Sentinel Physicians for the Environment: A Chilean Perspective to Address Global Health and Climate Resilience

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

You can find the recommendations both in the attached file and below.

1. The research, "Sentinel Physicians for the Environment: Lessons from Chile for Global Health and Climate Resilience," is theoretically innovative and an invaluable contribution to the region. The very nature of any breakthrough study is that it always breaks with structure and form in the service of its essence, requiring that it be presented and examined in extraordinary detail. This will surely be a worthwhile study if only its inadequacies are met. Nevertheless, the main flaws of the study are that it does not have empirical evidence, suffers from limited conceptual purity, and does not have appropriate concreteness at the practical level. If the issues are resolved, the work can be an excellent scientific paper; else, publication will be tough.
2. The article should be revised according to the International Journal of Environmental Research and Public Health's writing guidelines. Line numbers should be added for ease of review. There are some technical and stylistic errors.
3. The title of the article contains very presumptuous assumptions of a global nature. But all the information in the article is related to the Chilean case alone. Therefore, it is suggested that the title be changed to a more restrictive form such as "A Case Study from Chile" rather than "Lessons from Chile."
4. It is recommended that the abstract be redesigned according to the International Journal of Environmental Research and Public Health's writing guidelines. For example, while it successfully introduces the conceptual framework, it also provides concrete information about the methodological approach and findings. For example, the phrase "Early actions" is too general. A brief sentence or two about the nature of the methods used and the highlights of the findings are essential elements in the abstract.
5. Removing redundancy from this section will make it easier to read and understand. The authors comprehensively address the environmental and social issues of the South American continent in this section. However, this broad framework overshadows the Chilean experience, which is the focus of the article. The introduction should be simplified accordingly and the concept of SPE should be addressed directly. An introduction should be designed based on the article's focus, methodology, and findings. Environmental issues not addressed in the findings do not need to be explained.
6. When introducing the concept of SPE, comparisons with other sentinel systems are not made. For example, similarities and differences with influenza surveillance systems or zoonotic disease sentinel networks should have been discussed. This omission undermines the specificity of the concept.
7. The MAIS model is well explained. However, how SPEs are integrated into this model remains unclear. Following this explanation, it would be helpful to provide a concrete example of how SPEs would be positioned within the MAIS.
8. Figure 1 is presented, but its description is inadequate. The scientific contribution of the image is unclear. The data sources on which the image is based and how it should be interpreted should be clearly stated beneath the figure. Even if not all the components that make up a map, at least a scale and legend (descriptions) should be included. A geographic map cannot be like Figure 1. If a geographic map cannot be drawn, there is no need to call it a geographic map. Explanations should be written under the heading "Figure 1."
9. The Brazilian example is presented in detail. However, no direct connection to Chile is made. A brief commentary should be added after each regional example, under the heading "Implications for Chile" or its context.
10. The three pillars of SPEs (epidemiology, participation, and collaboration) are well presented. However, this structure is not exemplified in practice. A case study from Chile under each pillar would strengthen the scientific nature of the article.
11. The methodology section relies solely on documents and seminars, which seriously undermines the article's scientific integrity. It's perceived as a collection of generalizations and reductions derived from a literature review rather than a research paper. Empirical data is lacking, and this deficiency is a significant obstacle to publication. If possible, qualitative data from seminars (e.g., participant opinions, survey results) should be presented.
12. The discussion, in its current form, is in the form of a technical report and fails to engage in critical dialogue with the literature. It is recommended that academic sources critiquing the concepts of Planetary Health and One Health be included.
13. Figure 3 presents the conceptual model, but its integration with the text is weak. In its current state, its existence is incomplete. It would be more meaningful if each component in the figure (surveillance, prevention, communication, advocacy) were discussed under separate headings within the text.
14. The educational proposals are robust but lack operational clarity. A list of proposed curriculum topics and target competencies after the phrase "structured programs" would be more compelling. The "School of SPEs" proposal remains abstract. The scientific significance will be fully realized when the proposed regions for establishing the school, the institutions with which it will collaborate, and the monitoring indicators are specified.

Comments for author File: Comments.pdf

Author Response

Dear Reviewer 1,

We would like to sincerely thank Reviewer 1 for the careful, rigorous, and constructive review of our manuscript. We greatly appreciated the depth of the comments provided, which addressed conceptual clarity, methodological positioning, integration with existing health-system frameworks, and the scientific coherence of figures and examples. These observations were instrumental in guiding a substantial and meaningful revision of the manuscript.

In response to Reviewer 1’s comments, we have undertaken a thorough restructuring and clarification of several key components of the paper. In particular:

• We clarified the article type and methodological positioning, explicitly defining the manuscript as a narrative synthesis and policy-oriented conceptual analysis, and added a dedicated limitations statement to transparently acknowledge the absence of original empirical data.
• The Introduction was streamlined and refocused, with an earlier and clearer definition of Sentinel Physicians for the Environment (SPEs), and background elements not directly addressed in the analysis were reduced or removed.
• We refined the conceptual architecture of the SPE framework, explicitly distinguishing between enabling conceptual dimensions (environmental epidemiology, participation, intersectoral collaboration) and the four operational pillars (surveillance, prevention, communication, advocacy), to avoid ambiguity and ensure internal coherence.
• At the reviewer’s request, we strengthened empirical grounding by adding concrete Chilean practice-based examples illustrating how these dimensions and pillars are operationalised within primary health care and the MAIS framework.
• We expanded the Discussion to include a critical comparison with established sentinel systems (e.g. influenza and zoonotic surveillance) and to engage explicitly with academic critiques of One Health and Planetary Health, positioning SPEs as a pragmatic, PHC-based operational response to these debates.
• The integration of SPEs within the Chilean MAIS model has been clarified through both textual explanation and revised figures, including concrete examples of information flows and governance linkages.
• All figures were revised and better integrated into the text: conceptual figures are now clearly identified as such, with expanded captions, clarified data sources, and explicit guidance for interpretation.
• Finally, the education and training proposal was substantially operationalised, with a new subsection detailing curriculum topics, target competencies, institutional partners, and monitoring indicators for the proposed School of SPEs.

All these changes were made directly in response to Reviewer 1’s comments and are documented point by point in the attached Authors’ Responses to Reviewer 1, with precise indications of where each modification can be found in the revised manuscript.

We are very grateful to Reviewer 1 for helping us significantly improve the scientific clarity, coherence, and policy relevance of the paper, and we hope that the revised version adequately reflects the care and seriousness with which we addressed all the issues raised.

With kind regards,

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Lauriola P et al. have carefully reviewed the manuscript. The following suggestions may help further enhance the quality of the paper:

1. Title refinement – Consider making the title more vivid, for example: “Sentinel Physicians for the Environment: A Chilean Perspective to Address Global Health and Climate Resilience.”
2. Discussion section – The authors could elaborate on the robustness and practical relevance of the proposed model.

Overall, the manuscript is written in an impressive manner. Incorporating these revisions would further enrich the paper.

Author Response

Dear Reviewer 2,

We would like to sincerely thank Reviewer 2 for the constructive and focused feedback provided on our manuscript. Although concise, the comment was highly relevant and helped us improve the clarity, communicative strength, and positioning of the paper.

In particular, Reviewer 2 suggested that the title should be more vivid. We carefully considered this recommendation and fully agree with its importance, given the conceptual and policy-oriented nature of the manuscript.

In response, we have revised the title to make it more vivid, informative, and engaging, while preserving scientific accuracy and avoiding overstatement. The revised title now more clearly conveys:

• the central role of Sentinel Physicians for the Environment (SPEs) as a practice-oriented and policy-relevant framework;
• the anchoring of the manuscript in the Chilean experience, while maintaining broader international and regional relevance;
• the explicit connection with primary health care and environmental governance, which are core themes of the article.

This revision also ensures consistency with related comments raised by Reviewer 1 regarding the need to clearly foreground Chile as the empirical and conceptual reference point of the manuscript.

We believe that this modification strengthens the manuscript’s accessibility and clarity for a broad interdisciplinary readership, without altering its scientific scope or intent.

We are grateful to Reviewer 2 for this helpful suggestion, which contributed to improving the overall quality and presentation of the article.

With kind regards,

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for submitting this manuscript on “Sentinel Physicians for the Environment (SPEs)” and the Chilean experience. The topic is timely and important: you are addressing the intersection of climate change, primary care, social vulnerability, migration, and environmental justice in Latin America. Positioning frontline physicians as environmental sentinels is conceptually strong and clearly relevant to health system resilience.

However, in its current form, the manuscript reads more like an informed policy brief / position paper than a fully formed scholarly article. The manuscript requires structural reorganization, clearer definition of article type, and significant strengthening of the Methods section to meet publication standards. Author need to more carefully distinguish current achievements from aspirational plans to avoid overstating evidence. Author also need to add a realistic discussion of implementation barriers and evaluation metrics.

There are structural, methodological, and evidentiary gaps that need to be addressed before it can be considered for publication.

 

My detailed comments follow.

 

1. Article type, scope, and positioning

The manuscript combines: (i) narrative background on climate and health inequities, (ii) conceptual framework for SPEs, and (iii) institutional/political developments in Chile in 2024–2025. However, it is not yet clear what genre of article this is intended to be. It is written at times like an original research article (“we show,” “this experience demonstrates”), at times like a narrative review, and at times like a policy/practice commentary or perspective. This ambiguity becomes a problem for evaluation, because different article types require different levels of methodological transparency and evidentiary support.

Please clearly define the article type in the Introduction or Methods. If this is a policy framework / perspective grounded in documentary evidence and institutional experience, say that explicitly and align the structure accordingly. If you are claiming it as an original case study (implementation study), then you will need to produce much stronger, more systematic evidence of implementation outcomes.

Right now the manuscript sits in between and risks being judged against the standards of a design/implementation study, which it cannot meet in its current form.

 

2. Methods and evidence base

The paper states that it draws on peer-reviewed literature, institutional reports (PAHO, UNICEF, ECLAC, COLMED, etc.), and “experiential knowledge” from seminars, MoUs, and professional networks in Chile. But the Methods section is not developed enough for publication. There is no description of how literature was identified, no indication of which sources were systematically reviewed vs. selectively cited, and no description of how the outputs from the COLMED seminars / MoUs were analyzed. “Experiential knowledge” is vague. Is this qualitative synthesis of meeting minutes? Is this official documentation? Is it personal observation by the authors? Journals will immediately question whether this is anecdote. To improve, please revise substantially strengthen the Methods section. At minimum you must:

• State explicitly that this is a narrative synthesis / policy analysis (if that is the intention), not a systematic review.
• Describe the source types and how they were gathered (databases searched, time window, languages considered; for internal documents, whether you analyzed agendas, minutes, position statements, signed MoUs, etc.).
• State limitations: e.g. “This article does not present new surveillance data; instead it proposes an operational model.” That is important for transparency.

Without this clarification, the manuscript is methodologically under-specified.

3. Evidence vs. advocacy

Many of the claims are stated with a high degree of confidence (“scalable,” “replicable,” “a pragmatic path for Latin America and beyond”), but at times the support is conceptual rather than empirical. The Chilean experience is highly valuable, but in several places you describe proposed or upcoming initiatives (e.g. national School of SPEs, a Santiago Declaration, structured sentinel family health centres) as though they were already implemented, evaluated, and producing measurable outcomes.This makes it difficult to distinguish what has actually occurred on the ground from what is envisioned.
Throughout the manuscript, clearly separate:

• What has already happened (seminars delivered, MoUs signed, municipal/regional engagement that has already taken place).
• What is in active development (working groups, training curricula under construction).
• What is aspirational / proposed (national School of SPEs, formalized sentinel centres, regional declaration).

This separation is essential. Otherwise, readers will interpret proposed future actions as established fact.

 

4. Internal coherence (concept → mechanism → implementation)

The manuscript makes a compelling ethical argument: primary care physicians are embedded, trusted, and see vulnerable populations first (children, migrants, low-income communities exposed to wildfire smoke or pollution). From that you derive the idea of Sentinel Physicians for the Environment.

However:

• In Section 4 you list major climate-related threats (wildfires, air pollution, water stress, migration, vector-borne disease expansion, antimicrobial resistance, zoonotic spillover), but you do not consistently explain how, in practical terms, an SPE would intervene in each case.
• In Section 5 you outline the pillars of the SPE model (surveillance, prevention, community engagement, advocacy), but you do not yet discuss operational constraints, reporting pathways, or evaluation metrics.
• In Section 7 you describe COLMED activity in Chile, but mostly as a political/educational timeline, rather than as an operational test of sentinel behavior in clinics.

As written, the chain “problem → intervention model → implementation → outcome” is not fully closed.
For each major hazard class you highlight (e.g. wildfire smoke events; dengue expansion into new latitudes; migrant health precarity):

• briefly state what an SPE actually does in that scenario,
• where that information flows (clinic dashboard? municipal health authority? ministry?),
• and how success would be measured (faster alerting, better continuity of care, targeted risk communication to vulnerable groups, etc.).

This will transform the manuscript from a vision statement into an operational framework.

 

5. Over-repetition and structure

• Chile, COLMED, and the role of PHC are introduced in the Introduction, discussed again in Section 2, revisited in Section 7. This creates redundancy and diffuses impact.
• The section labeled “Objectives of the paper” could be merged into the Introduction.
• The Chilean timeline in Section 7 would read more convincingly if it were structured chronologically (awareness → formalization via MoUs → regionalization → proposed national School and regional declaration). Right now, it jumps in time and mixes confirmed and planned actions.

Tighten the structure:

• Use the Introduction to motivate the problem and announce what the paper will do.
• Use Section 2 to provide technical/system context for Chile (PHC model, environmental exposure landscape).
• Use Section 7 to narrate, in chronological order, how the initiative has unfolded in Chile and what concrete institutional outputs already exist.

You can then cut repeated material from the Introduction and Section 2.

 

6. Realism: barriers, governance, and sustainability

• The Discussion argues that SPEs are not just individuals but part of a governance network, which is exactly the right framing. You also connect SPEs to planetary health and One Health.
• But you barely discuss barriers: physician workload, burnout, legal authority to report environmental hazards, political resistance from polluting industries, data infrastructure needed to turn “clinical impressions” into actionable surveillance, funding for training, etc.
• You also do not discuss sustainability: who pays for SPE training, who maintains the data channels, and how this becomes institutional rather than a one-off initiative driven by a few motivated actors.

Add a dedicated paragraph (in Discussion or Conclusion) that realistically addresses:

• operational burdens on primary care staff,
• governance and reporting mechanisms,
• funding/stewardship of a national School of SPEs,
• risks of stigmatizing certain communities (e.g., migrant settlements) when issuing environmental/health alerts.

This will increase credibility with reviewers who are skeptical of purely aspirational frameworks.

 

7. Evaluation and impact metrics

A reader will reasonably ask: how will you know if SPEs “work”? At present, the manuscript does not define even basic indicators of success (timeliness of alerting, number of community advisories issued during smoke episodes, uptake of guidance for migrants, etc.). Without at least a proposed evaluation framework, the model risks being seen as rhetorical. Please include a short subsection (either at the end of Discussion or in Conclusions) outlining potential evaluation metrics for SPE implementation. Even a conceptual monitoring and evaluation (M&E) sketch would strengthen the manuscript.

 

 

Comments for author File: Comments.pdf

Author Response

Dear Reviewer 3,

We would like to express our sincere gratitude to Reviewer 3 for the exceptionally thorough, rigorous, and constructive review of our manuscript. The comments provided were pivotal in helping us substantially strengthen the scientific clarity, methodological transparency, structural coherence, and operational credibility of the paper.

In particular, Reviewer 3 correctly identified the need to clearly define the article type, align the language and structure accordingly, and avoid ambiguity between empirical research, narrative review, and policy commentary. In response, we have undertaken a comprehensive revision that has reshaped the manuscript in several fundamental ways.

First, we have explicitly defined the manuscript as a narrative synthesis and policy-oriented conceptual analysis, grounded in peer-reviewed literature, institutional and policy documents, and documented professional and organisational experience. This positioning is now clearly stated in the Methods section and consistently reflected throughout the Introduction, analytical sections, Discussion, and Conclusions. Language typical of original research articles has been systematically revised to ensure full coherence with this article type.

Second, in direct response to the reviewer’s methodological concerns, the Methods section has been substantially expanded and strengthened. We now clearly describe:

• the databases searched, time windows, and languages considered for the scientific literature;
• the categories of institutional and policy documents analysed;
• the nature of the materials derived from COLMED-led activities (seminar programmes, agendas, minutes, reports, signed MoUs);
• and the analytical approach used to synthesise these materials.
  The concept of “experiential knowledge” has been explicitly clarified as a structured synthesis of documented institutional processes, not anecdotal observation. A dedicated limitations paragraph has been added to ensure full transparency regarding the absence of original empirical or outcome data.

Third, following Reviewer 3’s repeated and well-founded requests, the manuscript now clearly distinguishes between actions already implemented, initiatives in active development, and aspirational or proposed components. This separation has been systematically applied across all relevant sections, particularly in Section 7, which has been fully reorganised into a chronological and operational narrative of the Chilean experience. Language implying completed implementation or evaluated outcomes has been carefully revised to avoid overstatement.

Fourth, we have significantly strengthened the operational dimension of the SPE framework. New and expanded sections now explicitly describe:

• what Sentinel Physicians for the Environment (SPEs) do in practice across major climate- and environment-related hazard scenarios;
• how information flows from primary care to municipal, regional, and public health authorities;
• and how SPEs complement, rather than replace, existing surveillance systems.
  This includes a new subsection explicitly closing the chain “problem → intervention model → implementation → expected outcomes,” as suggested by the reviewer.

Fifth, in response to concerns regarding credibility and evaluation, we have added a conceptual monitoring and evaluation framework, outlining proposed process and output indicators (e.g. timeliness of alerting, continuity of care for vulnerable groups, integration into decision-making processes). While explicitly presented as developmental and not as reported outcomes, this framework clarifies how the SPE model could be assessed in future implementation and research.

Finally, the Discussion section has been substantially strengthened to address operational barriers, governance constraints, sustainability, funding, data infrastructure needs, and ethical risks (including stigmatization). These issues are now discussed explicitly and critically, situating the SPE model within realistic primary-care workloads and institutional contexts, and aligning it with current critiques of One Health and Planetary Health frameworks.

Overall, the reviewer’s comments prompted a profound refinement of the manuscript’s scientific positioning, internal coherence, operational clarity, and credibility. We are deeply grateful for this contribution and believe that the revised manuscript is substantially stronger, clearer, and more robust as a result.

With kind regards,

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,
The care and comprehensive revisions you have shown during the revision process are significant. Clarifying the conceptual framework, clarifying the methodological positioning, and strengthening the examples have significantly enhanced the integrity of the article. In addition, the expansions in the discussion section and the better integration of visuals have increased the value of the study both scientifically and policy-wise.
Best Regards

Author Response

Dear Reviewer 1,

The authors thank you for the positive and encouraging comments.

Please find in the attached Authors’ Responses Table our comments in response to your observations.

The Authors

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Good to go ahead.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you very much for the effort of authors to revised a manuscript. It has made substantial progress in addressing several concerns, particularly regarding the explicit definition of article type, the separation of implemented versus aspirational actions, and the operational description of SPE functions for each hazard scenario. However, some areas require additional attention before the manuscript can be considered for publication. The most critical gap is the absence of the promised dedicated paragraph on implementation barriers and sustainability, which is essential for establishing the credibility of the SPE framework as a realistic and achievable model rather than a purely aspirational proposal. The other comments address important but somewhat less critical gaps related to systematic pillar-by-pillar treatment, clinical operational examples, measurable success indicators, and a conceptual monitoring and evaluation framework. I encourage the authors to address these remaining issues, particularly the barriers and sustainability discussion.

1. Operational constraints, reporting pathways, and evaluation metrics for each pillar

The authors stated in their response that Section 5 has been expanded to systematically discuss operational constraints, reporting pathways, and evaluation approaches for each of the four SPE pillars (surveillance, prevention, communication, and advocacy). While I acknowledge the addition of Table 1 and the general mention of SWOT analysis, Eisenhower matrix, and the "5 Ws and How" methodology, the promised pillar-by-pillar treatment has not been adequately delivered in the revised manuscript.

The current approach applies these frameworks collectively across all pillars rather than providing the systematic, differentiated treatment that was requested. For instance, the surveillance pillar should have its own explicit discussion of what institutional capacity is required, how clinical observations flow from the consultation room to municipal epidemiology units to regional authorities, and what specific indicators would demonstrate surveillance effectiveness. Similarly, the prevention, communication, and advocacy pillars each warrant dedicated discussion of their unique operational constraints, information pathways, and evaluation metrics.

I recommend that the authors either expand the narrative accompanying Table 1 or create a supplementary table that addresses each pillar individually. For each pillar, the text should specify: (a) the key operational constraints and resource requirements; (b) the precise reporting and information flow mechanisms; and (c) at least two or three concrete indicators that could be used to assess performance. This systematic treatment would substantially strengthen the operational credibility of the SPE framework and demonstrate that the authors have thought through the practical realities of implementing each function.

2. In section 7 as documentation of operational sentinel behavior

The authors promised that section 7 would be revised to include "concrete practice-based examples to demonstrate how COLMED-supported activities translate into early forms of sentinel behaviour at clinic level." While I appreciate the improved structure of section 7, with its clear separation into implemented actions, initiatives in development, and aspirational proposals, the section still reads primarily as an institutional and educational timeline rather than as documentation of operational sentinel clinical practice.

Section 7.1, which describes what has already been implemented, focuses almost entirely on institutional milestones: seminars delivered, memoranda of understanding signed, journal sections created, online courses offered, and organizational integrations completed. These are valuable preparatory activities, but they do not constitute evidence of sentinel behavior being tested in clinical settings. The concrete clinical example that does exist in the manuscript—the Biobío Region pilot involving the heat surveillance protocol—appears in section 5 rather than in section 7 where it would more appropriately demonstrate implemented sentinel practice.

I recommend that the authors strengthen section 7.1 by incorporating specific examples of sentinel clinical behavior that has actually occurred. For example, the authors could describe instances where SPE-trained physicians documented environmental exposures during patient consultations, identified clusters of environment-related symptoms, or transmitted clinical observations to municipal health authorities. Even preliminary or small-scale examples would be valuable. Quantitative details, where available, would further strengthen this section—for instance, the number of patients who received environmental anamnesis during a pilot period, or the number of heat-related cases identified and reported during a specific alert episode. This would transform section 7 from a chronicle of institutional progress into evidence of the SPE model being operationalized in real clinical practice.

 

3. Closing the problem-intervention-implementation-outcome chain with measurable success indicators

The authors indicated that the new section 4.5 would close the chain from problem identification through intervention and implementation to outcome measurement by specifying what SPEs do, where information flows, and how success would be measured for each major hazard scenario. I commend the authors for the substantial improvement in section 4.5, which now clearly articulates SPE actions and information pathways for heatwaves, wildfire smoke, urban air pollution, vector-borne disease expansion, migration-related vulnerability, and antimicrobial resistance and zoonotic spillover. However, the third component—measurable success indicators—remains inadequately addressed.

The current text acknowledges at lines 346-350 that "these mechanisms are developmental and do not represent formal evaluation outputs" and should be interpreted as "illustrative operational pathways rather than performance indicators." While this transparency is appreciated, it does not fulfill the request for concrete indicators of success. The "expected benefits" mentioned for each hazard (such as "earlier outreach, continuity of care and reduced morbidity" for heatwaves) are aspirational outcomes rather than measurable metrics.

I recommend that the authors add one or two specific, measurable success indicators for each hazard scenario. These need not be indicators that have already been measured; they can be proposed indicators for future evaluation. For example, for heatwaves, the authors might propose measuring the proportion of high-risk patients receiving documented heat-vulnerability screening during meteorological alerts and the mean time from clinical cluster identification to municipal notification. For wildfire smoke episodes, indicators could include the number of respiratory exacerbation cases with documented smoke exposure history and the timeliness of community advisories following SPE cluster reports. For vector-borne diseases, the detection lag between the first atypical febrile case presentation and formal epidemiological alert could serve as a meaningful indicator. Adding such concrete metrics would genuinely close the problem-to-outcome chain and demonstrate that the authors have considered how the effectiveness of SPE interventions could eventually be evaluated.

4. Barriers, sustainability, and implementation challenges

This represents the most significant gap between the authors' promised revisions and what appears in the revised manuscript. My explicitly requested a dedicated paragraph in the ciscussion addressing operational burdens on primary care staff, governance and legal authority to report environmental hazards, funding and stewardship of the national School of SPEs, data infrastructure requirements, political resistance from polluting industries, and risks of stigmatizing vulnerable communities when issuing environmental health alerts. The authors' response table indicated that "the Discussion section has been expanded with a dedicated paragraph that critically examines the real-world challenges" and listed all of the requested topics as having been addressed.

Upon careful review of Section 8 (Discussion), I cannot locate this dedicated paragraph. The manuscript contains only brief, scattered mentions of challenges: line 934-935 states that "challenges remain in terms of resources, political will, and training infrastructure," and lines 959-977 discuss general One Health implementation barriers in low- and middle-income countries. These general statements, embedded within other discussion content, do not constitute the dedicated, comprehensive treatment of barriers that was promised and that the comment deemed essential for credibility.

The following critical issues remain entirely unaddressed in the revised manuscript: physician workload and burnout risks associated with additional sentinel functions; time constraints on already-stretched primary care teams; legal authority and accountability for physicians reporting environmental observations; political and economic resistance from industries that might be implicated by environmental health alerts; data infrastructure requirements for transforming clinical observations into actionable surveillance intelligence; sustainable funding mechanisms for SPE training and coordination beyond pilot phases; and ethical risks including the potential stigmatization of vulnerable populations such as migrant communities when environmental health alerts target specific neighborhoods or population groups.

I strongly recommend that the authors add a dedicated subsection to Section 8 titled something like "Implementation Challenges and Sustainability Considerations." This subsection should frankly acknowledge the operational burdens that SPE functions may place on primary care professionals and discuss strategies for integration into existing workflows rather than adding new tasks. It should address whether physicians have legal authority or mandate to report environmental observations and how accountability would be structured. The subsection should acknowledge potential opposition from economic interests affected by environmental health surveillance and discuss mechanisms for maintaining scientific independence. It should describe what information systems and data infrastructure would be needed and acknowledge current gaps. It should clarify funding sources and pathways for institutional sustainability beyond initial enthusiasm. Finally, and importantly, it should explicitly address the ethical risk that environmental health alerts could reinforce stigma against already-marginalized communities and propose safeguards such as community co-design of messaging and equity-focused framing.

 

5. Monitoring and evaluation framework

The authors promised to include "a conceptual monitoring and evaluation (M&E) framework" in a "new short subsection" at the end of the Discussion, with "proposed process and output indicators" including timeliness of alerting, number of community advisories issued, continuity of care metrics, and integration of SPE observations into municipal decision-making. While Section 7.5.4 does include some monitoring indicators and Section 9.2 mentions that future pilot initiatives will generate empirical indicators, the promised dedicated M&E subsection does not appear in the revised manuscript, and the indicators that are provided focus primarily on training and capacity building rather than operational SPE performance.

The indicators listed in Section 7.5.4 (lines 756-762) include number of trained professionals, adoption of environmental anamnesis in primary care, local environmental risk-mapping activities, integration of sentinel observations into municipal surveillance systems, and strengthening of community preparedness. While these are relevant metrics, they primarily measure inputs and processes related to education and capacity building. My previous comment specifically requested indicators that would measure SPE operational effectiveness—metrics such as timeliness of alerting during environmental emergencies, the number and scope of community advisories issued following SPE signal detection, and uptake of guidance among vulnerable populations including migrants. These operational performance indicators are largely absent from the current text.

I recommend that the authors add a dedicated short subsection either at the end of Section 8 or at the beginning of Section 9, explicitly presenting a conceptual M&E framework for SPE implementation. This subsection should distinguish between different types of indicators. Process indicators might include the number of consultations incorporating environmental anamnesis, the number of cluster reports generated by SPE-trained physicians, and the frequency of SPE participation in municipal coordination meetings. Output indicators might include the number of community risk advisories issued following SPE signal detection, the proportion of vulnerable patients with documented environmental exposure assessment, and the mean time from clinical cluster identification to municipal notification. Outcome indicators, acknowledging that these would require longer-term evaluation, might include reduction in detection lag compared to pre-SPE baseline and the proportion of municipal emergency responses informed by SPE-generated intelligence. The authors should explicitly acknowledge that these are proposed indicators for future pilot evaluation rather than already-measured outcomes. This addition would demonstrate that the authors have seriously considered how SPE effectiveness would eventually be assessed and would fulfill the comment's request for "even a conceptual M&E sketch."

Comments for author File: Comments.pdf

Author Response

Dear Reviewer 3,

The authors would like to sincerely thank you for your thorough, insightful, and constructive review of the manuscript. We greatly appreciate the time and care you devoted to assessing both the conceptual robustness and the operational credibility of the proposed framework.

Your comments were extremely valuable in guiding this second round of revision. In response, the manuscript has been substantially revised to strengthen the operational differentiation across pillars, clarify clinical and hazard-specific applications, introduce proposed measurable indicators, and explicitly address implementation barriers, sustainability considerations, and monitoring and evaluation aspects. These revisions were undertaken to enhance the realism, transparency, and evaluability of the SPE model, while remaining consistent with its current developmental stage.

A detailed account of how your comments were addressed is provided in the attached Authors’ Responses Table. We are very grateful for your guidance, which has significantly improved the scientific quality and policy relevance of the manuscript.

With kind regard

The Authors

Author Response File: Author Response.pdf

Round 3

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,
Thank you very much for your corrections. I have reviewed the updated version of the article and can confirm that the requested changes have been properly implemented. I am sincerely grateful for your efforts to address the comments comprehensively and constructively. I would also like to remind you that the file you uploaded requires significant editorial correction regarding image resolution, highlights, and web links.

Reviewer 3 Report

Comments and Suggestions for Authors

i have accepted in a current format.