María Neira is a doctor specializing in endocrinology. She worked with Doctors without Borders in Honduras and with the United Nations in Mozambique and Rwanda. Subsequently, she joined the WHO as the director of the Department for the Prevention and Eradication of Infectious Diseases. She was president of the Spanish Agency for Food Security of Spain's Ministry of Health and Consumption, where she was responsible for the development and execution of national food and nutrition plans.

Why is the COP21 agreement to fight climate change so important for global health?

The agreement reached on climate change, signed by all the UN countries on December 2015 in Paris, addresses decision-making and brings solutions for global warming to the table. It is important for health because all of the decisions that are going to be made to fight climate change will in the end benefit health enormously. In this regard,  measures must be taken, for example, to reduce traffic and we must also consider whether we use a  type of energy that pollutes or not; all these decisions are going to have an impact on our lungs and on our cardiovascular systems. If we manage to reduce the pollution in the air we breath, the benefits will be enormous, as 7 million people die each year from air pollution.

What are the main impacts of climate change on the health of the population at the international level and, more concretely, in Europe?

Climate change is affecting the pillars of our society: access to drinking water and food; and the way we protect ourselves, in other words, our housing.  Massive displacements may occur due to natural disasters, the lack or poor quality of water and the scarcity of food resulting from episodes of drought. All of this has an enormous impact on our health.

In addition, the increase in temperature from climate change affects the environmental conditions of many vectors that transmit diseases, as is the case with mosquitoes, which could not reproduce in mountainous areas of Kenya because the temperature was not high enough, and now they have just the right temperatures to do so, so we are beginning to detect cases of malaria in areas where it did not exist before.

In Europe, climate change is related to the distribution of fresh water, which is going to become a scarce good. It also affects the use of transport and management of air pollution, and the distribution of harvests at the international level and the new distribution of diseases. It is wrong to think that it is a problem that is only going to affect developing countries. Of course, it is going to affect them much more than developed countries, but it is also going to be a problem for the developed countries.

What public health challenges does a country like Spain face as a consequence of climate change?

Climate change is going to change our life styles. Ironically, this will be a positive result of global warming. People must understand that when the planet suffers – something that is thought to be very distant – our health also suffers.

I think that in Europe we will notice if we take action to combat air pollution and if we change our models for living. We need to think about how we always use private vehicles instead of public transport or walking; or the fact that we do not do physical activity; we move about in cars or on motorbikes; we live very sedentary lives. All of this has a great impact on non-communicable diseases.

One of the problems is that people do not see the connections between global warming and health. Therefore, we have to explain the connections. Once they understand, for example, that the increase in cases of asthma or allergies is related to climate change, people become leaders in the movement to fight global warming. This is not just an issue for committed environmentalists, but it is an issue that has so much to do with our health.

How do environmental factors affect us? How do we minimize their effects on our health?

Environmental factors are responsible for nearly 13 million deaths each year. From a positive point of view, if we manage the environment in a logical, intelligent and sustainable way, we will avoid 13 million deaths a year, and people will have a better quality of life.

If we focus on the individual and the public in designing our cities, and if we plan them thinking of the possibility of people walking or using bicycles, having access to green areas and breathing cleaner air, we will be protecting our health. The idea is not to avoid illness, but to protect health, thanks to better designed cities, focused on their own populations. And these types of actions are also fundamental in fighting climate change.

Among environmental conditions, which are the most important in regard to health? Can we prevent diseases through taking care of the environment?

Prevention is the best medicine. The better we protect the natural environment, which is what sustains us, feeds us, provides us with water to drink and air to breathe, the better we protect ourselves. There is no other alternative. The environment is what decides.

Evidently, one of the main challenges that we face is access to drinking water. In Europe this seems unimportant, but there still many countries where the population does not have regular and easy access to drinking water. It is not just turning a tap, it is a major daily struggle. Other environmental conditions are air pollution, exposure to chemical substances, pesticides and other toxic substances in our daily lives, as well as waste management.

Optimizing our urban environments is essential to improving our health. The better we plan our environments, the greater the benefit to health. The better we plan collective public transport, the greater the decrease in traffic congestion and in the number of deaths and injuries caused by accidents. All this has an enormous positive impact on health. We want healthy urban policies to be developed that take into consideration the public, who will benefit or suffer from these policies.

What impact will improvements in urban environments have on health?

It is important to reduce air pollution, as it causes almost 7 million deaths annually,  a figure that we should remember. This is currently one of the most important environmental health risks that we face. Obviously, air pollution affects developing countries much more than developed countries, but it is worrying that 80% of the world's population is going to be living in cities in approximately 20 years. We have got to do something.

Every city must do its own assessment of the origin of this pollution. A great deal of it is caused by vehicles moving around the city. Another part of it comes from waste management: there are places in the world where garbage is burned in people's homes, which produces toxic substances and pollution. Agricultural production around cities and industrial production in some countries that do not have regulations regarding factory emissions, cause air pollution. There is no single cause of air pollution, as it depends for example on the type of fuel, diesel or gasoline, used in vehicles.

Based on this, we must employ a range of measures to reduce it. The ideal would be that citizens understand that reducing air pollution is important for our health, that they begin to demand measures to improve urban life in this sense and that they use private vehicles less to move about, and improve waste management and use more energy efficient practices in the home - not using too much heat or air conditioning, among other things.

Almost two thirds of deaths worldwide are attributed to non-communicable diseases. How can we address this enormous social and public health challenge?

Increasingly taking into account, for example, that making a decision related to the future of a city has to be done thinking about which diseases might be avoided and which might be caused. Exposure to environmental risk factors is one of the first causes of death from cardiovascular disease. We used to think that only other risk factors, such as diet, lack of exercise and the consumption of tobacco and alcohol, which are also very important,  had an influence. But today we know that one of the most important risk factors is exposure to air pollution. Therefore this is one of the remaining tasks to be addressed.

There are many ways to deal with the effects of air pollution on health, but the role of the media in educating people is fundamental. This is not a campaign to save the planet, which sounds like something very distant; it is an action to save “my lungs and “my heart”, a health prevention campaign for everyone. I think that this is a message that is going to reach the public more.

What are the main health problems faced by developing countries? How should they be dealt with?

These problems should be addressed intelligently, making strategic decisions at the country level on how and where to invest. Of course, education and health are always the best investments, especially if they are made in a manner that is sustainable over time.

It is also necessary to reflect on decisions about the energy sources that are going to be used in developing countries that are industrializing and changing their model of life, decisions that will affect the transport model that they are going to develop. Are they going to copy ours? Are they going to copy our industrial system, which was very polluting? Are they going to act like China, where all development has involved polluting rivers and the air, where the economy comes before everything else despite the problems this has created?

The main message is that there can be a kind of economic development that does not destroy natural resources and does not affect people’s health. The diseases that we face in the developing countries are of two types. On the one hand, infectious diseases, that is, malaria, tuberculosis, etc., continue to be a problem, but in addition, problems such as diabetes and cardiovascular disease have appeared, which are related to sedentary lifestyles and obesity. That is, these countries live with two epidemics, which makes it more difficult to resolve the problem.

How can we improve public health through education, culture, research and innovation? Could you propose three measures that you believe could represent a radical change in this area?

Education is fundamental in changing the health situation in countries.  Governance is also basic: no matter how wealthy a country is, if there continues to be corruption, poor resource management and bad investment decisions, there is not going to be adequate development in health, even with a lot of assistance, as has occurred in Africa.  There must be a population which demands good management and less corruption.

Starting from this foundation, there are three measures that could lead to change: first of all, girls’ education. It is important that girls go to school, since they are the ones who are going to manage the home and its resources. It has been found that thanks to the investment in the education of girls and the resulting better management of household resources, as adults, these girls will also send their children to school. Educating girls is always an excellent investment.

Another measure is to invest in health. This must be a priority in a country’s agenda. It is not only about hospital building, but also, for example, reducing maternal deaths through health education in clinics. The third measure would be to strengthen solidarity. That is, to continue helping in an intelligent and strategic way in the areas where there are results. In addition, another important measure would be to provide access to drinking water and education for everyone, as basic pillars to improve public health.

What public policy recommendations would you make to improve the health of the population?

In countries with greater resources, such as ours, we need to understand that health is multi-sectoral. That is, health is not hospitals. They are fundamental for people’s health, but they are the last step. Hospitals are for when people are already ill.

I would recommend investing in primary prevention, with the understanding that health policy is not only made by the Health Ministry but also by other ministries, such as the Environmental, Industry and Energy Ministry, or in the corresponding ministries in each country that make welfare policies. All ministries should be aware of the following task: demonstrating what percentage of their work is contributing to improving people’s health. All of them must contribute to health because well-being and the absence of illness is generated through all government policies. The Health ministry should not only be concerned with the person who is ill, it must also be concerned with and work for the healthy so that they remain so.

What changes in individual behaviour are necessary to bring about better health?

There are many. Our behaviour is related to the way we consume every day. We have to be very conscious about what we consume and how we do it. We have to reflect on the amount of plastic and paper waste we generate every day, what our contribution to the carbon footprint is and how we move about our cities. This is fundamental.

We must also think about how much we pollute: how do I use energy in the home and how aware am I that energy is not an inexhaustible resource and that using it causes pollution? It is essential to think about my consumption of water and food and also how much exercise I do.

In addition, there are risk factors such as smoking, the excessive consumption of fats and alcohol, and other things. However, these shouldn’t be dealt with in a repressive manner by saying to people “this is prohibited.” We need to think about a culture for a better life. The idea is “this is better for me” and not about feeling bad. It's about that in my life and regarding my health, this is better for me and makes me happier.

Environmental and social conditions can lead to poor health, and poor health may push more people into poverty due to rising health care costs, loss of housing or income. How can we break this vicious circle between environmental conditions and poverty?

We can break it by preventing people from becoming ill. Currently, 97% of health resources go primarily to curing disease. We invest only 3% in prevention. These percentages must be changed. We have to invest a lot in curing illnesses, but we need to be intelligent in looking after health, as I said before, through all of the ministries and all of our policies. For example, any type of construction project should have to have an impact study on health. A culture of primary prevention would break with this vicious circle.

What would it mean to eradicate a disease?

It would be an injection of optimism. There is no doubt that if we could finally eradicate polio, for example, the injection of optimism would be enormous. But then we would have to go on to eradicate the next disease. We would not be able to rest on our laurels for even five minutes. For the international community I imagine it would be like winning the world cup in football. But eradicating a disease does not mean that the possibility of becoming ill is still not significant because of  all the risk factors to which we are exposed. Therefore, we have to reduce them.

Finally, the WHO has stated that violence is a fundamental global public health problem. As it is a complex problem and understanding that there are different forms of violence, what preventive measures stand out to try to tackle it?

Education, education, education. It is clear that a society is what it wants to be. If a boy is taught from childhood that he is superior to a girl or that violence solves problems or is a model in our daily life, obviously that society will develop following those ideas. Personally, this is not the kind of society I want to live in. I believe that education has to raise awareness, and we have to educate everywhere: in the home, at school, on the street, through the media, and on billboards. But without repression, simply educating.

Interview by Raül Toran Navarro