International Non-Governmental Organizations (INGOs) in Humanitarian Field: why and how to engage with Planetary Health?

Planetary Health is an emerging field reshaping Global Health understanding of health concerns and interventions living into the Anthropocene. Many challenges faced by humanitarian actors are exacerbated by the climate crisis that could be considered itself another humanitarian crisis. However, often the humanitarian response focuses mainly on disaster risk reduction and on efforts to decarbonize operations. Arguing that Planetary Health offer the missing piece to assess and respond to the complexity of the climate crisis, authors identify the added-value of this approach for humanitarian programs. They pinpoint the main barriers among humanitarian actors in adopting or exploring further the Planetary Health approach. Finally, they share few suggestions toward integrated Planetary Health programs in Low and Middle Income Countries (LMICs). Ultimately, this personal viewpoint calls for an inclusive debate to bring Planetary Health insights, critics, and innovations into Non-Governmental Organization (NGOs) hard daily-work in order to strengthen co-benefits for health and environment.

While responding to current crisis, International Non-Governmental Organizations (INGOs) witnesses the ongoing dramatic direct and indirect effect of the climate crisis on health in those complex settings. Their experience in responding to such dramatic crisis push to stating that climate crisis is (another) humanitarian crisis.

Humanitarian responses to the climate crisis
To tackle environmental issues in developing countries since the late Seventies, United Nations (UN) experts and INGOs focused their efforts in risk and vulnerability analysis and Disaster Risk Reduction 13  Organizations 16 , INGOs committed to maximize the environmental sustainability of operations. Decarbonizing the aid sector is in line with the principle of "do no harm" extended from populations to ecosystems too. Implementation of this principle to the health sector could contribute to reduce the greenhouse gases emissions of the health sectors, of which many INGOs are part of, a sector that accounts for the 5% of global emissions 17 . However, it is difficult to measure the real carbon footprint of the humanitarian sector and it seems that reductions may achieve mainly symbolic goals 8 .
Interestingly, flights accounted for one of the UN's biggest emissions sources. 18 Reducing travels means challenging the programs' ownership and power relationship between headquarters based in the so-called Global North and field operations in the Global South. It is not a simply logistical decision: it is matter of decentralization, empowerment, and, finally, decolonization of aid. Despite the debate about decolonization is regularly gaining space into humanitarian selfreflection 19 , sustainability action is likely to have limited impact on both the carbon footprint and decolonization journey.
For sure, awareness of the impact of unnecessary flights, what Swedish call "flygskam" or flight shame, is a first step toward changing habits and social norms about travelling and even organizational schemes and power imbalance.
Despite the importance of both strategies, DRR-CCA and decarbonizing the aid sector, they may result insufficient to respond to the magnitude of the ongoing complex climate crisis.
Climate crisis is also a crisis of humanitarian aid In the authors experience in humanitarian field and within global health networks of experts participating to and observing the emergent discourse about climate, the debate about how facing the climate crisis is often narrowed about operational

An imaginative gap
An INGO CEO admitted that "With the climate problem […] the humanitarian sector isn't able to say to its support base 'that's the problem, we've got a solution,' because we haven't." When there are no answer, it is probably better to reformulate the question. In this case, this could sounds like: "why we are not able to imagine such a solution?" Not only imagination is one of the greatest resources humans have 23 since primates' brain allowed them to engage in storytelling, but it promotes changes. Future is difficult to forecast, but not to imagine. In the postmodern era, there is no a single truth 24 to build over a revolutionary expectations for a better future. Therefore, science provides more and more evidences of the disaster our specie is facing, having broken 6 out of 9 planetary boundaries 25  Understanding and assessing syndemics: Planetary health framework zooms out from a single disease and it encompasses all those upstream factors that represents the deep roots a syndemic -the presence of two or more disease states that adversely interact with each other, negatively affecting the mutual course of each disease trajectory, enhancing vulnerability, and which are made more deleterious by experienced inequities 33 . Applying such lenses to humanitarian settings will offer coherent and meaningful assessment of complex and interrelated elements of complex humanitarian emergency (CHE) and syndemics in humanitarian and fragile settings. problems. The author identified ten frames that often drive the conversation about this topic within the humanitarian actors and limit its development: 1. "It is (another) buzzword": being Planetary Health a storytelling in progress, some could believe that this concept is just a fashionable title for smart Linkedin profiles instead of a emerging field for research, policy, and action.
2. "It is not my field": Breaking silos, moving from coordination (a mantra in the humanitarian field in the last 20 years) to integration of diverse expertise and practices, implies a huge change in works habits and not enough support is given to such professional behavioural change; health, in addition to suffer from colonial power imbalance, is a conflictive space and there is no reason for Planetary

"I don't know":
Health being different. The political consequences of this approach deserve further research by social sciences; 7. "It is too fresh and new": wishing to ensuring professionalism, global health networks of experts set standards and protocols of interventions. Nowadays, there is limited room and scarce boldness for innovation in terms of processes, creativity is not nurtured, and piloting is considered too risky (and not funded).
8. "It is too complex": Planetary Health accepts complexity. For this reason, despite many good local practices, the lack of a ready-to-use handbook water down enthusiasm among frontline workers who are asked to solve urgent real problems; 9. "It is not measurable": complex processes where global and local phenomena interact constantly, simultaneously, in nonlinear way, and with feedback mechanisms cannot be reduced to discrete units. Therefore, measurement becomes a scientific endeavour rather than a task for those implementing programs, despite the pressure by donors within a neoliberal system based on the concept of performance, cost-benefits analysis, measuring rather than solving 43 .

Conclusions
It could be quite easy to acknowledge that, living in the Anthropocene, scaling up 'business-as-usual' is not an option. However, it is much more difficult to find a more meaningful alternative action able to respond to current needs and to next social and environmental changes. This paper pointed out the imaginative gap that precede the operational one. This particularly affects the ability of humanitarian actors to rethink at their practice beyond equipping the aid system to face the consequences of the climate crisis, thus preventing and responding to disaster, while no harming.
We evoked the potential of the Planetary Health approach in expanding the understanding of complex crisis and syndemics, contributing to decolonizing aid and global health.
However, we also highlighted some misunderstanding and stigmatizing assumptions about Planetary Health that limit the debate among humanitarian actors as well as creativity in exploring new approaches to new needs.
We sketched few recommendations that attempt to promote the dialogue between the Planetary Health scholars with humanitarian actors. It is pivotal to build the Planetary Health narrative via an inclusive and participative process, and this paper has been an humble attempt to add one voice to such a polysemic discourse. INGOs could fruitfully contributing to such a dialogue and also connecting the Planetary Health discourse with the local reality of marginalized or underrepresented communities. Only inclusive dialogue let emerge collective intelligence that may ultimately fill the imaginative gap humanitarian community is suffering now and making Planetary Health a reasonable hope to cope with the Anthropocene and its related humanitarian crisis and finally thrive.

Declarations
Authors declare no competing interests.