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©1997 Blackwell Science, Inc.

Ecosystem Health, Ecological Iatrogenesis, and Sustainable Human Development

Trevor Hancock

Faculty of Environmental Studies, York University, North York, Ontario, Canada L0J 1C0

INTRODUCTION

“Ecosystem Health: Bridging the Gap” is concernedwith bridging the gap between environmental sci-entists and environmental epidemiologists. BecauseI don’t consider myself to be either—I am a pub-lic health physician with a particular interest in therelationship between health and the natural, built,social, economic, cultural, and organizational envi-ronments—let me redefine this in terms of bridg-ing the potential gap between those interested inecosystem health and those interested in humanhealth.

Accordingly, I will begin with some thoughtsabout what might separate and what might unitepeople with those parallel but somewhat differentinterests, before discussing an integrated, holisticapproach to improving health. I will close withsome thoughts about action at the local level andabout the implications for public health and envi-ronmental epidemiology.

BIOCENTRIC OR ANTHROPOCENTRIC?

What might separate and what might unite us isrooted in the somewhat different values and phi-losophies of those interested on the one hand inecosystem health and on the other in humanhealth. The former are more likely to have a bio-centrist approach, whereas the latter would be ex-pected to have an anthropocentric approach. It isa conflict I am familiar with in my own work, assomeone who is concerned with human healthbut teaches part-time in a Faculty of Environmen-tal Studies. A biocentrist approach, at its most ex-treme, says that biology, ecology, other life forms,and the planet are more important than is hu-

manity. Indeed, some might even go so far as tosuggest that humanity is a plague or a parasitethat has been loosed upon the planet and theother species. These deep ecologists might argue,for example, that the carrying capacity of the

planet is

,

500 million humans and that we there-fore need to have a substantial reduction in popu-lation.

On the other hand, anthropocentrics—andgiven my training in medicine and public health,I tend to anthropocentrism—suggest that weneed to be concerned about humanity, the hu-man species human well-being, and human devel-opment. At its most extreme, this view—which Ido not share—says that humans are superior toall other life forms and have dominion over theearth. An anthropocentric can nonetheless arguethat we need to protect ecosystem health, buthere the motivation is that in doing so we wouldprotect human health, whereas a biocentristmight well argue that we need to protect ecosys-tem health even if it is at the expense of humanhealth. My perspective is that we humans are butone small part of the biosphere and that ulti-mately our health depends on the health of ourecosystems. Protecting ecosystem health is pro-tecting human health in the long-run, even if it hashealth consequences for some in the short-term.

ECOSYSTEM MEDICINE

Another potential difference between those inter-ested in ecosystem health and human health is moreapparent than real, at least I hope so. One of thefactors that appears to have interested some writ-ers in the area of ecosystem health has been theidea of applying the methodology of medicine to

ecosystem health (Costanza

et al.

1992). Thiswould imply developing the capacity to investi-gate, diagnose, and treat ecosystems, a form of ec-osystem medicine. There are at least two potentialflaws in this approach that many of us interestedin human health have come to understand.

Based on a presentation at the special session “Ecosystem Health: Bridging the Gap,” International Society of Environ-mental Epidemiology Conference, Edmonton, Alberta, Can-ada, August 1996.

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The first is that medicine is not a particularlypowerful determinant of human health, at leastnot in comparison with the power of environmen-tal, social, economic, and cultural determinants(Evans

et al.

1994). Modern, western allopathicmedicine is quite useful in some circumstances,particularly in the case of acute infections or trau-matic conditions, but its whole emphasis has beenon dealing with problems after they arise. Very lit-tle attention has been paid to preventing diseasein the first place or to protecting and promotinghealth. (This approach is the public health ap-proach, which has been overwhelmed and ne-glected by the proponents of the medical model.)Thus, adopting the medical model, as opposed tothe public health model, and applying it to eco-systems runs the risk of focusing attention on thenarrow issue of restoring damaged ecosystemswhile paying too little attention to the muchbroader issue of maintaining healthy ecosystemsand the need to address the social, political, andeconomic conditions that result in impaired eco-system health in the first place.

IATROGENESIS

The second danger of applying medicinal meth-odology to ecosystem health comes from iatro-genic (doctor-created) problems. In a landmarkbook some 20 years ago, the cultural critic Ivan Il-lich (1977) described several aspects of iatrogeni-sis that have resulted from the medicalization ofsociety. Iatrogenic disease, in its strict and narrowsense, refers to disease that results from the appli-cation of medical practice to individuals. Here, ia-trogenic disease refers to unwanted or harmfulside effects from investigation or from treatment,in which “physicians or hospitals are the patho-gens, or ‘sickening’ agents” (Illich 1977). For ex-ample, some investigations carry a significant (al-though fortunately low) risk of injury or evendeath: an example would be coronary artery an-giography, used in the diagnosis of coronary ar-tery disease. More common are the unwantedside effects of treatment, including the side ef-fects—sometimes even fatal—that result from theuse of medications, the greater risk of acquiringan infection—particularly a multiple drug-resis-tant infection—in hospital, anesthetic, or surgicalmishaps, and so on. Illich termed all of this clini-cal iatrogenesis.

But Illich’s critique was more profound thansimply the critique of the relatively well-under-

stood phenomenon of clinical iatrogenesis. Hesuggested two other forms of iatrogenesis: socialiatrogenesis and cultural iatrogenesis. Accordingto Illich (1977), social iatrogenesis is the result of“reinforcing a morbid society in which social con-trol of the population by the medical system turnsinto a principal economic activity.” This includesthe dominance of the medical establishment overself-medicalization and mutual care, the monopo-lization of the care of illness, the labeling of thedisabled as unfit, and so on. Social iatrogenesiscan only be reversed by political action that “re-trenches” professional dominance. He identifiedsix “symptoms” of social iatrogenesis:

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dependence on professional care,

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dependence on pharmaceuticals,

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medicalization of the life cycle,

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medicalization of prevention,

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medicalization of major rituals, and

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unbounded multiplication of sick roles.

“Cultural iatrogenesis,” according to Illich(1977), occurs when “the health professionalshave an even deeper, culturally health-denying ef-fect in so far as they destroy the potential of peo-ple to deal with their own human weakness, vul-nerability and uniqueness in a personal andautonomous way.” This renders individuals inca-pable of responding in a healthy manner to suf-fering, impairment, and death. In Illich’s view,those cultural processes relating to key aspects oflife—such as birth, illness and suffering, anddeath—for which coping systems and rituals haveevolved in many different cultures have been ap-propriated by medicine.

ECOLOGICAL IATROGENESIS

But writing as he was in the 1970s, Illich neithersaw nor anticipated what could be the ultimateform of medicalization, namely, the applicationof the medical model to the natural world. Theconcept of ecological medicine as a method of di-agnosing and treating “sick” ecosystems carrieswith it the prospect of “ecological iatrogenesis,”perhaps the most worrisome form of iatrogenesis.It perpetuates the cultural iatrogenesis that hastransformed our relationship with nature fromone of living in awe of, with respect for, andwithin nature to one of dominance over nature,thus rendering us incapable of responding in ahealthy manner to the death or destruction of na-

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ture. It reinforces the social iatrogenesis thatleads us to believe we can “treat” nature throughthe application of professional care and that thisabsolves us as individuals from a personal role incaring for our ecosystem and living responsibly. Italso leads to the danger of clinical iatrogenesis ifour treatment of the environment leads to unan-ticipated adverse effects. Before embracing themedical model as a suitable one to apply to natu-ral ecosystems, we would do well to consider thevery real dangers inherent in the model that arerevealed by the concept of iatrogenesis.

Of course, in describing the biocentrenic/an-thropocentric divide and in emphasizing the dan-gers of the medical model and ecological iatro-genesis, I am perhaps overemphasizing the dangerand overcharacterizing, even caricaturing, the po-sition of the proponents of biocentricism and ec-osystem medicine. I only do so to highlight thedangers and to emphasize what might separateus, with the emphasis on “might.” On the otherhand, I think it is much more likely and certainlymuch more desirable that we can find commonvalues and philosophies that unite us in our con-cern with ecosystem and human health.

COMMON VALUESAND CONCERNS

I suggest that what unites us is or should be a con-cern with both people and the planet, a desire todevelop an integrative, holistic approach to prob-lems and a commitment to action, particularly atthe local level. Clearly, people cannot be healthyif the local and planetary ecosystems of whichthey are a part and upon which they are depen-dent are themselves unhealthy. At the same time,it is hard to deny that most of us have a concernwith seeing the human species thrive, as long as indoing so it does not threaten ecosystem health.However, the dilemma we face is that our im-proved health over the past century or two ismainly attributable to the social and economicdevelopment that have resulted from industrial-ization and which in turn have been based on theexploitation of natural resources, accompaniedby pollution. Further improvement in the healthof people in the developing countries appears todepend on further social and economic develop-ment, but in the long-run that developmentthreatens the very basis of our health—the ecosys-tem. It seems doubtful if human health can besustained over the course of the next century if we

continue on our present development path—butalso doubtful if we don’t!

The roots of the dilemma we face are com-plex and embedded in our social, economic, po-litical, and cultural systems and addressing themwill not be easy; there are no easy or quick an-swers. We need an entirely new path for develop-ment, one that promotes human health anddevelopment through social and economic devel-opment while protecting and indeed enhancingecosystem health. To do this, we will need a so-phisticated, complex, integrative, and holistic ap-proach—an ecological approach—to these issues.We will need to marry the skills, knowledge, andunderstanding of those concerned with thehealth of natural ecosystems with the skills, knowl-edge, and understanding of the human ecolo-gists—of which public health is one branch—if weare to understand and affect those sociocultural,political, and economic human systems.

Finally, I believe there is a great commitmenton the part of many of those interested in bothecosystem health and human health to applyRené Dubos’ dictum - think globally, act locally.Whereas many of the challenges we face are glo-bal in nature, their roots can be found in the val-ues, attitudes, and behaviors of individuals andcommunities as well as in the values and behav-iors of national governments and multinationalcorporations. In the final analysis, if we do notchange the values and expectations of individualsand communities, we will not change the behav-ior of governments and corporations. In the nexttwo sections, I explore my own understanding ofa holistic approach and its application at the locallevel, recognizing that the dilemma remains, butin the belief that addressing and reconciling thatdilemma requires personal and local involvementand action.

ECOLOGICALLY SUSTAINABLE HUMAN DEVELOPMENT

The concept of sustainable development was firstproposed by the International Union for the Con-servation of Nature (1980) and popularized inthe Brundtland Report, the report of the WorldCommission on Environment and Development(1987). The concept refers (or was taken to refer)primarily to ensuring that economic develop-ment—which was deemed to be necessary for thefour-fifths of the planet that live in relative pov-erty—is environmentally sustainable. However,

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only too often the concept has been twisted overtime, particularly by the G7, (the Group of Seven,the world’s largest economies) from sustainabledevelopment to sustained development and fromthere to sustained growth! Along the way, the fo-cus on the environment has been lost, and the em-phasis has become the standard mantra of eco-nomic growth.

Another aspect of the concept of sustainabledevelopment that has emerged since the Brundt-land report has been to understand that it is notjust the physical environment that needs to besustained but the social environment as well: eco-nomic development that undermines familiesand communities is not socially sustainable. Forexample, economic development is socially un-sustainable if it results in high unemployment(the so-called “jobless recovery”); destroys the re-source base of a community (as in the CanadianEast Coast cod fishery), requires people to worklonger hours while their income declines; resultsin family and community disruption, stress, andviolence; or fails to invest adequately in publicbenefits (such as education, child care, or jobtraining) that build community capacity and well-being. In short, economic development is sociallyunsustainable if it reduces human and social capi-tal, just as it is environmentally unsustainable if itreduces ecological capital (see below).

What we require is a form of economic devel-opment that is environmentally and socially sus-tainable. However, this still leaves the emphasison economic development. I prefer the formula-tion that we arrived at as a taskforce of the Cana-dian Public Health Association looking at thehealth implications of the global ecological crisis.We felt that the emphasis needed to be upon thedevelopment of human potential and thus rede-fined sustainable development as follows: “Hu-man development and the achievement of humanpotential requires a form of economic activitythat is environmentally and socially sustainable inthis and future generations” (Canadian PublicHealth Association 1992). In this definition, thereis a clear relationship between human well-beingand the health of the ecosystem and the society,while economic activity is a means for achievinghuman development, but only if it does not un-dermine the environmental and social conditionsthat are the basis for health. One way of under-standing this is shown in Figure 1, which is an at-tempt to explain the relationship between human,social, environmental, and economic spheres, withhuman development being the focus.

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One way to understand these themes is to seethem as forms of capital, which is what the WorldBank is now beginning to do. In a recent publica-tion (World Bank 1995), the Bank has begun toexplore the development of a new measure of na-tional wealth to replace the Gross National Prod-uct, a particularly problematic measure of progress.They have suggested that national wealth be basedon an assessment of four forms of capital, as fol-lows:

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natural capital: the air, water, wildlife, wil-derness, fisheries, forests, farm land, energy, minerals, and other resources that are the stock that constitutes the basis of human wealth;

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human capital: the level of health, educa-tion, innovativeness, creativity, and self-esteem of individuals;

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social capital: the soft infrastructure of family and community life (civicness) and the formal systems of human services that support and create human capital; and

FIGURE 1. The relationship between human, social, en-vironmental, and economic spheres, with human devel-opment being the focus.

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Here, my anthropocentrism is apparent. I have been criti-cized by some of my environmental colleagues, quite rightly form their perspective, in that they believe that ecosystem health should be the overall context within which this hap-pens, not merely one of the spheres. I would suggest that if we see all of these elements as occurring within the planet, then perhaps we are not that far apart, and we might talk about “planetary health”—a topic for another day—as the ultimate determinant, reserving the term “ecosystem health” for more localized ecosystems.

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economic capital: the hard infrastructure of utilities, buildings and roads, factories, and economic investment and activity.

Moreover, their assessment suggests that at aglobal level, only 20% of wealth is represented byeconomic capital, with another 20% represented byecological or natural capital. The remaining 60%consists of both human and social capital, whichthey had trouble distinguishing. Interestinglyenough, their league table of national wealth basedon this new measurement puts Australia at the top(because 70% of its wealth is based on land and re-sources), with Canada (also rich in natural re-sources) in second place. Luxembourg, Switzerland,Japan, and Sweden (3rd–6th place) owe their wealthmainly to human capital, as does the United Stateswhich ranks 12th on this scale (World Bank 1995).

If we begin to accept this model or somethinglike it, then it is clear that our best strategy is tomaximize human, social, ecological, and eco-nomic capital simultaneously. The capitalist sys-tem has been extremely successful when appliednarrowly to economic capital; so what might it doif we applied it simultaneously to the other formsof capital? A holistic, integrative approach to eco-logically and socially sustainable human develop-ment will call for an expansion of the concept ofcapitalism and a commitment to creating human,social, and ecological capital at the same time aswe build economic capital. Failure to do this is topractice a very narrow, self-defeating, and ulti-mately deadly form of capitalism.

THINK GLOBALLY, ACT LOCALLY

“Our Planet, Our Health: Think Globally, Act Lo-cally.” (Theme for World Health Day, 1990)

In my view, it is at the local level where we canmost readily see the development of these inte-grated approaches to building human, social, natu-ral, and economic capital. Indeed, although I tendto be pessimistic when faced with the challengeswe see at the global level, when I look to the com-munity level I am more optimistic or at least hope-ful. In the last few years, there has been a growingemphasis on the community as a locus of action.This is evident in the Healthy Cities/Communitiesmovement, the Sustainable Communities move-ment, and similar initiatives around the world.

The Healthy Cities/Communities movementbegan as a small project of the European Regionof the World Health Organization in 1986. It has

now grown to involve literally thousands of cities,towns, and villages in dozens of countries all overthe world; it was the theme for World Health Dayin 1996. The factors that determine the health ofa city/community and its people are very broadand include the cultural, social, economic, built,and natural environments. The physical environ-ment—both built and natural—is often a focus ofconcern and activity for Healthy City/Communityprojects. Issues that are tackled as part of HealthyCity projects include air, water, soil, and noisepollution; energy and resource consumption; lo-cal biodiversity; and the impacts of the city and onthe city of global change, including global warm-ing. There are numerous examples of cities thatare addressing issues related to health and the en-vironment (Price & Tsouros 1996).

The Sustainable Cities/Communities move-ment has grown in parallel with the Healthy Cit-ies/Communities movement, but here the focusis more clearly on the environment, sustainability,and how cities and city governments can play animportant global role. The International Councilfor Local Environmental Initiatives has played aleading role in mobilizing cities around the worldto address issues of environmental sustainabilityand has ensured that local action is an integralpart of the United Nations Agenda 21. At a morelocal level, the concept of “primary environmen-tal care” combines the concepts of the WorldHealth Organization’s primary health care strat-egy with local action for sustainable developmentand environmental improvement, particularly indeveloping countries (Borrini 1992).

In recent years, there has been a growing in-terest in linking the concepts of healthy and sus-tainable cities and communities as two sides ofthe same coin. The 1995 Madrid Conference isone example of those linkages (Price & Tsouros1996), while similar initiatives have taken place inCanada (Nozick 1992; Ontario Social Develop-ment Council 1994; Hancock 1997). Addressingissues of human and ecosystem health at the com-munity level and engaging citizens and local gov-ernments in this process is, I believe, one of themost significant strategies for attaining sustain-able human development.

IMPLICATIONS FORPUBLIC HEALTH

The long tradition of local action for publichealth makes it imperative that the public health

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sector, including environmental epidemiologists,become actively engaged in creating healthierand more sustainable communities. Therefore, Iwant to conclude with some comments about thepublic health field and the implications for publichealth of the need for sustainable human devel-opment and the creation of sustainable healthycommunities.

(1) First, I think we need a little humility: we need to recognize that the environmental movement has been doing public health’s work for the past 20 years or more in drawing public atten-tion to the health effects of environmental problems and in urging and securing action. By and large, public health professionals have not played a strong leadership role in comparison with the environment movement.

(2) We have to recognize the economic, social, and political forces that lie behind environ-mental pollution and other environmental threats to health and that we cannot address environmental health issues without address-ing social and political issues explicitly.

(3) We need to recognize global change and im-paired ecosystem health and integrity as vital issues that need to be addressed in the name of health.

(4) We need to accept the responsibility to act in the face of uncertainty, recalling that uncer-tainty cuts both ways—things may actually be worse than predicted!

(5) We need to accept the moral responsibility to confront the economic, social, and political forces that harm human and ecosystem health.

As Rudolf Virchow wrote 150 years ago, hav-ing examined the environmental, social, political,and economic factors behind a typhus outbreak inUpper Silesia, “Medicine is a social science, and pol-itics but medicine writ large” (Ackernecht 1981).

Environmental scientists and environmentalepidemiologists must become actively engaged ascitizens within their own communities and in thewider world in addressing the economic, social,political, and ultimately ethical challenge of trans-forming our current inadequate form of capital-

ism and in seeking a resolution of the dilemmaposed by the need for both human and ecosystemhealth. It is a duty we owe to our descendants inour role as what Jonas Salk called “responsible an-cestors.”

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EcosystemHealth

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New Goals for Environmental Management

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