Intended for healthcare professionals

Rapid response to:

Feature Medicalisation

A new deal on disease definition

BMJ 2011; 342 doi: (Published 03 May 2011) Cite this as: BMJ 2011;342:d2548

Rapid Response:

Disease definition: The socio-environmental context

Ray Moynihan's article on disease definition (BMJ2011;342:d2809)
refers to the social and environmental determinants of health and
disease1, suggesting that the membership of newly renovated panels that
define diseases might be broadened to take a more holistic approach: a
clinical and social approach. This is mentioned somewhat tentatively in
the context of government policy, which it is suggested is dominated by
clinical medicine. However, such an holistic strategy is essential.

The reason an holistic approach makes sense is that whilst the
medical model of health is extremely important, we must remember that we
are essentially social animals living in very large numbers in an
increasingly technological world. We are good at coping with
technological change, which is what makes us so successful (depending, of
course, on how one interprets 'success'). Such success brings challenges:
living in very large groups (towns and cities); impacts on the environment
(climate change, pollution, urbanisation etc); a strong draw to novelty
(which, in turn, helps us be inventive); materialistic desires,
consumption and competition (from 'keeping up with the Joneses' to
fighting over natural resources).

By way of an overview leading up to our current circumstances, humans
branched off from the common ancestor around 5-7 million years ago and
human culture began to change rapidly from around 50,000 years ago. For
most of the last 500,000 years we were no more than a few hundred million
in number. We are now about 7 billion in number and have been subject to
the 'stresses and strains' of major technological advances and massive
population growth for 'only' around 200-300 years of our evolution. It is
surely not surprising then that we are obliged to take a clinical and
social approach to health.

Moynihan and colleagues (he mentions Fran Baum, public health
professor at Flinders University, Australia) are right that there is a
role for a wider membership of panels and this includes environmentalists.
There are environmental experts working across a range of sectors and who
bridge science and social science in pursuit of sustainable development.
Environmentalists who are trained and competent across the scientific,
economic and socio-political disciplines are in a strong position to work
with medical experts, and especially those who subscribe to a non-
medically dominated view of health.

Environmentalists could contribute to a panel by reminding people
that humans for most of our history have lived in a more natural
environment. We have gradually become detached socially, emotionally and
physically from nature and small community groups, which is not good for
our health and well-being. The significance of inequalities is, of
course, a central plank of the Marmot Review2, and the creation of healthy
and sustainable places and communities. In 'Making Space for Nature: A
Review of England's Wildlife Sites and Ecological Network', Lawton et al3
drawn on evidence of the benefits, in terms of attention levels, in
children with attention deficit disorder resulting from access to natural
spaces. Putting aside for the moment some of the other key messages Ray
Moynihan highlights (for example, potential conflicts of interest), the
socio-environmental setting should be a major consideration in the
definition of disease to ensure we don't over-medicalise.

The Marmot Review and the Lawton Report are both key documents
bridging the public health and environmental agendas. In other words,
health and environmental professionals have a lot to offer each other and
society in general to promote and protect the public's health.
Environmentalists and public health professionals must work together to
radically influence government policy, disease definition and strategic

1. WHO, Reports of the WHO Commission on the Social Determinants of

2. Marmot, M., Allen, J., Goldblatt, P., Boyce, T., McNeish, D., Grady,
M., Geddes, I. Fair Society, Healthy Lives: The Marmot Review of Health
Inequalities. An Anatomy of Economic Inequality in the UK, Report of the
National Equality Panel, 2010, Government Equalities Office.

3. Lawton, J.H., Brotherton, P.N.M., Brown, V.K., Elphick, C., Fitter,
A.H., Forshaw, J., Haddow, R.W., Hilborne, S., Leafe, R.N., Mace, G.M.,
Southgate, M.P., Sutherland, W.J., Tew, T.E., Varley, J., & Wynne,
G.R. (2010) Making Space for Nature: a review of England's wildlife sites
and ecological network. Report to Defra.

Competing interests: No competing interests

29 July 2011
Richard Campen BSc PhD MBA PGDip EDM
Peak District, Derbyshire