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