THERE IS NOT ONE HEALTH, THERE ARE MANY

Health across Cultures and Time

The definition of health has been changed by, adapted to, and rooted in our worldviews. Some of the earliest conceptions of health failed to see a distinction between our health and the health of the world around us. Understanding the land and the sustainable use of its resources were essential skills for providing for families and communities for many generations. Relationships with nature provided key contributors to health, including basic needs like food, water.

shelter, riches, and happiness from deeply held cultural and spiritual connections with nature (Summers et al., 2012). These relationships and elements, when put together, are what health promotion specialists now call environmental and social determinants of health.

Some Indigenous peoples see health not as physical well-being of an individual but as the well-being of the whole community from a whole-life perspective. The tradition of taking a long-term view to health aligns with dedication to sharing and protecting the land to preserve its benefits for future generations. The interconnection of land, language, and culture are the foundations of health and wellness for many Indigenous peoples (see Chapter 14 for a specific example). Their land-health connections are formed from specific localized knowledge coupled with layers of personal and family experience (Johnston et al., 2007). Indigenous ways of knowing and being generally place environmental determinants on par with social determinants as positive contributions to health and wellness (Scott, 2005). Research and management that separate land use and health promotion are inconsistent with many Aboriginal and Indigenous people’s perspectives of health being the result of a complex interplay between environmental, social, and individual characteristics.

The idea that health is a product of our interactions with the world around us can also be found in the writings of the ancient Greeks who recognized that good health was determined by natural rather than supernatural causes and that health could not be dissociated from physical and social environments (Tountas, 2009). The need for harmony between the individual, social, and natural environments is reflected in Hippocrates’ w'riting. Hippocrates advocated for physicians to tailor treatments by paying attention to the characteristics of each person, his or her daily habits, the place he or she lived in. and the season of the year. Understanding the natural and built environment was essential to a proper health investigation. Several Asian traditions similarly view health as a harmonious equilibrium between internal elements, environmental conditions, and external sources of harm (Chan et al., 2002; Tai, 2012). Health, in these traditions, is not just about the condition of the body but also about the relationship between the complete person, his or her social environment, and the natural environment.

The path to separating an individual’s health from his or her environment began in Western cultures in earnest when taboos against dissection opened new opportunities to understand anatomy, physiology, and pathology. With the invention of the microscope, the doors to microbiology began to open. These advances heralded a shift in emphasis in the health professions from keeping people healthy to reducing suffering and aiding in recovery from specific diseases. By the late 18th and early 19th centuries, it was now possible to cure people of certain afflictions. At the same time, public health gains started coming from interventions directed at people’s relationship with their world, such as what they ate and where and how they lived. Health as the absence of disease developed its primacy in this phase of Western medicine.

The advent of statistics further shaped our view of health. The use of population data on trends and patterns of disease helped to identify circumstances and situations that predisposed to disease. Coupled with the germ theory. Western medicine was now adept at linking disease to specific causal factors. Statistics redefined what we meant as normal. No longer was normal what we usually saw- in our daily existence, but rather where an individual fell within the range of an attribute with respect to the rest of the population. Volumes were published that began to medicalize health by classifying people as healthy or unhealthy based on the comparison of their clinical or sub-clinical signs of change or possession of a risk factor in comparison to a statistically expected normal.

Health took on a new social meaning in the Industrial Revolution, where a healthy workforce w'as defined as one that enjoyed good conditions and w-orking ability and suffered few lost w-orkdays due to illness. Darwinism began to tie the meaning of life to physical survival. The idea that health allow-ed people to tolerate and resist not just biological hazards but also environmental influences began to emerge. Coupled with earlier success in social engineering to reduce diseases such as tuberculosis, these insights began to re-tie health to our relationships with the world around us (Svalastog et al., 2017). In 1948, the World Health Organization (WHO) declared that health w'as not merely the absence of diseases but rather a state of complete physical, mental, and social well-being. This definition w'as applauded for recognizing the coexisting physical, mental, and social domains of health, but it was criticized on tw-o fronts. Firstly, the ideal of complete well-being in each of those domains would be hard to achieve and even harder to recognize. Secondly, it unintentionally medicalized society by expanding the scope of factors for medical practice to measure. It unintentionally allowed health professionals to categorize more people as unhealthy most of the time because they were unable to attain full satisfaction of all physical, social, and environmental determinants of health (Huber et al., 2011).

The WHO’s Ottawa Charter for Health Promotion (1986) and the concept of salutogenesis, introduced in the 1970s-1980s, emphasized health as the capacities and resources needed to adapt to, respond to, or control life’s challenges and changes. The salutogenesis concept asks why an individual, group, or community stays well despite stressful situations and hardships (Eriksson and Lindstrom, 2006). The Ottawa Charter advocated for resources, capacities, and processes that enable people to have the opportunity to lead a good life. The Ottawa Charter guided the development of health promotion and shaped modern public health practice. It focuses on building healthy public policy, creating supportive environments for health, strengthening community actions, developing personal skills, and reorienting health services to enable people to increase control over and improve their health by realizing aspirations, satisfying needs, and coping with their environments (WHO, 1986). The health of individuals, communities, and environments were once again connected through the concept of reciprocal care outlined in the Ottawa Charter. The Charter declared that the “overall guiding principle for the world, nations, regions and communities alike, is the need to encourage reciprocal maintenance - to take care of each other, our communities and our natural environment.” Explicit attention to the links between people and their environment became the basis for a socio-ecological approach to health.

TABLE 2.1

Comparing Human Determinants of Health with Those Proposed for Fish and Wildlife

Human Determinants of Health

Fish and Wildlife Determinants of Health

Biological endowment

Biological endowment

Physical environment

Abiotic environment

Health services

Human expectations and policies

Healthy child development

Education

Personal health practices

Social environment

Inter- and intra-specific social environment

Social support and social status

Gender

Culture

Income and employment

Access to the resources for daily living

Source: Adapted from Wittrock et al„ 2019. See Figure 1.1 for additional details.

Population health became a foundation of public health policy and practice in the 1990s. This approach assesses health status and inequities over the lifespan at the population level. It captures not only adverse outcomes like disease but also the positive dimensions of health. The concept of determinants of health is fundamental to the population health practice. The determinants of health are those individual and collective factors and conditions that enable a person or population to be healthy. For people, these include income and social status, employment and working conditions, education and literacy, childhood experiences, physical environments, social supports and coping skills, healthy behaviours, access to health services, biological and genetic endowment, gender, and culture (WHO, 2020). Similar determinants have been found for fish and wildlife (Table 2.1).

Population health considers the entire range of determinants of health, as well as their interconnections, when planning population or community-level interventions to promote and protect health before a disease occurs. This approach recognizes health as a cumulative effect requiring a combination of health protecting and promoting actions. It aims to manage the root causes of health problems or benefits by working on the social or environmental drivers of vulnerability and resilience. The philosophy guiding population health is that action on root causes has greater potential for health gains even if the root causes are difficult to change.

With the advent of health promotion and population health, we have seemingly come full circle to Indigenous ways of knowing and the lessons of Hippocrates that saw' health as a product of our interactions with the w'orld around us. Health is not just about the state of an individual but also about the state of his or her environmental, social, and economic conditions and of the community, social, and political processes that shape those conditions. Each of the perspectives briefly described above can still be found today. The prevailing Western notion of health is but one of many ways people describe their health, their community’s health, and the health of the world around them. As we expand beyond the realm of human health, the concept of health becomes even more diverse.

Animal Health

The history of animal health parallels that of human health in many ways. Different sociopolitical situations have been associated with differences in how- animal health and welfare are viewed. Buddhism and Hinduism, for example, do not share the Judeo-Christian view that people have dominion over animals. This fundamental difference influences attitudes towards animal use, abuse, health, and wellness. With globalization and increasing affluence around the world, these differences seem to be changing. Chinese concepts of animal welfare, for example, are beginning to merge with those of North America and Europe (Lu et al., 2013).

Our attitudes towards animal health and welfare not only vary across cultures but also betw-een species. It would be rare to find a person who found it acceptable to hunt a deer by snagging the animal on a hook, dragging it behind a vehicle, and suffocating it before butchering. But that is basically what w'e do w'hen we go fishing. Rare would be a person w-ho deemed his or her pet house cat to be terminally unhealthy because it was unable to produce offspring, but it would be a common practice to cull a dairy cow that was unable to conceive a calf and produce milk. Substantial investments are made in creating the circumstances that w ill help sustain healthy charismatic wildlife like whales and pandas, but efforts to protect and promote the health of non-charismatic species, such as the lamprey discussed in Chapter 19, are less popular and poorly funded. Social factors influence our attitudes towards animals, including (i) the extent to which we are responsible for harming them, (ii) the extent to w'hich the harmed animals are under our stewardship, (iii) the severity of the problems that cause the harms, and (iv) the cultural and economic factors, including the popularity of the species (Kirkwood and Sainsbury, 1996). Regulations, legislations, and expectations for animal health differ based on social uses of the species, i.e. whether they are farm animals, pets, laboratory animals, wild animals, or pests. Our view's of animal health are, therefore, closely tied to how w'e regard the animal.

Health is rarely defined in veterinary textbooks. It is largely defined as the absence of specific infectious diseases in national legislation and international agreements. Gunnarsson (2006) recognized five categories of health in the veterinary literature: (i) health as normality, (ii) health as biological function, (iii) health as homeostasis, (iv) health as physical and psychological well-being, and (v) health as productivity, including reproduction. A higher proportion of textbooks wr itten for non-veterinarians contained definitions of health or disease than those w'ritten for veterinarians. Western veterinary medicine still largely regards health as a dichotomous state reflected by the absence of disease or ability to produce economically valuable products like meat or milk in profitable amounts. Companion animal medicine tends to emphasize disease prevention, treatment, and recovery. Herd health of animals used for agriculture or aquaculture extends the idea of health beyond the absence of disease to include external measures of physiological or economic performance. Herd health considers not just animal determinants of health but also environmental and social characteristics. Wildlife lie somewhere in between. Literature explicitly dealing with wildlife health almost exclusively deals with diseases, with a recent emphasis on infectious and parasitic diseases. However, when the literature is more broadly searched to include domains involved in wildlife management, like resilience, wildlife health is seen as a cumulative effect involving multiple factors that extend beyond the disease and pathogen focus of many wildlife health studies and legislation. Six themes have been identified as determinants of fish and wildlife health: (i) the biologic endowment of the individual and the population, (ii) the animal’s social environment, (iii) the quality and abundance of resources providing the animal’s needs for daily living, (iv) the abiotic environment in which the animal lives, (v) sources of direct mortality, and (vi) changing human expectations (Wittrock et al., 2019) (see Chapter 1, Figure 1.1). These parallel the determinants of health recognized for people (Table 2.1). Yet, legislatively, animal health is still largely defined as the absence of a specific subset of infectious diseases of trade, public health, or economic importance.

Animal welfare and health are allied concepts. Some people similarly conceive health and welfare as normal functioning and freedom from disease. Others conceive welfare more like the salutogenesis concept of a sense of coherence between the capacity to identify, benefit, and use resources to deal with stress and the reality of current living conditions (Stephen and Wade, 2018). This parallels the viewpoint that animal welfare is compromised when adaptations possessed by the animal make an imperfect fit to the challenges it faces in the circumstances in which it lives (Fraser et al., 1997). Animal welfare legislation and regulations generally address commonly expressed ethical concerns that animals should (i) lead natural lives through the development and use of their natural adaptations and capabilities, (ii) be free from prolonged and intense fear, pain, and other negative states, and experience normal pleasures, and (iii) have satisfactory health, growth, and normal functioning of physiological and behavioural systems (Fraser et al.. 1997). The five freedoms and the 3 Rs are well-known guiding concepts of animal welfare (Table 2.2).

Organizations governing experimental use of animals have often developed animal welfare guidelines that are damage focused and intend to reduce harm by minimizing stress to individuals and discouraging procedures that have lasting negative individual or population effects, or affect the species’ existence. New animal farming methods, emerging experimentation technologies, ongoing exploitation of wildlife, new understanding of animal needs, and increasing public awareness are inspiring a growth in animal welfare laws in the European Union that recognize animals as sentient beings. These regulations tend to place priority on meeting the physical and psychological needs of animals to prevent unnecessary pain, suffering, or injury (Caporale et al., 2005). The UK’s 2007

TABLE 2.2

The Five Freedoms and 3 Rs of Animal Welfare

The Five Freedoms of Animal Welfare

The 3 Rs of Laboratory Animal Welfare

Freedom from hunger and thirst by ready access to fresh water and a diet to maintain full health and vigour

Replace - use alternatives which avoid or replace the use of animals in an area where animals would otherwise have been used

Freedom from discomfort by providing an appropriate environment, including shelter and a comfortable resting area

Reduce - decrease the number of animals being used to answer a research question, or maximize the information obtained per animal without compromising animal welfare

Freedom from pain, injury, or disease by prevention or rapid diagnosis and treatment

Refine - modify husbandry' or experimental procedures to minimize pain and distress and to enhance animal welfare from the time of birth until death

Freedom to express normal behaviour by providing sufficient space, proper facilities, and company of the animal’s own kind

Freedom from fear and distress by ensuring conditions and treatment which avoid mental suffering

Animal Welfare Act placed a duty of care on animal owners to provide for their animals’ basic needs, such as adequate food and water, access to medical care, and an appropriate environment to live in. Such regulatory approaches to animal welfare are not found all around the world. Rapid economic changes and greater access to information from around the world is shifting societal awareness of animal welfare issues but with varying degrees of consistency and uptake (Lu et al., 2013).

Wellness and Well-Being

Like health, there is no generally accepted definition of well-being, nor is there an agreement on how to measure it. One definition of community well-being that resonates with many of the themes in this book is well-being as a state of being with others and the natural environment that arises where needs are met, where individuals and groups can act meaningfully to pursue their goals, and where they are satisfied with their way of life (McCrea et al., 2014). The concept of well-being provides a link between health and society. Health provides the raw materials for well-being. Wellness is the state of living that leads to health. Well-being is the result of health and wellness. It is the unimpaired flourishing, free of obstacles, to live in a way that conforms with expectations, opportunities, and abilities. Wellbeing not only encompasses basic health needs such as adequate food, safety, and lack of disease but also considers how people think and feel about their life situation, or the situation of the animals or environments they care for. Well-being implies successful biological function, positive experiences, and freedom from adverse conditions. As we learn more about the mental capacity and complexity of animals, we need to recognize their ability to feel emotions and to have needs and a degree of consciousness that may determine their well-being. Well-being may be a relevant aspiration in animal and environmental health management in that it reflects how people feel about the circumstances and states that provide the capacities and resources for animal or ecosystem health. The American conservationist Aldo Leopold recognized this in his conception of the land health in that he noted: We see a thing as being right w’hen it tends to preserve the integrity, stability, and beauty of a biotic community (Leopold, 1989).

Ecosystem Health

Shared cultural beliefs and attitudes function as root causes of our attitude towards ecosystem and environmental changes (Stern et al., 1992). The over- exploitation of ecosystem services and resources has been traced back to the Judeo-Christian tradition that separates mankind and nature. The bias towards economic growth can be traced to Protestant teachings, w'hile humanistic values from the Enlightenment put human w'ants ahead of nature and presumed that humanity could solve all problems. Western materialism divorced the consumer from awareness of the realities of production, which further impacted ecosystems. As the environmental movement gained popularity in the 1960s-1970s, the public grew increasingly aware that human population growth and economic development was depleting raw materials for our future health. A strong interest in measuring ecosystem health for planning, management, and public reporting emerged.

Aldo Leopold’s idea of land health w'as an influential parent of ecosystem health concepts that gained prominence in the 1970s. Leopold’s idea of land health combined productive use, self-renewal, and stewardship of the land wdth the ability to act for conservation and environmental justice (Berkes et al., 2012). As the idea of ecosystem health flourished, so did the perspectives used to define and measure it (Lu et al., 2015). Some viewed ecosystem health as the ability of the ecosystem to function w'ithin acceptable limits, becoming “diseased” when inadequate homeostatic repair mechanisms existed. Others closely linked the idea of ecosystem health with sustainability or resilience. Still others viewed an ecosystem to be healthy if it could sustainably convert solar energy and cycle nutrients. The concept of ecological health is usually tacitly understood to be undefinable in a rigorous sense. Lancaster (2000) believed the "notion that the ecological health of the environment can be assessed is a ridiculous notion in a scientific context because there can be no objective definition of ‘health’ or method for defining degrees of health. Ecological health is a value judgement.” Ecosystems are context-specific entities because they cannot be delimited w'ithout a specific social, science, or policy context. Health, analogously, is not a biological state but rather a set of capacities and expectations defined within one’s social circumstances. Therefore, the idea of ecological or ecosystem health is normative because someone must decide what ecosystem conditions or functions are good (Lackey, 2001).

There have been substantial scientific efforts towards establishing indices that measure ecosystem health. Most attempts have been heavily criticized. Many of the criticisms focus on (i) the challenge of extrapolating indices across scales, gradients, and species; (ii) the oversimplification and generalization of biological processes resulting from indices; (iii) problems in calibrating and validating indices; and (iv) challenges in linking measures such as abundance and distribution to outcomes such as productivity (Niemi and McDonald, 2004). Principle challenges to identifying suitable indicators include (i) practical constraints that restrict monitoring to a small number of indicators that fail to adequately consider the complexity of the ecosystem, (ii) vague management goals and objectives clouding the choice of indicators, (iii) failure to use a defined, consistent, and rigorous protocol for identifying indicators (Dale and Beyeler, 2001), and (iv) the complexity of dynamic ecological systems complicating prediction, thus reducing the value of indicators as forward-looking tools. Concepts linked to ecosystem health, such as resilience and well-being, have subjective, relational, and context-specific aspects in addition to more objective measurements (Brown and Westaway, 2011). There are, therefore, no universally accepted indicators of ecosystem health, nor is there a single definition of the concept.

 
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