest risk region for exposure to natural disasters such as tropical storms, flooding, and sea level rise. Not affected areas that had high levels of vaccination, and typhoid fever
only vulnerable to the disasters themselves, Oceania receives this rating because of the limited capacity its incidence “increased or remained unchanged in 12 subdivisions where
institutions have to respond to those disasters, its geographic isolation, and the relative poverty experienced little to no vaccination had occurred.”24
by its populations. Along with four other small island nations in the Pacific, Fiji ranks among the top 15 countries
facing the highest disaster risk internationally.22 xv As of writing, large-scale typhoid vaccination has been limited to
post-disaster measures, and are not part of Fiji’s national immunization
program.25 An assessment of the 2010 vaccination campaign concluded
xiv For example, 37% of Fiji’s Regional, local, and household risk factors exacerbate the that more research is needed into the effectiveness of post-disaster xviii One issue with the typhoid
population derives income from the effects of global anthropogenic change on typhoid transmission. vaccination in settings where typhoid fever is endemic, and that the vaccine has been sustaining the levels
agricultural sector—this is even more of immunity it creates in a person in
true for people living near or on the
Nestedness, a concept borrowed from ecology, explains the need “provision of safe water, adequate sanitation, and good hygiene (WASH) the long run, needing to re-vaccinate,
poverty line. With climate change to consider each of these scales when creating a planetary health is the mainstay of typhoid prevention and control efforts.” xviii or give booster doses every 2-5 years.
affecting precipitation patterns, pest intervention. Nestednessxvi is about assessing how actions in
presence, and the water available
for irrigation, Fiji’s most vulnerable one environment can exacerbate the changes that take place in
populations could be affected by just another. To conceptualize the idea, imagine an onion. “Once you know the risk at those different layers it allows you
the slightest change in productivity. to intervene at each. That way you’re addressing the problem at
Not unique to Fiji, climate change will
disproportionately affect the poorest Just as an onion has many layers, so too does Fiji’s vulnerability multiple levels and across multiple time scales,” summarizes Aaron
people in countries worldwide. to typhoid transmission. Each layer represents a complex set of Jenkins. Intervening in river catchment systems allow planetary
environmental stressors. The outer layer includes human-caused health practitioners to address many nested problems at once.
xv Take a look at the countries with
highest degree of climate change environmental changes at a global scale, including climate change
vulnerability. Where do you think they which is simultaneously increasing ocean temperatures, the
rank with respect to greenhouse gas intensity of cyclones and other disasters, and rising sea levels.
emissions? There are many indexes
that address this question, but there The second layer is activity at the river catchment level: forest
are common threads among them. fragmentation and the resulting erosion, the construction of dams,
↘ Here is one think tank’s approach to
measuring such risk
disposal of waste into the river, and other upstream industry that
affects people living downstream. Peel away further still and you
have a layer at the village-level, where inadequate sewage systems,
xvi This concept is referred to as the
“ecological model or approach or outdated water reservoirs, and inadequate water treatment put
framework” in some academic writing. people at risk. Household activity is at the core of the onion: food
and personal hygiene practices including whether water is boiled,
xvii How would you apply this concept
of nestedness to a disease that is food rinsed, hands washed, and toilets flushed or covered.xvii
more common in where you are from?
Diabetes? Hypertension? Dengue?

284 285
 Views of Naqarawai village and its
proximity to the river.

286 287
From Where the Water Naqarawai, the Central Division village where Rosa Batiri lives Once it enters the reservoir’s concrete tank, water travels through the
Flows with Ruci and her other children, is a scenic spot. Reaching the retaining wall via a valve and pipe that feeds the untreated spring
community requires visitors cross a concrete suspension bridge that water directly to Naqarawai’s taps. The filtration system on that pipe
offers stunning views of the village on one side, and hillsides speckled is far from formal. Jovili Mototabua, head of the village’s drinking
with taro fields on the other. Residents gather below the bridge in the water committee, crouches and removes the filter: an additional
evening to play volleyball and rugby near the river’s edge. piece of piping with marble-sized holes polka-dotting its surface,
and layers of steel mesh to filter smaller particles. This reservoir is
It’s a 15-minute walk from the base of the bridge to reach the reservoir characteristic of the primary way in which rural Fijian villages access
where Naqarawai residents access drinking water. The path runs drinking water.
first along the banks of the river, through swaying cassava plants,
and finally, down a steep embankment approaching the sound It’s also representative of some of the challenges presented by
of running water. The reservoir is a man-made tank with a two- that source. Constructed in 1997, this is the second location for
foot high concrete retaining wall covered in tufts of green moss. Naqarawai’s reservoir. It was originally found further down the small
Upstream, a cascade of waterfalls channels water into the reservoir; stream, closer to the village. “But there were many farms in that area,
the wind blows gently through the dense forest and ferns. This water and a lot of people would cross with their animals which would
sprouts from a spring upstream, and Naqarawai benefits from being make the water dirty,” says Mototabua of the first location. While
the only village reliant on this source. this second reservoir site has eliminated the animal crossings that
polluted the water, Mototabua says the source is still far from ideal.

For one thing, the reservoir’s function is easily disrupted when there
is too much rain or not enough. Mototabua says a week of heavy
precipitation or a cyclone leads to the pipe getting clogged with mud
and dirt; not enough rain and the water level in the storage tank is
too low to feed the pipe. Water that collects sediment is also prone
to transporting other nutrients and bacteria. Once gathered, that
material can wash into and potentially contaminate village reservoirs
and surface water sources like nearby rivers.26

Mototabua blames a logging road upstream for the increase in

reservoir clogging sediment. “All the mud from the logging road
is swept down the stream and collects here when it rains,” he says,
gesturing towards the concrete tank. “That clogs the pipe and dirties
the water that does get through.” That can be problematic, he says,
since people often don’t boil the water coming from the reservoir
since there is the assumption that it’s safe for drinking.

Upstream forest clearing also increases the risk of waterborne

disease for villages like Naqarawai. Dense forests historically covered
subcatchments in Fiji’s Central Division; rivers were tree-lined and
ripe with vegetation. In recent years, however, economic activities
such as logging and its associated infrastructure has reduced river
buffer zones—the name for the forested area fringing rivers and
streams—in more than 85% of subcatchments.27 Buffer zones in
Jovili Mototabua inspects the sediment that’s collected around Naqarawai’s makeshift water filter.
288 289
 Central Division are “highly fragmented in 69% of subcatchments, This reservoir and the pipe it feeds are
without a single kilometer stretch of continuous riparian forest.”28 the main water source for the village.
xix Another case study looks at the This affects the ability for those forests to regulate the mitigation When it’s clogged or dry, community
ecosystem services provisioned of floods, purify water, and limit the spread of diarrheal disease.29 xix members rely on the nearby river—which
by forests to people living around
Gunung Palung National Park in West
contributes to a risk of waterborne
Kalimantan, Indonesia. Deforestation or other land use change can influence human disease.
settlement patterns, motivating people to live near river flood plains
Does your country of origin have
regulations on river buffer zones? and other low-lying catchment areas, which can increase their
Are they respected? exposure to contaminated water and, subsequently, disease.30 Even
if communities understand this added risk, many are hesitant to
relocate given the relationship and cultural significance associated
with the land where their families have lived for generations. While
riverside economic developments reap benefits for certain parties,
that often comes at a cost to rural and remote villages like Naqarawai.

Surface water pollution affects riverside villages, even those that do

have access to a basic system of reservoir and tapped water supply.
The water collected in Naqarawai’s reservoir tank is not always
enough to provide for all the village. When the reservoir’s pipe is
clogged by storms or upstream sediment, residents instead depend on
surface water from the Wainawene River. Interrupted water supply
and contaminated drinking water, including that which is gathered
from surface water sources, is yet another commonly identified
environmental risk factor for typhoid fever.31

Despite its relatively isolated location in the highlands, the

Wainawene River that runs through Naqarawai is pollutant prone.
This is because of activities like deforestation and cattle rearing,
in addition to the behavior of the two villages that sit upstream.
“They are using the same river as well, and it has caused us diarrhea,
sickness, skin disease, ringworms, and scabies—these are the kinds
of issues we face when there is no supply of water in the reservoir and
we have to use the river,” Mototabua explains.

Ratu Ilaisa Kuruibua, Naqarawai’s chief, says he has tried to explain

to upstream villages that what they cast into the river can affect
Naqarawai’s drinking water. Ultimately, he says these messages
haven’t held much weight. “When they slaughter pigs or cows the
waste ends up in the river,” explains Chief Kuruibua. His wife,
Sereana, has seen an entire cow’s head and bones floating down the
river, in addition to diapers and vegetable peels. “Those attitudes are
hard to change, even though we tell them that if the environment is
healthy it brings healthy living,” Chief Kuruibua sighs.
290
Returning to Naqarawai village after
a visit to the drinking water reservoir.
Customary Ownership While more abstract than deforestation and land use change, the overlain on communal policies have created significant debate
xxi In your place of origin, are there
and the Link to Land stripping of customary land ownership rights of rural, Indigenous about who has which rights to engage in particular practices in tensions over land tenure laws that
Tenure iTaukei communities can also contribute to this detrimental particular locations.32 xxi relate to use of natural resources?
behavior towards water resources.
In Fiji and other Pacific Islands, vanua is the concept used to
Land tenure—and as an outcome its environmental management— describe the relationship between people, land, and sea. “[That
is a contentious and complex topic around the world, and Fiji is no relationship] may define among other things the due of care that
exception. Customary land is any area that has been traditionally people have to each other, the future generations as well as the
overseen by a community-level governance system. In Fiji, the environment,” says one paper looking at the impact customary
property right to own and occupy customary land exists within land tenure can have on natural resource management in the xxii What other concepts are similar to
village clans (mataqali) and resource management is typically Pacific Islands. xxii vanua?
overseen by chiefs like Ilaisa Kuruibua.

Despite this Indigenous system of land tenure, the British

colonial government brought a system of its own to Fiji. This
meant that landscapes were at once governed by two conflicting
systems: customary and colonial. Today, Fiji’s government legally
categorizes land in three ways: iTaukei (customary), Freehold, and
Crown lands. An estimated 91% of Fiji is iTaukei land today. These
are areas the British administration permanently transferred
to clans and other groups of iTaukei landowners in the late 19th
century—disregarding that the land was never considered theirs
to give.

Community governance of iTaukei land still isn’t independent.

Ownership and leasing of this land is managed solely through
the iTaukei Land Trust Board (TLTB), a body first established by
a British colonial-era act, and one that receives a 25% commission
on all leasing agreements. TLTB’s lease granting motivations have
been challenged in the past, with court cases often ruling in favor
of the board rather than the landowners it was created to benefit.
FijiFirst, the political party that was re-elected in November 2018,
ran on a platform that promised the creation of an Independent
Lands Tribunal. The purpose of that newly created group would be
to mediate complaints between iTaukei landholders and the TLTB
and, in theory, ensure iTaukei were able to gain greater economic
xx What type of land tenure laws exist benefit from their land.xx
in your country? How and when were
they created? Are there different Stacked mahogany sits awaiting transportation
regimens of land tenure? Land leases? Land tenure has critical implications on natural resource in Fiji’s Central Division. An invasive species
Government owned? Communally management. For one, colonial land ownership policies can introduced by the British, mahogany trees soon
owned? National parks? Indigenous create confusion with customary land policies, and this can affect became a valuable part of the timber trade. Like
territories? Special laws for water- gravel extraction and cattle rearing, logging has
basin areas? Coastal zones? Protected how and by whom an environment is utilized. This is evident affected the water quality in river catchment-
forests? worldwide. In Nigeria, for example, colonial land use policies dependent villages.
294 295
 Back in Waisea Naisilisili’s pick-up truck, he says he fears this
relationship and the respect for traditional mataqali authority is
being forgotten, and that it’s affecting the reverence people have
for the surrounding environment. “This is how Fiji has always been
governed—by chiefs from respective villages and provinces, and the
children are taught to respect and listen. If the children cannot listen
at home, then it’s useless. Their parents and grandparents cannot
advise them of the environmental connection,” he says. “If we keep
on the track of today, all these connections will be lost for good.”

Going forward, Naisilisli suggests the government set rules that

safeguard the customary laws of communities. After all, the
farming activity happening on Naisilisili’s customary land is not
illegal—iTaukei land is available to lease through TLTB for periods
ranging from 30 to 99 years.

Legally, this new lease holder has to use the land as it was zoned—
for agriculture. “He needs to follow the proper rules for farming.
For example, he’s not allowed to farm too close to the streams
and rivers. That’s why I took the photo, because there’s a stream
nearby,” Naisilisili explains. If he had his way, the scale of these
developments, as well as their environmental impact, would be
held to a higher level of scrutiny by the respective government
ministries.

Unfortunately, this is not always the case in Fiji. “We’re very good across any industry: “there is no reason why a landowner should be An area in the Fijian highlands that
at producing laws, but not very good at enforcing them. Lease responsible for a river when the government and the rest of society has been cleared to make space for the
roadway and agricultural land.
holders are not monitored or held to task,” shrugs Dick Watling, are not paying for it. We need proper legal structures in place [for
a long-time environmental consultant and Founder of NatureFiji- environmental development].”
MareqetiViti, an environmental conservation organization. He
xxiii In your own words, what is meant says the governance of rivers is particularly confusing.xxiii For Waisea Naisilisili, the legal structures around natural resource
by governance? In the context of management already exist through the traditional mataqali
“governance of rivers”, what is Mr.
Watling referring to? According to Fiji’s Department of Town and Country Planning, system. He says a strong sense of customary land ownership would
“the beds of navigable rivers and streams are Crown land,” which, mean a stronger sense of environmental protection: “The majority
like iTaukei land, cannot be sold but can be made available for lease. of people don’t want [industrial activities like mining] to take place
“With the state ownership of the river it can still be pretty dicey because it’s going to destroy the area and the livelihoods of all the
where customary land ownership ends and state responsibility people living downstream.”
begins,” Watling says. He adds that environmental impact
xxiv How would you include a long-
term sustainability component into assessments aren’t always mindful of the long-term sustainability In addition to global and regional challenges like climate change
environmental impact assessments? of natural resources.xxiv and land use change, the loss of customary control over traditional
land is yet another factor that broadly affects water quality and the
While Watling believes gravel extraction from riverbeds is Fiji’s spread of disease.
most dire environmental challenge, he says the problem applies
296 297
Community and Confusion over land tenure and interactions between anthropogenic Today, after a month of rain, the river passing through Nabukavesi
Household Sanitation activities, water quality, and health occur in river catchments across is some four-meters wide, its current meandering lazily along green
and Hygiene Fiji’s Central Division. “Coastal villages are at the receiving end of the banks. Two women squat along the grassy edge washing clothes.
entire catchment and they can’t control the risks that are produced A young girl leaps from the bridge, her flip flops bobbing next to
by upstream practices,” says Marc Overmars, Chief of WASH with the spot where her splash sends ripples downstream. The scene is a
UNICEF Pacific. “Deforestation is one thing, but there are also good illustration of the role the river plays in the lives of community
cows and pathogens that go in the stream and attach to sediment members: play area, washing machine, and, when the taps are off, a
particles. These go down the stream, go into the water intake, and source of water for drinking, cooking, bathing, and cleaning.
people don’t treat the water. You can boil water in a household but
it’s actually already too late.”
Overmars’ role with UNICEF Pacific is dedicated to accounting for
and improving the water, sanitation, and hygiene (WASH) standards
available in villages—the inner layer of the onion when it comes to
addressing the risk of typhoid transmission in a nested manner.

Travel along the Queen’s Road highway from Naqarawai back to the
capital city of Suva and it’s hard to miss the sign announcing your
arrival in Nabukavesi—the village’s name is emblazoned in bold
white text on a billboard advertising Fiji Bitter, one of the country’s
most popular lagers.

Turn off the highway and the road continues along a concrete bridge
crossing the Nabukavesi River. Part of the Navua River catchment
that extends into the highlands, Nabukavesi is one of the last
downstream communities in Central Division before the river spills
into the Pacific Ocean. Along its journey, this river runs through
more than two dozen villages and settlements, including Naqarawai,
splitting to form smaller tributaries and creeks that serve as primary
and secondary sources of community drinking water.

The Nabukavesi River.

On one side of Nabukavesi is the home of chief Ratu Aisea Waisea Naisilisili (far left) and
Naisilisili, Waisea Naisilisili’s uncle. As is customary when Naqarawai Chief Ilaisa Kuruibua (far
right) with other residents of the village.
arriving in any Fijian village, the visit starts with a kava ceremony: They’re sitting around a tanoa, the name
the presentation of the dried kava root which is ground, mixed for the carved wooden bowl that holds
with water, and strained to make a drink called yaqona. Served in kava, a ceremonial drink in Fiji and
a large tanoa bowl, kava ceremonies are considered your passport other Pacific cultures. It’s often during
rounds of kava that important matters
to a village. In Fijian culture, many important topics are discussed are discussed.
over hours of this slightly sedative mixture. Today, one of those
topics is water security.

298 299
Ratu Aisea Naisilisili is the chief
of Nabukavesi village Nabukavesi for the past six years, and is one of two volunteers
in charge of tracking village health data and advising on basic
community health concerns. She leads the way past homes
constructed of corrugated metal and wood slats; stray dogs
basking in the sun; and large blue plastic barrels that collect and
store piped reservoir water for in-home use, especially when the
taps are turned off.

Down the concrete path, you pass nearly as many outhouses as

homes. While not the most visually appealing part of a village tour,
the type of latrine system used by a family has notable impact on
typhoid fever risk. Of the typhoid fever cases included in a Central
Division case-control study, 95% of people who tested positive for
the disease had unimproved sewage systems or improved systems
that had been damaged. Damage can be caused by the aging of
infrastructure, but also by externalities like increased use due to
the growing population of communities and natural disasters.
When damaged, the buried steel drum systems can corrode and
flood, contaminating surface water and everything in its path,
including food sources.

Baulina Tabuamoli, head of Nabukavesi’s women’s committee, is

one of the residents who has changed her behavior since the typhoid
outbreaks affected her community. As part of the committee, she
and other women gather weekly for communal meals of bele (a type
of cabbage), cassava, taro, and other boiled vegetables with coconut
milk. Large community gatherings are an important part of Fijian
culture, and everyone in the village is put at risk if unhygienic food
Baulina Tabuamoli is the head of the
preparation is practiced. The meals served at those gatherings now women’s committee in Nabukavesi.
involve boiled water for drinking, the washing of vegetables, and Communal food preparation is common
Born in 1957, Chief Naisilisili says Nabukavesi looks a lot different cleaning thoroughly afterwards. “Cleanliness is close to godliness, in Fijian culture, and in Nabukavesi the
women’s committee has taken it upon
today. He was a teenager when the New Zealand army built the isn’t it?” chimes in Elenoa Lewavunivalu, another Nabukavesi themselves to ensure everyone is using
reservoir and pipe system that still supplies the village with water. resident. “We have to be clean in everything. Prevention is better clean water to wash vegetables, clean,
At the time, the water was enough for the 20 households. Now, than a cure.” and cook. She’s pictured with Asela, one
that water supply is exhausted daily by the 100 homes and 250 of the younger residents of Nabukavesi.
students who come from nearby villages to attend the local school. The role of WASH practices in the broader context of environmental
Household taps are closed mid-morning and in the afternoon to changes like land use change and climate change support the need
prioritize water for school use. Nabukavesi’s reservoir also faces for a nested solution to improve water quality—one that addresses
many of the same sediment clogging issues as that of Naqarawai. actions and behaviors at various scales. A new project has set out to
consider these nested, water-related complexities at a household,
There’s also the issue of aging or insufficient sanitation community, river subcatchment, and national level, and get
infrastructure. That’s highlighted in a village tour with Luse stakeholders at all levels working together in addressing them.
Mociwai. Mociwai has been a community health worker in
300 301
An Integrated Approach For all the damage Cyclone Winston caused in 2016, the natural is our responsibility, we don’t control all the moving pieces that
to Fiji’s Water Challenges disaster is often seen as a turning point in the way Fiji deals with affect water,” she says. “So the ministry’s role in [the Watershed
issues of water safety and water-related disease. At no time are new Interventions for Systems Health (WISH) project] is very
and multidisciplinary ways of working together more urgent than much addressing this responsibility while also pulling in other
in the weeks following an emergency. stakeholders who are in charge of aspects like access to water and
infrastructure.”
Much of that collaboration was out of necessity—Fiji had depleted
its emergency WASH kits within four weeks of Winston’s landfall,
and was left scrambling to prioritize disaster and recovery
response. The national government needed more data about water
quality to do that, and turned to surveillance from the four Fijian
ministries that deal with the issue. “During Winston, our lack of
coordination as key government agencies working in the WASH
sector showed up,” says Suliasi Batikawai, a Senior Environmental
Health Officer and WASH Coordinator with the Ministry of
Health. Batikawai says there was duplication of services and
overlap between government agencies once the recovery process
began in mid-April 2016. Each agency was doing their own water
sampling and monitoring.

Winston was the first time multiple sectors collaborated on the

issue of drinking water safety, says Dr. Aalisha Sahukhan, the
Head of the Health Protection Division with Fiji’s Ministry of
Health. She says the monitoring data the country needed was
challenging to gather. “We had existing surveillance systems but
these were often hampered by delays in the time from reporting
to action, which was not helpful for early warning for outbreaks,”
says Sahukhan.

Post-Winston disaster response and recovery pressed the

xxv A silver lining of disasters and government to make monitoring more effective.xxv The country
emergencies is that if done right, one started using a World Health Organization system called EWARS
can look back and learn a lot from
the original response. What are some (Early Warning, Alert and Response System) to better detect and
examples of lessons learnt of disaster respond to disease outbreaks. It has since become one of Fiji’s The WISH project is the latest intervention to address integrated These large plastic vats are a familiar
and emergency response in your scene outside of homes in rural Fiji.
country, and how these have been
permanent surveillance systems. The country also started creating water management in Fiji. The project launched in October
While some homes have indoor taps,
incorporated in new legislation or a National Drinking Water Quality Committee and National 2018, and brings together stakeholders from various academic many families rely on these containers
procedures? Drinking Water Standards, and Sahukhan hopes both can be disciplines, Fijian ministries and agencies, and international and filled with tapped water from the local
formalized through the multi-sectoral collaboration. Pacific region NGOs. reservoir.

At a national level, Sahukhan sees an opportunity for the Ministry

of Health to better collaborate with other groups focused on water
quality. “While drinking water quality and the spread of disease

302 303
An Integrated Watershed Approach in Guam A $2 million project funded by the Australian government through
its Indo-Pacific Centre for Health Security, WISH addresses
WISH isn’t the Pacific Region’s only example of an integrated watershed management project. Another is the water, sanitation, and river catchment management tactics
underway on the tiny island of Guam, a U.S. territory in the West Pacific. It’s called the Guam Restoration that could reduce outbreaks of Fiji’s “three plagues”: typhoid
of Watersheds initiative (GROW), and it’s a project of the University of Guam’s Center for Island fever, dengue fever, and leptospirosis.xxvi Just as typhoid cases are xxvi Before moving forward, what
common risk factors do you think
Sustainability. increasing in Fiji, so too is incidence of the latter two diseases. these three diseases have?
There were more than 15,000 confirmed cases of dengue fever,
Similar to Fiji, Guam faces a number of inland challenges that affect the island’s marine environments. The a mosquito-borne disease, during an outbreak in 2013-2014.36
most urgent of those is southern Guam’s badlands. Badlands are once forested areas that are now bare, Similarly, there’s been a three-fold increase in leptospirosis in Fiji,
with topsoil wiped away to expose bedrock that makes the regrowth of vegetation difficult. The island’s another water-borne disease transmitted when people come in
badlands area has grown by nearly 9% between 1973 and 2001, and research has found that badlands contact with infected urine. Like typhoid, leptospirosis outbreaks
are the category of land cover that contribute the largest amount of soil erosion each year—much of are more common after flooding events, with 83% of cases
which ends up in waterways and coastal ecosystems.33 The expansion of badlands can be attributed occurring within six weeks of a flood.37 Landscape changes such
due to natural causes like heavy rainfall and cyclones, as well as human activity.34 That activity includes as deforestation and river damming are suspected to affect the
irresponsible off-roading, arson fires, and invasive species such as deer and pigs. spread of all three diseases.38

GROW is experimenting with several creative and low-tech approaches to replant and restore the The WISH team is made up of 10 chief investigators from
badlands. One method involves the use of sediment filter socks—sausage-shaped, biodegradable socks universities in Australia and Fiji, including Dr. Aaron Jenkins and
that stretch across a high-erosion area, preventing sediment from reaching waterways. A study on the Dr. Joel Negin, the WISH project lead and head of the University of
effectiveness of this method found 19 kilometers of sediment socks, installed with 11,000 replanted trees, Sydney’s School of Public Health. WISH also brings in 10 associate
could trap enough sediment to allow the coral reefs of one bay in southern Guam to recover from the investigators, experts from the Pacific Community, UNICEF,
effects of erosion.35 the World Health Organization, and Fijian government bodies
including the Ministry of Health and Medical Services and the
Two other innovations more specifically target reforestation. Seed balls and sling stones are easily- Water Authority of Fiji. All have worked on some aspect of health,
produced creations of soil, clay, seeds, fertilizer, and compost. Dropped from drones or tossed onto water, or sanitation before, though this is the first time the group
the badlands by hand, the seed sling stones take root and begin revegetating erosion prone areas. “We is gathering as part of a project with a common aim.
deliberately chose native plants that were easy to recognize and gather so there’s enough availability
of seeds,” says Else Demeulenaere, a botanist and the Associate Director of the Center for Island Building on the work of many researchers, public health officials,
Sustainability. There’s also a traditional link—sling stones were historically an almond-shaped weapon and NGOs in this room, WISH has determined river subcatchments
crafted of limestone and clay and thrown during battles. to be the most relevant scale in which to investigate and intervene
in water-related diseases. Over the next three years, the project
According to Demeulenaere, getting the community and the off-roading industry involved in badlands will work in 18 rural and peri-urban villages in three Central
restoration is key. “The watersheds are so big, and we really wanted people to take reforestation into their Division subcatchments. A baseline survey at the beginning of Dr. Aaron Jenkins—a self-portrait.
hands, even if the degradation is often not their fault,” Demeulenaere says. “We also made it a fun activity. the project will measure the water access and sanitation behaviors
I think it’s more sustainable to engage communities rather than just solving the problem yourself and not of 15 households in each of those 18 villages, and a community
talking about it.” mapping exercise will plot where people get their water and which
latrines are most likely to pollute those sources. This will allow the
project to address the inner layers of the onion—the community
and household behaviors that can mitigate the spread of disease.

The WISH project also relies heavily on village-level participation

in data collection. An objective is to gather as much real-time
information on the layered factors that put people at-risk of water-
304 305
 Village scenes from Nabukavesi, one of the
borne and water-related diseases—those upstream, community, rural communities where the WISH project
and household actions identified in the 2014-2017 typhoid case- could work.
control study. That information could populate a national database
and, after integrating with meteorological and rainfall data—the
outer layer of the onion that includes global climatic shifts—create
a score for each community based on its risk of waterborne disease.

That score could then be used for informed decision-making

at both a village and national level. Village-wise, community
members could learn which simple actions to prioritize in order
to secure their drinking water quality—anything from cleaning
water tanks to repairing a leaking reservoir pipe to deciding which
water source to use for cooking versus cleaning. The project also
involves an education component: working with safe drinking
water committees and other village groups to protect ecosystems
like forests that provide natural protection from waterborne
disease—the regional layer in the onion analogy.

At a national level, a risk score could be used by relevant government

agencies to prioritize funding and water safety interventions before
disaster strikes. Finally, when a natural disaster does inevitably
occur, the national government could use the information
platform to see which villages are most vulnerable to water-related
disease outbreaks and prioritize emergency response. The ease of
access and interpretation of this data is key—“we’re drowning in
data but starved for information,” reminds one individual at the
WISH project launch.

In the case of outbreaks, WISH is training a team of Fiji Outbreak

Field Officers (FOFOs), a group that will rapidly respond to disease
outbreaks and use the EWARS tool to do local surveillance. “If
information is being regularly collected every time there’s an
outbreak, then we start to learn about the conditions in which
those events normally occur,” says Aaron Jenkins. “You can then
program machine learning into the database and that would allow
us to improve the prediction and response to water-related disease.
This is what we’re thinking about in the long-term.”

306 307
Epilogue WISH is just one project to address the relationship between While the restoration of physical ecosystems could reduce
healthy environments and healthy people. Addressing these disease transmission, so too could the restoration and respect of
intersections at individual, household, and community levels is cultural traditions, customary land ownership, and the agency of
not enough. Regional restoration of landscapes can contribute to Indigenous iTaukei clans to manage their lands. Only then can
addressing poor water quality at its source. There’s some history of people fully maintain reverence for that environment, treating it
this being successful in Fiji. with the same care as past generations as opposed to with a sense
of complacence. “Our villages are very unique, and there are rules
River buffer zone protection—the fringing of trees next to water of the chief that bind them,” says Waisea Naisilisili. “When outside
bodies—and reforestation can improve an ecosystem’s ability development and worldviews come in it makes people do whatever
to provide critical services such as clean water. In 2017, research they want to do, and that includes disrespecting the environment.”
linking forest clearing and typhoid was successfully used to lobby
Fiji’s Forestry Department to commit to enforcing river buffer zone Naisilisili is optimistic the WISH project can successfully work
laws. These policies set aside areas ranging in width from 10 meters with local communities, and respect their cultural traditions.
to 30 meters, preventing development too close to the riverbank.39 This, he says, is because the work deals with peoples’ lives and their
That commitment came as part of the national strategy for source of water—a key medium for physical health and cultural
typhoid prevention and control—a key acknowledgement of how well-being.
public health research can be used to influence natural resource
management and policies. Buffer zone restoration could also According to him, projects must tap into the traditional
reduce the amount of eroded sediment that washes into streams, connections clans have with their local environment. “This is the
which could translate to healthier freshwater and marine fish only way we can understand more, because this is our identity and
species, a win for conservation, food security, and local livelihoods. this is how we connect ourselves to nature. It’s always important
that scientific research respects traditional knowledge,” Naisilisili
To that end, the WISH project also fits into the goals of a larger says. “There is a place where the two will meet, and in this case it’s
ridge-to-reef approach in Fiji. While WISH will implement and that they agree on the importance of water.”
measure interventions that affect the inland health of people and
ecosystems, a complementary project called Vibrant Reefs assesses
how those interventions affect marine ecosystems. The project is
being led by the Wildlife Conservation Society in Fiji.

Prior research has connected algae growth and coral bleaching to

sediment and nutrient run-off from commercial agriculture and
mining activities.40 Those impacts on marine ecosystems can
collapse fisheries, which affects the food security and well-being
xxvi Coastal ecosystems are explored of people who depend on the resource.xxvi Vibrant Reefs intends to
in depth in the Sri Lanka study. monitor the impact that reduced sediment runoff and improved
How does eutrophication and coral
bleaching affect human health, both water quality has on coral reefs and food fish. Like WISH, that
directly and indirectly? information will then be used to drive policy-making—by
establishing which river subcatchments should be prioritized in
order to offer the best return-on-investment for inland and coastal
ecosystems as well as public health.

308 309
Keeping Track of Who’s Suliasi Batikawai Rosa Batiri Dr. Aaron Jenkins Ratu Ilaisa Kuruibua Elenoa Lewavunivalu
Who
Senior Environmental Health Officer and Naqarawai resident, mother of Ruci Fisheries ecologist; planetary health Chief of Naqarawai village Nabukavesi resident
WASH Coordinator, Fijian Ministry of researcher whose PhD focused on the
Health environmental determinants of typhoid

Luse Mociwai Jovili Mototabua Ratu Aisea Naisilisili Waisea Naisilisili Dr. Joel Negin
Community health worker in Nabukavesi Head of Naqarawai’s drinking water Chief of Nabukavesi village Fisheries and Operations Support Officer WISH project lead, Head of the
committee with the Wildlife Conservation Society, University of Sydney’s School of Public
Fiji; resident of Nabukavesi Health

Marc Overmars Dr. Aalisha Sahukhan Baulina Tabumoli Dick Watling

Pacific WASH Coordinator, UNICEF Head of the Health Protection Division Head of Nabukavesi’s women’s Environmental consultant and Founder
with Fiji’s Ministry of Health and committee of NatureFiji-MareqetiViti.
Medical Services

Acknowledgements Dr. Aaron Jenkins was my main contact for this case study. Thank
you for helping coordinate this visit, Aaron, and for being a pioneer
when it comes to planetary health research. I also appreciate your
efforts in planning the Oceania Planetary Health Forum that I was
fortunate to attend in Nadi. To Waisea Naisilisili for the insightful
conversations, expert truck driving, and interpretation assistance:
this case would not have been possible without you! I am especially
thankful for your patience in explaining the importance of kava
ceremonies within Fijian villages. Dr. Stacy Jupiter and the team
at the Wildlife Conservation Society in Suva were instrumental in
helping set up field interviews, and were kind enough to allow me
to work with Waisea for several days. Marc Overmars and Roger
Singleton provided much needed context about the importance of
water, sanitation, and hygiene in Fiji and the Pacific Region. To
all those I met and who hosted me in Naqarawai and Nabukavesi:
a heartfelt thanks and it was a privilege learning from you all.

An area of cut forest in the highlands of Viti Levu, Fiji’s largest island.

310 311
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15 Prasad, N. and Jenkins, Aaron P, et al. 2017 restoration as a tool for improving coral reef resilience against
16 Kumar, SA, et al. 2016 climate change and other human impacts.” Estuarine, Coastal
17 A Snapshot of Water and Sanitation in the Pacific.” World and Shelf Science. June 27, 2016; http://dx.doi.org/10.1016/j.
Health Organization. 2017; https://www.unicef.org/EAPRO_ ecss.2016.06.027
Pacific_Snapshot_Final_2017_27_10_2017.pdf 35 “Dengue Fever.” Ministry of Health & Medical Services.
18 “Summary Assessment of Damage and Needs.” Asian https://www.health.gov.fj/?page_id=2129
Development Bank. https://www.adb.org/sites/default/files/ 36 Ritter, Jana M., et al. “A Large Leptospirosis Outbreak
linked-documents/50181-001-sa.pdf following Successive Severe Floods in Fiji.” The American
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
07
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Today’s
Please cite this case study as “Duff H., Faerron Guzmán, C.,
Almada, A., Golden, C., and Myers, S. “Today's Solutions
for the Future of Food.” Planetary Health Case Studies:
An Anthology of Solutions. 2020; https://doi.org/10.5822/
phanth9678_7

Please note this work is licensed under a Creative Commons

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Solutions
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for the Future

of Food
—
 Executive Summary A 2019 landmark report presents the need for food system change
as an opportunity and an urgent call to action. The time for change
Many of the topics addressed in this is now: the food system produces a quarter of all global greenhouse
case are explored in depth in chapter gas emissions, and the world’s population is projected to grow to
5 on nutrition and food systems in:
↘ Planetary Health: Protecting Nature 10 billion by 2050.
to Protect Ourselves.
This case study focuses on a trio of strategies for redesigning the
food system: the need to sustainably intensify production; promote
Learning Objectives
a shift towards healthier plant-based diets; and reduce global food
After discussing this case concerning loss and waste. Building on scientific evidence, this case study
global food systems, students should
be able to:
highlights real-world examples of how individuals, organizations,
and companies are putting these planetary health strategies into
➀ Correlate the impacts of current action.
food systems on Earth’s natural
systems and human health.

➁ Understand the role of technology, This case study was written based on interviews conducted in Candeleria (Guatemala),
culture, governance, history, and Madrid, Berlin, and London (UK) between November 2018 and May 2019.
socioeconomic status in shaping
both food systems and the solutions
that address current food systems
challenges.

➂ Explore the connections between

personal food choices, food systems,
health outcomes, and environmental
impacts.

➃ Apply a food security lens to

current challenges within the food
system.

317
Introduction The global food system is currently unsustainable to ensure the Organization of the United Nations (FAO) estimates that a third of
well-being of people and the planet. As a result, an equitable the food produced globally each year is lost or wasted. That equates
and science-driven overhaul is needed to maximize benefits and to 1.3 billion tons valued at nearly a trillion US dollars.12 This has
minimize harm for human health and for the environment. dire environmental implications: if food waste were a country,
it would be the world’s third largest emitter of greenhouse gas
This call to action is urgent, especially with the world’s population emissions.13 The issue is of particular concern in the Global North,
projected to reach 10 billion people by 2050. Globally, the food where wealthy countries waste nearly as much food as the entire
system accounts for a quarter of all greenhouse gas emissions.1i net food production of sub-Saharan Africa.14v v Think of the food production system
Agriculture makes up 50% of the world’s habitable land, disrupting from seed to table. Where do you
think most food is wasted?
valuable biodiversity and displacing communities.2 Though Structuring a food system to sustainably feed 10 billion people is
i What are the other big sectors that phosphorous and nitrogen fertilizers boost crop yields worldwide, no small task—but it is possible and important. “Food is the single
account for GHG emissions?
↘ Read more here their run-off into water bodies leads to eutrophication, a dire strongest lever to optimize human health and environmental
environmental condition that deprives ecosystems of oxygen sustainability on Earth,” declares the EAT-Lancet Commission
and threatens marine life. In 2019, for example, nitrogen and on Food, Planet, Health. Released in 2019, the landmark report
phosphorous run-off from agricultural fields drained into the brought together 30 of the world’s leading scientists in food
Mississippi River, creating an 18,000 square kilometer “dead zone” systems and the environment. The report outlines science-backed
ii ↘ Care to read more? in the Gulf of Mexico.3ii Other agrochemicals, including herbicides strategies and targets for revolutionizing the global food system
v Access the full document here:
and insecticides, have negative impacts on biodiversity and human based.v ↘ https://www.thelancet.com/
health.4 Increases in atmospheric concentration of carbon dioxide commissions/EAT
is projected to affect the nutrient availability of protein, iron, zinc The verdict is clear: changing the world’s food system is complex
and certain vitamins in crops, further exacerbating deficiencies in and demands more than a single strategy. That’s why this case study
regions of the world where people already struggle to meet their focuses on three complementary pathways: edible insects as an
daily nutrient intake.5 6 More broadly, climate change contributes option for sustainably intensifying food production and improving
to food shortages that have already triggered conflict and nutrition; shifting policy and young people’s perceptions in order
displacement.7 8 to promote plant-based diets, and letting consumers and retailers
reduce food waste in a way that is convenient and beneficial for the
Global nutrition is inequitably distributed. Though enough food is environment and wallet.
produced to feed the world’s population, an estimated 815 million
people globally still go hungry, unable to get enough calories to meet Finally and importantly, the global food system can’t be divorced
iii On the contrary, how many people their minimum dietary energy requirements.9iii Micronutrient from the realities and motivations of the people it’s meant to feed.
in the world consume more than deficiencies affect more than two billion people globally, and This is a common theme throughout the case study. A small taste
their necessary share? Where is this
consumption the greatest? are especially prevalent in low and middle income countries.iv of how this theme emerges: nutrition programs must be mindful
↘ Explore caloric intake per country Derived only from a person’s diet, micronutrient deficiencies of peoples’ inability to access or afford traditional food or land.
here
are particularly harmful for children and can hinder motor and Those advocating for a shift to plant-based diets must not turn a
cognitive development, increase risk of blindness and infection blind eye to poorer populations dependent on animal-source foods
iv What is the rate of malnutrition from disease, and prevent healthy weight gain and growth.10 The for critical nutrients. Food loss and waste policies must be mindful
in your region or country of origin?
Where is the problem at its worst?
nutritional challenges continue: the rapidly growing burdens of of the power relations in the supply chain in order to equitably
↘ Learn more here obesity and metabolic diseases, including cardiovascular disease distribute responsibility and prevent the abuse of small-scale and
and diabetes.11 individual producers. Revolutionizing the food system offers the
opportunity to advocate for human and animal well-being, social
Food system challenges are not solely associated with what we eat justice, environmental sustainability, and more.
or cannot eat—it also involves the amount of edible food that is
lost or wasted along the supply chain. The Farm and Agricultural
318 319
Sustainable The food system has a significant environmental footprint.vi chicken.17x While water use varies by climatic region, mealworms x Analyze these two infographics
Intensification: A Big Role Changing the ways in which the world produces nutritious diets have a lower water footprint to nutritional protein ratio, and related to the total estimated average
emissions for different foods.
for Mini-Livestock? has the potential to yield a number of co-benefits,vii including demand five times less freshwater than beef.19 ↘ Across the food chain
improving food security in less environmentally detrimental ways. ↘ Food types
vi Try to map where in the food One proposed pathway is through sustainable intensification of Additionally, mealworm production requires less energy than that
system is this environmental footprint the food system—producing more food with fewer inputs of water, required for beef or pork (though more research is needed into
created.
energy, fertilizer, and other agrochemicals.15 reducing the energy necessary to keep larvae warm). Until then,
commercially rearing mealworms uses approximately the same
vii According to the Intergovernmental ↘ Appendix: What are the environmental impacts of food and energy as chicken and milk production.
Panel on Climate Change co-benefits agriculture? (Source: Our World in Data)
are the positive benefits related to the
reduction of greenhouse gases. Mealworms grow in a low-cost, lo-fi farm
Sustainable intensification is important because of the influence created in the highlands of Guatemala.
the food system has over many of the Earth’s system processes.
That includes freshwater use, land-use systems, nitrogen cycling,
viii Learn more about the Planetary biodiversity loss, and climate change. A planetary boundaryviii
Boundaries framework here exists within each of these processes—the suggested threshold
within which the food system must remain in order to reduce
risks for people and the environment. According to the EAT-
Lancet Commission, sustainable intensification can reduce yield
gaps on cropland, improve the efficiency of fertilizer and water
use, redistribute the global use of nitrogen and phosphorus, offer
climate mitigation opportunities, and enhance biodiversity within
agricultural systems.16

So how can the world produce enough nutritious food while limiting
environmental burdens? Experts worldwide increasingly present
entomophagy, the technical term for the human consumption of
insects, as an opportunity to accomplish many of these needed
ix Have you ever tried insects? Would intensifications.17ix Higher nutritional content has been the main appeal of edible
you? insects to date. Insects are typically high in protein, fat, amino
The Benefits of Mini-Livestock acids, and micronutrients such as iron, magnesium, and zinc.20
The Food and Agriculture Organization of the United Nations They also contain vitamins and chitin, which may serve as a
(FAO) released a seminal report in 2013 detailing the potential of dietary fiber. One study suggests mealworm larvae are 46% protein,
edible insects for both food and animal feed security. It argues that contain valuable amino acids lacking in many staple crops, and
entomophagy offers co-benefits for the environment, health, and possess a high level of other fatty acids and minerals.21
livelihoods.

Insect agriculture has been shown to have less impact on land,

water, and other natural processes when compared to conventional
livestock and agriculture. Take mealworms, for example. Raising
a kilogram of mealworms for food produces significantly less
greenhouse gas emissions and requires much less land than
producing a kilogram of edible protein from beef, pork, and
320 321
Canadian Grocery Chain Buys into the Buzz Dr. Valerie Stull is looking at the health benefits of insects beyond
their nutritional value. Stull is the Principal Investigator with
The changing food system is a hot topic of discussion for Kathlyne Ross and her team at Loblaw Companies Mission to Improve Global Health Through Insects (MIGHTi),
Limited, Canada’s largest food retailer. “A lot of our conversation right now is focused around alternative and a collaborative research project that views edible insects as one
plant-based proteins, not only for health and wellness but also for environmental impact and animal welfare,” solution to tackle food insecurity and the changing climate. She
says Ross, the company’s Vice President of Product Development and Innovation. was also lead author on a study that suggests cricket powder
consumption could improve gut health.22 “I’m really interested in
To that end, Loblaw’s flagship President’s Choice brand introduced a new product in March 2018: 100% cricket seeing if supplementing a low nutrient diet with insects could lead
powder. Ross says it meets a few key requirements: it’s high in protein, rich in vitamins and minerals, and to not only improved micronutrient status, but improved health
is produced using less space and water than conventional livestock. Plus, it’s good for marketing. “We knew because of beneficial shifts in the microbiome,” Stull says.
insects were getting a lot of buzz, pardon the pun,” laughs Ross. “We were asking ‘what can we do with
a product like that to make it viable and bring it to Canadians in a more accessible way.’” Powder, as opposed Stull believes entomophagy can play a leading role in sustainably
to whole crickets, was eventually chosen as the presentation means of choice. intensifying the food system. “I think it’s really exciting that insect
agriculture has the potential to be both a player in the larger food
The decision to sell cricket powder wasn’t made overnight. In fact, Ross says it took nearly two years of referring system if we sustainably ramp up production, and also a player in
back to consumer surveys, speaking with scientists about the environmental benefits of edible insects, and food justice and food sovereigntyxi at smaller scales because it can xi How would you define ↘ food
convincing others within the company that entomophagy wasn’t a fad. Rather, the cricket powder is meant give people at a household level more autonomy over what they eat sovereignty?

to appeal to the growing demand of consumers who want flexitarian diets. and what they’re able to produce,” she says. Even people with no
land and access to only the most basic of technologies are able to
“It’s about saying to consumers ‘we are offering you a choice. We’re always going to sell chicken and beef and start low-cost insect rearing operations.23
there’s nothing wrong with having them in your diet,’ but we want to always be the brand that presents the
opportunity of an alternative,” Ross says. Loblaw is currently developing other plant-based protein products that The intersection of food justice, increased household autonomy,
will be stocked alongside the cricket powder over the next year. and environmentally-sustainable production is important. This is
especially true for food insecure countries that are vulnerable to
The cricket powder itself comes from Canadian company Entomo Farms. The family-owned business has been climate change.
producing insect protein since 2013, and sells other products like whole roasted crickets and mealworms.
Insects are not a new menu option, and already factor into
“In the beginning we hoped that people’s affinity to care about the environment would be enough to drive traditional diets worldwide. An estimated two billion people live
xii Where in the world are insects
consumer change [towards edible insect products], but we learned that it wasn’t going to be enough,” says in countries where insect eating is practiced.24xii That includes eaten? ↘ Explore the map here
Jarrod Goldin, President of Entomo Farms. With 35 staff and more than 100 million crickets, Goldin suggests the in Guatemala, where one organization is using entomophagy to
company is the world’s largest livestock farm. promote a way for families to grow their own protein source—
fewer inputs of water, land, and energy required.
Mindful of animal welfare, Entomo Farms retrofits former chicken barns and other industrial spaces with what it
calls “cricket condos”—blocks with a large surface area where insects can hide and access fresh food and water Worms are the Way
on-demand. Expanding the market to include edible insects involved some bureaucracy, and Entomo Farms and It takes a few knocks before Doña Irma Hernandez opens the white
Loblaw worked with the Canadian Food Inspection Agency to create safe procedures and protocols to farm and metal door of her home in the village of Candeleria, Guatemala.
manufacture the crickets. She has her hands full, quite literally, with her 18-month-old son,
Alejandro. His three-year-old brother, Denis, runs around the
So has the buzz paid off? Kathlyne Ross thinks so. Media coverage of the product launch meant the company family’s small front room, making what seems to be as much noise
exceeded sales targets by over 200%—though Ross admits the company was tame in its initial production as humanly possible.
volume. “Sales are steady now. We’ve certainly kept the Entomo guys farming a lot of crickets,” she says.
“The product is not going away.”

322 323
 Doña Irma Hernandez watches as her two sons play
with the family’s mealworm farm. Constructed from
low-cost and locally available materials, the farm can
be kept inside the house and out-of-reach when Irma
isn’t harvesting mealworms for flour.

324 325
Both boys momentarily quiet down as their mother takes a box off 815 million people and is responsible for 45% of child mortality.29 xiii xiii Where in the world is this a
the shelf. Wrapped in a fleecy flower blanket is a plastic container For organizations like MealFlour, it’s not just about making sure problem? Take a guess before
↘ clicking on this link
the size of two shoeboxes. In it sits a plastic strainer, not unlike the people have enough nutritious food to eat, it’s about creating
type you’d use to drain pasta. There’s a rustle of activity inside: an intervention that addresses the objectives of food security:
a few dozen mealworm beetles wriggle in loosely packed oats, availability, access, utilization, and stability.
their shiny black exoskeletons catching the light. A handful of
mealworms are already a few centimeters long. They’ll be plucked Food Security in the Guatemalan Highlands
out and roasted when they reach a certain size. What’s the cooking Guatemala has a long and complicated track record with chronic
time? “Until they’re brown!” Hernandez laughs. malnutrition. This is especially true in the country’s rural
Indigenous areas where 70% of children are malnourished,
Hernandez is one of five women who participated in the pilot compared to the already-alarming rate of 50% among the general
program of MealFlour, an edible insect organization operating in population.30 The western highlands where Irma Hernandez lives
Guatemala’s western highlands. The pilot program was a six-week with her family is home to many Indigenous groups.xiv xiv Guatemala is one of the countries
training course where women learned how to build a mealworm with a higher percentage of
Indigenous peoples in the world, with
farm using readily available and low-cost materials, how to care Physical access to land is challenging for Indigenous communities. around 60%. What role do you think
for the insects, and how to process adult mealworm larvae into Land ownership is one of the most contentious issues in this plays in food security?
powder. The goal was for the farms to produce a weekly output of Guatemala and was a contributing factor to the country’s civil war.
larvae that could be roasted and ground as flour. The premise in Occurring between 1960 and 1996, the war pitted the Guatemalan
doing this was that families would have a more affordable, stable government—a military regime installed after a U.S.-backed
source of protein. Mealworm flour could eventually be sold, adding coup d’état in 1954—against rural Indigenous groups31 who were
to overall income and helping families edge away from the poverty struggling for the land that had been taken from them over the
line. past two centuries. Those evictions continue today.32

Mealworm farms like this could offer a solution for the series of
A recently harvested corn field in the
larger challenges facing Guatemala and the world. Low and middle Western Highlands of Guatemala. Food
income countries are experiencing the greatest effects of climate security remains an issue for many
change. Guatemala is no exception, and the country is consistently families living in poverty, despite corn
and other crops being grown in most
ranked one of the world’s most vulnerable to natural disasters regions.
and the effects of climate change.25 As the MealFlour team wrote
in a submission to The Lancet Planetary Health, “an effective
strategy to improve nutrition and increase food security must
be environmentally sustainable and adaptable to environmental
change.”26

MealFlour was founded in 2016 by Elizabeth Frank, Joyce Lu,

and Gabrielle Wimer. The organization has since partnered
with five Guatemalan organizations to address the food security
challenges of protein shortages and chronic malnutrition in the
country. Nearly half of Guatemalan children under the age of
five are stunted, meaning they’re shorter because of chronic
malnutrition or repeated infections.27 Guatemala has the highest
rate of chronic malnutrition in Latin America, and one of the
highest rates worldwide.28 Globally, chronic malnutrition affects
326 327
 Elizabeth Frank, Andrea Monzón, and
Land ownership issues were a key reason for MealFlour’s Gabrielle Wimer. Elizabeth, Gabrielle,
establishment in the western highlands. “We had initially designed and another classmate created MealFlour
the program to be for crowded urban areas. We viewed it as a after witnessing the shortcomings in
some other global health programs. With
way for people in cities to grow their own source of protein,” says experience in entomophagy, Andrea
Gabrielle Wimer, one of MealFlour’s Founders. “But the more we joined the MealFlour team in 2018 and
learned about Guatemala, the more we saw the issues with land leads the organization’s expansion into
being taken away from families and the lack of access to natural other regions of Guatemala.
resources to produce your own food.”

Agriculture is a main livelihood in the western highlands. Yet, an

inability to access land means the availability of healthy food and
protein remains a challenge. Indigenous farmers commonly work
as campesinos, laborers who tend agricultural land belonging to a
landlord. Pay is poor and the food grown is often sold in urban
centers or to the global market, reducing what’s available for local
xv In essence, although surrounded by families. As a result, many household diets sustain on imported MealFlour’s partner organizations. “Families have those animals
food crops, these villages act as food
deserts. Are food deserts common corn-based products purchased at the market, even if the entire for emergency situations. They sell them to get out of a crisis.”
where you are from? village is growing fruits and vegetables.xv Additionally, poor pay for campesino workers keeps them locked
in poverty and unable to afford education, including knowledge
Poverty presents a further barrier, especially in the western regarding what constitutes healthy eating in the first place. Poverty
xvi Extreme poverty rates are double highlands where extreme poverty is most acute.xvi Protein sources can also affect utilization, the ability for a person’s body to absorb
for Indigenous groups in Guatemala such as eggs and beans are available in villages, though are often energy and nutrients from food.xvii
and unlike national poverty rates, are
not showing a significant decline. unaffordable.33 As a result, protein supplements are a common
feature of nutritional programs in the western highlands. But Back in Irma Hernandez’s home, she explains that protein
availability and stability of those supplements isn’t guaranteed. supplements were the family’s main source of protein before their
International aid agencies donate the majority of supplements, involvement with MealFlour. Those protein supplements cost 9
with the national government responsible for stocking health posts quetzales (about US $1.17) per pack, an expense that wasn’t always
and hospitals around the country. “Most times the supplements affordable for the family of four. Now, when possible, Hernandez xvii How do you think poverty and
are completely out of stock or aren’t distributed to where they’re supplements the family’s meals with mealworm flour pancakes. the ability for a person to absorb
energy and nutrients from food are
supposed to go because of corruption and supply chain breaks,” “Feeding the worms costs me nothing. I peel my carrots, I leave connected? What biological pathways
explains Lily Bodinson, the Medical Programs Coordinator with it a bit in the sun, and then I feed the peels to them, so I save a lot may be in place?
Timmy Global Health, an American nonprofit based in the western of money,” says Hernandez, adding that her mealworms also eat
highlands. By training women to raise and harvest mealworms, potato peels. “I don’t need to pay to go to the market. I just toast
MealFlour hopes to increase food stability and reduce reliance on [the worms], grind them, and eat them.”
protein supplements that may be available one day and gone the
next. Hernandez produces approximately half a pound of mealworm
flour every two months. This lasts the family a week or two. “I feel
Even families who own livestock are not necessarily food secure. like this lets some protein get into their small bodies,” she says of
“When we visit families we can see that they have chickens and the mealworm pancakes she makes for her sons. “If one day I do
pigs, but it’s not because they’ll be eating them,” says Zuri Sarai not have the worms, [Alejandro and Denis] will be missing their
de León Pineda, a Health and Nutrition Specialist with Fundación protein.”
Contra el Hambre (Foundation Against Hunger), an organization
that works in 215 rural Guatemalan communities, and one of
328 329
Dining with Chef Mario Melgarejo
Irma Hernandez outside of her home
Mexican chef Mario Melgarejo is one of the country’s most vocal entomophagy specialists. He can regularly be
in Candeleria.
found hosting workshops in culinary schools and catering private events where he serves dishes with a creative
combination of insect and non-insect ingredients (cockroach flan, anyone?). Meeting Melgarejo, it’s clear he’s
a presenter. His face smiles as he effortlessly weaves stories through the conversation.

Image (Mario and Josh): Chef Mario Melgarejo and Josh Galt (another edible insect advocate and founder
of the website Entovegan) in Guatemala City.

One involves a four-course meal he once prepared for a small group. A guest had brought her young daughter,
who made it through three quarters of the insect-based meal with no complaints. “But the dessert was a big
garden spider with long black and yellow legs,” says Melgarejo. “When she saw that caramelized on her plate
with jelly she burst into tears! Eventually I talked her through it. She ate it and realized it wasn’t so bad. What
I said was ‘tu temor tiene un sabor’ (your fear has a flavor).” Melgarejo has used this approach ever since: “when
I talk to people and they’re grossed out by the cockroaches and spiders, I say ‘look, you’re scared of them, but
I’m going to show you that you can eat your fear and find it’s delicious!’ It’s that mindset change.” Melgarejo
is a proponent of serving insects whole, as opposed to disguising them or using them as powder.

Melgarejo is in a good place. Mexico has an estimated 549 species of edible insects, more than any other
country worldwide.34 “Mexico has a taste for edible flowers, edible insects. This is prehispanic food, but
when the Spanish arrived all of it was lost,” he says. Since starting his entomophagy-driven culinary journey,
Melgarejo has been working with home chefs in rural areas across Mexico, learning how they collect insects
and how to cook them. The result is a fusion of modern Mexican food and prehistoric recipes, the likes of which
can be seen on Melgarejo’s Instagram.

330 331
Next Steps: Scale and Market Acceptance Bringing Plant-based It may only be mid-morning, but a group of young students at Otto-
Low harvest rates are an issue for Hernandez and MealFlour, and Food for Thought into Nagel Grammar School in the suburbs of Berlin, Germany, are not
the organization doesn’t have a metric to measure success. Many the Classroom only talking about lunch—they’re making it. Crowded around
challenges relate to varying climatic conditions, the use of low- a long kitchen countertop, they stare attentively at recipes for
cost materials, and the fact that very little research exists around spaghetti with tofu bolognese sauce and vegan banana chocolate
best practices for small-scale insect farming. The 2013 FAO report muffins.
on edible insects also highlights this challenge, noting that it’s
only in recent years that insect farming businesses (many of them ↘ Video: Inside the Plant Powered Pupils Project
small and family-run) have been able to commercialize insects for
animal feed, not to mention human consumption. The report notes These particular students have just come from their desk-filled
more development is needed to create automated, industrial-scale classroom. They spent the last 30 minutes learning about the
rearing technology that can keep pace with the production of other impact of their food choices and sharing what they know about
traditional forms of livestock.35 plant-based diets with Kathleen Gerstenberg, an employee with
food awareness organization ProVeg International, headquartered
MealFlour has experienced some of these shortcomings in its own in Berlin. After talking about plant-based foods, it’s time to make
work. Despite the excitement around entomophagy, the MealFlour a meal themselves.
team says this hasn’t translated to research and development funding.
“That’s something we’ve been struggling with,” says Gabrielle Wimer. Down in the kitchen, the students start chopping. No one
“We saw the need for a program to actually be on the ground but minds dicing carrots and mushrooms, or measuring various dry
there are still research questions that haven’t been looked into and as ingredients into the muffin mixing bowl. They’re more dubious of
a small organization we don’t have enough funding to answer them.” the brown blocks of smoked tofu. “Does someone want to try it
raw?” one girl asks. “Nah, not really,” responds another, crumbling
Scaling edible insect production presents one possible solution it tentatively with her fork.
to sustainably intensify food production. In the future, its
environmental and social impacts must be further researched to
Not your average cafeteria! Middle school
maximize sustainability and acceptability. For example, while insects students in Berlin, Germany, prepare
require less land and water to rear and feed, and are more lightweight their lunch as part of the Plant-Powered
to transport, the food industry must also prioritize energy efficient Pupils program.
production and transportation to reduce its overall carbon footprint.
As the edible insect market continues to grow, conservation and trade
policies must be created to ensure insect populations are sustainably
harvested. Additionally, more localized research is needed to
understand the complex cultural and social structures that influence
whether people are willing to eat certain types of insects and under
what conditions. If edible insects are to play an increasing role in a
new food revolution, these questions must be asked, answered, and
addressed with attention to local context.

Edible insects are just one piece of the puzzle. As the next section of
this case study discusses, a sustainable food system and nutritious
diets doesn’t require everyone to start eating insects—though they
could be part of a healthy, plant-based diet.

332 333
 Cornelia Lemke, a teacher in Berlin, has
Alexa Gnauck is not concerned by the soy product skepticism. used the Plant-Powered Pupils program
Gnauck is the International Coordinator of the School Programme as a starting point to discuss other
with ProVeg, one of the partners on a project called Plant-Powered types of diets in her home economics
classroom. In a recent assignment,
Pupils. “[The project] gives pupils the opportunity to figure out for students were asked to design recipes
themselves what foods they like and don’t like. When children get catering to different dietary needs
practical there’s a different kind of openness, especially for foods
they don’t know,” she smiles. The Plant-Powered Pupils project
reached more than 33,000 students from 65 German schools
between its launch in 2016 and July 2019.

Influencing individual behaviors and changing policy are key long-

term goals of Plant-Powered Pupils and another of ProVeg’s past
projects, Climate Efficient School Kitchens (KEEKS). ProVeg was
one of five partners in KEEKS, a project initiated by the Institute
for Future Studies and Technology Assessment (IZT) as part of
Germany’s National Climate Initiative. Jointly, the projects were
a winner in the planetary health category of the 2018 Momentum
for Change Lighthouse Awards handed out by the United Nations ProVeg International’s mission is to halve the global consumption
xviii What is the role of the UNFCCC? Framework Convention on Climate Change (UNFCCC).xviii of animals by 2040.xxi To do this, the organization is promoting xxi Care to guess how many animals
↘ Click here to learn more humans eat each year? ↘ Learn more
plant-based diets—a food choice that corresponds with a recently
here
Both projects catered, literally and figuratively, to school-aged released planetary health reference diet.
children and the school canteens in which they eat. Working with
children was a deliberate choice when then-ProVeg volunteer Putting Planetary Health on the Menu
Kristin Höhlig came up with the concept for Plant-Powered Pupils. “Diets inextricably link human health and environmental
xix Does your institution have a
While many universitiesxix and other institutions had plant- sustainability” writes the EAT-Lancet Commission. The
program like this? If not, why not start based diet initiatives, she found a similar project was lacking for Commission released a planetary health reference diet as part of
one?! elementary and secondary school students. its report. It’s designed so that 10 billion people can get the calories
Höhlig saw an opportunity to reach a generation that hadn’t yet and nutrients they need in a way that ensures healthy people and
developed fixed eating habits or prejudice against certain foods. protects the biosphere.
“You can make the foundation for eating habits and preventing
disease early on,” says Höhlig, now a Campaign Manager with Rather than prescribing specific foods, the reference diet suggests
xx Can you remember anything you ProVeg. “[Children] often have a deeper connection to animals, the caloric and macronutrientxxii intake people should get from xxii What type of macronutrients
were taught early on in your life while exist? ↘ Learn more here
in school that has stuck with you too. I think we lose this openness over time, but children are still broad food categories such as whole grains, fruits, added fats, and
since? very willing to talk about these topics.”xx protein sources. The vagueness is deliberate. “Local interpretation
and adaptation of the universally-applicable planetary health
diet is necessary and should reflect the culture, geography and
demography of the population and individuals,” the Commission
writes.36 Translation: no two plates are the same. A planetary
xxiii What do you think an ideal
health diet will look different in Belgium, Kenya, Bolivia, and planetary health plate would look like
Vietnam.xxiii for you?

↘ Appendix 1: Table 1 from the EAT-Lancet Summary Report

334 335
 Importantly, the protein category includes much more than connected to increased risk of type two diabetes, cardiovascular
animal-source foods. In fact, experts say that food system disease, colorectal cancer, and other health conditions.42
sustainability demands a greater than 50% reduction in the global
consumption of red meat in favor of meals that balance fruits, There are also economic and environmental arguments in favor
vegetables, legumes, and nuts.37 of plant-based diets. For one, plant-based diets would reduce the
burden on the healthcare system, and equate to annual savings of
The urgency of the world’s meat consumption crisis is growing. US $735 billion by 2050.43 The authors note that the reference plant-
Despite global searches for terms like “vegan” having quadrupled based diet in their study would also lead to 29% less greenhouse
between 2012 and 2017,38 people are eating more meat than ever gas emissions by 2050 when compared with unchanged diets.xxvii xxvii Which parts of the meat industry
before. Meat production worldwide has increased four to five fold do you think produce the most
greenhouse gases?
since 1961. This is most evident in Asia, where there has been a As an organization, ProVeg International believes there are
15-fold increase in production over the same time period.39 Two five motivating factors for why people opt for plant-based diets:
factors come into play: a growing population and rising incomes.40 health, animal welfare, the environment, social justice, and
An increase in a country’s gross domestic product (GDP) correlates taste. Its philosophy is that, by appealing to one or more of these
to people getting a higher percentage of their daily calories from motivations, people are more likely to reduce their consumption
animal-protein. Protein sources that were once economically of meat and switch to a plant-based diet that is better for human
xxiv For example, according to the inaccessible for people are brought within their financial reach.xxiv health, animals, and the planet.xxviii xxviii Do you have any vegetarian or
World Bank, around 850 million vegan friends? Ask them what their
people living in China are no longer motivations are.
living in extreme poverty. The need to reduce consumption of animal-source protein is Beyond Animal Welfare
not universal. While on average the world is eating nearly three Headquartered in Berlin, Germany, ProVeg International
times the amount of red meat suggested to stay within planetary was established in 1892 as the German Vegetarian Union
health boundaries, over-consumption is particularly problematic (Vegetarierbund Deutschland). The organization was started as
in wealthier regions like Europe, increasingly parts of Asia, and a lobbying group for vegetarians and vegans in the country, the
North America. The average North American diet includes more majority of whom made their dietary choice because of animal
than six times the recommended amount of red meat and more welfare.
xxv What are some health than twice the suggested amount of poultry and eggs.xxv
consequences of this meat That changed in 2017 when the organization restructured and
overconsumption?
On the other end of the spectrum are countries where rebranded as ProVeg International. ProVeg went from being
undernutrition is a significant problem because of micronutrient primarily a vegan lobby group to an international food awareness
deficiencies arising from a lack of access to animal-source or organization. “Before, we were making sure vegans and vegetarians
xxvi Case study 5 takes us to nutrient-dense foods.xxvi This discrepancy in the ability to access had their needs catered to and worked to attract people only in
Madagascar where bushmeat plays meat and the valuable nutrients it provides demonstrates that Germany towards plant-based eating. But we realized this is not
an important role in helping people
meeting their nutritional needs—but local and regional realities, in addition to cultural contexts, matter the way to change the world, and that the people we needed to
also threatens the country’s endemic when considering what ends up on people’s plates. reach out to are the majority of the global population who are
biodiversity. not vegetarian or vegan,” says Jens Tuider, Chief of Staff at ProVeg
Experts advocate for a shift to healthy, plant-based diets in order International. An expanded global mindset, there are now ProVeg
to reduce the global consumption of red meat. Plant-based diets, operations in the United States, South Africa, Spain, and three
particularly among wealthy nations, have a number of human other countries.
health and environmental co-benefits. A University of Oxford study
estimates a shift to plant-based diets would prevent 5.1 million ProVeg International updated its organizational mission to
deaths globally per year, with the greatest reduction in mortality reflect its focus on plant-based diets, aiming to reduce the global
coming from lower rates of coronary heart disease, stroke, and consumption of animals by 50% by 2040 (50by40). One way to
cancer.41 Overconsumption of red processed meat has been accomplish that outcome is for half of the world to become vegan.
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 But the organization believes a much more realistic outlook is to A Question of Taste
instead encourage as many people as possible to be mindful eaters,
reducing their meat consumption in favor of plant-based or cell- Taste is perhaps the most important factor motivating people to eat one food over another. The importance
xxix Read more about cell-based meats based/cultivated alternatives.xxix of taste cannot be ignored when promoting a planetary health diet.
↘ Click here

An important takeaway from ProVeg’s approach is its solutions- For example, more research is needed to determine the most appetizing serving style of edible insects. They’re
focused messaging. “We want to replace animal-based products currently prepared in two ways: served whole or ground to create insect-based flours that can be used as
with plant-based or cell-based alternatives that are attractive, additives.
affordable, and available,” says Tuider. “If we find something that
has the same taste and textural experience, nothing has to suffer Preferred serving method is deeply dependent on culture and context. Take Guatemala, where many regions
and die for it, and the future isn’t jeopardized, people are more consider whole insects a delicacy, a culture MealFlour hopes increases appeal and eases acceptability of its
likely to say ‘I’ll give this a shot.’ We don’t try to tell people that mealworm program. For now, the organization is reducing the need for other protein supplement powders
sausage is bad. We say it’s great, you just need the right kind of through the creation of its mealworm flour. There’s the potential for whole insects, too. In Huehuetenango,
sausage.” another western highlands department where the organization has a partner, there’s a culture of eating spiders
and zompopos de mayo, large ants fried with butter and served with tortillas and lime.

Another factor of taste is determining whether people are willing to eat insects that are domesticated rather
than harvested from the wild. Wild insects currently make up the majority of edible insects consumed
worldwide.44 “If we’re farming insects and feeding them different things than they might eat in the wild it may
change their taste,” says Dr. Valerie Stull. “People want to know if they’ll taste good, and if they don’t then they
will be hard pressed to buy them. People’s perceptions of mini-livestock are complicated.”

Taste also matters when urging a shift to plant-based diets. In fact, a 2018 survey of American consumers found
taste is the main motivator for why people switch to plant-based proteins—ranking above concerns for the
environment, animal welfare, and health.45

Companies such as Impossible Foods and Beyond Meat have made tasty plant-based options mainstream.
Beyond Meat’s non-genetically modified “meat” is made with proteins from pea, mung bean, fava bean, and
brown rice, combined with fats such as coconut and sunflower oil, with other added minerals and natural
flavors.46 The American company is considered the market leader, and in May 2019 became the first publicly
traded plant-based protein company. Since then, stock has surged and plummeted. Analysts attribute the
volatility to the nascent market for plant-based protein and uncertainties around market demand and growing
competition.47

Among other ingredients, Impossible Foods creates its “meat” with a blend of soy and potato proteins, coconut
oil, sunflower oil, and heme. The company describes the latter as “the molecule that makes meat taste like
meat.”48 Imitating the taste of meat and even the juicy “bleed” of traditional beef has increasingly become
a part of plant-based protein products, acknowledging that not everyone is reducing their meat consumption
for reasons linked to animal welfare.

A Beyond Meat burger. Photo via

Pixabay.
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 School programs like Plant-Powered Pupils and Climate Efficient “Plant-Powered Pupils was one of our first partnerships,” says
School Kitchens (KEEKS) are two of the ways in which ProVeg Michael Blasius, head of BKK ProVita’s marketing and health
is using education to influence peoples’ long-term food choices. promotion department. He says the partnership represented
Plant-Powered Pupils is about getting kids to think critically about the company’s shift from seeing health strictly as the absence
how the food they eat impacts their health, the environment, and of physical disease to looking at what people could do from a
animals. Another aim is to shape the taste preferences of the future prevention standpoint. “Now we have a pyramid of values with
generation of consumers and decision makers. If ProVeg can get 10 physical activity, food, and mindfulness as the base and health
to 15-year-old students eating—or at least thinking about plant- on top, which is our core goal,” he says. “Climate and health work
based diets—there’s a greater chance they’ll change their long-term perfectly together once you understand the concept.”
behavior and share their motivations with family and friends.
Institutionalizing Change
In many cases, a student’s ability to choose a plant-based meal
hinges on the school canteen’s ability to prepare one. That’s why
ProVeg is one of the key partners in the complementary Climate
Efficient School Kitchens (KEEKS) project. Since 2016, the KEEKS
team across Germany has conducted 120 cooking trainings and
educational events with over 3,000 participants. The purpose was
to educate school caterers in the creation of sustainable and tasty
plant-based meals. Seen as “multipliers,” those trained caterers
were then responsible for transferring knowledge to their teams.
In addition to focusing on what meals are made, KEEKS also
addresses the how.

With the creation of a measures map, KEEKS project partners

analyzed 19 ways in which school canteens could reduce their
greenhouse gas emissions. The project calculated that emissions
could be slashed by 40% if school canteens reduced their use of
climate inefficient foods and adopted other energy-efficient
behaviors and technology.49

“We saw schools make changes in what they’re serving. We also

had some changes in energy-saving in the kitchen,” says Malte
Schmidthals, an environmental engineer with project initiator
IZT. “For example, they used less frozen meals, and this saves
Further validation of the health impacts of plant-based diets has energy from putting things in the deep freezer. We also had
come from BKK ProVita, a German health insurance company. schools that reduced the amount of meat in a recipe.” The KEEKS
BKK ProVita is ProVeg’s key partner in the Plant-Powered Pupils project created an online database of recipes to improve the ease in
project. A traditional insurance company for more than 150 years, switching to plant-based menus.50
BKK ProVita also went through a recent transformation of core
values, prompted by severe health issues faced by the company’s While the KEEKS project has ended, ProVeg International wants
CEO, Andreas Schöfbeck. Following that scare, Schöfbeck became to continue identifying the “big wheels” that can turn in order to
xxx How do you think an insurance
company can incentivize its customers vegan and decided to restructure his entire company to incentivize shift policy around school lunches. One goal is to get more plant-
to choose a plant-based diet? customers to adopt plant-based diets and healthier lifestyles.xxx based options on menus across the country. Jens Tuider, ProVeg’s
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 Chief of Staff, says that involves more systemic change, such as
building plant-based diet training into the curriculum for school
teachers and canteen staff. Challenges exist, including pushback
from parents who already hold strong beliefs on how to feed and
raise their children. Institutional adoption is also a slow process.
Despite German Nutrition Society standards for school meals
suggesting “predominantly plant-based” dishes, these guidelines
aren’t mandatory and local areas are responsible for creating their
own menus.

ProVeg says an indicator of success is its partnership with Sodexo,

one of the world’s largest food service providers. Sodexo prepares
120,000 meals daily for more than 1,000 schools and daycare centers
across Germany. During a special “Week of Action” organized by
ProVeg, Sodexo says plant-based meals were ordered by students
68,669 times—11% of the total meals served in the five day period.

Sodexo kitchen staff receive twice-a-year training from ProVeg on

the preparation of plant-based cafeteria meals. The company says
that 90% of its schools and daycares have the possibility to offer a
xxxi Do you think something like this
might work in your context? Why or plant-based meal daily, and that it’s working to make that option
why not? available in all of its facilities in the coming months.xxxi

A Final Taste Test Twelve-year-old Joyce is the outspoken voice of dissent. “My mom Lunch is served—students at Otto-Nagel
Back in the kitchen at Otto-Nagel Grammar School, the students usually makes tomato sauce with beef. I expected the tofu to be Grammar School get ready to test their
plant-based meal.
are debating the merits of mushroom versus no mushroom as similar but it ended up being quite different,” she says. “I really
they top their spaghetti with the tofu bolognese sauce. Tucking liked the plant-based Parmesan and pasta, and the banana muffins
into their lunch, students are asked to raise their hand if they’re were alright.” Still, Joyce tried the tofu sauce and did learn some
enjoying the meal. All hands go up except one. “I liked the salty new information about the animal welfare aspect of plant-based
cheese flavor of the almond Parmesan because it was similar to diets.
what I know,” says one boy. “I really enjoyed the baking,” adds
another. Would they make the dish again? “My parents would find Ultimately, this is what matters: getting kids eating and talking
it bad if I cut out the meat,” says Hannah, age 12. “On the weekend about plant-based foods, and when it comes to influencing their
when I have the choice of our dinner I would pick this,” counters future behavior, at least offering some food for thought.
11-year-old Charlotte.

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Europe’s Food Waste Ensuring the global food system exists within planetary boundaries The Food Recovery Hierarchy
Warriors requires addressing what goes on people’s plates and how it’s
produced. It’s also about reducing the amount of food that is Food waste apps like Too Good To Go are part of what’s categorized as a secondary market for food waste.
disposed of without being eaten. This means they divert would-be waste by creating either a new market or new products. In addition to food
waste apps, secondary markets include everything from charitable soup kitchens to subscription food boxes for
Hotel buffets can be a large producer of food waste, but at Novotel unwanted fruits and vegetables.
Blackfriars in central London, England, the kitchen team is doing
something about it. The breakfast buffet is winding down but “These secondary market systems are a really important part of the whole [change that needs to be made to
there’s still plenty of food: baskets of sticky pastries, bowls of fruit, our food system],” says Martin Bowman with This is Rubbish. “But there is a need to fix the core system that is
and steaming trays of sausage, bacon, and eggs. While head chef spitting out this food in the first place.”
Azad Choudhury says the kitchen adjusts its cooking volumes based
on the number of guests, he says they generally prepare five to 10% Bowman references the Food Recovery Hierarchy, the inverted pyramid that prioritizes the actions that should
more food to make sure they don’t run out. Hot leftovers are given be taken around food waste. Developed by the United States Environmental Protection Agency, the first
to staff, but cold buffet items end up in the trash. suggested action is to reduce waste at its source, followed by finding a way for that wasted food to feed hungry
people—the purpose of secondary markets. The hierarchy demonstrates there are a number of pathways to
That’s when Marion Schumacher and Charlotte Bastiaanse walk divert food waste, and that not all are created equally.
in. Taking out their smartphones, a waitress swipes their screen
and hands them a takeaway carton. As the guests filter out of the
breakfast area, Schumacher and Bastiaanse are free to pack up Those environmental impacts aren’t always apparent. “Food
whatever they want from what remains. waste is a vastly overlooked driver of climate change,” reads a 2018
Washington Post column.53 The story raises an oft cited statistic: that
The two women stop by this buffet at least twice a week. It’s a food waste contributes 8% of total global greenhouse gas emissions
convenient breakfast—they work at an office just across the street. due to the methane and other gases released as it decomposes.xxxv
And with London food prices not getting any cheaper, the buffet Food waste equates to a quarter of all greenhouse gas emissions xxxv In comparison, 14% of all
offers all you can eat options for £2.50. produced by the food system, behind livestock and fish farms (31% greenhouse gas emissions are from
the transport sector, which gets far
of emissions) and crop production (27% of food sector emissions).54 more attention than food waste in the
In Madrid, Spain, a sticker at the
entrance of a restaurant indicates app Schumacher and Bastiaanse are users of an app called Too Good To “There are some FAO stats that came out saying that if food waste mitigation agenda.
users can find their surplus food listed on Go, the most downloaded food waste app in Europe. Between 2016 were a country it would be the third largest source of emissions
Too Good To Go. and early 2020, 20.7 million users in 15 European countries have after the United States and China,” says Martin Bowman with This
rescued more than 32 million meals from the trash. The company is Rubbish, a United Kingdom-based organization that focuses on
xxxii In comparison, the average car estimates that has prevented 80,700 tonsxxxii of greenhouse gas food that’s wasted at the industrial production level.
in the USA emits about seven tons of emissions from being released into the atmosphere.
CO2 in a year.
Halving food loss and waste is one of the strategies the EAT-Lancet
xxxiii Food loss is anything that is unfit Apps like Too Good To Go are one solution to an urgent problem: Commission identifies as necessary to create a sustainable food
to sell or serve to people because the FAO estimates that a third of the food produced globally each system. The strategy aligns with the UN’s Sustainable Development
it has spoiled at the production end
of the supply chain. Food waste is year is lost or wasted.xxxiii That equates to 1.3 billion tonsxxxiv valued at Goals, calling to “halve per capita global food waste at the retail
characterized as items that are fit for nearly a trillion US dollars.51 These statistics contain an unfortunate and consumer levels and reduce food losses along production and
human consumption, but for various
irony: in 2018 an estimated 821 million people worldwide faced food supply chains, including post-harvest losses” by 2030.55
reasons go to waste. Waste happens
later in the supply chain at the retail insecurity.52 While food is rotting, others are struggling to eat. The
and consumer levels. conversation around food waste has traditionally been framed in Strategies to accomplish this goal look differently worldwide.
three ways: the social justice aspect linked to hunger, the economic Nearly all food loss in low and middle income countries happens
xxxiv In comparison, an adult male
white rhinoceros weighs around loss of that waste, and its environmental impact. ↘ Appendix 2: Food at the start of the supply chain, during production, post-harvest,
a one ton. Recovery Pyramid from EPA and during processing.56 This is in part due to technological
344 345
 inefficiencies that affect the way food is harvested, stored, that shelf value by at least 50% and divide leftovers into a number of
refrigerated, and transported. But Bowman from This is Rubbish portions. Too Good To Go calls those portions “magic bags,” partly
says there’s a risk in focusing too closely on this simple narrative. because of the sense of mystery of what’s inside, and partly because
“The solution is then generally touted as a technological one— of the act taking place: food that would previously go to waste is
often multinational companies modernizing supply chains and the now being saved. “Waste Warriors”—Too Good To Go’s term for its
day is saved,” he explains. According to Bowman, the food system users—can then buy those magic bags in the app, picking them up
also needs to address social and power distribution problems, such at the time indicated by the retailer. Too Good To Go takes a small
as the cosmetic disposal of “ugly” crops, unfair trading practices transaction fee from each meal saved, and the remainder goes to
such as grocery chains delaying supplier payment in order to the food retailer.
push through unfavorable contract terms,57 and the systemic
overproduction that can happen because producers are concerned Too Good To Go was founded in 2015 by a group of young
about retribution if they under-supply. These are challenges that entrepreneurs in Denmark, the country where the company is
Bowman says would benefit from a regulatory approach, with headquartered. “They saw that food waste was a problem for
xxxvi If you had the power to create legislation promoting fair trade and fines for companies that restaurants and they realized they would buy that food if there
policies within a food system, what
would be your top priorities? And breach agreements with suppliers.xxxvi was the chance,” says Javier Miranda, Too Good To Go’s Chief
why? Marketing Officer, picking up the story. “So they decided to build
In North America, Europe, and industrialized Asia, consumers a solution: at the end of the day someone would come take your
and retailers play a more central role in what goes to waste. While leftovers and that person would pay for it, so it was a win-win-
these regions have the technology, money, and political power win—good for the consumer, good for the restaurant, and of
to ensure the preservation of food along the supply chain, an course, good for the environment.”
estimated 40% of losses are still attributed to retail or consumer
xxxvii Before moving forward, think waste.58 The remaining losses come from earlier production stages Launching its app in early 2016, the idea was quickly picked up
about what you do when you need to
dispose of food? Is there anything you in the supply chain.xxxvii across Europe. After a brief experiment with an open-source
can do to reduce your food waste? franchise model, the company reeled in independent operations
The Origins of an App the following year and brought on investors, a professional board of
Curbing food waste at the retail level is exactly what food waste directors, and an executive team. While Too Good To Go is not yet
app Too Good To Go is doing. Back at the buffet in central London, profitable, Miranda points out that’s because of rapid growth and
Marion Schumacher and Charlotte Bastiaanse have filled their expansion into new markets, and not because of lack of generated
cartons with an assortment of veggie sausage, croissants, cheese, funds. The company has raised €16 million in private investment
hash browns, and granola. “The cafe in our office is not as well since its founding and is prioritizing growth from 27,000 retail
stocked as this. This is a better buffet for a better price, plus it’s for partners to 75,000 by the end of 2020.
a good cause,” says Schumacher, adding that she and Bastiaanse
work in the food sustainability field. “Convenience and pricing While the premise of Too Good To Go has always been to save
are important to some consumers, but what really attracted me to meals that would otherwise go to waste, retail partners say they’re
the app was the sustainability part because European regulation drawn to the app for a number of other reasons, too.
makes it rather difficult for companies to sell their food waste. I
think [Too Good To Go] is a great initiative to actually make that Getting Businesses on Board
happen.” Cookie Lab in Madrid, Spain, is still quiet by the time Dana Knowles
arrives for the day. It’s just after 10:30 a.m. and the generous sized
Here’s how Too Good To Go works: the app’s retail partners cookies and brownies displayed in the shop’s front case aren’t
estimate the retail value of the food that would go to waste each exactly morning food, especially by Spanish standards.
day—an assortment of sushi platters normally priced at €15 each,
or €150 worth of buffet food, for example. Retailers then reduce
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 This haven of baked goods is Knowles’ newest food venture.
Originally from rural Arkansas, Knowles now lives in Madrid and
has been operating a chain of import businesses called Taste of
America for 23 years, stocking products that appeal to the homesick
expat. Cookie Lab is her first foray into freshly prepared foods.

With the new business came a new challenge: food waste. While
much of the excess stock at Taste of America is non-perishable and
donated to food banks or charities, Knowles had a difficult time
finding a home for Cookie Lab’s surplus sweets. “The philosophy
of the business is that everything is freshly made every day, but we
still don’t want to throw things away,” explains Knowles.

The Cookie Lab is Dana Knowles’ first

foray into fresh foods. Knowles’ has
been selling ‘magic bags’ of leftover
baked goods on Too Good To Go since
she opened in September 2018, and
says it’s beneficial for the environment,
marketing, and gets customers in at the
end of the day.

Cookie Lab’s attempts to sell leftover products weren’t working.

Reduced price goodies would go unsold because of fewer walk-in
customers in the evening. Charities said they would accept the
products, but only if they were delivered. Even giving the cookies
to people on the street had logistical demands. “You need someone
who will go out and do that, and as a small business we can’t dedicate
a lot of resources on our end,” Knowles says. Posting surplus baked
goods on Too Good To Go immediately resonated: “I said ‘this is
perfect, because I have a product that needs to be useful in some
way, but it’s difficult for me to find the avenue where it can be.’”

Knowles says this convenience piece is core in Too Good To Go’s

appeal. Unlike other food waste apps that require business owners
to guess exactly which products will be left at the end of the day, Too
Good To Go gives shops the freedom to add whatever products they
348
have to the magic bag, so long as they equal the value advertised Education and marketing isn’t limited to ugly fruit. It’s lunchtime in
in the app. It’s a tool she says her staff actually want to use, and London, and Too Good To Go user Matt Bannister is getting ready
one that brings customers through the door near closing time when to pick up a magic bag from BEBOZ, an Italian street food spot.
business slows. Bannister initially started using the app for convenience, needing
something for dinner before heading to music shows. “Before, I’d
Listing leftover products on the app also helps Knowles tap find the nearest MacDonald’s on the way to the tube station,” he
into the values (and smartphones) of her millennial target laughs. “Now there are multiple reasons for using Too Good To Go.
market. “Customers are interested in all the components around It costs less, it’s actually good food that’s tasty, and you get the feel
sustainability and food waste,” she says. “Whether it’s the source good factor as well knowing you’ve helped the environment.”
of their ingredients or animal welfare […] I think it’s all tied up in
the same package of sustainability and how we can belong to a
A recent Too Good To Go purchase in
community in a more responsible way. Businesses haven’t always London, United Kingdom. To motivate
had this financial incentive to save food, so it’s good that consumers its ‘Waste Warriors’ each Too Good To
are leading that demand and the change of thinking and practice.” Go receipt offers users an environmental
fact — for example, the amount of
carbon dioxide avoided by saving a meal
Spain also has a large number of fruterías: small shops that sell rather than letting it go to waste.
unblemished, perfectly shaped fruits and vegetables in orderly piles.
But, as Adrian Santamaria Lagunar says, a display like this comes
with a dark side.

Lagunar is the owner of Frutería Santamaría in Madrid. Surrounded

by glossy stacks of fruit, he ushers towards his storage room and
reveals what he says is a disturbing sight to many customers: a box
of “ugly” fruits and vegetables. “What people are thinking is that
if the food is ugly it is completely inedible. It’s normal. You buy a
computer and you don’t want it to have scratches,” he says.

Exacerbating the odd bruise and lump is Madrid’s summer Two years in, Bannister says he uses the app weekly, and regularly
temperatures. The average July day is 32°Celsius, and three to four rescues meals with his friends and work clients. It’s also prompted
kilograms of food spoil daily, regardless of air conditioning. On him to change his food behaviors in general. “I now go straight to
these days, Lagunar tries to haul home anything he can to share the yellow sticker discount aisle when I’m grocery shopping. Too
with his two brothers, parents, and grandfather. “I could feed Good To Go has massively changed the way I look at this. Some
another family as big as ours with the food left, and on some days of their marketing campaigns were quite shocking and opened
many more,” he says. Too Good To Go offers an outlet for him to sell my eyes. I’m more vigilant about what I’m throwing away.” It’s a
magic bags with the ugly produce, reducing the amount that ends changed perception of value, to go from waste to want.
up in the trash.

Lagunar says it comes down to education and marketing— Too Good To Go’s Food Waste Movement
changing the mindset that people have around food waste. That’s Changing user perceptions around ugly produce and “less desirable”
starting with some consumers, he says: “an app like Too Good To food is only the beginning. While it could focus solely on being a tech
Go rewrites this story. It changes the focus from people buying ‘bad company, Too Good To Go envisions having a greater educational and
fruit’ to people doing something positive for society by managing policy impact. In addition to creating awareness within households
the food waste.” and businesses, promoting education and advocating for policy
350 351
 change are the four pillars of a new food waste movement Too Good Epilogue Ultimately, the responsibility of changing the global food system
xxxviii ↘ Learn more about Too Good To Go launched in April 2019.xxxviii does not fall on any one individual, government, or country,
To Go's food waste movement by
clicking here
though certain regions of the world need to change their actions
“Our job is to educate and bring visibility to a problem that is more than others (i.e. reduced red meat consumption in North
unfortunately not visible and tangible. We are not plastic,” says Javier America and across high and upper-middle income countries).
Miranda with Too Good To Go, referring to the success campaigners Examining our food system offers the chance to reflect on many
have had in changing behaviors around items like straws and single- of the cross-cutting principles of planetary health. One principle,
use water bottles. global citizenship, demands we recognize how individual and
regional food choices and policies ripple outwards and affect
Making the invisible visible demands working with people at many the international community. Another principle, unintended
levels. Too Good To Go’s goal is to collaborate with 500 educational consequences, demonstrates the need for long-term thinking so
institutions worldwide by the end of 2020. That means attending short-term food production gains don’t burden future generations
conferences, writing case studies, and creating other classroom with environmental and human health consequences.
materials for students from elementary school to university age. The
company is also financing research at a university in the Netherlands The science is in, strategies and targets set, examples of real-world
looking at emissions related to food waste, and Miranda says the solutions identified. The next step is for individuals, industry, and
company is open to funding requests from university students government to have the courage to change the menu at the scale
working on other related projects. required for a better future.

Policy-wise, Too Good To Go is actively campaigning to change retail

food waste legislation in at least five of its countries of operation by
the end of 2020. At the moment, the company is focused on the best
before labelling of products in Denmark, Norway, and France, the
app’s largest markets. “People see these labels as the deadline for food,
and that’s absolutely not true,” says Miranda. “There are products like
dehydrated pasta or rice where this makes no sense, so we’re going
to either push to change the food labelling on certain products or to
remove the expiration date completely.”

The European Union has the most progressive attitude worldwide

towards some of these policy changes. In 2018, Martin Bowman
and the This is Rubbish team led lobby efforts that prompted the
European Parliament to adopt targets for food waste under its Waste
Framework Directive. As a result, as of 2020 all EU member states must
measure and report the amount of food wasted from manufacturing
through to consumer level. While this makes the EU a global leader
in this issue, the target to halve the amount of food wasted remains
aspirational and non-binding.

As more retailers take measures to reduce their food waste, either

voluntarily or by-law, Too Good To Go is aiming to be their outlet.
Getting more retailers on board is a key step for the company’s business
growth. Until then, the app has more users than meals to save.
352 353
Keeping Track Lily Bodinson Elizabeth Frank Irma Hernandez Zuri Sarai de León Pineda Dr. Valerie Stull
of Who’s Who
Medical Programs Coordinator, Timmy MealFlour co-founder Resident of Candeleria in Guatemala’s Health and Nutrition Specialist, Principal Investigator with Mission to
Global Health western highlands; mother of two and Fundación Contra el Hambre Improve Global Health Through Insects
one of the participants in MealFlour’s (MIGHTi)
pilot project

Gabrielle Wimer Michael Blasius Alexa Gnauck Kristin Höhlig Malte Schmidthals
MealFlour co-founder Head of Marketing and Health International Coordinator of the School Campaign Manager, ProVeg Environmental engineer, IZT
Promotion, BKK ProVita Programme, ProVeg International International

Jens Tuider Matt Bannister Charlotte Bastiaanse Martin Bowman Dana Knowles
Chief of Staff, ProVeg International Too Good To Go user (London, UK) Too Good To Go user (London, UK) EU Campaigns Manager, This is Rubbish Owner of Cookie Lab and retail partner
(UK) with Too Good To Go (Madrid, Spain)

Adrian Santamaria Marion Schumacher

Lagunar
Owner of Frutería Santamaría and retail Too Good To Go user (London, UK)
partner with Too Good To Go (Madrid,
Spain)

Acknowledgements This case was a collective effort of folks on three continents.

First, thank you to everyone quoted in the narrative of this case.
In Guatemala, I benefited from the help and time of the entire
MealFlour team, Josh Galt, Mario Melgarejo, and Mario, my
interpreter in Guatemala City. In Berlin, my added thanks to the
entire ProVeg International team, but especially Katleen Haefele,
Alexa Gnauck, and Ruchir Sharma. For the food waste section,
thank you to members of the Too Good To Go team who helped
coordinate interviews in two countries: Nerea Esgueva, Anoushka
Grover, Alexandra Macleod, Jonathan Zarzalego. Finally, thanks
to Angela Shields and Darya Minovi for helping with the initial
conception of this case.

Mealworms and mealworm beetles grown as part of MealFlour's pilot program in Guatemala.

354 355
Bibliography
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356 357
Appendix 1_ Table 1 from the EAT-Lancet Summary Report ↘ Back to page Appendix 2: Food Recovery Pyramid from EPA ↘ Back to page

358 359
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
08
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Family
Please cite this case study as “Duff H., Faerron Guzmán,
C., Almada, A., Golden, C., and Myers, S. “Family Planning
for People and Planet: A Population, Health, Environment
Approach in the Lake Victoria Basin.” Planetary Health
Case Studies: An Anthology of Solutions. 2020; https://doi.
org/10.5822/phanth9678_8

Please note this work is licensed under a Creative Commons

Planning for
Attribution-NonCommercial-NoDerivatives 4.0 International
License. To view a copy of the license, visit https://
creativecommons.org/licenses/by-nc-nd/4.0/

To access the full Planetary Health Case Studies: An

Anthology of Solutions, please visit https://www.
planetaryhealthalliance.org/case-studies

People and
Planet
A POPULATION, HEALTH, ENVIRONMENT
APPROACH IN THE LAKE VICTORIA BASIN
 Executive Summary This case study illustrates the relationship between population,
family planning, community health, and the sustainability of
natural resources in the Lake Victoria Basin, the largest lake basin
Topics of population growth and
the beneficial roles of providing
on the African continent. It demonstrates how these dimensions
girls education, women’s economic are shaped by many factors, including human-caused alterations
opportunities, and access to to the lake, access to sexual and reproductive health services, and
contraception for couples are
explored in depth in chapter 3 of
environmental degradation.
↘ Planetary Health: Protecting
Nature to Protect Ourselves. The case analyzes the effectiveness of addressing these challenges
using an integrated approach called PHE. PHE stands for
population, health, and environment. Since 2012, Pathfinder
Learning Objectives
International’s Health of People and Environment in the Lake
After reviewing this case, students Victoria Basin (HoPE-LVB) has been a flagship PHE project in
should be able to: the region. Its approach has three arms: (a) increasing education
➀ Explain how population growth, and access to the tools that help with healthy timing and spacing
poor resource management, and of children (population); (b) improving sexual and reproductive
health are intertwined.
health, in addition to sanitation and hygiene standards among
➁ Analyze how the historical families (health); (c) supporting the shift to sustainable fishing and
and socioeconomic contexts can agriculture (environment).
determine the health of ecosystems
and humans.
Using these three arms of PHE, Pathfinder’s project in Uganda
➂ Assess how gender, economic, and Kenya has demonstrated why a comprehensive approach
and other power dynamics shape
planetary health challenges.
is necessary to address the Lake Victoria Basin’s complex suite
of problems. With a focus on policymaking, advocacy, and
➃ Appraise the utility of the PHE institutionalization of best practices, HoPE-LVB is a model for how
approach.
district, national, and regional bodies can adopt multi-sectoral
➄ Design population-wide PHE approaches in their work.
interventions to address planetary
health challenges with scalability and This case study is based on interviews conducted on Bussi Island, Zinga Island, and
sustainability in mind. Kampala (Uganda) as well as Nairobi, Kenya in September and October 2018.

363
Introduction In East Africa, the shade of a tree provides an informal meeting and government health clinics. Accessible only via an hour-long
place. This afternoon, there is a gathering of a half dozen young motorboat ride from the mainland, Bussi Island is one of four
mothers. Namakula Edith, a sprightly 47-year-old who looks a focus areas for the Health of People and Environment in the
decade younger, is convening. And today, she’s brought props. Lake Victoria Basin (HoPE-LVB) project in Uganda and Kenya. A
Reaching into her family planning kit, Edith pulls out blister project of Pathfinder International,i a long-running sexual and i ↘ Learn more about Pathfinder’s
packs of birth control pills and rattles them in the air. But the real reproductive health NGO based in the United States, HoPE-LVB work here

fun begins when it’s time to talk condoms. Edith doles out a few is an example of an internationally-funded project that has been
to the women sitting tentatively on the benches around her and proven to support positive behavioral, environmental, and policy
searches through her envelope for a slightly more phallic prop. For changes at regional, national, district, and local levels. In the case
demonstration purposes, of course—though it draws giggles from of this project, local gets really personal—into the homes and
the surrounding women and a double take from passing motorbike bedrooms of families across the region.
drivers.

Contraceptive methods and family planning are the main topics of

conversation today, but the meeting also touches on the connection
between family size, health, and the environment. It’s a concept
referred to as Population, Health, Environment (PHE). Edith finds
the approach is best explained with an easy-to-grasp example.
In an island village like Seeta where Edith and the women live, it
makes sense for that story to start with a fish.

“Think of the resources your family needs,” Edith says. She means
the food, firewood, shelter—everything essential to a family’s basic
Namakula Edith, a Village Health Team
member on Bussi Island. survival. “If the father brings one fish and he has 10 children, it
means the fish will not be enough,” she explains. “If you are many,
you use a lot of things.” She goes on: “if there are fewer children,
then you will need only one piece of fish to provide nutrients for
your home, and the rest of the money can go towards education
and healthcare. You will have fewer children, but you will be able to
support them better,” she says. “And because there are fewer people
at home you will not need to collect as much firewood to cook that
fish, so the forest will be better maintained. Making the decision
to use family planning to time the birth of your children conserves
the environment around you. Your fish goes further, and so does
your family,” Edith says. These are the first messages Edith uses
when talking to her peers about PHE. It may be a simplification
of the linkages between family size, health, and the surrounding
environment, but it’s a start.
One of the wooden motorboats that
transport people from the mainland and
Edith and these women live on Bussi Island in the Ugandan serve as commuter boats between Lake
portion of Lake Victoria. It’s here where Edith serves as a member Victoria’s islands.
of the Village Health Team (VHT), a group of government-hired
community volunteers who provide the bridge between villages
364 365
 Just as planetary health examines how human health and the Lake Victoria in the Lake Victoria is the largest freshwater lake on the African
spread of disease are influenced by human-caused disruptions to Anthropocene continent. Its shores connect Uganda, Kenya, and Tanzania, and
the Earth’s natural systems, PHE also looks at the health of people its catchment area extends to include the countries of Burundi and
and the environment. Rwanda. Today, the Lake Victoria Basin (LVB) is an integral part
of the economy and culture of all five East African countries. An
“The planetary health concept can be strengthened even further estimated 44 million people live in the LVB, and despite making
when it includes addressing women and men’s sexual and up less than 10% of the land area, the region is home to a third
reproductive health rights,” write1 Suzanne York and Robert of the people living below the poverty line in the East African
Engelman, two PHE experts. York is the Director of Transition Earth Community (EAC).2
and Engelman is a Senior Fellow at the Population Institute. “If
couples were empowered to make their own reproductive choices, Lake Victoria’s positioning in the region presents several
ii What is the rights-based approach? and provided with the means to choose the number and timing of environmental and health challenges. In addition to being a
Can you think of other examples
where this approach is used?
their pregnancies, the resulting impact on human fertility would transboundary ecosystem with management subject to the
powerfully alter future trajectories of population growth and its political will and cooperation of multiple countries, the LVB’s
According to the organization Family
Planning 2020, human rights- environmental impacts, while also adding to the health and well- residents are also unique. “These are people who do not seem to
based family planning approaches being of families and communities,” they continue. The HoPE- belong to any country,” explains Doreen Othero, the Regional
support the right of all individuals LVB project takes this rights-based approachii to family planning, Programme Coordinator for the Integrated PHE Programme of
to “choose whether, when, and how
many children to have; to act on providing couples with the knowledge, access, and choice to plan the Lake Victoria Basin Commission, an institution created by
those choices through high-quality for the timing and spacing of their children. EAC to oversee the sustainable development of the region. “The
sexual and reproductive health
services, information, and education;
people living here cross borders, do their business, and then return
and to access those services free The “population” dimension of HoPE-LVB includes voluntary home.”
from discrimination, coercion, and family planning and contraceptive information sessions for women
violence.” More information can be
found in this resource guide.
and men alike. Health-wise, the project has worked to ensure
women have safe pregnancies and childbirth and more recently,
iii What is the burden of HIV has aimed to reduce rates of mother-to-child HIV transmission.iii
in Uganda? ↘ Learn more here The health element also addresses minimizing disease through
improved household hygiene and sanitation, and reducing the
risk of respiratory conditions through the construction of energy-
efficient clean cookstoves. Finally, the “E” in PHE talks about the
importance of, and the best ways to, conserve the environment.
That ranges from adopting sustainable fishing and agricultural
practices, to diversifying livelihoods to reduce reliance on any one
natural resource.

While the dimensions of PHE can be defined separately, a key

element of this approach is recognizing the linkages that exist
among the three—how demographic trends and poor access to
sexual and reproductive health affect the environment, how the
changing environment affects health, and so on. The goal is to
create an integrated solution that considers the complex everyday
A landing site on Lake Victoria. These sites connect people who live on islands like Bussi
realities of people, including barriers of poverty, culture, and with the mainland and other island communities. Sometimes described as an inland sea
health access. due to its immense size, Lake Victoria is essential to the health and livelihoods of millions
of people living in five countries.

366 367
 That transience is because of the region’s primary industry: fishing. The introduction of Nile perch to Lake Victoria came first through
Home to valuable ecosystems and essential natural resources, a secretive release by the Uganda Game and Fisheries Department
along with a rapidly growing population, the LVB sits at the crux as early as 1954. Dozens more individual Nile perch were introduced
of many human health, environmental, and economic challenges. from Ugandan and Kenyan shores over the following decade.4
Nothing new, the anthropogenic threats facing Lake Victoria The introduction of Nile perch favored the interests of the British
started decades ago. colonial forces who controlled Uganda, Kenya, and Tanganyika
(present day Tanzania) until the countries gained independence in
A Colonial Past and the Demise of Lake Victoria’s Biodiversity the early 1960s.
A small aquarium sits near the Ugandan shores of Lake Victoria.
Follow the mechanical whir of the filtration systems and you’ll The premise was that Nile perch would provide ample catch
come across a rectangular room, walls lined with some dozen for sport fishing, while serving as a predator for hundreds of
tanks, each containing a common type of fish found in the nearby endemic but small haplochromine cichlid species. The British
waters. The invasive fish species that has forever altered the ecology administration deemed these cichlids “trash fish,”5 and thought
of the lake sits unassuming in a tank on the left side of the room: they’d be much better utilized as the primary diet for Nile perch,
the Nile perch (Lates niloticus). While the one in this tank is only a a species with a higher commercial value.
half-meter long, fish of up to two-meters in length have been fished
from Lake Victoria.3 YouTube videos show fisherfolk hauling huge Two decades later, the Nile perch population exploded. “All of a
Nile perch from their boats, the fish hoisted over their shoulders. sudden whenever fishermen would cast their nets they were seeing
a fish they had never seen before. It took over the space in the lake,”
The Nile perch was an introduced species to Lake Victoria. Its says Winnie Nkalubo, a fisheries biologist with NaFIRRI. The
effects on the ecosystem have been well documented by scientists, difference in total annual fish catch was notable: the size of the
including the ones working in the buildings surrounding this fishery increased by a factor of five between the early 1970s and
particular aquarium. The aquarium is in the town of Jinja, and the 1989.6
researchers work with the National Fisheries Resources Research
Institute (NaFIRRI), a semi-autonomous Ugandan government Illicitly introduced into Lake Victoria
agency that has long had its finger on the metaphorical pulse of in the 1950s, the Nile perch has had a
significant impact on the lake’s ecology.
the lake.
The National Fisheries Resources
Research Institute (NaFIRRI) aquarium.

368 369
Commercial processing factories soon cropped up along the shores
of Lake Victoria, intensifying fishing pressures. Those factories
were responsible for preparing catches of Nile perch for mass
export to Europe and the Middle East—the first time Lake Victoria
fish were sold internationally. Previously, the fishery had provided
subsistence food for local and regional markets, and had been a
resource used in pre-colonial bartering systems.7 8

Perch and Population

The expansion of the Nile perch market in the 1980s and early
90s attracted a gold rush-style migration to Lake Victoria. “The
population pressure pushed fish stocks to the lowest level, but
fishers were still in business and had to switch to illegal nets,”
Nkalubo says. Illegal nets had a finer mesh, and could be used to
catch younger, smaller fish. “There was an open access policy on
the lake, so there was no regulation that limited the number of
fishermen,” Nkalubo adds.

“In terms of economics, the introduction of the Nile perch was

a blessing,” adds Herbert Nakiyende, another NaFIRRI fishery
biologist. By the 1980s, it’s estimated the economic value of the
fishery increased fivefold.9 During that time, people living along
the shores of Lake Victoria benefited from the fishery. It improved
incomes, brought infrastructure to the region, and created jobs at
new processing factories. Local fisherfolk could sell their catch to
factory middlemen while still having enough to feed their families.

“But for conservationists [the introduction of Nile perch] was

obviously a curse since we had so many extinctions,” Nakiyende
expands. It’s estimated that the feasting of Nile perch contributed
to a 63% decline in the number of the lake’s haplochromine cichlid
species between 1960 and 2010.10 Today, memory of those fish is
found only at NaFIRRI, in a small building that bears the slightly
tragic name “museum.” Inside, jars of formaldehyde-preserved
fish are stacked on floor-to-ceiling shelves—species that currently
populate Lake Victoria, and the ones that were made extinct by
Jessy Lugya, a research assistant in fish
Nile perch.
biology at the National Institute for
Fisheries Research (NaFIRRI), inspects
the jars of now-extinct haplochromine
cichlid species. The introduction of the
Nile perch extinct an estimated two-
thirds of the small fish living in the lake.
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 The economic bubble created by the Nile perch boom soon burst. the HIV virus that causes AIDS continued to rise in the region,
The European Union slapped export bans on Lake Victoria fish with first cases reported the following year in Tanzania, and the
between 1997 and 1999 due to traces of salmonella, cholera, and year after that in Kenya.
other hygiene and chemical concerns.11 Some processing factories
experienced an estimated 75% reduction in operations during Isiah Kisiki remembers this time well. Born on Bussi Island, he’s
these bans.12 one of the few people who grew up on the island rather than
arriving as a result of the temporary boom in Nile perch supply. He
Despite temporary export bans, local and regional demand recalls how people started to behave when fish stocks declined: “A
remained. Fisherfolk who had migrated to the LVB during the lot of fishermen started fighting. Prostitution increased, domestic
boom continued fishing, and it became clear there was a decline violence, and more drunkenness, too,” he says. When it came to
in fish stock. Nile perch biomass declined nearly 10-fold from 1.9 the spread of HIV, Kisiki remembers that many people came to
million tons in 1999 to 200,000 tons in 2008.13 Since then, the the island as a way to isolate themselves. But it didn’t work like
biomass of Nile perch has recovered slightly. And yet, only 5% have that. Fisherfolk were traveling further and more frequently to get
reached the stage of maturation where they can breed,14 indicating the same amount of fish. Many were living unknowingly with
that fish stocks will continue to be limited. HIV, and would unwillingly pass the virus among multiple sexual
partners across various parts of the lake.vii Kisiki says a reduction vii What other conditions back then,
iv How many people worldwide With more than 800,000 peopleiv relying on Lake Victoria’s fishery in fish stock also had detrimental environmental effects: “People and even today, fueled the HIV
depend on fish as a main source of epidemic?
for direct employment and stocks declining, fisherfolk increasingly had little revenue coming in from fishing and started to cut trees
income or dietary protein? How about
in your country of origin? turned to illegal methods to capture what fish remained.15v These to burn for cooking and to sell as firewood.”
illegal methods included the use of small hooks and finer-mesh
v What are some of the illegal fishing
methods that fisherfolk can use to monofilament nets to capture younger Nile perch that hadn’t yet
Isiah Kisiki is a lifelong resident of Bussi
increase their catch? reached full maturity. Catching smaller fish comes with short-term Island. This is what fishing on Lake
gain as they can be sold at the local market. The long-term effects Victoria looked like when he was a
on the ecosystem are more dire, and interfere with reproduction child—before the population boom of the
Nile perch, introduction of HIV-AIDS,
and the natural replenishing of the lake’s perch population.16 and eventual collapse of the fishery.

The decline in fish stock also meant fisherfolk had to go further

from shore to reach their catch. This increased the travel of an
already transient population. The biodiversity of the lake and its
ecosystems were at-risk. It was obvious that the lake’s natural
resources were key to maintaining livelihoods and food security—
at the same time, the protection of ecosystems also affected human
health.

Fish Catch and the Rise of HIV

As Lake Victoria was experiencing the ups and downs of Nile
perch supply, the region was also seeing a rise in something more
vi ↘ Here is a timeline on global HIV ominous—the prevalence of HIV/AIDS.vi Fishing communities have always been one of the groups most
infection since it’s origin in the 1980s. vulnerable to the transmission of HIV/AIDS. While 18% of Uganda’s
The first case of AIDS in the Lake Victoria region was reported in general population was infected at the peak of the infection in
1982 in a fishing village in southwestern Uganda.17 Prevalence of 1992,18 epidemiologist and former director of the country’s HIV/
AIDS Control Program, Dr. Alex Opio, estimates that prevalence
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 could have been as high as 30% on island and fishing communities Compounding that spending culture is the fatalistic attitude held
during the same period. The first survey to quantify the rate of by many fisherfolk. “Fisherfolk see their risk of mortality coming
HIV prevalence in island communities did not happen until 2011. from different sources,” Opio explains. “They see people dying
Opio and his co-authors found the rate in island communities to of HIV, but they also regularly see other fisherfolk drown. They
be 22%—more than three times higher than the 6% prevalence would say ‘if I can survive the rough waves of water, what about
viii ↘ Take a look at this link with found in the general population.19viii this HIV?’ To them, the risk of dying from infection was much less
global distribution of HIV burden of than the risk of dying while on the lake.” This fatalism translated
disease
A reason for the increased occurrence is the lack of physical to a resistance towards using condoms, as well as a lack of urgency ix This is a perfect example of
how gender and gender roles can
access to health services, coupled with the nature and culture to protect natural resources. Survive and catch fish on the lake determine health and disease. Can
of fishing communities. “It was very apparent that the islands today—worry about tomorrow, tomorrow. It’s a culture that’s still you think of other examples? Think
were lacking health facilities,” says Opio. More often than not, prevalent in island communities today.ix about where you live—does gender
determine your health?
fishing communities are serviced by outreach or mobile services,
as opposed to a dedicated health post. The frequency of travel by
fisherfolk made it more difficult still for HIV awareness messaging Healthy People, Healthy Planet
to be communicated and treatment offered. “So fishermen had no There are many linkages demonstrating how the protection of Lake
knowledge or health access if they did contract the disease, making Victoria’s ecosystems can benefit human health. The same is also
transmission rates higher,” Opio says. true in reverse, and was a topic explored in a 2017 paper authored
by Dr. Kathryn Fiorella and her Cornell University research group.
High prevalence rates were paired with risk-taking behavior. That study quantified how human health and well-being in the
Fisherfolk, Opio says, don’t live in isolation—they come to an Kenyan portion of Lake Victoria influences the capacity of people
island knowing there’s fish, and they leave their family somewhere to sustainably manage their natural resources.
else in the country. “They do their fishing at night and by 9 a.m.
they’ve sold their catch and have money,” he says. “Then they The findings directly contradict a common hypothesis: that sick
would often either go to sleep, drink alcohol, or have affairs with people have less of an environmental impact. “By this logic, ill
the commercial sex workers who go to the island.” people reduce the time and effort that they put into extractive
livelihoods and, thereby, their impact on natural resources,”20 the
paper reads.
Two men untangle a fishing net after
unloading the day’s catch. The mesh
size on this net is legal, though there are Fiorella and her team found a more complex story. The study
many fisherfolk in Lake Victoria who use demonstrated that a fisher’s mental and physical health had no
smaller meshes, pulling in adult-sized fish
while disrupting the growth of those that
effect on the total hours fished per month, the number of nights A man fishes for Nile perch and tilapia
spent away, or the income per hour fishing (a metric of fishing near the shores of Lake Victoria.
haven’t yet reached breeding maturity.
“success”). People who were sick were fishing just as much as when
they were healthy. Poor physical health did, however, influence the
choices people made around fishing methods and fishing location.
Fisherfolk with poor physical health were 69% more likely to use an
illegal method in inshore fishing areas—closer to shore locations
that often served as habitat for smaller, easier-to-catch fish. Sick
people were still fishing, but in even less sustainable ways.x x Why do you think this was the case?

↘Appendix 1: Figure 1 from Fiorella et al 2017 PNAS Fishing and

Morbidity

374 375
 “In contrast, methods used by physically healthy fishers require Nile perch economy, and standard prices are set by fishery managers, fish-for-sex transactions introduce the
fishers to reach deep water or fish overnight to target the more opportunity for a non-monetary bargaining chip. Jaboya relationships have existed for several generations due
xi Dagaa (Rastrineobola argentea) sustainable mature Nile perch and dagaaxi fisheries,” Fiorella and to the transient nature of the fishing industry, though exchanges are now being altered by fluctuations in Nile
is the Kiswahili name for the small, her team write. perch and dagaa catch.
sardine-like fish found in Lake
Victoria. Fisheries researchers
attribute the rise in dagaa biomass Lake Victoria’s fishery is male-dominated, but it’s not only the These transactions are among the many factors that have contributed to higher-than-average HIV rates in the
to the decline in Nile perch stock, health of men that affects the sustainable use of natural resources. Lake Victoria Basin.
as dagaa was released from
competitive pressure with the demise Nor is it only men who are impacted by the negative side effects
of the cichilds. Food preference-wise, of ecosystem destruction. Illegal fishing practices and the
it is considered less valuable than Nile
perch or tilapia, as there exists
unsustainable management of the fishery can lead to increased Finally, physical health and well-being hinges on gender equity.
a culture of eating larger table fish. vulnerability for women (see textbox 1). Poor health is just one That includes women having control over their reproductive health
The dagaa fishery could, however, factor that contributes to destructive fishing practices. (the ability to access contraception, avoid diseases, and safely plan
be a way to make the lake’s fishery
more gender equitable, as women
for and deliver children). Removing a woman’s right to make
play a larger role in the harvest, As illustrated in appendix 1, those fishing practices can impact decisions about her sexual and reproductive health and limiting
drying, and selling of dagaa versus family food security and livelihoods—less fish means less for her bargaining power within economic systems has a negative
traditional Nile perch.
families to eat. It can also increase reliance on other natural impact on her welfare. That, in turn, has a similar impact as a sick
resource-based livelihoods such as charcoal-making and farming. fisherman: the unsustainable use of natural resources.
If done unsustainably, those activities can lead to deforestation
or damaging agricultural practices. Natural resource degradation As demonstrated by Fiorella’s research, environment and human
xii Can you think of other examples of and food insecurity can then increase illness, which again fuels health feedback loops are complex. Environmental conservation
this “negative cycle”? the cycle of poor health and unsustainable natural resource use.xii cannot be done without considering the health and well-being of
the people who rely so heavily on the services provided by those
ecosystems. Any project that wanted to improve the outcomes of
one would have no choice but to integrate the other. This was the
Gender Dynamics in the Lake Victoria Fishery context in which the HoPE-LVB project began.

The introduction of Nile perch and declining fish stocks exacerbate the inequitable gender dynamics that exist
in Lake Victoria’s fishery. Traditionally, men are the ones who fish, selling their catch at the shore to women who
manage the processing, transportation, and sale of those fish. The role of women in the fishery shifted after the
introduction of Nile perch with the rise of larger packaging plants to prepare the fish for international export.
To this day, women are primarily excluded from the more lucrative Nile perch market and instead take on the
responsibility of drying and trading dagaa, a small, sardine-sized fish that has become populous in the lake.
They also locally trade and process undersized Nile perch.

A 2015 paper authored by Dr. Kathryn Fiorella and her research group investigates how declining fish catch
affects women. In Kenya, she found many women exchange sex for preferential access to fish.

Whereas periods of high catch means fish is plentiful and can be purchased using money alone, a declining
stock means women have to compete for catch using non-cash methods. This has affected jaboya
relationships—the Luo word used to describe fish-for-sex. Transactional sex relationships like jaboya, are
different than sex work. They are often with a regular partner and include other benefits such as housing and
emotional support.21 Jaboya transactions typically involve a woman exchanging sex with a man in order to gain
preferential access to purchase the fish he has caught. While women are conventionally excluded from the

376 377
 Namakula Edith, the volunteer team
The Need for an The Lake Victoria Basin has long been shaped by changing
member with the HoPE-LVB project,
Integrated Solution demographics and population pressures. Even before the Nile holds up the packet of birth control she
xiv What’s the population density perch boom of the 1980s, the LVB had a higher population density uses in her presentations with couples.
where you live? than the rest of the continent.xiv As of 2015, an estimated 246 people Pathfinder isn’t telling families to have
inhabit every square kilometer of lakeside in Uganda, Kenya, and fewer children. Rather, it gives couples
The African continent has a population
density of 36 people per square Tanzania, compared to 45 people per square kilometer in 1960.22 access to the knowledge and tools
kilometer. Urbanization compounded It’s notable that in the case of Tanzania and Kenya, the population they need to make decisions about the
by birth rates, however, has meant density in lakeside areas is two to three times higher than the healthy spacing of children.
that Africa’s most populated cities
have dramatically higher population density of the country at-large.23 These demographic trends can
densities. Take Cairo, Egypt be attributed to two key factors: an influx of in-migration to the
(population: 19.5 million, population
density: 19,376 people per square
fishery, particularly following the Nile perch boom, and birth rates
kilometer) and Kinshasa, Democratic that surpass national averages.xv
Republic of Congo (population: 9.4
million, population density: 19,900
people per square kilometer).
The result is 44 million people whose lives and livelihoods are
intertwined with and dependent on a finite set of resources. While
xv Population Research Bureau data limiting in-migration to the region could be one way to mitigate
says Ugandan women of childbearing natural resource pressures, Pathfinder International is addressing
age give birth to an average of 5.4
children, and that number sits at 3.9 the issue through a rights-based PHE approach. The organization
children per woman in Kenya—both is ensuring that couples have access to contraceptive choice and
substantially higher than the global sexual and reproductive health services. This empowers women
average of 2.4 children per woman.
and men to plan for the healthy spacing of their children, reduce
the risk of contracting or infecting others with HIV, and live within
the means of what their local natural environment can sustainably
support.

Pathfinder and PHE

‘Integration’ is a word that comes up often among the Pathfinder
International team. In this case, integration involves multi-sectoral
project objectives: to conserve Lake Victoria’s natural resources,
improve the health and well-being of the people who live on its
shores, and provide families access to sexual and reproductive
health services. Add to the list a mission to combat traditional
gender roles, advocate for greater healthcare access, women’s
economic empowerment, and institutionalization of PHE policies
at various levels of government, and you have the organization’s
Health of People and Environment in the Lake Victoria Basin
(HoPE-LVB) PHE project. If it sounds multi-faceted, that’s because
it is—but Pathfinder’s belief is that complexity is the only way to
address complexity.

Sono Aibe, a former Senior Program Advisor at Pathfinder, has

been thinking about integration since her public health career
 started in 1988. One of her first projects involved creating an PHE and Planetary Health
integrated reproductive health, environmental sanitation,
and maternal health project in the Philippines, a country long Sono Aibe and others in the PHE community say they view planetary health as a broad umbrella under which
considered a leader in integrated PHE approaches. “Having come issues of human health and the environment can be discussed. “Initially when we were trying to join the
from that background made me a proponent for taking a broader conversation around planetary health it seemed skewed heavily towards climate scientists and more abstract
view of sexual and reproductive health because women’s lives are issues that were very macro-level,” Aibe says.
complex, and their problems are intertwined,” says Aibe. While it
would be possible to dedicate entire projects solely to managing There was also concern that some would misperceive PHE approaches as accusatory—suggesting they were
and restoring natural ecosystems, family planning, or health, the proposing family planning as a means to curb birth rates in lower income countries in order to protect areas
premise is that it takes addressing all three to target the root causes of high biodiversity. Aibe says this is not the case. She reaffirms that PHE approaches advocate for individuals’
of a region’s challenges. sexual and reproductive health rights as opposed to prescribing the number of children families have.

Pathfinder had already tested the waters of combining Ultimately, planetary health and PHE approaches are working towards similar messaging: that integrated
environmental and health programming by 2009 when Aibe was solutions and multi-sectoral collaboration are the best way to achieve the United Nations’ Sustainable
hired. Whether it was an HIV-focused project with a livelihood or Development Goals. “[PHE] is an acknowledgement of direct connections between the reproductive health
agricultural component, or integrating HIV education and family of individuals—women, men, and youth—along with the well-being of communities in remote, biodiversity-rich
planning, Aibe says she had an inkling that PHE programming was areas, and the health of the natural environment upon which all life depends,” say Suzanne York and Robert
something Pathfinder could adopt. Engelman in a blog post summarizing the topic.

What came next wasn’t easy. “There definitely was pushback in

the sense that people thought [PHE] would be a mission creep. Just as Aibe faced challenges in introducing the PHE concept to
They envisioned us having to work with environmental groups, Pathfinder International, the country teams faced their own
share resources, and learn about conservation terminology and unique start-up obstacles with HoPE-LVB—namely, the need to
monitoring indicators. There was this whole anxiety around going work across so many sectors. According to Dorah Taranta, Project
into a completely non-health sector,” Aibe recalls. Manager for HoPE-LVB in Uganda, starting a PHE project meant
the organization needed to find partners in sectors beyond health.
Another reason for Pathfinder’s apprehension was that the That meant reaching out to ministries of all backgrounds: water
“population” element of PHE has historically attracted controversy. and environment, agriculture, education, gender, and others. “It
“Some environmental groups still talk about problems of was really a learning project,” says Taranta of HoPE-LVB. “We had
environmental degradation being because developing countries all these activities and objectives based on the funding proposal,
xvi This narrative stems from what is are growing too fast,” Aibe says.xvi “That’s a very harmful narrative but then we had to fit in and achieve everything. Many times we
known as neo-Malthusianism. Care for what we’re trying to advocate for, which is reproductive health came back to the drawing board to say ‘what did we do right and
to read more? Read Chapter 2 of Betsy
Hartmann’s Reproductive Rights and and rights, and the fact that a woman has to be given a full basket what went wrong. Are we really doing integration or are we still
Wrongs. of choices and accurate information to make a decision about the different sectors working in the same room?’”
number of children she wants. So there was this nervousness of
‘are we going to be working with groups promoting the value of Taranta says there was a “whole shopping list” of indicators at
smaller families, which is diametrically opposed to the universal the start of the project—nearly 35 points the team had outlined
access to sexual and reproductive health and reproductive rights to measure the impact of the project. The challenge was creating
that we stand for.’” Aibe says she firmly believed the challenges of indicators that demonstrated integration: how family planning
cross-sectoral work could be overcome by partnering with African lessons were being used in farming. How energy efficient cookstoves
communities to hear how people articulated the linkages (an echo affected health and the environment. “It was about bringing best
of the “radical listening” discussed in the Health In Harmony case practices from one sector into the other and looking at how one
study). affected the other,” Taranta says. “Then we had to make sure the
communities also understood it this way.”
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 These integration needs meant HoPE-LVB was an iterative process. A Model Household Drive a motorbike along the red dirt roads of Bussi Island and
Partners from various sectors were brought on board and dropped Approach you start to notice some key differences between households:
if they weren’t a good fit for the PHE approach; donors and their a rubbish pit sitting at the edge of the property, a dish drying
demands changed from phase to phase. “That calls for a lot of rack, a garden containing various crops and fruit trees, the size
xviii The HoPE-LVB project works in
patience, especially when you’re leading a project. You are like two sites in Uganda and two sites of which provide ample shade for homeowners and their guests.
this small punching bag where everyone is saying ‘we asked you in Kenya. In Uganda, it is Wakiso On Bussi Island and the other three lakeside regions where HoPE-
for this,’” Taranta laughs, explaining that HoPE-LVB’s approach District (home to Bussi Island) and LVB operates, xviii homes with these features are most likely model
Mayuge District; in Kenya, the project
would sometimes shift to satisfy donor and partner demands. operates in Siaya County and Homa households—living demonstration sites that illustrate the project’s
“It’s complex, but very interesting work.” Bay County. PHE interventions.
A model household on Zinga Island,
nearby to Bussi. The HoPE-LVB project
A PHE Approach in Madagascar encourages model households to
intersperse food crops and other plants,
creating shade and balancing nutrients.
A well-studied Population, Health, and Environment initiative is the work of Blue Ventures in Madagascar.
The small trough in the back of the
Blue Ventures was founded as a marine conservation organization in 2003. Its first intervention was working garden is used to store excess rainwater.
with fishing communities to temporarily close a small area of their fishing ground to octopus fishing—octopus
is a marine species that recovers rapidly with protection. Through the temporary closure and resulting recovery
of octopus populations in these sites, Blue Ventures demonstrated to communities that they could generate
quick profit by protecting their marine areas for a short period of time. It made a business case for locally-led
conservation.

“Rather than international companies coming in and telling people who have fished off these coasts for
generations that they can’t fish anymore, we’re turning this on its head—making marine management pay
for coastal communities,” says Vik Mohan, Blue Venture’s Medical Director. “Protecting fisheries means better
income for people, so they want to protect those areas.” Similar to HoPE-LVB’s advocacy towards community
by-laws, this protection involved the creation of local regulations using dina, the name for customary Malagasy
laws.
The model household concept is not new. It has existed in past
Blue Venture’s family planning and maternal health program was introduced in 2007 in response to community PHE projects outside of Pathfinder’s work, as well as in other global
members highlighting their unmet health needs—especially those linked to reproductive health. Maternal and health and development programs. What Pathfinder staff say is
child health was poor and couples were having more children than they wanted. Women and men were seeing different is that the positive behaviors exhibited in HoPE-LVB
the connection between their family size and depleting fish stocks. Today, family planning and other maternal model households protect human health and the environment in
health services are offered either by community support workers or through strengthened government-led ways that are specific to the needs of Lake Victoria communities.
clinics. Blue Ventures also partners with international organizations like Marie Stopes, USAID, and Population “In PHE you need to look at what ecosystem you’re conserving,
Services International to improve access to health services for the communities it serves. what are the health issues of the people living around there, and
what are the demographic issues in that area,” says Dorah Taranta.
For more information: Blue Ventures (www.blueventures.org) Only then can a project address the intertwined pressures faced by
that community.

xvii Take a moment to think through if When it came time to apply HoPE-LVB’s PHE approach in the A home visit is the best way to see a model household in action.
a PHE approach is needed where you communities, the focal point of that integration was peoples’ Namuyaba Margaret and her husband, Kayemba Taddeo, sit on
live and how it would be implemented.
homes.xvii wobbly blue plastic chairs in the shade of their generously sized

382 383
 mango tree. Margaret and Taddeo are one of four original model made of worn wooden slats. Inside is the energy efficient cookstove
households in Gombe Village on Bussi Island, and the couple live where Margaret prepares the family meals. Training to build these
with their five children who range in age from six to 17-years-old. cookstoves is offered by the HoPE project. Whereas cooking would
The eldest, Helen, is kneeling off to the side, scrubbing aggressively typically be done over an open fire with less efficient means of
at the family’s laundry. Home visits are nothing new for the burning wood,xix these clean cookstoves require only two to three xix The HoPE-LVB baseline study
couple—one requirement of becoming a model household is an branches per meal. The design of this particular stove funnels found that 81% of households in its
Uganda and Kenya sites relied on
agreement to talk and tour neighbors and other officials so they can smoke outside the small cooking space, reducing the risk of firewood as their main source of
learn about the benefit of integrated PHE activities. The integrated cardiorespiratory disease caused by smoke inhalation24 and the cooking fuel.
nature of the model household was what originally appealed to the opportunity for cooking pots to spill on unsupervised children.xx
couple: “other projects came with only one intervention, but HoPE This more efficient stove is also used by families to boil drinking xx Worldwide, how many people cook
came with three: P, H, E,” Taddeo says. water. with open fire stoves, and how many
people cook with enhanced means?

Outside the cooking area is a dish drying rack raised from the What is the burden of disease due
ground for sanitation purposes. Beyond, a latrine is located an to this risk factor in Uganda and
worldwide? ↘ Learn more here
appropriate distance from the home. Latrines are challenging
to build in the sandy soils of Bussi Island, but HoPE-LVB links
families like Margaret and Taddeo with government funding and
other NGOs that focus on that specific infrastructure.

Namuyaba Margaret and her husband,

Kayemba Taddeo, stand outside their It’s hard to overlook the PHE interventions when you visit Margaret
home on Bussi Island. The brick and Taddeo’s property. Taddeo walks behind the red brick structure
building is where the family sleeps, and that serves as the couple’s one-room home. Onions, tomatoes, and
the wooden structure is the area where
Margaret makes the family’s meals.
collard greens that go by the local name sukuma grow in the shade
of a banana tree. Kitchen gardens are a feature of every model
One of the clean cookstoves that has been
household, and ensure families have access to a healthy source of constructed as part of the HoPE-LVB
vegetables. Beyond the kitchen garden is a small shack, its walls project.

384 385
 Access to clean cookstoves and improved household water, Changing Perceptions of Sexual and Reproductive Health
sanitation, and hygiene (WASH) standards are part of the health Other behavioral shifts related to family planning. “We used
element of this PHE approach. HoPE-LVB’s baseline study found to think about planning our family but didn’t know how,” says
that just 41% of people had access to a protected drinking water Margaret outside her home. “We would hear the rumors about
source. Lake Victoria filled the gap, and was the main source of family planning, like that if I used contraception I’d give birth to a
usable water for activities like drinking, washing, cooking, and child with a defective brain. This scared us off, but the education
disposing of waste.25 By 2018, six years after the baseline study we got from HoPE helped shed those fears.” Margaret now takes
was conducted, WASH standards had improved in sites across birth control in the form of an implant, and the couple has chosen
Uganda and Kenya, even in non-model households. This was to not have another child.
due to the construction of new latrines and education around
handwashing practices. These interventions reduced the risk Margaret is not alone in her contraception fears. Back in Seeta
of water-borne diseases in households. In fact, one Pathfinder Village where Village Health Team (VHT) member Edith has
publication noted that not a single HoPE-LVB model household finished demonstrating how to properly fit a condom over her
in Uganda was affected during a 2015 cholera outbreak in the Lake phallic wooden prop, she’s just opened the session to questions.
Victoria region.26xxi
Nakajubi Jackie and Mbatudde Stellah
“Is it true birth control will sit undissolved in my stomach and are Pathfinder’s field officers for the
While a latrine and other features of a model household require cause a tumor?” asks one woman. Edith swiftly pops one of the HoPE-LVB project in Uganda. While
families to invest some of their savings, a USAID external review pills from its blister pack and puts it in a cup of water. Moments Jackie comes from a background
in sexual and reproductive health
of HoPE-LVB noted that “some of the most important PHE later she passes it around, pointing out that the pill has dissolved and Stellah from one working in
outcomes are the least costly, with some requiring no up-front into the liquid. The women nod their heads. Just as model conservation, the two women regularly
capital expenditure whatsoever. This is a valuable lesson of high households demonstrate the visible benefits that PHE can bring to find themselves talking about both
applicability to other potential PHE sites.”27 One example is a low- a home, education around family planning requires the same level areas—that is the purpose of a PHE
A tippy-tap in action. project, after all.
cost innovation found outside Margaret and Taddeo’s latrine. It’s of learning by example.
called a tippy-tap, and it’s fashioned from an old jerry can, a piece
xxi Can you list some examples of
water-borne illnesses? Are they still of string, and a small stick. Taddeo steps gingerly on the stick and Edith says regular educational campaigns are key in encouraging
prevalent where you live? If not, what the string tips the bottle, enabling family members to wash their contraception uptake. “You go to church once, but you need to keep
measures are currently being taken to hands without touching a dirty surface. preaching the gospel,” she explains. “So yes, I have trained these
prevent them?
women on family planning before, but I need to continue training
Other interventions were low-cost because they related to them. For example, you can’t teach all four to five methods in one
behavior shifts rather than the creation of new infrastructure. go, so each session needs to focus on a different method.”
“Before, people were only focused on earning money and didn’t
understand how to make the best decisions for their family’s Beyond education, considering the religious beliefs of Ugandan
health,” explains Jackie Nakajubi, one of two HoPE-LVB field and Kenyan communities is important. Both countries are deeply
staff in Uganda. Nakajubi focuses on health and family planning religious, with an estimated 85% of the population identifying
while her counterpart, Stellah Mbatudde, covers environmental as Christian. Across sub-Saharan Africa, religious leaders have a
conservation. “People would fish and sell everything because of platform to share their message, and it isn’t always one in favor of
the amount of money they could make. As a project we tried to family planning. For example, one Catholic archbishop in Kenya
ask them to start with themselves first, including when it came to started a campaign against contraception because he claimed it
eating fish,” Mbatudde explains. harmed women, was “unbiblical,” and “encouraged unfaithfulness
in marriage.”28 There’s an audience for this kind of message: a
2014 poll found that 38% of Ugandans and 33% of Kenyans deemed
contraceptive use immoral.29 Another study done in Mwanza,
a Tanzanian community on the shores of Lake Victoria, found
386 387
 The upgraded hospital on Bussi Island.
that religious tradition affected the way couples perceived family
planning.30 It was clear that the HoPE-LVB project had to tailor its
approach to not only consider education around family planning,
but religious beliefs as well.

Improving Access and Building Healthcare Demand

Once their misconceptions are debunked, HoPE-LVB has also
made it easier for community members to access family planning
methods. Almost half of pregnant women surveyed during the
project’s baseline study said they would have preferred to get
pregnant later or not at all.31

Baseline data also found that less than 1% of respondents received

their contraceptives from a community-based clinic or outreach
service. This meant they had to travel to a public health center,
often accessible only by motorbike or, on smaller islands, by
traveling to the nearest large island. Despite short-acting methods Advocacy-wise, the project wanted to provide families more
xxii Short-acting methods of of contraceptionxxii being provided for free at these centers, the contraceptive choice and guaranteed access. With short-acting
contraception include the birth control financial cost of reaching them often restricted physical access. methods of contraception available for free from the government—
pill, patch, and vaginal ring, all which
involve the release of hormones. This was compounded by the fact that husbands wouldn’t allow albeit with the previously mentioned access barriers—the second
women to make solo clinic visits. phase of HoPE-LVB successfully advocated at the district and
national government level for free access to long-acting and
One approach to these challenges might have been to open a permanent methods of contraception. That includes intrauterine
xxiii This is an approach called series of HoPE-LVB facilities offering contraceptives. Rather, contraceptive devices (IUCDs) and implants for women, and
capacity building, or health system the project prefers to build the capacity of existing community vasectomies for men. With this success, HoPE-LVB has offered
strengthening, and it seeks to
eliminate duplication of efforts, groups for this role, and advocates for better services to be offered thousands of Couple Years of Protection (CYP)32 to families in
and provide long-term sustainability. by government health facilities for long-term sustainability and Uganda and Kenya. It has also facilitated more than 118,000
↘ Learn more here country ownership.xxiii visits to facilities and communities for contraception between
2012 and 2017.33 Not solely used to help couples plan pregnancies,
In her role as a Village Health Team member, Edith is one of the contraceptive use has also been linked to reduced maternal and
community members who has received capacity training through child mortality and lessened risk of developing certain cancers. 34
HoPE-LVB. In isolated island communities like Bussi, VHT Finally, HoPE-LVB also improved the health information
members are often the only public health professional women can management systems in each country to ensure government
see. Pathfinder offered VHT members 10-days of family planning clinics always had a range of contraceptive methods in stock.
training when the project began. Following that training, VHTs
can distribute condoms and provide birth control to women who Pathfinder staff acknowledge these successes were possible because
have already been given the medication by a trained health worker. of their work with already-established government-formed groups
They’re also trained to offer follow-up and support—listening to like Village Health Teams. Partnering with existing groups was a
xxiv Do community health workers
exist where you live? What are their a woman’s concerns during contraception use or pregnancy and strategic decision. “These groups have a common goal as to why
main roles? referring them to a health worker when needed.xxiv they’re together, so it’s easier than picking individuals and forming
a group here and there,” says Stellah Mbatudde, the conservation
field officer in Uganda. “If you form a group, it dissolves at the end
388 389
 Taddwa Lawrensio at Kyanjazi landing site.
of the project, so we worked with existing ones for sustainability.”
It was also a matter of trust. Despite being Ugandan, project
staff Jackie and Stellah were at first seen as outsiders from the
capital city. “When people get someone of their own giving them
testimony about family planning or fishing then they understand
it better,” says Jackie Nakajubi.

That community sensitization and working with existing

groups is the way HoPE-LVB took on one of its most challenging
tasks: deconstructing the traditional gender roles in which men
normally dealt with natural resources and women with sexual and
reproductive health.

Rewriting Gender Norms

Despite its place along the world’s largest freshwater fishery,
Kyanjazi landing site on Bussi Island is remarkably quiet. A half
dozen wooden boats have been pulled onto the shore, paint
peeling and faded in the equatorial sun. Fisherfolk stand around,
cigarettes dangling as they untangle fishing nets and repair their
boats. A man in knee-high rubber boots navigates his motorbike
over loose sand. It’s early in the morning, and yet the final packing
preparations are already being done on the catch of the day.
Taddwa Lawrensio picks up a two foot-long tilapia fish, his fingers
pressing into the gelatinous eye sockets. Today’s catch is meager. A
large woven basket mounted on the back of a motorbike is all that’s
needed to carry the fish to another landing site where they’ll be
sold on Uganda’s mainland.

Lawrensio is the chairman of Kyanjazi’s Beach Management Unit

(BMU). BMUs were created by the government in 2006 with the
goal of curbing illegal fishing activity, protecting fish breeding
zones, and training fisherfolk on sustainable practices. HoPE-LVB
works with BMUs to encourage members to more sustainably
use the lake’s resources and diversify their economic activities.
Perhaps unexpectedly, topics of family planning come up. By
adopting this approach, the project offers positive reinforcement
to the idea that men can be involved in the conversation around
sexual and reproductive health and family planning, and that
women can make decisions regarding the natural environment.
Untangling these deeply entrenched gender norms is called a
“gender transformative approach.”

390 391
“Usually men would say these topics of contraception are for bring up topics of conversation—including questions about family
women,” Stellah Mbatudde explains. Men would also say they planning that were then addressed by health workers in attendance.
were often suspicious about maternal health and the desired By pairing environmental conservation information with messages
aims of family planning. “As fishermen we were not using family about healthy timing and the spacing of pregnancies, boys and men
planning. We thought people were telling us not to give birth,” in HoPE-LVB communities showed increased knowledge about
says Lawrensio, staring out at the water. “Now we know women family planning.37 And they were willing to talk about it with their
should go to safe delivery services which prevents our children friends and wives, too.
from getting HIV.” HoPE-LVB also works with Beach Management
Units to provide boat fuel so women in need of specialized delivery Education and social acceptability are two ways to increase access
services can easily reach mainland hospitals. to maternal healthcare for women. Another is empowering women
with greater agency, and raising the status of women within their
Project success wouldn’t be possible without buy-in from both men communities and homes—something that has proven to have a
and women. “For community level change, women are important positive impact both on families and the environment.
pillars, but if you’re not talking to men you won’t change things
because of the paternalistic nature of our societies,” said one Consider Namudu Annet who, at 38-years-old, holds many titles
Pathfinder team member. Following the second phase of the project in her village on Bussi Island: model household, leader of a young
(2014-2017), model households in Kenya were 20% more likely to mother’s group, BMU member, and mother of seven. Annet says
discuss the number and spacing of children, and in Uganda, it the negative stereotypes that exist around the roles of women
was a 34% increase. Three-quarters of families only started having are beginning to change. So too are the places where women are
these conversations during HoPE-LVB.35 allowed to speak up—while there were some female BMU members
before HoPE-LVB started, she says a woman’s place was still very
Once men understand the importance of sexual and reproductive much within the home.
health, they become advocates who encourage and support women
in their access to health services. This is a significant change from
Namudu Annet and a few of her children
previous attitudes when men were reluctant to allow their wives outside of their home on Bussi Island.
and daughters to visit health facilities. In the past, health center
visits may have come through referral from a Village Health Team
member. Now, HoPE-LVB has created champions in men and other
non-traditional groups. Health referrals from Beach Management
Unit (BMU) members increased 43-fold between 2012 and mid-
2014. Referrals also rose from farming group members over the
same time period.36 Further, a September 2018 internal review of
the first and second phases of HoPE-LVB found that the number
of women delivering babies in healthcare facilities had greatly
increased, as did HIV testing and immunization for children under
five. Health referrals from the traditionally male-dominated BMU
and farming groups contributed to this rise in service use.

While Lawrensio received family planning training through his

role with the BMU, HoPE-LVB recognized the need to start these
challenging conversations in comfortable settings. That’s where
the project’s campfire outreach sessions came in. Fire blazing and Annet hasn’t always felt a sense of empowerment. Pregnant with
maize roasting, men would slowly approach the gathering and her first child at the age of 16, she was expelled from her family’s
392 393
 home. “I was seen as an outcast and a waste in my family,” Annet Does PHE Integration Educating people to consider and value the connection between
says. “The boy who got me pregnant couldn’t look after me, and so Work? population, health, and their surrounding environment is one of the
I was a burden to his family and turned into a housemaid.” That key objectives in HoPE-LVB’s theory of change.
relationship didn’t work out, and Annet moved to Bussi Island 18
years ago with her current husband. Research supports and quantifies the effectiveness of the project’s
integrated efforts. A 2018 paper authored by Samuel Sellers for
Many of HoPE-LVB’s interventions empower women with the Environmental Conservation looks specifically at HoPE-LVB’s four
dignity and skills that Annet didn’t have as a young mom. Women sites, and Pathfinder’s hypothesis that a PHE approach could be
get skills training for free, and then apply those skills to create a used to deconstruct established gender roles, increase income, save
sustainable income-generating activity. “We gather young mothers family time, and improve community cooperation. Each of these
together and teach them to immunize their children and other factors improve conservation and health outcomes.
skills, like how to build clean cookstoves, make mandazi (a fried
bread snack), and soap. That income means they don’t have to Here’s an example from Sellers’ research on how PHE integration
depend on their husbands,” Annet says. The scale of these income helped prompt a shift to sustainable livelihoods—especially
xxv How would you define women’s generating activities is notable: more than 25,000 energy efficient important since a large percentage of Uganda and Kenya’s
empowerment? What different
approaches would you take to achieve cookstoves had been built by women in Uganda and Kenya by the populations are youth of working age.
this goal? end of HoPE-LVB’s second project phase.38xxv
Following the first 2.5 years of the program (2011-2014), model
“When our husbands realized we could bring income into the household couples reported having more time because of the project’s
family, they started respecting us more,” says Annet. A USAID interventions. That increased time came through three pathways:
review of HoPE-LVB supports this claim—it found that the majority people needed to care for fewer children because of their ability to
of respondents from Uganda and Kenya say their relationship use family planning to space their pregnancies; were sick less often
with their partner had improved as a result of income-generating because of increased access to healthcare; and because they had to
activities.39 spend less time collecting firewood for energy efficient cookstoves.
“This additional time was often devoted to livelihood activities such
Further, a woman’s access to sexual and reproductive health and xxvi In your community, if people had as beekeeping, tree planting, or gardening, all of which the project
rights is explicitly tied to her long-term ability to work. Studies more time, would this translate into has provided training in […] and most of which are likely to have
have shown that female participation in the labor force among better environmental outcomes? positive or at least neutral conservation outcomes,” Sellers writes.
Why or why not? What would need
women aged 25 to 39-years-old can decline by 10 to 15% with each to change for positive environmental In other words, more free time translated to reduced pressure on
additional child.40 Research into the value of HoPE-LVB’s PHE outcomes? vulnerable natural resources like firewood and fisheries.xxvi
integration also found that women who earned additional income
“frequently invested in sustainable income-generating activities, ↘ Appendix 2: Linkages between project interventions and improved
such as tree nursery management or beekeeping, in addition to maternal health outcomes and natural resources management, from
other investments such as school fees.”41 Samuel Sellers’ integration paper

Linked to the ability to work is a woman’s bargaining power within Another HoPE-LVB hypothesis was that the more sustainable use
her home. Following HoPE-LVB, women have more freedom to of natural resources would lead to people recognizing the benefits
engage in discussions about the sustainable use of natural resources. that come with a healthier lake or reforestation. The theory was that
They are also more likely than before to become members of couples may reconsider their family size in order to reduce strain
traditionally male-dominated spaces such as Beach Management on the environment. While Sellers’ research found people were
Units, farming groups, and tree planting projects. Similarly, men starting to understand this connection between birth rates and
have become more invested in sexual and reproductive health. But environmental sustainability, no family had specifically chosen to
the question remained: do PHE integrations actually work? not have a child because of it.
394 395
 The State of the Lake

Population pressures and illegal fishing are two of the many challenges being faced by Lake Victoria and,
in turn, the people who depend on the lake for their livelihoods, water, and food.

Algal blooms (eutrophication) have also been a threat since they first appeared in 1986.42 Scientists have
connected the increase in algal blooms to the extinction of several haplochromine cichlid species due to the
introduction of Nile perch.43 These extinctions affected the food chain in Lake Victoria, reducing the fish
species that historically moderated the amount of vegetation and animal decay in the lake. Algal blooms reduce
oxygen in the water, killing fish species and compounding matters of overfishing. Lakeside population growth
also plays a role: the more wastewater and other effluent that enters the lake, the more the nutrient content
favors the growth of algal blooms.44

Prior to extinction, the haplochromine cichlid species also fed on Biomphalaria and Bulinus, two species of snails
that serve as an intermediate host for schistosomiasis,45 a parasitic disease that, in the Lake Victoria region,
goes by the name of bilharzia.xxvii As schistosomiasis was not well documented prior to the introduction of Nile
perch, the connection has not been confirmed but is plausible.

xxvii Another case study in this

anthology looks at how land use
Annet, the mother of seven, says she also uses concepts of family
management and dam construction planning in her garden. A cluster of matooke trees grows around
in the Senegal River Basin in West the back of her house. It is here that Annet says people are able to
Africa has affected the spread of
schistosomiasis in the region.
first grasp the concept of PHE. “The more matooke trees you have
growing next to one another, the smaller the bunch of bananas they
A tree nursery that has been started on Interestingly, family planning concepts have changed the way produce,” she explains. “You need to thin your banana plantation to
Zinga Island as part of the HoPE-LVB’s fisherfolk look at their fishing activities. “When you don’t illegally get a bigger bunch. This is the same with family planning—if you
reforestation efforts.
fish, it gives some time for the young fish to grow which means have a smaller family then they’re often healthier because of it.”
they’ll be bigger and able to breed other fish later. It connects to
family planning—we now plan for the lake,” explains Lawrensio, This community-level change demonstrated by Lawrensio and
the head of the Beach Management Unit. Annet is a key part of HoPE’s local-level advocacy. A longer-term
goal of HoPE-LVB was to make sure these changes remained once
the project ended—and that they could be used to inspire new PHE
projects across the region.

396 397
Epilogue: In Kenya’s capital city of Nairobi, the jacaranda trees are flowering, communities and add more model households) also helped HoPE-
Institutionalizing a PHE their distinctive purple blooms arching over the roadway. Pathfinder LVB grow to a larger geographic area during the second phase
Approach International’s Kenyan office sits down a road like this. Inside the (2014-2017), though the approach was tweaked to meet different
boardroom surrounded by PHE literature is Pamela Onduso, the local contexts and settlement patterns.
organization’s Youth, Advocacy, and Partnership Advisor in Kenya.
An expert in reproductive health, family planning, and PHE Next came the creation of PHE steering committees in the
programming, Onduso has worked with Pathfinder for over two two Ugandan districts and two Kenyan counties where HoPE-
decades. LVB operates. Committee members come from multi-sectoral
ministries whose work links to PHE efforts. Pamela Onduso says
Onduso supports Pathfinder’s Kenya office in resource those steering committees have been key to earning acceptance
mobilization, sexual and reproductive health program at county and district levels of governance, which bridges the
implementation, and sustainability efforts. The latter includes gap between community decision-making and national policy.
dealing with the inevitability that accompanies any international “Everyone can see the problem, but you can’t begin to break it
development project, including HoPE-LVB: what happens when down and see how your different perspectives and resources can
funding finishes and the project must end? Knowing such a future contribute to a solution until you have a common understanding
was on the horizon, the Pathfinder team designed HoPE-LVB with and platform to bring you together,” she says of the steering
sustainability and scalability in mind. This meant finding ways committees.
to get policymakers at all levels to understand PHE and adopt its
integrated development practices into policies and programs. When it comes to engaging various levels of government, PHE
adoption is a long-term process. Onduso explains that advocating
To that end, Pathfinder partnered with ExpandNet, a global for PHE and sexual and reproductive health requires tact and good
network of public health professionals and scientists who develop communication skills.
strategies to scale public health solutions. ExpandNet has worked
with the HoPE-LVB team from the beginning to plan, implement, Just as HoPE-LVB employed diverse strategies to effectively
and expand the PHE approach to benefit more people and support engage communities, there are also best practices when it comes
long-lasting policymaking. to advocacy with the public sector and faith-based organizations.
That means that while Pathfinder International frames HoPE-
That meant engaging target communities through public, private, LVB as a “rights-based approach” to sexual and reproductive
and faith-based organizational partnerships to pilot diverse health, it also wants to avoid misinterpretation of what services
PHE integration models, monitor implementation, and plan for fall under the category of family planning. As a result, increased
expansion based on successful, evidence-based interventions. In access to contraception and the concept of healthy timing and
its first three years, the HoPE -LVB project succeeded in fostering a spacing of pregnancy are promoted within the framing of helping
high degree of ownership among government stakeholders in both communities improve their health and livelihoods, as well as
Kenya and Uganda. Community, district, national, and regional conserve critical ecosystems. Knowing which messaging to use has
stakeholders were briefed about the project early on, told about the been key in making PHE advocacy a success.
proposed model household interventions, and asked about their
own pressing needs and obstacles. Strategic local, national, regional, and global partnerships
have also helped. In 2015, HoPE-LVB signed a Memorandum of
This participatory exercise shaped the project in significant ways.45 Understanding (MoU) with the Lake Victoria Basin Commission
For example, it informed the decision to include district and (LVBC), a specialized institution of the East African Community
county officials in environmental conservation activities. Doing (EAC).xxviii One of the roles of the LVBC is to coordinate the design xxviii EAC countries in the Lake
so boosted project buy-in and the approval of new local by-laws. and implementation of an integrated PHE program across the Lake Victoria Basin include Kenya, Uganda,
Tanzania, Rwanda, Burundi .
Building for scalability (anticipating to expand the project to new Victoria Basin, applying integrated solutions to interlinked health
398 399
and environment challenges. “We use evidence from HoPE-LVB for PHE projects. “Some officials are still cagey about the multi-
to advocate to change policies in each of the relevant ministries, sectoral approach, and questions arise about how we will pool
and now there is an EAC PHE Strategic Plan,” says Doreen Othero, resources,” Tiondi says. “But they’re not looking at the bigger
the Regional Programme Coordinator for the Integrated PHE picture. As a government you may not be able to deliver an outcome
Programme at the LVBC. “Without that evidence we would not because you need other players to play a role in that delivery.”
have convinced our ministers.”
As with any initiative, more funding is needed to support PHE
Projects Precede Policy integration across the Lake Victoria Basin. Pathfinder and its
Evidence from the HoPE-LVB project has also helped Andrew collaborators still struggle with single sector funding: “everyone
Tiondi, a bureaucrat with Uganda’s National Population Council, always looks at which budget PHE activities should come from—
and Coordinator of the country’s National PHE Network. Like Conservation? Health? Planning?” says Dorah Taranta, HoPE-
Onduso, Tiondi collaborates with government officials in various LVB’s Uganda Project Manager. Meanwhile, Doreen Othero of the
ministries and jurisdictions to adopt a multi-sectoral approach to Lake Victoria Basin Commission remains hopeful that the PHE
solving some of the country’s development challenges. Raised in a integration efforts started by HoPE-LVB can be continued, even
fishing community in northern Uganda, Tiondi understands some without donor funding. “That has been my main worry, and I’ve
of the environmental pressures villages face. Not all policymakers told Pathfinder many times that they need to build capacity of the
have the benefit of that firsthand experience, and concepts like people who will be here beyond the project life cycle,” she says.
family planning and improved latrines can go over the heads of
bureaucrats sitting in a bustling capital city. That’s why field visits There are some positive signs of financial support in Uganda.
to model households are important. The national government has pledged 4 billion Ugandan shillings
(about US $1.5 million) to start PHE model households in the Mount
Government officials understand once they see the model Elgon region of Kenya and Uganda. The area bears similarities
households in action, Tiondi says. “The PHE model households to the Lake Victoria Basin: large family sizes and environmental
address important issues the government is grappling with: degradation, though in mountainside communities. “While several
preventative health by having basic sanitation interventions in LVBC environmental programs have been implemented in this
place, health and nutrition, and the fact that Uganda’s population area before, it was realized that there was the need to pay attention
is increasing but its land and resources are finite,” Tiondi says. to the link between environmental challenges in the basin and
Ultimately, there are mutual benefits to be gained from HoPE- community health issues,” Othero says. “Previous challenges were
LVB cooperating with the national government, and vice versa. addressed vertically: per sector, and in silos.”
For the government, the project’s community-level interventions
help reach every household in a way national or district-level Ultimately, Pathfinder International is confident HoPE-LVB has
programs may struggle to do, particularly in rural and isolated demonstrated that a PHE approach is needed—and possible—
fishing communities. From HoPE-LVB’s perspective, support from across multiple complex ecosystems, socioeconomic contexts,
national government leaders is needed to work with district level and geographies. “In the past, people thought PHE was a little
staff in departments like community development, culture, and boutique project,” says Sono Aibe, the Pathfinder International
health. Senior Advisor who first led the way for the organization’s PHE
efforts. “Thankfully, I think Pathfinder was able to fill that gap,
Uganda and Kenya have recently finalized their national PHE demonstrating scalability, institutionalization, and the advocacy
strategies. Now, government PHE champions like Tiondi can work for new policies.”
to weave PHE values into specific ministerial policies related to
health, water, environment, and beyond. It may seem like a lot of
paperwork, but these policy pieces are needed to institutionalize
the value of integration and advocate for greater budget allocations
400 401
Keeping Track Sono Aibe Namudu Annet Namakula Edith Dr. Kathyrn Fiorella Isiah Kisiki
of Who’s Who
Former Senior Program Advisor at Model household and mother, Bussi Village Health Team Member, Bussi Assistant Professor, Department of Life-long resident of Bussi Island
Pathfinder International, PHE specialist Island Island Population Medicine and Diagnostic
Sciences at Cornell University

Taddwa Lawrensio Stellah Mbatudde Jackie Nakajubi Herbert Nakiyend Namuyaba Margaret
and Kayemba Taddeo
Community health worker in Nabukavesi HoPE-LVB field staff in Uganda in HoPE-LVB field staff in Uganda in Fisheries biologist, NaFIRRI
charge of environmental conservation charge of health and family planning A couple and model household family on
Bussi Island

Winnie Nkalubo Pamela Onduso Dr. Alex Opio Doreen Othero Dorah Taranta
Fisheries biologist, NaFIRRI Youth, Advocacy, and Partnership Epidemiologist and former director of Regional Programme Coordinator for the Project Manager for the HoPE-LVB
Advisor, Pathfinder International Kenya Uganda’s HIV/AIDS Control Program Integrated PHE Programme at the Lake project in Uganda
Victoria Basin Commission

Andrew Tiondi
Coordinator of Uganda’s National PHE
Network

Acknowledgements Thank you to the Pathfinder International teams in the United

States, Uganda, and Kenya—and an additional shout-out to Jackie
and Stellah for helping with my visit to Bussi and Zinga islands. Dr.
Katherine Fiorella and the staff at the National Fisheries Resources
Research Institute in Jinja, Uganda, helped me better grasp the
human health and natural resources nuances of this case. As
with the entire anthology, this case study would not have been
possible without the help and stories of those interviewed. Finally,
thank you to Anisha Mohil and Nikita Smeshko for hosting me in
Kampala.

A mother and her child on Zinga Island in the Ugandan portion of Lake Victoria.

402 403
Bibliography
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org/10.1641/0006-3568(2005)055[0780:TOOTNP]2.0.CO;2 23 World Bank 37 Aibe, Sono. 2018. Acronyms
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Responses and Adaptations.” Africa. November 2005; https:// http://carbonfinanceforcookstoves.org/about-cookstoves/ 39 Lopex-Carr, David, et al. AIDS – Acquired immunodeficiency syndrome
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the Nile Perch Boom in Lake Victoria.” PLOS ONE. October Pathfinder International. 2013; https://www.pathfinder.org/ 2015; https://www.ippf.org/sites/default/files/2020_gender_ FP – family planning
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9 Reynolds, J. Eric, et al. “Thirty years on: the development of Environment-Lake-Victoria-Basin-Project-Baseline-Study- 41 Sellers, Samuel. “Does Doing More Result in Doing Better? HoPE-LVB – Health of People and Environment in the Lake
the Nile perch fishery in Lake Victoria.” The Impact of Species Synthesis-Report-1.pdf Exploring Synergies in an Integrated Population, Health Victoria Basin
Changes in African Lakes. 1995; https://doi.org/10.1007/978- 26 Aibe, Sono. “Scaling-up the Population, Health, and and Environment Project in East Africa.” Environmental IUCD – intrauterine contraceptive devices
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of Nature (IUCN). 2018; https://www.iucn.org/theme/species/ Pathfinder International. September 2018; https://www. 42 Ochumba, Peter B.O., et al. “Observations on blue- MoU – Memorandum of Understanding
our-work/freshwater-biodiversity/what-we-do/lake-victoria researchgate.net/publication/327780767_Scaling-up_the_ green algal blooms in the open waters of Lake Victoria, NaFIRRI – National Fisheries Resources Research Institute
11 Njiru, M., et al. “An overview of the current status of Lake Population_Health_and_Environment_Approach_in_the_ Kenya.” African Journal of Ecology. March 1989; https://doi. NGO – non-governmental organization
Victoria fishery: Opportunities, challenges and management Lake-Victoria_Basin_ A _Review_of_the_Results_from_ org/10.1111/j.1365-2028.1989.tb00925.x RH – reproductive health
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13:1. January 22, 2008; https://doi.org/10.1111/j.1440- 27 Lopez-Carr, David, et al. “Health of the People and Nile Perch on the Detritivorous/Phytoplanktivorous Species SRH – sexual and reproductive health
1770.2007.00358.x Environment in the Lake Victoria Basin (HoPE-LVB) Project in the Sublittoral Areas of Lake Victoria.” Conservation VHT – Village Health Team
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13 Turyaheebwa, Nicholas. “Perception on fishery trends sites/default/files/350%20HoPE-LVB%20Report%20Final_ 1739.1993.07030686.x
in Lake Victoria.” Norwegian College of Fishery Science. with%20annexes_4-25-18.pdf 44 Anderson, Donald M., et al. “Harmful Algal Blooms
https://munin.uit.no/bitstream/handle/10037/7140/thesis. 28 Mbenywe, Mactilda. “Church to establish anti-contraceptive and Eutrophication: Nutrient Sources, Composition, and
pdf?sequence=2 movement.” Standard Digital. December 27, 2017; https:// Consequences.” Estuaries. August 2002; https://www.whoi.
14 LVFO Secretariat. “Fisheries Management Plan III (FMP www.standardmedia.co.ke/article/2001264213/church-to- edu/cms/files/Anderson_etal_2002_Estuaries_29903.pdf
III) for Lake Victoria Fisheries 2016 - 2010.” East African establish-anti-contraceptive-movement 45 Slootweg, R. “Prey Selection by Molluscivorous Cichlids
Community. http://www.lvfo.org/sites/default/files/Final%20 29 Lipka, Michael. “Africans among the most morally opposed Foraging on a Schistosomiasis Vector Snail, Biomphalaria
FMP%20III%202016%20to%202020_0.pdf to contraception.” Pew Research Center. April 16, 2014. https:// glabrata.” Oecologia 74:2. 1987; https://www.jstor.org/
15 Njiru, M., et al. w w w.pew research.org /fact-tank/2014/04/16/africans- stable/4218454
16 LVFO Secretariat. “Fisheries Management Plan III for Lake among-the-most-morally-opposed-to-contraception/ 46 Omimo, Antony, et al. “Applying ExpandNet’s Systematic
Victoria Fisheries 2016-2020.” East African Community; 30 Sundararajan, Radhika, et al. “How gender and religion Approach to Scaling Up in an Integrated Population, Health
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404 405
Appendix 1 - Figure 1 from Fiorella et al 2017 PNAS Fishing and Morbidity ↘ Back to page Appendix 2 - Linkages between project interventions and improved maternal health outcomes and natural resources management,
from Samuel Sellers’ integration paper ↘ Back to page

406 407
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
09
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

Coastal
Please cite this case study as “Duff H., Faerron Guzmán, C.,
Almada, A., Golden, C., and Myers, S. “Coastal Conservation
takes Root: Education and Economic Agency as a Way to
Protect Sri Lanka's Mangroves. ” Planetary Health Case
Studies: An Anthology of Solutions. 2020; https://doi.
org/10.5822/phanth9678_9

Please note this work is licensed under a Creative Commons

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planetaryhealthalliance.org/case-studies

Takes Root

EDUCATION AND ECONOMIC AGENCY AS A WAY

TO PROTECT SRI LANKA’S MANGROVES
 Executive Summary This case study takes us to Sri Lanka, where mangrove ecosystems
play a central role in the lives of people residing in coastal fishing
communities. An important breeding, feeding, and shelter zone
Further discussion of ecosystem for fish and other marine species, intact mangroves are key in
services and its limitations as a
framework are discussed in the ethics
ensuring food security. Additionally, healthy mangroves safeguard
section of chapter 17 in coastal communities from the full severity of storms and natural
↘ Planetary Health: Protecting Nature disasters. Mangroves also mitigate the effects of climate change
to Protect Ourselves.
by being highly productive ecosystems for carbon sequestration.
Despite providing these services, Sri Lanka’s mangroves have
been threatened by civil unrest, large-scale economic activities
Learning Objectives
such as industrial prawn farming, and unsustainable, small-scale
After examining this case, students household use.
should be able to:

➀ Identify the main threats to This case study looks at why an approach to mangrove conservation
mangrove ecosystems. must be considerate of coastal communities and the complex
➁ Analyze the importance and
factors motivating their interactions with mangrove ecosystems.
connections of mangrove ecosystems The Seacology-Sudeesa Sri Lanka Mangrove Conservation Project
in relation to human health. educates stakeholders at both the community and government
➂ Appraise the utility of the
level about the financial and health benefits of intact mangroves.
ecosystem services framework. The program also focuses on the economic well-being of coastal
communities which, combined with an increased understanding
➃ Develop projects, programs,
and policies that consider complex
of mangroves, has emboldened people to become environmental
social and environmental contexts, activists.
while being inclusive of community
members.
By pairing grassroots empowerment with scientific research
into mangroves, the two organizations have shifted government
perception of the ecosystem. This effort has led to a core policy
win: lobbying the Sri Lankan government to become the first
country worldwide to nationally protect its mangroves.
This case study is based on interviews conducted in Colombo, and Sri Lanka’s
Northwestern and Northern provinces in January 2019.

411
Introduction It’s mid-morning, and Douglas Thissera sits on the bow of a small Less visible are the salt secreting glands and the miniscule micro-
motorized boat puttering through the Chilaw Lagoon. Found filtration systems that allow the roots to extract freshwater and
off the west coast of Sri Lanka, the lagoon’s shallow waters are a secret excess salt. While each of the 22 species of mangroves found
brackish blend of freshwater from inland rivers and saltwater from in Sri Lanka are adapted slightly differently, they share these
the nearby Indian Ocean. Squinting in the already-sweltering important survival features.
sun, Thissera steadies his digital camera, zooming in to focus on
the water’s edge. To an untrained eye, Thissera is documenting Sri Lanka is not the only place where mangroves are found.
a thicket of unremarkable shrubs and greenery. But those who Mangrove ecosystems exist in most tropical countries, and the
live along this body of water know better: the Chilaw Lagoon is distribution belt runs as far north as parts of Florida and southern
home to nearly every mangrove species found in the country. It is China, and as far south as the Tropic of Capricorn. What’s notable
towards a group of these plants that Thissera is directing his gaze. in Sri Lanka are the novel approaches that have been taken towards
the sustainable management and conservation of mangroves.
Douglas Thissera, Sudeesa’s Director of
Mangrove Conservation, documents the Thissera is one of the people responsible for that shift. Directing
mangroves in the Chilaw Lagoon, not far the boat away from the mangroves and back into one of the lagoon’s
from the Sudeesa headquarters. canals, Thissera looks at ease. That’s perhaps due to familiarity—
he’s lived next to this lagoon his entire life and has been fishing
here since 1974, when he was just an 11-year-old boy. In the past
decades, his role has also been one of protector: defending the
mangroves from deforestation and destruction.

Now, his defender role has an official title: Director of Mangrove

Conservation with Sudeesa, a small fisherfolk federation that
originated along the shores of this very lagoon. Together with
a team of coastal residents, a collection of community-based
organizations and, since 2001, a partnership with an American
non-profit environmental conservation organization called
Seacology, Sudeesa has turned the tides on the behavior that was
putting the country’s mangroves at-risk. A loss of mangroves would
mean an inability for coastal communities to benefit from their
Often mistaken for a single type of tree, mangroves are any group many important services, including providing a breeding ground
of plants that grow in intertidal areas like the Chilaw Lagoon— for food fish species and offering coastal protection from storms
environments where terrestrial and marine ecosystems meet, and and natural disasters.
where fresh and saltwater mix. Mangroves survive in these muddy,
salty environments because of a number of genetic adaptations, Today, the mangroves in the Chilaw Lagoon—and the others
including their most recognizable feature: a distinctive series of found in Sri Lanka’s 82 major lagoons—are nationally protected by
prop roots that increase the tree’s stability and appear as dozens government policy. In 2015, Sri Lanka became the first country in
of narrow stilts jutting out of the green shrubbery and into the the world to nationally protect its mangrove ecosystems. Sudeesa
mudflat. Pulling the boat closer to a grouping of mangroves, and Seacology were at the forefront of making that happen.
Thissera points at the shiny surface of the leaves, glossiness that
helps reflect intense sunlight. The stubby fingers growing upward
out of the mud are another adaptation: respiratory roots that
transport oxygen into parts of the root system buried in mud.
412 413
Distinctive mangrove roots are
clearly visible on this mudflat
in northern Sri Lanka.

414 415
The Pearl of the Indian Sri Lanka is an island country in South Asia, located off the an estimated one in three people were displaced at the height of
Ocean southeastern tip of India. Despite a land area smaller than the war.5
the majority of American states, the teardrop-shaped island is
geographically diverse. Mountain peaks and valleys dominate The conflict also took an environmental toll that made it difficult
the central and southern regions of the country. Many of those for people returning home to resume environment-dependent
interior hillsides are covered by commercial tea plantations—a livelihoods. For one, mangroves in the Northern Province were
cash-crop industry introduced when Sri Lanka, then called Ceylon, extensively cleared to allow for better lines of visibility between
was a British Crown colony. Ceylon tea remains the country’s opposing forces. Inland, returnees found that many agricultural
i Sri Lanka is the fourth largest largest export today.1i The hill areas flatten into coastal plains, areas still contained unexploded landmines and that irrigation
producer of tea in the world, after
countryside dominated by fluorescent green rice paddy fields for farming was affected by contaminated waterways and wells.6
China, India, and Kenia.
which produce the staple food of Sri Lankan cuisine. Then, there’s And while Jaffna district, the largest in the north, had contributed
the 1,700 kilometers of coastline. Sandy beaches rim the island and a quarter of the country’s marine fish production in pre-war
a series of lagoons, estuaries, and canals dip inland, providing the years, production dropped to as low as 3 to 5% in 2002.7 Post-war
ideal environment for mangrove ecosystems like the ones found in resettlement has meant pockets of extreme poverty remain in Sri
the Chilaw Lagoon. Lanka, with three of the poorest districts found along the coast of
the Northern and Eastern provinces.8ii ii Those three coastal districts are
↘ Appendix 1: Map of Sri Lanka (source) Mullaitivu (28.8% in extreme poverty),
Mannar (20.1%) and Batticaloa (19.4%).
Kapila Gunarathne, the National Coordinator of the International
Sri Lanka’s 14 coastal districts are some of the country’s most Union for the Conservation of Nature’s (IUCN) Mangroves for
populous regions, with people concentrating in urban centers the Future program says the lengthy civil conflict and the need to
like the capital city of Colombo, Galle and Matara in the south, make money in the years following meant development often took
Batticaloa in the east, and Jaffna in the north. An estimated 25% priority over mangrove protection.
of the country’s population of 21.44 million live along the ocean,
and the coast is home to nearly two-thirds of Sri Lanka’s industry, ↘ Drone Flyover: Mangroves from Above
with marine fishing and aquaculture making up the brunt of that
economic activity.2 Extreme poverty rates have dropped from 13% “When mega projects came, poorer families saw they could
in 2002 to less than 3% a decade later, and the country has one of have a livelihood from that project. They were not in a healthy
the lowest extreme poverty rates in the region. economic position to oppose them,” Gunarathne says of economic
development he saw while working in the Eastern Province
Sri Lanka’s Civil War immediately following the war. “People just wanted to survive.
The end of Sri Lanka’s 26-year civil war is one reason for the Because of the poverty and this weak link between mangroves and
decrease in extreme poverty. Occurring between 1983 and 2009, the the coastal community it allowed groups to invest money and do
civil war was a conflict between the Sinhalese majority Sri Lankan projects as they wish.”
government, and the Liberation Tigers of Tamil Eelam (LTTE), a
group known more commonly as the Tamil Tigers. The latter was While development and jobs are necessary, Gunarathne and other
fighting for an independent state to be created in the north of the mangrove advocates in Sri Lanka say they should not come before
country. More than 100,000 soldiers and civilians were estimated calculating the value lost by destroying mangrove forests. Balancing
to have died, particularly during the final months of the civil war. 3 the conservation of any ecosystem with economic development
By the end of the conflict, hundreds of thousands were forced becomes more clearly justified when people understand the many
from their homes, becoming either internally displaced persons or ways in which those ecosystems support people and planet.
refugees, most commonly in Tamil Nadu state in southern India.4
These effects were felt more acutely by the Tamil minority living in
conflict areas in the Eastern and Northern provinces. In the latter,
416 417
 Dr. Mala Amarasinghe has dedicated
The Value of Mangrove Mangroves are found along tropical and subtropical coasts in 118 her entire career to studying Sri Lanka’s
Ecosystems countries worldwide. According to a 2010 study using satellite mangrove ecosystems.
data to plot the worldwide distribution of the ecosystem, three
quarters of mangroves are located in just 15 countries, the majority
iii ↘ Click on this link, to see a in Southeast Asia. Less than 10% are in protected areas.9 Globally,
world map from the World Resource figures estimate that between 20% and 35% of mangrove area has
Institute and Global Forest Watch
to determine where mangroves are been lost since 1980.10 The extent of that loss is greatest in low
located (make sure to zoom in!) income countries across Asia.iii

According to most recent data from a 2010 Forest Department

survey, Sri Lanka is home to approximately 157 square kilometers
of mangroves11—though figures in recent years have estimated the
extent may be double. Either way, mangroves make up less than
10% of the country’s total forest cover,12 and a small percentage of
iv That’s only 0,1% of the worlds the global mangrove extent of 137,760 square kilometers.13iv More
terrestrial land. However, around 3% than 20 species of mangrove trees are located along the narrow
of the world’s population live near a
mangrove. For more information, coastal belt, with the largest distribution in the Northern and
↘ read the Atlas of Ocean Wealth. Eastern provinces, and Puttalam Lagoon in North West Province. Every natural ecosystem has value beyond what people can tangibly
In Sri Lanka, coastal management and ownership falls under see and sell. “Natural resources are produced and reproduced
the responsibility of various government departments, though through a complex network of ecological processes,” Amarasinghe
historically coastal communities have been able to access and wrote in a 1997 research paper.14 These processes include
utilize the areas for their own needs. photosynthesis and decomposition. While both are required for
life on Earth, this natural productivity has zero value in today’s
↘ Appendix 2: Distribution and extent of mangroves in the coastal market. In other words, a piece of mangrove wood can be sold for
districts of Sri Lanka (source) a certain financial figure, whereas it’s much more difficult to put a vi Before moving forward: If you were
tasked to put a monetary value on
dollar figure on the value that would have come from keeping that an ecosystem like a mangrove, how
While mangrove area may be minimal in comparison to other tree alive.vi would you go about it?
types of forest, Dr. Mala Amarasinghe says it’s a mistake to focus
v Total forests account for around 40 on area alone.v A Professor of Botany at the University of Kelaniya Other examples of this tension exist worldwide (and in this case
million square kilometers Mangroves near Colombo, Amarasinghe is one of Sri Lanka’s leading mangrove study anthology): cutting down the rainforest may allow for
are about 0.3% of total forest cover
globally. researchers. “If we go just by the number of mangrove species and billions of dollars to be extracted from new oil palm concessions,
where they are found, we forget their critical importance for life on but disregard the role those forests played in provisioning clean
Earth,” she says. Instead, Amarasinghe wants people to determine water for communities. Over-exploitation of a marine area may
the ecological value of mangroves based on the services they reap short-term benefits for some, but those benefits may pale in
provide. “We need to know how much value we are going to lose comparison to the costs of reduced food production or tourism
when we convert these wetlands into something else,” she says. revenue in the long term.

The way society assesses the services produced by nature has

evolved over time. In 2005, the Millennium Ecosystem Assessment
popularized the term ‘ecosystem services,’ which categorized
the four services produced by nature: provisioning, regulating,
habitat (also known as supporting services), and cultural. This
categorization proved to be an influential way to attach a dollar
418 419
 figure to some of the invisible and undervalued functions of Apart from potentially undervaluing the non-material values
ecosystems. That value could then be directly compared to the of natural systems, a second criticism of the ecosystem services
value pegged to commercial market use. framework is that it can only account for the services that have been
quantified. Because science is ever evolving, our understanding
However, a criticism of the ecosystem services framework was of the biology and ecology of natural systems can never represent
that it was too economics-focused. In recent years, the academic a full tally of the values associated with a functioning ecosystem.
and policymaking community has moved towards a new way Ethnobotanists and biologists are discovering new compounds with
of framing the values offered by the natural world. The latest value to medicine and manufacturing; biological solutions, evolved
framework, created by the Intergovernmental Science-Policy over millennia, can form the basis for biomimicry in manufacturing
Platform on Biodiversity and Ecosystem Services (IPBES), uses the and design.
term ‘nature’s contributions to people.’
Appendix 3a / 3b: Two IPBES figures – the evolution of ecosystem services
It recognizes that many groups, particularly Indigenous and the non-material, material, and regulating categories of ‘nature’s
communities, reap significant non-material benefits from natural contributions to people.’ ↘ Link to 3a; ↘ link to 3b (source)
systems. This framework also includes perspectives from social
sciences, the humanities, and other disciplines, in an aim to Currently, the value of Sri Lanka’s mangroves has been assessed
understand how cultural context dictates the relationship people using the older model of ecosystem services, and advocates say it
vii Does nature have any “special” have with nature. By shifting this framing, the aim is to more is still this economic-focused outlook that has the most influence
value for you? Is nature part of your effectively emphasize the non-material (or ‘priceless’) value that on policymaking and conservation efforts in the country. To that
identity? Why, or why not? How nature has for certain groups of people—for example the role end, one ecosystem services study places the value of mangroves in
do western worldviews differ from
indigenous worldviews regarding natural systems can play in shaping cultural identity or providing Southeast Asia, including in Sri Lanka, at an average of US $4,185 per
nature? spiritual connection and inspiration for communities.vii hectare per year,15 which is $418,500 per square kilometer. Drawing
on data from four dozen studies on Southeast Asian mangroves, this
calculation valued ecosystem services such as fuel wood, fisheries,
Shanika Lakmali and her three daughters
behind their home in Kalipatiya. While coastal protection, and water quality.
her family does not rely on the mangroves
for their livelihood, Shanika does enjoy Based on this figure and the estimated 157 square kilometers of
taking her three girls to walk among and
admire the mangroves.
mangrove extent mentioned earlier, Sri Lanka’s mangroves provide
more than $65.7 million in annual material value. This figure would
arguably be higher today if the assessment also accounted for the
non-material value of mangroves.

Mangroves also play an integral role in the country’s Blue Economy.

A term coined by the World Bank to explain the “sustainable use
of ocean resources for economic growth, improved livelihoods and
jobs, and ocean ecosystem health,”16 the concept acknowledges how
the three are deeply intertwined.

People residing in Sri Lanka’s coastal communities reap the greatest

benefits from the Blue Economy and the contributions provided
by mangroves—they’re also the ones who are disproportionately
affected when they’re destroyed.

420 421
 Food Security and Sustenance Brush Parkviii Fishing in the Negombo Lagoon
The waters that fringe Pappamoddai are a serene juxtaposition
to the flurry of activity happening at the small weighing stations Dr. Menake Gammanpila is verifying the scientific value of these traditional methods. He says Indigenous
knowledge passed down from father-to-son has been used to create the best practices that help brush park
along the shore of the Northern Province town. The sun has just fishers maximize their yields. That includes:
risen. It’s prime business hour. Men hoist fish-laden nets from
their boats and dump the night’s wriggling catch onto the concrete • Installing brush parks near main canal segments to allow them to better come in contact with migratory fish
floor. Birds swoop into the scene, eagerly sampling the remnants of routes;
crab legs and fish scum that stain the floor of the boats. Large blue • Harvesting the brush park within 30 days of installation;
nets have been spread across the road and bushes, left to dry before • Releasing young fish that may be caught in the brush park to allow them to reach maturation;
the next day of fishing. This is a daily routine for the fishermen in • Using branches from different mangrove species depending on the species of fish or prawn a fisher is
Pappamoddai, and for Jacopillai Thomai, it’s the way he’s started attempting to catch.
the better part of the past 45 years.
By verifying the value of this Indigenous knowledge, Gammanpila is using his research to find a compromise
between unwritten customary fishing practices and government rules and regulations. “The government
should understand this traditional knowledge, otherwise they compete with it. We can use this knowledge for
management strategies to conserve these fishing activities,” he says.

After all, he says the government and fishing communities are working towards the same goal: conservation.
“The brush park fishers are not doing any harmful activities to destroy the mangroves. They know the
importance of those resources and they are not going to destroy those things. The government and brush park
fishers should be sitting at the same table to discuss decision-making for the lagoon.”

“The prawns and fish breed and grow in the lagoon area under the viii Brush parks are one of the
mangroves,” Thomai says, crossing his arms and looking down at traditional fishing methods used in the
Negombo Lagoon. ↘ Click here to see
a stray dog nuzzling its nose in a drying net. Today, his personal what brush parks look like.
catch is 15 kilograms of small prawns. During other seasons he can
bring in as much as 50 kilograms at a time. Not the best day, he
shrugs.

Mangroves support the breeding, feeding, and nursery location

of many fish species. For example, some fish lay eggs in mangrove
ecosystems. Once those eggs hatch, the fish larvae swim into the
complex stilted root system, which protects them from predation,
strong waves, and temperature variation. Aside from physical
protection, mangroves also play a key role in marine food chains.
Certain species feed on the mollusks and other invertebrates that
grow in the mangrove mud. Within the lagoon, decaying leaf
Crabs, prawns, and fish—and in turn, the
people who fish and eat them—depend litter supports the growth of the phytoplankton and zooplankton,
on healthy mangrove ecosystems. This is which are eaten by bottom feeding fish.17
part of the daily catch by a fisherman in
Sri Lanka’s Northern Province.

422 423
 The life cycles of mud crabs and tiger prawns, two commonly After 2009, they resettled in Pappamoddai and Thomai resumed
harvested types of aquatic fauna in Sri Lanka, are also inherently fishing. The environmental destruction from the civil war had left
linked to mangroves. In studies further south from Pappamoddai, notable impact.
70 commercially valuable species of finfish and crustaceans have
been documented in mangrove ecosystems.18 This connection “I saw areas with no mangroves where the sand and dirt was in
has been drawn elsewhere in the world, including in the Florida the lagoon, and there was no way to pass in our boat. It is much
Everglades, where a decline in critically endangered goliath more difficult to collect fish in these areas. The mangroves stop
grouper fish was linked to a decline in mangroves.19 the sand from going in the water,” Thomai notes. Like Douglas
Thissera, Sudeesa’s Director of Mangrove Conservation, Thomai’s
↘ Appendix 4: Life cycle of Tiger-Prawn (penaeus monodon) knowledge comes not from a formal education, but lessons learned
(source: Seacology-Sudeesa Mangrove Museum) from his father and decades of fishing experience.

Fishermen like Thomai understand the connection between their Anecdotally, Thomai says his life wouldn’t be the same without
livelihood and mangrove health. Thomai is also happy to be back mangroves. “It is the perspective of us fisherfolk that the mangroves
at the coast after he and his family were displaced during the civil are our gift from God. They are our livelihood base.”
war. The conflict forced the family inland and restricted Thomai’s
access to the coast—his family had no income during that time. Coastal fisheries play a key role in supporting human health and
well-being. Along with rice, fish is a staple food in Sri Lanka’s
coastal communities and increases the intake of protein and
micronutrients such as iodine, vitamin D, and omega-3 fats.20
While fish are an important source of these micronutrients for
people worldwide, they’re especially vital to coastal communities
where access to other food sources may be limited or prohibitively
expensive. Eating too few micronutrients has been linked to
nutritional deficiencies and non-communicable diseases, as people
turn to processed food that is often less expensive and more easily
accessible.21

Fisheries also provide an important livelihood. FAO figures

estimate that 59.6 million people worldwide are employed by
primary fishing activities and production, including aquaculture.22
Another paper estimates global marine fisheries could support
up to 260 million full-time and part-time jobs, with 210 million
people employed through indirect sectors such as manufacturing
and processing.23 In lower income countries, small-scale fishers
like Thomai make up the majority of the fisherfolk.ix ix Although small scale fishers account
for 90% of the fishery workforce, they
represent only about 50% of the total
The livelihood opportunities presented by healthy mangroves catch. Source: Mora et al. 2009.
extend beyond direct fishing activity. The provisioning service of
mangrove ecosystems in Sri Lanka also includes the collection of
firewood, use of bark in creating fishing nets, home construction,
fruit collection, and traditional medicine.
Fisherman Jacopillai Thomai.

424 425
A mangrove-fringed fishing site in Sri
Lanka’s Northern Province.

426 427
 The tsunami damage in Sri Lanka
The Medicinal Properties of Mangroves following the 2004 tsunami. Photo by
MediaJet, via Wikimedia Commons
Mangroves have played an important role in traditional medicine in Sri Lanka, and scientists are now studying
the implication the species could have on modern medicine.

Scientists at the University of Colombo in Sri Lanka are researching how extracts from the leaves and stem bark
of select mangrove species could be used to improve human health. In adapting to their hostile, high-salinity
environments, research shows mangroves develop unique compounds that could be useful in creating new
cancer treating drugs. The hypothesis is that the cytotoxicity (toxic to living cells) of the leaf and stem bark
extract could be used to limit the spread of breast cancer cells and hepatocellular carcinoma cells, commonly
associated with liver cancer. The conclusion was that extracts from certain types of mangroves found in Sri
Lanka could be used for cancer therapy.24

The research also highlighted a variety of traditional medicinal uses of mangroves in the country, from the
treatment of diabetes, hepatitis, typhoid, and ulcers, to more common ailments such as diarrhea, nausea, and
vomiting.

Tsunami Mitigation Something became apparent as the country took toll of the
An important environment for water and food access, 90% of Sri damage: coastal communities that had intact mangrove forests
Lanka’s coast is considered vulnerable to tsunamis and storm had been less affected than those with no mangroves. This was
surge.25 In the case of these natural disasters, mangroves offer vital true of communities not only in Sri Lanka, but in the South Indian
protection. state of Tamil Nadu and in coastal Indonesia.

The regulating abilityx of mangroves received a tragic public The mangrove roots and stems absorbed the hydraulic force of the
x Which is to say the name for the relations boost in the months following December 2004. On tsunami waves, converting it into vibration energy and reducing
category of ecosystem service. December 26 of that year, a tsunami triggered by a 9.0 magnitude its impact on homes and communities.27 As for the influx of water,
earthquake off the Indonesian island of Sumatra devastated it was channeled into the networks of mangrove creeks, reducing
countries across Asia, including Sri Lanka. More than 35,000 flooding and saltwater intrusion into inland agricultural fields.
people died in the country and over half a million were displaced.26 Natural vegetation and landforms that have the ability to mitigate
Waves extended as far as two kilometers inland, wiping out entire the effect of waves and storm surges have been given the name
towns along Sri Lanka’s eastern and southern coasts. ‘bioshields.’28

Nasiva was one of the Sri Lankan communities offered natural

protection from a bioshield. The small village is found in Batticaloa
district, one of the east coast districts most affected by the tsunami.
A sandy beach, coconut palm plantation, and the Odu Lagoon are
found in the 800 meter stretch between the coast and the village.
In 2004, that lagoon was rimmed with a five to six meter belt of
mangroves. It was these mangroves that bore the brunt of the
waves that pounded the shore.

428 429
 Post-tsunami environmental assessments found a high level of The risk of increased sea level intrusion is met by one of potentially less freshwater. Sri Lanka has three climatic
damage to those mangroves: prop roots completely uprooted and zones: wet, dry, and intermediate. The largest extent of mangroves is found in the dry zone, making them vulnerable
plants permanently left leaning because of the force of the waves. to changing weather patterns. Precipitation levels have declined in 13 out of 15 monitoring stations across the
“The damage observed to mangroves visibly decreased as their country since the 1950s,32 and a reliance on rain-fed agriculture means the natural flow of freshwater rivers could be
distance from the sea increased,” noted an International Union redirected in order to supply irrigation systems. Both sea level rise and the possibility of decreased water reaching
for the Conservation of Nature (IUCN) assessment. “It was also coastal lagoons will impact the health of mangrove ecosystems in the long-term.
observed that where mangroves were dense and thick, the damage
was generally limited to the frontline 2-3 m.”29 The tsunami caused
no human casualties in Nasiva, and only minor structural damage Conservationists in Sri Lanka say the 2004 tsunami opened the
xi This annual amount is still just a
to homes—a far cry from villages razed by the tsunami. The six- fraction of the amount of gasoline
eyes of everyday people and the government to the value of healthy
meter waves had dissipated to just 40 centimeters by the time they used in the United States each mangroves. While there is some pre-2004 evidence of people
reached the community. day—7.7 million liters of gasoline is the planting mangroves along the shoreline to lessen the effects of
equivalent to just over 2 million U.S.
gallons. Figures from the U.S. Energy monsoon storms and prevent erosion,33 this behavior was limited.
Nasiva wasn’t the only village to benefit from a mangrove bioshield. Information Administration report “People only thought earlier of the value that could come when you
The IUCN assessment revealed less inland damage in other coastal that 391.71 million gallons of gasoline change mangroves into some other type of land use,” says Kapila
are used daily in the United States.
areas with thick belts of mangroves. This natural security feature (https://www.eia.gov/tools/faqs/faq. Gunarathne with IUCN. “After the tsunami, mangroves were
is not exclusively linked to mangrove ecosystems—sand dunes php?id=23&t=10) discussed more deeply and widely, and became popular.”
and other varieties of trees were also found to offer protection,30
though trees were less likely to survive in the weeks following the This popularity wasn’t always the case, however, and mangroves
tsunami due to increased soil salinity.31 have historically faced human-caused destruction.

Carbon Sequestration and Climate Change Mangroves Under Threat Dr. Mala Amarasinghe, the mangrove researcher at the University
of Kelaniya, was starting her career when Sri Lanka’s mangroves
It’s not only Sri Lanka’s coastal communities that benefit from the ecosystem services offered by mangrove faced their first large-scale threat. It was 1982, and Amarasinghe
ecosystems. Mangroves are also one of the most effective ecosystems for carbon storage, making them a key player had just become the first junior scientist hired by the National
in global climate change efforts. With a growing interest in carbon financing, Sri Lanka has the potential to tap into Aquatic Resources Research and Development Agency (NARA)
these funds through mangrove conservation. to study the country’s mangroves. She was starting from scratch,
researching an ecosystem that she says was relatively unknown
Researchers in the country are currently focused on measuring the amount of carbon sequestered by the Sri Lanka’s and undervalued by decision makers in the government’s
mangroves. One such study was performed in the Negombo Lagoon in Sri Lanka’s North Western Province. The environmental agency.
lagoon has 3.5 square kilometers of mangrove forests, which were found to annually absorb the amount of carbon
dioxide emitted through the combustion of more than 7.7 million liters of gasoline.xi The amount of carbon stored in That lack of understanding aligned with a period of development
mangroves varies based on species (Sri Lanka has more than 20 species) and the soils in which they grow. This makes in Sri Lanka. By the mid-1980s, shrimp farming had already yielded
it difficult to estimate the economic value provided by this carbon storage service. economic success in Thailand, the Philippines, and Indonesia.34 The
shrimp industry was not new to Sri Lanka, though had previously
While mangroves can mitigate the effects of climate change, climate change can also impact mangrove ecosystems. xii Aquaculture is the controlled involved wild prawns, not those raised through aquaculture.xii The
cultivation of aquatic animals and first semi-intensive aquaculture farms were trialed in the country’s
plants, usually for food.
Sri Lanka has minimal tidal range, meaning the difference between high and low tide is no more than 0.7 meters Eastern Province in the 1970s, but the industry didn’t boom until
in most of the country. Changes in sea level would affect the intertidal areas in which mangroves have adapted, the ponds used for shrimp farming started cropping up across the
disrupting the salt and freshwater balance. “Brackish areas will become more salty and there will be no space for Northwestern Province a decade later, inspired by the economic
mangrove areas to move inland because of encroaching development,” says one official with the International Union success of neighboring countries.35
for the Conservation of Nature (IUCN).

430 431
An aerial scene of industrial-scale
shrimp farms near the Chilaw Lagoon in
northeastern Sri Lanka.

432 433
 That was problematic for mangroves and the people who relied on In the beginning, intensive shrimp farming was seen purely
their various ecosystem services. The ideal territory for intensive through the lens of economic benefit. Unfortunately, coastal
shrimp farming is also the environment in which mangroves exist: communities were not benefiting from the development happening
coastal areas with a large amount of interchange between fresh and in their lagoons. “The investors were mostly from outside the area,
saltwater. Due to the salinity of soil, mangroves were considered and they thought employing the villagers would lead to problems
unsuitable for agriculture, and as a result, undeveloped.36 This was with them stealing harvest. To avoid that, they brought in migrant
the classification given to mangrove areas by the local government, labor from elsewhere so the locals didn’t get jobs,” describes
meaning the forests were viewed as areas yet to be converted into Amarasinghe. Not only did coastal communities not get a stake in
something of value. According to Amarasinghe, that made it easy the farming—they also couldn’t count on the shrimp feeding their
for land to be sold to shrimp farmers—if it was sold at all. Improper families. The majority of prawns were shipped to Japan, the United
monitoring of the industry meant that a large number of farms set States, and the European Union, which remain three of the largest
up in the first years were unauthorized and established wherever import markets of shrimp today.40
state land was available.37 No environmental impact assessment
was necessary. The inability to benefit from jobs in this new and lucrative market xiii Do you eat shrimp? Are you aware
was a factor motivating locals to create illegal shrimp farms.xiii By of its origins? Fishing technique?
Species?
The economic value of shrimp farms was undeniable. The industry 1999, nearly half of all shrimp farms in the Northwestern Province
was growing across Asia, where aquaculture production of shrimp were unauthorized, meaning they had been started without any
increased by more than 420% between 1984 and 1994.38 Shrimp approval or environmental assessment.41xiv xiv Remember, Sri Lanka was going
quickly became one of Sri Lanka’s most important exports, with through a period of civil conflict, and
during which institutions usually get
export value almost tripling between 1990 and 1998.39 These While Sri Lanka’s contribution of shrimp to the global market weakened.
exports infused the country with much-needed foreign exchange was insignificant when compared to exports from Thailand and
earnings—convertible currencies that come only from the sale of other parts of South Asia, the amount of land being converted by
goods on the international market. industry was substantial. Take in Puttalam district in Sri Lanka’s
west coast. Mangrove distribution in the lagoon was 11.81 square
kilometers in 1981. That area decreased by more than half over the
Douglas Thissera gestures at a place
where ponds for shrimp farming have led next decade.42 By this time, Amarasinghe and her colleagues at
to deforestation of the natural mangrove NARA were creating zonal plans to advise the government on areas
ecosystem. where shrimp farms were and were not recommended. Coupled
with a newly introduced environmental impact assessment, the
technical advice was ignored by the government. “After a couple
of months we would visit the places we mapped and saw the area
was under a shrimp farm. It was so frustrating,” Amarasinghe
remembers. She left NARA in 1997, determined to instead quantify
the value of mangrove ecosystems in a way policymakers would
understand.

Poverty as a Determinant of Environmental Destruction

While Amarasinghe was dealing with the shrimp farm expansion
at a government level, Douglas Thissera and his fellow fishers in
the Chilaw Lagoon were witnessing the changes before their very
eyes. The shrimp farms were just the latest example. Mangrove
areas along the western coast were being converted into residential
lots, and around Bentota, a town in the southwest, into hotels. Salt
434 435
 farming had started to dominate the eastern coasts. All the while, “The struggle to conserve mangrove ecosystems was a part of life,”
people living along Sri Lanka’s lagoons were continuing with Thissera recalls, sitting in his Sudeesa office overlooking the lagoon
their traditional use of the mangroves: home construction, bark where he once fished. “The young people always struggled with the
collection to extract tannin for fishing nets, and firewood use. conservation component because the fishing community is not just
limited to conservation activities, but also income generation.” Like
Unlike industrial shrimp aquaculture, these traditional uses were Thomai, the fisherman in Pappamoddai, fisherfolk understood, to
primarily for household means. Bark collection was the only an extent, the value of mangrove ecosystems, but they also knew
traditional use that also had a commercial market.43 It’s important they needed materials for their home, food to feed their family,
to note the difference between the value coastal communities and money to survive. This is one of the reasons why poverty is
glean from mangroves when compared to their larger commercial a determinant of environmental destruction—it forces people to
use by external stakeholders. Fisherfolk use mangroves to meet xv Can you think of other examples in choose short-term gain over long-term benefit.xv
their subsistence survival needs—namely food and shelter. which this is the case? How about in
your home country?
This is inherently different than the purely economic value It’s also why a conservation-only approach to mangrove protection
gained by larger-scale market activities, though both can lead to would not work, says Dr. Leela Batuwitage, Seacology’s Field
overexploitation. Officer in Sri Lanka, and a retired high-level bureaucrat with the
country’s Ministry of Environment. “Environmental conservation
Whether it was limiting small-scale mangrove destruction or as a standalone may be seen as a luxury for poverty stricken
opposing industrial development, Thissera often mobilized communities, without paying due attention to their social well-
the community to help the police arrest the people doing these being,” she says. “I always advocate strongly for environmental
activities. There were no government policies to preserve conservation and I experience the difficulties. If you read Buddhist
mangroves per se, and when traditional avenues of justice principles, they really are about sustainable development, which is
weren’t sufficient, Thissera says he and the other fisherfolk would to say: take the middle path. We need to use our natural resources
sometimes use displays of force, taking the perpetrators’ boats as a but be careful to conserve as well.”
way to enforce conservation.
Boating among the mangroves in
Northern Province, Sri Lanka. Mangrove Conservation It was the early 1990s when Dr. Anuradha Wickramasinghe
Takes Root began to appreciate the striking connection between people and
mangrove ecosystems.
Dr. Anuradha Wickramasinghe is the
Founder of Sudeesa, the Small Fishers
Federation of Lanka. In nearly three
decades of work, Sudeesa has partnered
with communities, government bodies,
and international organizations in order
to create programs and incentives to
protect mangrove ecosystems.

436 437
Born and raised in Kandy, a city in Sri Lanka’s interior hill country, The call from Silverstein was congratulatory in nature.
Wickramasinghe had spent his research and career thus far focused Wickramasinghe was informed he had been awarded that year’s
on conservation management of the forest and water resources Seacology Prize in recognition of Sudeesa’s mangrove conservation
that surrounded his hometown. In 1989 he was urged by a former work. The annual prize recognizes one islander worldwide who
professor from St. Francis Xavier University in Canada to head out has committed to preserving the environment and culture of their
of the hills and towards the coast. home country. With the title came a cash prize of US $10,000, an
amount that went towards setting up a mangrove center in Sri
Thirty years later, Wickramasinghe recalls one story with ease: he Lanka’s Southern Province.
was walking along the river near an estuary and coastal bed when
he saw a mother carrying a fish basket under her arm. Her young The Seacology Prize was the start of a partnership that has
son was running down the beach. Suddenly the mother stopped continued until today, and has developed into the largest project of
and took something from the water and put it in the soil. The boy both Seacology and Sudeesa. The latest iteration of the partnership,
asked “mom, what are you doing?” and the mother said “son, this is the Sri Lanka Mangrove Conservation Project, started in 2015.
the mangrove plant. The fish comes because of this.” Funding for the five-year, $4 million project comes from Seacology
and a grant from the Global Resilience Partnership. Other recent
Wickramasinghe was struck by what he heard. “This is the real recognition has come in the form of the UN Climate Change
rural peoples’ Indigenous knowledge about the mangroves— Secretariat’s Momentum for Change award, where the project was
they know that they’re vital for livelihoods and fish breeding,” a winner in the planetary health category.
Wickramasinghe surmises. “It was because of this moment that I
focused my entire dissertation on this connection.” Seacology had long-recognized the importance of mangroves, and
was partnering with other organizations on small-scale mangrove
Wickramasinghe’s dedication to mangroves has continued far projects in the Philippines, Micronesia, Kenya, and Tanzania, in
beyond his dissertation. In 1992, Wickramasinghe was standing addition to Sri Lanka. By 2015, they wanted to go larger-scale.
by the Chilaw Lagoon when he first met Douglas Thissera. They
discussed the mangroves, Thissera’s experience as a fisherman, “Country-wide protection was what we wanted,” says Karen
and the challenges faced by fisherfolk communities. Together with Peterson, Senior Manager of Special Initiatives at Seacology. “It
other fisherfolk from the lagoon, they established the Small Fishers was a fortunate time for this project in Sri Lanka because of the
Federation of Lanka (SFFL, more commonly known as Sudeesa), war being over and people in these coastal communities really
a network dedicated to protecting the mangroves in 20 villages eager for some new infusion of resources and attention to help
around the North Western Province. As with Wickramasinghe’s them get back on their feet.”
initial research, Sudeesa continued working with women and
children in fishing communities, and he became the first Chairman The project’s large-scale ambition garnered the skepticism of
(Director) of the organization. some, including Kapila Gunarathne with the International Union
for the Society of Nature. Gunarathne says he thought it would be
A New International Partnership more effective for Seacology and Sudeesa to identify smaller case
In 2001, Wickramasinghe fielded a telephone call from an American study areas, places where the project could work with different
number. On the line was Duane Silverstein, the Executive ethnic groups to understand incentives and motivators around
Director of Seacology, a non-profit environmental conservation conservation, introduce various mangrove livelihoods, and observe
organization based in Berkeley, California. Established in 1991, local economic and climatic stressors. Sudeesa’s Chairman, Dr.
Seacology’s mission is to protect “the threatened habitats of the Wickramasinghe, saw it differently: mangroves are located around
world’s islands by working directly with local communities to both the entirety of the country’s and so the Sri Lanka Mangrove
conserve their natural resources and improve their quality of life.” Conservation Project had to be comprehensive in its coverage area.

438 439
 Expanding well beyond Sudeesa’s initial work with 20 communities they had the opportunity to study at all. The training later goes
in a single district, the project now operates in 1,300 villages across on to explain the species of mangroves found in Sri Lanka, and the
the country’s 14 coastal districts. While the scope of the project has role they play in fish breeding and tsunami protection. The women
expanded, Sudeesa’s approach remains the same. The organization nod their heads, and a few kids sit on their mothers’ laps, eyes fixed
has always worked with fisherfolk communities and vulnerable on the glossy posters.
women, and recognizes not only the need for conservation, but
also the important role education and economic empowerment
A group of women in Kalpitiya in
must play. Sri Lanka’s North Western Province
learn how to propagate a mangrove
seedling. Just one aspect of the five
days of training, the training from
The Seacology-Sudeesa The goal of the Sri Lanka Mangrove Conservation Project was to Sudeesa also introduces concepts of
Approach find a way for this same grassroots approach to be scaled across environmental protection and business
coastal communities across Sri Lanka, including those far from skills development. To date, 12,000
Sudeesa’s main headquarters in the Chilaw Lagoon. women across Sri Lanka have received
this training.

The organization knew it wouldn’t be viable to have a staff member

in each community and that leadership needed to come from
a local level. To that end, the project created community-based
organizations (CBOs) in coastal villages across the country. The
CBOs have an average of 10 members, comprised of women who live
xvi Why do you think they chose in the same community.xvi Today, 12,000 women are part of 1,300
women to be the heads of these CBOs in coastal villages across Sri Lanka, a key accomplishment
CBOs?
of the project. The project chose to empower women for various
reasons: despite men formally being the head of household in Sri
Lanka, women are often the ones who manage the family, finances, Manjula Nibsi is one of those CBO members. The training is
and make day-to-day decisions. CBO membership prioritizes happening next to her home, and she hurried through her daily
vulnerable women: those who are widowed or disabled—a housework, laundry, and cooking so she could attend the day-long
particularly common occurrence in the Northern Province due to event. It helps that CBO members receive an allowance of 2,500 Sri
the civil war—and those with low incomes, large families, or who Lankan rupees (about US $14) to attend the five days of training.
have dropped out of school. Despite her lack of prior education, Nibsi knew mangroves were
important to her family’s well-being. “My father and two brothers
Two dozen of these CBO members have gathered at the side of a fish in the lagoons and mangroves. I didn’t know many things, but I
house near Kalpatiya, a town on Sri Lanka’s west coast. They’re understood that fishing is their livelihood, and that the mangroves
taking part in one of the main CBO activities: five days of training were where they do that. The income they make from catching
dedicated to mangrove conservation, CBO management, and crabs and big fish helps pay for my children’s school activities.”
business planning. Shaded by swaying palm trees, they watch as
a Sudeesa trainer shows booklets, posters, and then a mangrove The goal of the environmental education is not to make experts
xvii A propagule is the seed of a propagule.xvii The teachings are broad: explaining the components out of Nibsi and her peers. Instead, it’s a first step towards getting
mangrove used for replanting. of the environment, that trees absorb carbon dioxide and produce them to shift their outlook: understanding that the mangroves are
oxygen, and about global warming and how these women can not only a place that can provide for them, but also an environment
Manjula Nibsi outside her home in
play a part in reducing it by planting more mangroves. The vast that needs protection in order to keep providing these benefits. Kalpitiya.
overview of basic scientific concepts may seem simplistic, but it’s
more than most CBO members have ever learned in school—if
440 441
 The Dual Benefits of Economic Empowerment These days, microloan granting ceremonies are a regular
Improving the economic well-being of women in the CBOs is occurrence for the Sudeesa team. On any one day the team may
another integral facet of Sudeesa’s approach. Two days of Sudeesa’s be visiting a handful of communities, awarding the bright yellow
training are dedicated to financial skills, and women are taught envelopes that contain a new microloan.
to create a business plan for a current or new small enterprise.
Once they’ve completed training and a business plan, each woman
After completing their five days of
is awarded a 15,000 Sri Lankan rupee (approximately US $84) training, women are given a microloan
microloan to put towards her business or getting a larger loan from to start or expand an existing business.
a formal banking institution. Sudeesa had been offering training These women in Moonrampiddi village
have just received their yellow envelopes.
and microloans before 2015, but the amount has since doubled and Repayments are made into a rotating
xviii What are micro-loans? Why are the payback model changed.xviii fund managed by their community
they important to break the cycle of group, as opposed to paid back to
poverty?
While not a substantial amount of money, the purpose of the Seacology or Sudeesa.
microloan is to help women start or expand a business in order to
earn income and better support her family’s needs. That includes
having the financial means to stop cutting mangroves for firewood.
In exchange for the microloan and business training, women
commit to protect and replant local coastal belts. Each CBO is
responsible for protecting 85,000 square meters of mangroves
(an area the size of about 12 football fields). They also commit to
replanting an additional 25,000 square meters, which is around
3,500 mangroves. The mangrove seedlings come from Sudeesa’s
own nurseries or are grown by CBO groups.
Judi Andonitte is a recent microloan recipient. A mother of four
“The microloan is a catalyst that says the project can look after whose husband was left disabled after the civil war, Andonitte is the
them economically,” says Dr. Leela Batuwitage with Seacology. primary breadwinner for her family. She’s spent the past five years
“It is the foundation for further education.” Not only that, but working as a tailor, and also teaches sewing to other women and
women are busy. That’s why a sustainable solution can’t solely girls in Moonrampiddi, her Northern Province village. Andonitte
add another task to a woman’s plate—insisting she replant and plans to use the microloan to buy a second sewing machine, and
protect mangroves, for example. By offering the microloans, hopes to eventually employ another woman from her village. Not
business training, and environmental education, Batuwitage says just an infusion of capital, Andonitte says the financial training
the project aims to more thoughtfully acknowledge the everyday from Sudeesa has taught her how to incorporate bookkeeping
priorities, challenges, and education levels of communities. skills into her business.

“People, especially those living in poverty, need holistic solutions. Sudeesa’s microfinance program has some key differences from
Otherwise it is like five blind men with an elephant. One touches other microloan institutions in Sri Lanka. For one, it avoids the
his leg and he thinks it’s a log. Another touches his ear and predatory lending practices that plagued parts of rural Sri Lanka,
thinks it’s a fan. But they are all missing the bigger picture—that particularly after the civil war. Microfinance companies had been
it’s an elephant,” Batuwitage describes. Focusing exclusively on charging as high as 70 to 80% interest rates on loans, and in 2018
conservation, finance, or education alone is the same. “It’s not only the national Ministry of Finance had to step in and write off the
about looking at one perspective but to see the whole animal. Then debts of more than 45,000 women who had become overburdened
we can better understand,” she concludes. by high interest rates.44

442 443
 CBOs who receive Seacology-Sudeesa microloans decide on Education and the Mangrove Museum
their own payback scheme and interest rates—the recommended Sudeesa goes directly to communities for the one-time CBO
xix The interest rate ceiling of period is one year with 18% interest.xix Loans are repaid directly training. But when it comes to the project’s other key educational
microloans in Sri Lanka is nearly twice to the CBO, creating a rotating fund of repayment plus interest efforts, the purpose is for visitors to come to them.
this, at 35%.
that members can continue to borrow from in the future. This is
different than Sudeesa’s past lending model and the one held by There’s a new set of buildings along the shore of the Chilaw Lagoon
most microfinance companies, where payback is to the institution where Dr. Anuradha Wickramasinghe and Douglas Thissera first
itself. Sudeesa created this new policy based on the lessons met in 1991. The largest and most recent addition is the Seacology-
learned between the project launch in 2015 until the change was Sudeesa Mangrove Museum—the world’s first museum dedicated
implemented in 2018. to the coastal ecosystem. Constructed as part of the Sri Lanka
Mangrove Conservation Project, the museum opened on July 26,
Members say CBO-management of the microloan allows groups to 2016, in celebration of the second-annual World Mangrove Day.
factor in emergencies or other financial hardship. “A community
member might be in trouble if her husband passes away, and she The museum has since received more than 14,800 visits from
may be unable to repay the amount for a few months. The CBO is students of all ages and nationalities, government representatives,
free to look at the situation of that affected community member community members, researchers, and other groups. Similarly,
and make a decision about her payment,” explains Annet Primrose the Mannar Training Center in Northern Province was opened in
Fernando, the coordinator of Sudeesa’s microfinance program. July 2018 with funds from the Global Resilience Partnership. Land
The program has an extraordinary 96% loan repayment rate,45 and for the museum and the Northern training center was donated by
the Sudeesa team supports CBOs as needed. the government, a testament to Sudeesa’s cooperation with local
officials. Both boast various infographic displays about the role of
mangroves, a nursery area with thousands of young propagules, and,
A visual illustration of the financial
in the Chilaw Lagoon location, rows of cases displaying the dozens
and physical support provided by
the microfinance program. Arujodi of fish and crustacean species that live in mangrove ecosystems.
Kulendran, a Sudeesa staff member, is
pictured with a CBO recipient.
The Mannar Training Center is
a museum, training, and meeting space
for mangrove conservation groups.

444 445
 This education and economic empowerment approach was what the community is feeling, which helps them make decisions. We
first attracted Dr. Mala Amarasinghe from the University of Kelaniya are connected to all areas because of our network,” he says. That
to Sudeesa. Disenchanted by what she saw as the Sri Lankan network includes the substantial connections Sudeesa has with
government’s disregard for Environmental Impact Assessments fisherfolk across the country and the professional relationships
and the advice of scientists in the 1980s and 1990s, she realized the Wickramasinghe built with government officials throughout his
solution needed to come from the community. “When I saw what school and working years. A government official with Sri Lanka’s
Sudeesa was doing, I said ‘oh, this is what should be done’ because Ministry of Mahaweli Development and Environment says working
they were straight away dealing with communities and were aware of with the Seacology-Sudeesa project is the most direct way the
their problems and aspirations,” she says. In addition to her role with ministry receives input from the community.
the University of Kelaniya, Amarasinghe works closely with Sudeesa
and the organization’s Scientific Forum to provide the research basis Ultimately, Sudeesa aspires to make itself redundant by strengthening
to understand the role of mangroves and their ecosystem services. the role of community members as enforcers. At a community
level, fisherfolk communities and women’s groups have developed a
sense of ownership and responsibility for the mangroves. That has
Display cases in the Seacology-Sudeesa
Mangrove Museum near the Chilaw prompted people to report mangrove destruction to government
Lagoon. The windows look out onto field officers—representatives from the departments of wildlife and
mangroves at the edge of the lagoon. forestry who have the power of legal enforcement. Sudeesa offers a
day of mangrove conservation training to those officials in order to
enhance their understanding of the value of the ecosystem. Today,
even the Sri Lankan navy has gotten involved with replanting efforts.

From Community to Sudeesa’s connection to local, district, and national levels of

Country-wide government has been valuable. Ultimately, it is still the responsibility
of the Forestry Department and the Wildlife Conservation
Department to monitor the coast and enforce mangrove cutting.
While community members can report mangrove destruction,
their comments would be legally inconsequential if not for the
understanding and buy-in from the government.

Sudeesa’s approach is a compromise between the status quo top- The most significant act of government commitment came in 2015
down environmental management and grassroots management, when Seacology, Sudeesa, and the national government signed
Amarasinghe adds. “Top-down management hasn’t done anything a tripartite agreement to protect the entirety of the country’s
in places like the Chilaw Lagoon. The government has the mangroves. “All the government people are supporting us because
infrastructure, institutions, and laws but it still hasn’t worked,” they know we always take the middle ground and never try to
she says. “The grassroots communities have common sense and interfere politically,” says Dr. Wickramasinghe, adding that NGOs
understanding that the mangroves are important for their own do not normally sign agreements with the government. With that
survival, and that has driven them to protect them. Sudeesa is trying memorandum of understanding (MoU), Sri Lanka became the
xx What are some pros and cons to combine these two.”xx first country in the world to nationally protect its mangroves. This
of top-down and bottom-up protection meant the construction of new concrete posts along the
approaches?
Dr. Wickramasinghe, Sudeesa’s Chairman, sees the organization as coast, demarcating mangrove areas where people cannot fish, chop
a bridge between community perspective and government policy. wood, and do other activities without government permission.
“At policy-level meetings, we inform the government about what Sudeesa and its community-based organizations are still able to run
mangrove conservation activities in these areas.
446 447
A concrete marker that indicates a
coastal mangrove area has been set aside
for protection.

448 449
The 2015 mangrove declaration received substantial international dissolving after they’ve met their reforestation quotas—only to
media coverage. “The declaration focused a lot of positive attention have those mangroves later die. Replanting done under the Sri
on Sri Lanka at a time when [the government] could really use Lanka Mangrove Conservation Project is an exception, as women’s
it,” says Karen Peterson with Seacology. “With the way Sri Lanka groups are trained and their conservation activities are recognized
is growing economically, we wanted to have it out there in the by law.
universe that these mangroves are protected. I take the point that
it is ambitious to protect the mangroves in the whole country, but
Douglas Thissera
we wanted to garner as much attention as possible so stakeholders
know this is the intention.”

The recognition didn’t end with the news coverage, and in

August 2018 Sri Lanka was chosen to lead a Commonwealth-
wide initiative on mangrove conservation. The Commonwealth
of Nations is a group of countries primarily composed of former
British territories. More recently, Seacology was chosen as one of 25
organizations to showcase at Expo 2020 in Dubai—the mangrove
conservation project will be the focus of that display.

Importantly, the 2015 declaration was also the first step in creating
a dedicated national mangrove policy for Sri Lanka. Mangrove
protection in the past had been ad hoc at best—a hodge-podge of
protection under a number of policies, ordinances, and acts, each
from different government departments. The national mangrove
policy was drafted by a taskforce representing a number of key
government departments, academics, and mangrove experts
including members of the Sudeesa team.

The national policy was approved by the Sri Lankan cabinet in

January 2020—a key victory bookending the mangrove protection
efforts Sudeesa started in 1992. The policy is an added layer of
protection for the country’s mangroves and can be used to draft
new laws and government action plans. It also means mangrove
protection is enshrined in law and above any changing political
priorities.

The policy also includes the creation of national guidelines for

mangrove restoration. As Douglas Thissera, Sudeesa’s Director
of Mangrove Conservation is quick to point out, there’s an art to
restoring and replanting. As a result, Sudeesa helps CBOs select
which mangrove species to plant and outlines the distance between
seedlings. An official from the Ministry of Mahaweli Development
and Environment says a lack of expertise around replanting has
been problematic in the past, and has led to small NGO projects
450 451
 Other challenges like corruption could also influence mangrove lot at play that we cannot see as outsiders,” says Karen Peterson
protection. Sri Lanka received a 38 out of 100 rating from with Seacology. “It’s about learning what those vulnerabilities are
Transparency International’s annual Corruption Perceptions for the sake of building flexibility into the program and being able
xxi ↘ Check out the latest CPI report Index,46xxi and Wickramasinghe says it is still one of the biggest to deal with unexpected shocks and stresses.”
here. Zero on the index represents problems in the country today. Still, he remains optimistic,
countries that are highly corrupt, with
100 being very clean. especially because of the declaration of the national protection According to Peterson, Seacology doesn’t start projects assuming it
and the new national mangrove policy. knows what communities want. “We’re going to do everything we
can to make sure what we’re providing is really what people need,
“If corruption happens, we can go to the police,” he says. “If the and this involves going in to the relationship with a very open
police don’t listen, then we go to the court. Having the mangrove mind.” For the Sri Lanka Mangrove Conservation Project, that
policy written is the first step and then a law will come so involved building on the success of Sudeesa’s existing approach,
people know they can’t cut mangroves in that area.” Further, while offering funding and in-kind support. Seacology has assisted
the international recognition Sri Lanka has received by being in administrative and accounting practices over the course of the
a mangrove champion—combined with community activism project, and has also directed international media and academia
around mangrove protection—means people are paying attention opportunities towards Sudeesa.
to the decisions the government makes around the ecosystem.
This public pressure and awareness may lower corruption rates. The Sri Lanka Mangrove Conservation Project ends in May
2020. Following that date, Seacology will continue to monitor
With corruption often stemming from economic pressures, Sudeesa CBO conservation activities and the performance of livelihood
hopes its ongoing appraisal of the ecosystem services offered by initiatives. The organization will also continue to meet regularly
mangroves will put mangrove protection on a level playing field with government officials to track the progress of national-level
with other, traditionally more lucrative means of industry. It’s mangrove conservation activities. Finally, though Seacology’s
not about banning economic development altogether—rather, it’s financial support of Sudeesa will end, the organization will
approving projects that are more strategic and sustainable. “There continue to fund other smaller-scale conservation initiatives in Sri
are places where prawn farming can be done, and there are places Lanka.
where people can do salt production, but you need to ensure these
areas are not mangrove related,” says Douglas Thissera, Sudeesa’s
In exchange for the skills training and
Director of Mangrove Conservation. Thissera says the economic microloan, the Mangrove Conservation
value of mangroves needs to be further quantified in order to Program hopes women will not only
compare dollar-for-dollar the gains and losses between economic conserve and protect existing forests, but
replant new ones, too.
development and environmental conservation. “There should be
a balance so people know that if the natural system is destroyed
then their economic activity is also in trouble,” he says.

The Art of International and Local Partnerships

Outside of the relationships formed with coastal communities and
governments is the connection between Seacology and Sudeesa. The
partnering of an international NGO with a grassroots organization
is not a new model. What is unique is the way Seacology and
Sudeesa work together on the mission of mangrove conservation,
and the fact that their relationship has existed for nearly two
decades. “It really takes time to understand a country, a culture,
the political systems, economic structure, and volatility. There’s a
452 453
Epilogue Replanting, education, and economic empowerment activities in Sudeesa envisions an expansion of the five-day livelihood training
Sri Lanka’s 14 coastal districts will continue after the project’s CBO members received through its former project, offering
2020 end date. One such replanting is happening after a microloan further training on environmental law and business marketing.
ceremony in the Northern Province. Women gingerly lift their It’s also going through the process of registering each CBO under
brightly-colored sarees, unwrap the mangrove seedlings from their the Environment Act of Sri Lanka, providing the groups legal
plastic nursery bags, and swing a hoe into the soft coastal mud. recognition by the government so they can create action plans to
restore and protect local mangrove areas. Building on the small
A mangrove replanting session in financial boost offered by the original project’s microloans, Sudeesa
northern Sri Lanka. wants to help women establish a network of business cooperatives
to better brand and sell their products and access support from the
formal banking system. Each of these activities is to ensure women
across Sri Lanka have the knowledge, resources, and agency to
make their own decisions—with regards to mangrove protection
and for their own lives.

In the coming years, Douglas Thissera will continue mapping the

country’s mangrove areas, creating a resource that government and
communities alike can use to better plot areas for conservation. Mangrove seedlings growing outside the
That, in conjunction with the research Dr. Mala Amarasinghe Mannar Training Center in northern Sri
Lanka.
and others are doing to quantify ecosystem services, are tools to
ensure the national protection of mangroves remain enforced as
Sri Lanka’s coasts face mounting commercial pressures.

As for the Seacology-Sudeesa Mangrove Museum, it could soon

The Sri Lankan government recently reported that 22 square have a new companion. Wedged next to the mangrove nursery
kilometers remain before the country’s entire coastal belt is at the Chilaw Lagoon is a small clearing where Sudeesa hopes to
replanted. An estimated 3.2 million seedlings are needed to complete construct a coral reef museum. Some fish species go into the corals
this task. That presents a next step for groups like Sudeesa—as of and then cycle back to the mangroves, says Wickramasinghe,
early 2020, its CBOs had replanted 700,000 seedlings in nearly 5 justifying the reason for the museum. It’s one of many ways that
square kilometers of coastal area. Sudeesa has not yet confirmed mangrove ecosystems are connected to others, both marine and
if and how it will grow the remaining number of seedlings in its terrestrial. Those ecosystems, in turn, directly influence the health
nurseries or in partnership with CBO members. and well-being of the people who live among them. Long-term
preservation demands the highlighting of this, as well as holistic
After replanting sessions, women return home to countless other solutions that consider the complex realities of people—fisherfolk
household responsibilities. The hope of Seacology and Sudeesa and beyond.
is that defending the mangroves will continue to be one of these
responsibilities, especially now that women understand the value
they bring to their families. Sudeesa plans to continue supporting
these CBOs even after the Sri Lanka Mangrove Conservation
Project with Seacology finishes—though it needs renewed funding
to do so. Dr. Anuradha Wickramasinghe has expressed an interest
in preparing funding proposals for Sri Lankan government
ministries and international groups like embassies and NGOs.
454 455
Keeping Track Dr. Mala Amarasinghe Judi Andonitte Dr. Leela Batuwitage Annet Primrose Fernando Kapila Gunarathne
of Who’s Who
Professor of Botany and mangrove Community-based organization member Sri Lanka Field Officer, Seacology Microloan coordinator, Sudeesa National Coordinator of the
researcher, University of Kelaniya in Moonrampiddi International Union for the Conservation
of Nature’s Mangroves for the Future
program

Manjula Nibsi Karen Peterson Duane Silverstein Douglas Thissera Jacopillai Thomai
Community-based organization member Senior Manager of Special Initiatives, Executive Director, Seacology Director of Mangrove Conservation, Fisherman in Pappamoddai
in Kalpatiya Seacology Sudeesa

Dr. Anuradha
Wickramasinghe
Chairman, Sudeesa

Acknowledgements I was fortunate to visit a number of villages across Sri Lanka, and
am grateful to each of those communities and groups for opening
their homes and celebrations to me. Thank you to the Seacology
team, especially Karen Peterson and Dr. Leela Batuwitage—Dr.
Leela and I shared many hours in a taxi from Negombo to Chilaw,
and I always appreciated her insights and candor. To Dr. Anuradha
Wickramasinghe and everyone with Sudeesa: you are doing such
important work, and I am grateful for your kindness, coordination
help, and humility. I also appreciate the generosity extended by Dr.
Anuradha’s wife, Kumari, during my visit to Kandy. Conversations
and lagoon outings with Dr. Mala Amarasinghe and Dr. Menake
Gammanpila brought a greater scientific vigor to this case. Finally,
Michelle Ng provided some helpful contextual research at the start
of this case—thanks, Michelle!

Surrounded by mangroves, a fisherman sits in the shallows of Negombo Lagoon on the northwest coast of Sri Lanka. Visible to his right
are the distinctive stilt roots that make up mangrove species.
456 457
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458 459
Appendix 1 - Map of Sri Lanka ↘ Back to page Appendix 2 - Distribution and extent of mangroves in the coastal districts of Sri Lanka ↘ Back to page

460 461
Appendix 3a - The Evolution of Ecosystem Services ↘ Back to page Appendix 3b - The 3 categories of nature_s contributions to people ↘ Back to page

462 463
Appendix 4 - Life cycle of Tiger-Prawn (penaeus monodon) ↘ Back to page

464 465
 This anthology is a project of the Planetary Health Alliance
(planetaryhealthalliance.org). The Planetary Health Alliance
is a consortium of over 200 partners from around the world
committed to understanding and addressing the human
health impacts of global environmental change.
10
Case studies were written and photographed by Hilary Duff
with editing and support from Amalia Almada, Christopher
Golden, and Sam Myers. Teaching guides were written by
Carlos A. Faerron Guzmán.

The
Please cite this case study as “Duff H., Faerron Guzmán,
C., Almada, A., Golden, C., and Myers, S. “The
Interconnectedness of People and Planet: Learning from
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LEARNING FROM MAORI WORLDVIEWS

 Executive Summary Many Indigenous perspectives on health and well-being are well
aligned with the emerging field of planetary health. In Aotearoa
New Zealand, the Indigenous Māori population has long
This case study addresses issues of understood the interconnectedness between the natural
traditional knowledge, connection
to place and mental health which are
environment and human health and well-being. This is reflected in
also explored in chapters 9 and 18 of Māori worldviews and their conceptualization of health and well-
↘ Planetary Health: Protecting Nature being: hauora.i Hauora values a number of dimensions, including
to Protect Ourselves.
the emotional, mental, social, and spiritual well-being of families.
It also articulates the fluidity that exists within the Māori sense of
i As noted by Dr. Fiona Cram et
al in a 2019 report on Māori health identity: that an individual’s personhood hinges not only on one’s
inequities, the terminology used physical health, but also on the well-being and protection of their
to describe health and well-being community and the natural world.
and the act of achieving it has
changed over time. Hauora is one
term currently in use, as are waiora, Despite this deep understanding of the integrated nature of
rapuora, and whakaoranga.
human health and a flourishing natural environment, Māori
and Indigenous people worldwide are among the groups most
Learning Objectives
vulnerable to environmental change. These changes exacerbate
After examining this case, students the ongoing effects of colonialism, and the destruction of the
should be able to:
natural world has significant implications on the physical, mental,
➀ Recognize the existence of diverse and spiritual well-being of Māori tribes.
worldviews and cultures, including
one´s cultural values, identities, and
assumptions, and their effect on the
The New Zealand government has made some progress in
understanding of others in the context recognizing and modeling Māori worldviews of health and well-
of planetary health. being in its healthcare and natural resource policies—though
➁ Compare and contrast how
many shortcomings remain. This case reiterates the importance
Indigenous worldviews and of meaningful relationship-building and partnership in order to
traditional knowledge systems differ learn from Indigenous ways of knowing to strengthen our ability
from dominant western thoughtii
concerning the relationship to the to address the unique challenges faced in the Anthropocene.
natural environment.
This case study was drafted based on interviews conducted in Aotearoa New Zealand in
➂ Describe how Indigenous July and August 2019. It was reviewed by Gabrielle Baker (Ngāpuhi) in September 2019.
worldviews and lived experiences
determine the extent of the
consequences of anthropogenic
environmental change.

➃ Apply intercultural principles and

Indigenous knowledge appropriately
to health-related actions, projects,
programs, and policies.

ii Although a contentious term, for the

lack of a better word, we use western
thought to describe the post-colonial
dominant worldviews imposed
throughout many part of of the world
mainly by European colonials and
settlers.
469
A Note on Language This case study uses the te reo Māori terms for Māori concepts. Te Mana (pronunciation) - a sense of authority, control, or power;
reo Māori, which translates to “the Māori language,” is an official a sense of “awesome.”
language of New Zealand. Around 55% of Māori adults have some
ability to speak te reo Māori,1 and the language is increasingly used Māori (pronunciation) - Indigenous person of Aotearoa.
in official government documents and in the media. The original inhabitants of New Zealand.

While it’s difficult to directly translate concepts to definitions, this Maramataka (pronunciation) - Māori calendar based on the cycles
case study draws from the explanations received by the case study of the moon.
author and confirmed by the case study reviewer. Te reo Māori
proficiency is one of the measures used to gauge a person’s cultural Marae (pronunciation) - the courtyard of a Māori meeting house,
well-being.2 The te reo Māori name for New Zealand, Aotearoa, often used for ceremonies and meetings; a significant place in Māori
is also used in this case. Both describe the island country. Finally, culture.
this case indicates iwi (tribe) affiliations. Iwi identities are listed in
parentheses after the first mention of a person’s name. Mātauranga (pronunciation) - the body of traditional and
contemporary knowledge about the world—both physical and
We encourage readers to visit the Māori Dictionary website, where spiritual—held by Māori. It also involves ways of knowing.
you can find definitions and audio pronunciations (linked below).
The New Zealand Ministry of Education has also developed Mirimiri (pronunciation) - a massage; considered a rongoā
a helpful pronunciation guide. treatment.

Rongoā (pronunciation) - any medicine, drug, or treatment;

Glossary Aotearoa (pronunciation) - the te reo name for New Zealand. not always physical in nature.

Hapū (pronunciation) - a clan or subtribe that is part of a larger iwi Taonga (pronunciation) - a treasured item (physical or non-physical).
and made up of a number of whānau groups.
Te Tiriti o Waitangi (tay tear-ee-tea oh wah-tan-gi) - the treaty signed
Hauora (pronunciation) - a Māori term for health or vigor. Typically in 1840 by North Island iwi chiefs and the British Crown.
includes four pillars: physical well-being, mental and emotional
well-being (self confidence), social well-being (self esteem), spiritual Tikanga (pronunciation) - a procedure or custom.
well-being (personal beliefs).
Utu (pronunciation) - the Māori concept of reciprocity.
Iwi (pronunciation) - people or nation. Iwi are the largest partition
of Māori society and often compose several hapū which then include Whakapapa (pronunciation) - to place in layers, to establish
whānau. genealogy and ancestry not only with other human beings but
among other species, too.
Kaitiakitanga (pronunciation) - the Māori concept of guardianship
or stewardship. Whakawhanaungatanga (pronunciation) - the process
of establishing relationships and relating to others.
Karakia (pronunciation) - a prayer or blessing.
Whānau (pronunciation) - extended family including multiple
Kaumātua (pronunciation) - a respectful term used for older folks. generations; the smallest partition of Māori society.

Kaupapa (pronunciation) - a theme or topic for discussion. Whenua (pronunciation) - land, placenta, afterbirth.
470 471
Introduction Standing next to a strip of overturned soil, Hone Moetara A range of practices constitute rongoā, including the rongoā rākau
(Ngāpuhi) envisions the future. The strip of land is a couple plant remedies and mirimiri (massage). Sometimes these practices
iii A marae is a traditional gathering hundred meters long, bordered on one side by the Paparoa Maraeiii treat a physical malady, such as the symptoms Moetara mentioned
place and a sacred focal point of and a train track on the other. Every so often the peace of the rainy earlier. But he and others are quick to add that the practice of rongoā
Māori society.
drizzle is disrupted by the rattle of a timber-filled train heading to is more than a jumble of leaves boiled in water. Rongoā practices are
the nearby port, a fitting illustration of the juxtaposition between about treating a whole person, identifying the emotional, mental,
iv In western societies, these practices
Māori tradition and contemporary society. community, or spiritual problems that may be manifesting in the are sometimes referred to as
form of physical illness.iv integrative or holistic.
This is the place where Moetara plans to construct a garden filled
with plants and trees native to Aotearoa. He intends to use the
This is the land that will soon become the
land as a teaching tool, ensuring that rongoā rākau practices— rongoā rākau garden. A teaching tool for
the creation of remedies, medications, and tonics derived from the community, Moetara says the Rongoā
nature—can continue and be passed on to subsequent generations. Planting Project will also help improve
health, social, and environmental
This land is in Te Puna, a rural community near the eastern coast outcomes for the Pirirakau Hauora
of the country’s North Island. health center, the Pirirakau hapu (sub-
tribe), and the wider community.
Today, only a few native plants fringe the soon-to-be garden.
Moetara points them out. There’s the tall tī kōuka (cabbage tree)
whose palm can serve as a food source. The bark of the houhere
plant is used to make hats and handkerchiefs, and is effective at
coaxing phlegm from the lungs. Then there’s the heart-shaped
leaves of the kawakawa plant, a multipurpose healer commonly
used as a blood thinner, diuretic, and to open the respiratory
system. Externally, it’s turned into a salve that can be applied to
abscesses and other wounds.

↘ Video: Hone Moetara introduces the kawakawa plant. “There is intention in rongoā, it’s the love behind it,” adds Moetara.
“It’s reading the person and asking how this is going to suit what
For Moetara, a rongoā practitioner at the nearby Pirirakau Hauora is going on in them.” For example, is it best to pick from a young
health center, these plants are nature’s medicine cabinet. “You have plant for an elderly person? Should the leaves of a female tree be
to stand back and look at the horizon of what’s growing where,” harvested for a male patient? When it comes time to harvest, karakia
describes Moetara of the plants and their healing properties. “If is essential. Often translated to mean prayer, Moetara says karakia
the land has been scarred, the plants that come up first are the is more about mindfulness and the setting of intention—engaging
ones you use when you scar your body. The plants growing in wet with the bush before you step into it. “It’s about paying respect to
areas are the plants you use for fungal infections and athlete’s Mother Earth by saying thanks before you cut anything down,” he
foot. It’s relating the land back to the body and the plants that are explains. Rongoā can also be conversation, laughter, time spent in
growing in those areas. We forget that. We just go to the doctor nature, bringing family members together—anything that makes
and they give us a tube of stuff.” Moetara’s Rongoā Planting Project a person feel well.
is meant to recognize the many opportunities that nature presents
for learning, whether it be lessons related to mental health, human The healing properties of community and nature are two
biology, spirituality, ecology, and more. dimensions underpinning the way in which Māori and Indigenous
cultures worldwide view health and well-being. Contemporary
Western culture commonly views people and planet as separate
472 473
 pillars, with one’s sense of identity firmly pinned to their individual Iwi is the name for the largest social unit of Māori society, and they
v Where in history does western actions.v Māori and Indigenous cultures worldwide, however, take are the independent nations or tribes that make up New Zealand.
thought emerge? At which points a broader view. For Māori, a sense of identity extends beyond the According to most recent census data, 85% of Māori identify as
in the last 400 hundred years was
this idea of people and planet being individual to include the community and their ancestral land—a belonging to one of 10 large tribes, though it’s estimated that there
separate strengthened? recognition of the essential fluidity between human health, well- are more than 70 across New Zealand.5 A single iwi is made up of
being, and protection of the natural world. These dimensions several hapū—clans or sub-tribes within the larger iwi. Whānau is
cannot exist in isolation. the smallest entity in Māori society. Not a nuclear family of two
parents and their children, whānau are extended, multigenerational
This interconnectedness is an illustration of utu, the principle of family groups.viii viii How are “social units” organized
reciprocity—a recognition that people need to value the resources in your culture? How long has this
been this way? What elements
the land provides. Said one stakeholder in a report on rongoā Viewing whānau as the smallest partition of society is significant. It (celebrations, holidays, beliefs, etc.)
Māori: “There is reciprocity between man and the environment. speaks to the value of decision making that places collective needs of your culture strengthen these social
units?
When the language of the country is sung or chanted, the plant is over individual wants. “[This generational element of relationships]
vi What are other cultures that are
similar to the Māori, at least broadly, revived, the land replenished. The heart, head, spirit, there is no causes us to always think about the future. Our children and
in their worldviews? separation, all is related, whole.”3vi grandchildren will reap the benefits of what we invest today in
terms of energy, well-being, and prosperity,” explains Reweti Te
Mete (Ngāi Te Rangi), a project manager with Ngā Mataapuna
Kaupapa Māori: One in seven people living in New Zealand identify as Māori— Oranga, a Māori primary health organization. Considering the
The Aspirations and 16.5% of the country’s population of 4.7 million.4 The country’s broader implications of one’s actions governs the relationships
Philosophy of Community Indigenous people have been broadly categorized as “Māori” since Māori have with each other and with the environment.
European settlers first came to New Zealand, and this single ethnic
vii This would be the equivalent grouping continues today.vii However, many criticize this broad, The multigenerational, collective worldviews held by Māori and
of a foreign nation colonizing the all-encompassing category of Māori. “Māori is non-existent,” says other Indigenous groups worldwide are a key difference between ix Before moving forward, what
whole American continent today and do you think are some of these
classifying us under one same culture. researcher Apanui Skipper (Ngāti Tamaterā, Ngāti Raukawa). “Our Indigenous and contemporary Western cultures. Another
key differences? What are some
knowledge would always be held by different iwi. People identify by difference is the way in which Indigenous peoples perceive the similarities? Has this changed
iwi, not as Māori.” Earth and are affected by environmental loss.ix recently?

Apanui Skipper in what is today known The Kauri tree is symbolic in Māori
as Thames. Behind him is the sacred culture. It represents Tāne Mahuta
mountain for his iwi. (pictured), the Māori God of the Forest.
Kauri dieback disease, caused by a mold,
has been killing Kauri trees across New
Zealand for the past half century. Photo
via Flickr user itravelNZ.

474 475
 “Environmental change means a lot for Indigenous cultures
because we’re the ones who feel the impact first as the caretakers
of the environment, even when the land is taken away from
us [i.e. through colonization],” says Hone Moetara, the rongoā
practitioner. “We’re the ones reading the weather patterns, what
the oceans are telling us.” Moetara references the dying kauri trees
in New Zealand, explaining it’s a sign that Mother Nature isn’t
happy. “When you talk to other Indigenous cultures their signs
are the same. The Earth is being used as a commodity and it’s a
question of how do we go forward as Indigenous people to save our
planet?”

Māori Views of Health and Well-being

Each Indigenous culture has its own creation story and set of
behaviors governing the interactions between people and the
natural world. Many, however, share similar guiding values.

One of those values is the recognition that an individual’s health,

well-being, and sense of identity depends on blurred dimensions
of physical, mental, social, and spiritual well-being. For Māori,
protection and care for the land of one’s iwi is central to spiritual
well-being. When combined, each of these dimensions leads to an
outlook on health that goes beyond an assessment of a person’s
physical state. This is consistent with the way in which the World
Health Organization (WHO) defines health and well-being.
“Health is a state of complete physical, mental and social well-
being and not merely the absence of disease or infirmity,” declares
x This definition was created in the preamble of the agency’s constitution.6x
the post-WWII era. If you were to
rewrite it today, would you define it
differently? How? For Māori, hauora is one term to describe this outlook on health Through the lens of hauora, a number of dimensions must be The underside of a silver fern, one of
and well-being. Hauora literally translates to “the breath of life.” balanced in order for a person and their family to be considered New Zealand’s most emblematic native
plant species. Silver ferns hold much
It’s one of the many teachings of Mātauranga Māori, the traditional well and strong.7 These dimensions are articulated through the significance in Māori culture, and some
and contemporary wisdom that has been developed and refined many models of health and well-being that exist in New Zealand. iwi (tribes) would use them as trail
over the centuries in which Māori have lived in Aotearoa. It Two of the most widely recognized are Te Whare Tapa Whā and Te markers, flipping the silver side upwards
in order to note the correct path through
encompasses the empirical knowledge that has been gleaned from Pae Mahutonga. These models have been articulated by Sir Mason
the dark. Photo via Flickr user @cogdog.
observing and knowing a natural environment, and a deep sense Durie (Rangitāne, Ngāti Kauwhata, Ngāti Raukawa), one of the
of belonging within it. country’s most respected Māori health experts. A third model, Te
Wheke, was conceptualized by revered tohuna tipua and keeper
of wisdom, Dr. Rose Pere (Ngāi Tūhoe, Ngāti Ruapani, Ngāti
Kahungunu). The three models share common values, and see an
individual as part of a multigenerational interconnected system
that includes the community and the natural world.

476 477
Two Additional Models of Māori Health and Well-being Te Pae Mahutonga, Durie’s health promotion model, is inspired
by the te reo Māori name for the Southern Cross constellation.
Two other models of Māori health and well-being are commonly referenced in addition to Te Pae Mahutonga: The constellation holds great significance in Māori culture. Just as
Te Whare Tapa Whā and Te Wheke. Both are explored below and are helpful in providing context around how the Southern Cross has four central stars, the Te Pae Mahutonga
Māori communities conceptualize hauora. model outlines the four dimensions needed for people to have
control over their own health and well-being. Durie expands on
Te Whare Tapa Whā these concepts in a 1999 paper advocating for an Indigenous model
In 1984, the Māori Women’s Welfare League released a ground-breaking report, “Rapuora: Health and Māori of health promotion.13
Women.” Rapuora discussed aspects of Māori health and well-being as involving interrelated physical, mental,
spiritual and family (whānau) elements.8 From there, Sir Mason Durie conceptualized the model of health called The first dimension, mauriora, is about attaining a sense of
Te Whare Tapa Whā. It takes the shape of a whare (house). Forming the walls of the house are taha tinana, taha cultural identity. This includes the security and means to access
hinengaro, taha whānau, and tapa wairua, representing 1) physical, 2) emotional and mental, 3) social, and 4) both physical and non-physical worlds, including traditional land,
spiritual health. language, and cultural practices.
Sir Mason Durie. Photo via Flickr user
Simon Fraser University.
Social health (whānau) acknowledges the importance of the collective health of an extended family, and Next, waiora is the harmonizing of people with their natural world
includes the connection people have with their ancestors and future generations. Emotional and mental health and the ability to protect it. “A central element of indigeneity is the
(hinengaro) is the ability for people to think, to communicate, and to have the safety and security of knowing close association between people and the natural environment—
they belong in the world. The dimension of spiritual health (wairua) is the one most commonly excluded in land, waterways, the air, beaches, harbors and the sea, native flora
mainstream models of care.9 Spiritual balance involves the well-being of a person’s life force, referred to as their and fauna. Good health is compromised where there is atmospheric
mauri, and a sense of belonging related to “who and what we are, where we have come from and where we are pollution, contaminated water supplies, smog, random mining
going.”10 activities, or commercial developments that exploit the land they
cover,” wrote Durie.14 He offers further comments on waiora in
Te Wheke another paper15: “It is not simply a call for a return to nature, but an
Wheke means octopus in te reo Māori, and this model draws its inspiration from the animal’s eight tentacles. attempt to strike balance between development and environmental
In Te Wheke, the head of the octopus represents iwi, hapū, or whānau, the three levels of Māori society. The protection and recognition of the fact that the human condition is
tentacles of the octopus are: intimately connected to the wider domains of Rangi and Papa.”xi xi In western thought, what concept
resembles waiora?
• Wairuatanga – spirituality; Toiora is the third foundation of Te Pae Mahutonga, and is the In the Māori creation story, Rangi is
• Hinengaro – the mind; ability for Māori to lead healthy lifestyles. This means having the the sky, and father of all things. Papa
• Taha tinana – physical well-being; agency to overcome some of the trappings of poverty and the built is the Earth, and the mother of all
things.
• Whanaungatanga - extended family; environments in which Māori often live: “the number of alcohol
• Mauri – life force in people and objects; outlets per head of population, the number of fast food outlets per
• Mana ake – unique identity of individuals and family; head of population, the traffic density on the road that goes past the
• Hā a koro ma, a kui ma – breath of life from forbearers; school,” explained Durie at the launch of He Korowai Oranga, the
• Whatumanawa – the open and healthy expression of emotion.11 Māori Health Strategy.16 “Whether we’re talking about the natural
environment or manmade environments, we should remember
“The model proposes that sustenance is required for each tentacle/dimension if the organism is to attain waiora that they are hugely important determinants of good health and a
or total well-being,” writes Dr. Catherine Love (Te Atiawa, Taranaki, Ngāti Ruanui, Nga Ruahinerangi) in a paper flourishing mauri.”xii xii What does the idea of mauri
describing Te Wheke.12 “The octopus can survive, but not function optimally, without the use of a tentacle.” resemble?

Finally, te oranga involves a person’s participation in society. This Mauri is loosely described as
includes the ability for Māori to not only access the goods and someone’s life force or sense of
services provided by society, but also participate in the shaping ‘awesomeness’

of them. Durie notes that te oranga is generally not met, and that
478 479
 “Disparities between Indigenous and non-Indigenous populations knowledge.19 Establishing whakapapa with someone new is a core
are well documented and confirm gaps on almost every social value of Māori worldviews.
indicator…” including health.17

Though Te Pae Mahutonga is an oft referred model of health and Māori Environmental Indicators
well-being, health leaders say there are limitations in thinking a
single model can apply to all Māori. “Well-being is culture and The sharing of Mātauranga Māori means tribes across the country have developed centuries of observation-
practice. It’s being allowed to use our cultural models as we see fit, based, empirical data to read the patterns of their local flora, fauna, and weather. Apanui Skipper is a researcher
not other people’s cultural models,” explains Cindy Mokomoko (Te who has looked at how this traditional ecological knowledge can be used to predict natural hazards and their
Rarawa, Te Arawa), Managing Director of Te Puna Hauora Ki Uta resulting health outcomes.
Ki Tai, a mental health and addiction services organization. “There
are quite a few Māori models that have been written, but we don’t According to Skipper’s research, environmental indicators come in the form of tohu, signs in nature. An
even want those imposed on us. We have our own experiences and example of tohu is offered by the Pohutukawa, one of New Zealand’s most iconic trees. Around December, the
our own connections to our land and environment.” Pohutukawa trees blossom with bright red bursts. “If it’s flowering from the bottom up, that’s a strong signal
that it will be a dry summer,” explains Skipper. “In the middle of the year we also have the rising of Matariki
Hauora and Mātauranga Māori are highly place-based. Learning (The Pleiades). The stars represent certain parts of our knowledge and we look to see if it will be a wet or dry
from these models requires an expanded understanding of Māori summer. If [Matariki] is bright and clear and not hazy, we know it will be dry. This is one of our strongest signs.”
worldviews and values, and an exploration of the relationships
people have with one another and the natural world. Skipper and his colleagues have also documented how tohu have been used to predict hazardous weather.
For example, Ngāti Pare, an iwi in the northeast of the North Island say that if kākā parrots begin twisting and
squawking above the forest then you know a storm is on its way. For the Ngāti Ruanui iwi in the southwest of
the North Island, “the continuing cry of the matuku [bird] as it moves around at night” means floods are likely.20
Worldviews Grounded A person’s iwi (tribal affiliation) is more than a casual classification This traditional ecological knowledge offers an alternative source of weather information. The regular reading of
in Place of where they’re from—that place is central to Māori identity. these signs would inform how frugal people were with their water or food, when to prepare for a storm, or take
This is apparent from the moment of introduction. In addition to other actions to adapt to the changing environment.
identifying their tribe, people will also commonly share the land,
river, and mountain from which their tribe draws its spiritual The Maramataka is another traditional tool Māori have to read the environment. Based on the lunar cycle and
power or mana. Māori are tangata whenua, which means “people of the stars, this Māori calendar can be used to make weather predictions on a monthly, daily, or seasonal basis.
the land.” The term whenua also means placenta, illustrating just It can also inform when to best plant or harvest certain crops or animals—choices that have implications on
how deeply the land is seen as a motherly source of life and part of human health.
one’s identity.18
Dr. Isaac Warbrick is an exercise physiologist who is looking at contemporary applications of the Maramataka
The process of introducing oneself by place is called as it relates to fitness and overall well-being for Māori families. “There were specific days around the full moon
whakawhanaungatanga. The concept broadly translates to mean that were better for high energy activities, and there were certain days that were low energy where people
how you relate to someone. Whakawhanaungatanga is used to would fix the fishing nets or talk in a lower voice,” explains Warbrick of past applications of the Maramataka.
establish trust and belonging in traditional and contemporary The Maramataka could be used equally so today, allowing people to be more in sync with the changes to their
Māori society. In the past, it was a process to prevent sabotage surrounding environment. “I think it’s a better way of managing our time and energies rather than this whole
between warring tribes. Today, it’s a way of sharing how your values ‘wake up on Monday, work 9 to 5, and expect to do the same thing on Tuesday, Wednesday, and crash on the
have been shaped by the place you’re from. People can see if those weekend,” Warbrick says. “I don’t think [that schedule] aligns with any kind of natural environmental rhythm. It
values are shared with others in the room, creating the grounds sounds kind of out there, but any scientist knows that animals and plants respond to different seasons or stages
for relationship-building. Whakawhanaungatanga is also a way of the moon cycle. We’re the only living organism that tries to change our lifestyle while ignoring what’s going
to express whakapapa—the genealogical connection people have on in the environment.”
with their ancestors and ancestral land, and a way to communicate
480 481
 There are examples of groups already applying the Maramataka to their activities. Warbrick notes a Māori group “Moa was eradicated because Māori had no whakapapa to it. They
that trains for the Iron Man competition in the ocean during Tangaroa days [those associated with ocean-based didn’t see them as being relatives so they openly slaughtered them.
activities], and runs and cycles in the forest during Tāne days [those associated with forest-based activities]. Whakapapa is a restraining influence,” Perrott says. The connection
They also schedule race events on high energy days and recovery sessions on those that are low energy. In other established through whakapapa leads to tikanga, the custom and
instances, he gives the example of workplaces that schedule high intensity meetings on high energy days and practice that governs the way you act around something. Because
offers employees a shortened day on low energy ones. there was no whakapapa, there was no such protocol. Perrott says
extinction of the Moa evolved Māori views of whakapapa, and
Though the Maramataka shifts based on place and year, Warbrick says the most important takeaway is that continues to influence Māori-led environmental conservation to
people reconnect with their ability to observe and to adapt: “I would think that a lot of our mental health and this day.
stress related issues are a result of us not aligning with these natural rhythms and being able to observe what’s
going on in our body, family, and environment.” Another story illustrating the importance of whakapapa—and the
role it can play in having natural resources legally protected—is
that of the Whanganui River. There’s a well-known Māori proverb:
Seeing whakapapa in practice is best illustrated by a few stories. In Ko au te awa. Ko te awa ko au. “The river is me, I am the river.”22
his office in the science department of the Auckland University of This proverb is used by the tribe whose traditional land lies along
Technology, Dr. John Perrott (Te Arawa, Ngāti Pakeha), an expert the Whanganui River on Aotearoa’s North Island. It speaks to the
in Mātauranga Māori, pulls a book off his shelf. Perrott is joined by connection Māori feel to that river, and how they consider it as
Pete Edwards (Te Rarawa, Te Aupouri, Ngā Puhi), one of his PhD part of their identity. Local tribes whakapapa to that river and
students. “Moa: The Life and Death of New Zealand's Legendary consider it one of their own ancestors, just as someone would their
Bird,” the cover reads. The Moa was a giant flightless bird endemic human descendants.
to New Zealand, one that went extinct with the first arrival of
Māori to Aotearoa.21 The extinction of the Moa is still referenced
as a reason why Māori cannot be responsible conservationists, but
Perrott has an explanation for the behavior of his ancestors.

Dr. John Perrott and Pete Edwards at

Auckland University of Technology.

The Whanganui River (Photo via

Wikimedia Commons.
482 483
The Pohutukawa tree commonly
features into Māori environmental
indicators or tohu (signs).

484 485
 Rivers are of particular significance to Māori culture. “Before people One final illustration of whakapapa and traditional ecological xv In this example, environmental
die, we ask someone to go back to the place where that person is knowledge relates to the sprightly hihi (stitchbird).xv The bird is indicators are defined as generational
from to get water from the stream so they can drink it,” says Apanui named after the first rays of sun—hihi. In Māori culture, these knowledge that has been developed
through observations of the natural
Skipper. “It might sound simple but it’s a pretty powerful illustration sun rays are healing. “In this country our birds do a dawn chorus, environment and how its changes
of the connection we feel to that land.” and the hihi bird is one of them. They come from the darkness of affect ecosystem and human health.
For Māori iwi, many of these measures
the forest, go to the canopy, expose themselves to the sun, and are connected to birds. Pre-human
In 2017, the Whanganui River became the first river worldwide ruffle their feathers,” shares John Perrott. “Light comes through contact, birds represented nearly all
xiii The notion of giving non- to gain legal personhood,xiii meaning it now has the same human the gaps in the canopy and you see flashes of yellow light: the of the fauna found in New Zealand.
human entities intrinsic rights or They had few predators—only bats
rights as a person.23 The legislation was passed by the New Zealand hihi flying through the beams and capturing the healing rays of and a few other aerial birds. Due to
“personhood” is explored in Chapter
17 on ethics of ↘ Planetary Health: Parliament and represented a legal settlement to a series of historical the sun. During the day it flies through the forest spreading its this lack of land-based predators,
Protecting Nature to Protect claims that were first filed in the 1870s.24 This isn’t the first or last medicine. Healers learned from these birds, created a whakapapa many birds evolved to be flightless.
Ourselves. The introduction of invasive species
instance of natural resources in New Zealand gaining personhood.25 to that, and then started using them as a way of learning about the like rats had a large impact on ground-
In 2014, Te Urewera, a large forested area, also gained environmental forest. Because they were the most sensitive to the conditions of dwelling birds. As a result, many
personhood. And six months after the Whanganui River gained legal the forest, hihi were the first to go when it was disturbed. Māori native birds have become locally
extinct, including the hihi which is
xiv What other countries has provided rights, the same status was recognized for Mount Taranaki, a sacred learned very early that hihi were indicators of forest health and as today found only in a few island bird
personhood to environmental mountain for several iwi.26 Environmental personhood means that if a result, human health.” reserves.
elements? What implications does this
have for conservationists around the the forest, river, or mountain is harmed, there are legal repercussions
world? just as there would be if the act were committed against a human.xiv
The yellow plumage of a male hihi
(stitchbird) at Tiritiri Matangi, one of
New Zealand’s bird reserves. The island
Environmental Personhood - Where and to What Effect? reserve is one of the only places in the
country where you can find the hihi. It
was driven to local extinction on the
New Zealand isn’t the only place where natural landscapes have been recognized as “persona”. Shortly after the mainland due to introduced species
Whanganui River was granted personhood, the same legal rights were bestowed on the Ganges river in India in like rats. Today, the vulnerable species
an attempt to curb pollution.27 The Ganges is a sacred body of water for more than a billion people. A Lake Erie has been introduced to a few islands off
the mainland, though the population
Bill of Rights was established after a vote by residents in Toledo, Ohio in 2019.28 In July 2019, Bangladesh took
remains unstable.
environmental personhood further even still, declaring that all rivers in the country had legal rights.29

But what exactly is the process for people to, as guardians, claim legal rights on behalf of a landscape? And are
those rights legally binding? Colombia presents a promising case. The South American country has recognized
a number of rivers and its portion of the Amazon rainforest ecosystem as legal persons. The recognitions have
led to the stoppage of mining activity along various rivers. And Ecuador became the first country to successfully
uphold the legal rights of nature when a provincial government ruled that the Vilcabamba River was under threat
by a road widening project. The ruling meant that areas of the river had to be rehabilitated and remediated in
order to protect the environment for this generation and those of the future.30
While whakapapa may sound abstract or spiritual, Perrot explains
The concept of environmental personhood is nascent, and it will take further court rulings to prove whether the this knowledge has been developed from empirical observations
granting of legal rights to landscapes goes beyond the symbolic. passed from one generation to the next.

486 487
The Environmental and Health Impact of Belonging and I know his children are there. They’re my relations, and that
“You’ve got to have whakapapa because without that you don’t makes me feel better.”
have belonging and you lose your sense of something bigger,”
contextualizes Pete Edwards, Perrott’s PhD student. “You then
[take the environment] for granted and treat it as a commodity.” Environmental Change When one’s mental health and sense of identity hinge so heavily
and Mental Healthxvi on connecting with familiar lands and waters, what happens
Edwards is talking about the connection and care people must when those environments change or are lost? This is the question
have with the land around them. He studies kaitiakitanga, the xvi For further discussion of this term being asked today by scientists and clinicians alike—and is
Māori concept of guardianship and protection of the environment and other associated terms and more the unfortunate reality facing Māori and many Indigenous
general discussion of the mental
and other taonga (treasures). He and Perrott are researching how health burdens associated with communities.
customary tikanga (practice/custom) relating to the harvest of environmental change, see Chapter
native birds could inform mainstream conservation and wildlife 9 on Mental Health in ↘ Planetary No culture, community, or country is immune to the impacts of
Health: Protecting Nature to Protect
management policies. Not only does the research project aim to Ourselves environmental change—but these challenges are magnified for
stem the decline of biodiversity, but it also aims to slow the loss of certain groups. Due to the whakapapa Māori and other Indigenous
Mātauranga due to the passing of kaumātua (elders) who held this peoples have with their land, they are particularly affected
knowledge. by disruptions to those places. Worldwide, Māori and other
Indigenous groups are some of the most vulnerable to the effects of
The late Reverend Maori Marsden, a self-described “writer, healer, climate change.31 Those vulnerabilities can affect people’s physical
minister, and philosopher” of Māori worldviews, wrote extensively xvii Although whakapapa seems like health, but also their mental health and sense of identity. xvii
about the importance of environmental belonging among a foreign concept, we all feel deep
connections with our natural and built
Indigenous cultures. In his book, “The Woven Universe,” Marsden environment whether we realize it or “Climate change is a threat multiplier [for Indigenous
references a quote from Dr. Ranginui Walker, a Māori-Lebanese not. What is a place you would feel communities],” says Dr. Rhys Jones (Ngāti Kahungunu), a public
academic. It compares Indigenous worldviews to that of what he specially concerned about losing? health physician and co-convener of OraTaiao, the New Zealand
Think of why you chose this place,
calls “metropolitan culture”—the dominating worldview of the west: and what cultural elements define this Climate and Health Council. “Māori tend to be at higher risk of
importance. any health impact as a result of social and economic deprivation
“[Indigenous cultures] think of themselves as holding a and marginalization. So as a pretty general statement, anything
special relationship to Mother Earth and her resources; as that has an impact on health will tend to disproportionately
an integral part of the natural order; recipients of her bounty impact Māori communities.”
rather than controllers and exploiters of their environment.
Therefore Mother Earth is to be treated with reverence, love Jones and his co-authors articulate the effects of climate change
and responsibility rather than abuse and misuse.” on physical and mental well-being in a 2014 paper. Drought,
extreme weather conditions, climate change-related migration,
“How you perceive nature affects how you interact with it, and and loss of culturally significant sites will compound already
how you interact with it impacts your health,” says John Perrott. higher-than-average mental health rates and suicidal behavior by
“Whakapapa is the starting point to personification, and this Māori.32 Additionally, trauma from extreme weather events can be
concept of seeing things [in nature] as familiar.” particularly impactful for remote and rural Māori communities.
Finally, food and water contamination will make it more
Whakapapa also has a direct influence on mental health. “My challenging for iwi tribes to access, consume, and share culturally-
background is the ocean. I studied marine science, but personally relevant foods. This list of negative implications is not exhaustive.
I’ve grown up next to the sea. The sea is me and I am the sea,”
volunteers Pete Edwards as an example of this connection. “When
my mauri (life force or sense of ‘awesomeness’) is not feeling the
best, I jump in the sea with Tangaroa [the Māori God of the Sea]
488 489
How Climate Change Mitigation Strategies Can Deepen Health Disparities

Mitigation efforts meant to lessen the effects of climate change can exacerbate health disparities among Māori
and Indigenous communities.33 “If our sole focus is to reduce greenhouse gas emissions then maybe putting
wind turbines wherever makes sense, even if it’s on traditional land,” offers Dr. Rhys Jones as one example of
a decision that could harm people’s spiritual health.

Another example was the introduction of a regional fuel tax in Auckland, New Zealand’s largest city, with
revenues intended to mitigate climate change by improving public transit. “The more progressive people were
quite keen on the idea but many warned of the regressive impacts,” counters Jones. “This particularly applies
to Māori and Pacific communities where people don’t live in areas that are well served by public transit, or do
shift work when transit services aren’t running. They’re more car dependent out of necessity.” As a result, the
fuel tax could further stress the socio-economic situation of Māori, with lessened opportunity for them to take
advantage of the benefits.
Sheep farming and cattle rearing
Mitigation strategies aside, Jones says climate change, racism, and colonization are inextricably intertwined: are two of New Zealand’s largest
“Climate change amplifies existing threats to health and human rights, and climate change itself is intimately industries. Both were introduced
linked to colonialism. Colonialism is at the root of the global economic system that fuels anthropogenic climate to the island in the 18th and 19th
change and is responsible for the social conditions that limit Indigenous peoples’ resilience and adaptation centuries following the “discovery”
capacity. It is not possible to understand or address the effects of climate change for Indigenous health without of the island by European settlers.
acknowledging and confronting colonization.”34 Stats NZ estimates 45% of the
country’s land is being farmed
for agricultural and horticultural
As a result of this history and the possibility of exacerbated harm, the onus is on policymakers to identify the
use—sheep and cow farms make
potential unintended consequences of climate change mitigation measures. Others in New Zealand have
up two thirds of that land use.
written about the opportunity to introduce programs that systematically address a reduction in greenhouse gas
Though important economic
emissions and an improvement of health equity outcomes. One opportunity could be the introduction of drivers, these industries have also
a sustainable energy management plan to retrofit hospitals with solar panels, modernized heating, ventilation, greatly affected New Zealand’s
and cooling systems, and energy efficient lighting. The savings from that plan could then be “re-invested into native forests, including the ability
collaborative community projects that create healthy, energy-efficient homes in communities with a high for them to be accessed by the
proportion of Māori and Pacific peoples.”34 tribes who whakapapa to that
land.

The gradual loss or deterioration of one’s natural environment

also affects emotional and spiritual health — the other pillars of
hauora. Australian philosopher Glenn Albrecht calls these effects
‘solastalgia.’ Solastalgia is the sense of distress that comes when
people witness the effects of environmental change on their home
and land.36 It’s a sense of longing for a place or environment that is
being lost, has been taken, or no longer exists — the stripping away
of a key component of one’s identity.

490 491
 Solastalgia is similar to another term: ecological grief. Ecological Hone Moetara, the rongoā practitioner in Te Puna, says the loss
grief is a condition that comes as a result of ecological loss. of land affects his work. For one thing, there is a lack of resources
According to one study, ecological grief caused by anthropogenic for traditional practices. “Our bush is getting further and further
environmental change has been linked to “acute and chronic away from us. The seed banks are taken off the soil due to farming.
mental health experiences, including: strong emotional responses We have to go out of the area to find traditional medicines. That’s
such as sadness, distress, despair, anger, fear, helplessness, really hard for our families because they’re not in a place where
hopelessness and stress; elevated rates of mood disorders, such as they can afford to search for what you should be able to find outside
depression, anxiety, and pre- and post-traumatic stress; increased your backdoor.”
drug and alcohol usage; increased suicide ideation, attempts and
death by suicide; threats and disruptions to sense of place and Ecological grief is also caused by an inability to fulfill
place attachment; and loss of personal or cultural identity and manakitanga,xviii the act of being hospitable to guests. Dr. Rhys Jones xviii A tribe’s spiritual power or sense
ways of knowing.”37 offers the example of tribes who have experienced contamination of authority.

of their traditional food sources or shifting patterns of availability

Dr. John Perrott, the expert in Mātauranga Māori, says of that food because of land use change, pollution, or climatic
contemporary Māori use the term ‘land sickness’ to describe a disruption. This not only affects Māori from a nutritional
concept similar to solastalgia and ecological grief. In the context perspective “but because it’s a source of mana and esteem for local
of Māori communities, land sickness affects people in two ways: people. If I come from a coastal area and we have visitors, it’s a
through the misuse of ecosystem resources (the loss of taonga or source of pride to be able to provide the local food. [...] Not being
treasures) and Māori disenfranchisement from land management able to fulfill your cultural obligations can have negative impacts
decisions (a loss of mana or authority).38 on mental well-being,” Jones says.

Philosopher Glenn Albrecht notes that land loss from

Hone Moetara is a rongoā rākau and
mirimiri therapist at Pirirakau Hauora environmental change can mimic the displacement that first
health center in Te Puna. happened when European settlers forcefully relocated Indigenous
communities worldwide. This compounds the fact that climate
change is already seen as a manifestation and intensification of
colonialism. An excerpt from a 2019 article by Rhys Jones for the
journal “Global Health Promotion”:

“Indeed, the worldviews, values, and systems that underpin

the colonization of Indigenous peoples are also at the root
of environmental changes that threaten local and global
ecosystems. Modern Western societies are underpinned
by anthropocentric understandings of the world and
individualistic values, and tend to associate consumption
with improvements in quality of life. The resulting capitalist
systems have driven the commodification and exploitation of
natural resources, with societies pursuing economic growth
while externalizing the negative environmental impacts.”39

To understand the effect of colonization on Māori health requires

some historical retrospective into the relationship between
Aotearoa’s first people and European settlers.
492 493
Aotearoa and the Crown: Māori were the first human inhabitants of Aotearoa, arriving from referenced in either version, Article 2 affirms that Māori remain
A Disturbance of Taonga East Polynesia between 1200 and 1300 AD.40 A seafaring people, in charge of themselves and will be able to protect their taonga,
the Polynesian explorers “discovered the country on deliberate the name for treasured possessions including health, whenua
voyages of exploration, navigating by ocean currents and using (the environment) and other sacred places, te reo (the Māori
the wind and stars.”41 The stars and sky continue to be of great language), whakapapa, and all other material and non-material
significance to Mātauranga Māori. For example, the Māori calendar, treasures.46 Article 3 guarantees Māori the same rights as British
Maramataka, is based on lunar cycles that dictate scheduling citizens, including health equity. More recently, the New Zealand
around planting and harvest; matariki is the name for the Pleiades, government created a series of treaty principles that must be
a cluster of stars used to signify the Māori New Year and predict followed by the Crown, including the three most commonly
climatic conditions for the coming season. referenced: participation, protection, and partnership.47 In 2019,
these principles were named reductionist and outdated.48
xix Pākehā is the name for New European settlers or Pākehāxix first came to Aotearoa in 1642
Zealanders of European descent and with the “discovery” of the island by a Dutch explorer. British “Within days [the Crown] started breaching Te Tiriti and haven’t
other non-Māori. Tauiwi is the term
used for all non-Māori. explorers made three voyages to Aotearoa starting in 1769, laying stopped,” says Came. There’s ample legal validation to back her
the groundwork for their eventual colonization of the islands. observation. In 1975, the New Zealand government established the
The next half century led to the introduction of Christianity from Waitangi Tribunal. The tribunal is the legal process that hears and
English and French missionaries and increased access to trade. investigates claims that the Crown has breached the text of either
There are certain similarities between the European colonization treaty. The tribunal’s 20 members are the permanent commission
experience of Māori and other Indigenous groups worldwide. of inquiry charged with interpreting both texts, and the body has
These interactions led to the spread of infectious disease, certain reported on more than 1,000 claims — though more than twice
groups gaining preferential access to food and firearms which that number have been registered and await the legal process.
escalated tribal wars,42 and disempowerment and depopulation. Though recommendations from the tribunal are not binding,
By 1896, the Māori population was estimated at 42,000 people, a many have been incorporated into government legislation or used
decline from a population of 70,000-90,000 half a century prior.44 to create new institutions.

A landmark event in New Zealand’s history occurred in 1840 with Most of the Waitangi Tribunal’s business to date has focused
the signing of Te Tiriti o Waitangi, the Māori language text of the on claims of historical treaty breaches by the Crown, with the
treaty between the British and North Island hapū. The English Tribunal hearing these claims on a geographic, district by district
version, the Treaty of Waitangi, was signed later. Domestic law basis. The Tribunal has more recently started to consider claims of
recognizes the two documents as the basis of the relationship national significance on a thematic (or kaupapa) basis. The first of
between the British Crown and Māori. these looked at issues surrounding military veterans. The second
kaupapa inquiry initiated by the Tribunal looks specifically at
However, there’s one issue: though often considered health services and outcomes for Māori.
interchangeable, Te Tiriti o Waitangi and the Treaty of Waitangi
are dramatically different. 45 “[Article 2 of] Te Tiriti reaffirms Māori The health kaupapa inquiry (known by its reference number, Wai
tino rangatiratanga, which is a declaration of self-determination,” 2575) began hearings in 2018 and focused initially on primary
says Dr. Heather Came, whose PhD research related to Crown health care. The Tribunal released its report in July 2019, ruling
breaches of Te Tiriti agreement. “In the [Treaty of Waitangi] many that the Crown had failed in its treaty commitments to ensure
argue that Māori surrendered their sovereignty to the British equitable health outcomes for Māori. Another Tribunal report
Crown.” focused on Māori mental health was published a month later.

Both documents contain articles governing the Crown-Māori The tribunal references Ministry of Health statistics in its
relationship. Though neither health nor hauora are directly findings49: Māori are more than 2.5 times more likely to die from
494 495
 cardiovascular disease and more than five-and-a-half times more Whānau Ora: Recall the building blocks of Māori society. Rather than considering
likely to be hospitalized for heart failure compared to non-Māori. Reconstructing individuals as the smallest social group, Māori see this as whānau
Māori are twice as likely to die from all types of cancer. Māori Contemporary — extended, multigenerational families.
babies account for a higher number of sudden unexplained deaths, Healthcare Systems
and suicide rates are higher than in non-Māori demographics. The With a Māori Worldview Since 2002, “Whānau Ora” has been New Zealand’s overarching
xx Before moving forward, what are list goes on.xx effort to incorporate Māori cultural values into a health initiative.
the primary determinants of health Whānau Ora is defined as “Māori families supported to achieve
that you think are playing a role in
these health inequities? “Māori health inequities are not only caused by health issues, but their maximum health and well-being.”53 However, there was
are influenced by a wide range of factors including income and arguably little specific action dedicated to achieving this aspiration,
poverty, employment, education, and housing – termed the social leading to the establishment of a targeted Whānau Ora program
determinants of health,” states the tribunal. It also attributes by the Government in 2011.
inequities to the long-term impacts of colonialism, noting the
ongoing existence of institutional racism.50 The Whānau Ora program was led by Dame Tariana Turia
(Ngāti Apa, Ngā Rauru, Tūwharetoa), then a government minister,
Claimants who testified as part of the mental health tribunal and informed by a taskforce chaired by Sir Mason Durie. Durie
brought up dozens of issues, including the lack of culturally explained the approach during an address to the Royal Australasian
appropriate mental health services, the failure to accommodate College of Physicians: “If whānau are going to be well in the future
Mātauranga Māori knowledge and rongoā in healthcare policy, the this is well outside the health sector alone. It includes education,
need to interlink mental, physical, and spiritual health, and the social development, economic and employment concerns, housing.
suppression of Māori health practices and protocols.51 On a community level, the aim of Whānau Ora is to bring those
interests together. Whānau don’t live their lives in silos.”54
Today, these health and socio-economic inequities are usually
considered a common thread binding Indigenous communities, As a result, Whānau Ora isn’t solely a health program. Instead,
writes Sir Mason Durie, the conceptualizer of a number of Māori it aims to acknowledge the interconnectedness between people’s
health models. “However, the defining element of indigeneity is not lives and the role that natural and built environments play in
colonization, socio-economic disadvantage or political ambitions. xxii How would you integrate the achieving overall health and well-being.xxii
Instead, most Indigenous peoples believe that the primary starting Māori worldview if you were to co-
design a health system with them?
point is a strong sense of unity with the environment — and a What would be the defining elements? A Whānau Ora Approach to Type 2 Diabetes
healthy environment.”52 Adding to the list of health inequities, type 2 diabetes and its
complications are more common among Māori and Pacific
The Wai 2575 inquiry brought up much bigger questions: is it communities than other ethnicities.55 A new Māori-designed
possible for New Zealand’s Western-influenced healthcare system primary care program called Mana Tū is “aiming to improve
to recognize the interconnected identities and needs of Māori diabetes outcomes and reduce disparities in incidence,
tribes when the worldviews of each are diametrically opposed? hospitalization, and mortality rates by transforming primary
What is the role of a healthcare system or its practitioners in health care.”56
ensuring a healthy environment?
Mana Tū is overseen by the National Hauora Coalition (NHC),
New Zealand has made some progress in incorporating Māori a Māori-led primary health organization. It’s one of the best
xxi Successful intercultural health worldviews in its strategies and approaches. While the system is examples to-date of an intervention that incorporates Māori
services vary from country to country, far from perfect, it offers some examples of the first steps that can experience and values. The program’s design addresses the social
and from context to context, however,
they all share some common principles. be taken to better integrate human health, well-being, and the connectedness of Māori communities and acknowledges that it’s
What do you think these are? natural world.xxi not possible to treat an individual alone.

496 497
Developed in collaboration with a diverse group including Mana Tū is tailored to some of the central tenants of Whānau
secondary care clinicians, dental specialists, nurses, social Ora and Māori models of health. It taps into the concept of mana,
workers, kaumātua (Māori elders), and long-term diabetes patients, a person’s self-authority. “Let’s use our own cultural models and
Mana Tū addresses what Dr. Matire Harwood (Ngāpuhi) says was cultural ways of knowing and doing to inform something like taking
a failure of mainstream practitioners to serve the needs of Māori control of diabetes,” describes Harwood of the program’s approach.
and Pacific families. Harwood is the general physician who led the
program’s research. In practice, whānau can personalize Mana Tū to meet their needs.
It shifts a whānau’s first point of contact from a general practitioner
“When we had whānau designing Mana Tū, they said ‘we don’t to a Kai Manaaki, an appointed community case manager who
[go to traditional clinics] because they tell us off. They just throw is more in tune with the cultural needs of the whānau. The Kai
more drugs at us. They don’t talk to us about what’s actually going Manaaki works as part of a primary health clinic team, with general
on in our lives,’” Harwood says. “To me, that was key, that idea practitioners administering insulin and other medication. Families
that doctors thought they knew best, though they likely didn’t meet with the Kai Manaaki twice a week at the beginning of the 12-
have diabetes and may be wealthy and have good health literacy. month program in order to develop a relationship. Gradually, those
It was them not understanding the context in which some of these meetings are held every two weeks, then in self-prescribed intervals
people are living.” after two months.

Launched in March 2018, Mana Tū is operating with 200 people Despite positive research results, Harwood says her team has faced
at 10 general practice clinics. Nine month data shows promising challenges in getting recognition from mainstream health clinics
progress on key indicators: a clinically significant reduction in the and funders. She notes that while a Mana Tū approach that
group’s Hemoglobin A1C (HbA1c) and weight loss. The program recognizes the wider determinants of health could be applied to
has also shown benefits for entire families: “They’re more likely to conditions like chronic obstructive pulmonary disease (COPD) and
go as a whānau for walks and take the kids to play at the park. It’s mental health, proposed programs that draw from Māori philosophy
not just being physically active, but spending time together so that often face hurdles of racism and bias.
social engagement and bonding happens,” adds Harwood.
Systemic racism and bias are just two of the reasons why many are
Mana Tū’s effectiveness will be assessed in two ways over the long- skeptical that Māori worldviews can be adopted in a colonial policy
term. The first is similar to western medicine: by using clinical environment that was never meant to consider them.
indicators to measure a reduction in physical disease. The second
assessment will use Hua Oranga, a tool developed by Sir Mason Whānau Ora and Māori Models of Hauora: Reality or Rhetoric?
Durie to measure Māori health outcomes.57 Conceptualized The Whānau Ora program has its challenges and shortcomings.
around Māori models of health and well-being, tools like Hua Even its conceptualizer, Sir Mason Durie, admits that, telling the
Oranga include more qualitative markers of health and well-being. Royal Australasian College of Physicians that implementing the
approach has been easier in communities when compared to
For example, Hua Oranga gauges the mental health and well-being a government policy level.
of an entire whānau as opposed to that of an individual alone. It
also measures improvements in waiora, the sense of spirituality Gabrielle Baker (Ngāpuhi) has faced similar challenges from a policy
that exists when people are able to protect and be part of the perspective. Baker is a former civil servant who spent 15 years as
natural world. “I think it’s really important to use some of these part of the Ministry of Health’s Māori health policy team. Part of
Indigenous health outcome tools when assessing the impact of our her role involved advising ministers on spending around Māori and
interventions,” Harwood says. “Whānau and waiora weren’t being Indigenous health, and working on the team that helped create the
captured by any of the tools we had used before.” Whānau Ora program and the country’s Māori health strategy, He
Korowai Oranga.
498 499
 Baker notes the frustrations of working inside government
agencies, specifically “that amazing policy was being developed
but would sit on shelves and lead to very little change.” She says
that despite plenty of rhetoric existing around improving Māori
health equity, there remains a lack of funding, ongoing policy
stewardship, monitoring, and political will to make the changes
needed.

“The ideas of having whānau-centered interventions that support

whānau aspirations, the kind of thing talked about in the Whānau
Ora policy, would at most get a few dollars thrown at them,”
describes Baker of the government’s approach to Māori health
and well-being. Despite some government investment in Whānau
Ora, Baker says very little changed for Māori health. Instead,
greater responsibility was placed on the shoulders of Whānau Ora
providers or families themselves.

The head of one Māori-led primary health organization feels

similarly. “The health system in New Zealand is essentially
following the British National Health Service (NHS),” says Simon
Royal, Chief Executive of the National Hauora Coalition. He points
out that the NHS is a system tailored to the needs of an individual.
“That [individual view is] backed up by insurance and basically
all the infrastructure of the healthcare system. All algorithms
for funding or public policy are generated out of a view about the
relative importance of the individual vis a vis the group. This is Janice Kuka (Ngāti Ranginui, Ngāi Te Rangi) was another of the Reweti Te Mete, Janice Kuka, and
why the Whānau Ora concept has been significant but it’s been claimants in the first stage of Wai 2575. Kuka is the Managing Cindy Mokomoko all advocate for an
independent, self-determined Māori
bastardized by the Crown because they didn’t allow Māori to roll Director of Ngā Mataapuna Oranga (NMO), another Māori-led health authority. They’re hopeful a 2019
it out.” primary health organization. She says the next step following the Waitangi Tribunal report will open the
ruling is to look at what systems and models could inform the doors for much-needed change.
Simon Royal, Chief Executive of the Royal, along with National Hauora Coalition Trustee, Henare creation of an independent health authority. That could mean
National Hauora Coalition. Mason (Te Arawa and Ngāi Tuhoe), was a claimant in stage one drawing on multiple Māori models of health or, as has been the case
of Wai 2575, the Waitangi Tribunal inquiry into Māori primary at NMO, designing new models based on the unique needs of each
health care. The recent ruling of the tribunal validates the demand tribe. There’s also a call for the New Zealand Public Health and
for a health system that is not only designed by Māori, but also Disability Act to be updated to better include Te Tiriti o Waitangi.
managed by them. It calls for the establishment of an independent
Māori health authority as a way to end the health disparities facing
communities.58

500 501
Alaska’s Nuka System of Care For Hone Moetara, the rongoā practitioner at the start of this
case study, an independent Māori health authority may mean the
Many Māori health leaders point to the Nuka System of Care as an example of a model that more holistically ability for him to get funding and support to continue creating
serves the needs of Indigenous communities. The system was created by Alaskan Native people, and is traditional medicine. That demands not only recognition of the
overseen by the Southcentral Foundation, a nonprofit healthcare organization based in Anchorage, Alaska. role Māori medicines and approaches to well-being play within
healthcare, but also the importance of being able to harvest from
According to Southcentral Foundation’s President and CEO, Katherine Gottlieb, the Alaskan Native population the government’s Department of Conservation sites.
historically experienced health disparities similar to those faced by Māori communities. Patients were waiting
an average of four weeks to get an appointment or were only coming in for emergency care. “There was a “It’s the need for an entirely new system where we’re not butting
disconnect between care for the mind and care for the body,” Gottlieb writes.59 up against red tape across all systems — academia, health, and
conservation,” Moetara says. For Māori, it’s not only about
In 1975, the United States government passed the Indian Self-Determination and Education Assistance Act. That physical health but about every element of one’s identity:
legislation was the beginning of the federal government handing over self-rule for tribal authorities across the a balance of spiritual, physical, mental, emotional, and community
country. Southcentral Foundation took full ownership and management of the Alaska Native Medical Center in needs. Determining whether those needs can be met within New
1999 and redesigned the services to be more culturally appropriate. Zealand’s existing healthcare system is still an open question.
What is certain, however, is the need to better include the holistic
The Nuka System of Care was the result. Gottlieb says one advantage of the system is that it’s more responsive way in which Māori derive their sense of personhood: through
to the needs of families. For example, when a recent needs assessment found there was a gap in oral health care a connection with one another and with the land.
for youth, Southcentral Foundation started building a new program with this target population in mind. Survey
results that demonstrated an increased need for behavioral health and addictions services led to the creation
of new substance abuse activities and more beds dedicated to the detox program.

Gottlieb wants to be clear: it’s not just Indigenous communities that benefit from holistic, patient-centered
systems of care. “If we started with the population we’re serving to see what their highest needs are and then
addressed them, it would change health disparities across the United States. [Southcentral Foundation] did this
and it just so happens that Alaskan Natives are our target population,” she says, adding she’d do the same thing
in any other state. “Engaging a community is key to address health outcomes.”

502 503
Epilogue: Learning from There is no one approach to infuse the principles of planetary then you’re not going to protect it or mourn its loss, reflects Dr.
Mātauranga Māori health into policy worldwide—as we’ve seen in this case, John Perrott. “Part of who you are is a sense of belonging, but that
deconstructing systemic bias and entrenched silos is a significant comes from associating with something bigger than yourself,”
challenge even when there is political will and a guiding holistic he says.
vision based on Māori worldviews. Planetary health practitioners
by definition recognize the empirical connection between human Māori worldviews are but one example of how we can step away
health and the environment; this understanding and the solutions from an individual mindset and become part of a paradigm
we create as a field should be deepened in learning from the values that harmonizes rather than prioritizes human health over
that underpin Māori and many other Indigenous worldviews of environmental well-being.
health and well-being.

Whakapapa reminds people of their connection to one another

and to the environment, and demands learning from the past
and considering the future. It also creates a sense of belonging
within the world which can act as a moral lens through which
to filter our actions. Mana outlines the importance of agency so
people can be physically, mentally, socially, and spiritually well.
Tino rangatiratanga gives families the self-determination to
choose what’s best for themselves. Kaitiakitanga reminds us to be
guardians of the natural environment. Taonga highlights the true
treasures worth protecting: one’s natural environment, health,
family, culture. Finally, Indigenous worldviews demand a respect
for partnership and collaboration to understand sense of place
and context when designing and implementing solutions to the
challenges we face in the Anthropocene.

Ultimately, it’s about learning from Mātauranga Māori to remember

that all of our systems are interconnected. Those connections
have been evident throughout this case study anthology. A dam
in the Senegal River led to an upstream spike in schistosomiasis
for villages that depend on that water source. Men logging the
rainforests of Borneo were doing so in order to pay for their
family’s healthcare. The hunting of lemurs and other wildlife in
Madagascar that has pushed species to the brink of extinction
is often a necessary source of nutrition. Human behavior in
Fiji’s watersheds has contributed to a higher risk of water-borne
disease. Each of these cases illustrate how the health of humans
and the Earth’s natural systems must be considered as a complex,
dynamic whole.

A full appreciation of that interconnectivity demands empathy

towards others and towards the Earth. If you don’t feel emotionally
connected to the natural world through stories and experience
504 505
Keeping Track Gabrielle Baker (Ngāpuhi) Dr. Heather Came Sir Mason Durie (Rangitāne, Pete Edwards (Te Rarawa, Dr. Matire Harwood
of Who’s Who Ngāti Kauwhata, Ngāti Raukawa) Te Aupouri, Ngā Puhi) (Ngāpuhi)
Former civil servant with the Ministry of Senior lecturer based in the Taupua
Health’s Māori health policy team Waiora Centre for Māori Health Māori health expert and conceptualizer PhD student of Dr. John Perrott and General physician and head researcher
Research, Auckland University of several models of Māori health researcher studying kaitiakitanga for the Mana Tū diabetes program
of Technology promotion; chair of the Whānau Ora
taskforce

Katherine Gottlieb Dr. Rhys Jones Janice Kuka Hone Moetara Cindy Mokomoko Dr. Rose Pere
(Ngāti Kahungunu) (Ngāti Ranginui, Ngāi Te Rangi) (Ngāpuhi) (Te Rarawa, Te Arawa) (Ngāi Tūhoe, Ngāti Ruapani, Ngāti
President and CEO, Southcentral
Kahungunu)
Foundation in Alaska public health physician, co-convener of Managing Director, Ngā Mataapuna Rongoā practitioner with Pirirakau Managing Director, Te Puna Hauora Ki
OraTaiao, Senior Lecturer at Te Kupenga Oranga Hauora Uta Ki Tai Managing Director, Ngā Mataapuna
Hauora Māori (TKHM), University of Oranga
Auckland

Dr. John Perrott Simon Royal Apanui Skipper Reweti Te Mete Dr. Issac Warbrick
(Te Arawa, Ngāti Pakeha) (Ngāti Tamaterā, Ngāti Raukawa) (Ngāi Te Rangi) (Ngāti Te Ata, Te Arawa, Ngā Puhi)
Chief Executive, National Hauora Exercise physiologist and Senior Research Fellow and Director of Taupua Waiora Centre
Expert in Mātauranga Māori with the Researcher of Mātauranga Māori and Project Manager, Ngā Mutaapuna
Coalition for Māori Health Research, Auckland University of Technology.
Auckland University of Technology traditional ecological knowledge Oranga

Acknowledgements This case study would not have been possible without the trust
extended and stories shared by a number of folks across Aotearoa.
To everyone whose voice is included in this case: a heartfelt thank
you for your patience in sharing your knowledge and helping the
author untangle her own colonial understanding of health and the
environment. Thank you to Hector Kaiwai and Georgina Martin
from the Whānau Ora Commissioning Agency for spending hours
speaking with me about the systemic bias and institutional racism
that whānau face within the New Zealand health system. Professor
Kate Diesfeld and Dr. Valance Smith from the Auckland University of
Technology were instrumental in helping me connect with the right
folks from their institution. Thank you, too, to Laura Goodall and
her writing and advice around approaching the topics mentioned in
this case. Gabrielle Baker came onboard with her edits and expertise,
and I’m eternally grateful for that. Gordon Lamb and Daniel Fortin
were generous enough to open their home to me during my time in
Auckland.

Finally, to Indigenous nations worldwide: it is my sincerest hope that

the planetary health community can use its privilege and power to The kawakawa plant is a commonly used healer in Māori culture. The holes in the leaves are caused by the Kawakawa Looper Moth
elevate your diverse worldviews and ways of knowing. Your guiding caterpillar. While the practices of healers differ greatly, one school of thought is that the more holes a leaf has, the more medicine it holds
(because it’s trying to heal itself).
values, expertise, and stories are needed now more than ever before.
506 507
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