Indexing the environmental costs of public health achievements: What international comparisons teach us

"Environmental indexing" of public health achievements in relationship to environmental costs is a growing practice. This practice arises from an increasing recognition that the environmental costs of high public health status must be considered if economies are to become sustainable and reduce their ecological footprint. Usually, indexing employs a “ratio” approach. But, it is better to use a weighted average of key factors – this makes comparisons fairer and exposes relevant values. For example, international and intra-national social justice and health disparities must be reflected in the measure. Some nations and regions achieve high average health status at relatively low environmental cost; others maintain an environmentally costly economy with little relative health improvement. Of most interest are countries that enjoy high health status at low ecological footprint. Understanding the public health practices of these countries can help environmentally less efficient countries to protect their high health status during the next century. We also consider whether these are the same or different nations identified in the 1980s work on "good health at low cost." And, we consider the long term sustainability of these nations' achievements. In the international debate over climate change and other environmental challenges, public health has not been taken sufficiently into account. As countries strive to lower their environmental impact, especially their carbon footprint, indexing allows us to ensure that public health is a salient criterion of success. Indexing also highlights some major challenges in maintaining high international public health status during the next generations.