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Monday, March 16, 2026

Irreducible complexity

From Wikipedia, the free encyclopedia

Irreducible complexity (IC) is the argument that certain biological systems with multiple interacting parts would not function if one of the parts were removed, so supposedly could not have evolved by successive small modifications from earlier less complex systems through natural selection, which would need all intermediate precursor systems to have been fully functional. This negative argument is then complemented by the claim that the only alternative explanation is a "purposeful arrangement of parts" inferring design by an intelligent agent. Irreducible complexity has become central to the creationist concept of intelligent design (ID), but the concept of irreducible complexity has been rejected by the scientific community at large, which regards intelligent design as pseudoscience. Irreducible complexity and specified complexity are the two main arguments used by intelligent-design proponents to support their version of the theological argument from design.

The central concept that complex biological systems which require all their parts to function could not evolve by the incremental changes of natural selection, and so must have been produced by an intelligence, was already featured in creation science. The 1989 school textbook Of Pandas and People introduced the alternative terminology of intelligent design, a revised section in the 1993 edition of the textbook argued that a blood-clotting system demonstrated this concept.

This section was written by Michael Behe, a professor of biochemistry at Lehigh University. He subsequently introduced the expression irreducible complexity along with a full account of his arguments, in his 1996 book Darwin's Black Box, and said it made evolution through natural selection of random mutations impossible, or extremely improbable. This was based on the mistaken assumption that evolution relies on improvement of existing functions, ignoring how complex adaptations originate from changes in function, and disregarding published research. Evolutionary biologists have published rebuttals showing how systems discussed by Behe can evolve.

In the 2005 Kitzmiller v. Dover Area School District trial, Behe gave testimony on the subject of irreducible complexity. The court found that "Professor Behe's claim for irreducible complexity has been refuted in peer-reviewed research papers and has been rejected by the scientific community at large."

Definitions

Michael Behe defined irreducible complexity in natural selection in terms of well-matched parts in his 1996 book Darwin's Black Box:

... a single system composed of several well-matched, interacting parts that contribute to the basic function, wherein the removal of any one of the parts causes the system to effectively cease functioning.

A second definition given by Behe in 2000 (his "evolutionary definition") states:

An irreducibly complex evolutionary pathway is one that contains one or more unselected steps (that is, one or more necessary-but-unselected mutations). The degree of irreducible complexity is the number of unselected steps in the pathway.

Intelligent-design advocate William A. Dembski assumed an "original function" in his 2002 definition:

A system performing a given basic function is irreducibly complex if it includes a set of well-matched, mutually interacting, nonarbitrarily individuated parts such that each part in the set is indispensable to maintaining the system's basic, and therefore original, function. The set of these indispensable parts is known as the irreducible core of the system.

History

Forerunners

The argument from irreducible complexity is a descendant of the teleological argument for God (the argument from design or from complexity). This states that complex functionality in the natural world which looks designed is evidence of an intelligent creator. William Paley famously argued, in his 1802 watchmaker analogy, that complexity in nature implies a God for the same reason that the existence of a watch implies the existence of a watchmaker. This argument has a long history, and one can trace it back at least as far as Cicero's De Natura Deorum ii.34, written in 45 BC.

Up to the 18th century

Galen (1st and 2nd centuries AD) wrote about the large number of parts of the body and their relationships, which observation was cited as evidence for creation. The idea that the interdependence between parts would have implications for the origins of living things was raised by writers starting with Pierre Gassendi in the mid-17th century and by John Wilkins (1614–1672), who wrote (citing Galen), "Now to imagine, that all these things, according to their several kinds, could be brought into this regular frame and order, to which such an infinite number of Intentions are required, without the contrivance of some wise Agent, must needs be irrational in the highest degree." In the late 17th-century, Thomas Burnet referred to "a multitude of pieces aptly joyn'd" to argue against the eternity of life. In the early 18th century, Nicolas Malebranche wrote "An organized body contains an infinity of parts that mutually depend upon one another in relation to particular ends, all of which must be actually formed in order to work as a whole", arguing in favor of preformation, rather than epigenesis, of the individual; and a similar argument about the origins of the individual was made by other 18th-century students of natural history. In his 1790 book, The Critique of Judgment, Kant is said by Guyer to argue that "we cannot conceive how a whole that comes into being only gradually from its parts can nevertheless be the cause of the properties of those parts".

19th century

Chapter XV of Paley's Natural Theology discusses at length what he called "relations" of parts of living things as an indication of their design.

Georges Cuvier applied his principle of the correlation of parts to describe an animal from fragmentary remains. For Cuvier, this related to another principle of his, the conditions of existence, which excluded the possibility of transmutation of species.

While he did not originate the term, Charles Darwin identified the argument as a possible way to falsify a prediction of the theory of evolution at the outset. In The Origin of Species (1859), he wrote, "If it could be demonstrated that any complex organ existed, which could not possibly have been formed by numerous, successive, slight modifications, my theory would absolutely break down. But I can find out no such case." Darwin's theory of evolution challenges the teleological argument by postulating an alternative explanation to that of an intelligent designer—namely, evolution by natural selection. By showing how simple unintelligent forces can ratchet up designs of extraordinary complexity without invoking outside design, Darwin showed that an intelligent designer was not the necessary conclusion to draw from complexity in nature. The argument from irreducible complexity attempts to demonstrate that certain biological features cannot be purely the product of Darwinian evolution.

In the late 19th century, in a dispute between supporters of the adequacy of natural selection and those who held for inheritance of acquired characteristics, one of the arguments made repeatedly by Herbert Spencer, and followed by others, depended on what Spencer referred to as co-adaptation of co-operative parts, as in:

"We come now to Professor Weismann's endeavour to disprove my second thesis—that it is impossible to explain by natural selection alone the co-adaptation of co-operative parts. It is thirty years since this was set forth in 'The Principles of Biology.' In § 166, I instanced the enormous horns of the extinct Irish elk, and contended that in this and in kindred cases, where for the efficient use of some one enlarged part many other parts have to be simultaneously enlarged, it is out of the question to suppose that they can have all spontaneously varied in the required proportions."

Darwin responded to Spencer's objections in chapter XXV of The Variation of Animals and Plants Under Domestication (1868). The history of this concept in the dispute has been characterized: "An older and more religious tradition of idealist thinkers were committed to the explanation of complex adaptive contrivances by intelligent design. ... Another line of thinkers, unified by the recurrent publications of Herbert Spencer, also saw co-adaptation as a composed, irreducible whole, but sought to explain it by the inheritance of acquired characteristics."

St. George Jackson Mivart raised the objection to natural selection that "Complex and simultaneous co-ordinations ... until so far developed as to effect the requisite junctions, are useless". In the 2012 book Evolution and Belief, Confessions of a Religious Paleontologist, Robert J. Asher said this "amounts to the concept of 'irreducible complexity' as defined by ... Michael Behe".

20th century

Hermann Muller, in the early 20th century, discussed a concept similar to irreducible complexity. However, far from seeing this as a problem for evolution, he described the "interlocking" of biological features as a consequence to be expected of evolution, which would lead to irreversibility of some evolutionary changes. He wrote, "Being thus finally woven, as it were, into the most intimate fabric of the organism, the once novel character can no longer be withdrawn with impunity, and may have become vitally necessary."

In 1975 Thomas H. Frazzetta published a book-length study of a concept similar to irreducible complexity, explained by gradual, step-wise, non-teleological evolution. Frazzetta wrote:

"A complex adaptation is one constructed of several components that must blend together operationally to make the adaptation 'work'. It is analogous to a machine whose performance depends upon careful cooperation among its parts. In the case of the machine, no single part can greatly be altered without changing the performance of the entire machine."

The machine that he chose as an analog is the Peaucellier–Lipkin linkage, and one biological system given extended description was the jaw apparatus of a python. The conclusion of this investigation, rather than that evolution of a complex adaptation was impossible, "awed by the adaptations of living things, to be stunned by their complexity and suitability", was "to accept the inescapable but not humiliating fact that much of mankind can be seen in a tree or a lizard."

In 1985 Cairns-Smith wrote of "interlocking": "How can a complex collaboration between components evolve in small steps?" and used the analogy of the scaffolding called centering—used to build an arch then removed afterwards: "Surely there was 'scaffolding'. Before the multitudinous components of present biochemistry could come to lean together they had to lean on something else." However, neither Muller or Cairns-Smith claimed their ideas as evidence of something supernatural.

An early concept of irreducibly complex systems comes from Ludwig von Bertalanffy (1901–1972), an Austrian biologist. He believed that complex systems must be examined as complete, irreducible systems in order to fully understand how they work. He extended his work on biological complexity into a general theory of systems in a book titled General Systems Theory.

After James Watson and Francis Crick published the structure of DNA in the early 1950s, General Systems Theory lost many of its adherents in the physical and biological sciences. However, systems theory remained popular in the social sciences long after its demise in the physical and biological sciences.

Creationism

Versions of the irreducible complexity argument have been common in young Earth creationist (YEC) creation science journals. For example, in the July 1965 issue of Creation Research Society Quarterly Harold W. Clark described the complex interaction in which yucca moths have an "inherited action pattern" or instinct to fertilize plants: "Before the pattern can be inherited, it must be formed. But how could yucca plants mature seeds while waiting for the moths to learn the process and set the pattern? The whole procedure points so strongly to intelligent design that it is difficult to escape the conclusion that the hand of a wise and beneficent Creator has been involved." Similarly, honeybees pollinate apple blossom: "Again we may well ask how such an arrangement could have come about by accident, or how either the flowers or the bees could have survived alone. Intelligent design is again evident."

In 1974 the YEC Henry M. Morris introduced an irreducible complexity concept in his creation science book Scientific Creationism, in which he wrote; "The creationist maintains that the degree of complexity and order which science has discovered in the universe could never be generated by chance or accident." He continued; "This issue can actually be attacked quantitatively, using simple principles of mathematical probability. The problem is simply whether a complex system, in which many components function unitedly together, and in which each component is uniquely necessary to the efficient functioning of the whole, could ever arise by random processes." In 1975 Duane Gish wrote in The Amazing Story of Creation from Science and the Bible; "The creationist maintains that the degree of complexity and order which science has discovered in the universe could never be generated by chance or accident."

A 1980 article in the creation science magazine Creation by the YEC Ariel A. Roth said "Creation and various other views can be supported by the scientific data that reveal that the spontaneous origin of the complex integrated biochemical systems of even the simplest organisms is, at best, a most improbable event". In 1981, defending the creation science position in the trial McLean v. Arkansas, Roth said of "complex integrated structures": "This system would not be functional until all the parts were there ... How did these parts survive during evolution ...?"

In 1985, countering the creationist claims that all the changes would be needed at once, Cairns-Smith wrote of "interlocking": "How can a complex collaboration between components evolve in small steps?" and used the analogy of the scaffolding called centering—used to build an arch then removed afterwards: "Surely there was 'scaffolding'. Before the multitudinous components of present biochemistry could come to lean together they had to lean on something else. Neither Muller or Cairns-Smith said their ideas were evidence of anything supernatural.

The bacterial flagellum featured in creation science literature. Morris later claimed that one of their Institute for Creation Research "scientists (the late Dr. Dick Bliss) was using this example in his talks on creation a generation ago". In December 1992 the creation science magazine Creation called bacterial flagella "rotary engines", and dismissed the possibility that these "incredibly complicated arrangements of matter" could have "evolved by selection of chance mutations. The alternative explanation, that they were created, is much more reasonable." An article in the Creation Research Society Magazine for June 1994 called a flagellum a "bacterial nanomachine", forming the "bacterial rotor-flagellar complex" where "it is clear from the details of their operation that nothing about them works unless every one of their complexly fashioned and integrated components are in place", hard to explain by natural selection. The abstract said that in "terms of biophysical complexity, the bacterial rotor-flagellum is without precedent in the living world. ... To evolutionists, the system presents an enigma; to creationists, if offers clear and compelling evidence of purposeful intelligent design."

Intelligent design

The biology supplementary textbook for schools Of Pandas and People was drafted presenting creation science arguments, but shortly after the Edwards v. Aguillard ruling, that it was unconstitutional to teach creationism in public school science classes, the authors changed the wording to "intelligent design", introducing the new meaning of this term when the book was published in 1989. In a separate response to the same ruling, law professor Phillip E. Johnson wrote Darwin on Trial, published in 1991, and at a conference in March 1992 brought together key figures in what he later called the 'wedge movement', including biochemistry professor Michael Behe. According to Johnson, around 1992 Behe developed his ideas of what he later called his "irreducible complexity" concept, and first presented these ideas in June 1993 when the "Johnson-Behe cadre of scholars" met at Pajaro Dunes in California.

The second edition of Of Pandas and People, published in 1993, had extensive revisions to Chapter 6 Biochemical Similarities with new sections on the complex mechanism of blood clotting and on the origin of proteins, written by Behe though he was not initially acknowledged as their author. He argued that "all of the proteins had to be present simultaneously for the blood clotting system to function", so it could not have evolved. In later publications, he named the argument "irreducibly complexity", but changed his definition of this specific system. In Doubts About Darwin: A History of Intelligent Design (2003), historian Thomas Woodward wrote that "Michael Behe assisted in the rewriting of a chapter on biochemistry in a revised edition of Pandas. The book stands as one of the milestones in the infancy of Design."

On Access Research Network, Behe posted (on 3 February 1999) "Molecular Machines: Experimental Support for the Design Inference" with a note that "This paper was originally presented in the Summer of 1994 at the meeting of the C. S. Lewis Society, Cambridge University." An "Irreducible Complexity" section quoted Darwin, then discussed "the humble mousetrap", and "Molecular Machines", going into detail about cilia before saying "Other examples of irreducible complexity abound, including aspects of protein transport, blood clotting, closed circular DNA, electron transport, the bacterial flagellum, telomeres, photosynthesis, transcription regulation, and much more. Examples of irreducible complexity can be found on virtually every page of a biochemistry textbook." Suggesting "these things cannot be explained by Darwinian evolution," he said they had been neglected by the scientific community.

Behe first published the term "irreducible complexity" in his 1996 book Darwin's Black Box, where he set out his ideas about theoretical properties of some complex biochemical cellular systems, now including the bacterial flagellum. He posits that evolutionary mechanisms cannot explain the development of such "irreducibly complex" systems. Notably, Behe credits philosopher William Paley for the original concept (alone among the predecessors).

Intelligent design advocates argue that irreducibly complex systems must have been deliberately engineered by some form of intelligence.

In 2001, Behe wrote: "[T]here is an asymmetry between my current definition of irreducible complexity and the task facing natural selection. I hope to repair this defect in future work." Behe specifically explained that the "current definition puts the focus on removing a part from an already functioning system", but the "difficult task facing Darwinian evolution, however, would not be to remove parts from sophisticated pre-existing systems; it would be to bring together components to make a new system in the first place". In the 2005 Kitzmiller v. Dover Area School District trial, Behe testified under oath that he "did not judge [the asymmetry] serious enough to [have revised the book] yet."

Behe additionally testified that the presence of irreducible complexity in organisms would not rule out the involvement of evolutionary mechanisms in the development of organic life. He further testified that he knew of no earlier "peer reviewed articles in scientific journals discussing the intelligent design of the blood clotting cascade," but that there were "probably a large number of peer reviewed articles in science journals that demonstrate that the blood clotting system is indeed a purposeful arrangement of parts of great complexity and sophistication." (The judge ruled that "intelligent design is not science and is essentially religious in nature".)

The scientific theory of evolution incorporates evidence that genetic variations occur, but makes no assumptions of purposeful design or intent. The environment "selects" the variants which have the highest fitness for conditions at the time, and these heritable variations are then passed on to the next generation of organisms. Change occurs by the gradual operation of natural forces over time, perhaps slowly, perhaps more quickly (see punctuated equilibrium). This process is able to adapt complex structures from simpler beginnings, or convert complex structures from one function to another (see spandrel). Most intelligent design advocates accept that evolution occurs through mutation and natural selection at the "micro level", such as changing the relative frequency of various beak lengths in finches, but assert that it cannot account for irreducible complexity, because none of the parts of an irreducible system would be functional or advantageous until the entire system is in place.

The mousetrap example

Michael Behe believes that many aspects of life show evidence of design, using the mousetrap in an analogy disputed by others.

Behe uses the mousetrap as an illustrative example of this concept. A mousetrap consists of five interacting pieces: the base, the catch, the spring, the hammer, and the hold-down bar. All of these must be in place for the mousetrap to work, as the removal of any one piece destroys the function of the mousetrap. Likewise, he asserts that biological systems require multiple parts working together in order to function. Intelligent design advocates claim that natural selection could not create from scratch those systems for which science is currently unable to find a viable evolutionary pathway of successive, slight modifications, because the selectable function is only present when all parts are assembled.

In his 2008 book Only A Theory, biologist Kenneth R. Miller challenges Behe's claim that the mousetrap is irreducibly complex. Miller observes that various subsets of the five components can be devised to form cooperative units, ones that have different functions from the mousetrap and so, in biological terms, could form functional spandrels before being adapted to the new function of catching mice. In an example taken from his high school experience, Miller recalls that one of his classmates

...struck upon the brilliant idea of using an old, broken mousetrap as a spitball catapult, and it worked brilliantly.... It had worked perfectly as something other than a mousetrap.... my rowdy friend had pulled a couple of parts—probably the hold-down bar and catch—off the trap to make it easier to conceal and more effective as a catapult... [leaving] the base, the spring, and the hammer. Not much of a mousetrap, but a helluva spitball launcher.... I realized why [Behe's] mousetrap analogy had bothered me. It was wrong. The mousetrap is not irreducibly complex after all.

Other systems identified by Miller that include mousetrap components include the following:

  • use the spitball launcher as a tie clip (same three-part system with different function)
  • remove the spring from the spitball launcher/tie clip to create a two-part key chain (base + hammer)
  • glue the spitball launcher/tie clip to a sheet of wood to create a clipboard (launcher + glue + wood)
  • remove the hold-down bar for use as a toothpick (single element system)

The point of the reduction is that—in biology—most or all of the components were already at hand, by the time it became necessary to build a mousetrap. As such, it required far fewer steps to develop a mousetrap than to design all the components from scratch.

Thus, the development of the mousetrap, said to consist of five different parts which had no function on their own, has been reduced to one step: the assembly from parts that are already present, performing other functions.

Consequences

Supporters of intelligent design argue that anything less than the complete form of such a system or organ would not work at all, or would in fact be a detriment to the organism, and would therefore never survive the process of natural selection. Although they accept that some complex systems and organs can be explained by evolution, they claim that organs and biological features which are irreducibly complex cannot be explained by current models, and that an intelligent designer must have created life or guided its evolution. Accordingly, the debate on irreducible complexity concerns two questions: whether irreducible complexity can be found in nature, and what significance it would have if it did exist in nature.

Behe's original examples of irreducibly complex mechanisms included the bacterial flagellum of E. coli, the blood clotting cascade, cilia, and the adaptive immune system.

Behe argues that organs and biological features which are irreducibly complex cannot be wholly explained by current models of evolution. In explicating his definition of "irreducible complexity" he notes that:

An irreducibly complex system cannot be produced directly (that is, by continuously improving the initial function, which continues to work by the same mechanism) by slight, successive modifications of a precursor system, because any precursor to an irreducibly complex system that is missing a part is by definition nonfunctional.

Irreducible complexity is not an argument that evolution does not occur, but rather an argument that it is "incomplete". In the last chapter of Darwin's Black Box, Behe goes on to explain his view that irreducible complexity is evidence for intelligent design. Mainstream critics, however, argue that irreducible complexity, as defined by Behe, can be generated by known evolutionary mechanisms. Behe's claim that no scientific literature adequately modeled the origins of biochemical systems through evolutionary mechanisms has been challenged by TalkOrigins. The judge in the Dover trial wrote "By defining irreducible complexity in the way that he has, Professor Behe attempts to exclude the phenomenon of exaptation by definitional fiat, ignoring as he does so abundant evidence which refutes his argument. Notably, the NAS has rejected Professor Behe's claim for irreducible complexity..."

Claimed examples

Behe and others have suggested a number of biological features that they believed to be irreducibly complex.

Blood clotting cascade

The process of blood clotting or coagulation cascade in vertebrates is a complex biological pathway which is given as an example of apparent irreducible complexity.

The irreducible complexity argument assumes that the necessary parts of a system have always been necessary, and therefore could not have been added sequentially. However, in evolution, something which is at first merely advantageous can later become necessary. Natural selection can lead to complex biochemical systems being built up from simpler systems, or to existing functional systems being recombined as a new system with a different function. For example, one of the clotting factors that Behe listed as a part of the clotting cascade (Factor XII, also called Hageman factor) was later found to be absent in whales, demonstrating that it is not essential for a clotting system. Many purportedly irreducible structures can be found in other organisms as much simpler systems that utilize fewer parts. These systems, in turn, may have had even simpler precursors that are now extinct. Behe has responded to critics of his clotting cascade arguments by suggesting that homology is evidence for evolution, but not for natural selection.

The "improbability argument" also misrepresents natural selection. It is correct to say that a set of simultaneous mutations that form a complex protein structure is so unlikely as to be unfeasible, but that is not what Darwin advocated. His explanation is based on small accumulated changes that take place without a final goal. Each step must be advantageous in its own right, although biologists may not yet understand the reason behind all of them—for example, jawless fish accomplish blood clotting with just six proteins instead of the full ten.

Eye

Stages in the evolution of the eye
(a) A pigment spot
(b) A simple pigment cup
(c) The simple optic cup found in abalone
(d) The complex lensed eye of the marine snail and the octopus

The eye is frequently cited by intelligent design and creationism advocates as a purported example of irreducible complexity. Behe used the "development of the eye problem" as evidence for intelligent design in Darwin's Black Box. Although Behe acknowledged that the evolution of the larger anatomical features of the eye have been well-explained, he pointed out that the complexity of the minute biochemical reactions required at a molecular level for light sensitivity still defies explanation. Creationist Jonathan Sarfati has described the eye as evolutionary biologists' "greatest challenge as an example of superb 'irreducible complexity' in God's creation", specifically pointing to the supposed "vast complexity" required for transparency.

In an often misquoted passage from On the Origin of Species, Charles Darwin appears to acknowledge the eye's development as a difficulty for his theory. However, the quote in context shows that Darwin actually had a very good understanding of the evolution of the eye (see fallacy of quoting out of context). He notes that "to suppose that the eye ... could have been formed by natural selection, seems, I freely confess, absurd in the highest possible degree". Yet this observation was merely a rhetorical device for Darwin. He goes on to explain that if gradual evolution of the eye could be shown to be possible, "the difficulty of believing that a perfect and complex eye could be formed by natural selection ... can hardly be considered real". He then proceeded to roughly map out a likely course for evolution using examples of gradually more complex eyes of various species.

The eyes of vertebrates (left) and invertebrates such as the octopus (right) developed independently: vertebrates evolved an inverted retina with a blind spot over their optic disc, whereas octopuses avoided this with a non-inverted retina. (1 photo-receptors, 2 neural tissue, 3 optic nerve, 4 blind spot)

Since Darwin's day, the eye's ancestry has become much better understood. Although learning about the construction of ancient eyes through fossil evidence is problematic due to the soft tissues leaving no imprint or remains, genetic and comparative anatomical evidence has increasingly supported the idea of a common ancestry for all eyes.

Current evidence does suggest possible evolutionary lineages for the origins of the anatomical features of the eye. One likely chain of development is that the eyes originated as simple patches of photoreceptor cells that could detect the presence or absence of light, but not its direction. When, via random mutation across the population, the photosensitive cells happened to have developed on a small depression, it endowed the organism with a better sense of the light's source. This small change gave the organism an advantage over those without the mutation. This genetic trait would then be "selected for" as those with the trait would have an increased chance of survival, and therefore progeny, over those without the trait. Individuals with deeper depressions would be able to discern changes in light over a wider field than those individuals with shallower depressions. As ever deeper depressions were advantageous to the organism, gradually, this depression would become a pit into which light would strike certain cells depending on its angle. The organism slowly gained increasingly precise visual information. And again, this gradual process continued as individuals having a slightly shrunken aperture of the eye had an advantage over those without the mutation as an aperture increases how collimated the light is at any one specific group of photoreceptors. As this trait developed, the eye became effectively a pinhole camera which allowed the organism to dimly make out shapes—the nautilus is a modern example of an animal with such an eye. Finally, via this same selection process, a protective layer of transparent cells over the aperture was differentiated into a crude lens, and the interior of the eye was filled with humours to assist in focusing images. In this way, eyes are recognized by modern biologists as actually a relatively unambiguous and simple structure to evolve, and many of the major developments of the eye's evolution are believed to have taken place over only a few million years, during the Cambrian explosion. Behe asserts that this is only an explanation of the gross anatomical steps, however, and not an explanation of the changes in discrete biochemical systems that would have needed to take place.

Behe maintains that the complexity of light sensitivity at the molecular level and the minute biochemical reactions required for those first "simple patches of photoreceptor[s]" still defies explanation, and that the proposed series of infinitesimal steps to get from patches of photoreceptors to a fully functional eye would actually be considered great, complex leaps in evolution if viewed on the molecular scale. Other intelligent design proponents claim that the evolution of the entire visual system would be difficult rather than the eye alone.

Flagella

The flagella of certain bacteria constitute a molecular motor requiring the interaction of about 40 different protein parts. Behe presents this as a prime example of an irreducibly complex structure defined as "a single system composed of several well-matched, interacting parts that contribute to the basic function, wherein the removal of any one of the parts causes the system to effectively cease functioning", and argues that since "an irreducibly complex system that is missing a part is by definition nonfunctional", it could not have evolved gradually through natural selection.

Reducible complexity. In contrast to Behe's claims, many proteins can be deleted or mutated and the flagellum still works, even though sometimes at reduced efficiency. In fact, the composition of flagella is surprisingly diverse across bacteria with many proteins only found in some species but not others. Hence the flagellar apparatus is clearly very flexible in evolutionary terms and perfectly able to lose or gain protein components. Further studies have shown that, contrary to claims of "irreducible complexity", flagella and the type-III secretion system share several components which provides strong evidence of a shared evolutionary history (see below). In fact, this example shows how a complex system can evolve from simpler components. Multiple processes were involved in the evolution of the flagellum, including horizontal gene transfer.

Evolution from type three secretion systems. The basal body of the flagella has been found to be similar to the Type III secretion system (TTSS), a needle-like structure that pathogenic germs such as Salmonella and Yersinia pestis use to inject toxins into living eukaryote cells. The needle's base has ten elements in common with the flagellum, but it is missing forty of the proteins that make a flagellum work. The TTSS system negates Behe's claim that taking away any one of the flagellum's parts would prevent the system from functioning. On this basis, Kenneth Miller notes that, "The parts of this supposedly irreducibly complex system actually have functions of their own." Studies have also shown that similar parts of the flagellum in different bacterial species can have different functions despite showing evidence of common descent, and that certain parts of the flagellum can be removed without eliminating its functionality. Behe responded to Miller by asking "why doesn't he just take an appropriate bacterial species, knock out the genes for its flagellum, place the bacterium under selective pressure (for mobility, say), and experimentally produce a flagellum—or any equally complex system—in the laboratory?" However a laboratory experiment has been performed where "immotile strains of the bacterium Pseudomonas fluorescens that lack flagella [...] regained flagella within 96 hours via a two-step evolutionary pathway", concluding that "natural selection can rapidly rewire regulatory networks in very few, repeatable mutational steps".

Dembski has argued that phylogenetically, the TTSS is found in a narrow range of bacteria which makes it seem to him to be a late innovation, whereas flagella are widespread throughout many bacterial groups, and he argues that it was an early innovation. Against Dembski's argument, different flagella use completely different mechanisms, and publications show a plausible path in which bacterial flagella could have evolved from a secretion system.

Cilium motion

The cilium construction of axoneme microtubules movement by the sliding of dynein protein was cited by Behe as an example of irreducible complexity. He further said that the advances in knowledge in the subsequent 10 years had shown that the complexity of intraflagellar transport for two hundred components cilium and many other cellular structures is substantially greater than was known earlier.

Response of the scientific community

Like intelligent design, the concept it seeks to support, irreducible complexity has failed to gain any notable acceptance within the scientific community.

Reducibility of "irreducible" systems

Researchers have proposed potentially viable evolutionary pathways for allegedly irreducibly complex systems such as blood clotting, the immune system and the flagellum—the three examples Behe proposed. John H. McDonald even showed his example of a mousetrap to be reducible. If irreducible complexity is an insurmountable obstacle to evolution, it should not be possible to conceive of such pathways.

Niall Shanks and Karl H. Joplin, both of East Tennessee State University, have shown that systems satisfying Behe's characterization of irreducible biochemical complexity can arise naturally and spontaneously as the result of self-organizing chemical processes. They also assert that what evolved biochemical and molecular systems actually exhibit is "redundant complexity"—a kind of complexity that is the product of an evolved biochemical process. They claim that Behe overestimated the significance of irreducible complexity because of his simple, linear view of biochemical reactions, resulting in his taking snapshots of selective features of biological systems, structures, and processes, while ignoring the redundant complexity of the context in which those features are naturally embedded. They also criticized his over-reliance on overly simplistic metaphors, such as his mousetrap.

A computer model of the co-evolution of proteins binding to DNA in the peer-reviewed journal Nucleic Acids Research consisted of several parts (DNA binders and DNA binding sites) which contribute to the basic function; removal of either one leads immediately to the death of the organism. This model fits the definition of irreducible complexity exactly, yet it evolves. (The program can be run from Ev program.)

One can compare a mousetrap with a cat in this context. Both normally function so as to control the mouse population. The cat has many parts that can be removed leaving it still functional; for example, its tail can be bobbed, or it can lose an ear in a fight. Comparing the cat and the mousetrap, then, one sees that the mousetrap (which is not alive) offers better evidence, in terms of irreducible complexity, for intelligent design than the cat. Even looking at the mousetrap analogy, several critics have described ways in which the parts of the mousetrap could have independent uses or could develop in stages, demonstrating that it is not irreducibly complex.

Moreover, even cases where removing a certain component in an organic system will cause the system to fail do not demonstrate that the system could not have been formed in a step-by-step, evolutionary process. By analogy, stone arches are irreducibly complex—if you remove any stone the arch will collapse—yet humans build them easily enough, one stone at a time, by building over centering that is removed afterward. Similarly, naturally occurring arches of stone form by the weathering away of bits of stone from a large concretion that has formed previously.

Evolution can act to simplify as well as to complicate. This raises the possibility that seemingly irreducibly complex biological features may have been achieved with a period of increasing complexity, followed by a period of simplification.

A team led by Joseph Thornton, assistant professor of biology at the University of Oregon's Center for Ecology and Evolutionary Biology, using techniques for resurrecting ancient genes, reconstructed the evolution of an apparently irreducibly complex molecular system. The April 7, 2006 issue of Science published this research.

Irreducible complexity may not actually exist in nature, and the examples given by Behe and others may not in fact represent irreducible complexity, but can be explained in terms of simpler precursors. The theory of facilitated variation challenges irreducible complexity. Marc W. Kirschner, a professor and chair of Department of Systems Biology at Harvard Medical School, and John C. Gerhart, a professor in Molecular and Cell Biology, University of California, Berkeley, presented this theory in 2005. They describe how certain mutation and changes can cause apparent irreducible complexity. Thus, seemingly irreducibly complex structures are merely "very complex", or they are simply misunderstood or misrepresented.

Gradual adaptation to new functions

The precursors of complex systems, when they are not useful in themselves, may be useful to perform other, unrelated functions. Evolutionary biologists argue that evolution often works in this kind of blind, haphazard manner in which the function of an early form is not necessarily the same as the function of the later form. The term used for this process is exaptation. The mammalian middle ear (derived from a jawbone) and the panda's thumb (derived from a wrist bone spur) provide classic examples. A 2006 article in Nature demonstrates intermediate states leading toward the development of the ear in a Devonian fish (about 360 million years ago). Furthermore, recent research shows that viruses play a heretofore unexpected role in evolution by mixing and matching genes from various hosts.

Arguments for irreducibility often assume that things started out the same way they ended up—as we see them now. However, that may not necessarily be the case. In the Dover trial an expert witness for the plaintiffs, Ken Miller, demonstrated this possibility using Behe's mousetrap analogy. By removing several parts, Miller made the object unusable as a mousetrap, but he pointed out that it was now a perfectly functional, if unstylish, tie clip.

Methods by which irreducible complexity may evolve

Irreducible complexity can be seen as equivalent to an "uncrossable valley" in a fitness landscape. A number of mathematical models of evolution have explored the circumstances under which such valleys can, nevertheless, be crossed.

An example of a structure that is claimed in Dembski's book No Free Lunch to be irreducibly complex, but evidently has evolved, is the protein T-urf13, which is responsible for the cytoplasmic male sterility of waxy corn and is due to a completely new gene. It arose from the fusion of several non-protein-coding fragments of mitochondrial DNA and the occurrence of several mutations, all of which were necessary. Behe's book Darwin Devolves claims that things like this would take billions of years and could not arise from random tinkering, but the corn was bred during the 20th century. When presented with T-urf13 as an example for the evolvability of irreducibly complex systems, the Discovery Institute resorted to its flawed probability argument based on false premises, akin to the Texas sharpshooter fallacy.[117]

Falsifiability and experimental evidence

Some critics, such as Jerry Coyne (professor of evolutionary biology at the University of Chicago) and Eugenie Scott (a physical anthropologist and former executive director of the National Center for Science Education) have argued that the concept of irreducible complexity and, more generally, intelligent design is not falsifiable and, therefore, not scientific.

Behe argues that the theory that irreducibly complex systems could not have evolved can be falsified by an experiment where such systems are evolved. For example, he posits taking bacteria with no flagellum and imposing a selective pressure for mobility. If, after a few thousand generations, the bacteria evolved the bacterial flagellum, then Behe believes that this would refute his theory. This has been done: a laboratory experiment has been performed where "immotile strains of the bacterium Pseudomonas fluorescens that lack flagella [...] regained flagella within 96 hours via a two-step evolutionary pathway", concluding that "natural selection can rapidly rewire regulatory networks in very few, repeatable mutational steps".

Other critics take a different approach, pointing to experimental evidence that they consider falsification of the argument for intelligent design from irreducible complexity. For example, Kenneth Miller describes the lab work of Barry G. Hall on E. coli as showing that "Behe is wrong".

Other evidence that irreducible complexity is not a problem for evolution comes from the field of computer science, which routinely uses computer analogues of the processes of evolution in order to automatically design complex solutions to problems. The results of such genetic algorithms are frequently irreducibly complex since the process, like evolution, both removes non-essential components over time as well as adding new components. The removal of unused components with no essential function, like the natural process where rock underneath a natural arch is removed, can produce irreducibly complex structures without requiring the intervention of a designer. Researchers applying these algorithms automatically produce human-competitive designs—but no human designer is required.

Argument from ignorance

Intelligent design proponents attribute to an intelligent designer those biological structures they believe are irreducibly complex and therefore they say a natural explanation is insufficient to account for them. However, critics view irreducible complexity as a special case of the "complexity indicates design" claim, and thus see it as an argument from ignorance and as a God-of-the-gaps argument.

Eugenie Scott and Glenn Branch of the National Center for Science Education note that intelligent design arguments from irreducible complexity rest on the false assumption that a lack of knowledge of a natural explanation allows intelligent design proponents to assume an intelligent cause, when the proper response of scientists would be to say that we do not know, and further investigation is needed. Other critics describe Behe as saying that evolutionary explanations are not detailed enough to meet his standards, while at the same time presenting intelligent design as exempt from having to provide any positive evidence at all.

False dilemma

Irreducible complexity is at its core an argument against evolution. If truly irreducible systems are found, the argument goes, then intelligent design must be the correct explanation for their existence. However, this conclusion is based on the assumption that current evolutionary theory and intelligent design are the only two valid models to explain life, a false dilemma.

In the Dover trial

At the 2005 Kitzmiller v. Dover Area School District trial, expert witness testimony defending ID and IC was given by Behe and Scott Minnich, who had been one of the "Johnson-Behe cadre of scholars" at Pajaro Dunes in 1993, was prominent in ID, and was now a tenured associate professor in microbiology at the University of Idaho. Behe conceded that there are no peer-reviewed papers supporting his claims that complex molecular systems, like the bacterial flagellum, the blood-clotting cascade, and the immune system, were intelligently designed nor are there any peer-reviewed articles supporting his argument that certain complex molecular structures are "irreducibly complex." There was extensive discussion of IC arguments about the bacterial flagellum, first published in Behe's 1996 book, and when Minnich was asked if similar claims in a 1994 Creation Research Society article presented the same argument, Minnich said he did not have any problem with that statement.

In the final ruling of Kitzmiller v. Dover Area School District, Judge Jones specifically singled out irreducible complexity:

  • "... creationists made the same argument that the complexity of the bacterial flagellum supported creationism as Professors Behe and Minnich now make for ID. (P-853; P-845; 37:155–56 (Minnich))." (Page 34)
  • "Professor Behe admitted in "Reply to My Critics" that there was a defect in his view of irreducible complexity because, while it purports to be a challenge to natural selection, it does not actually address "the task facing natural selection." and that "Professor Behe wrote that he hoped to "repair this defect in future work..." (Page 73)
  • "As expert testimony revealed, the qualification on what is meant by "irreducible complexity" renders it meaningless as a criticism of evolution. (3:40 (Miller)). In fact, the theory of evolution proffers exaptation as a well-recognized, well-documented explanation for how systems with multiple parts could have evolved through natural means." (Page 74)
  • "By defining irreducible complexity in the way that he has, Professor Behe attempts to exclude the phenomenon of exaptation by definitional fiat, ignoring as he does so abundant evidence which refutes his argument. Notably, the NAS has rejected Professor Behe's claim for irreducible complexity..." (Page 75)
  • "As irreducible complexity is only a negative argument against evolution, it is refutable and accordingly testable, unlike ID [Intelligent Design], by showing that there are intermediate structures with selectable functions that could have evolved into the allegedly irreducibly complex systems. (2:15–16 (Miller)). Importantly, however, the fact that the negative argument of irreducible complexity is testable does not make testable the argument for ID. (2:15 (Miller); 5:39 (Pennock)). Professor Behe has applied the concept of irreducible complexity to only a few select systems: (1) the bacterial flagellum; (2) the blood-clotting cascade; and (3) the immune system. Contrary to Professor Behe's assertions with respect to these few biochemical systems among the myriad existing in nature, however, Dr. Miller presented evidence, based upon peer-reviewed studies, that they are not in fact irreducibly complex." (Page 76)
  • "...on cross-examination, Professor Behe was questioned concerning his 1996 claim that science would never find an evolutionary explanation for the immune system. He was presented with fifty-eight peer-reviewed publications, nine books, and several immunology textbook chapters about the evolution of the immune system; however, he simply insisted that this was still not sufficient evidence of evolution, and that it was not "good enough." (23:19 (Behe))." (Page 78)
  • "We therefore find that Professor Behe's claim for irreducible complexity has been refuted in peer-reviewed research papers and has been rejected by the scientific community at large. (17:45–46 (Padian); 3:99 (Miller)). Additionally, even if irreducible complexity had not been rejected, it still does not support ID as it is merely a test for evolution, not design. (2:15, 2:35–40 (Miller); 28:63–66 (Fuller)). We will now consider the purportedly "positive argument" for design encompassed in the phrase used numerous times by Professors Behe and Minnich throughout their expert testimony, which is the "purposeful arrangement of parts." Professor Behe summarized the argument as follows: We infer design when we see parts that appear to be arranged for a purpose. The strength of the inference is quantitative; the more parts that are arranged, the more intricately they interact, the stronger is our confidence in design. The appearance of design in aspects of biology is overwhelming. Since nothing other than an intelligent cause has been demonstrated to be able to yield such a strong appearance of design, Darwinian claims notwithstanding, the conclusion that the design seen in life is real design is rationally justified. (18:90–91, 18:109–10 (Behe); 37:50 (Minnich)). As previously indicated, this argument is merely a restatement of the Reverend William Paley's argument applied at the cell level. Minnich, Behe, and Paley reach the same conclusion, that complex organisms must have been designed using the same reasoning, except that Professors Behe and Minnich refuse to identify the designer, whereas Paley inferred from the presence of design that it was God. (1:6–7 (Miller); 38:44, 57 (Minnich)). Expert testimony revealed that this inductive argument is not scientific and as admitted by Professor Behe, can never be ruled out. (2:40 (Miller); 22:101 (Behe); 3:99 (Miller)).

Planetary health

From Wikipedia, the free encyclopedia

Planetary Health is a multi- and transdisciplinary research paradigm, a science for exceptional action, and a global movement. Planetary health refers to "the health of human civilization and the state of the natural systems on which it depends." In 2015, the Rockefeller Foundation–Lancet Commission on Planetary Health launched the concept which is  currently being developed towards a new health science with over 25 areas of expertise.

Background and milestones

There are a number of ideas, concepts that can be understood as precursors to the concept of planetary health. According to Susan Prescott, the term "planetary health" emerged from the environmental and holistic health movements of the 1970-80s. In 1980, Friends of the Earth expanded the World Health Organization's definition of health, stating, "health is a state of complete physical, mental, social and ecological well-being and not merely the absence of disease - personal health involves planetary health." James Lovelock created the term "Planetary Medicine" in 1986. In 1993 the Norwegian physician Per Fugelli wrote: "The patient Earth is sick. Global environmental disruptions can have serious consequences for human health. It's time for doctors to give a world diagnosis and advise on treatment." In the 1990s, a model curriculum Terra Medicine (Planetary Medicine) was developed at the Catholic University of Eichstätt-Ingolstadt as part of the Altmühltal Agenda 21 project. In 2000, James Lovelock published his book Gaia: The Practical Science of Planetary Medicine.

Milestones

Fourteen years later, a commentary in the March 2014 issue of the medical journal The Lancet called to create a movement for planetary health to transform the field of public health, which has traditionally focused on the health of human populations without necessarily considering the surrounding natural ecosystems. The proposal recognized the emerging threats to natural and human-made systems that support humanity.

In 2015, the Rockefeller Foundation and The Lancet launched the concept with the Rockefeller Foundation–Lancet Commission on Planetary Health. The Planetary Health Alliance was founded in December 2015, by Harvard University, together with the Wildlife Conservation Society and other partner organizations. The Rockefeller Foundation Economic Council on Planetary Health at the Oxford Martin School was established on 1 June 2017 to further define the new discipline of planetary health. The open-access journal "Lancet Planetary Health" published its inaugural issue in April 2017.

The Planetary Health Education Framework, developed in 2021 by the Planetary Health Alliance, aims to guide the education of global citizens, practitioners, and professionals able and willing to address complex Planetary Health challenges. The framework also seeks to inspire all peoples across the globe to create, restore, steward, and conserve healthy ecosystems for a thriving human civilization. The framework considers five foundational domains that form the essence of Planetary Health knowledge, values, and practice: (1) interconnection with nature, (2) the Anthropocene and health, (3) equity and social justice, (4) movement building and systems change, and (5) systems thinking and complexity.

The São Paulo Declaration on Planetary Health is a multi-stakeholder call to action co-created by the global Planetary Health community at the 2021 Planetary Health Annual Meeting in São Paulo, Brazil. The declaration calls on governments, the private sector, civil society, and the general public to commit to the Great Transition to safeguard a healthy and equitable future for humanity and protect all life on Earth.

In 2022, on the occasion of the 50th anniversary of the first UN environmental conference "United Nations Conference on the Human Environment" in Stockholm 1972, the UN published the report: 'UN Conference Stockholm+50: A Healthy Planet for the Prosperity of All - Our Responsibility, Our Opportunity'.

In 2023 the Association of Faculties of Medicine of Canada published the "Academic Health Institutions' Declaration on Planetary Health," which calls on all academic health institutions throughout the world to take immediate action to halt both the negative impact of their activities on the planet's natural systems, and to institute adaptive and regenerative measures, including through advocacy. More than 40 academic health institutions have signed the declaration. These include medical schools, faculties of medicine, schools of nursing, schools of public health, and other health-related academic institutions from various countries including Canada, India, Finland, Dominican Republic, South Africa, Germany, Portugal, Indonesia, and others.

The Royal Netherlands Academy of Arts and Sciences published a comprehensive report in June 2023 on the state of planetary health research and the future research agenda, which has relevance not only for the Netherlands but also internationally (Planetary Health Advisory Report).

In April 2024, the Global Planetary Health Roadmap and Action Plan, a map to guide a path forward for Planetary Health was created by over 100 members of a worldwide community, building on the principles and call to action of the 2021 São Paulo Declaration on Planetary Health. The roadmap encompasses key domains, such as governance, education, business, and communications, providing a strategic framework to nurture this growing movement and safeguard the health and well-being of all life on Earth.

Research paradigms and agenda

Drawing from the definition of health – "a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity" – as well as principles articulated in the preamble of the constitution of the World Health Organization, The Lancet Commission report elaborated that planetary health refers to the "achievement of the highest attainable standard of health, wellbeing, and equity worldwide through judicious attention to the human systems – political, economic, and social – that shape the future of humanity and the Earth's natural systems that define the safe environmental limits within which humanity can flourish."

The report laid down the overarching principles guiding the idea of planetary health. One is that human health depends on "flourishing natural systems and the wise stewardship of those natural systems". Human activities, such as energy generation and food production, have led to substantial global effects on the Earth's systems, prompting scientists to refer to the modern times as the Anthropocene.

A group of Earth system and environmental scientists led by Johan Rockström from the Stockholm Resilience Centre proposed the concept of nine planetary boundaries within which humanity can continue to develop and thrive for generations to come. According to a 2024 update, six of the planetary boundaries – climate change, biosphere integrity, biogeochemical flows, land-system change, freshwater use, and novel entities-had already been exceeded. A seventh boundary, ocean acidification is approaching its threshold.

The Rockefeller Foundation–Lancet Commission on Planetary Health report concluded that urgent and transformative actions are needed to protect present and future generations. One important area which required immediate attention was the system of governance and organization of human knowledge, which was deemed inadequate to address the threats to planetary health.

The report made several overarching recommendations. One was to improve governance to aid the integration of social, economic, and environmental policies and for the creation, synthesis, and application of interdisciplinary knowledge. The authors called for solutions based on the redefinition of prosperity to focus on the enhancement of quality of life and delivery of improved health for all, together with respect for the integrity of natural systems.

International research agenda for planetary health

In June 2023, the Royal Netherlands Academy of Sciences presented their planetary health report  Planetary Health, An emerging field to be developed based on a two-year consultative process. Many knowledge gaps were identified in the field of planetary health. A review of the literature and subsequent consultation with experts resulted in a longlist of more than one hundred specific knowledge gaps. Knowledge for the health impacts of global environmental change on human health are incomplete, pathways are poorly understood, the effectiveness of mitigation and adaptation measures are still unclear, how timely policy and behaviour change can be realised. The Academy concluded that: "Filling all Planetary Health knowledge gaps requires an international collaborative effort in research funding". The Academy will cooperate with international partner and 'umbrella academies' (such as EASAC, FEAM and ALLEA) how to take this agenda forward."

In 2025 the United Nations Environment Programme (UNEP) report GEO-7 found that investing in planetary health can deliver trillions in additional global GDP, avoid millions of deaths and reduce poverty and hunger.

Issues

Nutrition and diet are important contributors to and indicators of planetary health. Diets, agriculture, and technology must adjust to sustain population projections upwards of 9 billion while reducing harmful consequences on the environment through food waste and carbon-intensive diets. A focus of planetary health research is nutritional solutions that are sustainable for the human species and the environment, and the generation of scientific research and political will to create and implement desired solutions. In January 2019, an international commission created the planetary health diet.

Planetary health aims to seek out further solutions to global human and environmental sustainability through collaboration and research across all sectors, including the economy, energy, agriculture, water, and health. Biodiversity loss, exposure to pollutants, climate change, and fuel consumption are all issues that threaten human and health, and are, as such, foci of the field. A number of researchers think that it is actually humanity's destruction of biodiversity and the invasion of wild landscapes that creates the conditions for malaria, and new diseases such as COVID-19. Some propose incorporating concern for the impact of digital technology in planetary health and health promotion, including the impact of generative AI on climate, biodiversity, and pollution.

Planetary Health Alliance

The Planetary Health Alliance is an informal global consortium of over 470 universities, non-governmental organizations, government entities, and research institutes with over 20,000 newsletter subscribers.

Several PHA regional hubs function as locally rooted communities that bring PHA members together in geographic clusters to collaboratively advance planetary health research, education, policy, and outreach relevant to specific local contexts.

The alliance's mission is "to promote, mobilize, and lead an inclusive, transdisciplinary field of Planetary Health and its diverse science, stories, solutions, and communities to achieve a comprehensive shift in how human beings interact with each other and Nature, in order to secure a livable future for humanity and the rest of life on Earth." Since November 2023, the secretariat of PHA is based at Johns Hopkins University alongside the Johns Hopkins Institute for Planetary Health.

Regional Hubs

There are eight established Planetary Health Regional Hubs that function as locally rooted communities which bring PHA members together in geographic clusters to collaboratively advance planetary health research, education, policy, and outreach relevant to specific local contexts.

While additional hubs are under development, the eight established Planetary Health Regional Hubs are:

  • Caribbean
  • East Africa
  • Europe
  • Japan
  • Latin America
  • Oceania
  • South & Southeast Asia
  • West Africa

In 2022, the inaugural Planetary Health Europe Regional Hub meeting was held in Amsterdam, with 72 institutions represented. The inaugural meeting was organized by the Planetary Health Alliance, the European Environment and Sustainable Development Advisory Councils Network (EEAC Network), and Natura Artis Magistra (ARTIS). The PHA Europe Secretariat has been located in the Netherlands. It is jointly coordinated by Maastricht University and the University Medical Center Utrecht (UMC Utrecht).

Next Generation Network

The Planetary Health Next Generation Network is composed of students and next-generation leaders worldwide who are dedicated to advancing the emerging field of Planetary Health through local community efforts, educational events, and research projects. This open-access network brings together the Planetary Health Campus Ambassadors (PHCAs), Planetary Health student club leaders and members, former and current Travel Scholars to Planetary Health Annual Meetings, and any youths who would like to engage with the Planetary Health community. The Planetary Health Alliance staff team and Impact Fellows work to support these diverse efforts by providing introductory resources, workshop materials, mentorship opportunities, and community-building platforms.

Campus Ambassador program

The Planetary Health Campus Ambassador program formally recognizes next-generation leaders in planetary health on academic campuses and within the international planetary health community at-large. During the program, ambassadors build their planetary health network and gain leadership and organizational skills with the support of their program cohort, staff, fellows, and alliance members. Ambassadors are empowered to take leadership on their campus and beyond, to educate their community, and to facilitate collaborations between existing disciplines and initiatives within the scope of human health and environmental change. They also become part of the program's broader Next Generation Network, composed of individuals from a variety of academic and cultural backgrounds, career stages, and interests. They also have access to leadership opportunities within other initiatives, such as the global Planetary Health Annual Meeting, Planetary Health Regional Hubs, Clinicians for Planetary Health, and various education projects.

Annual meeting

The Planetary Health Annual Meeting, convened by the Planetary Health Alliance, is an international conference series established in 2017, serving as a global forum for advancing the field of Planetary Health. First launched at Harvard University, these meetings have evolved into comprehensive gatherings connecting diverse stakeholders including scientists, policymakers, healthcare professionals, educators, students, and community leaders from over 130 countries. The meetings rotate globally, having been hosted in the United States (Harvard University 2017, 2022; Stanford University 2019), Scotland (University of Edinburgh 2018), Brazil (University of São Paulo 2021, virtual), and Malaysia (Sunway University 2024), reflecting a commitment to geographic and cultural diversity in addressing planetary health challenges. A meeting is planned for October 2025 in the Netherlands (Erasmus University).

The meetings consistently focus on planetary health themes, including climate change, biodiversity loss, food systems transformation, health equity, and education. Each meeting has produced significant outcomes that have shaped the field: from establishing foundational frameworks in the early meetings to the São Paulo Declaration on Planetary Health (2021) and the Kuala Lumpur Call to Action (2024), accompanied by the launch of the global Planetary Health Roadmap and Action Plan. Through plenary sessions, research presentations, workshops, and community engagement activities, these meetings have been instrumental in building capacity, fostering collaboration, and driving actionable solutions for planetary health challenges.

Comparison with other fields

Planetary health is considered a response to existing fields and paradigms such as public health environmental health, ecohealth, One Health and international health.

While there may be competing definitions of global health, it is loosely defined as the health of populations in a global context, a response to the cross-border movement of health drivers as well as risks, and an improvement over the older concept of international health with its new emphasis on achieving equity in health among all people. Some scholars hold that advocacy of planetary health amounts to an over-expansion and totalization of health.

The editor in chief of The Lancet, Richard Horton, wrote in a 2014 special issue of The Economist on planetary health, that global health was no longer able to truly meet the demands which societies face, as it was still too narrow to explain and illuminate some pressing challenges."Global health does not fully take into account the natural foundation on which humans live – the planet itself. Nor does it factor in the force and fragility of human civilizations."

In 2015, Judith Rodin, president of the Rockefeller Foundation, declared planetary health as a new discipline in global health.

In 2023, the US Bureau of Labor Statistics updated the definition of environmental engineering as using, "engineering disciplines in developing solutions to problems of planetary health."

In September 2024, the Consortium of Universities for Global Health (CUGH) put forth a set of planetary health learning objectives, noting "the knowledge of planetary health science, interventions, and communication that is essential for future global health professionals." CUGH included planetary health in the updated edition of their Global Health Competencies Toolkit.

In 2026, Daniel Oerther proposed that the profession of engineering modify the paramountcy clause to, "hold paramount the health, safety, and welfare of the public and the planet,” in recognition of the interconnectedness of all life.

Coronary artery disease

From Wikipedia, the free encyclopedia
 
Coronary artery disease
Other namesArteriosclerotic heart disease, atherosclerotic heart disease, atherosclerotic vascular disease, coronary heart disease.
Illustration depicting two arteries: the one on the left is a normal artery and the one on the right is an atherosclerotic coronary artery disease
SpecialtyCardiology, cardiothoracic surgery
SymptomsChest pain, shortness of breath
ComplicationsHeart failure, abnormal heart rhythms, heart attack, cardiogenic shock, cardiac arrest
CausesAtherosclerosis of the arteries of the heart
Risk factorsHigh blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol
Diagnostic methodElectrocardiogram, cardiac stress test, coronary computed tomographic angiography, coronary angiogram
PreventionHealthy diet, regular exercise, maintaining a healthy weight, not smoking
TreatmentPercutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG)
MedicationAspirin, beta blockers, nitroglycerin, statins
Frequency110 million (2015)
Deaths8.9 million (2015)

Coronary artery disease (CAD), also called coronary heart disease (CHD), or ischemic heart disease (IHD), is a type of heart disease involving the reduction of blood flow to the cardiac muscle due to a build-up of atheromatous plaque in the arteries of the heart. It is the most common of the cardiovascular diseases. CAD can cause stable angina, unstable angina, myocardial ischemia,[16] and myocardial infarction.[17]

A common symptom is angina, which is chest pain or discomfort that may travel into the shoulder, arm, back, neck, or jaw. Occasionally it may feel like heartburn. In stable angina, symptoms occur with exercise or emotional stress, last less than a few minutes, and improve with rest. Shortness of breath may also occur and sometimes no symptoms are present. In many cases, the first sign is a heart attack. Other complications include heart failure or an abnormal heartbeat.

Risk factors include high blood pressure, smoking, diabetes mellitus, lack of exercise, obesity, high blood cholesterol, poor diet, depression, and excessive alcohol consumption. A number of tests may help with diagnosis including electrocardiogram, cardiac stress testing, coronary computed tomographic angiography, biomarkers (high-sensitivity cardiac troponins) and coronary angiogram, among others. Ways to reduce CAD risk include eating a healthy diet, regularly exercising, maintaining a healthy weight, and not smoking. Medications for diabetes, high cholesterol, or high blood pressure are sometimes used. There is limited evidence for the efficacy of early detection through screening of low risk individuals that do not show symptoms. Treatment involves the same measures as prevention. Additional medications such as antiplatelets (including aspirin), beta blockers, or nitroglycerin may be recommended. Procedures such as percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) may be used in severe disease. In those with stable CAD it is unclear if PCI or CABG in addition to the other treatments improves life expectancy or decreases heart attack risk.

In 2015, CAD affected 110 million people and resulted in 8.9 million deaths. It makes up 15.6% of all deaths, making it the most common cause of death globally. The risk of death from CAD for a given age decreased between 1980 and 2010, especially in developed countries. The number of cases of CAD for a given age also decreased between 1990 and 2010. In the United States in 2010, about 20% of those over 65 had CAD, while it was present in 7% of those 45 to 64, and 1.3% of those 18 to 45; rates were higher among males than females of a given age.

Signs and symptoms

Illustration of someone suffering coronary artery disease

The most common symptom is chest pain or discomfort that occurs regularly with activity, after eating, or at other predictable times; this phenomenon is termed stable angina and is associated with narrowing of the arteries of the heart. Angina also includes chest tightness, heaviness, pressure, numbness, fullness, or squeezing. Angina that changes in intensity, character, or frequency is termed unstable. Unstable angina may precede myocardial infarction. In adults who go to the emergency department with an unclear cause of pain, about 30% have pain due to coronary artery disease. Angina, shortness of breath, sweating, nausea or vomiting, and lightheadedness are signs of a heart attack or myocardial infarction, and immediate emergency medical services are crucial.

With advanced disease, the narrowing of coronary arteries reduces the supply of oxygen-rich blood flowing to the heart, which becomes more pronounced during strenuous activities, during which the heart beats faster and has an increased oxygen demand. For some, this causes severe symptoms, while others experience no symptoms at all.

Symptoms in females

Symptoms in females can differ from those in males, and the most common symptom reported by females of all races is shortness of breath. Other symptoms more commonly reported by females than males are extreme fatigue, sleep disturbances, indigestion, and anxiety. However, some females experience irregular heartbeat, dizziness, sweating, and nausea. Burning, pain, or pressure in the chest or upper abdomen that can travel to the arm or jaw can also be experienced in females, but females less commonly report it than males. Generally, females experience symptoms 10 years later than males. Females are less likely to recognize symptoms and seek treatment.

Risk factors

Illustration depicting atherosclerosis in a coronary artery

Coronary artery disease is characterized by heart problems that result from atherosclerosis. Atherosclerosis is a type of arteriosclerosis which is the "chronic inflammation of the arteries which causes them to harden and accumulate cholesterol plaques (atheromatous plaques) on the artery walls". CAD has several well-determined risk factors contributing to atherosclerosis. These risk factors for CAD include "smoking, diabetes, high blood pressure (hypertension), abnormal (high) amounts of cholesterol and other fat in the blood (dyslipidemia), type 2 diabetes and being overweight or obese (having excess body fat)" due to lack of exercise and a poor diet. Some other risk factors include high blood pressure, smoking, diabetes, lack of exercise, obesity, high blood cholesterol, poor diet, depression, family history, psychological stress and excessive alcohol.About half of cases are linked to genetics. Apart from these classical risk factors, several unconventional risk factors have also been studied including high serum fibrinogen, high c-reactive protein (CRP), chronic inflammatory conditions, hypovitaminosis D, high lipoprotein A levels, serum homocysteine etc. Smoking and obesity are associated with about 36% and 20% of cases, respectively. Smoking just one cigarette per day about doubles the risk of CAD. Lack of exercise has been linked to 7–12% of cases. Exposure to the herbicide Agent Orange may increase risk. Rheumatologic diseases such as rheumatoid arthritis, systemic lupus erythematosus, psoriasis, and psoriatic arthritis are independent risk factors as well.

Job stress appears to play a minor role, accounting for about 3% of cases. In one study, females who were free of stress from work life saw an increase in the diameter of their blood vessels, leading to decreased progression of atherosclerosis. In contrast, females who had high levels of work-related stress experienced a decrease in the diameter of their blood vessels and significantly increased disease progression.

Air pollution

Air pollution, both indoor and outdoor, is responsible for roughly 28% of deaths from CAD. This varies by region: In highly developed areas, this is approximately 10%, whereas in Southern, East and West Africa, and South Asia, approximately 40% of deaths from CAD can be attributed to unhealthy air. In particular, fine particle pollution (PM2.5), which comes mostly from the burning of fossil fuels, is a key risk factor for CAD.

Blood fats

Different forms of dietary fats associated with increased atherosclerotic risk include trans-unsaturated fat, present in processed foods made with partially hydrogenated oils, and saturated fat which are largely derived from animal sources. The linear configurations of trans-unsaturated and saturated fats promote their deposition along the vascular endothelium, leading to the build-up of plaques which narrow the arterial lumen.

The resultant reduction in the heart's blood supply due to atherosclerosis in coronary arteries is consistent with the development of CAD.

Genetics

The heritability of coronary artery disease has been estimated between 40% and 60%. Genome-wide association studies have identified over 160 genetic susceptibility loci for coronary artery disease.

Several RNA Transcripts associated with CAD - FoxP1, ICOSLG, IKZF4/Eos, SMYD3, TRIM28, and TCF3/E2A are likely markers of regulatory T cells (Tregs), consistent with known reductions in Tregs in CAD.

Transcripts associated with CAD identified by RNA-seq. The differentially expressed genes identified by RNAseq were curated by automated and manual analysis to identify the molecular pathways involved. The resulting pattern points to changes in the 'immune synapse', which involves both endocytic pathways of T cell receptor-containing vesicles, as well as ciliary protrusions that couple to intracellular signaling pathways.

The RNA changes are mostly related to ciliary and endocytic transcripts, which in the circulating immune system would be related to the immune synapse. One of the most differentially expressed genes, fibromodulin (FMOD), which is increased 2.8-fold in CAD, is found mainly in connective tissue and is a modulator of the TGF-beta signaling pathway. However, not all RNA changes may be related to the immune synapse. For example, Nebulette, the most down-regulated transcript (2.4-fold), is found in cardiac muscle; it is a 'cytolinker' that connects actin and desmin to facilitate cytoskeletal function and vesicular movement. The endocytic pathway is further modulated by changes in tubulin, a key microtubule protein, and fidgetin, a tubulin-severing enzyme that is a marker for cardiovascular risk identified by genome-wide association study. Protein recycling would be modulated by changes in the proteasomal regulator SIAH3 and the ubiquitin ligase MARCHF10. On the ciliary aspect of the immune synapse, several of the modulated transcripts are related to ciliary length and function. Stereocilin is a partner to mesothelin, a related super-helical protein, whose transcript is also modulated in CAD. DCDC2, a double-cortin protein, modulates ciliary length. In the signaling pathways of the immune synapse, numerous transcripts are directly related to T-cell function and the control of differentiation. Butyrophilin is a co-regulator for T cell activation. Fibromodulin modulates the TGF-beta signaling pathway, a primary determinant of Tre differentiation. Further impact on the TGF-beta pathway is reflected in concurrent changes in the BMP receptor 1B RNA (BMPR1B), because the bone morphogenic proteins are members of the TGF-beta superfamily, and likewise impact Treg differentiation. Several of the transcripts (TMEM98, NRCAM, SFRP5, SHISA2) are elements of the Wnt signaling pathway, which is a major determinant of Treg differentiation.

Other

  • Endometriosis in females under the age of 40.
  • Depression and hostility appear to be risks.
  • The number of categories of adverse childhood experiences (psychological, physical, or sexual abuse; violence against mother; or living with household members who used substances, mentally ill, suicidal, or incarcerated) showed a graded correlation with the presence of adult diseases including coronary artery (ischemic heart) disease.
  • Hemostatic factors: High levels of fibrinogen and coagulation factor VII are associated with an increased risk of CAD.
  • Low hemoglobin.
  • In the Asian population, the b fibrinogen gene G-455A polymorphism was associated with the risk of CAD.
  • Patient-specific vessel ageing or remodelling determines endothelial cell behaviour and thus disease growth and progression. Such 'hemodynamic markers' are patient-specific risk surrogates.
  • HIV is a known risk factor for developing atherosclerosis and coronary artery disease.

Pathophysiology

Micrograph of a coronary artery with the most common form of coronary artery disease (atherosclerosis) and marked luminal narrowing. Masson's trichrome.

Limitation of blood flow to the heart causes ischemia (cell starvation secondary to a lack of oxygen) of the heart's muscle cells. The heart's muscle cells may die from lack of oxygen and this is called a myocardial infarction (commonly referred to as a heart attack). It leads to damage, death, and eventual scarring of the heart muscle without regrowth of heart muscle cells. Chronic high-grade narrowing of the coronary arteries can induce transient ischemia, which leads to the induction of a ventricular arrhythmia, which may terminate in a dangerous heart rhythm known as ventricular fibrillation, which often leads to death.

Typically, coronary artery disease occurs when part of the smooth, elastic lining inside a coronary artery (the arteries that supply blood to the heart muscle) develops atherosclerosis. With atherosclerosis, the artery's lining becomes hardened, stiffened, and accumulates deposits of calcium, fatty lipids, and abnormal inflammatory cells – to form a plaque. Calcium phosphate (hydroxyapatite) deposits in the muscular layer of the blood vessels appear to play a significant role in stiffening the arteries and inducing the early phase of coronary arteriosclerosis. This can be seen in a so-called metastatic mechanism of calciphylaxis as it occurs in chronic kidney disease and hemodialysis. Although these people have kidney dysfunction, almost fifty percent of them die due to coronary artery disease. Plaques can be thought of as large "pimples" that protrude into the channel of an artery, causing partial obstruction to blood flow. People with coronary artery disease might have just one or two plaques or might have dozens distributed throughout their coronary arteries. A more severe form is chronic total occlusion (CTO) when a coronary artery is completely obstructed for more than 3 months.

Microvascular angina is a type of angina pectoris in which chest pain and chest discomfort occur without signs of blockages in the larger coronary arteries of their hearts when an angiogram (coronary angiogram) is being performed. The exact cause of microvascular angina is unknown. Explanations include microvascular dysfunction or epicardial atherosclerosis. For reasons that are not well understood, females are more likely than males to have it; however, hormones and other risk factors unique to females may play a role.

Diagnosis

Coronary angiogram of a male
Coronary angiogram of a female

The diagnosis of CAD depends largely on the nature of the symptoms and imaging. The first investigation when CAD is suspected is an electrocardiogram (ECG/EKG), both for stable angina and acute coronary syndrome. An X-ray of the chest, blood tests, and resting echocardiography may be performed.

For stable symptomatic patients, several non-invasive tests can diagnose CAD depending on pre-assessment of the risk profile. Noninvasive imaging options include; Computed tomography angiography (CTA) (anatomical imaging, best test in patients with low-risk profile to "rule out" the disease), positron emission tomography (PET), single-photon emission computed tomography (SPECT)/nuclear stress test/myocardial scintigraphy and stress echocardiography (the three latter can be summarized as functional noninvasive methods and are typically better to "rule in"). Exercise ECG or stress test is inferior to non-invasive imaging methods due to the risk of false-negative and false-positive test results. The use of non-invasive imaging is not recommended on individuals who are exhibiting no symptoms and are otherwise at low risk for developing coronary disease. Invasive testing with coronary angiography (ICA) can be used when non-invasive testing is inconclusive or show a high event risk.

The diagnosis of microvascular angina (previously known as cardiac syndrome X – the rare coronary artery disease that is more common in females, as mentioned, is a diagnosis of exclusion. Therefore, usually, the same tests are used as in any person suspected of having coronary artery disease:

Stable angina

Stable angina is the most common manifestation of ischemic heart disease, and is associated with reduced quality of life and increased mortality. It is caused by epicardial coronary stenosis, which results in reduced blood flow and oxygen supply to the myocardium. Stable angina is short-term chest pain during physical exertion caused by an imbalance between myocardial oxygen supply and metabolic oxygen demand. Various forms of cardiac stress tests may be used to induce both symptoms and detect changes by way of electrocardiography (using an ECG), echocardiography (using ultrasound of the heart) or scintigraphy (using uptake of radionuclide by the heart muscle). If part of the heart seems to receive an insufficient blood supply, coronary angiography may be used to identify stenosis of the coronary arteries and suitability for angioplasty or bypass surgery.

In minor to moderate cases, nitroglycerine may be used to alleviate acute symptoms of stable angina or may be used immediately before exertion to prevent the onset of angina. Sublingual nitroglycerine is most commonly used to provide rapid relief for acute angina attacks and as a complement to anti-anginal treatments in patients with refractory and recurrent angina. When nitroglycerine enters the bloodstream, it forms free radical nitric oxide, or NO, which activates guanylate cyclase and in turn stimulates the release of cyclic GMP. This molecular signaling stimulates smooth muscle relaxation, resulting in vasodilation and consequently improved blood flow to heart regions affected by atherosclerotic plaque.

Stable coronary artery disease (SCAD) is also often called stable ischemic heart disease (SIHD). A 2015 monograph explains that "Regardless of the nomenclature, stable angina is the chief manifestation of SIHD or SCAD." There are U.S. and European clinical practice guidelines for SIHD/SCAD. In patients with non-severe asymptomatic aortic valve stenosis and no overt coronary artery disease, the increased troponin T (above 14 pg/mL) was found associated with an increased 5-year event rate of ischemic cardiac events (myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery).

Acute coronary syndrome

Diagnosis of acute coronary syndrome generally takes place in the emergency department, where ECGs may be performed sequentially to identify "evolving changes" (indicating ongoing damage to the heart muscle). Diagnosis is clear-cut if ECGs show elevation of the "ST segment", which in the context of severe typical chest pain is strongly indicative of an acute myocardial infarction (MI); this is termed a STEMI (ST-elevation MI) and is treated as an emergency with either urgent coronary angiography and percutaneous coronary intervention (angioplasty with or without stent insertion) or with thrombolysis ("clot buster" medication), whichever is available. In the absence of ST-segment elevation, heart damage is detected by cardiac markers (blood tests that identify heart muscle damage). If there is evidence of damage (infarction), the chest pain is attributed to a "non-ST elevation MI" (NSTEMI). If there is no evidence of damage, the term "unstable angina" is used. This process usually necessitates hospital admission and close observation on a coronary care unit for possible complications (such as cardiac arrhythmias – irregularities in the heart rate). Depending on the risk assessment, stress testing or angiography may be used to identify and treat coronary artery disease in patients who have had an NSTEMI or unstable angina.

Risk assessment

There are various risk assessment systems for determining the risk of coronary artery disease, with various emphases on the different variables above. A notable example is Framingham Score, used in the Framingham Heart Study. It is mainly based on age, gender, diabetes, total cholesterol, HDL cholesterol, tobacco smoking, and systolic blood pressure. When predicting risk in younger adults (18–39 years old), the Framingham Risk Score remains below 10–12% for all deciles of baseline-predicted risk.

Polygenic score is another way of risk assessment. In one study, the relative risk of incident coronary events was 91% higher among participants at high genetic risk than among those at low genetic risk.

Prevention

Up to 90% of cardiovascular disease may be preventable if established risk factors are avoided.Prevention involves adequate physical exercise, decreasing obesity, treating high blood pressure, eating a healthy diet, decreasing cholesterol levels, and stopping smoking. Medications and exercise are roughly equally effective. High levels of physical activity reduce the risk of coronary artery disease by about 25%. Life's Essential 8 are the key measures for improving and maintaining cardiovascular health, as defined by the American Heart Association. AHA added sleep as a factor influencing heart health in 2022.

Most guidelines recommend combining these preventive strategies. A 2015 Cochrane Review found some evidence that counseling and education to bring about behavioral change might help in high-risk groups. However, there was insufficient evidence to show an effect on mortality or actual cardiovascular events.

In diabetes mellitus, there is little evidence that very tight blood sugar control improves cardiac risk, although improved sugar control appears to decrease other problems such as kidney failure and blindness.

A 2024 study published in The Lancet Diabetes & Endocrinology found that the oral glucose tolerance test (OGTT) is more effective than hemoglobin A1c (HbA1c) for detecting dysglycemia in patients with coronary artery disease. The study highlighted that 2-hour post-load glucose levels of at least 9 mmol/L were strong predictors of cardiovascular outcomes, while HbA1c levels of at least 5.9% were also significant but not independently associated when combined with OGTT results.

Diet

A diet high in fruits and vegetables decreases the risk of cardiovascular disease and death. Vegetarians have a lower risk of heart disease, possibly due to their greater consumption of fruits and vegetables. Evidence also suggests that the Mediterranean diet and a high fiber diet lower the risk.

The consumption of trans fat (commonly found in hydrogenated products such as margarine) has been shown to cause a precursor to atherosclerosis and increase the risk of coronary artery disease.

Evidence does not support a beneficial role for omega-3 fatty acid supplementation in preventing cardiovascular disease (including myocardial infarction and sudden cardiac death).

Secondary prevention

Secondary prevention is preventing further sequelae of already established disease. Effective lifestyle changes include:

Aerobic exercise, like walking, jogging, or swimming, can reduce the risk of mortality from coronary artery disease. Aerobic exercise can help decrease blood pressure and the amount of blood cholesterol (LDL) over time. It also increases HDL cholesterol.

Although exercise is beneficial, it is unclear whether doctors should spend time counseling patients to exercise. The U.S. Preventive Services Task Force found "insufficient evidence" to recommend that doctors counsel patients on exercise, but "it did not review the evidence for the effectiveness of physical activity to reduce chronic disease, morbidity, and mortality", only the effectiveness of counseling itself. The American Heart Association, based on a non-systematic review, recommends that doctors counsel patients on exercise.

Psychological symptoms are common in people with CHD. Many psychological treatments may be offered following cardiac events. There is no evidence that they change mortality, the risk of revascularization procedures, or the rate of non-fatal myocardial infarction.

Antibiotics for secondary prevention of coronary heart disease

Early studies suggested that antibiotics might help patients with coronary disease reduce the risk of heart attacks and strokes. However, a 2021 Cochrane meta-analysis found that antibiotics given for secondary prevention of coronary heart disease are harmful to people with increased mortality and occurrence of stroke. So, antibiotic use is not currently supported for preventing secondary coronary heart disease.

Neuropsychological assessment

A thorough systematic review found that indeed there is a link between a CHD condition and brain dysfunction in females. Consequently, since research is showing that cardiovascular diseases, like CHD, can play a role as a precursor for dementia, like Alzheimer's disease, individuals with CHD should have a neuropsychological assessment.

Treatment

There are a number of treatment options for coronary artery disease:

Medications

It is recommended that blood pressure typically be reduced to less than 140/90 mmHg. The diastolic blood pressure should not be below 60 mmHg. Beta-blockers are recommended first line for this use.

Aspirin

In those with no previous history of heart disease, aspirin decreases the risk of a myocardial infarction but does not change the overall risk of death. Aspirin therapy to prevent heart disease is thus recommended only in adults who are at increased risk for cardiovascular events, which may include postmenopausal females, males above 40, and younger people with risk factors for coronary heart disease, including high blood pressure, a family history of heart disease, or diabetes. The benefits outweigh the harms most favorably in people at high risk for a cardiovascular event, where high risk is defined as at least a 3% chance over five years, but others with lower risk may still find the potential benefits worth the associated risks.

Anti-platelet therapy

Clopidogrel plus aspirin (dual anti-platelet therapy) reduces cardiovascular events more than aspirin alone in those with a STEMI. In others at high risk but not having an acute event, the evidence is weak. Specifically, its use does not change the risk of death in this group. In those who have had a stent, more than 12 months of clopidogrel plus aspirin does not affect the risk of death.

Surgery

Revascularization for acute coronary syndrome has a mortality benefit. Percutaneous revascularization for stable ischaemic heart disease does not appear to have benefits over medical therapy alone. In those with disease in more than one artery, coronary artery bypass grafts appear better than percutaneous coronary interventions. Newer "anaortic" or no-touch off-pump coronary artery revascularization techniques have shown reduced postoperative stroke rates comparable to percutaneous coronary intervention. Hybrid coronary revascularization has also been shown to be a safe and feasible procedure that may offer some advantages over conventional CABG though it is more expensive.

Epidemiology

Estimates of annual death rates from ischaemic heart disease

As of 2010, CAD was the leading cause of death globally resulting in over 7 million deaths. This increased from 5.2 million deaths from CAD worldwide in 1990. It may affect individuals at any age but becomes dramatically more common at progressively older ages, with approximately a tripling with each decade of life. Males are affected more often than females.

The World Health Organization reported that: "The world's biggest killer is ischemic heart disease, responsible for 13% of the world's total deaths. Since 2000, the largest increase in deaths has been for this disease, rising by 2.7 million to 9.1 million deaths in 2021."

It is estimated that 60% of the world's cardiovascular disease burden will occur in the South Asian subcontinent despite only accounting for 20% of the world's population. This may be secondary to a combination of genetic predisposition and environmental factors. Organizations such as the Indian Heart Association are working with the World Heart Federation to raise awareness about this issue.

Coronary artery disease is the leading cause of death for both males and females and accounts for approximately 600,000 deaths in the United States every year. According to present trends in the United States, half of healthy 40-year-old males will develop CAD in the future, and one in three healthy 40-year-old females. It is the most common reason for death of males and females over 20 years of age in the United States.

After analysing data from 2 111 882 patients, the recent meta-analysis revealed that the incidence of coronary artery diseases in breast cancer survivors was 4.29 (95% CI 3.09–5.94) per 1000 person-years.

Society and culture

Names

Other terms sometimes used for this condition are "hardening of the arteries" and "narrowing of the arteries". In Latin it is known as morbus ischaemicus cordis (MIC).

Support groups

The Infarct Combat Project (ICP) is an international nonprofit organization founded in 1998 which tries to decrease ischemic heart diseases through education and research.

Industry influence on research

In 2016 research into the internal documents of the Sugar Research Foundation, the trade association for the sugar industry in the US, had sponsored an influential literature review published in 1965 in the New England Journal of Medicine that downplayed early findings about the role of a diet heavy in sugar in the development of CAD and emphasized the role of fat; that review influenced decades of research funding and guidance on healthy eating.

Research

Research efforts are focused on new angiogenic treatment modalities and various (adult) stem-cell therapies. A region on chromosome 17 was confined to families with multiple cases of myocardial infarction. Other genome-wide studies have identified a firm risk variant on chromosome 9 (9p21.3). However, these and other loci are found in intergenic segments and need further research in understanding how the phenotype is affected.

A more controversial link is that between Chlamydophila pneumoniae infection and atherosclerosis. While this intracellular organism has been demonstrated in atherosclerotic plaques, evidence is inconclusive regarding whether it can be considered a causative factor. Treatment with antibiotics in patients with proven atherosclerosis has not demonstrated a decreased risk of heart attacks or other coronary vascular diseases.

Myeloperoxidase (MPO) has been proposed to be involved in the development of CAD. In a 2024 study, MPO serum levels in individuals with CAD did not differ significantly from those in controls, though they were slightly lower on average. In addition, serum concentration showed no significant association with the disease extent.

Plant-based nutrition has been suggested as a way to reverse coronary artery disease, but strong evidence is still lacking for claims of potential benefits.

Several immunosuppressive drugs targeting the chronic inflammation in coronary artery disease have been tested.

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