ABSTRACT
In the second decade of the twenty-first century there are many challenges facing environmental health and indeed the societies generally around the globe. These challenges are both economic and environmental. It can be argued that unless solutions to economic problems take account of the environmental imperative presented by climate change fully (and the fundamental risks to public health), then the responses will be inadequate. The issue of climate change should actually dictate how economic problems are resolved. Yet, however the challenges are tackled, fundamental to the philosophy underpinning environmental health is the notion of equity or fairness, and in particular equity in health. Equity in health means that there should be no
disparities in health (or in the major social determinants of health) as the result of social systems, between groups in that society which have underlying social advantage or disadvantage (as the result of economic wealth or power). Inequities in health come about when society puts groups which are already disadvantaged, as the result of poverty, gender, race or sexual orientation or are otherwise disenfranchised, at further disadvantage with respect to their health. Equity is an ethical principle; it also reflects and is closely related to human rights principles. So it should be recognised that climate change and the economic crisis could actually
increase inequity, and that the further down the social ladder one is (that is the less wealth one has), the greater will be the adverse effects, and this applies as much between countries as within countries. One problem is that the main indicator of a
country’s economic performance is the Gross Domestic Product (GDP) and this is used to measure ‘progress’. However, this is a crude measure of total economic activity, and as such is a poor reflection of health and well-being. So that, for example, expenditure on tobacco appears in GDP, as would money spent on food that has little nutritional benefit. So one might ask, for example, in such an economic situation where should the effort be put to achieve more in environmental health terms: more food safety inspections or actions to achieve healthier eating and better diets for those on lower incomes and to reduce obesity. From a public health rather merely consumer protection perspective, the latter would be the obvious course. The reality is that the effects of economic growth
have made us worse off in health terms. The measure GDP takes no account of increasing inequality, pollution or damage to people’s health and the environment. Indeed it also treats crime, divorce and other elements of social breakdown as economic gains. This current model therefore will always undermine the notion of sustainable development, and it cheats ourselves, other countries and future generations. We need to redefine progress,
and replace GDP with new indicators of progress. An alternative such as an Index of Sustainable Economic Welfare (ISEW) would be a better way of reflecting economic performance, but that is not for this book. However, this does put into context the issues facing environmental health and why inequality is such an important issue in environmental health. Environmental health (even if we did not always
call it that) has seen similar momentous changes and crucial moments in history, to those we now face. In the UK there were great economic social and environmental changes in the eighteenth and nineteenth centuries, when urbanisation and industrialisation brought millions of people together in crowded, sprawling and insanitary settlements. In response, society underwent a period of rapid change particularly motivated when the effects of the insanitary conditions spread to the middle and upper classes and the causes of cholera and typhoid were identified. New models for the delivery of public services to
protect public health and maintain both a healthier workforce and reduce the strain on the Poor Law Commission (and later Board) and Parishes were introduced.1 The municipal corporations of the 1830s and the new Boards of Health were largely conceived to deal with outbreaks of communicable disease and to afford basic measures of health protection. Subsequently, a new concept of health arose: the idea of public health. New philosophies for the delivery of education and other public services began to take shape, and a new form of democracy evolved – extended suffrage, which became universal in the early twentieth century. At the beginning of the twenty-first century, we are at a comparable watershed. In the West, urbanisation and industrialisation are largely behind us. Our horizons now are increasingly global, not
merely national. We deal, typically, in symbols and abstractions, in information rather than in manufactured objects. Engineered solutions are no longer the answer in themselves and where they still have a role to play they need to be managed and discussed with those they affect. The problems themselves have assumed less tractable, more qualitative dimensions to do with ‘lifestyles’, quality of life and psychological (mental) health and well-being. More
importantly, perhaps, the manageable, predominantly urban concept of public health that was developed in the nineteenth century has been replaced by a much bigger concept, that of the global biosphere. As a result, we are grappling with the much bigger issue of the future of life and health on earth, a question that rarely occurred to the Victorians. Environmental health, having been invented as
part of the sanitary movement in the nineteenth century, needs always to be reinvented or at least to be reassessed. For example, the work by the WHO Commission on Social Determinants of Health in its final report Closing the gap in a generation: Health equity through action on the social determinants of health [1] highlights the inequalities or inequity that exists within and between countries and indeed between generations. These inequities in health, avoidable health inequalities, arise because of the circumstances in which people grow, live, work, and age, and the systems put in place to deal with illness. The issue of inequities in health are further highlighted in the Marmot Review undertaken for the Department of Health by a Commission chaired by Michael Marmot [2]. Although many of the new threats are global, the
response will often be regional or local reflecting cultural differences, even individual. Without change there will be increased inequity in health, continuing environmental degradation, a decaying family and community fabric, increasing stress and the deterioration of the state into a kind of reactive, coping mechanism. Against such a background, the emphasis within environmental health would inevitably be on cure (a sticking plaster approach) rather than prevention, hard technological solutions rather than a softer people-based response, and probably professional compartmentalisation rather than integration, since the former may appear to offer more certain career gains to individuals. This can be reflected in a purely mechanical regulatory non-strategic approach to soften the edges of adverse health impacts from activities and policies. Many diseases of the modern way of life, such as
cardiovascular disease, obesity and cancer, will take much longer to conquer if prevention, or upstream interventions, remains a low priority and integrated planning and delivery of services is compromised by demands for quick fixes. For example, the research
needed to understand them will be slower to materialise and this provides an opportunity for powerful rearguard actions by well-organised vested interests including industrial lobbies. There is, however, a further complexity to consider; when prevention does become a higher priority it is often in the context of finite or limited resources. This is where some hard decisions may have to be made about the shifting of resources from treatment and care to prevention and all the ethical issues that this entails. A review of National Health Service expenditure in 2002 [3] highlighted the economic benefits of upstream investment and the potential contribution of public health measures in reducing the burden of disease. However, there has often been a lack of solid evidence on which measures to use and indeed on outcomes of those measures. Success requires ‘full engagement’, that is, increased, or better directed, spending and high public engagement to achieve improved health status and increased healthy life expectancy across the whole of society. In recent years, while those lower on the social scale have barely seen an increase in healthy life expectancy, at the top there has been a marked increase. This also has economic implications with an increase in the age for eligibility for state pension, if those on lower incomes are unfit to work from their early fifties. Disability-free life expectancy (DFLE) is about 15 years between those in the most deprived neighbourhoods and those in the least deprived [2] who on average have a DFLE of 70 years. The social determinants of health are the condi-
tions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries. The environmental impact on health is an inevi-
table by-product of human activity, and it is therefore the nature of that activity, and the attitudes that go with it, that hold the key. So it will be to the soft technologies – the technologies of mind, reason and social organisation – that we must
increasingly look for solutions. Hard ‘engineered’ technologies are at best a partial answer, at worst a diversion. The answers offered are much more difficult. They require vision, ambition and leadership; they also require debate, consensus and agreement. In the worst case scenarios described, these solutions will be more, not less, difficult to realise and they will need a new kind of environmental health practitioner to tackle them. The World Health Organization (WHO) has also contextualised environmental health into human rights: human rights cannot be secured in a degraded or polluted environment. The fundamental right to life is threatened by soil degradation and deforestation and by exposures to toxic chemicals, hazardous wastes and contaminated drinking-water. This is because social and environmental condi-
tions determine the extent to which people enjoy their basic rights to life, health, adequate food and housing, and traditional livelihood and culture. It is time to recognise that those who pollute or destroy the natural environment (and indeed those who provide financial backing for such activities whether as investors or customers) are not just committing a crime against nature, but are violating human rights as well. (Klaus Toepfer, Executive Director of the United Nations Environment Programme at the 57th Session of the Commission on Human Rights, Geneva, 2001). To fulfil their future role environmental health practitioners need to have an understanding of the following:
the definitions and principles of environmental health;
the agenda with which they need to be engaged;
the skills and expertise required of their professional practice;
the objective of their environmental health activities.
