Part 1: Introductory Concepts in Planetary Health

1 Understanding Planetary Health — Sharing Space in the Biosphere

Authors: Grynszpan, D., & Montelpare, W.


Learning Objectives

This chapter sets the stage for the textbook. At the end of this section the student should be able to:

  • Define planetary health
  • Describe the effects of human civilization on the current state of our ecosystems
  • Define the biosphere
  • Describe the elements within the biosphere
  • Define the Anthropocene
  • Describe the value of measuring change using a geological time clock
  • Describe the relationship of planetary health to human health

Key Words

The important keywords for this chapter are:

  • Planetary Health, biodiversity, the biosphere, the Anthropocene, ecosystems, human health

Setting the Stage – defining the biosphere

To understand planetary health, we begin by considering the place in which planetary health is established – the biosphere.

Planet earth is protected from the external universe by five thin layers of gases and particulate matter, beginning at sea level and extending four hundred kilometers outward. The five layers, starting with the layer closest to the earth’s surface are: the troposphere (from sea level to ~18 km), the stratosphere (~18 – 75 km), the mesosphere (~75 – 250 km), the thermosphere (~250 – 400 km) and the exosphere (> 400 km) (1). While each of these layers is essential to maintaining the balance of life on earth, the troposphere is the layer in which we live.
Image of earth’s atmosphere from – downloaded December 19,2022.

In 1543, Nicolaus Copernicus broke with the traditional beliefs of the Holy Roman Catholic Church to declare his radical belief that the sun rather than the earth was the center of the universe. Although we often act as if we as humans are the center of the universe, and all we do is condoned because we are that center point, we must realize that we are not alone here!

We exist in the troposphere as part of the community of ecosystems known as the biosphere. Here we define the biosphere as the entire earth in which living organisms exist (Gillard, 1969), while the term ecosystem is best explained by Blew (1996) as being organism centric and localized within a defined environment.

Folke (2011) referred to the biosphere as, “the global ecological system” which accounts for the implicit links between all living entities, consisting of flora and fauna, and the interaction and impact of these constituents on the environment.

Just as are we, the constituents of the biosphere are alive, and our actions have consequences on life within the biosphere for all of our neighbors and the elements upon which the biosphere exists and depends (i.e., the land, sea, and air). Taking responsibility for our actions is essential to our existence and the existence of the constituents with whom we share this space. Ignoring this existential call to action will lead to a devastating future in which extremes of negative consequences will be the norm.

An unhealthy ecosystem within the biosphere

Downloaded from: environmental-degradation.html Sept. 29, 2022
A healthy ecosystem within the biosphere
Image Source: WJ Montelpare, 2022

Defining our time – entering the Anthropocene

Steffan, Crutzen, and McNeill (2007) suggested that we are currently in the midst of a new geological time period which we refer to as the Anthropocene. That is, considering Earth’s geological time record beginning with the Paleozoic era, and moving forward past the age of dinosaurs in the Mesozoic era and into the Cenozoic Era, the Anthropocene represents the most recent epoch (e.g., a period) within the Cenozoic era. According to Steffan and colleagues, the Anthropocene period began around the mid-1800s with the introduction of the industrial revolution and has continued to the present day. The period of the Anthropocene is derived from the term anthropo – as in human and cene which is used in describing a period within an era of geologic time. Hence these researchers refer to the Anthropocene as the “age of mankind”.

The Anthropocene is marked as a period of tremendous flux during an age of development (Whitmee, et al., 2015). The Anthropocene accounts for the migration of humans away from agrarian economies and subsistence farming to widescale production of commodities but with little regard for the impact of such activities on the biosphere. The Anthropocene denotes the accelerated impact of the human quest for development across a broad spectrum of measurable outcomes, some of which led to positive advancements in the civilization of humans and especially in the enhancement of human health (Whitmee, et al., 2015).

During the Anthropocene, we accomplished advances in the production of mechanisms to make our work and everyday life tasks easier (Zalasiewicz, Williams, Haywood, and Ellis, 2011). We created new strategies to genetically modify foodstuff so that we could increase product yield and reduce crop failure. We improved travel on land, sea, in the air, and even into space beyond the biosphere. We built economies that are based on fuel sources which are not limited to fossil fuel resources but may include natural sources such as the sun, wind, water, and tidal flows. We also developed methods by which we can harness the power of the atom by producing electricity from nuclear resources via fusion and fission reactions (Horvath and Rachlew, 2016).

In the life sciences, we discovered ways to reduce the risks of disease through advances in medicine, and biomedical engineering, along with illness prevention and health promotion including various new and emerging treatments, strategies for harm reduction, and the use of widespread and regularly scheduled immunization strategies; and we improved the quality of life through rehabilitation and the replacement of body parts that are either worn out or non-functional (Hansson, 2021; Jiang et al., 2022).

These are but a few examples of the many human civilization accomplishments during the Anthropocene that have enhanced the quality of life for our current existence on earth. However, much of what we have done has been without consideration of the collateral damage to the other constituents and natural elements in the biosphere (Baumann, 2021). Increased concentrations of human populations, leading to increased urbanization and encroachment on natural habitats, tied with the direct effects of climate change, and both economic shocks and ecological disruption are among the direct causal mechanisms of negative impacts on the biosphere which are leading to negative health consequences.

Emblematic of the Anthropocene age has been the impact of increased population density on the biosphere. The rapid growth of human populations and the uncontrolled infringement of these populations on the natural environment has led to an unprecedented mixing and removal of habitats and the subsequent reduction in biodiversity.
Image from the UN Report: Nature’s Dangerous Decline ‘Unprecedented’; Species Extinction Rates ‘Accelerating’ — Image Source:

As habitats give way to human development and species become extinct at rates that range from 100 to 1000 times higher than that which occurred in the past half billion years (May, 2011) the normal flow of life in the biosphere is in peril. However, since many of us have not yet recognized the impacts of the loss of biodiversity, we do not view these events as part of the wicked problem that mankind has created during the age of the Anthropocene (Sukhdev, Whitmer, Schröter-Schlaack, Nesshöver, et al., 2010).

Image Source:

Planetary Health
The term planetary health is based on the understanding of the interconnectedness of all living elements (Whitmee, Haines, Beyrer, Boltz, et al., 2015) and the acknowledgment that our sustained existence depends on a drastic human behavioral change across all aspects of life. At every level of society, humans must realize and act on the threats to our existence. The research evidence is clear. We are messing up the balance of life in the biosphere to a point from which we may never return.

We are negatively influencing Planetary Health.
Our influence on climate ultimately influences the health of all flora, fauna, and humans.

Image Source:
Image Caption:

FILE – Volunteers help clean up a heavily polluted river in the Tembisa Township, north of Johannesburg, March 25, 2021. One out of five people in the world depends on wild species for food and income, according to a new UN-backed report. Climate change, pollution and overexploitation, however, have put a million species of plants and animals at risk of extinction. (AP Photo/Denis Farrell, File)

There is growing momentum to reverse our destabilizing influence on our environment. No longer can we ignore the loss of biodiversity on the constituents of the hierarchy that comprise the food chain, the continued disposal of particulate matter and toxic gases into the air that we breathe, or the wasteful exploitation of potable water resources, in addition to the detrimental effects on our oceans through the careless management of our rubbish. We have moved well beyond the ability to ignore our impact on the non-living physical environment as our current exploitive actions perpetuate the cataclysmic degradation of the essential infrastructure that maintains the balance needed to sustain life on earth.

The term planetary health is based on the understanding of the interconnectedness of all living elements (Whitmee, Haines, Beyrer, Boltz, et al, 2015) and the acknowledgment that our sustained existence depends on a drastic human behavioral change across all aspects of life.

For example, knowing the importance of sea ice as a naturally occurring solar radiation reflection mechanism should be enough to realize that without this “white shield” the earth has no mechanism to reflect solar radiation. As we transition from our frozen tunic to a fluid state, we increase solar heat absorption of oceans and large bodies of water (Trenberth, Chang, Jacobs, Zhang, and Fasullo, 2018). Losing the ability to cool our oceans not only leads to a reduction in the ability of the oceans to absorb carbon dioxide from the atmosphere, but the increased environmental heat sequestration also changes the habitat on which billions of organisms depend.

Consider also the effects of increased environmental temperatures as a stimulus for increased frequency and intensity of hurricane-force storms in regions that have never experienced such tropical weather-related events. As Trenberth and co-workers explained, the ocean heat content (OHC) increase is a direct outcome of increased radiant heat resulting from greenhouse effects, leading to an overall increase in sea surface temperatures (SSTs). This increase is associated with a change in the normal pattern of more frequent smaller storms in tropical ocean environments to less frequent but more severe storms of greater size and more severe intensity, which can then travel into areas that maintain higher sea surface temperatures. 

In more recent days (September 2022), we witnessed the effects of Fiona, a sub-tropical storm that traveled north from the Caribbean Ocean to devastate parts of Atlantic Canada with the force of a Category 2 hurricane (a Category 2 Hurricane has wind speeds of 154-177 km/hr (96-110 mph), NASA, 2014). In the images below we observe the wrath of Fiona on the landscape at Brackley Beach, Prince Edward Island, Canada. While this may seem like an incidental change to the beachscape, the sub-tropical storm Fiona completely destroyed the dunes which were the nesting place for piping plovers, thereby negatively hampering recovery efforts for this endangered bird (Thomas and Laheunesse, 2004). Knowing that climate change can lead to species extinction (Thomas, Cameron, Green, et al., 2004), we must ponder the question, will the wrath of sub-tropical storm Fiona be a sufficient causal mechanism in the subsequent extinction of the endangered piping plover?

The images below show the destruction by Sub-Tropical Storm Fiona (September 2022) to the beachscape of Brackley Beach, Prince Edward Island, Canada (source: Twitter feed for Mary Lynn Futers @gathertonourish, downloaded October 1, 2022).

Images of Brackley Beach prior to Sub-Tropical Storm Fiona (September 2022). Images of Brackley Beach following Sub-Tropical Storm Fiona (September 2022).

Earth exists as a biosphere in which homo sapiens (aka the wise human) are an integral part. Our existence as a species requires us to maintain the dynamic integration between the living and non-living components of the system, which together act as a functional unit. Humans need to demonstrate their wisdom and maintain the health of this ecosystem – to be the stewards of our planet and maintain the positive state of all parts of the biosphere.

We cannot overstate the importance that a healthy biosphere is fundamental to human health and hence the sustainability of civilization. As Whitmee and colleagues reported, ecosystems within the biosphere provide multiple services, such as the availability of food and water, structural materials such as wood and fiber, as well as medicines and fuels. Ecosystems regulate life on the planet; they regulate climate, erosion, disease, and the replenishment of flora through processes such as pollination. Healthy ecosystems provide an aesthetic in which culture, recreation, and spirituality flourish.

Degrading or severely altering the biosphere within earth’s ecosystems not only impacts the individual constituent parts that comprise the ecosystems but will also lead to a direct negative impact on the health of humans. Degrade the ecosystem that enables global food production and observe increases in malnutrition and diseases associated with food insecurity. Degrade the ecosystem that ensures appropriate access to potable water and observe the increase in drought-related crop failures, dehydration, and pestilence associated with the lack of quality drinking water. Degrade the environment to the extent that severely reduces pollinators and observe the starvation of millions of inhabitants across the biosphere.

Here we show a video of the drought in Spain reported by Reuters Press Aug 10, 2022

The UN Secretary-General António Guterres said the [IPCC, 2021] Working Group’s report was nothing less than “a code red for humanity. The alarm bells are deafening, and the evidence is irrefutable”. (IPCC report: ‘Code red’ for human-driven global heating, warns UN chief | | 1UN News).

Our planet is in a code-red situation regarding planetary health. As a first step to mitigating the condition, we need to first increase awareness and understanding of planetary health. Next, we need to provide achievable actions so that every level of society can pursue meaningful and sustainable behavior change. This means moving away from dependency on fossil fuels and moving toward renewable energy sources. This also means increasing carbon capture and storage through innovative mechanisms, a warning that has been stated many times but largely ignored.

The months of July through October 2022, were filled with a series of cataclysmic climate-related global events. Examples include but are not limited to the wrath of hurricanes Fiona in Atlantic Canada, and Ian in Florida and the Carolinas, along with extreme flooding throughout Pakistan in which at least one-third of the country was directly affected by flood waters, and in contrast, the severe droughts in China and in Spain that have impacted essential food production. 
Here we show a video of the drought in China reported by the BBC News Aug 23, 2022— China faces severe drought amid a record-breaking heatwave –
From a positive perspective, one might think that changing the behaviors of society by taking full advantage of a transformative utopian impulse for planetary health – that point at which society is inclined to take action that will transform society positively (Basso and Krpan, 2022) – is now more likely than ever before.

As a society, we need to reduce consumption, reduce waste, and reduce unnecessary development of the environment, especially when such development is based on inappropriate policies and poor planning. Societies need to seek better ways to mitigate coastal erosion through the development of wetlands and salt marshes and continue to invest in the production of alternative energy sources such as wind, solar, and geothermal energy production.

Changing the behaviors of society by taking full advantage of a transformative utopian impulse for planetary health – that point at which individuals in a society are inclined to take action that will transform their society positively (Basso and Krpan, 2022) – is now more likely than ever before. Recent reports by the International Panel on Climate Change suggest that human activity got us into this mess and so human activity can get us out. Our challenge is to spread the word, translate the knowledge, and continue developing strategies that eliminate the degradation of the biosphere.

Planetary Health influences on Human Health

The consequence of human activity throughout the Anthropocene on planetary health has led to problems that are intractable and without comprehensive solutions. Horst Rittel first described such problems of extreme complexity as wicked problems (Churchman, 1967). That is, problems with no stopping rules and which can only be tamed or for which elements of the problem can be resolved but which there is no complete solution (Rittel and Weber, 1973).

As humanity continues to strive for economic growth and the pursuit of prosperity in all aspects of life, we continue to create situations with complex outcomes that impact the entire biosphere and ultimately give rise to wicked problems for planetary health. Climate change by itself is a wicked problem. Climate change, defined by the Australian Academy of Science (2022) refers to changes in patterns of weather that are related to changes in ocean activity, land surfaces, and ice sheets, which occurs over decades. This builds on the definition of Werndl (2016), which added that climate change requires “a finite distribution” of events related to climates over time that result as a consequence of “varying external conditions”.

Lazarus (2009) called climate change a super wicked problem because the relationship between human health and the effects of climate change on planetary health is extremely complex and it is disproportionately different across the planet. The complex problems associated with climate change are dependent on the multiplicity of factors that are a function of the physical and social determinants of health (Patz, Frumkin, Holloway, Vimont, and Haines (2014). As Dr. Margaret Chan, the former Director-General of the World Health Organization stated in 2008, “The warming of the planet will be gradual, but the effects of extreme weather events – more storms, floods, droughts, and heatwaves – will be abrupt and acutely felt. Such events will affect some of the most fundamental determinants of health: air, water, food, shelter, and freedom from disease.” Further, as Al-Lamki (2008) suggested, the learned among us are expected to provide the important message to the general public that the negative consequences of climate change will have a direct effect on the health of all civilizations, as borne out by the data.

Despite the gradual pace of planetary health, the people most at risk will be those that are most disadvantaged. Marginalized and poor populations — the intentionally ignored, will suffer more devastating effects of negative planetary health, more often, and at a greater cost to their health than those who are well situated in developed environments, and who can afford to act sooner to recognize and mitigate potential effects. Food and water insecurity leading to higher costs and more frequent shortages of essential commodities will be among the early bellwether events followed by loss of income and opportunities to maintain livelihood through work or government support. The consequences of climate change on place – as in loss of land through coastal erosion, wildfires, floods, and landslides will lead to population displacement and in some instances forced migration.

Understanding the importance of the geographic area is essential to understanding the impact of negative planetary health and the ensuing environmental conditions that will have a direct effect on human health. The degradation of planetary health may appear to be a relatively slow process because the effects are measured on a geological clock, especially when one considers the age of the earth. A common euphemism for the slow progress is to move at a glacial pace, as the creeping movements of glaciers were thought to be so slow. However, the speed of changing environments, which includes melting of the continental glaciers leading to increased sea level volumes, loss of biodiversity, increased concentrations of atmospheric carbon dioxide, and the permafrost melting which is leading to an overall increased load of methane gas, are each happening at a pace that has not been observed previously in the time record of the planet.

Recognizing the direct effects of human activity within local and regional locations is an important first step in identifying causal mechanisms for the rapidity of climate change — mechanisms that we can change. For example, Kovats and Akhtar (2008) describe the role of urban centers as heat repositories because of the built environment. At a local level, cities become “urban heat islands” resulting from daytime storage of heat caused by increased human activities with a concomitant loss of the necessary vegetation to mitigate the heat sequestering effect. As stated by Kovats and Akhtar, while urbanization can lead to urban heat islands that cause temperatures in both daytime and nighttime to increase, urbanization can also contribute to the intensity of rainfall, the formation of hail, and the severity of thunderstorms. The size of the urban area and the design of the built environment can have a measurable effect on local weather, and depending on proximity to coastal water and rivers, can contribute to the likelihood of flooding (Kovats and Akhtar, 2008). Yet, in addition to the heat load from urban areas, cities are a major source of greenhouse gas emissions and thereby contribute to environmental impacts at a global level.

Illnesses caused by undernutrition because of reductions in both the quality and security of food will increase in prevalence as well as the increase in both morbidity and mortality associated with vector-borne diseases like Zika, Lyme disease, West Nile Virus, and malaria. While these diseases were previously localized to specific geographic regions of the world, many are not only emerging in areas that were unscathed previously, but more importantly, the spread of such illnesses is occurring at a more rapid rate. For example, while Lyme Disease was once thought to be localized to the Northeast region of the United States, originating from the town of Lyme, Connecticut, it is reported to be the most common type of vector-borne disease in North America (Ginsberg et al., 2021). Lyme disease is caused by the spirochete bacteria from the Genus: Borrelia. The bacteria are carried by the black-legged tick (Ixodes scapularis) and are passed on to humans when the individual is bitten by the tick. As Ginsberg and colleagues suggested, the spread of the disease may be dependent on the tick-host relationship and can involve more than one host. Having more than one host to spread the disease increases not only the risk of infection to humans but the spread of the disease into areas that are frequented by any of the various hosts.

Here we see one of the MANY individuals that doubted that climate change is real. This is unfortunate when scientific evidence is trumped by populus politics.

The negative consequences of poor planetary health on human health are not events that might happen in the distant future. The negative consequences of poor planetary health are happening now, and we can both observe and measure the outcomes on human health. For example, research by Ahmad, Scholz, Al-Faraj, and Niaz (2016) supports that among the human health consequences attributed to the negative consequences on planetary health are the effects of extreme weather events leading to loss of freshwater resources which in turn will have a direct effect on food supplies and subsequently human health.

Similarly, Guirguis and coworkers (2013) reported that heat waves, resulting from extreme weather events are linked directly to an increased prevalence of heat-related illness. Seasonal mortality rate increases can be attributed to the increasing frequency, duration, and severity of heatwave conditions in both urban and rural areas. Similarly, as heat waves increase air quality is decreased and this relationship affects those with respiratory illness more severely since many will have difficulty finding necessary relief from heat-related air quality degradation. Portier et al (2010) referred to air quality because of the complex characteristics of atmospheric chemistry, which we know can increase risks for asthma and asthma-like symptoms, respiratory-related morbidity, and cardiovascular disease. Air quality is determined by the interactions of heat and humidity with the various concentrations of atmospheric elements such as smog (fog and smoke comprised of gases that include but are not limited to carbon monoxide, carbon dioxide, and sulfur dioxide), which is especially prevalent in urban areas, along with molds, fungi, airborne bacteria, and viruses, as well as particulate matter as that which occurs with greater abundance in areas with wildfires. Similarly, Kinney (2018) indicated that agricultural emissions like methane and ammonia are added to the toxic soup we are breathing.

Recognizing Planetary Health Through Zoonosis, Pandemics, and the Emergence of Infectious Diseases

As noted by Rizzardini, Saporito, and Visconti (2018), infectious diseases cause approximately 19% of all deaths worldwide per year. While many would think that vaccination regimens will make infectious diseases obsolete, there is growing concern that we cannot rest in our efforts to recognize and manage the continued rise of infectious diseases, especially related to planetary health. The WHO has addressed this potential lack of recognition for emerging infectious diseases by including the term Disease X in its blueprint of prioritized diseases (WHO R&D Blueprint Team, 2022).

An easy start to spread the word and the conversation on planetary health and infectious disease is by addressing the issues of the COVID-19 pandemic (SARS-CoV-2), and the ways in which humans have disrupted the natural systems of life on earth. The transmission of emerging infectious diseases (EIDs), many of which arise through zoonosis –the transmission of pathogens from animal to human (Jones et al 2008, Han, Schimdt, Bowden, and Drake, 2015) is well studied as a plausible vector of transmission for human contagion. According to Han, Schimdt, Bowden, and Drake (2015), more than 1 billion illnesses are attributed to zoonotic infections worldwide, each year. The emergence of the COVID-19 global pandemic is one such zoonotic infection that was not without forewarning (Jones et al, 2008). Research by Jones and coworkers included a review of some 335 EIDs identified between 1940 and 2004. The researchers found that the presence of EIDs was not a function of random occurrence but could be linked directly to increases in population density and population growth.

Moreover, Jones and coworkers reported that EIDs were linked not only to zoonosis in a general sense, as may be anticipated with domesticated animals, but directly to unconventional pathogens arising from wildlife. In their comprehensive review, the authors reported that while more than 60% of EIDs were associated with zoonosis, more than 71% of EIDs were associated with pathogens from wildlife, specifically listing Nipah virus (NiV), and SARS-CoV-1, as examples.

The work of Jones et al in 2008 was extremely important to public health awareness of global pandemic risk as it was the first analytical support for the suggestion that the “threat of EIDs to global health was increasing!” Likewise, noting that more than half of the zoonotic pathogens could be linked to wildlife, the authors explicitly stated that identifying the relationship between factors that increase contact between wildlife and humans is essential to developing not only predictive approaches to identify disease emergence, but to establishing strategies to prevent localized outbreaks and widespread contagion.

Later research by O’Callaghan-Gordo and Antó (2020) supported the presence of a transmission route for wildlife to human zoonosis by noting that the cause of the COVID-19 pandemic was attributed directly to open-air markets in Wuhan China where some 120 animals of 75 different species were sold. This plausible pathway for disease transmission was also affirmed in a separate investigation by the WHO which reported its findings in February 2021. According to O’Callaghan-Gordo and Antó some of the animals sold at the Wuhan open-air market were alive and included puppies of wolves, salamanders, crocodiles, scorpions, rats, squirrels, foxes, civets, and turtles; all of which could be considered active vectors for transmission of emerging infectious diseases. However, the most important overlooked issue related to the transmission of pathogens from wildlife to humans is that not only were the market traders among the earliest cases in Wuhan to be treated or to die as a result of contracting COVID-19 but that the risk of producing a virus-like COVID-19 (aka SARS-CoV-2) was predictable given the environment and what we had learned previously from the events which led to SARS-CoV-1 in Guangdong Province, China, more than 17 years earlier.

In the earlier development of SARS-CoV-1, it was believed that live bats were exposed to Civets (a cat-like mammal) which created an optimal pathway for disease progression between animal species. As O’Callaghan-Gordo and Antó suggested, despite having previous knowledge of routes for disease transmission scientists alerted officials that the current environment of live meat markets (not only in Wuhan but throughout China) was primed for another outbreak of widespread zoonotic infection as a function of exposures, the authorities chose not to act (O’Callaghan-Gordo and Antó, 2020).


Without question, the negative consequences of planetary health represent a real and present danger as an existential threat to humanity (Ramadan and Ataallah, 2021). Moreover, the relationship between the negative consequences of planetary health and human health is demonstrated continuously by both direct and indirect effects on rates of morbidity and mortality. The pace at which the degradation of our planetary health is occurring is not monotonic but is accelerating at a rate unprecedented in the chronological record of the planet. Now is the time to recognize and act on the direct and indirect effects of planetary health so that we can thwart the specific negative health outcomes that include chronic diseases (e.g., cardiovascular and respiratory), injuries, and fatalities from severe weather events (e.g., floods, landslides, heat waves, ice storms), emerging infections and vector-borne diseases (e.g., malaria, Zika, Covid-19, West Nile Virus), mental health outcomes (e.g., stress, and financial hardship resulting from disasters to the natural environment), food insecurity and loss of freshwater resources, to name but a few of the observable and measurable outcomes. The negative consequences of planetary health and climate change are not only affecting the existence of humans, but planetary health and climate change, are also having a negative effect on all our neighbors in the biosphere.

It’s time to take action — it’s time to make your voice heard! You may not be a celebrity but you are going to be impacted by planetary health!

Bibliographic References for this chapter are located at this hyperlink–> REFERENCES.



Sample of adding H5P content — here I incorporated a true/false question which is a feature of the H5P interactivity module.

We can continue to add all sorts of elements to each chapter to create a dynamic learning environment.

  1. *all referencing in this text will follow the Vancouver Style: Format (Print) 1. Author Last Name Author First Initial Author Middle Initial. Article Title. Journal Title. Published Date;Volume(Issue):Pages. (Digital) 1. Author Last Name Author First Initial Author Middle Initial. Article Title. Journal Title [Internet]. Date Published [cited Date Accessed]; Volume(Issue):Pages. Available from: URL


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