THE SOCIO-ECOLOGICAL APPROACH

The socio-ecological model of health was introduced in Chapter 1. It was first used in the 1970s to understand human development (Kilanowski, 2017). At its essence, the socio-ecological model recognizes that there is a nested hierarchy of interacting factors that determine the resources and opportunities that influence an individual’s well-being. Key messages for One Health from the socio- ecological approach are provided in Table 4.4. The model can be thought of as

TABLE 4.4

The Key Messages of the Socio-Ecological Model of Health

Key Messages

No single factor can explain why one individual (or community, or species, or systems) is healthy and others are not

There are many social, built, and natural environments with which an individual's biological endowment interacts to result in healthier outcomes

There are multiple levels of influence to shape the opportunities for healthy choices. Directing action at roots causes found in the outer circles of the socio-ecological model (known as upstream determinants) can have broad and significant influences on downstream outcomes

The interrelations among various circles in the socio-ecological model are dynamic and context-specific

The most effective approach to health promotion uses a combination of interventions at all levels of the model

An example of nested hierarchy to represent the socio-ecological model of health

FIGURE 4.1 An example of nested hierarchy to represent the socio-ecological model of health. The model emphasizes how relationships and forces beyond an individual level influence health of individuals, populations, and communities. The model represents how behaviours, decisions, and actions to influence health can be found beyond the level of the individual.

a series of nested relationships, with an individual at the core (Figure 4.1). The inner core contains an individual’s attributes and interactions and relationships with his or her immediate surroundings. It contains the individuals’ biological endowment, skills, and knowledge. The social and non-human environments include interactions with other individuals and the needs for daily living (like food and water) and hazards. The third level exerts social forces that positively or negatively influence relationships that are subordinate in this nested hierarchy. Examples here include social organizations and policies. Next come the capacities and services that ecosystems give us, that provide the “raw materials” found in our relationships with our immediate world that enable social decisions. Beyond this are global and planetary forces, both historic and current, that influence all aspects of the system, such as climate change. This model can be readily adapted to different circumstance and species as all types of health (individual, species, systems, communities) are influenced by higher and lower levels of organization.

There are many examples of socio-ecological thinking in the One Health and EcoHealth. Parkes and Horwitz (2009), for example, used watersheds as an integrating concept to more effectively link human well-being, health promotion, and disease prevention with ecosystem management at the local, regional, and global scales. The socio-ecological model underpinned calls for systems-based public health approaches to a climate change (Morris, 2010). The theory and practice of understanding and managing human activities as a socio-ecological system were used extensively in the Millennium Ecosystem Assessment (Zinsstag et al., 2011). Identifying linkages between human, animal, and ecosystem health and strategically communicating that information can influence how people consider their own behaviours such that they optimize benefits across these systems (Lapinski et al., 2015).

The socio-ecological model of health is most often used in reference to social forces influencing human health. One Health and EcoHealth more often refer to socio-ecological systems thinking rather than the socio-ecological model of health described in the UN Ottawa Charter for Health Promotion. The term socio-ecological system was coined in the 1970s to refer to an ecological system’s intricate links with and relationships with social systems. It was further developed in the 1990s to find ways to “match the dynamics of institutions with the dynamics of ecosystems for mutual socio-ecological resilience and improved performance” for local resource management (Colding and Barthel, 2019). Agriculture, sustainable development, infectious disease dynamics, conservation, and veterinary services delivery are just a few examples where there are problems being conceived of and managed as socio-ecological systems. Rtiegg et al. (2017) noted that “many health decisions are linked to dilemmas between scales, namely, individual versus social or global ecological interests. The solution lies in a continuous process of negotiation that includes all stakeholders and results in benefits from the interaction between different sectors. One Health acknowledges that people’s choices are made within the context of economic, social and cultural values.” Chapter 7 provides more detail on systems thinking in a health context.

Systems thinking can be hard and it can be messy, but there are three core systems concepts that can guide your thinking. First, a system is made up of parts, relationships, functions, and products. Understanding the relationships is as much or more important than knowing the parts. Second, because these relationships can be complex and dynamic, and because there are feedbacks, synergies, and antagonisms within relationships, systems do not act in a linear predictable fashion. Surprises are to be expected. Third, the goal of applying a systems perspective is not to elucidate the intricacies of all parts, products, functions, and all relationships. The goal is to know them well enough to find entry points that allow you to start to work in the system to find the leverage points where a small intervention can have a meaningful impact. Systems thinking has been applied to many different fields from health, to computers, to biology, and more. Interested readers will find few challenges in locating additional books and publications on systems thinking, but we encourage you to start exploring systems thinking in EcoHealth to bridge systems science with health management.

ANIMALS, HEALTH, AND SOCIETY

Rudolf Virchow, the 19th-century physician, pathologist, and biologist, is often quoted as saying, “between animal and human medicine there is no dividing line - nor should there be.” There is abundant literature on the influences of animals on human health and on the dependencies of animal health and ecosystems’ integrity on human decisions. As seen in the diverse examples throughout this book, “animals are part of the fabric of life, all around the world” (Rock et al., 2009). Animals are sources of many determinants of human health. Lack of attention to the interdependence of human and animal health neglects opportunities for reciprocal care in health promotion.

There is no shortage of examples in recent years exemplifying the need to work across the species divide to find shared solutions to shared problems through collective, cross-sectoral action. Antimicrobial resistance is an archetype of the cobenefits of a collaborative and cross-sectoral approach to a health threat. A One Health assessment of antimicrobial resistance would not only examine the implications for clinical care of people but also wider societal costs, impacts on animal health and welfare, higher costs of animal-origin food production, and reduced consumer confidence in food safety and international trade (Queenan et al.. 2016). A greater understanding is required by the medical and veterinary sectors alike of how health-seeking behaviour - for ourselves, our families, and our animals - influences the pandemics of multi-drug-resistant pathogens (Queenan et al., 2016) (see Chapter 23 for a more detailed consideration of this issue). Romenalli et al. (2014) argued that a better understanding of the relationships between biodiversity. health, and disease presents “major opportunities for policy development and can enhance our understanding of how health-focused measures influence biodiversity and how conservation measures affect health.” The dynamic and complex interdependence of people, animals, and the environment, and how they are collectively impacted by disasters, underscores the need for a cross-species health promotion approaches to disaster management (Gallagher et al., in press). A comprehensive, systems thinking approach that incorporates human, animal, and environmental considerations into each of the continuous and overlapping disaster management phases of mitigation, preparedness, response, and recovery is essential for inclusive and multi-sectoral actions to mitigate a disaster’s impacts. As a final example, the similarities between obesity in people and companion animals speak to the need to address shared environmental and lifestyle elements of this multifactorial disease (Bomberg et al., 2017).

There are even more examples of how health of one species can promote the health of another. Livestock contribute to health security either directly through consumption or indirectly through sales. Without healthy livestock, income and nutritional benefits would evaporate for livestock farmers (which include many of the world’s poor people), hence the focus on livestock disease control for international organizations such as the World Organization for Animal Health (also known as the OIE). Chapter 18 illustrates the important role healthy animals play in poverty reduction, food security, and farm sustainability in Sri Lanka.

Livestock provide cash for farmers and their families, fertilizer in the form of manure, draft power, and they can boost sustainable crop production in mixed crop-livestock systems (Smith et al„ 2013). Livestock production can transform human well-being by enhancing food and income security to pay for education, basic needs, and other health care. Wildlife and fish provide consumptive and non-consumptive economic resources for many Indigenous, rural, and remote communities around the world (Stephen and Duncan, 2017). They provide a sense of identity and purpose for a variety of natural resource workers and Aboriginal peoples. Recreational fishing, hunting, and other nature uses can promote exercise and group membership leading to healthy lifestyles and diets. Personal and spiritual connections with animals can influence healthy childhood development, mental health, and personal coping skills. O’Bryan et al. (2018) argue that predators and scavengers have far-reaching benefits to human health through disease mitigation, agricultural production, and waste-disposal services, and at the same time they show that human decisions are the key driver to the continued existence of these species.

In return for all these benefits, human actions and decisions are the primary modifier of the determinants of animal and ecosystem health. How we use animals, house them, shape their built or natural environments, and regulate their access to vital needs for living determine if some species thrive and others disappear. Unfortunately, constructive, well-balanced, and informed practices and policies that try to со-manage animal, human, and environmental health are rare. Many fields and programmes talk about it but few equally invest in concurrent care of people, animals, and environments. The question is no longer: Should we act together?” but “With whom can we act, and how can we act together?”

Reciprocal Care Health Promotion Teams

When there is a clear and urgent goal that transcends the needs, interests, and abilities of individuals, teams are necessary. The changes being witnessed in the Anthropocene that transcend single disciplines are shifting scientific disciplines away from their own unique solutions to problems. Given the complexity of health issues at the animal-environment-society interface, various types of partnerships will be essential to ensure that investigations and interventions are relevant to the priority population for whom they are intended, and are meaningful and appropriate to the targeted communities, populations, and species.

There is a variety of terms used to describe cooperative work of different groups or disciplines. Descriptors using the prefix “multi” are assigned to situations where different professional groups or disciplines work together. Multidisciplinary approaches allow teams to address a problem by more than one perspective, but members stay rooted in their own disciplines. Building the circumstances and situations conducive to reciprocal care of human, animal, and environmental health requires a wide suite of skills, capacities, connections, and knowledge, and therefore, a reciprocal care health promotion team must, at the least, have a multidisciplinary organization and orientation. When the prefix

“inter” is assigned to a team, it does more than work together. It also integrates knowledge and methods from different disciplines, striving to transfer knowledge from one discipline to another in order to synthesize knowledge and methods into a single coherent approach. Once the term “trans” is assigned to the team, such as transdisciplinary, the team is looking to transcend any disciplinary approach. Most often it is used to describe teams that go beyond academic interdisciplinarity to engage directly with the production and use of knowledge outside the academic environment to support action-oriented work. The composition of these various types of teams and the processes they use to w'ork together will, and should, vary with the context of the problems they address. EcoHealth and, increasingly. One Health are using transdisciplinary approaches to address the health of people, animals, and ecosystems.

Health promotion uses interdisciplinary and transdisciplinary perspectives and methods. It brings together practitioners from varied disciplinary backgrounds with the communities they serve to collectively address key determinants of health in the most effective manner (Orme et al., 2007). Team members bring with them their own histories, values, and knowledge. Having a shared conceptual framework for the problem at hand is, therefore, essential for transdisciplinary teams. Without a shared conceptual framework, team members might find themselves working on the same problem but on "different paths,” which could lead to disjointed outcomes and delays in research-to-action timelines (Min et al., 2013). There are several other challenges transdisciplinary teams confront such as; recognizing that a way of thinking that is appropriate in one situation can be inappropriate in another; unbalanced problem ownership; conflicts in the selection and application of methods; and even finding agreement that a transdisciplinary approach is appropriate (Norris et al., 2016). It can be challenging to overcome disciplinary perspectives in transdisciplinary teams. Dialogue at the outset of team building on how various forms of knowledge and perspective will be shared, respected, and accommodated can help avoid future team conflict.

HEALTH PROMOTION IN A ONE HEALTH WORLD

A foundational concept of health promotion is, “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” (WHO. 1986). It has been rare that coordinated and collaborative efforts truly seek policy and programme outcomes that concurrently take care of each other, our communities, and the natural environment. Too often there are winners and there are losers. Conservation programmes that protect wildlife but drive marginalized communities into poverty are not health promotion in this sense. Nor are programmes protecting people from emerging infections by eliminating wildlife reservoirs of those infections. In the world of specialists, it is rare to find a person who can think across and within the relationships between ourselves, our communities, and our natural environments. Chapter 5 provides some thinking on how we might get better at doing so, but elements of this trans-species thinking can be found throughout many of the case studies presented in this book. The goal of this book is to provide some foundational concepts and case studies to encourage future practitioners of true reciprocal care who are willing to become “specialized generalists”: that is, those people skilled at looking across disciplines, values, species, and generations; able to inspire incremental improvements in health that provide mutual benefits to animals, societies, individuals, and ecosystems.

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