This global question now confronts India, as a developing nation surging ahead towards its predicted destiny as the world’s third largest economy by 2030. In its pursuit of a neo-liberal growth model, focussed on indices such as Gross Domestic Product (GDP), the country has accorded lower priority to public health and environment (in the last national budget, the already low financial allocations for these sectors were slashed further by 20% and 25%, respectively). The growth model presumes that social benefits will accrue via the ‘invisible hand’ of market forces, possibly mediated by increased public revenues and spending following economic growth. Meanwhile, environmental conservation remains predicated on creation of regulations and reserves, while public health is contingent on access to clinics and care. Governance systems consider economy, ecology, and health as different domains, ignoring their inescapable connections.

India cannot afford to let this situation continue longer. The country confronts unprecedented air and water pollution and environmental contamination and degradation. Connections among health, economy, and environment revealed by recent research needs to urgently inform policy and praxis.

Pollution, health, and economy

Take the recent air pollution crisis in the national capital, New Delhi. Implicated in serious lung, respiratory, and other diseases affecting its citizens including over 2 million schoolchildren, the crisis exemplifies a country-wide malaise. Over 660 million people, half of India’s population, live in areas where fine particulate matter (PM_2.5) pollution exceeds the National Ambient Air Quality Standard, reducing life expectancy by an estimated 3.2 years on average.

In 2011, PM_2.5 and other atmospheric emissions from 111 coal-fired power plants across India resulted in 80,000 to 115,000 premature deaths and over 20 million asthma cases. The economic cost to the public and the government was estimated at US$ 3.2 – 4.6 billion. Agriculture, too, is seriously affected. Climate and air pollution impact (due to ozone and black carbon) has reduced average wheat crop yields across India in 2010 by up to 36%, with yield loss up to 50% in some densely populated states.

Indoor air pollution due to use of inefficient biomass-based cookstoves is another serious health issue. In India, it causes over one million deaths and affects the health of over 400 million people, particularly women and children.

Similar concerns, connecting health, ecology, and economy, arise in water pollution and over-dependence on chemicals in industrial agriculture. The Central Ground Water Board reported recently that over half of India’s districts suffered groundwater contamination, including with heavy metals above permissible levels in 113 districts across 15 states. Along rivers, about two thirds of the water courses are polluted, with nearly 275 of 290 monitored rivers having highly polluted stretches. Water pollution does not only cause water-borne diseases and other direct health impacts, it can negatively affect diet and livelihoods due to the loss of fish and aquatic resources, contamination of soils and loss of agricultural productivity downstream of industrial and mining sites.

A 2013 World Bank study estimated that the financial and social costs of environmental degradation in India amounted to about US$ 80 billion or 5.7% of the country’s GDP. Of this, outdoor air pollution accounted for 29%, followed by indoor air pollution (23%), cropland degradation (19%), water supply and sanitation (14%), and pasture and forest degradation (15%).

Environment, climate change, and public health

How environment affects public health is often difficult to trace, but connections are evident and significant. A 2006 World Health Organisation (WHO) study attributed 24% of the disease burden (healthy life years lost) and 23% of all deaths (premature mortality) worldwide to environmental factors. The burden of environment-mediated disease and mortality is also higher in developing countries. Further, a large part of this is due to non-communicable diseases (NCDs).

In 2014, the WHO country profile for India noted that 60% of the 9.8 million human deaths were due to NCDs. The four big killers—cardiovascular diseases, chronic respiratory diseases, cancer, and diabetes—account for 48% of all deaths and 80% of deaths due to NCDs. NCDs are a global problem—causing 68% of 56 million global deaths in 2012—that disproportionately affects low- and middle-income countries.

Cardiovascular and respiratory health suffers due to air pollution, while cancers and hormonal disruption are known to occur due to many pollutants in the environment.

Scientists predict that the health situation will worsen under ongoing climate change. Increasing incidence of NCDs, besides other effects such as rise in vector-borne diseases and injuries due to climate extremes, is likely. In 2014, the Intergovernmental Panel on Climate Change concluded with very high confidence that climate change will exacerbate existing health problems over the next few decades.

The economic fallout will also be high. One study estimated that India’s GDP in 2004 would have been 4% – 10% higher if NCDs were completely eliminated, while a 2014 report estimates that India stands to lose over US$ 4.58 trillion between 2012 and 2030 due to NCDs. Economic policies that alter occupation, mobility, and diet can exacerbate these problems, such as when lifestyles become more sedentary or livelihoods change from rural or forest-based occupations to working in polluted industrial areas as wage labour. The health – environment – economy connect has become a vital concern in recent debates such as over mining in forests where forest-dependent communities live, land acquisition of farms for industry and infrastructure, and reducing pollution from coal and shifting to renewables.

Health in all, for all

As research findings accumulate, the connections between environment, health, and economy grow stronger. This has many implications for policy. For instance, health impact assessments must become a mandatory part of environmental and social impact assessments in industrial and development projects. The GDP-centric measurement of progress should make way for more holistic indices that include progress in health and environmental protection. Instead of viewing environment as a ‘hindrance’ or public health as a ‘burden’, economic policy must consider these integral to human development, and provide higher financial outlays. Finally, India’s draft National Health Policy 2015 recognises the need to integrate environmental and social determinants of health across all sectors, in keeping with the ‘Health in All’ approach, but concrete actions required in individual sectors are yet to be identified.

Ultimately, human lives and livelihoods, health and resources derive from the natural environment: humans are a part of nature. The environment is, in that sense, the other invisible hand that leads to a cleaner and safer, more alive and inspiring world where people can live and flourish. Environmental health subsumes and is connected to human health, just as the health of one’s body subsumes and is connected to the health of one’s heart.