呼吁：亟须将气候和自然危机视作不可分割的全球卫生紧急情况
200余份健康领域期刊集体向联合国、各国政治领导人和卫生专业人员发出呼吁，必须认识到气候变化和生物多样性丧失是一种不可分割的危机，必须共同应对才能保护健康并避免灾难。现在，这种整体的环境危机已经严重到可以被视为全球卫生紧急情况的程度。
目前，全球都在应对气候危机和自然危机，似乎将它们视作两种截然不同的挑战，这是一个危险的错误。《联合国气候变化框架公约》第28次缔约方大会（Conference of the Parties，COP）将于2023年11月30日至12月12日在阿联酋迪拜举行，而《生物多样性公约》第16次缔约方大会将于2024年在土耳其举行。遗憾的是，分别为这两次大会提供证据的研究团体几乎不曾彼此沟通，但在2020年的一次研讨会上，两个团体相互交流并得出了以下结论：“只有认为气候和生物多样性属于同一个复杂问题......才能制定出能够避免适应不良的解决方案，并且最大限度地实现有益的结果。”[1]
随着星球健康（planetary health）概念的提出，全球卫生界认识到大自然是一个相互依存的整体系统。破坏一个子系统产生的后果，可能会破坏另一个子系统——例如，干旱、野火、洪水以及其他全球气温上升的影响会破坏植被，导致土壤侵蚀，从而抑制碳封存（carbon storage），导致全球变暖加剧。[2]气候变化将超越砍伐森林和其他土地利用变化活动，成为自然损失（nature loss）的主要驱动因素。[3]
大自然有强大的复原力。例如，被砍伐的土地可以通过自然再生恢复为森林，而作为天然碳库的海洋浮游植物，每8天就能转化超过10亿吨光合作用生物质。[4]土著土地和海洋管理在自然再生和持续恢复方面具有非常重要的作用。[5]
恢复一个子系统有利于另一个子系统——例如，补充土壤有助于大规模清除大气中的温室气体。[6]但是，有利于一个子系统的行动也可能会损害另一个子系统——例如，种植了同一种树的森林可以清除空气中的二氧化碳，但会损害对健康的生态系统至关重要的生物多样性。[7]
期刊中已有评论指出[8][9]，气候危机和自然危机都直接危害人类健康。[10]这一不可分割的全球性危机将破坏社会和经济系统，对健康产生重大影响——土地、住房、粮食和水资源短缺，贫困加剧，进而导致大规模移民和冲突。气温升高、极端天气事件、空气污染和传染病传播是气候变化加剧的主要健康威胁。[11]2022年，联合国秘书长安东尼奥·古特雷斯（António Guterres）在加拿大蒙特利尔举行的《生物多样性公约》缔约方大会上直言不讳地总结道：“没有自然，我们一无所有”（Without nature, we have nothing）。[12]即使将全球升温幅度控制在比工业化前水平高1.5°C的范围内，我们仍然可能因为破坏自然而对健康造成灾难性的损害。
获得清洁水源是人类健康的基础，但污染破坏了水质，导致水源传播疾病增加。[13]被污染的水从陆地流入海洋，也会对远处的生态系统产生深远影响。[14]食物种类的多样性是良好营养状况的基础，但食物系统中遗传多样性已经显著丧失。全球约有五分之一的人依靠野生物种获取食物、维持生计。[15]这些人群面临的主要挑战是野生动物数量减少，尤其是在中低收入国家。在许多非洲、南亚和小岛屿国家，鱼类提供了一半以上的膳食蛋白质，但海洋酸化降低了海产品的质量和数量。[16]
土地利用的变化迫使数以万计的物种更加紧密接触，增加了病原体的交换，导致新的疾病和流行病的出现。[17]人类缺乏与自然环境接触和生物多样性的丧失，都与非传染性疾病、自身免疫性疾病、炎症性疾病，以及代谢性、过敏性、神经精神疾病的增加有关。[10][18]对当地人而言，关爱自然和接触自然对健康尤为重要。[19]大自然也是药物的重要来源，因此生物多样性的减少也限制了新药的发现。
高质量的绿地有助于过滤空气污染，降低空气和地面温度，并提供体育活动的机会，让整个社区更加健康。[20]接触大自然可以减少压力、孤独和抑郁，同时促进社会互动。[21]但是这些益处正受到不断发展的城市化的威胁。[22]
最后，在国家之间和国家内部，气候变化和生物多样性丧失对健康的影响并不均衡，最脆弱的社区往往承受着最沉重的负担。[10]与此相关的是，不平等也助长了这些环境危机。同样的驱动因素导致了环境挑战与社会和健康不平等，解决这些挑战可能会带来共同利益。[10]
现在，亟须将气候和自然危机视为全球健康紧急状况。2022年12月，《生物多样性公约》缔约方大会同意在2030年前有效保护和管理全球至少30%的陆地、沿海地区和海洋。[23]工业化国家同意每年筹集300亿美元，支持中低收入国家的行动。[23]这些协议与《联合国气候变化框架公约》缔约方大会上的承诺相符合。
然而，在缔约方大会上做出的许多承诺并未兑现。这将生态系统进一步推向边缘，大大增加到达自然功能突然崩溃临界点的风险。[2][24]如果这些事件发生，将对全球健康产生灾难性的影响。
上述风险以及已经发生的对健康的严重影响，意味着世界卫生组织（WHO）应当宣布不可分割的气候和自然危机构成了全球卫生紧急情况。WHO宣布某一情况为“国际关注的突发公共卫生事件”（Public Health Emergency of International Concern）[25]的三个先决条件是：（1）严重的、突发的、不寻常或出乎意料的；（2）对公共卫生的影响跨越国境；（3）需要世界各国协调一致的国际反应。气候变化似乎符合所有条件。虽然气候变化的加剧和生物多样性的丧失并非突发或出乎意料，但肯定是严重且不寻常的。因此，我们呼吁WHO在2024年5月举行的第77届世界卫生大会之前或期间发表这一宣言。
应对这一紧急情况需要协调缔约方大会的进程。第一步，各会议必须推动将国家气候计划与生物多样性计划更好地结合[3]，正如气候和自然科学家在2020年研讨会所总结的：“能产生影响的关键点包括探索高品质生活的新视角、重新思考消费与浪费、转变人与自然关系的价值观、减少不平等，以及促进教育和学习。”[1]这些都有利于健康。
卫生专业人员必须大力倡导对健康有益的恢复生物多样性和应对气候变化措施。政治领导人必须认识到全球性危机对健康的严重威胁以及应对危机对健康的益处。[26]但首先，我们必须认识到这场危机的本质：一种全球卫生紧急情况。END
作者介绍及利益声明
VB is an employee of the Medical Journal of Australia and an unpaid committee member of Wildlife Queensland. TB receives unrestricted grants to his institution from GSK, Novo Nordisk Foundation, Simonsen Foundation, Lundbeck Foundation, Kai Foundation, Erik and Susanna Olesen’s Charitable Fund, Pfizer, MSD, and Gilead Sciences; is principal investigator for clinical trials funded by Pfizer, Boehringer Ingelheim, Gilead Sciences, MSD, Roche, Novartis, and Kancera AB; is an advisory board member for GSK, Pfizer, Gilead Sciences, MSD, Janssen, and Astra Zeneca; is a board member of Pentabase; reports consulting fees from GSK and Pfizer; reports honoraria for lectures from GSK, Pfizer, Gilead Sciences, Boehringer Ingelheim, AbbVie, and Astra Zeneca; and reports donation of trial medication (baricitinib) from Eli Lilly. LL-L is a member of the advisory group to the UK Climate Change Committee. RM reports a TEAM grant to his institution (Stellenbosch University) from VLIR (Belgium) to investigate primary health care and climate change in Africa. SH reports honoraria for hosting webinars from Procter & Gamble Oral-B. PY reports honoraria for lectures from bioMérieux and Pfizer; participation in a Data Safety Monitoring Board for the US National Heart, Lung, and Blood Institute; has received COVID-19 and influenza test kits from Atea Pharmaceuticals for a phase 3 clinical trial that he serves as a principal investigator; is a member of the Executive Committee of the antimicrobial stewardship study group for the European Society of Clinical Microbiology and Infectious Diseases; and is Editor-in-Chief of the East African Medical Journal, which is the official medical journal of the Kenya Medical Association. All the other authors declare no competing interests.
Kamran Abbasi, Editor-in-Chief, BMJ; Parveen Ali, Editor-in- Chief, International Nursing Review; Virginia Barbour, Editor-in-Chief, Medical Journal of Australia; Thomas Benfield, Editor-in-Chief, Danish Medical Journal; Kirsten Bibbins-Domingo, Editor-in-Chief, JAMA; Stephen Hancocks, Editor-in-Chief, British Dental Journal; Richard Horton, Editor-in-Chief, The Lancet; Laurie Laybourn-Langton, University of Exeter; Robert Mash, Editor-in-Chief, African Journal of Primary Health Care & Family Medicine; Peush Sahni, Editor-in- Chief, National Medical Journal of India; Wadeia Mohammad Sharief, Editor-in-Chief, Dubai Medical Journal; Paul Yonga, Editor-in-Chief, East African Medical Journal; *Chris Zielinski, University of Winchester
chris.zielinski@ukhealthalliance.org
This Comment is being published simultaneously in multiple journals. For the full list of journals see the BMJ website.
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[1] Quote direct from author and cannot be found in the text of the Article.
[2] The definition of miscarriage varies amongst countries and international organisations, based on different gestational ages of the foetus, whether pregnancy was confirmed by a urine test (for β-human chorionic gonadotropin) or by ultrasound scan, and, for recurrent miscarriage, if the pregnancy losses are consecutive or if the woman has livebirths in between miscarriages.
[3] Miscarriage management options are either expectant (ie, without medical intervention), medical (misoprostol, with or without mifepristone), or surgical (suction aspiration, or suction aspiration plus cervical preparation).
[4] The essential investigations include measurements of lupus anticoagulant, anticardiolipin antibodies, thyroid function, and a transvaginal pelvic ultrasound scan. Chromosome analysis of pregnancy tissue can be done for explanatory purposes. Selected women can benefit from parental karyotyping.
The key treatments to consider are first trimester progesterone administration, levothyroxine in women with subclinical hypothyroidism, and the combination of aspirin and heparin in women with antiphospholipid antibodies. They note that the evidence for these treatments is of moderate and low quality, and there is no high-quality evidence for any treatments to prevent recurrent miscarriage.
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