SDG 3 seeks to promote health and well-being for all. While the overall health of the world’s population has improved, many population groups have been left behind. Many diseases remain widespread and deadly, yet are preventable with access to appropriate healthcare. Unsafe drinking water, polluted air, and poor housing conditions are all linked with negative health impacts, and the goal calls for change in each of these areas. Progress in SDG 3 means stronger, more productive individuals and communities, and fulfills the basic requirement of good health for the successful pursuit many other SDGs. SDG 3 is further refined by targets that can be more readily translated into actions. These targets highlight the interconnected nature of the goals: For example, strategies to support Good Health and Well-Being also promote progress toward SDG 5 (Gender Equality) and SDG 6 (Clean Water and Sanitation). Below are a series of synergies that can come from providing access to products, services and systems that address Good Health and Well-Being.
Access to Healthcare Services
Expanding access to healthcare services is fundamental to improving health and wellbeing. In many parts of the world, lack of access to essential care means high numbers of preventable deaths. More than 300,000 women died from maternity-related causes in 2015, mainly in regions where antenatal care is less common and where most women do not receive professional assistance during birth.1 Vaccine and medicine access worldwide is also insufficient for diseases like HIV, pneumonia, and measles, allowing outbreaks to persist.2,3 Even where quality health services are available, affordability often proves to be the greatest barrier; low-income individuals in the US are less likely to have health insurance or to pursue primary or specialty care,4 facing higher rates of morbidity and mortality as a consequence.5 Recent action to bring health care to more people has made great strides in each of these areas, but more work remains to be done.
Access to Clean Water
Safe drinking water is fundamental for a healthy life, yet 2 billion people still use a drinking source contaminated by human waste, and over 800 million lack access to a basic drinkingwater source.6 Contaminated water spreads diseases like typhoid, cholera, and diarrhea, which kills more than 2,000 children each day — a greater toll than AIDS, malaria, and measles combined.7 Even where improved water systems exist, contaminants like lead and nitrates can elevate the risks of blood poisoning and cancer.8,9 Few cases better illustrate the fundamental link between clean water and health than the recent water crisis in Flint, Michigan; in the 18 months following a switch in water source for Flint residents, 12 people died and 87 fell ill from the unsafe water.10 Fortunately, solutions are possible and impactful: A $1 intervention to provide clean water access creates $25.50 of benefits on average as people spend less time and money dealing with illness, and as deaths from unsafe water are prevented.11
Access to Clean Air
The health effects of poor air quality are a growing concern as pollution levels increase globally, contributing to one out of every nine deaths12 and creating unhealthy air conditions for 95% of the world’s population.13 The use of coal and fossil fuels releases a large amount of pollutants, including particulate matter and black carbon, which causes respiratory disease, cardiovascular disease, and cancer.14 Indoors, nearly 40% of the population still relies on the burning of biomass, coal, and charcoal for heating and cooking, making air inside the home unsafe to breathe.15 Replacing exposure to unsafe air with access to clean air is an urgent need to enable healthy and full lives for all.
Access to Adequate Housing and Living Conditions
Access to affordable and quality housing is foundational for healthy lives. Individuals who experience homelessness or housing instability suffer negative mental health impacts and have more difficulty adhering to health treatment.16 Poor housing conditions also have adverse effects on well-being, often linked to respiratory problems when mold or hazardous materials are present.17 Problems such as these combine with lack of sanitation and clean water for the nearly 1 billion people living in substandard housing conditions in the southern hemisphere.18 Fortunately, efforts targeting better access to stable and adequate housing have been shown to improve health outcomes for many residents.19
SDG 3: References
1 World Health Statistics 2018: Monitoring health for the SDGs, World Health Organization (WHO)
3 Progress and challenges with achieving universal immunization coverage: 2016 estimates of immunization coverage. WHO/UNICEF Estimates of National Immunization Coverage (Data as of July 2017). Geneva: World Health Organization; 2017
4 Dhruv Khullar Dave A. Chokshi. 2018. Health, Income, & Poverty: Where We Are & What Could Help. Health Policy Brief. Health Affairs
5 Andersen, R. et al. 2002. Access to Medical Care for Low-Income Persons: How Do Communities Make a Difference? Medical Care Research and Review
6 Progress on drinking-water, sanitation, and hygiene, 2017. WHO
7 Diarrhea: Common Illness, Global Killer. CDC
8 Elevated Blood Lead Levels in Children Associated with the Flint Drinking Water Crisis: A Spatial Analysis of Risk and Public Health Response. Hanna-Attisha M, LaChance J, Sadler RC, Champney Schnepp A. Am J Public Health. 2016; 106(2):283-90
9 Environmental justice and drinking water quality: are there socioeconomic disparities in nitrate levels in U.S. drinking water? Laurel A. Schaider, Lucien Swetschinski, Christopher Campbell, and Ruthann A. Rudel. Environmental Health. 2019
10 Flint Water Crisis: Everything You Need to Know. NRDC. 2018
11 Diarrhea: Common Illness, Global Killer. CDC
12 Ambient air pollution: A global assessment of exposure and burden of disease. 2016. WHO
13 State of Global Air. 2018. Health Effects Institute
15 Access to Modern Energy: Assessment and Outlook for Developing and Emerging Regions. 2012. IIASA.
16 Taylor, Lauren. Housing And Health: An Overview of the Literature. Health Affairs Health Policy Briefs. June 2018
17 Butler, Stuart and Marcella Cabello. Housing as a Hub for Health, Community Services, and Upward Mobility. Brookings Institute. March 2018
18 Slum Almanac 2015/2016. Tracking Improvement in the Lives of Slum Dwellers. Participatory Slum Upgrading Programme. UN Habitat
19 Taylor, Lauren. Housing And Health: An Overview of the Literature. Health Affairs Health Policy Briefs. June 2018.
Rising income and wealth inequality is a widely recognized social concern in the United States. This is a multi-faceted issue, with root causes that vary according to demographics, and one that impact investors have shown strong interest in addressing.
Since the 1990s, there has been a growing disparity in economic opportunity for rural Americans. This demographic issue has gained public awareness in mainstream social discourse in the recent past. In this report, we lay out the key challenges faced by rural America, highlight approaches to revitalization that have proven effective, and describe existing investment strategies.
The decline of manufacturing and shift to a knowledge- and service-based economy left many rural communities unable to recover adequately from the Great Recession of the late ’00s. The resulting challenges can be summarized as:
- Lack of jobs, or a mismatch in skills with available jobs.
- Poor infrastructure: Rural communities often lack high speed internet, access to quality healthcare, and local banking services.
- Drug addiction, specifically opioids, which compounds the effect of limited health care access.
Effective strategies for revitalization
Asset-based community development (ABCD) is a “self-help” strategy that sets the stage to attract private loans and investments by taking advantage of a community’s existing strengths. Initially a community might use government or foundation funding to develop community assets, e.g. supporting existing local entrepreneurs or developing local natural resources to offer an attractive quality of life. Once an initiative proves viable it may be possible to attract private investment.
Community Development Finance Institutions (CDFIs) and other local intermediaries can help aggregate capital to support local investment. Aggregators attract capital to an investment theme and allocate sums to projects that need funding.
Real estate development is another possible path to revitalization, with Opportunity Zones potentially attracting investment that might not otherwise be economically feasible.
We highlight several initiatives that are under way related to broadband projects in small communities that may finally begin to deploy this critical infrastructure.
Lastly, we highlight how some communities are making a concerted effort to attract a younger population and stem the “brain drain” of rural youth to urban areas.
For investors interested in promoting capital investment in infrastructure and businesses that create jobs in rural America, there are various strategies one can consider across asset classes. We describe these strategies in this report; some are general categories of investment, and in other cases we refer to specific strategies available to our clients.
Discovery Ltd. is an innovative insurance company that was founded over 20 years ago. Today, its core purpose – making people healthier and enhancing and protecting their lives – is central to its shared-value business model.
When Discovery was founded in 1992, the complexity of the South African healthcare environment at the time provided a powerful incubator for innovation. South Africa’s high disease burden, an undersupply of doctors, and the vision of changing the way healthcare works required a new framework for addressing healthcare challenges. Health promotion and chronic disease prevention, as opposed to healthcare during illness, offered such a framework.
Incentivizing Behavior Change to Bring Down Insurance Costs
As reflected in its business model, Discovery’s focus has always been on placing the needs of society at the core of its strategy. Discovery designs its innovative insurance products around its shared-value approach, which manifests in its health-promoting integrated insurance programme, Vitality. These products use behavioral economics to translate positive behavior into immediate rewards, which in turn inspire long-term positive behavior change. Changed behavior results in lower insurance costs, and the savings are used to fund incentives that encourage the positive change in behavior. Members benefit from better health, increased insurance value and financial rewards; the insurer benefits from lower costs, and customer loyalty and retention.
Expanding Business Model
Discovery’s shared-value insurance model has become even more relevant in the context of the growing importance of the societal trends shaping the insurance industry. Shared-value health, protection and savings products that are dynamic in nature, offer people the opportunity to manage their evolving health needs throughout their lives and be rewarded for improvement. This will become increasingly important as populations age. For example, as the latest WHO report on aging has highlighted, effective health promotion programs that reduce the risks in older people for cognitive and mobility-related functional impairments save costs for individuals, families and society, as they allow people to live their lives to the fullest. On this chassis, Discovery can grow the business further in existing sectors and expand into new territories in adjacent sectors. The financial and societal success of the Vitality model has led to shared-value insurance becoming a compelling proposition for other insurers. Discovery recently established the Global Vitality Network, comprising partner insurers that employ the Vitality business model and participate in collective network assets such as global rewards partnerships, technology collaborations, and academic and media partnerships. Over the past five years, Discovery has partnered with AIA in Asia and Australia, Generali in Europe, John Hancock in the United States, Manulife in Canada, and Ping An Health in China – all of whom have evolved into ambassadors and proponents of shared-value insurance.
Targeting New Territory to Inspire Positive Change
By applying the same shared-value model, Discovery aims to expand into adjacent industries. Our evidence-based insights about many peoples’ inherent short-termism and seemingly “irrational” behavior has implications well beyond health insurance and applies, for example, to motor vehicle insurance. Discovery’s vehicle insurance business uses technology to track and measure clients’ driving behavior. The rewards programme incentivizes clients to improve their driving behavior and lower their risk.
Current available results validate the relevance of the shared-value approach in this area too: Driving behavior improves significantly, leading to fewer claims and lower claims costs for the insurer, and immediate and long-term benefits for clients in the form of financial rewards and savings, as well as increased safety on the roads. Considering the “irrationality” people generally display in their savings behavior, an opportunity exists to disrupt traditional business models in Discovery’s next targeted adjacency, the banking industry, through a shared-value model.
With this global expansion and because Discovery leverages personalized technologies to enable Vitality members to monitor their health and driving behaviors, the privacy and confidentiality implications from collecting large amounts of data are significant. To address this, Vitality has released a set of guiding principles for the responsible innovation of personalised technologies and the appropriate stewardship of data from these devices.
In August 2015, Discovery ranked 17th on Fortune’s first Change the World List, which recognizes organisations that have made significant progress in addressing major social problems as part of their core business strategy. This recognition for and impact of our model propels Discovery to continue to work towards and beyond our 2018 ambition of being the best insurance organization in the world and a powerful force for social good.
Gugu McLaren is Senior Sustainability Specialist at Discovery Limited. She has 10 years’ experience in driving the development and delivery of sustainability strategic frameworks and projects.
- Food safety innovation offers growth opportunities for investors. As we discussed in our July 2016 report Food Safety: In a State of Transformation, the global food safety testing market is expanding due to the enactment of government regulations such as the Food Safety Modernization Act (FSMA), quality improvement initiatives by food processors, and consumer demand for safer food.
- Our optimistic view on growth in food safety testing is supported by Neogen’s fourth quarter earnings release. Neogen is flagged in our report for having high exposure to the food safety theme.
– Revenues for the fourth quarter of Neogen’s 2016 fiscal year (ending May 31) were $90.08 million (+15% YoY), versus a consensus estimate of $86.3 million. Revenues for fiscal 2016 increased 13.5% over fiscal 2015. Fiscal fourth quarter EPS was $0.26 (+4% YoY), in line with consensus estimates. Fiscal 2016 EPS increased 7.8% over fiscal 2015.
– Food Safety segment revenues increased 11% during fiscal 2016 versus the prior year. Growth was driven by rapid tests for food allergens and AccuPoint Advanced Sanitation Monitoring System products.
– Animal Safety segment revenues increased 16% during fiscal 2016 versus the prior year (14% organic). Growth was driven by agrigenomics testing and biosecurity products.
- Biosecurity benefiting from consumer trends. Neogen’s Animal Safety business is positioned to benefit from growing demand for poultry raised without antibiotics. As antibiotic use is reduced, there’s a growing need for biosecurity products such as cleaners, disinfectants, rodenticides and insecticides. These maintain control over any infections that would become food safety problems as the food products pass through the farm gate (from the farm to the consumer).
- Prospective opportunities in seafood testing. Neogen CEO Jim Herbert believes the FSMA will have more impact on imported seafood than any other part of their market. The company offers products for salmon and trout genotyping, but it is interested in expanding further into the aquaculture market.
Please click here to read the full report.
Michael Shavel is a Global Thematic Analyst at Cornerstone Capital Group. Prior to joining the firm, Michael was a Research Analyst on the Global Growth and Thematic team at Alliance Bernstein. He holds a B.S. in Finance from Rutgers University and is a CFA Charterholder.
Sebastian Vanderzeil is a research analyst with Cornerstone Capital Group. He holds an MBA from New York University’s Stern School of Business. Previously, Sebastian was an economic consultant with global technical services group AECOM, where he advised on the development and finance of major infrastructure across Asia and Australia. Sebastian also worked with the Queensland State Government on water and climate issues prior to establishing Australia’s first government-owned carbon broker, Ecofund Queensland.
America, we have a problem:
Two Princeton economists startled Americans recently when they discovered that between 1999 and 2013, white, middle-aged, high-school-educated men in the United States died at an increasing rate from prescription and illegal drug overdose, alcohol and liver-related disease and suicide. Fortunately there is the impression that government and media are paying attention to this national epidemic. Earlier this month, President Obama announced his plans to invest more than $1.1 billion over the next two years to expand access to treatment for abuse of heroin and other drugs, avail the overdose-reversal drug naloxone to first responders, and support targeted enforcement activities. Also Congress passed the Comprehensive Addiction and Recovery Act (CARA), revising punitive drug policies, promoting best medical practices and strengthening data sharing among states’ prescription drug monitoring programs.
The Princeton study also forces us to recognize that drug abuse is not, as previously thought, a malady afflicting only poor, minority, inner-city communities, but rather is an across-the-country phenomenon, affecting in particular rural white adults. Interestingly, as the mortality trend demonstrates, the under-treatment of pain in minorities has inadvertently ‘protected’ them from overdose, reducing a decades-long death-rate gap between whites and non-whites. But will increased access to care for those already harmed by addiction; addressing the enduring shortfalls in prescriber education; and research for alternative abuse-deterrent medications actually reverse this deadly epidemic?
I think not.
Turns out the overdose epidemic is a social, not just a medical, problem.
First, researchers are struggling to understand why whites, in particular, are doing so poorly with drug abuse. Although there are no definite answers, many speculate that it is the combination of stress and lack of social support (risk factors for drug abuse in general) and acute job loss that are causing these deaths. Recession alone does not increase mortality, however when recession is associated with job loss, the rate of heart attacks, strokes and deaths rises. This may suggest that the increase in stress, despair and financial insecurity combined with engaging in unhealthy behaviors (like inactivity, smoking, drinking alcohol, and drug abuse) may be the cause of these deaths.
Second, and even more surprising, is that although awareness of the harms of opioid abuse is rising, the overwhelming majority of patients who survive an overdose continue to be prescribed high-dose opioids, often by the same prescriber. It is easy to attribute these results to poor care, bad decisions or sloppy prescribing, but many of these prescribers simply do not know that their patients are overdosing. Given the fact that there are no widespread systems in place to notify prescribers when overdoses occur, it is highly unlikely prescribers will suddenly increase the level of care for these patients.
Third, the notion that there is a small group of prolific prescribers that are driving the opioid overdose epidemic is not accurate. The bulk of prescriptions are made by general practitioners trying to help patients with a broad array of health conditions, and the distribution patterns of prescribing opioids between Medicare and Medicaid patients are no different than other drugs given for chronic diseases. These statistics suggest that adding law enforcement resources to address improper prescribing is not warranted. Fourth and most disappointing is that despite a plethora of local, regional, state and federal efforts to curb the overdose epidemic, things are actually getting worse. More people died from prescription and illicit drug overdoses over the past year than during any previous year on record.
Clearly there is a need to develop safer drugs and do a better job in prescribing and intervening before prescription drug misuse or other substance use progresses to addiction. But are these responses a big enough step in the right direction?
Under-assessment, the overlooked problem
The 18th century French philosopher Voltaire had many amusing quotes about medicine, such as: “common sense is not so common” and “the Art of Medicine consists of amusing the patient, while nature cures the disease”. However there is one particular quote that might provide an overlooked solution to the overdose epidemic. Voltaire said that “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing”. How does this statement reflect on current practice?
Obviously, nowadays we know much more on how to prescribe and how to cure diseases, but what about “knowing our patients”? How well do healthcare providers ‘know’ their patients and how does this intimate, context-sensitive, unbiased knowledge contribute to the decision to prescribe (or not) drugs? When was the last time a healthcare professional used an online multidimensional, patient-reported outcome tool during a routine office visit incorporating data on sleep, movement and diet based on a wearable FitBit-like device? When was the last time a prescriber was able to show a patient their longitudinal treatment outcome on a dashboard in real time, to justify continuing or stopping treatment?
Well if your answer is never, you probably understand that the problem of medicine in general is not the over- or under-prescription of drugs, or the over- or under-treatment of anything, but rather a fundamental under-assessment of patient’s complex physical condition and nuanced life narrative.
One billion dollars of funding devoted to appropriate, cost-effective treatments can be expected to help many. But in order to halt and not just attempt to reduce rising death rates from drug overdoses, prescribers really need to get to know their patients. Beyond human contact, professionals need to start quantifying human social traits (“phenotypes”) at every clinical encounter in addition to the routine use of lab tests and imaging. Insurance companies need to pay for this, so that lack of time will not be an excuse for not measuring behavior, and patients need to have this actionable information (‘health data’) available. Not measuring pain interference, mood, diet, activity, exercise and sleep limits the understanding of the effects of any therapy, and makes prescribers unable to guide patients and their families to cope with, and remove, the obstacles that deny them the health and wellbeing they seek.
As for patients, my recommendation is: “next time you see your doctor, ask to see your data”.
Dr. Alex Cahana is Director of Medical Affairs at the Center for Lawful Access and Abuse Deterrence and theme developer for ARK Investment Management. He has over 15 years of experience in policy and healthcare redesign and serves as a consultant for the Department of Defense and the Veterans Health Administration.
 Case A, Deaton A. PNAS 2015; 112(49):15078-15083
 http://www.cdc.gov/media/dpk/2015/dpk-eoy.html. Accessed on 2.3.2016
 https://www.whitehouse.gov/blog/2016/02/01/preventing-epidemic-opioid-abuse-and-heroin-use. Accessed 2.4.2016.
 https://www.govtrack.us/congress/bills/114/s524/text. Accessed 2.4.2016
 Noelke C, Avendano M, Am J Epidemiol 2015; 182(10):873-882
 Rudd RA, Aleshire N, Zibbell JE et al. CDC. MMWR. 2016; 64(50):1378-1382
 Francois Marie Arouet Voltaire (1760). In: Robert Allan Weinberg, The Biology of Cancer (2006), p. 726
 Ausielo A, Lipnick S. Big Data 2015; 3(3):203-208
Health is becoming personal, predictive, and preventive through advanced technologies – wearable devices, embedded sensors, artificially intelligent robots, and virtual reality headsets. A deluge of data and feedback generated by these technologies nudge consumers to engage in healthier activities, or are aggregated and analyzed for insights about diverse populations across geographies. Major technology companies are investing in solutions powered by “big data” that promise to improve the health of populations worldwide. The opportunities appear boundless.
Despite this promise, ethical, legal, and social concerns associated with these technologies have emerged, which could very well hinder benefits to health. The US federal government has targeted several health technology companies that are unable to support their scientific claims with compelling evidence, and studies demonstrate that insufficient privacy and security features underlying such technologies can lead to harmful effects for users. If these challenges are not proactively mitigated, the potential improvements to health may not be realized at scale.
Overcoming these issues requires the collective views of disparate stakeholders and cross-sector collaboration. One voice is not as powerful as multiple in unison. As a start, colleagues from Vitality, Microsoft, and the Qualcomm Institute at the University of California, San Diego published an open-access, peer-reviewed commentary that called for a public consultation to identify best practices to eliminate ethical, legal, and social barriers to health technologies. For 90 days in 2015, a wide range of stakeholders offered input on a draft set of guidelines for the responsible innovation of health technology and the appropriate stewardship of data from these devices. Feedback came from organizations such as the EU Commission, the US Food and Drug Administration, the National Academy of Medicine, and the American Heart Association.
In March 2016, Vitality released the finalized guidelines for personalized health technology. They included five recommendations:
- Build health technologies informed by science: Integrate scientific and behavioral evidence into the design of health technologies to better understand health risks and outcomes.
- Scale affordable health technologies: Develop cost effective health technologies that are accessible by all populations to minimize health inequalities.
- Guide interpretation of health data: Facilitate interpretation of health data through software design to support better health literacy.
- Protect and secure health data: Embed privacy and security design features into health technology to ensure end-to-end protection.
- Govern the responsible use of health technology and data: Disclose practices associated with the governance of health technologies and data to create shared values for all stakeholders.
The guidelines provide the foundation for a working group to pilot the implementation of the guidelines. These will be measured independently using tangible metrics, and results will be shared. Collaborating across sectors, the proposed guidelines seek to shift the dialogue around health technologies to one that promotes shared values for all stakeholders. They are an attempt to convene leading industry players to consider bringing greater transparency and accountability to health technology and data—to avert the sorts of issues that recently emerged between the US Federal Bureau of Investigation and Apple. The guidelines are not an attempt to preempt government regulation, but aim to fill holes where needed in existing regulatory frameworks.
Can we learn from the past to know if we are on track? The Human Genome Project (HGP) is one example where proactive consideration of ethical, legal, and social concerns led to broader individual and societal benefits. Twenty-five years ago, the HGP was founded as an international research collaboration to sequence human genes. Leaders of the HGP set aside a portion of the budget to foster basic and applied research on these issues, and established the Ethical, Legal, and Social Implications Research Program. Today, the National Human Genome Research Institute (NHGRI) at the US National Institutes of Health has a legislative mandate to allocate no less than 5% of the NHGRI budget to these issues. As a consequence, established and accepted protocols facilitate the routine sharing of genetic data for research. The vision for our guidelines is informed by past achievements in proactive investigation of concerns with the possession of genetic information.
Technologies are created by people, for people. Technologies that improve the public’s health should be informed by science, affordable, safe and protect the user’s health data. We can collaborate to shape the future of this new frontier in health data, or we can wait in anticipation and uncertainty only to discover the unintended consequences.
Gillian Christie is a Health Innovation Analyst at The Vitality Group in New York City.
Kevin Patrick is a Professor of Family Medicine and Public Health, and a researcher at the Qualcomm Institute at the University of California, San Diego in La Jolla, California.
Chris Calitz is Director of the Center for Workplace Health Research and Evaluation at the American Heart Association in Dallas, Texas.