Ecosystem HealthRestoring the Health in Health Care

Healing the Planet - PGS

John Howard MD, FRCPC

Professor of Paediatrics and MedicineSchulich School of Medicine

University of Western Ontario

Chair, Canadian Association of PhysiciansFor the Environment

Objectives

• To define Ecosystem Health from a health care perspective

• To look at some of our societal beliefs from “outside the box”

• To look how the health of the environment is being eclipsed by “individual human health”

• Describe an Ecosystem Health model for Ontario, and elsewhere

What is Ecosystem Health??

What does Ecosystem Health mean to me?

The UWO Definition

How can it form the basis for medical education and for health care?

The Evolution of the Doctor-Patient relationship

1) Traditional Medical Model

2) Patient-Centered Model

3) Ecosystem Health Model

Traditional Medical ModelWhere we were

PatientDisease

1. What is the disease?

2. How do I fix it?HEALTH

Patient-Centered Modelwhere we are trying to be

PatientDisease

Illness

Context

1. What is the disease?

2. How do I fix it?

3. What is my patient's unique illness??

4. How do I help my patient?

HEALTH

Ecosystem Health

• The health of the “context” and the interaction of the “context” with human health

- the physical, social, economic and political environment

Ecosystem Health ModelWhere we want to go

PatientDisease

Illness

HomeCommunity

RegionWorld

1. What is the disease?

2. How do I fix it?

3. What is my patient's unique illness??

4. How do I help my patient?

5. Why is this patient here?

6. What can I do to prevent others from having the same illness?

HEALTH

Ecosystem Health - Mission

• To train professionals to work with other professions to create a healthier world.

– Transdisciplinary thinking

Ecosystem Health Model

PatientDisease

Illness

HomeCommunity

RegionWorld

Something we care about

1. What is the problem?

2. How do I fix it?

3. What are the unique cultural needs?

4. How do I meet those needs?

5. Why did this problem occur?

6. What can I do to prevent similar problems

HEALTH

So what?

Does it make one think any differently?

Some thoughts about health, health care and the practice of medicine in Canada

What is Health?

HealthPhysical Mental

Nutritional Community

Personal Health

Environmental Social

PoliticalEconomic

Spiritual Moral

Societal Health

Ecosystem Health

Spiritual Health - Aboriginal

The Earth is our Mother, the female giver of Life to all her children, some of whom are human beings.

Decisions must respect 7 generations of our ancestors and 7 generations of our children to come

Moral Health?

$150B$/yr for 15 years would provide safe water and effective sanitation to every person in the world - UNEP Bailout

US $833BEEC $2,000B

Moral Health

6.450Provide safe clean water

19.1150.5TOTAL

0.65Eliminate illiteracy

1.310.5Stabilize population

1.915Provide health care

2.419Eliminate starvation and malnourishment

2.721Provide shelter

3.830Retire developing nation’s debt

Percent of current military spending

Annual cost in billion dollars

Cost of global human need programs

A Modest Proposal:

Alternative Security

Security is better achieved by trying to establish equityrather than dominating

3-4 kilometers per litreWilderness Capabilities

EH Health Care System?

Is our society’s attitude to the environment

morally healthy?

Let’s describe Health inits widest sense:

include moral health andspiritual health!!

Revelations• Many/all diseases have a significant

Ecosystem Health component• We need to put less money in sickness care• Uncertainty is more important than certainty• Bigger is better!• Things can be done!• Accountability should be replaced by

responsibility

Revelations

• Many/all diseases have an ecosystem health component?

• We need to put less money in sickness care• Uncertainty is more important than certainty• Bigger is better!• Things can be done! • Accountability should be replaced by

responsibility

Crohn’s Disease

Number of Paediatric IBD patients diagnosed per year of practice

0

5

10

15

20

25

30

35

1 3 5 7 9 11 13 15 17 19

Other Diseases

• Rheumatoid Arthritis – 2% of the population

• Asthma – 30% of SW Ontario children on puffers at some point in their lives

• Diabetes – massive increase in Type II Diabetes Mellitus – 1997 – 5.8% of US population diagnosed

Is it the environment??

Immunologic disruptors??

Revelations• Many/all diseases have a significant Ecosystem

Health component

• We need to put less money in sickness care!

• Uncertainty is more important than certainty• Bigger is better!• Things can be done!• Accountability should be replaced by responsibility

37%/5years7.4%/year

2006 Ontario Expenditures

Health46%

Social Support

11%

Education18%

Other25%

Environment0%

Sickness

Land, Air,

Water!!

Where are we going?

2010

2016

2044 = 100%Year

% o

f P

rovi

ncia

l Bud

get

Health Care

• NOT a determinant of health

• “The majority of the health care dollar is spent in the last 6 months of one’s life” - 1993

• Average health expenditures on people who are in their last year of life is between 50 and 100 times more than expenditures on those who are not. - Health Canada -2005

Revelations• Many/all diseases have a significant Ecosystem

Health component• We need to put less money in sickness care

• Uncertainty is more important than certainty

• Bigger is better!• Things can be done!• Accountability should be replaced by responsibility

Uncertaintynot part of our vocabulary

• Obsession with certainty– Double blind trials, critical appraisal– Evidenced based medicine

• The present scientific method is about reductionism– Inclusion, exclusion criteria, controls

Uncertainty - not part of our vocabulary

• EH - Can’t find appropriate controls, system has many interactions, etc.– Don’t study it– Absence of data implies no effect

• Complexity ≡ Uncertainty

• Complexity ≠ Complicated

Which is the More Important Question?

• Have pesticides used on land been proven to lead to illness in humans?

• Might pesticides cause illness in humans?

Or both!

Revelations

• Many/all diseases have a significant Ecosystem Health component

• We need to put less money in sickness care• Uncertainty is more important than certainty

• Bigger is better!• Things can be done!• Accountability should be replaced by

responsibility

Systems ThinkingThe Perspective for the 21st Century

23-04-20 40

Need to study big issues!!

Revelations

• Many/all diseases have a significant Ecosystem Health component

• We need to put less money in sickness care• Uncertainty is more important than certainty• Bigger is better!

• Things can be done!• Accountability should be replaced by

responsibility

Things can be done

• Smoking – a once-attractive pastime

• Automobile take-back

• So much potential

• we can be/are opinion leaders

3-4 kilometers per litreWilderness Capabilities

EH Health Care Institution?Advocate health

Revelations

• Many/all diseases have a significant Ecosystem Health component

• We need to put less money in sickness care• Uncertainty is more important than certainty• Bigger is better!• Things can be done!

• Accountability should be replaced by responsibility

Accountability

• Meet minimal standards – Health care:

• Single use instruments• Insurance issues, legal departments

– Much $$ spent on non-medical issues

• Limits boundaries

• One-way accountability

• Focus on practices

Responsibility

• Striving for excellence– Health Care-responsible for health

• Health in its greatest sense– Single use recyclable /Multiple use– Decisions to improve health

– Bidirectional• Public has a responsibility – behaviour,

resources

– Focus on Values

The NeedThe Need

The DesireThe Desire

Learning

• Knowledge

• Skills

• Attitudes (perspectives)

Learning in University

• Knowledge

• Skills

• Attitudes (perspectives)

Global/Ecosystem Health Learning

• Knowledge

• Skills

• Attitudes (perspectives)

How might Ecosystem Health be the basis for

a Health Care System?

A balance

Ecosystem Health Model for Health Care

PatientDisease

Illness

HomeCommunity

RegionWorld

1. What is the disease?

2. How do I fix it?

3. What is my patient's unique illness??

4. How do I help my patient?

5. Why is this patient here?

6. What can I do to prevent others from having the same illness?

People

ess

1. What are the regional diseases?

2. How do we fix them?

3. What are the unique regional problems??

4. How do we best help our people?

5. Why are the diseases happening?

6. What can we do to prevent the diseases/ improve health?

HEALTH

Political

Environmental Social

Economic

Ecosystem Health Model

EH Health Care System

• Disease → Disease + Health

• Focus on the Population/Region

• Consider health in its broadest sense

• Responsibility for health

Is there a crisis?If so what is the crisis?

2006 Ontario Expenditures

Health46%

Social Support

11%

Education18%

Other25%

Environment0%

SicknessHealth