I.	Editor's Note - Ecological Medicine	Carolyn Raffensperger
			II.	The Case For Ecological Medicine	Ted Schettler
			III.	Ecological Medicine: A Call for Inquiry and Action	February 2002

I. Editor's Note - Ecological Medicine

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By Carolyn Raffensperger Its always dangerous to hold staff or board meetings at the Science and Environmental Health Network because someone might ask a question that will launch entire new projects or turn our thinking inside out. On our staff we have a botanist (Mary O'Brien), a writer (Nancy Myers), and a physician (Ted Schettler). Ted has co-authored two books, one on reproductive toxicants and the other on neurotoxicants and learning disabilities. One day we asked, "What would a learning disorder look like in a Florida panther? What would a reproductive disorder look like in a Burr oak tree?" At the same time my husband and I were immersed in the medical world because of his metastatic cancer. How could we make choices that promoted healing and didn't cause further damage in the world? How could we invite our healers into a full ecological analysis? None of these were easy questions. But then, neither were the questions that had been posed by the Health Care Without Harm Campaign when it began dealing with toxicants like dioxin and mercury in health care. Or the questions asked by the environmental health movement as it sought to implement the precautionary principle in place of policies of measuring and managing risk. In February of this year SEHN convened a meeting to weave together many questions under the rubric of ecological medicine. We hoped to find some answers. Gathered at Commonweal in California were ecologists, physicians ministering to those in refugee camps, pioneers in the environmental health movement, the managing trustee for the free people's clinic in Bhopal, philosophers and many others. We offer the statement defining ecological medicine and a call to action written by this group. Preceding the ecological medicine statement is Ted Schettler's analysis of why we need new thinking about health and medicine. Two ideas might season your thinking on this topic as you read the rest of the newsletter, one from Aldo Leopold, the other from Wendell Berry. Aldo Leopold defines health as the internal capacity of the land or the organism for self-renewal. (Sand County Almanac) Wendell Berry says "health is membership" (Another Turn of the Crank). To your health! To the health of the Earth!

II. The Case for Ecological Medicine

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By Ted Schettler, MD MPH Medical advances have resulted in substantial decreases in morbidity and mortality in many parts of the world. Some of these advances come at considerable economic as well as environmental costs, and benefits are not equally distributed. Now medicine and public health struggle to address the changing patterns of disease resulting both from a rapidly changing and degraded earth and from the ways people live on it. In 1977, George Engel, professor of psychiatry and medicine at the University of Rochester, wrote a paper published in Science called "The Need for a New Medical Model: A Challenge for Biomedicine."1 Engel contended that medicine was in a crisis that derived from adherence to an outdated model of disease. He developed an argument for a biopsychosocial model of illness and disease, arguing that exclusion of psychosocial factors distorted perspectives and even interfered with patient care. "The boundaries between health and disease, between well and sick, are far from clear and never will be clear, for they are diffused by cultural, social, and psychological considerations." Engel's arguments were revolutionary at the time, but they have since entered the mainstream. No well-informed physician today can doubt that psychosocial factors impact a patient's health and response to care. It seems, however, that Engel's ideas need to be expanded. Engel encouraged us to consider how the psychosocial environment impacts human health and to incorporate those factors routinely into medical practice. It was a step toward getting us to think about other impacts of the environment on health--beyond social conditions to include the environment writ large. The Changing World In 1998, Jane Lubchenco, outgoing president of the American Association for the Advancement of Science, urged scientists to rethink their social contract with the public.2 "Part of our collective responsibility to society must include a scientific community-wide periodic reexamination of our goals and alteration of our course, if appropriate," she said. "Despite the plethora of reports examining the future of the scientific enterprise, I see the need for a different perspective on how the sciences can and should advance and also return benefit to society. This different perspective is firmly embedded in the knowledge of specific, identifiable changes occurring in the natural and social worlds around us." Some of those changes are the following: Over 6 billion people inhabit the planet, and reasonable mid-level estimates predict 9-10 billion by mid-century. Two and a half more "earths" would be needed to support today's population if everyone were to use as many resources as Americans do. Stratospheric ozone depletion is the direct result of the release of ozone-depleting chemicals used for various industrial and agricultural purposes. Carbon dioxide concentration in the atmosphere has increased by nearly 30% in the last 150 years. Human activities are responsible for more atmospheric nitrogen fixation than all other sources combined. Nitrates contaminate ground water and surface water, and nitrous oxides the air, at toxic concentrations. Humans are responsible for more mercury deposition on the surface of the earth than from other geological sources. Freshwater and marine fish are sufficiently contaminated with mercury to require warnings to women of reproductive age to limit consumption because of risks to fetal brain development. Large numbers of plant and animal species have been driven to extinction, and most marine fisheries are severely depleted. More than half the world's coral reefs are threatened by human activities. Novel synthetic industrial chemicals contaminate the world's ecosystems, its human and non-human inhabitants, their breast milk and egg yolk, ovarian follicles, and amniotic fluid. The toxicity of most is little known. Changing Patterns of Illness At the same time patterns of human disease are changing throughout the world. To remain focused on increases in life expectancy and decreasing child mortality in many parts of the world is to miss the "essential newness" of environmental change and associated diseases.3,4 Newly emerging infectious diseases and new geographical distribution of older infectious diseases illustrate the capacity of microorganisms to evolve and adapt to changing circumstances. Antibiotic resistance, including multidrug-resistant tuberculosis, is increasingly common. Chronic diseases like hypertension, heart disease, diabetes, and asthma are increasing throughout much of the world. Depression and other mental health disorders are becoming new public health threats in many parts of the world with profound consequences for individuals, families, and communities. Nearly 12 million children in the US (17%) suffer from one or more developmental disabilities. Learning disabilities alone affect 5-10% of children in public schools, and these numbers are increasing. Attention deficit hyperactivity disorder conservatively affects 3-6% of all school children, and the numbers may be considerably higher. The incidence of autism is increasing. The age-adjusted incidence of melanoma, lung cancer in women, non-Hodgkins lymphoma, and cancers of the prostate, liver, testis, thyroid, kidney, breast, brain, esophagus, and bladder has increased over the past 25 years. In the US, the incidence of some birth defects, including hypospadias, cryptorchidism, some forms of congenital heart disease, and obstructive disorders of the urinary tract is increasing. Sperm density is declining in some parts of the US and elsewhere in the world. Asthma prevalence and severity are sharply increasing throughout the world, often in epidemic proportions. Smoking, sun exposure, and diet explain few of these trends. Genetic factors explain, at most, about half of the population variance for a few of these conditions and far less for the majority of them. Improved understanding of development of the brain, immune, reproductive, respiratory, and cardiovascular systems and of gene-environmental interactions leads to the conclusion that other environmental factors contribute significantly to impairments. In laboratory animals, wildlife, and humans, considerable evidence documents a link between ambient levels of environmental contamination and malignancies, birth defects, reproductive success, and impaired behavior and immune system function. Medicine's Failure But there is more to the story. During the past 25 years, the medical-industrial complex has grown enormously in the US, and it now represents about 12% of the GNP. Its reach into many corners of our social and political institutions is extensive--patient care facilities and all the support services that these complex institutions require; medical device manufacturers; a large government, university, and corporate research enterprise; pharmaceutical sales; insurance companies; government regulatory agencies; public utilities; and so on. Ironically, during this time of unprecedented global environmental change, the expanding medical industrial complex has itself contributed substantially to environmental damage through the manufacture, use, and disposal of an extensive array of materials, including toxic substances like mercury, cadmium, solvents, dioxin precursors, cleansing agents, and pharmaceuticals. Health care institutions use large amounts of water and are second only to manufacturing in electricity consumption on a square foot basis. The exhaust from vehicles traveling to and from medical facilities adds considerably to resource depletion and air pollution. Some of these environmental threats are unique to the health-care industry. Others are shared by other industrial sectors. In sum, health care delivery services that are essential for addressing the "essentially new" ecological changes in the world also contribute to environmental degradation and resultant diseases. Like other enterprises intended to focus on the public good in return for public support, medical and public health practices have attempted to respond to societal needs as they were perceived and articulated in the last century. But even by prevailing standards, the shortcomings of the dominant medical model have become apparent. Some alternative or complementary forms of individual medical care address these deficiencies in substantive ways. A less positive result has been a weakening of the public health system. The public health approach, which emphasizes primary prevention for individuals, families, and communities, has often stood in contrast to and competed unsuccessfully for resources supporting the biomedical model of treating disease. And environmental health is often narrowly imagined as dealing with little more than the impacts of air, water, or food contamination on the wellbeing of people. The New Context The context for any of these approaches or practices has fundamentally shifted, and a new perspective is needed to guide how medicine advances and returns benefit to society. This perspective must be embedded in knowledge of changes in the natural and social worlds, and the shifting patterns of disease. Indeed, not only must health care providers and institutions reexamine their stance in the world, but all individuals and communities would do well to become aware of how their wellbeing is connected to other people, other species, and the natural world. The challenge is to integrate an ecological perspective into health care and public health practice in ways that demonstrate understanding of the identifiable changes occurring in the natural and social worlds around us, as we collectively develop the new social contract for medicine. References 1. Engel G. The need for a new medical model: A challenge for biomedicine. Science 196(4286):129-136, 1977. 2. Lubchenco J. Entering the century of the environment: A new social contract for science. Science 279:491-497, 1998. 3. McCally M. Environment and health: an overview. Can Med Assoc J 163(5):533-535, 2000. 4. McMichael A. Global environmental change and human health: new challenges to scientist and policy maker. J Public Health Policy 15(4):407-419, 1994.

III. Ecological Medicine: A Call for Inquiry and Action

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February 2002 Ecological Medicine is a new field of inquiry and action to reconcile the care and health of ecosystems, populations, communities, and individuals. The health of Earth's ecosystem is the foundation of all health. Human impact in the form of population pressure, resource abuse, economic self-interest, and inappropriate technologies is rapidly degrading the environment. This impact, in turn, is creating new patterns of human and ecosystem poverty and disease. The tension among ecosystem health, public health, and individual health is reaching a breaking point at the beginning of the Twenty-First Century. Public health measures, education, and medical advances have significantly reduced death and disease in many parts of the world, but some advances come at considerable cost, and the benefits are not equally distributed. Public health systems charged with creating healthful conditions for all have suffered in competition with technologically intensive health care aimed at individual consumers. Health care systems struggle to keep up with the changing patterns of disease that result both from a rapidly changing and degraded Earth and from the way people live. New and old diseases spread with increasing speed within and across national borders. Meanwhile, industrially based medicines and technologies that heal also contribute to the growing burden of environmental toxins in people, air, water, fish, animals, and plants. (See "The Case for Ecological Medicine," Article II.) Healing disciplines and movements of public health, ecology, conventional medicine, complementary and alternative medicines, conservation medicine, conservation biology, and campaigns such as Health Care Without Harm have sought to address this cycle of conflict among individual health, public health, and ecosystem health in different ways. Ecological Medicine honors these contributions and builds upon them. Ecological Medicine invites the biomedical community, ecologists, scientists, activists, and individuals who are concerned for personal health as well as the health of communities and future generations to learn from each other and to embrace a balanced, ecological approach to sustaining health. Ecological Medicine integrates the following concepts and values: Interdependence. Each of us is deeply connected with Earth's ecosystems; each of our lives is only a moment in the grand scale of time. Ultimately, we all depend on the health of the global community and of Earth's biosphere for our own health and happiness. Individuals cannot live healthy or happy lives in poisoned ecosystems and unhealthy communities. By the same token, healthy communities and biological systems depend on human restraint and responsibility in technologies, population, production, and consumption. Resilience. Health in humans and ecosystems is not a steady state but a dynamic one marked by resilience. Both medicine and ecosystem science and management should focus on promoting and restoring the innate ability of biological systems to protect themselves, recover, and heal. Systems that draw upon or mimic the elegance, economies, and resilience of nature offer promising paths for health care research and development. "First, do no harm." Health care should not undermine public health or the environment. This precautionary principle should be applied to decisions affecting the ecosystem, populations, communities, and individuals. Appropriateness. "Medicine," in its Greek origins, means "appropriate measures." The goal is to achieve maximal health with minimal intervention, promoting good health that is appropriate to an individual's stage of life without overburdening Earth's life-sustaining processes. Diversity. Health is served by diverse approaches, including many traditional healing systems, local adaptations, and indigenous science around the world. Ecological Medicine encourages freedom of medical choice, guided by informed consent and compassionate practice. Cooperation. In order to gain knowledge and improve practices, patients should be partners with practitioners, and medical professionals should cooperate with ecologists and other students of the natural world. Health care organizations should be managed with the active participation of the communities they serve, while communities must learn to integrate their welfare with that of their regional ecosystems. Reconciliation. Individual health care services should be economically sustainable, equitable, modest in scale, of high quality, noncommercial, and readily available to all. Societies should build and maintain infrastructures that assure all citizens the capability to meet basic needs such as health, nutrition, family planning, shelter, and meaningful work while minimizing harm to the Earth. Societies should increasingly devote their material and creative resources to policies and projects that restore and maintain the health of biological and human neighborhoods. All efforts to improve human welfare must be conducted within a cooperative framework established by the health of the Earth. Ecological Medicine sounds an urgent call to action. Understanding the ominous changes in the biosphere compels us to act, individually and collectively. Whether it is in the way we build clinics and hospitals; make, grow, and use medicines; choose areas for scientific study; communicate across disciplines; conduct public health services globally and in particular communities; or choose the means of maintaining our own health, we must do so with a commitment to enhancing life on this planet. Signatories Kenny Ausubel Founder, Bioneers* Janine M. Benyus, Natural Sciences Writer and Author, Biomimicry: Innovation Inspired by Nature The Biomimicry Guild* Charlotte Brody, RN, Executive Director Health Care Without Harm Gary Cohen, Executive Director Environmental Health Fund* Tracey Easthope, MPH, Director Environmental Health Project, Ecology Center Kathy Gerwig, Director Environmental Stewardship and National Environmental, Health, and Safety Operations Kaiser Permanente Tom Goldtooth Indigenous Environmental Network* Robert M. Gould, MD No affiliation indicated (eds.) Louis J. Guillette, Jr., PhD, Distinguished Professor of Zoology University of Florida Andrew Jameton, PhD, Professor Department of Preventive and Societal Medicine John M. Last, MD, Emeritus Professor of Epidemiology University of Ottawa Michael Lerner Commonweal Michael McCally, MD PhD, Professor of Public Health and Preventive Medicine Oregon Health and Sciences University Laurie Monti, PhD, Assistant Professor Ecological Restoration Institute Northern Arizona University Nancy Myers, Communications Director Science and Environmental Health Network* Gary Nabhan, PhD, Director Center for Sustainable Environments Northern Arizona University Jonathan A. Patz, MD MPH, Director Program on Health Effects of Global Environmental Change Department of Environmental Health Sciences Johns Hopkins University, Bloomberg School of Public Health Carolyn Raffensperger, MA JD, Executive Director Science and Environmental Health Network* Eric Rasmussen, MD FACP, Commander Medical Corps, U.S. Navy Adjunct Professor of Public Health San Diego State University Carebridge* Satinath Sarangi, Managing Trustee Sambhavna Trust* Bhopal (India) People's Health and Documentation Clinic Ted Schettler MD, MPH, Science Director Science and Environmental Health Network* Julia Walsh, MD DTPH, Adjunct Professor Maternal and Child Health and International Health University of California, Berkeley Bay Area International Group* Mark Jerome Walters, DVM Harvard Medical School Peter Warshall Peter Warshall and Associates *represents organization's endorsement. Other affiliations are for identification only.