Rediscovering the environment in public health

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shutterstock_33057802Professor George Morris works across the UK and internationally as a consultant and adviser on the environment and human health. Here, he explains how the natural environment is linked to our overall health and well-being.

Evidence going back 4,000 years and more suggests that humans have long appreciated the importance of the environment for their health and well-being, and when, in the 4th century BC, the ancient Greeks began to write down ideas about health and its determinants, the role of environmental factors was prominent.

Whilst early Greek thinking is not a template for how we think about these issues today, some concepts, such as an environment comprising of different compartments (air, water soil etc.); the importance of climate for health; and the potential for human activity to impact negatively on the natural environment, have contemporary resonance.

From the modern public health movement to individualisation

However, the modern public health movement can more accurately be traced back to the 19th century and society’s response to the disease and urban squalor of the industrial revolution. The measures which brought piped water supplies and water-rinsed sewerage impacted positively on health. Yet, just as importantly, they affirmed a role for the state in securing population health and created an environmental framing of the whole public health project which would endure, largely unchallenged, for over 50 years. Even the validation of the germ theory from 1890, and the growth of bacteriology as a science, did nothing to undermine the perceived importance of the environment, both physical and social, in people’s health.

A capacity to examine microbial causes of disease unquestionably fuelled scientific and medical advance in the late 19th and the 20th centuries, informing effective preventive and therapeutic measures. Yet, the related emphasis on the immediate causes and mechanisms of disease in individuals had an unexpected consequence. Over time, health and disease came to be viewed less as community or population attributes and more as characteristics of individuals, causing public health to lose much of its influence.

Lifestyle rather than environmental?

By the mid-20th century rapidly reducing levels of infectious disease shifted attention to emerging epidemics of non-communicable disease. However, the cancers, heart disease and peptic ulcers which became the focus of medical attention in the post- World War II era were not normally seen as involving environmental issues. Rather, in keeping with the individualisation of health status, they were blamed mainly on lifestyle choice. The behaviours understood to carry risk were often targeted directly and often without reference to social or environmental context. For a time at least, the environmental dimension within public health appeared rather marginalised and was addressed very narrowly and in hazard-focused terms.

The environment/health link resurgence

However, in the closing decades of the century, interest in the environment as a determinant of health was undergoing a resurgence. Epidemiological studies of the smog episodes of the 1950s and, from the late 1980s, traffic related pollution emphasised the dangers of chemical pollution in the air of towns and cities to human health.

Growing evidence of a psychosocial dimension to the relationship between the places people live and their health and well-being, related issues of stress biology and interest in the health promoting potential of environment each helped to drive the environment back up the public health agenda. But perhaps the strongest case for a reinstatement of the environment as a mainstream public health issue came with the realisation that environment can act, often quite subtle ways as part of a cocktail of individual and societal level influences to engender obesity, diminished mental health and well-being and, critically, inequalities.

Navigating such complexity to identify and deliver effective public health policy, remains uniquely challenging and is work in progress, but a more sophisticated understanding of how to manipulate environments for health seems key to success.

If the epidemiological transition changed the context for public health in the 20th century, today’s dominant transition is surely ecological. Damage to the global systems and processes on which we rely for health well-being and survival is now occurring on an unprecedented scale. As a consequence, society can no longer hope to deliver health, well-being, heath care or anything approaching equity in these things in the medium to long-term without a radical rethink of its attitude to the environment.

Health and well-being built on ecological principles

Health and well-being, must be built on ecological principles. Rayner and Lang (2012) have pointed to a need to recognise the dynamic tensions and interactions between ecosystem health and human health. The term “ecological public health” is increasingly coined to capture the “difficult and complex task that is now the 21st century’s unavoidable task”. There are many implications to making the concept of ecological public health operational. These include how we approach evidence, the ethical principles we adopt, matters of infrastructure and governance but not least how we frame the complex challenges we face in a policy-relevant way. However it is achieved, the task for society is to rediscover an environmental framing of public health, but this time with the wider picture and longer-term in mind.

Reference:

Rayner, Geof, and Lang, Tim. Ecological Public Health: Reshaping the Conditions for Good Health. Routledge 2012.

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