Ecosystem Health
Restoring the Health in Health Care
Healing the Planet - PGS
John Howard MD, FRCPC
Professor of Paediatrics and Medicine
Schulich School of Medicine
University of Western Ontario
Chair, Canadian Association of Physicians
For 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 Model
Where we were
HEALTH
Disease
Patient
1. What is the disease?
2. How do I fix it?
Patient-Centered Model
where we are trying to be
HEALTH
Illness
Disease
Patient
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?
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 Model
Where we want to go
HEALTH
1.
2.
3.
4.
Illness
Disease
Patient
5.
6.
Home
Community
Region
World
What is the disease?
How do I fix it?
What is my patient's
unique illness??
How do I help my
patient?
Why is this patient
here?
What can I do to
prevent others from
having the same
illness?
Ecosystem Health - Mission
• To train professionals to work
with other professions to create
a healthier world.
– Transdisciplinary thinking
Ecosystem Health Model
HEALTH
1.
2.
3.
4.
5.
Illness
Disease
Patient
Home
Community
Region
World
6.
What is the problem?
How do I fix it?
What are the unique
cultural needs?
How do I meet those
needs?
Why did this problem
occur?
What can I do to
prevent similar
problems
Something we
care about
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?
Spiritual
Environmental
Moral
Social
Nutritional
Community
Physical Health
Mental
Personal Health
Economic
Political
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
Bailout
every person in the world - UNEP
US $833B
EEC $2,000B
Cost of global human need programs
Annual cost in Percent of current
billion dollars
military spending
Provide safe clean water
50
6.4
Moral
Health
Retire developing
nation’s debt
30
3.8
Provide shelter
21
19
2.7
2.4
15
10.5
5
150.5
1.9
1.3
0.6
19.1
Eliminate starvation and
malnourishment
Provide health care
Stabilize population
Eliminate illiteracy
TOTAL
A Modest Proposal:
Alternative Security
Security is better achieved by
trying to establish equity
rather than dominating
EH Health Care System?
3-4 kilometers per litre
Wilderness Capabilities
Let’s describe Health in
its widest sense:
Is our society’s
include
attitudemoral
to the health and
environment
spiritual health!!
morally healthy?
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
35
30
25
20
15
10
5
0
1
3
5
7
9
11
13
15
17
19
Immunologic disruptors??
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??
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%/5years
7.4%/year
2006 Ontario Expenditures
Other
25%
Environment
0%
Land, Air,
Water!!
Health
Sickness
46%
Education
18%
Social
Support
11%
Where are we going? 2016
2010
% of Provincial Budget
50
45
40
35
30
1991
1996
2001
2006
Year 2044 = 100%
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
Uncertainty
not 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 Thinking
The Perspective for the 21st Century
Need to study big issues!!
2016-03-14
40
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
EHAdvocate
Health Care
Institution?
health
3-4 kilometers per litre
Wilderness Capabilities
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 Need
The 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
Ecosystem Health Model
for Health Care
Environmental
HEALTH
Illnesses
Diseases
Patient
People
Economic
Home
Community
Region
World
1.
1.
2.
2.
3.
3.
4.
4.
5.
5.
6.
6.
What
Whatare
is the
thedisease?
regional
Social
diseases?
How do I fix it?
How
them?
Whatdo
is we
my fix
patient's
What
unique
are
illness??
the unique
regional
How do problems??
I help my
How
patient?
do we best help
our
people?
Why
is this patient
Why
here?
are the diseases
happening?
What can I do to
What
prevent
canothers
we dofrom
to
Political
prevent
having the
the same
diseases/
improve
illness? health?
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
Other
25%
Environment
0%
Health
Education
18%
Social
Support
11%
Health
Sickness
46%