Toward an Ecological View of Health: An Imperative for the Twenty-First Century

by Ted Schettler, MD, MPH

Paper presented by The Center for Health Design and Health Care Without Harm at a conference sponsored by the Robert Wood Johnson Foundation, September 2006.

Nature's goods and services are the ultimate foundations of life and health, even though in modern societies this fundamental dependency may be indirect, displaced in space and time, and therefore poorly recognized.

– Lee Jong-wook, Director-General 2003-2006, World Health Organization, Ecosystems and Human Well-Being: Health Synthesis, a report of the Ecosystem Millennium Assessment, United Nations Environment Program 

The growing prevalence of chronic conditions such as diabetes, heart disease, and obesity will overwhelm attempts to fine-tune the delivery system if there are not strong benefit plans and a focused approach to disease management and prevention and wellness. 

– Ronald M. Hollande, President and Chief Executive Officer, Massachusetts Hospital Association, Boston Globe, July 15, 2006

At the beginning of the twentieth century, the quality of medical education and practice was haphazard and poorly regulated by professional or other institutions. The Flexner Report, commissioned by the Carnegie Foundation in 1910, concluded that medical practice was not sufficiently informed by science and that medical education should be designed so that physicians would be well-grounded in science and the pathophysiology of disease. The adoption of these recommendations, along with other social, cultural, economic, and political forces, helped to shape the trajectory of twentieth-century medicine. The medical profession acquired substantial power and authority, while scientific understanding of the origins of disease dramatically advanced (Starr 1982).

During this time, and not just coincidentally, the paths of medicine and public health diverged. Broadly speaking, medicine focused primarily on the pathophysiology and treatment of diseases, while public health emphasized disease prevention. To some extent, the two fields have competed for resources and authority ever since, and each has made important contributions. Improvements in sanitation, working conditions, housing, nutrition, care for poor people, and infectious-disease prevention dramatically improved the public's health. Technological achievements based on advances in biomedical understanding, translated into medical interventions, led to marked improvements in the outcomes of many diseases.

But technological achievements that emerged out of what is now a vast medical industrial complex have come at a steep price. In the United States, as a percentage of gross domestic product, medical expenditures grew from 5.1 percent in 1970 to 16 percent in 2005 (ASPE Issue Brief 2005, Kolata 2006).

Before designing the twenty-first century hospital, we should ask whether the healthcare system should continue on its twentieth-century path. Where is that path going? Is this relentless growth sustainable and will it continue to deliver value? To whom? Are there new opportunities for the healthcare sector to make unique contributions to the well-being of individuals and their communities? What are the determinants of health? What is health? To the extent that they address disease prevention at all, most health-care professionals and institutions concentrate on well-established, proximate causes of disease, rather than more distal or structural causes. Are there new opportunities and responsibilities for disease prevention? What are the relationships among medicine, public health, and environmental health? How are those relationships reflected in current institutional structures and practices?

Until these questions are addressed, it is impossible to know if the services provided by healthcare institutions are appropriate for delivering real value to their communities. And, without knowing what the mix of services and activities ought to be, discussion of building and infrastructure design is premature.
In the sections that follow, this paper addresses four basic themes.

First, as with all forms of life, humans are fundamentally dependent on environmental quality and ecosystem services for their well-being and quality of life. Locally, regionally, and globally, ecosystems and the services that they provide are under considerable stress and undergoing rapid change unique in human history with profound implications for human health.

Second, the healthcare sector not only treats people whose illnesses are in part or whole attributable to environmental conditions, but also contributes in multiple ways to environmental degradation that fosters ill health.

Third, the healthcare sector has both an opportunity and a responsibility to address these realities by modifying practices and modeling behavior in ways that demonstrate an understanding of ecological health. Ecological health embraces the deeply fundamental complex interrelationships that collectively influence human and environmental health.

Finally, as the costs of medical care continue to increase, we will increasingly come face to face with the uncomfortable question: How much are we really interested in disease prevention and health promotion and restoration?