Module 1: Health - FROM MULTIPLE PERSPECTIVES TO AN ECOSYSTEM APPROACH

SECTION 1 — EXPERIENCING AND NEGOTIATING HEALTH

DESCRIPTION

Health is a concept that can be intensely personal. It makes reference to one’s own worldview and life context. To get past the differences a common vision of the health problem and the ideal state of health, is needed. In this section, common definitions of human, animal and ecosystem health are provided. There is, however, no consensus on health definitions and a working definition must be negotiated by each research project or intervention in its particular context. Following the definitions, some strategies and tactics for negotiating visions and definitions of health are presented. Creative tension is purposely generated to help students understand how health is integrated into real world situations.

LEARNING OBJECTIVES 

• Deepen our understanding of what it means “to experience” in general and of experiencing health in particular, through a reflection on health and experiencing it
• Develop an appreciation of humility, through the sharing of experiences
• Explore the definitions of health by negotiating from different perspectives
• Practice the process of negotiating a definition of health 

KEY QUESTIONS 

• What is experience, and how does one experience health?
• Is it possible to arrive at one common definition of health?
• How do you negotiate a health? (biomedical, socio‐economic, etc.)
• In what ways is health a negotiable term?
• What are some of the processes by which we can negotiate health in our ecohealth work? 

DISCUSSION QUESTIONS 

• Does how we define health make a difference to how we treat health? How we develop our research or intervention? How we approach our practice?
• Can the same definition of health lead to multiple approaches to dealing with health?
• Can certain definitions of health lead to erroneous choices in methodology with respect to health?
• How can we make links between the individual experience and equity and gender issues (socially defined identities)?
• Why are these valuable? Why is it important to foster sharing of one’s values?
• What are you experiencing? What are you not experiencing?
• What are you capable of being aware or conscious of? What are you incapable of being aware of or conscious of?
• If the definition of health is always open to negotiation, how do we use it to inform our practice? 
• How does the process of negotiating health affect the way YOU experience your own health? 
• Is it necessary to reach a consensus on the definition of health?
• Does the definition of health change depending on the perspectives involved?
• How does the way we deal with or define human health issues affect animal and environmental health? 

REFLECTIVE PROMPTS 

• What do you do when you are healthy?
• What is it like to be healthy?What do you do when you are sick?
• What is it like to be sick?
• How can illness be prevented?
• Does what makes you healthy also make others healthy? What about animal health or ecosystem health?

Key Content

Defining Health

Health has a number of different definitions, and the concept of health challenges organizations that take up its cause. Classic definitions of health include those of the World Health Organization’s (WHO) Consitution: “...complete physical, mental and social well‐being and not merely the absence of disease or infirmity” (WHO, 1967) and the Alma Ata Declaration: “The extent to which an individual or group is able, on the one hand, to realize aspirations and satisfy needs; and, on the other hand, to change or cope with the environment” (WHO, 1978). 

The latter definition makes reference to an individual’s relationship with the environment. It does not, however, draw out the interdependence of the ecosystem’s health, human health and animal health. Some groups have attempted to rewrite the standard WHO definition of health; others go into more detail in mission statements or other documentation. One Health, for example, is dedicated to fostering collaborations between physicians, veterinarians and environmental scientists. The American Veterinary Medical Association defines it as “the collaborative effort of multiple disciplines – working locally, nationally, and globally – to attain optimal health for people, animals and our environment”. James Kay’s Diamond Diagram highlights how the needs of ecosystems are linked to the needs and wants of society in the presence of policy makers and other stakeholders (Kay et al. 1999).

Less attention has been paid to defining and refining the definition of “animal health”. Indeed, a study looking at how animal health is defined in veterinary texts found that most did not present a definition of health (Gunnarsson, 2006). While it was rare that an author referred solely to animal productivity, this would never be considered a pertinent category when referring to human health. Furthermore, the environment was rarely taken into consideration in these texts. When it was, it was often in reference to disease (not health) or a "failure to produce."

Attempts to define ecosystem health in modern science are much more recent. An early definition is the following: “an ecological system is healthy…if it is stable and sustainable— that is, if it is active and maintains its organization and autonomy over time and is resilient to stress” (Costanza et al. 1992, p. 9). Ecosystem health is routinely defined with regard to a few parameters (such as diversity or productivity) and assessment relates to populations rather than individuals. A true evaluation, however, would also examine the interrelationships between populations (Schaeffer et al. 1988). Further, the original state of many ecosystems is not known to science, although traditional ecological knowledge can sometimes be used to reconstruct how the ecosystem might have looked before perturbation (Houde, 2007). In addition, our tools are not sophisticated enough to allow us to accurately establish how healthy an ecosystem is (Vogt, 1997). These complications lead some scholars to wonder whether it is even useful to speak of ecosystem health (Vogt, 1997). Definitions of ecosystem health also make frequent reference to human health and policy making. Viewing ecosystems in terms of human health provides important opportunities for the integration of social and health sciences into environmental management (Rapport et al. 1998). Ecosystem health can be linked to the services that ecosystems provide human communities to sustain them (Rapport et al. 1998), resulting in the Millennium Ecosystem Assessment definition of ecosystem
health as “the ability of an ecosystem within its surrounding landscape to continue to provide a particular set of services.” (MA, 2003, p.69)

Health is Multiperspectival

When a problem is being defined, multiple perspectives are brought to the table. Each individual, species, or ecosystem will have its own definition or requirements for health. In order to fully understand the health problem, all of these perspectives need to be acknowledged and explored. Module 6: Participation and Research elaborates on this theme. This exploration often highlights the need to look at health in terms of complex systems [See Module 3: Complexity]. Further, bringing in different perspectives on health can often highlight issues of gender [See Module 5: Gender], power and equity.

Two particular perspectives, “Western” and “traditional” views of health, often clash. On the one hand, Western science is rooted in a worldview which grew out of the dualism of Descartes. In this system there is mind and body, humans and nature; elements which as antitheses to one another. Humans can understand nature because they are separate from it. Following Descartes, Hume and Berkeley introduced the inductive method and modern science as we know it was born (Russell, 1961). The methods presuppose a reductionist view of nature – by reducing nature to its constituent parts, scientists could understand its internal workings (Suzuki and Knudston, 1992). The health sciences, particularly with respect to quantitative methods (see Appendix), have largely adhered to these principals. 

Traditional views, on the other hand, often recognize the complexity of nature. They engage with local dynamics of an ecosystem to try to understand it as fully as possible, while retaining a certain awe of the enigmatic mysteries that nature offers us. Traditional Ecological Knowledge (TEK) is intrinsically ecosystemic and interdisciplinary. Both the scientific information and the methods used bear a striking resemblance to the ecosystem approaches to health. See the Appendix for an example of where differing definitions and a disregard for traditional knowledge led to a backlash. 

There is, however, some convergence between “Western” science and “traditional” views. Einstein’s Theory of Relativity shows that one can never know both the velocity and the position of an object at the same time, Heisenberg discredited Newtonian physics by showing that pausing nature to study it gives a false representation since nature is inherently dynamic, and Bohr demonstrated that the behaviour of subatomic particles can only ever be expressed in terms of probabilities. Further, systems thinking has revealed cases of synergy, where the properties of systems do not seem to equal the sum of their parts. Western science has been criticized as a “disconnected, inadequate description of the whole” (Suzuki and Knudston, 1992). Ecosystem approaches to health attempt to retain a holistic focus.

Negotiating Health

Ecohealth research and practice focuses on process. There can be as many different definitions of health as there are stakeholders. Different perspectives shed light on divergent worldviews and positions that are likely to come to the fore later on. Going through the process of acknowledging different perspectives can also help determine the positions and perspectives that are absent from the discussion. As the number of stakeholders and the complexity of the issue increases, the process of negotiating a common vision of health and of the issue at hand also becomes more complex. Yet, at the same time, the process of negotiating health can help foster a sense of community and better frame health issues. It highlights areas of convergence that can be used to develop a common vision. The focus is on the process instead of the outcomes, allowing us to understand where people are coming from and why they have a particular worldview. It then becomes part of the process of deciding how to go forward with the limitations expressed.

Activities

Specific Readings

Brewer JA, Worhunsky PD, Gray JR, Tang YY, Weber J, Kober H (2011) Meditation experience is associated with differences in default mode network activity and connectivity. Proceedings of the National Academy of Sciences of the United States of America 108: 20254‐20259 

Costanza R, Norton BG, Haskell BD (1992) Ecosystem health: new goals for environmental management. Island Press. 269 pgs. 

Gunnarsson S (2006) The conceptualisation of health and disease in veterinary medicine. Acta Vet Scand 48: 20

Houde N (2007) The six faces of traditional ecological knowledge: challenges and opportunities for Canadian co‐management arrangements. Ecology and Society 12: 34

Kay JJ, Regier HA, Boyle M, Francis G (1999) An ecosystem approach for sustainability: addressing the challenge of complexity. Futures 31: 721‐742

Millennium Ecosystem Assessment (MA) (2003) Ecosystems and Human Well‐Being: A Framework for Assessment. Island Press.

NESH (2011) NESH Approach. Available: http://www.nesh.ca/index_files/Page488.htm [accessed December, 13, 2011]

O’Neil JD, Elias B, Yassi A (1997) Poisoned food: cultural resistance to the contaminants discourse in Nunavik. Arctic Anthropology 34: 29‐40

Rapport DJ, Costanza R, and McMichael AJ (1998) Assessing ecosystem health. Trends in Ecology & Evolution 13: 397‐402

Russell B (1961) History of Western Philosophy. London: Routledge.

Suzuki D and Knudston P (1992) Wisdom of the Elders: Honouring sacred native visions of nature. Toronto: Bantam Books

Vogt K (1997) Ecosystems: balancing science with management. New York: Springer, 470 p. 

WHO (1967) The Constitution of the World Health Organisation. Geneva: WHO

WHO (1978) Declaration of Alma‐‐Ata. International Conference on Primary Health Care, Alma‐‐Ata, USSR, 6‐‐ 12 September, 1978

SECTION 2 — FRAMING AND MEASURING HEALTH

DESCRIPTION

This section explores some ideas about framing, measuring and describing health. The process of framing health in time, scale and along the health continuum will help students identify measurable variables that are indicative of the central processes influencing health within a negotiated definition. This ensures that identified variables address pertinent questions and take into account differences in temporal and spatial scales. Finally, we show how to use a conceptual framework to identify the types of information required and modes of inquiry for accessing this information.

LEARNING OBJECTIVES 

• To frame inquiry within a negotiated, multi‐perspective definition of health.
• To create a conceptual framework to frame and identify key questions.
• To recognize how health determinants act at different temporal and spatial scales.
• To identify indicator variables which address the questions and consider temporal and spatial scales.
• To critically discuss how the choice of conceptual framework and indicators influence the measured or described Health of a system. 

KEY QUESTIONS

Framing health  

• What factors influence the health context?
• How are the chosen concepts/populations/landscapes related or connected?
  – Directly, indirectly, feedbacks?
  – Do they operate on the same temporal and/or spatial scales?

 Developing a conceptual framework  

• What is a conceptual framework?
• What should be included in a conceptual framework and how is this based on the chosen definition of health?
• What are the areas/connections of the concept map [See Complexity Module] or conceptual framework that are of particular interest in your system?
• What populations (human and animal) and ecosystems are involved?
• How are animal health and ecosystem health related to human health?
• How does your specific system map onto the conceptual framework?
• How can you use a conceptual framework throughout the process of studying or addressing health problems?

Measuring and describing health  

• What different types of information and modes of inquiry are needed in order to address each of the spheres involved in the problem? How are they interconnected? Can you develop your intervention or research question so that your results will be complementary to the results of your colleagues from a different field?
• What kinds of variables are indicators of health states or processes? At what temporal and spatial scales are they acting?
• What tools can be used to measure these variables?
• What kind of conclusions can be drawn from these measurements? Do they address key questions?
• How does a project evolve during the different steps of the process? What could you have done differently? 

DISCUSSION QUESTIONS  

• Is there one “correct” conceptual framework?
• How does a conceptual framework change if:
  – You use a different definition of health?
  – Different people are involved in creating it?
• What cannot be included/captured in a conceptual framework?
• Is it possible to measure/describe everything of interest? What cannot be measured or described? How might this influence the interpretation of the results? How might this influence the generalizability or validity of your results?

Key Content

Framing Health

How to frame inquiry within a negotiated definition of health?
Human and ecosystem health, including animal and “vegetal health,” are embedded in multiple scales of ecosystems acting both in space and in time. In order to frame our health questions, it is important to understand this context. The health of the ecosystems and living beings can be affected by a multitude of factors or health determinants acting at different spatial or temporal scales, including both biogeophysical (air, earth, water) and built (houses, public infrastructures, road, etc.) ecosystems. We need to begin by understanding the physical, social and temporal contexts. Figure 1, referred to as an “onion skin diagram,” and developed by Donna Megler (unpublished) helps us to visualize the different contexts – all of which act on health – within which the health of an individual, animal or ecosystem rests.

Further, health is a continuum acting over time and its deterioration is influenced by the severity of the exposure to one or several factors acting simultaneously or not (ex. contaminants, pathogens, socio‐economic context, loss of culture, etc.). How one defines health and frames the health context can have important implications on which part of this continuum one is able to detect or improve on (see Figure 2).

The size of a population at risk of being impacted by a factor (Figure 3) will depend on the health outcome of interest and the health focus (Figure 4). So, how health is defined and how the context is framed has important implications on the target population.

The choices made in defining and framing health, leading to decisions about the size of the target population, in turn has implications on the type of study or intervention that will be carried out. The issue here is whether the focus is on the population as a whole or the individuals in the population. This will have impacts on which scale and moment in time intervention occurs. With a focus on individual health, therapeutic interventions become paramount; but, with a focus on community health, awareness raising and prevention are crucial.

In addition to issues of scale and time, there are a multitude of determinants of health, or factors that influence health outcomes (Figure 5). Increasingly, health practitioners and researchers recognize the social determinants of health, such as lifestyle, nutrition, education, etc. (Lalonde, 1974; CSDH, 2008). The ecosystem approaches to health seek to integrate these social determinants of health with environmental determinants of health, such as climate, housing, exposure to contaminants, etc. This approach leads to a vision of health which requires inquiry using natural, social and health sciences making it inherently interdisciplinary (Figure 6).

Developing a Conceptual Framework

What is a conceptual framework?
A conceptual framework is a visual constructed to outline some of the principal relationships between human health, animal health andor ecosystem health, and other relevant contexts such as economics, policy, culture, etc. The transdicisplinary nature of the ecosystem approaches to health means that most probably a great many factors will be deemed pertinent to the study of a particular health issue. On the other hand, including too many factors paints an unwieldy portrait. Creating a conceptual framework is an art and a balancing act. Conceptual frameworks are constructed to help focus one’s efforts. The process of constructing a conceptual framework leads the
scholar or practitioner to ask themselves many questions about their underlying definitions and the current context for the work. It may highlight areas that were neglected or assumptions that were made, which is in and of itself useful. However, the conceptual framework is also intended to be a road map used to guide the process of studying or improving a health issue, and should be continually consulted and reconstructed.
Note: Social science students may be very familiar with conceptual frameworks, whereas students from the natural sciences may not. This can be turned into a learning point if the reasons for this are discussed. This also means that when creating groups for activities, such as the one suggested at the end of this section, attention should be paid to getting a balance between the social sciences and natural sciences.

How to develop a conceptual framework
Several guiding questions can be used to develop a conceptual framework for addressing ecosystem, animal and human health based on the theory of complex systems and taking into account a negotiated definition of health: 

• How can the issue be framed in ecosystem terms?
• What are the issues related to human, wildlife and ecosystem (natural and built) health?
• What are the links between health and the ecosystem? Are they direct or indirect? Is there retro‐action or feedback loops? Do they operate on the same temporal and/or spatial scales?
• Where does the issue situate itself in the health continuum?
• What are the health determinants?
• Who are the populations involved? Among these populations, are any groups (human, animal or flora) more vulnerable? Are there specific gender and equity issues?
• Who are the important stakeholders and actors involved in the issue? 

From these guiding questions can emerge a wide diversity of conceptual frameworks. Figure 7, 8 and Box 3a present three different examples of frameworks, among many others. The Multiple Exposure Multiple Effects (MEME) model is a framework developed for the World Health Organization by Biggs (2003) to provide the conceptual and theoretical basis for the development, collection and use of children’s environmental health indicators. This model emphasizes the complex relationships between environmental exposures and child health outcomes. Figure 8 is an example of a conceptual framework of an agroecosystem’s health management (Neilsen, 2001). Neilsen (2001) notes of the process of constructing a conceptual framework; “to simplify and identify key relationships within and between ecosystems is helpful in understanding ecosystem functional relationships in pursuing management goals.”

Measuring and Describing Health

The process of defining, framing health and constructing a conceptual framework has identified different determinants, scales, populations, and contexts. Some aspects also need to be fleshed out or measured. Decisions made in the previous phases will have important consequences for the description or measurement of health. The measurements that will be taken or the medium used for describing health will be different according to the organism, population, scale or time frame chosen (e.g. individuals, herds, communities). Defining health in terms of early biological alterations vs. illness or death will mean that more sensitive tests will be required, ones that are on
a continuous scale and which can be conducted on smaller populations, as shown in Figure 9. Further, the ultimate use of the information flows directly from choices made in framing health. For example, focusing on early biological or psycho‐social alterations could eventually lead to preventive actions for a larger population. Ultimately, the process carried out in each project will lead to a unique methodology which is dependant on both technical, disciplinary knowledge and some of the broader considerations described in this module.

The conceptual framework can be broken down into its constituent parts to help identify which types of information are missing and how to go about collecting this information. Appendix Box 2a presents a conceptual framework of the interconnecting spheres of influence of a particular health problem in three separate natural ecosystems. The different components of this conceptual framework were then used in turn to help clarify the different types of information and modes of inquiry needed in order to address each of the spheres involved in the problem. This is a tangible example of how the methods for describing or measuring the different determinants or contexts
surrounding a health issue differ between scales/perspectives.

Two basic types of inquiry are used in studying health: qualitative and quantitative. Both seek to describe and explain phenomena. One of the distinguishing characteristics between the two is the focus on measurement and numeric data in quantitative methods as well as a strong intent to be “unbiased” and founded on the “objective” observation of facts, events and phenomenon. Quantitative approaches use controlled experiments, representative samples, standardized instruments, empiricism, generalization, positivism, and deduction. Results tend to be generated as numbers, percentages, and generalisations (see Appendix). Qualitative methods, on the other hand, recognize that the observer has an inherent bias and that research is conducted to describe and understand certain groups’ experiences, perspectives, etc. Qualitative methods aim to gain an “in‐depth” view based on personal experiences, rather than glean generalizations out of means. Five qualitative approaches are commonly used in the social, behavioural and health sciences: narrative research, phenomenology, grounded theory, ethnography, and the case study (Creswell, 2007). For a description of the modes of inquiry of each, similar to that presented for quantitative methods in Box 4, see chapter 4 in Creswell (2007). Mixed methods are becoming increasingly popular
(Creswell and Clark, 2011; Hesse‐Biber, 2010) and are particularly well suited to issues being examined with an ecohealth lens, as ecohealth projects often integrate several disciplines. The use of a conceptual framework should help in identifying the overall methodological approach (qualitative, quantitative or mixed methods) the appropriate tools and disciplinary knowledge needed to understand health in a particular system. It is important to recognize the limits of these methods and that the very same health issue can be studied from different angles. Examples of Ecohealth case studies using a combination of methodological approaches can be found in Charron et al. (2012).

Both applied research and targeted interventions – either of which can be carried out using an ecosystem approach to health – require a process, beginning with the conceptual phase (described in the defining, negotiating and framing health sections) and leading through to methodological choices, the empirical and analytical stages, and ending in a concerted effort to render the results of the inquiry or intervention available to interested parties. It is important to note that between all these different steps there should be a back and forth process as the comprehension of the health issue evolves in time. A self‐investigation of the process of defining, negotiating, framing and measuring health should be carried out in order to ensure that the best practices have been used in the move from theory to practice (Nguyen, 2011).

Notes: 

• Students might feel uncomfortable with the scope of what is presented here. You can introduce the idea that there is a dilemma between what a student can do and true transdisciplinarity. While it is important to produce good disciplinary research to feed into the overall comprehension of the interdisciplinary framework, this information needs to be somehow integrated at all the different steps of the process.
• To include a section on how to synthesize the breadth of information collected [See Module 3: Complexity].

Activities

Specific Readings

Briggs D (2003) Indicators: Making a difference: Indicators to Improve Children's Environmental Health, Geneva: WHO

Charron D (2012) Ecohealth: Origin and approach, Chapter 1. In: Ecohealth Research in Practice. Innovative Applications of an Ecosystem Approach to Health, Charron, D (editor). Ottawa: IDRC, pp. 1‐30. Available online: http://idlbnc.idrc.ca/dspace/bitstream/10625/47809/1/IDL‐47809.pdf

Creswell JW (2007) Qualitative inquiry & research design: Choosing among five approaches, second edition. Thousand Oaks, California: Sage Publications Ltd. Creswell, JW and V.L.P. Clark. 2010. Designing and conducting mixed methods research. 2nd edition. Thousand Oaks: SAGE Publications.

CSDH (2008) Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. Geneva: World Health Organization 

Fortin M‐F (2010) Fondements et étapes du processus de recherches: Méthodes quantitatives et qualitatives, 2e édition. Montréal: Chenelière Éducation, 632 pages 

Guerin M, Gosselin P, Cordier S, Viau C, Quénel P, Dewailly E (2003) Environnement et santé publique – fondements et pratiques. Paris : Éditions Tec&Doc.
http://www.dsest.umontreal.ca/recherche_rayonnement/environnement_sante_publique.html 

Hesse‐Biber S N (2010) Mixed methods research: Merging theory with practice. New York: Guilford Press.

Lalonde M (1974) A new perspective on the health of Canadians. A working document. Ottawa: Government of Canada

Nielsen NO (2001) Ecosystem approaches to human health. Cad. Saúde Pública 17:S69‐S75

Nguyen V (2011) Understanding the Concept and Practice of Ecosystem Approaches to Health in the Context of Public Health. Master’s thesis. Guelph: University of Guelph, p. 185

Webb J (2010) Environmental Contamination of Fish and Humans through Deforestation and Oil Extraction in Andean Amazonia. Doctoral thesis, Montreal: Department of Geography, McGill University

REFERENCES

Charron D (2012) Ecohealth: Origin and approach, Chapter 1. In: Ecohealth Research in Practice: Innovative Applications of an Ecosystem Approach to Health, Charron, C (editor), Ottawa: IDRC, pp. 1‐30. Available online: http://idlbnc.idrc.ca/dspace/bitstream/10625/47809/1/IDL‐47809.pdf

Forget G, Lebel J (2001) An Ecosystem Approach to Human Health. International Journal of Occupational and Environmental Health 7:S3–38 

Nielsen NO (2001) Ecosystem approaches to human health. Cad. Saúde Pública 17, suppl:S69–S75 

Waltner‐Toews D, Kay JJ, Lister NM (2008) The Ecosystem Approach: Complexity, Uncertainty and Managing for Sustainability. New York: Columbia University Press, 383p.

APPENDIX

The different components of this conceptual framework were used to help clarify the different types of information (Box 2a) and modes of inquiry (Box 2b) needed in order to address each of the spheres involved in the problem. This is a tangible example of how the methods for describing or measuring the different determinants or contexts surrounding a health issue differ between scales/perspectives.