Introduction

A frequently under-appreciated aspect of public health is its long-term dependence on sustainable development. The social determinants of health include, on the one hand, economic factors, such as employment, income and, generally, living standards, and, on the other hand, environmental factors like access to clear water and air, protection from natural disasters etc. Unfortunately, those economic and environmental factors are not necessarily in harmony: both a high-level economy which destroys the environmental basis of life-support systems and an environment, which is either protected or degraded to the point of being economically useless, are tangibly harmful to health. In a fateful triangular relation, long-term stability of public health requires a mutually supportive relation of the economy and the environment. Such a relation was termed «sustainable development» by the World Commission on Environment and Development (WCED), more commonly known as the Brundtland Commission after its chairperson, Gro Harlem Brundtland, politician, medical doctor and public health expert.

The Commission is best known for having coined the definition of sustainable development as development which «seeks to meet the needs and aspirations of the present without compromising the ability to meet those of the future.»* World Commission on Environment and Development (WCED), Our Common Future (OCF), Oxford: Oxford University Press, 1987, reprinted 2009, 40. Health was not explicitly mentioned either in this definition, in the Commission mandate or even in its recommendations at the end of its work. Nevertheless, the Commission left no doubt in its report that its work was also about public health. Malaria, schistosomiasis, respiratory illnesses, cancers, and injuries were only a few of countless health problems affected by environmental-economic factors like irrigation, air pollution, carcinogenic substances in industrial products, and natural disasters exacerbated by climate change, while biodiversity loss diminished potential material for medicines and food production. The WCED pointed out those connections and declared: «Integrated approaches are needed that reflect key health objectives in areas such as food production; water supply and sanitation; industrial policy, particularly with regard to safety and pollution; and the planning of human settlements.»* WCED, OCF, 109-110.

But what exactly was sustainable development? The often cited definition focuses on inter-generational justice but gives no hint of the vehement discussions the WCED had on numerous other issues, notably social justice or the role of physical limits for economic growth. Nor does it betray the underlying double challenge of balancing contradictory demands: those of economic needs versus those of environmental well-being, and to balance the need to be scientifically accurate with the need to be politically acceptable.Implicitly, this search for a reconciliation of these conflicts is also a story of an effort to balance contradictory demands on health.

Background

In December 1983, the United Nations General Assembly decided to establish a Special Commission, in charge of proposing «long-term environmental strategies for achieving sustainable development to the year 2000 and beyond.» As chairperson, UN Secretary-General Perez de Cuellar appointed Gro Harlem Brundtland, former Minister of the Environment and Prime Minister and then head of the opposition Labour Party and member of the Norwegian parliament.* Gro Harlem Brundtland, Madam Prime Minister, New York: Farrar, Strauss and Giroux, 2002, 192-3; UN Press Release SG/A/316, 23 Dec 1983, S-1051-0014-05, United Nations archive (UNA). Between October 1984 and February 1987, the Commission met eight times in different cities and discussed the selected topics on the basis of texts provided by the Secretariat, which was located in Geneva and headed by Jim MacNeill. Information came from a wide range of sources, including scientific institutions, NGOs, academics, consultants, industry and individual experts. Some papers were commissioned by the Secretariat, some were volunteered. Through a process of drafting, discussions and redrafting of texts, the WCED produced a report, later known as the Brundtland report or by its title, Our Common Future.

The Commission consisted of twenty-two Commissioners from twentyone countries in all parts of the world. Their geographical diversity was their strength as much as their challenge: coming from different backgrounds and representing different global views was essential to their ability to speak to and for large parts of the world population, but it clearly made finding common ground difficult. The biggest challenge was reconciling the diverging perspectives of participants from high-income countries of the North and low-income countries of the South. Though positions were more complex in detail, the Northern viewpoint traditionally favoured international regulation measures designed to address environmental degradation, a Southern concern was that environmental policies and regulations would stifle their economic development while selectively benefitting the North.

These difficulties showed in almost all topics, which the Commission discussed and which eventually became chapter topics of their report: population, energy, industry, agriculture, urbanization, international economic relations, global environmental monitoring to international cooperation, biodiversity, the commons and peace and security. Secretary General Jim MacNeill proposed the basic approach, readily accepted by the Commissioners: they would address causes, rather than manifestations of environmental degradation, and would regard development and environment as interlinked. Discussions were guided by a belief in «the mutually supportive relationship between environment and development, wherein the former is both a pre-requisite for development and its end result.»* Key Issues, WCED/84/10-1, Inaugural Meeting, Geneva, 1-3 Oct, 1984, IDRCA; MacNeill, From Controversy to Consensus, 246-47. This approach mitigated the economy-environment tension; it did not make it disappear. In fact, in some ways, it made it more difficult to grasp the underlying contradictions.

Struggling to define sustainable development

While initially all Commissioners had easily agreed on the mutually supportive relation of environment and development, the problematic nature of this assumption emerged during the public hearing in Oslo in June 1985, attended by many people from the rich Scandinavian environmentalist scene. Unease mounted as group after group explained their concerns, and it dawned on several Commissioners from Southern countries that, if rich Norway had difficulties dealing with problems created by industrialization, this did not bode well for low-income countries elsewhere. In a revealing exchange, Indonesian Commissioner Emil Salim asked Mats Segnestam, the representative of the Swedish Society for the Protection of Nature, that if the reason for economic growth was the same as the reason for environmental deterioration, how would it be possible to reconcile the two? A bewildered Segnestam replied that this was the question the Commission was expected to answer.^{* Oslo Public Hearing, Morning Session 25 June 1985, vol.35 doc.12, cassette seven, archive of the International Development Research Center (IDRC), 3 and 6.}

The question evaded an easy answer as discussions continued the following day. If Southern Commissioners had to acknowledge the seriousness of a global environmental challenge, Northern Commissioners had to confront the seriousness of a global development challenge. A draft paper by the Commission Secretariat on international economic relations and environment described the international economic system as an adjunct to the biosphere, which dispersed undesirable environmental effects worldwide.* International Economic Relations and the Environment, Secretariat Proposed Work Programme, WCED/85/19, Annex 11 of Oslo Meeting, June 1985, IDRC, 2. This paper provoked vehement disapproval from Commissioner Shridath Ramphal, then Secretary General for the Commonwealth, who criticized that this approach ignored the eminently political character of the issue. If low-income countries received acid rain and hazardous waste from industrial countries and were forced to cultivate their land in ways which caused erosion, this situation did not reflect the nature of industrialization as much as the context of poverty and brutal global inequality and the lack of choices they imposed on the South.^{* Ibid., Introduction by Shridath Ramphal, IDRC, 3.}

The ensuing discussion gradually made clear that the seemingly easy acceptance of the complementary character of environment and development early on had glossed over different understandings of what this meant. Above all, the – originally Northern – concept of global environmentalism as a common challenge in the one world shared by all people was partly rejected in the South, where daily experience indicated that neither the problems nor the wealth created by environmental destruction were in any way equitably shared. In a lively debate several Commissioners pointed out that the economic development of low-income countries was being blocked by the setup of the international economic system, which forced governments to prioritize debt repayment and export-oriented production over feeding their people and safeguarding their environmental resources. They insisted that the environmental issues could not be addressed without understanding the underlying economic questions. Others warned of focusing so much on economic questions as to lose sight of the environment. Still others argued that, irrespective of economic background, addressing environmental problems could not wait until all economic issues had been resolved.^{* Paulo Nogueira-Neto, Uma trajetória ambientalista: diario de Paulo Nogeira-Neto, Sao Paulo: Empresa das Artes, 2010, 287; Minutes of the Third Meeting, 21-28 June 1985, IDRC, 26-30.}

The controversy recalled discussions at the conference of Alma-Ata just a few years earlier, which had demanded «health for all» as the guiding principle of global policy. Here, too, the goal, to increase people’s wellbeing, had been linked to the international economic order, and the declaration of Alma-Ata had singled out the reduction of economic inequality as central to an improvement of health, calling for «[e]conomic and social development, based on a New International Economic Order.»* Declaration of Alma-Ata. International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978. This New International Economic Order, which called for technology transfer and for more control over global trade policies by developing countries, never materialized.* Kelley Lee, The World Health Organization (London/New York: Routledge, 2009), 79. At the time of the Brundtland Commission, the inequitable economic system was still in place and its repercussions on human wellbeing were still being discussed.

The debate continued at the next Commission meeting in Sao Paulo. A revised draft explained that understanding environmental degradation required an integrated view of the international economic dimension. Lack of development, i.e. poverty, was responsible for a series of environmental problems such as desertification, soil erosion, deforestation and the spread of urban slums. Therefore, poverty reduction would have to be at the center of all efforts and any effective strategy had to address the causes rather than the symptoms of poverty. However, the direction of world development was largely determined by the wealthy few, placing Southern societies at a disadvantage. Effective strategies would have to begin here, and seemingly indirect approaches, aiming at international trade relations or production policies, could have more decisive effects on environmental problems than policies addressing those problems directly.* Secretary-General to Commissioners, International Economic Relations, Environment and Development, WCED/85/23, 11 Oct 1985, IDRC, 1-13. An integrated approach should take into account both types of environmental degradation: that which resulted from economic development and that which derived from its absence. Commissioners tentatively accepted this version but kept the question open for further discussions.* Minutes of the Fourth Meeting, 25 Oct – 4 Nov, 1985, São Paulo, IDRC, 13-18. This position was politically ambivalent: by focusing on the international development order it challenged the privileges, which rich countries enjoyed in the existing system, but by concentrating attention on poverty it also downplayed the responsibility of the lifestyles of the rich for global environmental burdens.

In May 1986, as meetings and debates continued in Canada, the emphasis had shifted back to problems created by affluence. Thus, a new draft text cited rising purchasing power, growing population and increasing demand for food and for consumer goods and their confrontation with limits in resources and in eco-systemic waste absorption capacities as the origins of environmental pressures. Planning would, therefore, have to integrate the positive and intended as well as the unintended negative environmental effects of the same development processes.* WCED, Draft Chapter 2, 7 May 1986, WCED/86/3, ICDR, 1-3. Subsequent discussions raised sensitive related questions: to what extent would technological progress offset physical limits and how would these innovations reach those countries in the South, which most needed them? And the obvious and politically sensitive follow-up question: if technological progress could ease the environmental degradation only so far, to what extent would the rest have to be achieved through global wealth redistribution? * Interview of Janez Stanovnik, 7-8 Jan 2001, p. 87-88, The Complete Oral History Transcripts from UN Voices, CD-ROM (New York: United Nations Intellectual History Project), 2007; Interview Shridath Ramphal, 14-15 Jan 2002, UN Voices, 64-65; This was hardly a politically welcome suggestion, and Commissioners from the North and the South were moving towards deadlock.

Indian economist Nitin Desai, who had been hired as an expert in development economy, tried to distill central elements from the discussions and mold them into a position paper with which all Commissioners could identify. It confirmed the Commission position that the connection between patterns of development and environmental conditions was so direct and obvious that the issue was «no longer one of promoting development or protecting the environment» but that both objectives had to be pursued simultaneously and in a mutually reinforcing manner. This concept of sustainable development could provide a basis for such an integration:

Needs, it argued, were socially and culturally determined and an equitable system required that consumptions patters by the affluent be kept within a range of what was, in time, achievable by everyone and within ecological possibilities. The ability to meet needs depended on the technological development, on resource management skills, available capital and distribution, all of which should be optimized.* Ibid., 2-3. Finally, the paper declared that sustainable development required an economic organization, which broadly enhanced the present and future opportunities to meet needs. This process entailed economic growth in communities where basic needs were not yet satisfied and it allowed growth everywhere provided its content reflected «the broad principles of sustainability and non-exploitation of others.»* Ibid., 4. There were physical limits to this process. They were diffuse, since they depended on many factors, but they existed in crucial life-supporting structures and in regenerative capacities of exploited systems.^{* Ibid., 6-8.}

The paper reconciled central developmental and environmentalist positions, which was a major achievement. It lifted the concept onto a moral ground, which communicated ideas in terms of human needs instead of economic theory. This shift came with advantages and disadvantages. The needs-based definition provided a convenient sound bite, whose vagueness made widespread endorsement possible. But it also evaded some of the complexities included in more operational definitions, opening Commission findings to a range of (mis)-interpretations later.

This paper was accepted as the core of the Commission understanding of sustainable development, though discussions kept alternating between highlighting poverty and affluent lifestyles. In September 1986, the importance of poverty was upgraded again. A revised draft chapter argued that economic growth was required to reduce poverty in countries in the South, and their economic growth depended on economic growth in countries in the North. However, a transition to sustainable development required fundamental changes in patterns of production and consumption and an approach which integrated environmental considerations at every stage and every level of planning and decision-making, ranging from the household to the global system and in every sector of life, legal, political or private, and by everyone.^{* Draft Chapter 3, Towards Sustainable Development, WCED/86/14, IDRC, 48-56.}

This ambivalent position on growth aimed at balancing the radicalism of a changed system and political pragmatism by keeping but downplaying the politically sensitive elements of life-style changes and wealth redistribution.At a basic level, this meant accepting that people in low-income countries would wish to raise their living standards to a state of material wellbeing which people in high-income countries had and would wish to keep. It also meant glossing over physically necessary but politically unacceptable limitations to this generalized growth process. While earlier versions had discounted the concept of limits to growth, the final report omitted the offensive word altogether but retained the underlying idea by discussing crucial environmental pressures under the title of «survival.» Concerns such as «global warming,» the depletion of the ozone layer, acidification or desertification were considered not in terms of «limits» but of «thresholds» which could not be «crossed without endangering the basic integrity of the system.»* WCED, OCF, 32-33. Thus, the final text still contained strong language which did not shy away from politically controversial issues. It flatly declared «the distribution of power and influence» to be «at the heart of most environmental and development challenges.»* WCED, OCF, 38. But overall, the text focused on poverty and its role in environmental degradation, while deemphasizing references to the role of affluence.^{* WCED, OCF, 40.}

In this vein, the Commission proposed a long list of other measures as parts of sustainable development, such as the increased production and use of renewable forms of energy, a massive shift of research funds and attention towards needs of countries in the South, automatic forms of fundraising to be used for a transition towards a sustainable development regime, the integration of sustainable development principles in all national governments and all international agencies, aided by coordinating bodies, and others.

The result combined calls for radical change with a certain conservatism: the contents and international structure of the global economy should change while its principle goal, economic growth, should remain. On the radical side, the recommendations envisaged nothing less than a fundamentally changed world: a world in which considerations of sustainability were firmly integrated into structures, codes of conduct and policy decisions of all national and international public and private actors, in which global environmental data would be monitored and freely distributed, a world in which states were legally obligated to maintain biological diversity, to identify and respect the carrying capacity of a given ecosystem, to assess all major new policies regarding their effect on sustainable development and to release all relevant information about its potentially harmful pollution, a world in which the International Court of Justice had jurisdiction over international environmental and resource management conflicts, and in which automatically generated funds would be invested in the transition of economies towards sustainable development. On the conservative side, it recommended a growth rate of at least three percent in low-income countries. It was a message that carried both the promise of a continuation of the world into a bright future and the menace of the end of the world as it was known at the time.

On 27 April 1987, Our Common Future was officially released in London at the Queen Elizabeth II Conference Center and presented to the UN General Assembly on 19 October 1987.* WCED, Chronology, IDRC, 11, 15. In an impressive public relations blitz, Commissioners presented the report to numerous audiences, especially Gro Brundtland, who had become Prime Minister of Norway again, and who shamelessly used her position to give maximum visibility to the report.

Conclusions

The Brundtland report remains one of the most impressive consensus documents. That agreement would be reached was far from certain, and it was possible only because, on a personal level, relations between Commissioners remained fruitful, often cordial. Partly thanks to Brundtland’s leadership and partly as a result of over two years of shared experiences in discussions and public hearings, Commission members learned to truly listen to one another and to seek common solutions.^{* Jim MacNeill, “From Controversy to Consensus, The World Commission on Environment and Development,” Environmental Policy and Law, 37 (2007) 2-3, 242-265.}

The report was also an immense success in the sense that it prompted all UN agencies, numerous governments and academic institutions and countless people to consider the idea of sustainable development and to review their activities accordingly. The idea stimulated thousands of local national and global initiatives and fundamentally transformed development thinking. It provided the central theme for the UN Conference on Environment and Development, «Earth Summit» in Rio in 1992, which translated the concept into a detailed action plan, Agenda 21. However, the practical effects have remained frustratingly minimal.* Desta Mebratu, “Sustainability and Sustainable Development: Historical and Conceptual Review,” Environmental Impact Assessment Review 18 (1998), 493-520. In 2005, the health component of the Millenium Ecosystem Assessment, a gigantic work of global scientific cooperation, found evidence for «an increasing risk of non-linear changes in ecosystems, including accelerating, abrupt and potentially irreversible changes» with potentially «a catastrophic effect on human health.»* Carlos Corvalan, Simon Hales, Anthony McMichael et al., Ecosystems and Human Well-being. Health Synthesis. A Report of the Millennium Ecosystem Assessment (Geneva: WHO, 2005), 7.

Clearly, the Commission failed to bridge the divide between what was necessary to say and what was possible to communicate to people and agencies in order to convince them to act.

This should worry us, because, in fact, the Commission went far in mitigating the extent of necessary change for long-term sustainability. In the early 1990s, a critical study on «Strategies for Environmentally Sound Economic Development,» headed by the Assistant Director General of Statistics Norway, Olav Bjerkholt, conducted a model simulation of the recommendations of Our Common Future. It concluded that the financial transfers from Northern to Southern countries, which the report envisaged, were unrealistically high but that, even if implemented completely, the Brundtland recommendations were unlikely to achieve their goal of combining higher living standards with reduced environmental degradation.* Faye Duchin and Glenn-Marie Lange, The Future of the Environment, New York and Oxford: Oxford University Press, 1994, 8. This study supported those who criticized the Commission and its concept of sustainable development as being so devoid of tangible demands as being meaningless.* See Desta Mebratu, „Sustainability and Sustainable Development: Historical and Conceptual Review,“ Environmental Impact Assessment Review, 18 (1998), 493-520. This criticism overlooks the radical component of the report and it builds on the implicit assumption that a more outspoken concept would be more effective. Available evidence points to the opposite. In 2000, the declaration of the People’s Health Assembly voiced a more drastic version of demands discussed by the Brundtland Commission: the cancellation of Third World debt, a radical transformation of the World Bank and the IMF, and a reconsideration of growth-centred economic theories and their replacement with alternatives that created «humane and sustainable societies.» Crucially it called on the people of the world to «[r]educe overconsumption and non-sustainable lifestyles – both in the North and the South. [And to] Pressure wealthy industrialised countries to reduce their consumption and pollution by 90 percent.»* People’s Health Movement, People’s Charter for Health, http://www.phmovement.org/sites/www.phmovement.org/files/phm-pch-english.pdf, accessed 1 Oct 2011. Its effect has bordered on zero.

The Commission succeeded in reconciling ideas of environmental and economic needs sufficiently to convince people around the world that sustainable development was a challenge that was of relevance to them all. One may suspect that in the real world little more was possible. To what extent that has been enough to safeguard global health is an open question. More than 25 years after its publication Our Common Future still provides compelling reading to all those concerned with public health.

And to everybody else.