|Reconnecting medicine with public environmental health: an Ecologic Framework It’s January, the time of year when we learn what journal editors and surveys judge to be the prominent scientific breakthroughs in 2014—stories of last year’s successes and future promises. This year in the category of medical breakthroughs, personalized cancer treatments, a few new drugs, brain chips, and apps for tracking fitness are high on many lists. Proposed public health breakthroughs are big data to identify emerging epidemics quickly and the soda tax in Berkeley to combat obesity. Also worth noting—millions of Americans got health insurance for the first time.Most commonly, medical and public health breakthroughs are newly-discovered ways of treating a vexing disease, disease pattern, or some other public health problem—typically introducing a new, targeted technology. At SEHN we are among those who think that the way a problem is framed largely determines what we do about it. It’s why we believe that an ecologic framework should be a starting point from which to hone down on what to do.
An ecologic framework recognizes a progressively nested set of inter-relationships among cells, tissues, organs, people, families, ecosystems, society, and the planet. These are dynamic relationships that change over time—beginning in the womb for each of us individually, while reaching much further back into the history of families, communities, and societies. These multi-level systems create conditions out of which the risk of diseases and their patterns arise.
The origins of most common diseases are multifactorial, meaning they cannot be explained by single gene mutations or single environmental factors. Rather, they arise from combinations of genes, environmental exposures, and behaviors. Even though those combinations frequently differ from one person to another with the same diagnosis—whether diabetes, heart disease, cancer, asthma, or dementia—risk factors that largely determine disease incidence and patterns are spread throughout populations of people. Most common, complex diseases are systems problems and they need to be addressed in that way.
Admittedly, the framework is complex. But when it is applied to any of a number of common diseases it helps us acknowledge their complexity, understand the general architecture of the system that creates the risk, and identify places to intervene. Science has achieved many advances by reducing this complexity to component parts and focusing on only small pieces of it. But that approach has its limits. And when we encounter them, along with continuing the search for the next breakthrough drug or technology, we need to step back and look at the bigger picture.
In this issue of the Networker, we tell two illustrative stories:
The first summarizes the remarkable results of a recent pilot study that framed Alzheimer’s disease as a systems problem. Rather than relying on a single drug focusing on a single pathologic marker, the program was designed to shift biologic systems conditions in the participants. No drug intervention has ever shown this degree of success. Is it a breakthrough? Perhaps. Time will tell. It needs to be replicated in a larger trial. But these dramatic results deserve more coverage and critical scrutiny.
The second is an historical review of a landmark, unprecedented project undertaken in Finland in the 1970s when the eastern region had the highest cardiovascular disease mortality in the world. It illustrates the value of interventions that shift system conditions for an entire population—not just in individuals at high risk of disease.