- Email: [email protected]
Linking health and ecology in the medical curriculum
Environment International 29 (2003) 353 – 358 www.elsevier.com/locate/envint
Linking health and ecology in the medical curriculum David J. Rapport a,b,*, John Howard b, Robert Lannigan b, William McCauley b a
College Faculty of Environmental Design and Rural Development, University of Guelph, Guelph, Ontario, Canada N1G 2W1 b Faculty of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
Abstract Human health vulnerabilities to ecosystem degradation are well documented. Destabilization of natural ecosystems and the biosphere have posed an entirely new set of risks to human health and preclude any simple extrapolations from the past. Newly emerging diseases, increasing prevalence of many vector borne diseases, increased exposure to harmful UV radiation and a number of other transformations in the natural environment, have decidedly negative implications for the sustainability of human health. Curricula in medical schools are responding to these new realities by exposing the connections between health and ecology. The program in Ecosystem Health at the University of Western Ontario serves as one model for connecting these disciplines. This program has resulted in a perceptible shift in values and professional responsibilities of emerging physicians. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Air quality; Ecology; Education; Health; Medicine; Pollution
1. Introduction It is well known that air pollution has direct impacts on human health—exposures to contaminants and small particles in both indoor and outdoor air impairs respiratory functions; exposures to carcinogens can induce cancers in humans and other animals. Less appreciated, and more pervasive, are the indirect impacts. Air pollution, among a variety of other stresses that destabilize the dynamic ecological balance of natural systems, increases human health vulnerabilities through the destabilization of ecological functions. In recognition of the link between environmental degradation and human health, several medical schools (including veterinary medicine) and schools of public health (e.g., Harvard, Johns Hopkins, The University of Hawaii, Tufts and the University of Guelph) have introduced aspects of ecology in their medical or public health curricula. The University of Western Ontario has taken the further step of making ecosystem health a core element of its undergraduate medical curriculum. The topic is not only featured in a fourth year case-based elective on ‘ecosystem * Corresponding author. Faculty of Environmental Design and Rural Development, University of Guelph, Room 107, Johnston Hall, Guelph, ON, Canada N1G 2W1. Tel.:+1-519-824-4120x8476; fax:+1-519-7671692. E-mail address: [email protected] (D.J. Rapport).
health’, but is also featured prominently in the first year ‘introduction to medicine’ orientation section, and in a number of case studies that form the core curriculum throughout the 4 years of medicine. How this has come to pass is a story of the growing awareness of the critical importance of ecosystem functions for human health (McMichael, 2001). This includes an awareness of the opportunity the concept of ecosystem health affords to medical practitioners to become more effective in their practice (Rapport et al., 2002). What is meant by the term ‘ecosystem health’? At the most basic level, ecosystem health is the capacity for ecosystems to be self-sustaining and to carry out all of their normal functions. Among other things, healthy ecosystems are capable of converting energy into biomass, recycling nutrients, regulating water transport and cycling, sequestering contaminants, moderating climate, and providing habitat for diverse biota. In the normal course of things, there are many perturbations (e.g., storms, fires, heavy snowfalls, drought) that disrupt, at least temporarily, the functions of ecosystems. In healthy systems, such challenges exert a positive influence as they enable the ecosystem to adapt to changing environments (Holling, 1986). However, in disturbed or pathological ecosystems, such challenges may prove to be ‘the straw that broke the camel’s back’. Ecosystem ‘health’ is characterized not by the absence of pathology (negative elements), but in terms of the properties that underpin the capacity of ecosystems to persist. Key
0160-4120/02/$ - see front matter D 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0160-4120(02)00169-1
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D.J. Rapport et al. / Environment International 29 (2003) 353–358
parameters involve maintenance of resilience, organization, and vitality (productivity). These key parameters characterize the well functioning of natural systems (Rapport, 1989; Mageau et al., 1995). Humans are very much a part of that evolution. Today, humans dominate many of the earth’s ecosystems: they extract a disproportionate amount of energy, occupy or have severely modified more than 50% of the land surface, have greatly altered hydrological and nutrient cycles, and indeed the composition of the atmosphere-resulting in the ‘greenhouse’ effect. However, humans still remain completely dependent on the healthy functioning of the earth’s ecosystems and the biosphere for their very survival. The current rapid depletion of the world’s forests, species diversity, marine fisheries, and fertility of agricultural lands, is an ominous sign that the so-called ‘lifesupport’ systems are crumbling. The human health implications, direct and indirect, are profound. Many diseases, as the studies discussed below well illustrate, have their origins in adverse changes in the environment. This has encouraged increased awareness, within the practice of both medicine and public health, of the need to go beyond identifying and treating disease. There is a growing recognition of the need to look ‘upstream’ within the ecosystem and deal with human health vulnerabilities arising from the pressures humans bring to bear on the earth’s ecosystems. Our experience at The University of Western Ontario, where ecosystem health now forms a core part of the undergraduate medical curriculum, is that students are quick to grasp the significance of ecosystem health for human health. They recognize that while it is essential to deal with human health issues that arise, necessitating efficient diagnosis and treatment, it is also essential (and a new part of their ‘mandate’) to become proactive within their communities in order to reduce human health vulnerabilities owing to ecosystem degradation.
2. Case studies illustrating the relevance of ecology to human health Most people equate health with lack of disease, ignoring the more recent expanded definitions of health. Fascination with disease is a major force in medical students and others. To capture interest in ecosystem health, it is important to find specific disease states that can be linked, no matter how tenuously, to ecological disturbances or degradations. Many students are surprised to find that ecosystem health has its roots in Hippocratic medicine, as evidenced by this quotation from: Properties, Waters, Places attributed to Hippocrates: When a physician comes to a district previously unknown to him, he should consider both its situation and its aspects to the winds. The effect of any town upon the health of its population varies according as it faces
North or South, East or West. This is of the greatest importance. Similarly, the nature of the water supply must be considered—then think of the soil—Lastly, consider the life of the inhabitants themselves; are they heavy drinkers and eaters and consequently unable to stand fatigue or, being fond of work and exercise, eat wisely but drink sparingly? (Adams, 1985). Starting with a case-based scenario, it is possible to provide the students with a limited context that is easy to grasp and often within the realm of their experience. From this, connections can be explored leading to a broadening of the context to the level of the ecosystems in which we live. Although the focus is highly anthropocentric, the exploration of linkages allows discussion of other species within the system and leads to a better understanding of the importance of a ‘healthy’ ecosystem in maintaining human health. Such exploration also reinforces the concept that humans are not ‘above’ or ‘outside’ their ecosystems and are highly dependent upon them for healthy living. Each case is presented in two sessions, with sufficient time in between for students to explore issues raised in the first session. The second session is used to discuss findings, consider solutions, and identify the consequences of the proposed solutions. The consequences are important in that they further consolidate the concept of the interconnected nature of an ecosystem. 2.1. Example—Urban heat islands Most students are aware of reports of ‘heat waves’ leading to heat stress conditions in urban dwellers. The students can be placed as an emergency room physician dealing with an elderly urban dweller who is confused, dehydrated, and has an elevated temperature. The ‘heat wave’ has now been going on for 18 days. Medical students at first concentrate on the differential diagnosis, and the pathophysiology and treatment of heat stroke. However, it is relatively easy to turn the discussion to urban housing construction and design (much of which is substandard), the need for climate control of such dwellings, how that energy for climate control is generated, and the effects such power generation may have on changing the earth’s climate. If the notion that extreme weather events, such as heat waves, are part of the result of global warming, it brings the focus back to the original scenario. Many other aspects of urban ecology and its consequences can be pursued. 2.2. Example—Asthma The disease of asthma is also fruitful ground to explore. The increasing incidence of this disease in some geographic areas as opposed to others, and its possible associations with ecosystem disruptions, is a good beginning. Starting with a visit to the physician’s office of a mother concerned with the wheezing she noticed in her 1-year-old child, many areas
D.J. Rapport et al. / Environment International 29 (2003) 353–358
can be explored. What is causing the increasing numbers of children to develop asthma in some locales? How does our ‘developed’ lifestyle contribute to asthma, if at all? Air quality and its importance in triggering increasing numbers of asthma attacks in those suffering from the disease is a sound place to start. The shortcomings of epidemiology and the scientific method for analyzing such complex situations can also be brought in, as well as the topic of uncertainty. In exploring solutions, the effects on ground level ozone production by decreasing the use of automobiles in urban areas and the value of mass transportation systems is fertile ground for discussion. Lively discussions often revolve around the reasons why the economics of automobile production hinder the development of less polluting vehicles, and also around the sociology of direct personal ownership of motor vehicle as a status symbol and how this is maintained in our modern societies.
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the students are usually able to make intuitive disease links but many ‘surprising’ links arise as well. By using a variety of cases, it is possible, over the duration of the sessions, to have the students examine many of the determinants of ecosystem health and how these impact human health. Given the limited time available, the depths to which many of these issues are pursued is often quite superficial, but we have found the most important function is to encourage students to ‘think outside of the box’, as opportunities to do this are infrequent in traditional curricular material. While students are sometimes overwhelmed by the problems, they usually indicate they have gained a greater appreciation of the complexity and interconnectedness of human health and ecosystem health that they would not otherwise have learned.
3. Responsible professionalism 2.3. Example—Vector-borne diseases While vector borne diseases are obviously important and excellent examples of ecological changes associated with human disease burdens, we do not concentrate on these as a separate topic but use them, where appropriate, in other cases. Food- and water-borne diseases provide many examples. Recently, we experienced an outbreak of Escherichia coli O157:H7 in a local community and used it to good effect in teaching ecosystem health. Following the changing epidemiology of E. coli 0157:H7, as an agent of human disease, allows for a wide range of discussion. The occurrence of the organism in ground beef is a good starting point. Then, a discussion of its presence in vegetable and food crops, as a result of manure use for fertilizer, and its presence in potable water, as a result of ‘runoff’ from fields, makes for a discussion of many links between human food production methods and ecosystem degradation. Links from human food consumption to diseases related to the complications of atherosclerosis, the role of nutrition in the development of atherosclerosis, plus the politics, economics, and other aspects of food production, also promotes the interconnectedness and complexity of ecosystem health issues. We have also used natural disasters and the environmental refugees ensuing from them to highlight links between human health and ecosystem health. In our case, we use hurricane Mitch. The students determine the types of diseases that might occur in emergency camps for humans displaced by the hurricane. The students are first provided with an overview of the geography and the socio-politicaleconomic conditions in Honduras. From this, they develop a list of human health problems in the initial short term and longer term that they might expect to occur. The second session is hosted by a physician who went to Honduras as part of the relief team in the aftermath of hurricane Mitch, and has been there on several subsequent visits. In this case,
Degradation of ecosystems plays an increasing role in human disease and illness. Descriptions of ecosystem tragedies that have occurred or are occurring have received much time and attention. The same or greater efforts are required to develop programs to influence human behaviour to prevent these same types of tragedies. A key component of this effort is to ensure that each profession has the skills and attitudes necessary to contribute to the development of sustainable systems. All professions must be responsible for ensuring that their skills and actions result in sustainable systems. This concept of ‘responsible professionalism’ is put forward to describe the attitude that professions must embrace to ensure the restoration, rather than degradation, of the world in which we live. A critical step in changing people’s thoughts, and eventually their actions, is to define a paradigm in which people can see where they are and where they can potentially be. In our Faculty of Medicine and Dentistry at the University of Western Ontario, an ecosystem health paradigm of medical education has been an important step in the evolution of our medical curriculum. Although defined for medical schools, this paradigm has potential applications to other professional schools as well. The essence of this paradigm is widening the concept of ‘patient’ to include all systems in the environment, including, importantly, the ecosystem. Altering the concept of ‘disease’ to one of ‘problem’ and adopting a more general concept of ‘illness’ as the manifestation of the problem within the system allows this paradigm to apply to many different professions. Nearly all physicians have been trained in the traditional medical paradigm. In the traditional medical model, there is a disease within a patient. The task of the physician is to answer two basic questions: ‘What is the disease?’ and ‘How do I treat it?’ To fulfill their role, physicians learn everything there is to know about a patient—anatomy, physiology, biochemistry. Then they learn everything they need to know about diseases and how to treat them—
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pathology, medicine, surgery, pharmacology. They are then equipped to act as physicians in their traditional role. A new paradigm for medical care was defined in the early 1990s in the Family Medicine Department of the University of Western Ontario. Called the Patient-Centered Model (Stewart et al., 1995), this model embraces the traditional exemplar but adds to it. The critical concept of patient-centered is the ‘illness’—the unique experience of the disease by an individual patient. It recognizes that the experience and the needs are different in every patient with the same disease. Whereas the disease is generic to many patients, the illness is unique to each patient. The illness is critically dependent on the context in which the patient lives—the patient’s family, community and country, and the patient’s economic, social, and spiritual situation. This paradigm adds two more basic questions: ‘What are the unique needs of my patient?’ and ‘How can I meet those needs?’ In this paradigm, not only are the basic courses described in the traditional medical paradigm necessary, but learning centered around communication skills, holistic care, and in-depth learning about the patient’s context becomes critical in their training. In the late 1990s, an Ecosystem Health model was introduced to the faculty. This paradigm embraces all the principles of the first two paradigms described above but emphasizes the fact that human health is critically dependent on the environment of the patient—not only the physical environment but also the social, political, and economic environment. It expands the concept of the context into different spheres of interest—the immediate environment, the community environment, the regional environment, the national environment, and the world environment. It adds two more questions—perhaps the most important questions when it comes to human health. These are: ‘Why is this illness occurring—what has happened to cause the patient to come today with this disease?’ and ‘What can I do as a physician to help prevent this from happening again?’ Adopting this paradigm provides the necessity for physicians to look beyond the traditional medical disciplines, to learn about ecology, economics, social policy, and law. Physicians must understand the effects of the physical, environmental, political, and social environment on human health. Getting people to accept an evolving paradigm makes them more accepting of a global approach to human health. The Ecosystem Health paradigm has a number of advantages: it is inclusive of all physicians; it does not criticize more traditional thinking physicians but rather challenges them to reconsider their role as physicians; the paradigm is simple to understand and can be communicated in a short time. Our experience with this inclusive yet simple paradigm, which clearly shows alternative priorities, has proven to be effective in influencing a group whose ideas have traditionally been difficult to change. As stated above, the ecosystem health paradigm can apply to all professions. Changing the concept of ‘patient’ to ‘system’, changing the concept of ‘disease’ to ‘problem’,
and retaining the concept of ‘illness’ as the manifestation of the disease in the system, the Ecosystem Health paradigm can be applied to all professions. More importantly, the questions asked of the professional remain the same. In particular, the two questions applying to Ecosystem Health are equally valid in all professions, when presented with a problem. ‘Why is this illness occurring’ and ‘what can I do as a physician/lawyer/engineer/teacher/politician/or other to help prevent this from happening again’? If all professions considered the same model, the opportunities for collaboration would be endless.
4. Societal expectations: can medicine evolve to meet them? This broader look at physician –patient interactions to incorporate larger contextual issues is in keeping with societal expectations of physicians. In the province of Ontario, the Educating Future Physicians for Ontario (EFPO) project was initiated in the early 1990s (Neufeld et al., 1993). Part of the EFPO project involved an in-depth analysis of the public’s expectations of physician performance. Various sectors of Ontario society were approached, including multicultural groups, disabled and elderly people, and women’s groups. Information was obtained through focus groups, key informant interviews, and surveys. To complement the views of the public, a representative sample of health care professionals, other than physicians, were asked about their observations of the roles of physicians. From both the public and the health-care professionals came the strong message that there were major shortcomings in the performance of physicians as communicators, humanists, and patient educators. The people expected to be treated as human beings, not just ‘cases’, and to have more time when they are with their physicians for pressing questions and clear explanations. In addition, participants in the study made useful suggestions to Ontario’s medical educators about what might be done to improve matters (Neufeld, 1998). The society spoke out in favor of wanting their doctors to be more than healers. They identified several socially responsible roles for physicians to fulfill in their mandates. One of the roles identified by both the EFPO project and the Royal College of Physicians and Surgeons of Canada’s parallel project ‘CanMEDS 2000’ was that of the professional. Society wants their primary care physicians and their specialists to act as professionals. The concept of professionalism, however, has broad and diverse interpretations (Sullivan, 2000; Wynia et al., 1999). Sullivan suggests one concept is that professionalism for physicians embodies an ideology of social reform. The physician must put the patients’ welfare above all other considerations and it is the physician’s responsibility as a professional to safeguard and promote this trust in society at large (Wallace, 1997). From this, the concept of responsible professionalism is
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born. If physicians must put the welfare of the patient above all other considerations, we must reflect back on the patientcentered method. Each patient is different, and lives within a context. If a physician is going to put a patient’s welfare above all other considerations, then the context in which that patient exists must also be considered by the physician. This includes the sociopolitical, environmental, cultural, and economic spheres considered in the exploded contextual model of ecosystem health. By being responsible to the patient, a physician must, as a professional, be responsible to these many aspects of human health.
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role in social responsibility or ecosystem health; rather, they must be viewed by students and faculty alike as being an inherent part of medical training. Medical students have traditionally been taught to focus on the disease. Recently, the patient’s illness experience has become an inherent part of many undergraduate curricula. Medical education’s next challenge is to look at the big picture through a transdisciplinary lens. Students must learn to consider larger societal and contextual issues when dealing with an individual patient’s problems, and not just when studying a course entitled ‘Medicine and Society’. This concept will take strong leadership and the will of educators to embrace, as crucial, these ideas and the physicians’ roles in them.
5. Adding a trans-disciplinary focus Traditional medical curricula, as described above, have concentrated only on the patients disease, or perhaps their illness experience. The consideration of broader issues outside of the person, such as the impact of environmental issues on the development of human disease and illness, is truly unusual (Cruess et al., 1999; Wear and Castellani, 2000). By ‘thinking outside the box’ of conventional medical education, medical schools have the opportunity to create physicians who are not only considerate of their patients’ unique illness experience but are considerate of and for all aspects of human health. This is true whether they are issues of politics, economics, culture, or the environment. Stressing this social responsibility has not traditionally been considered important in most undergraduate medical curricula. To be successful in these pursuits, physicians will have to work with professionals from other disciplines, drawing expertise from them in the pursuit of a goal. This concept of interdisciplinary cooperation, although well entrenched in many medical disciplines, is relatively new to most physicians. Typically, physicians have worked individually, considering themselves experts in many areas and relying on paramedical professions to act as their ‘helpers’. Rehabilitation medicine, however, is one field that relies heavily on the interdisciplinary approach. Each discipline’s representative has their own role (i.e., occupational therapy, social worker, psychologist, physician) but also recognizes that they have valuable input for the other team members in working together towards a common goal. This is the model of cooperation that must exist for physicians to be involved in these larger contextual issues. Physicians must learn (be educated) to work alongside politicians, ecologists, and lawyers in order to tackle the problems inherent in the world that contribute to the development of human disease or that are impacted upon by the treatment of human disease. In order to foster the development of physicians with a genuine interest in responsible professionalism, we must look to the breeding grounds for physicians. Educational leaders in medical schools must be willing to incorporate, seamlessly, into their curricula issues of social responsibility. These cannot be add-on or stand-alone courses on the physician’s
6. Summary While some may debate the validity of the concept of ‘ecosystem health’, the usual objections is that ‘health’ is only a property of ‘organisms’ not ecosystems, or that ‘health’ is a value judgment that is not amenable to objective analysis. These arguments fail to recognize that ecosystems, while not organisms or supra-organisms, do have complex organization that can be disrupted by stress (or outside pressures). This is known due to the commonplace knowledge of pathology in lakes, forests, grasslands, coastal ecosystems, and others, in which fundamental properties of productivity, resilience, and organization are impaired. These arguments also fail to recognize that while ‘health’ may be a ‘value’, it is a value whether we speak of human or animal health, or ecosystem health. Thus, if the concept has validity in one realm, it must also have validity in the other. In any event, those familiar with real ecosystem health issues (e.g., dry land salinity in Australia) know that, philosophy aside, communities face the reality of faltering ecosystem functions and the reality of declines in their personal well being as a result of economic and social decline and increased health burdens. Ecosystem degradation is widespread as a result of cumulative impacts of human activity. These changes place human health at increasing risk. Increased exposure to toxic substances, the spread of vector borne diseases, increasing scarcity of potable water, overexploitation of marine fisheries are but a few of the many potential negative consequences for humans from the loss of healthy ecosystems. If the practice of medicine is to be more than identifying and treating disease, that is, if it is to have a significant preventive component, there is the need to better understand the relationships between ecosystem health and human health. Medical schools are beginning to rise to the challenge of expanding the traditional curriculum to include topics on these relationships. These programs encourage a new breed of professionals who, in addition to having the skills to diagnose and treat, may also have the skills to recognize that caring for local and regional environmental conditions is conducive to maintaining healthy populations.
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Caring for people, in many cases, ultimately involves maintaining healthy ecosystems.
Acknowledgements The authors would like to thank Mrs. Beryl Ivey, The Richard Ivey Foundation, and the McConnell Family Foundation for their financial support of the Ecosystem Health Program in the Faculty of Medicine at the University of Western Ontario.
References Adams F, editor. The genuine works of Hippocrates: preliminary discourse and annotations (Printed for the Sydenham Society 1849). On Airs, Waters and Places. Reprinted for The Classics of Medicine Library; 1985. Cruess RL, Cruess SR, Johnston SE. Renewing professionalism: an opportunity for medicine. Acad Med 1999;74:878 – 84. Holling CS. The resilience of terrestrial ecosystems: local surprise and global change. In: Clark WC, Munn RE, editors. Sustainable development of the biosphere. Cambridge (UK): Cambridge Univ. Press; 1986.
Mageau MT, Costanza R, Ulanowicz RE. The development and initial testing of a quantitative assessment of ecosystem health. Ecosyst Health 1995;1:201 – 13. McMichael AJ. Human frontiers, environments and disease: past patterns, uncertain futures. Cambridge (UK): Cambridge Univ. Press; 2001. Neufeld VR. Physician as humanist: still an educational challenge. Can Med Assoc J 1998;159:787 – 8. Neufeld VR, Maudsley RF, Pickering RJ, Walters BC, Turnbull JM, Spasoff RA, et al. Demand-side medical education: educating future physicians for Ontario. Can Med Assoc J 1993;148:1471 – 7. Rapport DJ. What constitutes ecosystem health? Perspect Biol Med 1989; 33:120 – 32. Rapport DJ, Howard J, Lannigan R, McMurtry R, Jones DL, Anjema CM, et al. Introducing ecosystem health into undergraduate medical education. In: Aguirre AA, Ostfeld RS, Tabor GM, House C, Pearl MC, editors. Conservation medicine: ecological health in practice. Cary, NC: Oxford Univ. Press, 2002. Stewart M, Belle Brown J, Weston WW. Patient-centered medicine: transforming the clinical method. Sage Publications; 1995. Sullivan WM. Medicine under threat: professionalism and professional identity. Can Med Assoc J 2000;162:673 – 5. Wallace AG. Educating tomorrow’s doctors: the thing that really matters is that we care. Acad Med 1997;72:253 – 8. Wear D, Castellani B. The development of professionalism: curriculum matters. Acad Med 2000;75:602 – 11. Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med 1999;341:1612 – 6.
Linking health and ecology in the medical curriculum David J. Rapport a,b,*, John Howard b, Robert Lannigan b, William McCauley b a
College Faculty of Environmental Design and Rural Development, University of Guelph, Guelph, Ontario, Canada N1G 2W1 b Faculty of Medicine and Dentistry, The University of Western Ontario, London, Ontario, Canada
Abstract Human health vulnerabilities to ecosystem degradation are well documented. Destabilization of natural ecosystems and the biosphere have posed an entirely new set of risks to human health and preclude any simple extrapolations from the past. Newly emerging diseases, increasing prevalence of many vector borne diseases, increased exposure to harmful UV radiation and a number of other transformations in the natural environment, have decidedly negative implications for the sustainability of human health. Curricula in medical schools are responding to these new realities by exposing the connections between health and ecology. The program in Ecosystem Health at the University of Western Ontario serves as one model for connecting these disciplines. This program has resulted in a perceptible shift in values and professional responsibilities of emerging physicians. D 2002 Elsevier Science Ltd. All rights reserved. Keywords: Air quality; Ecology; Education; Health; Medicine; Pollution
1. Introduction It is well known that air pollution has direct impacts on human health—exposures to contaminants and small particles in both indoor and outdoor air impairs respiratory functions; exposures to carcinogens can induce cancers in humans and other animals. Less appreciated, and more pervasive, are the indirect impacts. Air pollution, among a variety of other stresses that destabilize the dynamic ecological balance of natural systems, increases human health vulnerabilities through the destabilization of ecological functions. In recognition of the link between environmental degradation and human health, several medical schools (including veterinary medicine) and schools of public health (e.g., Harvard, Johns Hopkins, The University of Hawaii, Tufts and the University of Guelph) have introduced aspects of ecology in their medical or public health curricula. The University of Western Ontario has taken the further step of making ecosystem health a core element of its undergraduate medical curriculum. The topic is not only featured in a fourth year case-based elective on ‘ecosystem * Corresponding author. Faculty of Environmental Design and Rural Development, University of Guelph, Room 107, Johnston Hall, Guelph, ON, Canada N1G 2W1. Tel.:+1-519-824-4120x8476; fax:+1-519-7671692. E-mail address: [email protected] (D.J. Rapport).
health’, but is also featured prominently in the first year ‘introduction to medicine’ orientation section, and in a number of case studies that form the core curriculum throughout the 4 years of medicine. How this has come to pass is a story of the growing awareness of the critical importance of ecosystem functions for human health (McMichael, 2001). This includes an awareness of the opportunity the concept of ecosystem health affords to medical practitioners to become more effective in their practice (Rapport et al., 2002). What is meant by the term ‘ecosystem health’? At the most basic level, ecosystem health is the capacity for ecosystems to be self-sustaining and to carry out all of their normal functions. Among other things, healthy ecosystems are capable of converting energy into biomass, recycling nutrients, regulating water transport and cycling, sequestering contaminants, moderating climate, and providing habitat for diverse biota. In the normal course of things, there are many perturbations (e.g., storms, fires, heavy snowfalls, drought) that disrupt, at least temporarily, the functions of ecosystems. In healthy systems, such challenges exert a positive influence as they enable the ecosystem to adapt to changing environments (Holling, 1986). However, in disturbed or pathological ecosystems, such challenges may prove to be ‘the straw that broke the camel’s back’. Ecosystem ‘health’ is characterized not by the absence of pathology (negative elements), but in terms of the properties that underpin the capacity of ecosystems to persist. Key
0160-4120/02/$ - see front matter D 2002 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0160-4120(02)00169-1
354
D.J. Rapport et al. / Environment International 29 (2003) 353–358
parameters involve maintenance of resilience, organization, and vitality (productivity). These key parameters characterize the well functioning of natural systems (Rapport, 1989; Mageau et al., 1995). Humans are very much a part of that evolution. Today, humans dominate many of the earth’s ecosystems: they extract a disproportionate amount of energy, occupy or have severely modified more than 50% of the land surface, have greatly altered hydrological and nutrient cycles, and indeed the composition of the atmosphere-resulting in the ‘greenhouse’ effect. However, humans still remain completely dependent on the healthy functioning of the earth’s ecosystems and the biosphere for their very survival. The current rapid depletion of the world’s forests, species diversity, marine fisheries, and fertility of agricultural lands, is an ominous sign that the so-called ‘lifesupport’ systems are crumbling. The human health implications, direct and indirect, are profound. Many diseases, as the studies discussed below well illustrate, have their origins in adverse changes in the environment. This has encouraged increased awareness, within the practice of both medicine and public health, of the need to go beyond identifying and treating disease. There is a growing recognition of the need to look ‘upstream’ within the ecosystem and deal with human health vulnerabilities arising from the pressures humans bring to bear on the earth’s ecosystems. Our experience at The University of Western Ontario, where ecosystem health now forms a core part of the undergraduate medical curriculum, is that students are quick to grasp the significance of ecosystem health for human health. They recognize that while it is essential to deal with human health issues that arise, necessitating efficient diagnosis and treatment, it is also essential (and a new part of their ‘mandate’) to become proactive within their communities in order to reduce human health vulnerabilities owing to ecosystem degradation.
2. Case studies illustrating the relevance of ecology to human health Most people equate health with lack of disease, ignoring the more recent expanded definitions of health. Fascination with disease is a major force in medical students and others. To capture interest in ecosystem health, it is important to find specific disease states that can be linked, no matter how tenuously, to ecological disturbances or degradations. Many students are surprised to find that ecosystem health has its roots in Hippocratic medicine, as evidenced by this quotation from: Properties, Waters, Places attributed to Hippocrates: When a physician comes to a district previously unknown to him, he should consider both its situation and its aspects to the winds. The effect of any town upon the health of its population varies according as it faces
North or South, East or West. This is of the greatest importance. Similarly, the nature of the water supply must be considered—then think of the soil—Lastly, consider the life of the inhabitants themselves; are they heavy drinkers and eaters and consequently unable to stand fatigue or, being fond of work and exercise, eat wisely but drink sparingly? (Adams, 1985). Starting with a case-based scenario, it is possible to provide the students with a limited context that is easy to grasp and often within the realm of their experience. From this, connections can be explored leading to a broadening of the context to the level of the ecosystems in which we live. Although the focus is highly anthropocentric, the exploration of linkages allows discussion of other species within the system and leads to a better understanding of the importance of a ‘healthy’ ecosystem in maintaining human health. Such exploration also reinforces the concept that humans are not ‘above’ or ‘outside’ their ecosystems and are highly dependent upon them for healthy living. Each case is presented in two sessions, with sufficient time in between for students to explore issues raised in the first session. The second session is used to discuss findings, consider solutions, and identify the consequences of the proposed solutions. The consequences are important in that they further consolidate the concept of the interconnected nature of an ecosystem. 2.1. Example—Urban heat islands Most students are aware of reports of ‘heat waves’ leading to heat stress conditions in urban dwellers. The students can be placed as an emergency room physician dealing with an elderly urban dweller who is confused, dehydrated, and has an elevated temperature. The ‘heat wave’ has now been going on for 18 days. Medical students at first concentrate on the differential diagnosis, and the pathophysiology and treatment of heat stroke. However, it is relatively easy to turn the discussion to urban housing construction and design (much of which is substandard), the need for climate control of such dwellings, how that energy for climate control is generated, and the effects such power generation may have on changing the earth’s climate. If the notion that extreme weather events, such as heat waves, are part of the result of global warming, it brings the focus back to the original scenario. Many other aspects of urban ecology and its consequences can be pursued. 2.2. Example—Asthma The disease of asthma is also fruitful ground to explore. The increasing incidence of this disease in some geographic areas as opposed to others, and its possible associations with ecosystem disruptions, is a good beginning. Starting with a visit to the physician’s office of a mother concerned with the wheezing she noticed in her 1-year-old child, many areas
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can be explored. What is causing the increasing numbers of children to develop asthma in some locales? How does our ‘developed’ lifestyle contribute to asthma, if at all? Air quality and its importance in triggering increasing numbers of asthma attacks in those suffering from the disease is a sound place to start. The shortcomings of epidemiology and the scientific method for analyzing such complex situations can also be brought in, as well as the topic of uncertainty. In exploring solutions, the effects on ground level ozone production by decreasing the use of automobiles in urban areas and the value of mass transportation systems is fertile ground for discussion. Lively discussions often revolve around the reasons why the economics of automobile production hinder the development of less polluting vehicles, and also around the sociology of direct personal ownership of motor vehicle as a status symbol and how this is maintained in our modern societies.
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the students are usually able to make intuitive disease links but many ‘surprising’ links arise as well. By using a variety of cases, it is possible, over the duration of the sessions, to have the students examine many of the determinants of ecosystem health and how these impact human health. Given the limited time available, the depths to which many of these issues are pursued is often quite superficial, but we have found the most important function is to encourage students to ‘think outside of the box’, as opportunities to do this are infrequent in traditional curricular material. While students are sometimes overwhelmed by the problems, they usually indicate they have gained a greater appreciation of the complexity and interconnectedness of human health and ecosystem health that they would not otherwise have learned.
3. Responsible professionalism 2.3. Example—Vector-borne diseases While vector borne diseases are obviously important and excellent examples of ecological changes associated with human disease burdens, we do not concentrate on these as a separate topic but use them, where appropriate, in other cases. Food- and water-borne diseases provide many examples. Recently, we experienced an outbreak of Escherichia coli O157:H7 in a local community and used it to good effect in teaching ecosystem health. Following the changing epidemiology of E. coli 0157:H7, as an agent of human disease, allows for a wide range of discussion. The occurrence of the organism in ground beef is a good starting point. Then, a discussion of its presence in vegetable and food crops, as a result of manure use for fertilizer, and its presence in potable water, as a result of ‘runoff’ from fields, makes for a discussion of many links between human food production methods and ecosystem degradation. Links from human food consumption to diseases related to the complications of atherosclerosis, the role of nutrition in the development of atherosclerosis, plus the politics, economics, and other aspects of food production, also promotes the interconnectedness and complexity of ecosystem health issues. We have also used natural disasters and the environmental refugees ensuing from them to highlight links between human health and ecosystem health. In our case, we use hurricane Mitch. The students determine the types of diseases that might occur in emergency camps for humans displaced by the hurricane. The students are first provided with an overview of the geography and the socio-politicaleconomic conditions in Honduras. From this, they develop a list of human health problems in the initial short term and longer term that they might expect to occur. The second session is hosted by a physician who went to Honduras as part of the relief team in the aftermath of hurricane Mitch, and has been there on several subsequent visits. In this case,
Degradation of ecosystems plays an increasing role in human disease and illness. Descriptions of ecosystem tragedies that have occurred or are occurring have received much time and attention. The same or greater efforts are required to develop programs to influence human behaviour to prevent these same types of tragedies. A key component of this effort is to ensure that each profession has the skills and attitudes necessary to contribute to the development of sustainable systems. All professions must be responsible for ensuring that their skills and actions result in sustainable systems. This concept of ‘responsible professionalism’ is put forward to describe the attitude that professions must embrace to ensure the restoration, rather than degradation, of the world in which we live. A critical step in changing people’s thoughts, and eventually their actions, is to define a paradigm in which people can see where they are and where they can potentially be. In our Faculty of Medicine and Dentistry at the University of Western Ontario, an ecosystem health paradigm of medical education has been an important step in the evolution of our medical curriculum. Although defined for medical schools, this paradigm has potential applications to other professional schools as well. The essence of this paradigm is widening the concept of ‘patient’ to include all systems in the environment, including, importantly, the ecosystem. Altering the concept of ‘disease’ to one of ‘problem’ and adopting a more general concept of ‘illness’ as the manifestation of the problem within the system allows this paradigm to apply to many different professions. Nearly all physicians have been trained in the traditional medical paradigm. In the traditional medical model, there is a disease within a patient. The task of the physician is to answer two basic questions: ‘What is the disease?’ and ‘How do I treat it?’ To fulfill their role, physicians learn everything there is to know about a patient—anatomy, physiology, biochemistry. Then they learn everything they need to know about diseases and how to treat them—
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pathology, medicine, surgery, pharmacology. They are then equipped to act as physicians in their traditional role. A new paradigm for medical care was defined in the early 1990s in the Family Medicine Department of the University of Western Ontario. Called the Patient-Centered Model (Stewart et al., 1995), this model embraces the traditional exemplar but adds to it. The critical concept of patient-centered is the ‘illness’—the unique experience of the disease by an individual patient. It recognizes that the experience and the needs are different in every patient with the same disease. Whereas the disease is generic to many patients, the illness is unique to each patient. The illness is critically dependent on the context in which the patient lives—the patient’s family, community and country, and the patient’s economic, social, and spiritual situation. This paradigm adds two more basic questions: ‘What are the unique needs of my patient?’ and ‘How can I meet those needs?’ In this paradigm, not only are the basic courses described in the traditional medical paradigm necessary, but learning centered around communication skills, holistic care, and in-depth learning about the patient’s context becomes critical in their training. In the late 1990s, an Ecosystem Health model was introduced to the faculty. This paradigm embraces all the principles of the first two paradigms described above but emphasizes the fact that human health is critically dependent on the environment of the patient—not only the physical environment but also the social, political, and economic environment. It expands the concept of the context into different spheres of interest—the immediate environment, the community environment, the regional environment, the national environment, and the world environment. It adds two more questions—perhaps the most important questions when it comes to human health. These are: ‘Why is this illness occurring—what has happened to cause the patient to come today with this disease?’ and ‘What can I do as a physician to help prevent this from happening again?’ Adopting this paradigm provides the necessity for physicians to look beyond the traditional medical disciplines, to learn about ecology, economics, social policy, and law. Physicians must understand the effects of the physical, environmental, political, and social environment on human health. Getting people to accept an evolving paradigm makes them more accepting of a global approach to human health. The Ecosystem Health paradigm has a number of advantages: it is inclusive of all physicians; it does not criticize more traditional thinking physicians but rather challenges them to reconsider their role as physicians; the paradigm is simple to understand and can be communicated in a short time. Our experience with this inclusive yet simple paradigm, which clearly shows alternative priorities, has proven to be effective in influencing a group whose ideas have traditionally been difficult to change. As stated above, the ecosystem health paradigm can apply to all professions. Changing the concept of ‘patient’ to ‘system’, changing the concept of ‘disease’ to ‘problem’,
and retaining the concept of ‘illness’ as the manifestation of the disease in the system, the Ecosystem Health paradigm can be applied to all professions. More importantly, the questions asked of the professional remain the same. In particular, the two questions applying to Ecosystem Health are equally valid in all professions, when presented with a problem. ‘Why is this illness occurring’ and ‘what can I do as a physician/lawyer/engineer/teacher/politician/or other to help prevent this from happening again’? If all professions considered the same model, the opportunities for collaboration would be endless.
4. Societal expectations: can medicine evolve to meet them? This broader look at physician –patient interactions to incorporate larger contextual issues is in keeping with societal expectations of physicians. In the province of Ontario, the Educating Future Physicians for Ontario (EFPO) project was initiated in the early 1990s (Neufeld et al., 1993). Part of the EFPO project involved an in-depth analysis of the public’s expectations of physician performance. Various sectors of Ontario society were approached, including multicultural groups, disabled and elderly people, and women’s groups. Information was obtained through focus groups, key informant interviews, and surveys. To complement the views of the public, a representative sample of health care professionals, other than physicians, were asked about their observations of the roles of physicians. From both the public and the health-care professionals came the strong message that there were major shortcomings in the performance of physicians as communicators, humanists, and patient educators. The people expected to be treated as human beings, not just ‘cases’, and to have more time when they are with their physicians for pressing questions and clear explanations. In addition, participants in the study made useful suggestions to Ontario’s medical educators about what might be done to improve matters (Neufeld, 1998). The society spoke out in favor of wanting their doctors to be more than healers. They identified several socially responsible roles for physicians to fulfill in their mandates. One of the roles identified by both the EFPO project and the Royal College of Physicians and Surgeons of Canada’s parallel project ‘CanMEDS 2000’ was that of the professional. Society wants their primary care physicians and their specialists to act as professionals. The concept of professionalism, however, has broad and diverse interpretations (Sullivan, 2000; Wynia et al., 1999). Sullivan suggests one concept is that professionalism for physicians embodies an ideology of social reform. The physician must put the patients’ welfare above all other considerations and it is the physician’s responsibility as a professional to safeguard and promote this trust in society at large (Wallace, 1997). From this, the concept of responsible professionalism is
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born. If physicians must put the welfare of the patient above all other considerations, we must reflect back on the patientcentered method. Each patient is different, and lives within a context. If a physician is going to put a patient’s welfare above all other considerations, then the context in which that patient exists must also be considered by the physician. This includes the sociopolitical, environmental, cultural, and economic spheres considered in the exploded contextual model of ecosystem health. By being responsible to the patient, a physician must, as a professional, be responsible to these many aspects of human health.
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role in social responsibility or ecosystem health; rather, they must be viewed by students and faculty alike as being an inherent part of medical training. Medical students have traditionally been taught to focus on the disease. Recently, the patient’s illness experience has become an inherent part of many undergraduate curricula. Medical education’s next challenge is to look at the big picture through a transdisciplinary lens. Students must learn to consider larger societal and contextual issues when dealing with an individual patient’s problems, and not just when studying a course entitled ‘Medicine and Society’. This concept will take strong leadership and the will of educators to embrace, as crucial, these ideas and the physicians’ roles in them.
5. Adding a trans-disciplinary focus Traditional medical curricula, as described above, have concentrated only on the patients disease, or perhaps their illness experience. The consideration of broader issues outside of the person, such as the impact of environmental issues on the development of human disease and illness, is truly unusual (Cruess et al., 1999; Wear and Castellani, 2000). By ‘thinking outside the box’ of conventional medical education, medical schools have the opportunity to create physicians who are not only considerate of their patients’ unique illness experience but are considerate of and for all aspects of human health. This is true whether they are issues of politics, economics, culture, or the environment. Stressing this social responsibility has not traditionally been considered important in most undergraduate medical curricula. To be successful in these pursuits, physicians will have to work with professionals from other disciplines, drawing expertise from them in the pursuit of a goal. This concept of interdisciplinary cooperation, although well entrenched in many medical disciplines, is relatively new to most physicians. Typically, physicians have worked individually, considering themselves experts in many areas and relying on paramedical professions to act as their ‘helpers’. Rehabilitation medicine, however, is one field that relies heavily on the interdisciplinary approach. Each discipline’s representative has their own role (i.e., occupational therapy, social worker, psychologist, physician) but also recognizes that they have valuable input for the other team members in working together towards a common goal. This is the model of cooperation that must exist for physicians to be involved in these larger contextual issues. Physicians must learn (be educated) to work alongside politicians, ecologists, and lawyers in order to tackle the problems inherent in the world that contribute to the development of human disease or that are impacted upon by the treatment of human disease. In order to foster the development of physicians with a genuine interest in responsible professionalism, we must look to the breeding grounds for physicians. Educational leaders in medical schools must be willing to incorporate, seamlessly, into their curricula issues of social responsibility. These cannot be add-on or stand-alone courses on the physician’s
6. Summary While some may debate the validity of the concept of ‘ecosystem health’, the usual objections is that ‘health’ is only a property of ‘organisms’ not ecosystems, or that ‘health’ is a value judgment that is not amenable to objective analysis. These arguments fail to recognize that ecosystems, while not organisms or supra-organisms, do have complex organization that can be disrupted by stress (or outside pressures). This is known due to the commonplace knowledge of pathology in lakes, forests, grasslands, coastal ecosystems, and others, in which fundamental properties of productivity, resilience, and organization are impaired. These arguments also fail to recognize that while ‘health’ may be a ‘value’, it is a value whether we speak of human or animal health, or ecosystem health. Thus, if the concept has validity in one realm, it must also have validity in the other. In any event, those familiar with real ecosystem health issues (e.g., dry land salinity in Australia) know that, philosophy aside, communities face the reality of faltering ecosystem functions and the reality of declines in their personal well being as a result of economic and social decline and increased health burdens. Ecosystem degradation is widespread as a result of cumulative impacts of human activity. These changes place human health at increasing risk. Increased exposure to toxic substances, the spread of vector borne diseases, increasing scarcity of potable water, overexploitation of marine fisheries are but a few of the many potential negative consequences for humans from the loss of healthy ecosystems. If the practice of medicine is to be more than identifying and treating disease, that is, if it is to have a significant preventive component, there is the need to better understand the relationships between ecosystem health and human health. Medical schools are beginning to rise to the challenge of expanding the traditional curriculum to include topics on these relationships. These programs encourage a new breed of professionals who, in addition to having the skills to diagnose and treat, may also have the skills to recognize that caring for local and regional environmental conditions is conducive to maintaining healthy populations.
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Caring for people, in many cases, ultimately involves maintaining healthy ecosystems.
Acknowledgements The authors would like to thank Mrs. Beryl Ivey, The Richard Ivey Foundation, and the McConnell Family Foundation for their financial support of the Ecosystem Health Program in the Faculty of Medicine at the University of Western Ontario.
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