Ecological public health: the 21st century’s big idea? An essay by Tim Lang and Geof RaynerBMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e5466 (Published 21 August 2012) Cite this as: BMJ 2012;345:e5466
All rapid responses
I thank the authors for their excellent overview of the history of public health and its philosophical underpinnings. I agree with the body of the article and its conclusion that multilevel action 'coordinated across not just state but private spheres, commerce and civil society' is required. Community engagement is indicated, requiring the leadership of public health specialists that are 'noisy' and 'dare to confront power.'
However, I take issue with some aspects of the substance of the argument, in particular the label given to the approach advocated, 'ecological public health'.
The four existing models of public health are interestingly summarised, with their discrete descriptions allowing the authors to list problems neatly. While the separation of the models from one another is artificial, the problems listed are real. In particular, I noted the cost and reactive nature of the biomedical model and the underplaying of economic factors in the social-behavioural model.
Speaking as a non-specialist in public health, it strikes me these are problems not solved by the creation of a new model, but instead by the thoughtful application of the existing models in an integrated way, by practitioners that are 'noisy' or even downright blusterous. The examples given of problems the ecological model can deal with could already be dealt with by the existing models – antimicrobial resistance by the biomedical model, industrial pollution and toxicity by the sanitary-environmental. The model's nebulous conception of ill health as a 'mismatch of bodies and environment' and its key method of 'systems analysis in order to manage social transitions and create healthy habitats' seem to be examples of the essentially vapid 'managerial language' decried in the article.
Returning to my original thoughts, I do believe there is much of great value in this article – the edifying descriptions of past and present approaches, the lampooning of top-down approaches that fail to take account of populations not only as individuals but also as societies with cultural idiosyncracies, as well as the lampooning of approaches that pander to vested interests or attempt to compete with commerce on their own terms, the cry for integration of all the existing models of public health, and in particular, the call to all public health practitioners (I would add all medical professionals – doctors, nurses, etc) to be 'noisy', to have imagination, to be willing to 'address complexity' and 'dare to confront power'.
What I object to is labelling this approach as 'ecological.' The word is sexy but unjustified.
Competing interests: No competing interests
While I welcome the authors exploring models of public health, I was concerned that there seemed to be an inherent confrontational attitude to business and dismissal of the importance of working in partnership and an integrated way with business and industry to effect change.
The 2012 Olympics has brought private-public partnership to the fore. The corporate sponsors were essential to deliver what has been globally acknowledged as one of the most impressive and engaging Games to date, and certainly one of the most inspiring and important for disabled people. Public health was influential in some of the partnerships that developed and although there were compromises, and some may say too many, there were huge steps forward in establishing guidelines for sustainability, ethical frameworks for sponsorship and legal frameworks for partnership with industry.
The NHS has historical had an ideological block to ‘getting its hands dirty’ by working with the private sector. Many doctors and public health specialists view it as a position of last resort, however this does a huge disservice to the evolution of the corporate social responsibility agenda over the last thirty years.
Having done additional training in corporate social responsibility governance and accreditation processes, and having worked with a range of private sector companies over the last few years on public health projects I suggest that there is a middle path that can reap rewards without significant compromise.
Corporate Social Responsibility can be viewed as business working to:
- Improve the community and environment that they, and their supply chains, affect
- Improve the wellbeing of their own staff
- Improve the impact of their product itself through re-formulation, etc.
Business does, in general, care about its role in society. If only for the very simple PR risk associated with being publically ‘outed’ for polluting, damaging or discriminating. But most go further and recognise the value of being an organisation that is engaged with the local community and seen to be part of a positive society. Working with the private sector can bring huge collateral benefits, and using a model of partnership is significantly more powerful than simply asking for a cheque.
Working in partnership with business is not a skill that comes easily to doctors or the NHS and not one that is currently valued. Partnership takes time, preparing for meetings involves lots of ground work, for a first meeting the lead clinician should have read several years of annual reports, CSR documents as well as searching blog sites in addition to the corporate ones to understand the levers and risks of the company. There are often many meetings before the final paperwork gets signed and understanding the motivators for both sides is key.
Public Health is well positioned for this role, and I would urge colleagues to reach out to industry and build these relationships moving forward.
Competing interests: Currently working in partnership with Sanofi Pasteur MSD on an immunisation partnership project for London 2012 Legacy
We congratulate the authors on their essay and the accompanying podcast (http://www.bmj.com/podcast/2012/08/24/ecological-public-health, accessed 28 August 2012), which we feel provides direction for the future design of public health programs to address complex health issues for which the majority of determinants lie outside the health sector. As the authors point out this is not a new concept but one that may have become more applicable as we experience a seemingly escalating series of societal changes. Indeed, their suggestion may now have to compete for primacy against other frameworks with ecological leanings that have been coined to conceptualise the new world facing public health.
The first of these frameworks is perhaps the suggestion that “Ecosystem Health” should be included in the curriculum for veterinary medicine programs (VanLeeuwen et al., 1998), which then lead to the more formal Ecohealth movement that focuses on the interface between ecology and health with a view to supporting sustainable health (http://ecohealth.net/association.php, accessed 29 August 2012). Finally we have the broader concept of Health-in-all-Policies (HiaP) that appears to cover all bases and “One Health”, which currently has a focus on diseases that occur at the human-animal-environment interface with zoonotic diseases as a core focus (https://www.avma.org/KB/Resources/Reference/Pages/One-Health94.aspx, accessed 29 August 2012). The less than expected benefits from HiaP (Greaves and Bialystok, 2011) is interesting given that it would seem logical that HiaP should solve most public health issues by virtue of the requirement to formally address health impacts (positive and negative) as part of the design process for all policies.
Perhaps the key difference between the description of “ecological public health” and other frameworks is that it advocates for a focus on public health as the core element. One could also interpret ecological public health as the application of “holistic” principles to public health, which then implies the incorporation of systems thinking and an acceptance of complexity. Holistic thinking is already used by many healthcare practitioners without conscious thought, at least in Sweden (Strandberg et al., 2007).
Trying to define frameworks leads to lengthy and unproductive debates based on semantics. We would argue that complex systems in public health must be conceptualised at the highest level that provides opportunities for successful control, similar to the traditional epidemiological unit. This is important because public health research and interventions must be designed to function within these systems and information from the wrong level could lead to poorly designed programs based on erroneous assumptions. Furthermore, attempting to understand complex systems in their entirety or delaying action until better information become available may not improve the overall outcomes of a program. All systems have a set of critical components or control points that can be used to influence their outcomes. This method of dealing with risk is incorporated into the Hazard Analysis and Critical Control Points (HACCP) approach that is used to mitigate risk in complex food production systems.
The authors argue for the highlight the need for greater involvement of economists in public health (in the associated podcast). We agree and believe that it is not just more economics but rather the development of transdisciplinary economic analyses that provides holistic estimates of costs and benefits across ALL sectors, i.e. agriculture, health, commerce etc. Our own current and future work incorporates economics as a core component of each activity (Choudhury et al., 2012; Racloz et al., 2012a; Racloz et al., 2012b). The same principle applies for all information generating activities. Thus, the key questions become: 1) what information does an institution require to enable informed and rational policy development and implementation and 2) what information does the community require and in what form to enable a change in knowledge, attitudes and practices that lead to improved health. These questions need to be addressed across the “sectors” of each problem, i.e.: environmental, human and animal health, economic health, social health and institutional health.
In conclusion, we support the sentiments described by the authors in their essay and believe that this may provide an efficient framework for dealing with the future public health impact of complex emerging issues such as urbanisation and climate change where social and cultural change is likely to drive health outcomes.
Choudhury, A., Zinsstag, J., Racloz, V., Whittaker, M. 2012. The societal impact of bivine tuberculosis in select Asian countries. In GRF One Health Summit 2012: One Health-One Planet-One Future, Risks and Opportunities (Davos, Switzerland).
Greaves, L.J.P.D.U., Bialystok, L.R.P., 2011. Health in All Policies - All Talk and Little Action? Canadian Journal of Public Health 102, 407-409.
Racloz, V., Choudhury, A., Whittaker, M. 2012a. A strategy for addressing piublic health and zoonotic issues using a One Health approach. In GRF One Health Summit 2012: One Health-One Planet-One Future, Risks and Opportunities (Davos, Switzerland).
Racloz, V., Faddy, H., Choudhury, A., Whittaker, M. 2012b. A One Health approach to disasters. In GRF One Health Summit 2012: One Health-One Planet-One Future, Risks and Opportunities (Davos, Switzerland).
Strandberg, E.L., Ovhed, I., Borgquist, L., Wilhelmsson, S., 2007. The perceived meaning of a (w)holistic view among general practitioners and district nurses in Swedish primary care: a qualitative study. BMC Fam Pract 8, 8.
VanLeeuwen, J.A., Nielsen, N.O., Waltner-Toews, D., 1998. Ecosystem health: an essential field for veterinary medicine. J Am Vet Med Assoc 212, 53-57.
Competing interests: No competing interests