Rachel's Democracy & Health News #843, February 23, 2006


[Rachel's introduction: We "environmental health" activists could appeal to a larger segment of the public if we based our work on all three environments that determine human health: the natural, the built, and the social.]

By Peter Montague

Since 1970, we "environmental health" activists have tiptoed onto territory occupied by public health professionals. But so far we have not fully embraced the public health approach -- defining and conducting our "environmental health" work as a branch of public health -- and as a result, our work does not yet appeal to large segments of the public. We are seen as elitists worried about irrelevant problems. We could easily change this.

Health and "environmental health"

The U.S. Institute of Medicine (IOM) defines the mission of public health this way: "to fulfill society's interest in assuring conditions in which people can be healthy."

The preamble to the constitution of the World Health Organization (WHO, July 22, 1946), defines health as "a state of complete well- being, physical, social, and mental, and not merely the absence of disease or infirmity."

The WHO constitution also defines health as a basic human right: "The enjoyment of the highest standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition." This is consistent with Article 25 of the Universal Declaration of Human Rights of 1948, which says,

"Everyone has the right to a standard of living adequate for the health and well-being of himself and his/her family, including food, clothing, housing, and medical care."

The World Health Organization defines "environmental health" as "those aspects of human health, including quality of life, that are determined by physical, chemical, biological, social, and psychosocial factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling, and preventing those factors in the environment that can potentially affect adversely the health of present and future generations."

The Pew Commission on Environmental Health defined environmental health this way: "Environmental health comprises those aspects of human health, including quality of life, that are determined by interactions with physical, chemical, biological and social factors in the environment. It also refers to the theory and practice of assessing, correcting, controlling and preventing those factors in the environment that may adversely affect the health of present and future generations."

In the U.S., 3000 county and municipal health officials are represented by the National Association of County and City Health Officials (NACCHO). In Resolution 99-13, NACCHO specifically recognizes that "environment and health are intimately related, and environmental health is a public health activity..." So public health workers seem to be inviting "environmental health" activists onto their turf. What is holding us back?

The crux of the matter is that there are three "environments" that affect human health: the natural environment, the built environment, and the social environment. Each is crucial to public health. We "environmental health" activists have embraced the first two, but not all of us have yet embraced the third. Getting to that third "environment" is crucial for expanding our appeal to a broader audience.

The natural environment

For eons people have recognized that human health depends on the natural world. To thrive, we need clean water, clean air, and good food. However, there are two other "environments" upon which our health also depends -- the built environment and the social environment.

The built environment

We've known about the importance of the built environment for more than 2000 years. As humans began to crowd into small cities and disease rates soared, Hippocrates in Greece and later Vitruvius in Rome realized that positive steps must be taken to maintain conditions in which people can be healthy.

In Greece and Rome, buildings were oriented to take advantage of fresh air and sunlight. The Roman aqueducts brought in fresh water, which was then distributed city-wide. The Roman baths made cleanliness possible for everyone. Certain occupations, such as silver mining, were known to cause illness and death. These early understandings formed the basis for what in the late 19th century became known as "public health."

In England during the early, awful days of industrialization, which Charles Dickens described so convincingly in the 1840s, the government recognized that disease arose from both the built and the social environments. Disease was caused by fetid air and improper waste disposal, but it was also caused by poverty and human degradation. In 1845 Friedrich Engels published The Condition of the Working Class in England in 1844, cataloging what Charles Dickens had portrayed in novels -- unspeakable conditions of filth, poverty, and degradation giving rise to disease and death.

The social environment and the social determinants of health

The German physician Rudolf Virchow is known as the "father of modern pathology" but he also pioneered our understanding of how social conditions foster health or disease. In 1848 the German government sent Virchow to Upper Silesia to investigate an epidemic of typhus. In his report, he said the epidemic was attributable to miserable living conditions, inadequate diet, and poor hygiene -- and, he said, these conditions were, in turn, attributable to feudalism, lack of democracy, and unfair tax policies. Thus Virchow identified the social environment as an important factor in human disease.

From these roots grew the modern public health perspective on human well-being: society must create the conditions in which people can be healthy, and disease must be prevented whenever possible, rather than relying only on the curative powers of the physician. To this day, prevention is the keystone idea of public health practice. The medical model (one doctor, one patient) can only go so far. The public health model (preventive intervention by proper authorities at the level of the entire population) is essential for community health.

Providing clean water, offering vaccinations, establishing fire codes and structural requirements for buildings, requiring landlords to provide a modicum of sunlight and fresh air in rental properties -- these are population-wide public health interventions needed to prevent disease and injury.

Public health professionals fully understand that the natural and built environments are important for maintaining human health. The National Association of County and City Health Officials (NACCHO) has passed resolutions urging governments and the public to pay attention to both the natural and built environments, in order to maintain the health of populations. (See for example, NACCHO resolution 03-02 to support land use planning and design, and NACCHO resolution 98-06 on brownfields. And see NACCHO's statement, "Integrating Public Health into Land Use Decision-Making."

Activists in the "environmental health" movement also understand the importance of the natural and built environments to human health. Highways, sprawl, "brownfields," poisoned land, unsafe food additives, pesticides, contaminated drinking water -- these are all things that "environmental health" activists routinely tackle.

But in one respect, public health professionals are somewhat ahead of environmental health activists -- in recognizing how the social environment affects health. For example, NACCHO Resolution 02-04 acknowledges that "a significant body of research in the last fifteen years documents clearly that socioeconomic inequality, poor quality of life, and low socioeconomic status are principal causes of morbidity [sickness] and mortality [death]." We have put together a bibliography highlighting some of that research.

NACCHO Resolution 02-04 goes on to say, "We embrace social justice as the cornerstone of our work, recognizing that equity, shared decision making and attention to the social determinants of disease are central to promoting healthy communities."

In testimony before the National Institute of Medicine March 20, 2002, Dr. Adewale Troutman, representing NACCHO, described the "root causes of the current picture of ill health of large segments of our population: social injustice, economic inequality, and racism."

The World Health Organization (WHO) accepts that the "social determinants of health" must be addressed if we are to protect and maintain public health. In 1998, WHO said, "Policy and action for health need to be geared towards addressing the social determinants of health in order to attack the causes of ill health before they can lead to problems." Notice the preventive approach. Attack the causes BEFORE they can lead to problems.

In a 2003 booklet, called The Social Determinants of Health: The Solid Facts, WHO discussed 10 aspects of "the social determinants of health." Here are a few excerpts from that booklet:


Poor social and economic circumstances affect health throughout life. People further down the social ladder usually run at least twice the risk of serious illness and premature death as those near the top. Nor are the effects confined to the poor: the social gradient in health runs right across society, so that even among middle-class office workers, lower ranking staff suffer much more disease and earlier death than higher ranking staff. Both material and psychosocial causes contribute to these differences and their effects extend to most diseases and causes of death.


Stressful circumstances, making people feel worried, anxious and unable to cope, are damaging to health and may lead to premature death.

Social and psychological circumstances can cause long-term stress. Continuing anxiety, insecurity, low self-esteem, social isolation and lack of control over work and home life, have powerful effects on health. Such psychosocial risks accumulate during life and increase the chances of poor mental health and premature death.

In schools, workplaces and other institutions, the quality of the social environment and material security are often as important to health as the physical environment.


A good start in life means supporting mothers and young children: the health impact of early development and education lasts a lifetime.

...[T]he foundations of adult health are laid in early childhood and before birth. Slow growth and poor emotional support raise the lifetime risk of poor physical health and reduce physical, cognitive and emotional functioning in adulthood.

Slow or retarded physical growth in infancy is associated with reduced cardiovascular, respiratory, pancreatic and kidney development and function, which increase the risk of illness in adulthood.


Life is short where its quality is poor. By causing hardship and resentment, poverty, social exclusion and discrimination cost lives.

Relative poverty means being much poorer than most people in society and is often defined as living on less than 60% of the national median income. It denies people access to decent housing, education, transport and other factors vital to full participation in life. Being excluded from the life of society and treated as less than equal leads to worse health and greater risks of premature death. The stresses of living in poverty are particularly harmful during pregnancy, to babies, children and old people. In some countries, as much as one quarter of the total population -- and a higher proportion of children - live in relative poverty.

Social exclusion also results from racism, discrimination, stigmatization, hostility and unemployment. These processes prevent people from participating in education or training, and gaining access to services and citizenship activities. They are socially and psychologically damaging, materially costly, and harmful to health.


Stress in the workplace increases the risk of disease. People who have more control over their work have better health.

In general, having a job is better for health than having no job. But the social organization of work, management styles and social relationships in the workplace all matter for health. Evidence shows that stress at work plays an important role in contributing to the large social status differences in health, sickness absence and premature death.

Having little control over one's work is particularly strongly related to an increased risk of low back pain, sickness absence and cardiovascular disease.


Job security increases health, well-being and job satisfaction. Higher rates of unemployment cause more illness and premature death.

The health effects of unemployment are linked to both its psychological consequences and the financial problems it brings - especially debt.

Unemployment puts health at risk, and the risk is higher in regions where unemployment is widespread. Evidence from a number of countries shows that, even after allowing for other factors, unemployed people and their families suffer a substantially increased risk of premature death.

Policy should have three goals: to prevent unemployment and job insecurity; to reduce the hardship suffered by the unemployed; and to restore people to secure jobs.


Friendship, good social relations and strong supportive networks improve health at home, at work and in the community.

Social support and good social relations make an important contribution to health. Social support helps give people the emotional and practical resources they need. Belonging to a social network of communication and mutual obligation makes people feel cared for, loved, esteemed and valued. This has a powerful protective effect on health.


Individuals turn to alcohol, drugs and tobacco and suffer from their use, but use is influenced by the wider social setting.

Drug use is both a response to social breakdown and an important factor in worsening the resulting inequalities in health. It offers users a mirage of escape from adversity and stress, but only makes their problems worse.

The use of alcohol, tobacco and illicit drugs is fostered by aggressive marketing and promotion by major transnational companies and by organized crime. Their activities are a major barrier to policy initiatives to reduce use among young people....


Because global market forces control the food supply, healthy food is a political issue.

A shortage of food and lack of variety cause malnutrition and deficiency diseases. Excess intake (also a form of malnutrition) contributes to cardiovascular diseases, diabetes, cancer, degenerative eye diseases, obesity and dental caries. Food poverty exists side by side with food plenty. The important public health issue is the availability and cost of healthy, nutritious food Access to good, affordable food makes more difference to what people eat than health education.


Healthy transport means less driving and more walking and cycling, backed up by better public transport.

Cycling, walking and the use of public transport promote health in four ways. They provide exercise, reduce fatal accidents, increase social contact and reduce air pollution.

Because mechanization has reduced the exercise involved in jobs and house work and added to the growing epidemic of obesity, people need to find new ways of building exercise into their lives. Transport policy can play a key role in combating sedentary lifestyles by reducing reliance on cars, increasing walking and cycling, and expanding public transport.

[End of excerpts.]


So there you have it. By embracing all three environments -- natural, built, and social -- environmental health activists could broaden their appeal to segments of the public who now think of "environment" as irrelevant, divorced from the problems of real life. Embracing that third environment -- the social determinants of health -- would help us develop an effective, lasting movement for change. Another world IS possible.