WHAT SHOULD BE?

A WHOLE system health issue needs to be understood in the context of some kind of desired future - with a view to intentions, ideals, goals, aspirations. If there is no sense of what kind of “health” we are working towards or aspiring to, it becomes challenging to assess where we are at now. Any efforts to address or assess health need to be informed by an individual’s or a group’s perspective on health, which may help understand and assess when things are progressing well, even thriving or, alternatively when there is a problem (see Chapter 2 for more discussion on defining health).

Starting with "What should be?” (instead of “What is?”) provides a sense of direction or goal to work towards it. Asking “What should be?” is not intended to provide a moral directive but, rather, to encourage recognition of the intended conditions and principles that underlie a state of thriving, including those that can guide efforts to focus on WHOLE systems. The emphasis is not health in isolation but rather health in relationship with life (living systems) and in relation to others (equity). When viewed alongside living systems, equity applies among and between people, generations, and species, fostering attention to reciprocity and regenerative approaches (see Chapter 3 for more on interspecies and intergenerational equity).

Others working in socio-ecological contexts for health have outlined principles to guide how we can understand and respond to interconnected health issues (see, for example, Table 5.2 adapted from Poland and Dooris, 2010; Charron, 2012a,b). The orientation towards principles reflects the context-specific nature of work at this interface, which is not well suited to definitive, checklist concepts or approaches. These principles reflect a distillation of patterns, recurring values, and priorities that have consistently emerged in the several decades of work seeking to refine and extend the ambitious socio-ecological orientation of the Ottawa Charter for Health Promotion (WHO, 1986). Table 5.2 offers a synthesis of converging principles to inform leadership in building a healthier more equitable and sustainable future.

The principles in the left column in Table 5.2 are ongoing efforts to strengthen the decades of work with “settings” approaches to health, through a clearer focus on building health, equity, and sustainability (see also Capon and Dixon, 2007; Parkes and Horwitz, 2009; Hancock. 2011). The principles in the right column in Table 5.2 draw on developments in ecosystem approaches to health (also known as ecohealth) as a field of research, education, and practice that adopts systems approaches to promote the health of people, animals, and ecosystems in the context of social and ecological interactions (Webb et al., 2010; Parkes and Horwitz, 2016; Buse et al„ 2018). Both complementary sets of principles are relevant when considering a WHOLE-systems approach to “What should be?” The combined present and future orientation of the principles in Table 5.2 offers new ways of conceiving the role of the health sector, including expanding and unifying a perspective of “health for all” that considers equity and living systems for all species, including humans.

TABLE 5.2

Principles for Re-Engaging with the Socio-Ecological Context for Health Converging towards Health Equity for Future Populations

Principles for a Healthy and Sustainable Settings Approach (from Poland and Dooris, 2010)

Principles to Inform the Application of Ecosystem Approaches to Health (from Charron, 2012a,b)a

Adopt an ecological “WHOLE system” perspective

Systems thinking

Start where people are (listen to and respect lived experience, diverse forms of knowledge)

Participation

Practice rooted in place

Sustainability

Deepen the social analysis (connect lived experience to that of others and to the practices, structures that create and sustain inequity located in broader context of relations of power)

Transdisciplinary research

Asset-based/appreciative inquiry approach

Gender and social equity

Build resilience (for change) instead of efficiency (for narrow set of operating conditions)

Knowledge to action

a The order of Charron’s principles is adapted to highlight commonalities with Poland and Dooris (2010).

The principles and WHOLE-systems considerations presented in Tables 5.1 and 5.2 will need to be adapted to specific contexts. A WHOLE-systems perspective may, for example, need to be adopted when considering “What Should be?” in relation to the health of non-human species, recognizing the challenge of identifying a goal, aspiration, or desired future for animals that are not able to directly share that using human languagefs). This challenge of assessing health for those with other-than-human “voices” is explored in Chapters 2, 17, and 19. In many cases, expressing the desires or aspirations for animal health or welfare draws on a person or people whose expertise or experience to frame the heath needs and aspirations of “those that have no voice” (de Groot, 1998). This may include - for example - a pet owner, a livestock farmer, a conservation biologist, or a veterinarian. Although the challenge of “who speaks for health” is particular when considering animals, it is, arguably, equally challenging for those who are considering any form of health that is beyond individual or “personal health.” In 2020, the scope of health beyond individuals (humans or animals) extends to a whole new lexicon and framing, working across scales and contexts, from public health and population health through to planetary health (Buse et al., 2019; Redvers, 2018; Harrison et al., 2019).

The synergies across principles in Table 5.2 point to the benefits of re-learning old lessons about approaches that are integrative and regenerative (as compared to disintegrative and degenerative), with implications that span how we think about governance and priorities across scales and contexts. This requires a combined recognition of both “ideas” and content (often associated with understanding "What is?”), as well as practice and processes (often associated with "What Could be?”).

WHAT IS?

Those working with Brown’s learning cycle may experience considerable pressure to start with "What is?” There are, indeed, situations where this may be warranted, such as situations of urgency or acute crises, for example the 2020 COVID-19 pandemic. In these cases, health-oriented professionals (including a “specialized generalist”) may need to focus all efforts immediately on the demands of “What is?” (Where we are now? What is happening?) without having a sense of what we are aiming for, and where we want to get to. This may mean that a focus on the WHOLE may not be immediately relevant, or even possible.

As an analogy, when you have a broken-leg, it is time for a specialist, who can fix this particular problem with a cast or surgery. In this case, “What should be?” is the treatment of an immediate problem, but once the urgency has passed (e.g. especially in preparation for a patient with a broken leg to be discharged home), broader, contextual factors become much more relevant, including the need for an overall goal, grounded in both social and ecological context, that should be considered in the next phase of learning and assessment following initial response. Extra time may need to be spent on questions of principles, intentions, and direction. after an initial crisis is over. In this analogy, an initial crisis of “What is?” needs to be followed by learning about and paying attention to the upstream drivers that influence access to orthopaedic and rehabilitation services, or create settings conducive to injury or, conversely that increase opportunities for healing and recovery.

Brown argues that whether in situations of urgency and crisis or as part of intentional learning cycles, problem-oriented appraisals and analyzes of “What is?” will be improved and enhanced through overt, collective attention to “What Should be?" Having a sense of where we are heading provides a sense of where we wish to go, and therefore a better position to consider and interpret the patterns and parameters of "What is?” in terms of what we are currently experiencing or have experienced. This emphasis echoes related examples in Table 5.1 to plan before we act (Zuber-Skerritt, 2015) and to set-up and frame our decision-making processes (Williams, 2011) in ways that are consistent with WHOLE systems. In the same spirit. Box 5.1 provides a case to think through how the principles and concepts presented thus far can be applied in response to a presenting complaint that has both personal and collective implications for a WHOLE-systems approach to health.

Considering the learning cycles presented in Table 5.1, what w'ould you suggest as a WHOLE-systems approach to answering this student’s questions in Box 5.1? The hypothetical presenting complaint in Box 5.1 likely has a familiar ring to those interested in the themes of this chapter. The WHOLE-systems orientation introduced earlier challenges us to resist the temptation to define and describe the problem in order to select a solution and instead adopt a strength-based

BOX 5.1 A CASE STUDY OF “WHAT IS?”: A PROMPT FOR

LEARNING CYCLES AND WHOLE-SYSTEM PRINCIPLES

PRESENTING COMPLAINT (“WHAT IS?”)

A 27-year-old graduate student with a clinical health background is completing their Masters research addressing a complex issue that raises ecological, equity, and health concerns for humans and animals in New Zealand and that has necessitated a mixed methods study. The student’s experience to date has made them feel that to have the desired impact, their future work will require collaborative effort across difference disciplines and knowledge. The student has been looking into new approaches to understanding health in the context of social and environmental change and has become unclear about how to proceed.

This student approaches you for guidance and direction about the best way to build on their background, and presents you with a series of questions:

  • • I am thinking of doing a PhD. but should I gain practical “real- world” experience prior to undertaking doctoral studies?
  • • I am really interested in understanding health in relation to both ecosystems and equity, not one or the other. There are so many new fields claiming to address aspects of this. I have seen eco- health. One Health, planetary health, environmental justice, ecological public health. Which of these is best?
  • • Some people say studying for a PhD is all about becoming a specialist about one thing, but when I was doing clinical work, I was always more interested in and better at being a generalist - understanding the big picture. I want to do a PhD that gives me this big- picture view, but how can I become a specialist in the big picture?
  • • If I do pursue doctoral studies, I am worried about becoming further disconnected from my clinical and applied origins, because I really want to be able to make a difference and contribute to a better world. What do you recommend?

orientation that prompts questions such as “what do we need to know and understand about this system in order to enhance conditions for thriving?” The intent is not to demonstrate the “right” answer to these questions. Rather, responding to the questions in Box 5.1 draws on the ideas presented above in ways that address the student’s questions and also point to the w'ider challenge of strengthening capacity to support WHOLE-systems perspectives on ecosystems, equity, and health. Several notable challenges and dilemmas raised by the example in Box 5.1 are explored here.

Each of the questions in Box 5.1 presents the challenge to overcome dichotomous thinking. Dichotomies in the questions above are evident in the implied tone of the questions that it is necessary to make a choice between clinical versus academic and applied versus theoretical knowledge, or that there is an implied either/ or needed when considering the fields of ecohealth or One Health, or planetary health. Related and false dichotomies embedded in each of the questions include the idea of a choice between specialization and integration, or between nature and society, between individual and collective work, between the ecological and the social, between environment and equity, between the global and the local, and to some extent between highly populated (urban) and less populated (rural, remote) regions. A key consideration here is that “What is?” (in terms of career choices, and strengthening capacity through training) is often presented as binary either/ or choice between priorities or parameters of concern, which misses opportunities to see the important relationships and connections between these factors (Horwitz and Parkes, 2019; Waltner-Toews et al., 2019). Combatting these false dichotomies needs to be accompanied by alternative ways of understanding and respecting complementary knowledge and priorities that, at its simplest, require both/and thinking, engagement with paradox, and the potential of holding contradictory ideas in our minds at the same time. This idea is explored by multiple authors in Brown et al. (2019) and revisited in the "What can be” section to follow, including Box 5.2.

The questions in Box 5.1 also underscore a related dilemma: Although many integrative approaches to health are being proposed, overt emphasis on both social and ecological context for health remains especially rare. The student described in Box 5.1 has interests in health (of humans and animals) in relation to both ecological and social context (living systems and equity). Despite the aspiration of socio-ecological approaches to health promotion (WHO, 1984), concerted efforts to take stock of combined social and ecological context for health remained sparse in the decades following the Ottawa Charter (Cole et al.. 1999; Parkes et al., 2003; Hancock, 2011; Hallstrom et al., 2015).

The first two decades of the 21st century have seen considerable increase of options for the kind of student described in Box 5.1 to consider, including the rapid expansion of integrative efforts that focus on health relation to environment and ecosystems, with particular emphasis on what can be seen as a trio of emerging (and sometimes competing) fields of ecohealth, One Health, and planetary health (see Buse et al., 2018; Oestreicher et al., 2018; Harrison et al., 2019). Yet, despite ongoing developments, and associated calls for a healthy, just, and ecologically sustainable future (Capon and Dixon, 2007), concerted attention to both the social and ecological context for health remains an area which requires more attention in almost all integrative approaches. The sets of principles presented in Table 5.2 can be seen as an example of this, where calls for “Greening Healthy Settings” by Poland et al. (2019) is a direct response to the need for a more overt attention to the ecological and environmental perspectives, which are ironically often absent within what are often claimed as socio-ecological approaches (see Hancock, 2011; Hallstrom et al., 2015; Horwitz and Parkes, 2019). Similarly, although the ecological can be seen as integral to ecosystem approaches to health, it is possible to apply Charron’s six principles in ways that attend to social context, processes, and engagement across all six principles, and yet overlook the fundamental relationship between health and ecosystems in a living systems sense (see Parkes and Horwitz, 2016; Horwitz and Parkes, 2019).

Although responses to these dilemmas tend to flip-flop from one to another (w'ith emphasis, for example, on social and equity issues, that override an emphasis on living systems; or vice versa), there is a growing return to language that overtly brings these considerations together in the form of ecosocial approaches and various forms of socio-ecological approaches, including socio-ecological systems and health (Zinsstag et ah, 2011; Hancock, 2016; Horwitz and Parkes, 2019; Parkes et ah, 2020). A conversation with the student in Box 5.1 might acknowledge that the English language is especially clumsy in this regard (resulting in multiple syllables and hyphenated words), and that Indigenous languages often have a suite of words, metaphors, and terminologies that better reflect these interrelationships (see Panelli and Tipa, 2007; Bartlett et ah, 2015; Moewaka Barnes et ah, 2017; Redvers, 2018), and which warrant increasing respect and attention.

Finally, the options available in response to the student’s questions in Box 5.1 are heavily contingent on the proposed desired future or “What should be?” Identifying what is/are options for this student will be influenced by the student aspirations and intent to make a difference and contribute to a better world. Notions of difference and “better” could involve, for example, a shift in focus from understanding degenerative driving forces of change (creating cascades of effects and impacts that flow between ecological degradation, social inequities, and short-, medium-, and long-term health impacts) towards WHOLE-systems practices. To foster this. Brown’s collective learning cycle is overt about the need to shift from ideals, parameters, and content about integrative and regenerative perspectives ("What should be?” and "What is?”) towards a clear focus on potential processes and practicalities needed to adopt these integrative and regenerative approaches (“What could be?” and “What can be?”).

 
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