Ecological Medicine - October 2002
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!
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
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
- 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
- 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
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.
- 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
- 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
- Asthma prevalence and severity are sharply increasing throughout the world,
often in epidemic proportions.
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
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.
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
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.
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
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:
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.
- 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.
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
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 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
Satinath Sarangi, Managing Trustee
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 and Associates
*represents organization's endorsement. Other affiliations are for identification only.