Rachel's Democracy & Health News #843  [Printer-friendly version]
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

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

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

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

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

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


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


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