Ecological Public Health: reshaping the conditions for good health

Like many people in public health of my generation, John Ashton and Howard Seymour's book, The New Public Health was an inspiration. It plotted a path of public health from its Victorian roots to the 1980s. Many people I speak to who have read the book are particularly impressed by a series of photos from a class of schoolchildren in Liverpool going back 100 years. From stunted, adenoidal faces in the late 19th century to the smiling, white-toothed, well-looking children of the 1970s the pictures are a graphic illustration of the progress made in public health over that time. The Health For All ambition of the 1980s and the Ottawa Charter on which it is based, and which are described in detail in the book, saw public health building on that legacy by making cross-sectoral alliances at all levels in society. Working in settings such as the school and prison, working with partners in the voluntary sector, local government and health services at district, city and national level and forging alliances across nations we could fashion a future which would achieve this lofty goal of Health For All by the year 2000. But the dream has gone sour. A countervailing current of neo-liberal economics has played out across the globe since the 1980s creating greater inequality between people within and between nations than ever before. Furthermore, as our industrial culture expands and consumes ever-increasing amounts of material resources, chickens are coming home to roost, not least in the guise of climate change and other major environmental challenges. The time is ripe for a new framing for public health. Might Ecological Public Health: reshaping the conditions for good health signal a fresh approach? Both Geoff Rayner and Tim Lang are prominent figures in the public health field. Rayner has a background in environmental health and led the UK Public Health Association for some years. Lang was the first Professor of Food Policy in the UK. He invented the idea of "food miles" which describes the distance between the place where food is produced to where it is eaten. Both have a base at City University in London and have collaborated on a number of papers and projects in recent years relating to food, obesity and wider public health issues. Their new book is an impressive synthesis of the knowledge and practice of public health, which they have accumulated and developed over many years. But the question remains whether the book signals a significant shift from the previous traditions of public health or suggests an incremental improvement on it. The book is in three parts. The first part is entitled, "Images and models of public health" which introduces the idea of ecological public health. This is built around four dimensions of existence "material, biological, social and cultural". The authors then go onto describe a series of images of public health – public perceptions of what it aims to do. These include the application of science, state control and intervention in people's lives ("Big Brother"), combatants in the race against microbes and activists campaigning against anti-health forces. These images are a reflection of how society has multiple views on public health and are deeply embedded within its culture and structure. The second chapter explores some definitions of public health making the point that in the 21st century it is necessary to recognise that human health and eco-system health are co-dependent. With this in mind, they go on to set out a series of ambitions for the future to help us engage with the challenges of public health more effectively. The first of these is to recognise the challenge of complexity regarding this as essential given the inter-connectedness of the problems facing human health today. The authors then set out further ambitions including the need for a compelling narrative, inter-disciplinary approaches, democratic renewal and a rethink of public health based on ecological principles. In the third chapter of Part One, Rayner and Lang review the history of public health through five different lenses, which they call models: sanitary-environmental, social-behavioural, bio-medical, techno-economic and ecological. For anyone new to the field of public health, the book is worth obtaining for this chapter alone. It is a substantial review of the theory and practice of public health in the last two centuries and is well illustrated. Part Two is most substantive part of the book. It describes a series of transitions which public health will need to address in this century. The authors rightly point out that in the past, public health has tended to focus on two transitions – that of demography (both the size and age-structure of populations) and epidemiology (the pattern of disease). They set out to expand this with seven more transitions: urban, energy, economic, nutrition, biological, cultural and democratic. They realise that this excludes other possible transitions, but argue these transitions are those most relevant to their desire to establish a framework for ecological public health. Each of these transitions is mapped with scholarly detail. Each chapter is a useful introduction to both the transitions and the contested nature of their causes. The final part of the book is titled, "Reshaping the conditions for good health" and contains just one chapter, "The implications of ecological public health". The authors list eight implications in total and, since these encapsulate some important conclusions, it is worth exploring a few of them in detail. The first is to "Use ecological thinking to address public health". The implication in this statement is that there are no "silver bullets" in 21st century public health, which in the complex environment of today is very much the case. Nothing a simple as removing the handle on the water pump in Soho Square and hence curbing a cholera outbreak is likely to work. However, the authors also state the need to look upstream at prevention, rather than downstream at treatment of disease. In viewing public health in this dichotomous way, the authors are slipping into a linear trap, rather than embracing a complex view of reality. A different framing of 21st century public health suggests the river metaphor works better if we see ourselves as all swimming in it, some rather better than others. The task of the future public health becomes less the task of stopping people falling in, but helping them swim and enjoy the thrill, whilst they are at it. The next implication is to "Use the four dimensions (material, biological, social and cultural) to address complexity". Clearly four dimensions is better than one, but if we are truly to address complexity, we have to let go of categories altogether. If readers of this review have stayed with me to this point, you will have seen a trend in this book towards lists and taxonomies. Yet these are the very antithesis of truly ecological, complex, holistic thinking. Every now and again, the authors allude to different framing, when for example, they mention Murray Gell-Mann's description of life as a complex adaptive system. They recognise that his perspective invokes a "planetary consciousness and a sense of solidarity with all human beings and, to some extent, all other living beings. His was big thinking indeed!" Rayner and Lang can't quite take on this "big thinking" about complexity. Instead they say, "Our task was framed by our focus on health. Gell-Mann's was all life, essentially a major updating of the Enlightenment". For me, this is a critical shortcoming. Whilst espousing the need for an understanding of complexity to address modern public health challenges, they fail to engage fully with the implications. They see the connection between human health and the health of eco-systems, yet are not able to see they form part of a larger "complex adaptive system" which we call life. Interestingly, they almost contradict themselves in their final point as I will explain later. The third implication of ecological public health is to recognise the nine transitions, which they described earlier in the book as critical future determinants of health. They also recognise that nine is not an exhaustive list. I would agree. Tony Hodgson, for example, has recently described a World Model with twelve points to represent the key factors, which determine the health and sustainability of human societies. Hodgson also recognises these domains are not just in transition, which suggests smooth trends, but are subject to major discontinuities or shocks. In future, society will need to be resilient in the face of massive uncertainties. Again, I was surprised not to see more emphasis on resilience as a key component of ecological public health. The next implication is to invoke the public health imagination. This makes the important point that we have to envision our future if we want to shape it in a positive way. Having heard Tim Lang speak on several occasions, I know how capable he is of articulating this. Unless we imagine a positive future for ourselves, we cannot select from the present the promising innovations, which are likely to contribute to its emergence. Interestingly, the authors write about seeing the example from a healthy town and imagining it spreading it across society. What is lacking from this section are two thoughts: when we collectively imagine a healthier future we encounter tensions between different values and also, stepping into the unknown future takes personal courage. As Maureen O'Hara and Graham Leicester have described in their book, "Dancing at the Edge", it is often helpful to start small, but act in a way, which models the culture we want to live in. The authors are to be congratulated for their critique in the next section of evidence-based public health. They describe this as a need to shift from evidence to knowledge and state for example, "Whilst statistical methods can help resolve some difficulties, they cannot replace the value of human scrutiny, argument and judgement." I would go further and suggest that since ecological public health is based on complexity theory, where causes are effects and effects are causes, there simply is no evidence base currently for effective action. The future public health needs to not just learn to plan based on what we currently know, but in Don Michael's phrase, "plan to learn". Further implications of ecological public health include the need to re-invigorate public health institutions and recognise that many improvements in public health have come about through social movements. In terms of their budgets, traditional public health bodies such as the World Health Organisation and the UN are dwarfed by the multi-national corporations. MNCs have a track record in lobbying intensely to maintain their stranglehold on trade and suppressing controversial evidence of their harm, even if this is damaging to health. However, social movements in public health have become fragmented and confused. Knowing that both authors have considerable track records in leading public health movements, it would have been good to hear a bit more about their thoughts on responding to this challenge. The final implication of ecological public health is to unify natural and human sustainability. This is the very point they were reluctant to embrace in Part Two, that natural and human systems both contribute to a larger life-death-life process, which Gell-Mann would describe as a complex adaptive system. They get close to recognising this inconsistency, by stating that a new Enlightenment is needed in the 21st century. They suggest that as "sustainability is the single greatest challenge to the Enlightenment tradition of progress … it is its inheritor". They point to the importance of a vigorous debate about progress in the context of an economy based on ecological principles – what Tim Jackson has described as "prosperity without growth" and suggest the public health movement is well placed to lead and participate in this debate. Overall, Ecological Public Health provides an impressive overview of the history, theory and current challenges in public health. Many of the significant figures and achievements of public health are mentioned. The case for change and a fresh approach to public health for the 21st century is clearly made. I hope this book will lead to further explorations and debate in public health about the underlying shift in mindset we will need to embrace if we are to engage with the complexity and uncertainty of the health challenge ahead.