an understanding of local health and environment issues essay

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• Gen Z, Millennials Stand Out for Climate Change Activism, Social Media Engagement With Issue
• 3. Local impact of climate change, environmental problems

Table of Contents

• 1. Climate engagement and activism
• 2. Climate, energy and environmental policy
• Acknowledgments
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• Appendix: Detailed charts and tables

A majority of Americans say climate change is having at least some impact on their local community, and half say their area has experienced extreme weather over the past year, particularly those living in South Central states such as Texas and Alabama. On a related policy question, a large majority of Americans favor the idea of revising building standards so new construction can better withstand extreme weather events.

At the local level, experience with environmental problems – such as air and water pollution – varies across groups. Black and Hispanic adults are particularly likely to say they experience environmental problems in their local community, as are those with lower family incomes.

And when it comes to climate policy considerations, large majorities of Black and Hispanic adults – across income levels – say it’s very important to ensure that lower-income communities benefit from proposals aimed at reducing the effects of climate change.

More than half of U.S. adults say they have seen at least some local effects of climate change

Overall, 57% of U.S. adults say climate change is affecting their own community either a great deal (17%) or some (40%). Smaller shares say climate change is affecting their community not too much (27%) or not at all (15%).

Most Americans, including a majority of Republicans, say human activity plays at least some role in climate change

Most Americans (77%) say human activity contributes either a great deal (44%) or some (33%) to global climate change. Far fewer (22%) say human activities such as the burning of fossil fuels contribute not too much or not at all to climate change. 

Republicans continue to be less likely to believe that human activity plays at least some part in global climate change. Still, 59% of this group says human activity contributes at least some, while 40% say human activity has not too much of a role or no role in climate change. 

Democrats across generations are in broad agreement that human activity has at least some effect on climate change. Among Republicans, Gen Zers and Millennials are more likely than Gen X and Baby Boomer and older adults to see human activity as playing a role in global climate change. See the Appendix for details. 

The overall share of Americans who say their area is affected a great deal by climate change is down 7 percentage points, from 24% a year ago to 17% today.

Americans’ beliefs about local impact of climate change are more closely linked to their partisanship than to where they live. Perceptions of local climate impact vary modestly across census regions. The regions that are relatively likely to say climate change is impacting their communities, such as New England and the Pacific, tend to be places that lean Democratic in their political affiliation. There are also modest differences by generation in beliefs about its local impact.

A separate question in the survey finds that half of Americans say their local area experienced an extreme weather event in the past 12 months.

A large majority (84%) in the West South Central region say they have experienced extreme weather in the last 12 months. The region was impacted by a severe winter storm in February that led to a power crisis in Texas. In contrast to the overall partisan differences seen on this question, comparable majorities of Republicans and Democrats in the West South Central region report their communities have experienced extreme weather in the past year.

Wide public support for revised building standards to protect against extreme weather

Climate change is thought to be a key factor in the occurrence of more frequent and intense or extreme weather events. When asked about a federal government proposal to change building standards so that new construction will better withstand extreme weather events, 75% of U.S. adults responded in favor of this proposal, while 23% said it is a bad idea because it could increase costs and cause delays in important projects.

There is near consensus among Democrats and Democratic-leaning independents (90%) that revising building standards so construction better withstands extreme weather is a good idea. A 57% majority of Republicans and GOP leaners agree, although support is considerably higher among moderate and liberal Republicans (71%) than conservative Republicans (50%).

People who report direct experience with extreme weather in the past year are particularly likely to consider this a good idea (81% vs. 69% of those who do not report recent experience with extreme weather).

Black, Hispanic and lower-income adults more likely to report living in areas with big problems when it comes to air pollution, other environmental concerns

Overall, about six-in-ten Americans say they see at least moderate problems where they live when it comes to an excess of garbage (62%) and water pollution in lakes, rivers and streams (60%). About half (52%) say the same about local air pollution, and about four-in-ten say safe drinking water (41%) or a lack of greenspace (39%) are at least moderate problems.

Past research has found that Black, Hispanic and Asian American communities are more likely to be exposed to air pollution and other environmental hazards in their local area.

The Center survey finds Black and Hispanic adults particularly likely to say their local communities are having problems across this set of five environmental issues, and they stand out for the large share who consider these to be “big problems” where they live. About four-in-ten Black (41%) and Hispanic (37%) adults say the amount of garbage, waste and landfills in their community is a big problem. Black and Hispanic adults are also more likely than White adults to report that their community has big problems with air and water pollution, drinking water safety and a lack of greenspace and parks. A majority of Black (57%) and about half of Hispanic adults (53%) consider at least one of these five issues a big problem in their local area.

Lower-income Americans are also more likely to report that their area has big problems with these environmental issues. For example, about three-in-ten lower-income adults say their local community has a big problem with air pollution. About half as many upper-income adults (16%) say the same about their community. Half of those with lower family incomes say their local communities are having a big problem with at least one of these five environmental issues.

The Biden administration has brought a new focus to environmental justice concerns underlying climate and energy policy. Biden has called for $1.4 billion in his recent budget proposal for initiatives aimed at helping communities address racial, ethnic and income inequalities in pollution and other environmental hazards.

As Americans think about proposals to address climate change, Black (68%) and Hispanic adults (55%) stand out for the high shares who say it is very important to them that such proposals help lower-income communities.

More than half of lower-income Americans (54%) say this is very important to them, compared with 36% of upper-income adults.

Middle- and upper-income Black adults (70%) are about as likely as lower-income Black adults (66%) to say this is very important to them, however. Similarly, there are no differences on this question between middle/upper income Hispanic adults and those with lower incomes (54% vs. 57%, respectively).

A majority of Democrats and independents who lean toward the Democratic Party (59%) say it is very important to them that climate change proposals help lower-income communities; far fewer Republicans and Republican leaners (27%) say this.

Older Americans are more likely to say they regularly try to live in ways that help the environment

A large majority of Americans (86%) say they try to live in ways that help protect the environment all the time (22%) or some of the time (64%). Just 14% say they never or rarely make such an effort. These findings are largely unchanged since the question was last asked in October 2019 .

In contrast to views and behaviors related to climate change, Baby Boomer and older adults are more likely than those in younger generations to say they try to live in environmentally conscious ways all the time (29%, vs. 21% in Gen X, 16% of Millennials and 15% in Gen Z).

And, unlike views on many policy issues related to the environment, similar shares of Democrats (88%) and Republicans (84%) say they make an effort to do this at least some of the time.

Majorities of U.S. adults say they take some everyday actions in order to help protect the environment, including reducing their food waste (81%), using fewer plastics that cannot be reused such as plastic bags, straws or cups (72%) or reducing the amount of water they use (67%). More than half of Americans (54%) say they drive less or carpool to help the environment, and 40% say they eat less meat.

About one-in-five adults (18%) say they do all five of these activities to help the environment, a similar share to when these questions were last asked in October 2019. On average, Americans do 3.3 of these activities.

People who say they try to be environmentally conscious all the time are much more likely to say they are doing specific things to protect the environment. For instance, a large majority (89%) of people who make an effort to live in ways that help protect the environment all the time say they use fewer single-use plastics such as bags and straws in order to protect the environment. This compares with 35% of those who say they do not or don’t often make an effort to protect the environment.

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• Published: 24 September 2021

A community-engaged approach to understanding environmental health concerns and solutions in urban and rural communities

• Suwei Wang 1 , 2 ,
• Molly B. Richardson 3 ,
• Mary B. Evans 4 ,
• Ethel Johnson 5 ,
• Sheryl Threadgill-Matthews 5 ,
• Sheila Tyson 6 ,
• Katherine L. White 4 &
• Julia M. Gohlke 2  

BMC Public Health volume  21 , Article number:  1738 ( 2021 ) Cite this article

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Focus groups and workshops can be used to gain insights into the persistence of and potential solutions for environmental health priorities in underserved areas. The objective of this study was to characterize focus group and workshop outcomes of a community-academic partnership focused on addressing environmental health priorities in an urban and a rural location in Alabama between 2012 and 2019.

Six focus groups were conducted in 2016 with 60 participants from the City of Birmingham (urban) and 51 participants from Wilcox County (rural), Alabama to discuss solutions for identified environmental health priorities based on previous focus group results in 2012. Recorded focus groups were transcribed and analyzed using the grounded theory approach. Four follow-up workshops that included written survey instruments were conducted to further explore identified priorities and determine whether the priorities change over time in the same urban (68 participants) and rural (72 participants) locations in 2018 and 2019.

Consistent with focus groups in 2012, all six focus groups in 2016 in Birmingham identified abandoned houses as the primary environmental priority. Four groups listed attending city council meetings, contacting government agencies and reporting issues as individual-level solutions. Identified city-level solutions included city-led confiscation, tearing down and transferring of abandoned property ownership. In Wilcox County, all six groups agreed the top priority was drinking water quality, consistent with results in 2012. While the priority was different in Birmingham versus Wilcox County, the top identified reason for problem persistence was similar, namely unresponsive authorities. Additionally, individual-level solutions identified by Wilcox County focus groups were similar to Birmingham, including contacting and pressuring agencies and developing petitions and protesting to raise awareness, while local policy-level solutions identified in Wilcox County included government-led provision of grants to improve septic systems, and transparency in allocation of funds. Workshops in 2018 and 2019 further emphasized water quality as the top priority in Wilcox County, while participants in Birmingham transitioned from abandoned houses as a top priority in 2018 to drinking water quality as a new priority in 2019.

Conclusions

Applying a community-engaged approach in both urban and rural locations provided better understanding of the unique opportunities and challenges for identifying potential interventions for environmental health priorities in both locations. Results can help inform future efforts to address locally defined environmental health issues and solutions.

Peer Review reports

Introduction

A healthy environment is essential for improving the quality of life and the extent of healthy living. Worldwide, preventable environmental factors are responsible for 23% of all deaths and 26% of deaths among children less than 5 years old [ 1 ]. Environmental factors are diverse with far-reaching impacts on health [ 2 ]. Community engaged research in environmental health includes a variety of non-academic stakeholders, such as residents in affected neighborhoods, neighborhood leaders, non-governmental agencies, and government agency representation. It is designed to improve our understanding of environmental factors affecting health that may be the most promising to address based on local priorities and circumstances.

Focus groups are one of the methods for facilitating community-engaged research. It is an invaluable tool for researchers investigating community’s perceptions of environmental hazards, because they provide a setting for gathering resident’s knowledge and establishes common ground among participants and between participants and researchers [ 3 ]. Local focus groups can engage residents and identify ways to work towards solving a problem collaboratively [ 4 ]. Because of the small size and informal nature of focus groups, participants can build on and debate each other’s responses, which helps to better understand an issue and the influences surrounding it [ 5 ]. This understanding and information are obtained in a relatively short amount of time, so focus groups are an efficient way for researchers to attain information [ 6 ]. Furthermore, focus groups can enlighten researchers to perceived environmental hazards not previously considered [ 3 ]. All of these attributes are essential for developing a feasible, acceptable, and supported intervention to address health outcomes associated with environmental factors [ 7 ].

In 2010 we initiated a community-academic partnership, ENACT, between Friends of West End (FoWE) in Birmingham, Alabama (AL), and West Central Alabama Community Health Improvement League (WCACHIL) in Wilcox County, AL and Virginia Tech, University of Alabama at Birmingham, and Johns Hopkins University [ 8 ]. Through ENACT we work on environmental health issues in Alabama with successful completion of several environmental epidemiology studies, focus groups, workshops, and phone surveys [ 9 , 10 , 11 , 12 , 13 , 14 ]. In our initial focus groups in 2012, we found that abandoned houses was the highest environmental health priority in Birmingham, Alabama while inadequate sewer and water services was the top priority in Wilcox County, Alabama [ 9 ]. A follow-up larger scale and randomly sampled phone survey reaffirmed these priorities in each community and furthered our understanding of how resident priorities are similar or different from local health agency priorities [ 11 ]. Additionally, follow-up community-engaged research allows the dissemination of updated results and collection of new information to verify previous results and further refine the most appropriate path to mitigate health outcomes associated with environmental health priorities.

Water and sewage service issues and abandoned houses and lots are significant environmental health problems in rural and urban areas in the United States, respectively. Unsewered homes are common in rural areas of the United States, leading to increased risk of a variety of infectious diseases [ 15 ]. For example, soil transmitted helminth infections were identified in household members without adequate sewage in rural Alabama [ 16 ]. Drinking water service characteristics have also been associated with reported gastrointestinal illness in rural Alabama [ 17 ]. Garvin et al. (2013) found abandoned properties affect community well-being via overshadowing positive aspects of community, producing fractures between neighbors, attracting crime, and making residents fearful [ 18 ]. Other research found the problem is perceived as particularly widespread in the U.S. South, where our study areas are located [ 19 ]. Abandoned houses and lots can contribute to numerous health and safety hazards including falling debris, vermin, mold, standing water, toxic chemicals, and sharp rusty objects [ 20 ], and can have negative impacts on housing/neighborhood vitality, violence and crime prevention efforts, fire and vandalism risk, commercial district vitality, and assessed property values, etc. [ 19 , 21 , 22 , 23 , 24 ].

In the present study, we build from our previous findings to 1) better understand why those problems persist, 2) what residents feel the solution is, and who is responsible for enacting the solution 3) identify ways to support residents in identifying a process to address environmental concerns and 4) examine whether environmental health priorities change over time. Applying this community-engaged approach in both an urban and a rural location allowed us to better understand the unique opportunities and challenges in both locations.

Characteristics of focus group study populations

Birmingham, AL is the largest city in Alabama with a population of 209,403, of which 70.5% of the population identifies as Black or African American [ 25 ]. Birmingham has a poverty rate of 27.2%, and those identifying as Black or African American comprise 76.9% of those living in poverty [ 25 ]. Wilcox County, AL, a rural setting, has a lower population of 10,300, of which 71.3% identify as Black or African American [ 25 ]. A total of 33.4% of the population in Wilcox County live in poverty and of that 88.2% identify as Black or African American [ 25 ].

Focus group procedure

This study involved Virginia Tech and University of Alabama at Birmingham researchers collaborating with Friends of West End (FoWE) in Birmingham, AL, and West Central Alabama Community Health Improvement League (WCACHIL) in Wilcox County, AL as part of an ongoing community-academic partnership, ENACT [ 8 ]. The protocol was approved by the Virginia Tech Institutional Review Board (15–761). The community partners recruited participants aged at least 18 without regard to sex, ethnicity or ancestry. WCACHIL recruited 51 participants in Wilcox County and FoWE recruited 60 participants in Birmingham using a convenience and snowball sampling approach. The number of focus groups ( N  = 12, 6 in Birmingham city, AL and 6 in Wilcox County, AL) was based on the need to expand our line of questions from our previous focus groups investigating environmental health priorities in 2012 ( N  = 8 in total, 4 in Birmingham, AL and 4 in Wilcox County, AL) [ 9 ]. This new direction led us to include two more focus groups in each location, and this number of focus groups is consistent with previous studies exploring data saturation across a wide range of topics [ 26 , 27 , 28 , 29 ].

Community and academic partners together drafted and agreed upon a guide of questions to ensure appropriateness and consistency between groups. The guide followed a natural progression of identifying positive attributes of participants’ neighborhoods, determining whether previously identified environmental health priorities (abandoned houses and overgrown lots in Birmingham and drinking water access and quality in Wilcox County) [ 9 ] were still priority issues, why the problems persisted, who was responsible for solving them, and what participants felt were the solutions to address those priority issues.

We took a positivist approach in focus group data collection and analysis. The facilitator guide (Additional file  1 ) emphasized encouraging all participants to contribute, embracing new ideas, and enforcing respect for all participants’ comments [ 30 ]. Members of the community-academic partnership served as facilitators in each group. Facilitators were encouraged to utilize strong listening and questioning skills, prodding participants with prompts to encourage them to speak up or clarify statements. All facilitators had training in the value of focus groups and the best practices for facilitating focus groups that are partly based on works by Franz et al., Drake et al. [ 31 , 32 ] . Facilitators aimed to document subjects opinions and attitudes in an objective way, assuming a detached, independent role in the discussion, but ensuring focus groups followed the structured guide [ 33 ]. Facilitators were provided guidance and practice on how to draw out concerns while not bringing bias by sharing their own views [ 34 , 35 , 36 , 37 ], drawing adequate participation from each participant, and minimizing the influence of dominant speaker(s) views. In training and planning for focus groups, we placed emphasis on the importance of the role of the facilitator, having groups be of reasonable size (8–10 individuals), and individuals not being too familiar with other group members [ 33 ].

Twelve focus groups were conducted in September 2016, six in Birmingham and six in Wilcox County. Focus groups were organized to be at a time when participants would be available and within familiar neighborhood gathering places to increase comfort in active participation. Approximately 10 participants sat at each table with facilitators. Facilitators went through formal Institutional Review Board consent, then initiated recording of the focus group with digital recorders. Focus groups lasted approximately one-hour and participants completed a written survey. Facilitators’ field notes were considered during the coding process, described below.

Focus group data analysis

Researchers do not editorialize participants’ opinions and remained non-judgmental and respectful [ 37 ]. Recordings were transcribed by the second author. In the first stage, transcriptions were coded into categories based on questions posed (determined a priori) from the script independently by second author and third author (Additional file  2 ). The second author then went through all coded transcripts combining responses identified to be most inclusive [ 38 ]. In the event that a statement responded to multiple questions (i.e., responsible parties and solutions), they were coded to each question response. In the next stage, the second author and third/seventh author independently further subcategorized the inclusive coded transcripts per the subcategorization coding tree (Additional file 2 ). Summaries were then consolidated and presented by focus group and by location with verbatim. Recordings from all focus groups were analyzed and coded to ensure all themes discussed are presented in the results. Interrater reliability was assessed for topics: reasons for persistence, responsible parties, sources of trusted information, and other priorities brought up. Interrater reliability rate (IRR) was high in both Wilcox County transcripts and Birmingham transcripts (IRR = 90.6% in Wilcox County, 91.9% in Birmingham). An IRR of 90.6% reflects that 512 out of 563 responses were categorized the same between the two coders.

Follow-up workshops

Preliminary results from the focus groups were compiled and used to develop a survey instrument to further explore environmental health priorities and solutions and implemented at workshops in May 2018. Fifty-three participants from the same urban and rural locations (23 in Birmingham and 30 in Wilcox County) attended the workshops and completed the survey. A total of 92 participants from the same urban and rural locations (49 in Birmingham and 43 in Wilcox County) attended another two follow-up workshops in September 2019. A collaborative presentation by researchers and community partners on spatially explicit risk maps developed from our retrospective analysis of adverse health outcomes associated with heatwaves in Alabama was given. Participants filled out a written survey ranking the most concerning environmental health issues. Demographic information was also collected in the survey instruments administered in 2018 and 2019. The agendas for the workshops are shown in Additional file 1 . All survey instruments are accessible at our research outreach website [ 39 , 40 ].

Answers to the surveys were summarized and compared between Birmingham and Wilcox County participants in 2018 and 2019, respectively. The responses to open-ended questions were first coded into categories by the first author, then independently coded by the eighth author using the categories established by the first author. Any differences were discussed to resolve final categorization. The rankings of six environmental health issues were converted to Likert scale, with average ranks computed for ties. For a specific environmental health issue, the Mann-Whitney test was used to determine whether the medians of the ranks were different in Birmingham vs. Wilcox County.

Study population

Most participants in the 2016 focus groups (92%) and 2018 (98%) and 2019 (86%) workshops self-identified as Black or African American (Table  1 ). In 2016 focus groups, urban and rural participants had similar gender ratio (67, 80% female, respectively), education level (48, 53% with higher than high school diploma, respectively), annual household income (68, 55% at <$ 20,000, respectively), and general health (92, 90% responding in good health condition, respectively) while urban participants were older compared to rural participants (mean age 60 in urban vs. 52 in rural, p -value 7.9E-03). In 2018 workshops, the only urban-rural difference among participants was that a higher percent of rural participants participated in the 2016 focus groups (63% in rural vs. 26% in urban, p -value 0.02). In 2019 workshops, urban participants were younger (mean age 50 in urban vs. 58 in rural, p -value 0.02), had a lower percent in annual household income ≥$20,000 (42% in urban vs. 76% in rural, p- value 1.6E-04), a lower percent in participation of 2017 monitor study (16% in urban vs. 60% in rural, p -value 3.4E-05) and a lower percent in participation of 2016 focus groups (18% in urban vs. 62% in rural, p -value 8.8E-05) (Table 1 ).

Environmental health priorities and responsible parties identified in 2016 focus groups

A total of 83% participants in Birmingham and 12% participants in Wilcox County believed urban areas had worse environmental problems than rural areas ( p- value 6.3E-13). Most participants (88% participants in Birmingham and 84% participants in Wilcox County, p-value 0.56) believed their communities did not receive its fair share of state and local resources devoted to environmental health problems.

Table  2 reports the environmental priority findings in the six focus groups in Birmingham. All six groups agreed that the main priority was abandoned and unmaintained houses: “ All you have to do is ride through to see. It is a disgrace. Just driving through it’s so grown up (overgrown) that you can’t even see the house. ” Groups mentioned many health concerns they believed were exacerbated by abandoned housing and overgrown lots including general health (2 groups), carbon monoxide, cough, mold, and infectious diseases (1 group). For the reason(s) this issue persists, five groups brought up that authorities were unresponsive or they did not follow through, four groups discussed government maintenance was limited and slow, and four groups believed money was an issue. “ We’ve been going on 15 years trying to get something going with our councilor. You couldn’t get nothing. ” Five groups identified Birmingham City Council as the top responsible party. Solutions were proposed by participants. More individuals attending city county meetings (4 groups), contacting government agencies and reporting issues (4 groups), and asking for government patrol of abandoned houses and additional maintenance of properties (3 groups) were top suggested short-term solutions. For long-term solutions, ideas included greater participation in community and neighborhood meetings (2 groups): “(You) Gotta go out there and see. And if you don’t go out there and participate then you’ll never see. ”, buy or mortgage abandoned houses/lots (2 groups), community hold authorities accountable (2 groups), and government confiscates, tears down (5 groups) and transfer the ownership of abandoned houses for better maintenance (4 groups).

Table  3 reports the results in the six focus groups in Wilcox County. In Wilcox County, the focus groups focused on the priority issue of drinking water access and quality with some discussion on sewage and septic issues. All six groups were concerned about the smell, look and taste of water. Five groups were concerned about the lack of water access and water-borne diseases. Primary health concerns that arose in discussion included cancer (5 groups), obesity (1 group), and infectious agents associated with poor sanitation (1 group). “ And it’s just awful. It’s awful because it makes your yard smell. It makes everything smell like septic. ” Four groups believed this issue has persisted because of unresponsiveness from authorities, particularly the county commissioners, and three groups suggested the lack of knowledge, information, and resources led to problem persistence. As for individual level solutions, participants suggested pressuring and reaching out to local government representatives (5 groups), attending county commission meetings and water board meetings (4 groups), and avoiding the use of county water (e.g., use bottled water) (2 groups). At the neighborhood level, participants mentioned organizing petitions and protesting would raise awareness (5 groups) and building trust, uniting, and engaging communities and organizing community meetings (3 groups). At the government level, they saw providing grants for installation and improvement of septic systems (5 groups) as well as testing water and distributing findings (3 groups), as important next steps to solve this issue.

Environmental health priorities change over time

Compared to our initial focus groups in 2012 [ 9 ] and our follow-up phone surveys in 2016 [ 11 ], and finally our focus groups in 2016 and workshops in 2018 and 2019 described herein, environmental health priorities changed over time in Birmingham, but stayed consistent in Wilcox County. In the follow-up workshops in 2018, 16 (70%) of participants in Birmingham agreed that abandoned housing was the primary environmental health priority while 21 (70%) of participants in Wilcox County agreed that drinking water and wastewater issues was the primary environmental health priority (Tables  4 - 5 ). However, in the 2019 follow-up workshops, participants from both locations ranked water quality as the No.1 environmental health priority (Fig.  1 ). Based on the median ranks, Wilcox participants ranked sewage and septic systems a higher priority compared with Birmingham participants (4.0 in Wilcox vs. 3.0 in Birmingham, Mann-Whitney test p -value 0.049) while they ranked abandoned houses/lots a lower priority (2.0 in Wilcox vs. 3.0 in Birmingham, Mann-Whitney test p- value 0.046).

Mean Likert scale for environmental health issues in 2019 workshops. 95% confidence intervals were shown. Water.qual = water quality, climate.chg = climate change, Air.pollut = air pollution, Sewage = sewage and septic, Abnd.house = abandoned houses and lots, Anim.pest.ctrl = animal and pest control

In the 2018 follow-up workshops, more than half of the participants believed state and local resources were not fairly distributed to communities to address environmental health problems (87% in Birmingham and 67% in Wilcox, p- value 0.59), and both communities suggested a lack of leadership at the local level was the top reason behind this unfair distribution. In these workshops, Birmingham participants built from the 2016 focus group results described above, stating they would like to see neighborhood leaders attend city council meetings and report back to neighborhood residents (48% participants), and communicate progress, plans and timelines on addressing abandoned housing and vacant lots in their neighborhoods (22% participants). Birmingham participants stated that more state and local government resources should be devoted to hiring more work crews to tear down abandoned houses, mow overgrown lots (61% participants), provide incentives to build new business or new homes (26% participants), and provide more police presence (22% participants). Wilcox county participants in the 2018 follow-up workshops suggested community leaders should write grant proposals for money to fix the septic issues (50% participants) and hold local meetings to inform and unite residents (33% participants). They would also like to see state and local governing officials put more resources towards water lines, wells, and wastewater treatment (50% participants), and evaluate whether the pipes are safe or need to be replaced (37% participants) (Tables 4 - 5 ).

Sources of trusted information

The most trusted sources of information were news on television (TV), city council and city council representatives, and word-of-mouth in Birmingham, all of which were mentioned by four focus groups. Radio (5 groups), news on TV (4 groups), and word-of-mouth (3 groups) were the most trusted source of information in Wilcox County. One group in Wilcox County reported trust in local government, but not the county commission or mayor. In contrast, Birmingham focus groups frequently cited the government as a trusted source of information, in particular their city council and city council representative. Of the two Birmingham focus groups that did not cite the government as a trusted source of information, one did not mention any sources of trusted information and the other only cited the news and newspaper. While the Birmingham focus groups never mentioned distrusted sources of information, one group did say there was a lack of a trusted source of information. Similar to 2016 focus group results, in the 2018 follow-up workshops, Birmingham survey participants identified TV, city council meetings and neighborhood meetings, and conversations with community leaders as the most trusted information sources, while Wilcox County participants identified TV, radio, and county commission meetings as the most trusted information sources (Tables 4 - 5 ).

The ENACT community-academic partnership has been engaging with residents in Birmingham AL and Wilcox County AL since 2010 to understand environmental health priorities through focus groups, phone surveys, written surveys and workshops [ 9 , 11 ]. Here we present results from our most recent focus groups and workshops that clarified priorities, possible solutions, responsibly parties, and sources of trusted information on priority issues. We found that the environmental health priorities of abandoned houses in Birmingham and drinking water issues in Wilcox County in the focus groups were consistent with our previous findings [ 9 ].

The results suggest that participants saw local government non-responsiveness as the top reason for issues with abandoned housing persisting (5 of 6 focus groups), while also acknowledging government actions as the most promising solutions in addressing the abandoned housing issue in Birmingham (Table 2 ). In the 2018 workshops, 39% participants in Birmingham reported they believed local government (city, mayor, city councils) were most responsible for getting rid of abandoned houses (Table 4 ), showing consistency over time. In Wilcox County, five out of six focus groups discussed a range of solutions at the individual level, community level and government levels, which suggests that participants in Wilcox County see involving all stakeholders to tackle the water and sanitation problems is most promising.

The results, together with identified persistence reasons and potential solutions at the individual, community, and government levels may serve as evidence-based tools for identifying actions in the future. Follow-up workshops not only provided the opportunity to examine whether the identified environmental health priorities change over time but also serve as the events where research results were disseminated back to residents. As environmental health is a dynamic and evolving field, the environmental issues in Birmingham and Wilcox County communities can change over time. For example, Birmingham City Council programs initiated between 2016 and 2019 [ 41 , 42 ] could have contributed to reducing residents’ concerns over abandoned housing and vacant lots in 2019. Alternatively, the number of Public Water Systems with any violation dropped from 117 in 2013, to 61 in 2018, to 110 in year 2020 in Alabama [ 43 ], suggesting water quality issues have not changed.

Knowing from what sources people get trusted information on environmental health issues can shed light on why people are concerned about particular risks. Results showed that both communities trusted news on TV and word-of-mouth, and Birmingham groups trusted city council and Wilcox groups trusted radio programs. We also found a lack of trust in government in Wilcox groups. The results are consistent with a similar study surveying rural residents in El Paso, Texas where 54 and 46% participants had high confidence in television and radio, respectively, and the participants had low confidence in the government as a source of information [ 44 ]. As suggested by Byrd et al. (1997), the way that risk is portrayed by the media and the selection of stories may impact people’s perception of environmental health priorities [ 44 ]. Knowing the trusted information source may help community leaders monitor emerging or ongoing environmental health priority topics as well as use these sources to involve more residents, spread updates of meetings and policies, and disseminate evidence-based solutions. The names of specific TV programs or radios stations where participants get trusted information can be collected in future studies.

There are some limitations in the study. Bias may have been introduced with the use of nonprobability sampling methods to recruit focus group and workshop participants; however similar participant demographics in Birmingham and Wilcox County reduced potential bias when comparing results between the two locations, as studies have shown that gender, race, and culture are primary influences on risk perception [ 45 ]. As is common in health studies [ 46 ], the results presented herein reflect higher participation rates of women in both Birmingham and Wilcox County events, therefore male perspectives, if different, are underrepresented. Focus group participants may have refrained from bringing up issues in front of other community members or respected community leaders. However, in the focus group setting, participants could add to others’ responses to clarify issues and direct discussion in a meaningful way. Participants may also feel empowered by voicing their opinions and insights with other residents. There were some technical challenges in understanding some of the audio recordings, specifically distinguishing individual speakers within the group. This technical challenge coupled with high agreement within each group led to group-wise comparisons instead of individual counts as reported in previous focus groups [ 9 ]. As noted in the methods, the coding groups were not mutually exclusive, and topics could be counted multiple times, which is common to focus group analysis methodologies [ 38 ]. There was a higher percent of returning participants in Wilcox compared to Birmingham, which may have contributed to the result that drinking water quality was consistently the number one environmental priority in Wilcox County, however we do note that a randomly sampled phone survey we conducted also identified water quality as a top priority [ 11 ] .

Focus groups conducted in 2016 reaffirmed the identified environmental health priorities in 2012 focus groups, in both urban and rural communities. The top environmental health priority remained water quality and sewage treatment in the rural community in 2018 and 2019 surveys but switched from abandoned houses to water quality in the urban community in 2019. Participants identified ways to support the community in identifying and enacting solutions to their environmental concerns, which can be useful for community leaders to make future changes to address the problems.

Availability of data and materials

The dataset generated and analyzed during the current study are not publicly available due to the identifiable audio recordings, identifiable demographic information and questionnaires from participants. De-identified and aggregated data can be obtained by request to the corresponding author, Julia Gohlke, at [email protected] .

Abbreviations

Friends of West End

West Central Alabama Community Health Improvement League

Interrater reliability rate

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Acknowledgements

The authors gratefully acknowledge the funding from a grant from the National Institute of Environmental Health Sciences (R01ES023029). They recognize the crucial role of the Center for the Study of Community Health, supported by the Centers for Disease Control and Prevention (cooperative agreement number U48/DP001915). Thanks to focus group and workshop participants and volunteers from community organization partners for their time and efforts.

This work was supported by a grant (R01ES023029) from National Institute of Environmental Health Sciences.

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Translational Biology, Medicine, and Health Program, Virginia Polytechnic Institute and State University, Blacksburg, VA, 24061, USA

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Suwei Wang & Julia M. Gohlke

Division of Preventive Medicine, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, 35233, USA

Molly B. Richardson

Center for the Study of Community Health, University of Alabama at Birmingham, Birmingham, AL, 35233, USA

Mary B. Evans & Katherine L. White

West Central Alabama Community Health Improvement League, Camden, AL, 36726, USA

Ethel Johnson & Sheryl Threadgill-Matthews

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SW analyzed and interpreted data from workshops in 2018 and 2019, contributed to the data acquisition, and was one of the major contributors in writing the manuscript. MR analyzed and interpreted data from focus groups in 2016 and workshops in 2018, contributed to study design and data acquisition, and was one of the major contributors in writing the manuscript. ME, EJ, STM, ST contributed to study design and data acquisition. KW analyzed and interpreted data from focus groups in 2016. JG contributed to the conception, design of work, data acquisition and substantively revised the manuscript. All authors read and approved the final manuscript.

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Correspondence to Julia M. Gohlke .

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This study was approved by Virginia Tech Institutional Review Board (protocol #15–761). All methods were carried out in accordance with the Declaration of Helsinki. Informed consent was obtained from all the participants in the current study.

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Supplementary Information

Additional file 1..

Semi-structured discussion guide for focus groups and activities for workshops.

Additional file 2.

Transcript coding tree to identify persistence reasons, responsible parties, solutions, and source of trusted information.

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Wang, S., Richardson, M.B., Evans, M.B. et al. A community-engaged approach to understanding environmental health concerns and solutions in urban and rural communities. BMC Public Health 21 , 1738 (2021). https://doi.org/10.1186/s12889-021-11799-1

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Article contents

The environment in health and well-being.

• George Morris George Morris European Centre for Environment and Human Health, University of Exeter Medical School, Truro, United Kingdom
•  and  Patrick Saunders Patrick Saunders University of Staffordshire, University of Birmingham, and WHO Collaborating Centre
• https://doi.org/10.1093/acrefore/9780199389414.013.101
• Published online: 29 March 2017

Most people today readily accept that their health and disease are products of personal characteristics such as their age, gender, and genetic inheritance; the choices they make; and, of course, a complex array of factors operating at the level of society. Individuals frequently have little or no control over the cultural, economic, and social influences that shape their lives and their health and well-being. The environment that forms the physical context for their lives is one such influence and comprises the places where people live, learn work, play, and socialize, the air they breathe, and the food and water they consume. Interest in the physical environment as a component of human health goes back many thousands of years and when, around two and a half millennia ago, humans started to write down ideas about health, disease, and their determinants, many of these ideas centered on the physical environment.

The modern public health movement came into existence in the 19th century as a response to the dreadful unsanitary conditions endured by the urban poor of the Industrial Revolution. These conditions nurtured disease, dramatically shortening life. Thus, a public health movement that was ultimately to change the health and prosperity of millions of people across the world was launched on an “environmental conceptualization” of health. Yet, although the physical environment, especially in towns and cities, has changed dramatically in the 200 years since the Industrial Revolution, so too has our understanding of the relationship between the environment and human health and the importance we attach to it.

The decades immediately following World War II were distinguished by declining influence for public health as a discipline. Health and disease were increasingly “individualized”—a trend that served to further diminish interest in the environment, which was no longer seen as an important component in the health concerns of the day. Yet, as the 20th century wore on, a range of factors emerged to r-establish a belief in the environment as a key issue in the health of Western society. These included new toxic and infectious threats acting at the population level but also the renaissance of a “socioecological model” of public health that demanded a much richer and often more subtle understanding of how local surroundings might act to both improve and damage human health and well-being.

Yet, just as society has begun to shape a much more sophisticated response to reunite health with place and, with this, shape new policies to address complex contemporary challenges, such as obesity, diminished mental health, and well-being and inequities, a new challenge has emerged. In its simplest terms, human activity now seriously threatens the planetary processes and systems on which humankind depends for health and well-being and, ultimately, survival. Ecological public health—the need to build health and well-being, henceforth on ecological principles—may be seen as the society’s greatest 21st-century imperative. Success will involve nothing less than a fundamental rethink of the interplay between society, the economy, and the environment. Importantly, it will demand an environmental conceptualization of the public health as no less radical than the environmental conceptualization that launched modern public health in the 19th century, only now the challenge presents on a vastly extended temporal and spatial scale.

• environmental and human health
• environment
• environmental epidemiology
• environmental health inequalities
• ecological public health

Introduction

This article traces the development of ideas about the environment in human health and well-being over time. Our primary focus is the period since the early 19th century , sometimes termed the “modern public health era.” This has been not only a time of unprecedented scientific, technological, and societal transition but also a time during which perspectives on the relationship of humans to their environment, and its implications for their health and well-being, have undergone significant change.

Curiosity about the environment as a factor in human health and well-being, and indeed health-motivated interventions to manage the physical context for life, substantially predate the modern public health era. The archaeological record provides evidence of sewer lines, primitive toilets, and water-supply arrangements in settlements in Asia, the Middle East, South America, and Southern Europe, dating back many thousands of years (Rosen, 1993 ). Some religious traditions also imply recognition of the importance of environmental factors in health. For example, restrictions on the consumption of certain foods probably derive from a belief that these foods carried risks to health; a passage in the book of Leviticus conveys the existence of a belief in the relationship between the internal state of a house and the health of its occupants (Leviticus [14:33–45], quoted in Frumkin, 2005 ).

The sixty-two books of the “Hippocratic Corpus” dating from 430–330 bc are the accepted bedrock of Western medicine (Lloyd, 1983 ), not least because they departed from the purely supernatural explanations for health and disease which hitherto held sway. For the first time, ideas about medicine, diseases, and their causes were being written down. Among these were ideas about the environment and its relationship to mental and physical health (Lloyd, 1983 ; Rosen, 1993 ; Kessel, 2006 ). While scarcely a template for how societies would come to think about environment and health in the modern era, one Hippocratic text in particular, On Airs, Waters and Places , introduces several ideas that do retain currency. For example, the simple message that good health is unlikely to be achieved and maintained in poor environmental conditions is enduring. Also, through specific reference to the health relevance of changes in water, soil, vegetation, sunlight, winds, climate, and seasonality, On Airs, Waters and Places conceives an environment made up of distinct compartments and spatial scales from local to global, recognizing that perturbations in these compartments, and on these scales, may result in disease. Such thinking remains conceptually and operationally relevant today. Hazardous agents are still frequently addressed in “environmental compartments” such as water, soil, air, and food or by developing and applying environmental standards for the different categories of place where people work, live, learn, and socialize. In parts, the Hippocratic Corpus also presages the ecological perspectives now coloring 21st-century public health thinking. These include an understanding of the potential for human activity to impact negatively on the natural world and the importance of viewing the body within its environment as a composite whole.

Environment and Health in the Modern Public Health Era

Epidemiology is the basic science of public health and is concerned with the distribution of health and disease in populations across time and spaces, together with the determinants of that distribution. Environmental epidemiology is a subspecialty dealing with the effects of environmental exposures on health and disease, again, in populations. Since the early 19th century , the outputs of epidemiology have been key components of a “mixed economy of evidence” that has shaped and reshaped priorities and informed the decisions society takes to protect and improve population health (Petticrew et al., 2004 ; Baker & Nieuwenhuijsen, 2008 ).

In a classic paper from the 1990s, the respected epidemiologists, Mervyn and Ezra Susser, helpfully described different “epidemiological eras” in modern public health, each driven by a dominant paradigm concerning the causes of disease and supported by a particular analytical approach (Susser & Susser, 1996 ). This differentiation offers a useful framework within which to consider changing perspectives on the role of environment in health since the early 1900s.

The Environment in an “Era of Sanitary Statistics”

The Industrial Revolution came first to 19th-century Britain driven by technological innovation, abundant coal supplies, and supportive political/economic conditions. Also influential was a post-Reformation philosophy that extolled the work ethic and self-sufficiency. The events were to resonate throughout the world, bringing great prosperity to some, but others, especially the urban poor, endured poor housing, severe overcrowding, and an absence of wholesome water or sanitation. The growing industrial cities became crucibles of squalor, disease, and severely reduced life expectancy as their citizens suffered the ravages of typhus, tuberculosis, and successive cholera epidemics. Unhealthy working conditions and grossly polluted air also damaged health and compounded the misery of urban life at this time. Such challenges were common to all locations touched by the Industrial Revolution and became the catalyst for a new public health movement across Europe and North America (Rayner & Lang, 2012 ; Rosen, 1993 ).

Using the new science of medical statistics, investigators quickly established the locations with the poorest living conditions to be also those where disease and early death were most prevalent (Chadwick, 1842 ), fueling an ultimately transformational societal response—a “sanitary revolution” (Rosen, 1993 ). Such was the impact of this mix of slum clearance with the introduction of waterborne sewerage and piped water supplies that readers of the British Medical Journal , voting almost two centuries later, still chose it, from a shortlist of 15, as the most important medical milestone since the Journal was first published in 1840 . The 11,300 readers who voted even placed it above the discovery of antibiotics and the development of anaesthesia (Ferriman, 2007 ).

Despite its impact, the “sanitary revolution” was famously initiated and sustained on a biologically flawed paradigm regarding the mechanistic causes of disease. Yet “miasma” (the transmission of disease through noxious vapors), because it served as a metaphor for squalid insanitary conditions, still drove effective intervention (Morris et al., 2006 ; Nash, 2006 ). During this time, however, the emergence of epidemiology as the primary mode of inquiry of public health was also pivotal to success. Endorsing this view, Susser and Susser labeled the first half of the 19th century an “Era of Sanitary Statistics,” citing the frequent use of district-level data to link disease to, for example: filthy and degraded urban environments; overcrowding and poor housing and working conditions; and social factors like infant care (Susser & Susser, 1996 )).

Thus, recognition that the environment (physical and social) mattered for health and notions of a “permeable” human body in close connection with other organisms and the abiotic environment were embedded at the launch of the 19th-century public health movement. It is notable that the perspective of the reformers was quite properly “proximal,” that is, rooted in an acceptance of the importance of the local environment, physical and social. While the term “ecology” would not be coined until 1866 (Haekel, 1866 ) and “social ecology” much later still (Bookchin, 1990 ), the public health pioneers embraced what, in today’s terms, we would understand as a broadly socioecological perspective and discerned no conflict in this with their efforts to understand the immediate causes of disease and intervene in a focused way to prevent it (Nash, 2006 ).

Especially through the efforts to stop cholera, the sanitarians affirmed the pathogenic potential of unsanitary conditions and pioneered the epidemiological approach, initially as “environmental epidemiology” (Baker & Nieuwenhuijsen, 2008 ). Other legacies of the Era of Sanitary Statistics have been less enduring. Despite recent advocacy of a “precautionary principle” (see, e.g., Martuzzi, 2007 ; European Environment Agency, 2013 ), the willingness to act on the basis of strong suspicion of a societal-level environmental threat to population health has diminished, perhaps an inevitable casualty of increasing sophistication and “evidence-based” approaches in medicine and policy (Kessel, 2006 ; Brownson et al., 2009 ). Many of public health’s greatest triumphs have flowed from interventions that would have struggled to satisfy today’s evidential criteria. Also, despite a recent reconnection with such arguments, the inherent logic of seeing and tackling disease in its social and environmental context, so obvious to the pioneers of public health, has periodically been less visible in the rhetoric and actions of their successors.

It is appropriate at this point to emphasize the international character of the 19th-century public health movement. This movement can all too easily be presented as a British phenomenon, with seminal contributions from John Snow ( 1813–1858 ) on the investigation of cholera (Vinten-Johansen et al., 2003 ); William Farr ( 1807–1883 ), also on cholera but more widely on medical statistics (Susser & Adelstein,, 1975 ); Edward Jenner ( 1749–1823 ) on vaccination (Baxby, 2004 ), and Edwin Chadwick ( 1800–1890 ) on the assembly of data relating disease to the filth and squalor that came with poverty (Chadwick, 1842 ). In reality, public health, then as now, advanced through the contribution of many individuals in many nations. For example, the German pioneer of cellular biology, Rudolf Virchow ( 1821–1902 ), and his fellow countryman, the hygienist Johan Peter Frank ( 1745–1821 ), were hugely important (Rather, 1985 ). In France, Louis-Rene Vilerme ( 1782–1863 ), the doctor and pioneer of social epidemiology, highlighted links between poverty and death rates (Rosen, 1993 ) and, in the United States, the meticulous work of Lemuel Shattuck ( 1793–1859 ) bears direct comparison with that of Chadwick (Rayner & Lang, 2012 ).

It might be supposed that the consolidated outputs of European laboratories, especially in the decades between 1830 and 1870 , would have quickly expunged the miasmic paradigm from 19th-century medicine and public health. Yet, the concept of miasma was so inculcated in Western thought that, for many, it retained significant explanatory power. Thus, for much of the 19th century there was not a single settled view on disease contagion (e.g., see Kokayeff, 2013 ). Indeed, as late as 1869 some distinguished Medical Officers of Health in England still attributed diseases such as typhoid to “the insidious miasma of sewer gases” and dismissed germs as “pure nonsense.”

The Environment in an “Era of Infectious Disease Epidemiology”

Increasingly contested, the miasmic theory of disease was effectively supplanted in the 1880s by broad acceptance of the germ theory, ushering a new “Era of Infectious Disease Epidemiology” (Susser & Susser, 1996 ). In 1882 , Louis Pasteur’s techniques for growing organisms made it possible for Robert Koch ( 1843–1910 ) to demonstrate that a mycobacterium was the cause of tuberculosis and, shortly thereafter, to provide scientific proof that cholera was waterborne (Foster, 1970 ; Collard, 1976 ; Brock, 1999 ). In so doing, Koch established, what had been hypothesized by his teacher, Jacob Henle ( 1809–1885 ), some 40 years earlier that disease was microbial. Henle, Snow, Koch, and the biologist Ferdinand Cohn ( 1828–1898 ) are rightly seen as fathers of the science of medical microbiology that for a time would come to dominate thinking in medicine and public health (Rayner & Lang, 2012 ).

Initially at least, the germ theory did little to diminish interest in the environment as a determinant of health. Indeed, by revealing causal linkages between organisms isolated from their environmental carriers and specific diseases, it conferred scientific coherence on the established sanitary model and vindicated efforts to secure hygienic water, food, and housing. As Lesley Nash has observed, the germ theorists were initially content to meld the insights of bacteriology with longstanding environmental beliefs. Notions of a body in constant interaction with, and closely dependent on, its local social and physical context (in today’s terms a socioecological perspective) did not conflict with the narrower perspectives of laboratory science (Nash, 2006 ).

While relative contributions may be debated, over a short timeframe medical microbiology, isolation, immunization, and improving social/environmental conditions combined to sharply reduce the burden of infectious disease for Western society. Yet, by the early years of the 20th century , the capacity to examine disease at the microscopic level, which was the engine of diagnostics and therapeutics, was beginning to act on the very foundations that support public health. Medical science gradually made its focus the pathogenic agents of disease, moving attention away from the environment and eroding socioecological perspectives. Doctors seemed quite content to express health as an absence of disease, and medical science to project its role as the maintenance and reinforcement of “self-contained” human bodies (Nash, 2006 ). Through a growing tendency to see health, disease, and their determinants as attributes of individuals rather than characteristics of communities, wider society seemed almost complicit in an ‘individualization’ of health status. One implication of this blunting of a social/environmental thrust of public health was to divorce health from place, a development that would have profound implications in the very different epidemiological context that emerged following World War II.

The Environment in an Era of Chronic Disease Epidemiology

The dramatic reduction in infectious disease was certainly one reason why the epidemiological climate in Western society changed substantially in the mid- 20th century . But just as important was the emergence of a quite disparate set of pathologies believed to be of noncommunicable etiology. Coronary heart disease, cancers, and peptic ulcers, which became the targets in a new “Era of Chronic Disease Epidemiology” (Susser & Susser, 1996 ), were thought rather unlikely to have origins in exposure to what was an increasingly regulated and ostensibly improving physical environment. While the outputs of much postwar epidemiology seemed to endorse this view, it is useful, with hindsight, to recognize the influence of what might be seen as “fashions” in epidemiological inquiry. These fashions would influence how medical science and the wider society would come to regard diseases and their causes for a generation.

The response of the public health community to the new and alarming “noncommunicable” threats was, logically, to deploy descriptive epidemiology to reveal those most likely to be affected. Perhaps surprisingly, those who traditionally were most vulnerable to disease (the young, the old, the immunocompromised, etc.) did not appear to be at increased risk. Rather, the new epidemics disproportionately affected men in their middle years (Nabel & Braunwald, 2012 ). Supported by enhanced computing power and methodological advance (Susser & Susser, 1996 ), researchers began to converge on specific risk factors that correlated with diseases of greatest concern. Many, it seemed, were aspects of individual lifestyle and behaviors, ostensibly freely chosen. A particular attraction for the proponents of what was to become known as “risk factor epidemiology” was its capacity to represent, mathematically, the “relative risk” of contracting a disease between people exposed to a putative risk and those who were not. Some have dubbed this epidemiological approach to noncommunicable or chronic disease “black box epidemiology” because it can relate exposure to outcomes “without any necessary obligation to interpolate either intervening factors or even pathogenesis” (Susser & Susser, 1996 ). Another unfortunate characteristic of this approach to epidemiology is that, despite its laudable intent to understand and address disease in populations , its focus is on individuals within those populations. As a result, it fails to elucidate the societal forces whose influence and interplay shape the health and health-relevant choices of those individuals. When viewed through a policy lens, this mitigates in favor of simplistic solutions that target individuals divorced from context and that lack the traction to produce meaningful change.

In summary, the desire to create a mathematical measure of relative risk for a specific factor is understandable. However, risk factor epidemiology uses an approach that is much more flexible than material reality. In the real world, many different factors coexist and interact to create and destroy health. This is not, however, to deny risk factor epidemiology’s capacity, particularly in synergy with laboratory-based research, to break new ground. Notably, these methodologically driven approaches were key to elucidating links between smoking and lung cancer, heart disease and serum cholesterol, and between levels of prenatal folic acid intake and neural tube defects (Susser & Susser, 1996 ; Kessel, 2006 ; Perry, 1997 ).

The same basic criticism is voiced where similar “black box” epidemiological approaches are used to explore the contribution of a specific environmental agent, as in the case of much recent air pollution epidemiology (see below) (Kessel, 2006 ). Any specific pollutant under epidemiological investigation inevitably coexists with other pollutants and in a specific exposure context (e.g., prevailing climatic conditions). These coexisting factors may be critical in determining the health outcomes from exposure to the pollutant under investigation. Because the outputs of black box epidemiology are abstractions, the relative risk calculation represents an abstraction that can be limited in its capacity to inform policy.

The decades following World War II were a time of declining influence for public health and population perspectives, largely for reasons we have outlined. Yet, in its rhetoric and activities, the discipline of public health seemed at times almost complicit. Even its defining science of epidemiology seemed for a time more concerned to reinforce the insights of clinical medicine than to play the exploratory role on which its reputation had been founded (Susser & Susser, 1996 ). On the face of it, academic public health and the wider public health discipline had little to say about environment, no longer presenting it as an active component in the then current health challenges for Western society. As Nash has observed, physical environments were “recast as homogenous spaces which were traversed by pathogenic agents.” Nevertheless, divorced from the prevailing rhetoric, in many locations there was a parallel narrative depicting a workforce that continued to work at a local level, within established legal and administrative frameworks, to protect and maintain health-relevant environmental quality standards. However, the environmental health function was often set in the narrow, hazard-focused, and compartmentalized terms framed for it by laboratory science. The task was largely confined to identifying, monitoring, and controlling a limited set of toxic or infectious threats in their environmental carriers. Only when pathogenic organisms or toxic agents demonstrably escaped their industrial, agricultural, or marine confines to damage health and reinforce the porosity of the human body did environment briefly assume a higher profile.

Against this backdrop, it was not necessarily predictable or inevitable that environment would regain a central place in public health. Yet, by the end of the 20th century , a much richer understanding of the environmental contribution to human health and well-being had indeed emerged. This change cannot be attributed to a single factor in isolation. Some point to the key influence of Rachel Carson’s Silent Spring in 1962 (Carson, 1962 ), which expressed grave concern for the ecosystem effects of DDT, the linkage to potential human health effects, and the implications of a growing disconnect between humankind and nature. We do not deny the status of Carson’s work as a seminal text of a modern “environmentalism” that would rapidly gather pace and influence (Nash, 2006 ). However, we submit that it is only now, in the 21st century , when the reality of unprecedented anthropogenic damage to global processes and systems and its health implications is self-evident, that the health sector has fully made common cause with the environmentalist movement (e.g., see Butler et al., 2005 ; Butler & Harley, 2010 ) (We discuss this development later in this article under Ecological Public Health.

However, for reasons that are distinct from a mounting concern over anthropogenic threats to global environmental systems and processes, we argue that the closing decades of the 20th century and the early years of this century did see a rekindling of public health and societal interest in the local or proximal environment. This interest has continued into the 21st century . Developing interest in well-being as a concept, the belief that it is important and that it might be enhanced through the organized efforts of society, continues to engage the attention of academics and policymakers. Although well-being demonstrably impacts health and vice versa, well-being is about much more than health. Rather, it is a measure of what matters to people in every sphere of their lives. Despite its importance, well-being has proved a challenging target for policy. Some of its components are beyond the reach of policy. However, others, including aspects of the built and natural environment and people’s connection to it, are amenable to manipulation. Accordingly, research has been especially concerned to identify the qualities of their environment that are important for different people’s well-being, quality of life, and health at various life stages (Royal College of Physicians, 2016 ). Also, on a practical level, integrating the various well-being frameworks and indices that continue to emerge is an ongoing challenge. However, it is sufficient at this point simply to recognize that elevated concern for well-being and its connection to environment can only broaden and deepen concern for the environment in public health. It will continue to drive renewed interest in matters such as landscape, natural beauty and scenery; crime free, clean places; green, blue, and natural environments; and so on.

Reconnecting Health with Place

Five issues/developments merit particular mention for their role in reestablishing the local environment as a mainstream consideration in health in the developed world in the late 20th century . While recognizing that there is an interrelationship among some of the factors discussed, for simplicity, we discuss them separately here.

Air Pollution

In citing air pollution as a key factor in a late- 20th-century resurgence of interest in the environment, we recognize its much longer history as a contributor to ill health (Evelyn, 1661 ; Lloyd, 1983 ). We acknowledge, too, that accounts of the modern public health era since its inception have been suffused with references to air pollution events, their health implications, and the political and professional campaigns that have sought to mitigate risk (Kessel, 2006 ). However, despite a compelling case for action, the need for urgent intervention was only fully accepted after a number of high-profile air pollution episodes in the 20th century . In 1930 , a severe smog incident in Belgium’s Meuse Valley resulted in the death of sixty people. Prophetically, investigators were quick to highlight the potential for many more deaths, were such an incident to be repeated in a more highly populated area (Bell & Samet, 2005 ). In 1948 , a further twenty people were to die and many more suffer injury after an industrial pollution incident in Donora, Pennsylvania (Hamil, 2008 ), but the tipping point came four years later, with the London Smog of 1952 .

Between December 5 and December 9, a dense fog descended on London where it mixed with air, polluted by domestic and industrial emissions. The resulting thick smog was familiar to many urban dwellers, but in this case, a combination of cold weather and stagnant atmospheric conditions caused sulfur dioxide and smoke concentrations to reach and maintain extremely high levels for a sustained period. The smog had a paralyzing effect on the city’s transport system, and many other aspects of daily life were severely disrupted. But the most dramatic effects were on health. Death rates were to reach three times the normal level for the time of year, and demand for hospital beds far exceeded supply (Baker & Nieuwenhuijsen, 2008 ). While the smog dissipated after a few days, deaths rates remained high for several months thereafter. Subsequent analysis has revealed that, rather than the 3,000–4,000 deaths linked to the episode in at the time, a figure of 10,000–12,000 deaths is more probable (Bell et al., 2004 ).

The London smog is historically important, obviously because of the distressing toll in morbidity and mortality and because it catalyzed long-overdue legislative intervention in the UK in the form of the Clean Air Act of 1956 and the U.S. Clean Air Act 1963 . Critically, however, it reminded the public and politicians of the reality that, given the right conditions, population-level environmental exposures were still entirely capable of producing significant morbidity and mortality.

In combination with other factors, the clean air legislation that emerged in the wake of the smog reduced domestic and industrial fossil fuel emissions, and helped to secure significant reductions in background concentrations of smoke and sulfur dioxide (Royal College of Physicians, 2016 ). However, by the late 1980s, a new, more insidious, urban air pollution threat had begun to emerge. This pollution had its origins not in fixed-point emissions, but in the rapidly increasing numbers of motor vehicles and other fossil fuel-driven forms of transport in towns and cities. The pollutants of concern here, which lacked the visibility of the earlier sulfurous smogs, were fine particles, oxides of nitrogen, and ozone. So-called time-series analyses, using data on the temporal variation in environmental exposure and in health, aggregated over the same time period, were now applied to explore the issue of urban air pollution and health (e.g., see Pope et al., 1995 ; Dockery & Pope, 1996 ; Kessel, 2006 ). The studies revealed the cardiopulmonary effects of long-term exposure to much lower levels of ambient air pollution and, later, following further investigation, the absence of a threshold level for causing health effects. Recent outputs of ‘life-course’ epidemiology have also shown that air pollution affects health, not only through the exacerbation of symptoms in the elderly, but through various processes that have impacts from the womb, through childhood to adolescence, early adulthood, and on into middle and older age (Royal College of Physicians, 2016 ). Also, appreciation that air pollutants can be resident in the air for days or even weeks makes air pollution not simply a local problem, but one that demands source control at city, regional, and international levels. In the UK, for example, the equivalent of around 40,000 deaths every year can be attributed to fine particulates and NO 2 exposure from outdoor air (Royal College of Physicians, 2016 ).

Air pollution is probably the most thoroughly investigated of all environmental threats to health and well-being. Revelations about the true extent of its impact on health keep the issue in the headlines and emphasize the centrality of the physical environment within the public health project. Despite being a focus for academic interest and research fundings, the problem of urban air pollution is a very long way from resolution and is one factor that demands a fundamental reappraisal of how, as a species, we live, consume, and travel. (We discuss a wider, global dimension of the air pollution challenge later in this article.)

Everything Matters: The Environment as an Ingredient in Social Complexity

Another important and often overlooked reason for the late- 20th-century rekindling of interest in the environment and human health can be traced to developments within the wider discipline of public health. Ironically, the thinking behind what, by the 1990s, was being termed the “new public health” had its origins in much older ideas that gave prominence to the social structures in which health is created and destroyed (Baum, 1998 ; Awefeso, 2004 ). If we accept that health, disease, and social patterning in these matters are products of a complex interaction of influences at the level of society with the characteristics of individuals, then such complexity ought to be reflected in the policies and partnerships formed to address them. A growing number of analyses, beginning in the 1970s, would turn a spotlight on this complexity and fundamentally challenge the dominance of the biomedical/health care model and its capacity to solve the problems that beset public. These problems included the intractable burden of noncommunicable disease; growing levels of obesity; diminished psychological well-being; and, not least, stubborn and widening inequalities in the health and well-being of different social groups. Concern also mounted over containing rising, and potentially bankrupting, health care costs.

“A New Perspective on the Health of Canadians,” more commonly referred to as the Lalonde Report, after Canada’s then health minister Marc Lalonde, was published in 1974 (Lalonde, 1974 ). Despite its national focus, the report assumed wider relevance because of its analysis of one of public health’s greatest generic challenges, that of navigating among the many complex and interacting determinants of health to identify effective policies and actions. Implicitly offering a socioecological perspective, the Lalonde Report spoke of a “Health Field,” which included all matters that affect health and comprised four core elements: human biology, environment, lifestyle, and health care organization. Any issue, it was proposed, could be traced to one, or a combination, of these elements, allowing the creation of a “map of the health territory” for any problem (Lalonde, 1974 ). In this way, the contribution and interaction of the elements could be assessed. The analysis affirmed the health relevance of a complex environment comprising interacting physical and social dimensions in interaction with the human body. Lalonde’s message was logical and important, yet more than just an echo of an earlier, more inclusive, understanding of the determinants of health and disease. It recast these largely abandoned perspectives for a more scientific and sophisticated era. The proposal that thousands of “pieces” relevant to health and its determinants could be organized in “an orderly pattern” was alluring and progressive, as was the notion that the exercise alone would allow all contributors to more fully appreciate their roles and influence (Morris et al., 2006 ). In the ensuing years, Lalonde’s proposals for understanding and addressing complexity in the determinants of health have been refined and given greater policy relevance by others. In part, this has been through the development of conceptual models of the socioecological determinants of health. These models have been promoted as tools for presenting evidence that can make their implications more apparent (Evans & Stoddart, 1990 ; Dahlgren & Whitehead, 1991 ). In most of these representations, the local environment is accepted as a key driver of health and well-being (Morris et al., 2006 ).

Despite its inherent logic, the socioecological perspectives that emerged in the closing decades of the 20th century created scientific and policy challenges for all constituencies concerned with public health. There were obvious generic challenges, for example, around which of the models (each, necessarily, a gross simplification of a complex reality) might point to solutions (Morris et al., 2006 ; Evans & Stoddart, 1990 ; Reis et al., 2015 ); around the nature of evidence and its interpretation (Petticrew et al., 2004 ; Tannahill, 2008 ); and how, in practice, to traverse professional and policy silos to produce the interdisciplinary approaches that are inevitably required. In this connection, the task of motivating, supporting, and delivering effective intersectoral working, an abiding challenge for public health policy and practice, assumed a much higher profile in the late 20th century with the emergence of the socioecological model of health.

We emphasize that the continuing failure to adequately confront this challenge has the gravest implications for global public health. As Prüss-Üstün et al. recently observed, “Tackling environmental risks requires intersectoral collaboration. After nearly 50 years of actively promoting this concept, whether referred to as intersectoral action, breaking down silos or the nexus approach, it remains elusive as ever. The statement ‘intersectoral collaboration: loved by all, funded by no-one’ points to obstacles, mainly vested interests, that have burdened this approach ever since it was included as part of the WHO/UNICEF Alma Ata Declaration on Primary Health Care in 1978 . Environmental health, quintessentially intersectoral, has suffered most from this lack of progress” (Prüss-Üstün et al., 2016a ).

With specific reference to the role of the local environment, the recognition of socioecological complexity as the determinant of health meant that strict adherence to narrow hazard-focused and compartmentalized approaches became intellectually unsustainable. Yet, acceptance of the dynamic interaction of environment with other determinants of health demands a richer understanding of the environmental contribution than can be provided by toxicology or microbiology in isolation.

The Role of the Environment in Health Inequalities

The fact that the poorest, most degraded urban neighborhoods were those most blighted by disease and reduced life expectancy was clear even to the public health pioneers of the 19th century . Indeed, throughout much of the modern public health era, an acceptance of the importance of the environment for health and well-being has been accompanied by a recognition of the interplay between sociodemographic, economic, and physical factors in creating and sustaining health inequalities.

The term “health inequalities” refers to general differences in health, however caused. Where the differences in health are unfair, unjust, and avoidable, as they often are when linked to social variables, they should more properly be termed “health inequities.” However, in the extensive literature on the topic and in common usage, inequities are termed inequalities, and we adopt this convention here. Despite their importance, the emphasis on tackling health inequalities has varied considerably over time and according to place.

In 2008 , the final report of the Commission on the Social Determinants of Health (CSDH, 2008 ) elevated the global profile of health inequalities and emphasized the interplay of many societal-level factors in their creation in the 21st century . The significant achievements in public health across the world over nearly two centuries have not been shared equally between countries or by all social groups within countries. An important component has been the health-relevant differences in the physical context for people’s lives—the quality of the physical environment. Sometimes expressed in terms of environmental justice , or elsewhere as environmental health inequalities, attention to this area is key to tackling health inequalities across the world (CSDH, 2008 ; Morris & Braubach, 2012 ).

Estimates of the impact of environmental quality on health and well-being vary widely, depending on the definition of environment used. However, that impact is undeniable. Over a billion people in developing countries, for example, have inadequate access to water, and 2.6 billion lack basic sanitation . The World Health Organization estimates that environmental factors were responsible for 12.6 million deaths worldwide in 2012 , 23 percent of all deaths, and 22 percent of the total burden of disease. Addressing environmental risks could prevent 26 percent of all deaths of children under the age of 5 (Prüss-Üstün et al., 2016b ).

In addition, there is clear evidence that a “good” environment empowers health through access to environmental assets such as green spaces, access to a healthy diet, and safe environments in which to walk, cycle, play, and socialize. However, as these data suggest, there is also a fundamental equity dimension to the distribution of both the cause and distribution of environmental stressors, the susceptibility to exposure, and the adverse effects of those exposures. Deprived communities almost invariably live in poorer quality environments, with higher levels of indoor and outdoor air pollution, contaminated land, polluting industrial processes, overcrowded and poor quality housing, and lower levels of environmental assets (Prüss-Üstün et al., 2016a ; 2016b ; Royal College of Physicians, 2016 ; The Marmot Review Team, 2010 ). Populations in developed countries, including the former communist states of eastern Europe living in areas of high air pollution, are disproportionately deprived, for example (Kriger et al, 2014 ; Bell & Ebisu, 2012 ; Branis & Linhartova, 2012 ; Goodman et al., 2011 ). Poor indoor air quality is associated with unfit or inadequate housing standards, conditions that overwhelmingly affect the deprived (The Marmot Review Team, 2010 ). There is evidence that deprived communities are not only more exposed to environmental hazards but are also more susceptible to the effects of those exposures (Goodman et al., 2011 ; Carder et al., 2008 ; Richardson et al., 2011 ; 2013 ; Vinikoor-Imler et al., 2012 ). There are also concerns that stress, at both the individual and community level, can weaken the body’s defenses against external insult and influence the internal dose of toxicants (Gee & Payne-Sturges, 2004 ).

This effect is also seen in social and physical environments. An adequate and nutritious diet is essential to a healthy, productive, and fulfilling life, and it is a fundamental right predicated by a range of factors including personal knowledge, choice, convenience, availability, quality, cost, and social norms. The evidence is clear that deprivation compounds all these factors, with poorer people buying more unhealthy foods with fewer healthy components while being exposed to circumstances that make such “choices” inevitable (Rudge et al., 2013 ). The proportion of adults considered overweight or obese in 2008 in the 19 EU member states for which data were available ranged between 37 and 57 percent for women and between 51 and 69 percent for men ( EUROSTAT ). English children from deprived areas are almost twice as likely to be obese than those in affluent areas, and adult obesity is also associated with deprivation, particularly in women (Public Health England, 2016 ; National Obesity Observatory, 2013 ).

The poor in developed countries are adept at sourcing cheap calories and are exposed to a large numbers of local outlets selling cheap, calorie-dense takeaway food (Saunders et al., 2015 ). These meals are often super-sized and contain high levels of fats, sugar, and salt. At the same time, many of these areas provide limited access to healthy food options, creating a highly compromised public health environment (Saunders et al., 2015 ).

In addition, environmental stressors seem to have a cumulative impact, exacerbating this inequality. It is evident that poorer people have multiple health, social, and environmental stressors. It is entirely plausible that these stressors modify the effect of exposure to pollutants, as is reflected in the increased vulnerability of obese people to the effects of exposure to air pollutants, including increased risk of diseases such as cardiovascular events and respiratory symptoms (WHO, 2013 ; Jung et al., 2014 ). Long-term exposure to airborne pollutants has also been reported to increase the risk of obesity, and being overweight or obese is associated with an increased susceptibility to indoor air pollution in urban children with asthma (Lu et al., 2013 ).

The responsibility for, and relative benefits and costs of, environmental contamination are also important components of inequality. Environmental contamination may be tolerated by communities living in the vicinity of dirty industrial processes if they perceive a benefit in terms of local employment, although that trade-off has largely broken down in developed countries as those industries have declined in the 20th and 21st centuries. On a wider scale, the environmental consequences of contemporary affluent nations’ fuel economies are borne by those populations least able to bear them and with little or no responsibility for their causation (Patz et al., 2005 ). UNICEF has projected that 75–250 million Africans will be exposed to increased water stress due to climate change by 2020 (UNICEF, 2008 ), a phenomenon overwhelmingly caused by the First World. This is a gross injustice. These are also the same people with limited powers to prevent the dumping of rich countries’ waste in their communities. One appalling example is that of the “disposal” of 500 tons of toxic waste in and around Abidjan, the capital of Cote D’Ivoire, in 2006 . This poisonous cocktail of waste oil and contaminants was the result of the trading in, and processing of, hydrocarbon fuels by multinational commodity and shipping companies, criminal levels of cost cutting, and local political corruption, which led to 17 deaths and over 30,000 injuries in one of the poorest communities in the world (Bohand et al., 2007 ) There are many other examples, including the export, often illegally, of hundreds of thousands of tons of e-waste from Western countries to Africa, China, and Asia for recycling or disposal—transferring the costs and dangerous consequences of exposure to workers, including children, and local communities in these countries that do not have the technical or regulatory systems to deal safely with these toxic materials (ILO, 2012 ). Inuit mothers in northern Canada have elevated levels of chemicals such as PCBs—generated many hundreds, if not thousands, of miles away—in their breast milk (Johansen, 2002 ).

The redistribution of the environmental injustices historically endured by the poor also perversely appears to be affecting more affluent communities in the West. The huge expansion of “fracking” in North America, for example, may be leading to an export of risks from traditional “national sacrifice zones” to areas with no previous experience of such industry, creating “profound social, cultural, and economic shocks for middle class communities losing control over their environments” (Lave & Lutz, 2014 ). Despite their relative affluence, this would nonetheless be an injustice given the constraints on local democratic input and highly questionable direct economic benefits to those communities (Kinnaman, 2011 ; Lave & Lutz, 2014 ; Sovacool, 2014 ).

During a period when environmental catalysts for distress migrations are becoming more frequent (Thomas-Hope, 2011 ), there is a moral as well as a professional duty for the Environmental Health community to tackle these inequalities, which otherwise are likely to both widen and deepen.

The Health-Promoting Environment: Green, Blue, and Natural Spaces

While human communities have long valued access to natural resources such as green spaces, the industrialization of the 19th and early 20th centuries saw millions of people deprived of this access. This era did witness some far-sighted philanthropic gifting of areas of open recreational space for the working classes driven by a moral rather than evidence-based imperative. Though welcome, the distribution of, and access to, such resources was limited, inconsistent, unplanned, and vulnerable to the insecurities of voluntary funding. Subsequent local municipal development of parks and other open spaces increased access, and a greater understanding of the benefits of such access blossomed during the late 20th century as research demonstrated and quantified the public health dividends. Access to good-quality green spaces not only makes the places in which we live, work, and play more attractive, but also has a demonstrable effect on improving health and well-being. Green space is linked to lower levels of several diseases and conditions, including lower rates of mortality (Villeneuve et al., 2012 ), increased longevity in older people (Faculty of Public Health, 2011 ), improved mental health (Faculty of Public Health, 2011 ), better outcomes in disease treatment, and reduced medication (Faculty of Public Health, 2011 ), and it also helps reduce health inequalities (Mitchell & Popham, 2008 ; CABE, 2010 ). Plausible mechanisms for these benefits include the provision of a venue for physical activity, promotion of social contact, and the direct impacts of green spaces on psychological and physical health. Natural spaces also promote greater community cohesion and reduce social isolation, providing a platform for community activities, social interaction, physical activity, and recreation (Public Health England, 2014 ). Research from the United States has identified powerful associations between green space and major reductions in aggressive behavior, domestic abuse, and other crime in deprived urban areas (Kuo et al., 2001a , 2001b ).

And yet, there remain great inequalities in the distribution, use, and quality of this empowering resource. People living in the most deprived areas are less likely to live in the greenest areas and therefore have less opportunity to gain the health benefits of green space compared with people living in the least deprived areas (Public Health England, 2014 ). Children living in poor areas, for example, are nine times less likely than those living in affluent areas to have access to green space and places to play (National Children’s Bureau, 2013 ). It is entirely plausible that that this contributes to the sobering reality that children from deprived communities are up to three times as likely to be obese than those children growing up in affluent areas (National Children’s Bureau, 2013 ).

Accessibility, however, is not the same as availability or utility, nor is it simply a function of proximity. It is strongly impacted by the cost of access, whether it is actually physically available, opening times, and the ease of being able to get to it, for example, walking and good public transport. Deprived communities in particular appreciate the value of such spaces, but they tend to underuse them due to concerns about the safety and quality of the spaces (CABE, 2010 ). Experience has shown that quality of the green space is just as important, if not more so, than its size. Post-World War II urban developments in many countries have included large grassy areas, and substantially derelict former industrial sites have often been entirely grassed over. The sterility and sheer size of these sites, the cost of maintenance, and the lack of facilities have often led to misuse and subsequent abandonment by both communities and local municipalities.

The provision, maintenance, and promotion of good-quality and safe , publicly available spaces is not a subsidy; it is an investment delivering economic, health, and regeneration benefits . Research on Philadelphia estimated that maintaining city parks could achieve huge annual savings in health care costs, stormwater management, air pollution mitigation, and social cohesion benefits (The Trust for Public Land, 2008 ). The improved social cohesion associated with natural spaces also has economic benefits. A 2009 Scottish study estimated a £7.36 dividend for every £1 invested in conservation volunteering projects (Greenspace Scotland, 2009 ). It is clear from the evidence that increasing the use of good-quality green space for all social groups is likely to improve health outcomes and reduce health inequalities.

The Reemergence of the Infectious Threat

Among the developments that, for Western societies, consigned environment to the periphery of medical and public health interest in the post–World War II era, we highlighted the epidemiological transition in the mid- 20th century . Indeed, for a period in the 1960s and 1970s it seemed that infectious disease in the developed world had effectively been conquered (Fauci, 2001 ). It was even tempting to suggest that the developing world might eventually follow suit. Yet, within a relatively few years, the twin threats of emerging infectious disease and antibiotic resistance would shatter the earlier confidence and reestablish infection as a live threat to individuals, communities, and populations and one that presented, increasingly, on a global scale.

The term “emerging infectious disease” (EID) denotes an infectious disease, newly recognized as occurring in humans; one that has been previously recognized but is appearing for the first time in a new population or a different geographic area; one that now affects many more people; and/or one that is displaying new attributes, for example, in terms of its resistance or virulence ( adapted from The US Government & Global Emerging Infectious Disease Preparedness and Response ). Although the return of infection was not necessarily anticipated by a confident global community, many predisposing factors were clearly present. Changes in land use, growth and movement of populations, contacts between people and animals, international trade and travel, and, often, an absence of a public health infrastructure all played a part. Where such influences coincided, as in sub-Saharan Africa or parts of Asia, hotspots were created that were conducive to the emergence of infectious disease. Several hundred new infectious diseases appeared across the globe in the period between 1940 and 2004 , with the greatest number emerging in the 1980s (Jones et al., 2008 ). The 1980s was also the decade that notoriously witnessed the late 20th century ’s most sentinel infection event, the first reported cases of Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome (HIV/AIDS). By 2014 , AIDS alone would result in approximately 78 million cases worldwide . Although HIV/AIDS engendered particular alarm, the list of late- 20th-century EIDs of medical and public health significance is extensive. Variant Creutzfeldt-Jacob disease (vCJD), H5N1 Influenza and Ebola Virus Disease, the Northern Hemisphere debut of the mosquito-borne zoonotic viral disease, and West Nile Fever in New York City in 1999 were all public health and media events. The process continues unabated in the 21st century with the arrival of Severe Acute Respiratory Syndrome (SARS), H1N1 Influenza (“swine flu”), H7N9 Influenza (“bird flu”), and, despite having surfaced some 40 years earlier, Ebola revealed its potential as a global threat with the West African Outbreak of 2014–2015 . More recently still, the distressing incidence of microcephaly in South America putatively linked to the Zika virus simply emphasizes the abiding challenge posed by infection for public health and global economics (European Centre for Disease Control, 2016 ).

Antibiotic resistance has been a developing public health horror story over, perhaps, 50 years. The therapeutic use of antimicrobials and especially antibiotics was a key factor in slashing the burden of illness from infection in Western countries in the latter half of the 20th century . Yet all classes of organisms—fungi, protozoa, viruses, and bacteria—can develop antimicrobial resistance. Through their genetic processes, bacteria have derived multiple resistance mechanisms to antibiotics used in medicine and agriculture. The threat renders humankind vulnerable to a host of infections, notably in hospital settings where treatment options for many infections are now severely limited. As a consequence, even at the dawn of the 21st century , drug resistance was already being perceived as an increasing threat to global public health, involving all major microbial pathogens and antimicrobial drugs (Levy & Marshall, 2004 )

The challenges of EIDs and antimicrobial resistance are, unquestionably, game changers for medicine and public health in the 21st century . Importantly, they are among the factors that have revealed the true limitations of the biomedical model of health and disease in the 20th century and rekindled interest in the socioeconomic and environmental determinants of disease. HIV/AIDS merits special mention in this regard. Although it is believed to have origins in nonhuman primates in West Africa, it is not an environmental disease in the sense that there is a specific environmental reservoir. Medical sciences and epidemiology have shown transmission of the virus via unprotected sex, contaminated blood transfusions, hypodermic needles, and mother to child transmission during pregnancy, delivery, and breastfeeding. HIV (the infection) and AIDS (the disease) have shown the capacity to extend beyond the initially identified high-risk groups, potentially placing whole populations at risk. In some areas of sub-Saharan Africa where the infection is widespread, it impacts negatively on almost every aspect of society and the economy.

Over 30 years after it first emerged and despite concerted efforts, there is still no cure. In addition to banishing complacency, the infection and the disease call for a much wider perspective than that which took root in the postwar era of scientific positivism and medical paternalism. The failure to manage the threat stems in part from an incapacity to understand where to intervene to change behaviors and to see the disease in its social and environmental context.

Ecological Public Health

Earlier in this article, we identified five issues that helped reestablish awareness of the environment as a key component in the production of human health and well-being in the late 20th century . These issues, and our understanding of them, continue to evolve to challenge the public health community and wider society in the 21st century . In the most general terms, progress seems most likely where issues and challenges are framed with reference to a much wider range of pertinent factors by developing new approaches to evidence and its synthesis; by aligning institutional, physical, and educational infrastructures to the task; and by building governance structures in which all players are accountable and yet are encouraged to unite in common cause.

However, society must now embrace an additional and potentially more devastating threat to health and well-being. Human activity, including economic activity, is now directly and indirectly driving changes to the ecosystems and planetary processes on which we rely for health, well-being, and existence. For too long, human beings have lived, moved, consumed, and pursued health and well-being as if humankind is distinct and separate from nature rather than integral to it. The consequences of this disconnect for the natural world were graphically expressed by Rachel Carson in the 1960s and many others in the ensuing years (e.g., see Rockström et al., 2009 ; Steffen et al., 2015 ). However, developments in science and technology now reveal the true extent of the crisis, its accelerating nature, and its consequences both now and in the medium and longer term.

The term “ecological public health” is increasingly being used to encapsulate a need to build health and well-being, henceforth, on ecological principles. Rayner and Lang ( 2012 ) observe that, despite appearing difficult and complex, Ecological public health “is now the 21st century ’s unavoidable task.” Thus, the already complex challenge of navigating human social complexity to deliver health, well-being, and greater equity, which has defined public health in Western society for several decades, is made more challenging still. The relationship of the environment and human health and well-being must be understood and addressed on vastly extended temporal and spatial scales.

The notion that the planet is a finite resource on which human activity can place intolerable pressure and that the consequences of doing so are potentially catastrophic has been around for some time (e.g., see Carson, 1962 ; Meadows et al., 1972 ). A contemporary evolution of this thinking is expressed by Rockstrom and colleagues. Their sentinel paper, first published in 2009 (Rockström et al., 2009 ) and updated in 2015 (Steffen et al., 2015 ), lists the large earth system processes that are urgently in need of stewardship if humanity is to remain safe into the future. Where applicable, it proposes thresholds beyond which nonlinear, abrupt, and potentially catastrophic changes in these systems might be expected. This thinking is used as a basis for defining a “safe operating space for humanity.” The authors propose nine “planetary boundaries.” Three of these—climate change, ocean acidification, and stratospheric ozone depletion—are major planetary systems where evidence exists of large-scale thresholds in the history of the planet history of the planet. Also included are systems of a rather different sort. These are the slow variables that buffer and regulate planetary resilience. These slow variables comprise interference with the nitrogen and phosphorus cycles; land-use change; rate of biodiversity loss; and freshwater use. Two parameters, air pollution and chemical pollution, are especially difficult to quantify, meaning that thresholds cannot yet be defined. It is emphasized that, while for understandable reasons, the nine systems are often discussed independently, they are interrelated in ways meaning that changes in one system have profound implications for the others. Rockstrom and colleagues observe that in the preindustrial era, all nine parameters were within the safe operating boundaries, and yet by the 1950s, change was underway, most evidently in the nitrogen cycle. By 2009 , according to their analysis, three planetary boundaries had been transgressed: climate change; rate of biodiversity loss; and the nitrogen cycle.

An implicit challenge in limiting global ecosystem damage and its multiple implications is how to achieve recognition among the public and policymakers that the choices they make either directly or indirectly cause ecosystem damage and related environmental change (Morris et al., 2015 ). Climate change is simply the most striking example, but comparable challenges over communication exist in relation to other planetary process and systems. The fundamental rethink of society, the economy, and the environment, which is necessary if health and well-being are to be built on ecological principles, will happen only if the true implications for health and well-being of a “business as usual” approach are understood, communicated, and challenged. For any population, the environmental changes that may ultimately have profound implications may take place in countries and regions well beyond their borders or may not occur for some time, conferring a temporal and/or spatial remoteness that diminishes the sense of urgency. Appreciating the importance of these “distal” pathways of ecosystem damage to human health and well-being demands a greater understanding of ecosystem services (the benefits human beings get from the natural environment) and of why they matter. It also demands a much fuller appreciation of the global connectivity of social, economic, and ecological systems (Morris et al., 2015 ; Adger et al., 2009 ).

When initiating our discussion of the role of environment in health, we observed that the modern public health era was built on an environmental conceptualization of public health. It is now inconceivable that health, well-being, health care, and equity in any of these domains can be delivered without rediscovering an environmental conceptualization of public health for the 21st century .

For Western society, ecological public health is likely to require a rethink of society, the economy, and our stewardship of the natural environment (Rayner & Lang, 2012 ). At the very least, it will demand pursuit, through policy and action, of outcomes that recognize a ‘quadruple bottom line’ measured in health and well-being, environmental quality, equity, and sustainability. The extent to which we embrace ecological principles will be evidenced in policies that address how we live (for example, the energy efficiency of our homes), how we move (particularly our reluctance to substitute travel in fossil-fueled cars with more active forms of travel); how we consume (notably how we source and produce food) and, of course how we obtain and conserve energy.

Taking Stock

Despite being necessarily selective, this article has sought to illustrate how perspectives on the role of the environment in human health and well-being have evolved over the course of the modern public health era. Perspectives can be seen to shift owing to changes in the nature of environmental hazards and risks that are themselves products of the evolution of how societies live, move around, consume, source their energy, and so on. Our understanding of the health relevance of the built and natural environments is also shaped by advances in scientific understanding and technology and a much wider economic, social, cultural, and even political context. In structuring our account, we have adopted a loose framework based on the “epidemiological eras,” elegantly articulated by two of the 20th century ’s leading epidemiologists (Susser & Susser, 1996 ). These eras are differentiated according to the dominant paradigm of the time concerning the causes of disease, each underpinned by analytical approaches to understand and prioritize risk.

The importance accorded to the environment as a mainstream public health issue arguably reached its lowest point in the decades following World War II when the tendency to regard health and disease as characteristics of individuals, rather than communities or populations, gained prominence. This approach diverted attention from social and environmental factors, divorcing health from place. Notions that humans are self-contained and impervious to context have now been largely swept away, not least because denial of a socioecological perspective hugely undermined attempts to address the most serious contemporary health challenges. Also instrumental in challenging the notion of the self-contained body has been an environmentalist movement with a particular interest in pesticide and other chemical contamination of the biosphere. The toxic effects of chemical contamination reinforce the reality of a body that is permeable and invariably in a state of intimate exchange with its surroundings. As Nash ( 2006 ) has observed, “ the singular and self-contained body of the early 20th century came, by the end of that century to seem distressingly porous and vulnerable to the modern landscape” (p. 13). We would simply add that humans exhibit comparable porosity and vulnerability to the social and economic context in which they exist.

We recognize that our account contains only limited reference to the regulatory context that has been so central to controlling the environment for public health. We consider it appropriate to sound a warning in this regard. The processes through which environment is monitored and regulated to protect human health and well-being are sometimes taken for granted. Yet, since the 1980s, pressures have mounted in most Western nations to ‘deregulate’ markets to maximize profit. These pressures have led to environmental and public health regulation being increasingly perceived by governments and markets as “red tape” and a barrier to economic enterprise. Pressure to loosen or even abandon aspects of environmental regulation has weakened formal controls, leaving society vulnerable to corporate excess and irresponsibility, with often serious impacts on public health (Oldenkamp et al., 2016 ). This is not to argue that regulation should be static. Rather, it should adapt to changing technological, social, and economic circumstances and should be appropriately funded whether it relates to the quality of the air we breathe, the water we drink, the buildings we live, learn, and work in, or the nutritional aspects of the food we eat. Neither do we deny the potential to exploit citizen science and the power of new technology to supplement conventional regulation (e.g., enabling vulnerable individuals to avoid hazardous exposures and the opportunities for personal pollution monitoring to improve research).

Mainly anthropogenic damage to planetary resources and ecosystems demands that, wherever we are in the world, public health agencies must understand not just the proximal threats to health and well-being that have been the targets of public health intervention throughout the modern public health era. They must also understand and move to prevent, counteract, and contain more distal threats to health and well-being. The distal threats derive from changes to environments that appear remote in space or time or involve a complex interaction of social, environmental, and economic influences. These are no longer abstract considerations. The unprecedented global connectivity of economic and social systems and the growing understanding of ecosystem interdependencies demand that the implications of human activity for health and well-being be recognized, understood, and addressed on a vastly extended temporal and spatial scale.

Only by build health and well-being on ecological principles (Ecological Public Health) will society effectively address the more distal threats to health and well-being from global ecosystem damage; the socioecological complexity of the proximal environment and the interconnections between these.

Conclusions

In this necessarily brief and artificially linear account, our intention has been to reinforce the enduring importance of the environment for health and well-being. Along the way, we have identified three factors that have marginalized the environment as a component of health and disease. We suggest that they continue to represent clear and present threats, undermining public health and, in the case of the latter, an existential threat to humankind.

The Threat from Medical Reductionism

This tendency to think of disease almost exclusively in terms of pathogenic agents and organic dysfunction marginalizes any influence outside the crucible of the laboratory. This trend was most evident in the decades following World War II but remains an ever-present threat.

The Separation of Health from Place

Closely related to medical reductionism is the tendency to downplay the importance of local context for life. The idea that if local environment matters, it does not matter much and, that when it comes to health and disease, the real action is not out there in the neighborhood and among the community but “over here” in the laboratory and at the level of the individual. Such perspectives are divisive. They create artificial barriers between many academic disciplines, including some medical specialties, and those working to manage and improve the local social and environmental context within which “permeable” human beings live out their lives.

The Denial of Ecology

Science now permits humans to understand the true extent to which their activities are plundering natural resources and harming the planetary systems and processes on which they depend. The pace of change is such that health, well-being, heath care, or anything approaching equity in these things will not be sustained in the medium to longer term without radically rethinking society, the environment, and the economy. The global connectivity of social, economic, and environmental systems means, ultimately, that no one is insulated from the threat whether by distance or socioeconomic circumstance. Ecological public health, the pursuit of health and well-being on ecological principles, has been described as the 21st century ’s unavoidable task. It demands recognition of the dynamic interconnections between people and their environment. Manifestly, we depend on the environment we inhabit, and we powerfully affect it. Among the clearest impediments to delivering ecological public health and preserving a viable environment for future generations are the belief that we can manipulate and conquer the natural environment without consequence, and the irresponsible capitalist imperative that subverts regulatory standards and damages and exploits the environment for profit. Both are revealed as transparent absurdities by an ecological understanding and analysis.

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2021 Theses Doctoral

Essays in Health, Development and the Environment

Aguilar Gomez, Sandra

As multiple regions in the global south urbanize and transform, their social-environmental challenges also reshape. Climate change and ecological degradation intertwine with these processes in ways that have an uneven impact on people and firms with various degrees of vulnerability. In this dissertation, I look at such issues through the lens of sustainable development, with a regional emphasis on Mexico. Standard economic analyses of environmental policy focus on either reducing pollution externalities through mitigation or reducing the harms from exposure by encouraging adaptation. In practice, these issues are both critical, particularly when looking at the health effects of local air pollutants, which can be acute, and policymakers often pair information provision with short and long-run mitigation actions. In Chapter 1, I explore whether, in the context of the Mexico City air quality alert program, information policy is more effective when paired with mitigation. I find that the policy did not improve air quality or health outcomes until the mitigation component, which limited transport emissions, was introduced. I also use sensor-level traffic data, geo-tagged accident reports, and search data as a measure of awareness of the policy to unveil the mechanisms through which considerable short-run improvements in air quality and health are achieved after issuing an alert. I find that the alert reduces car usage even before the driving restrictions enter into place, suggesting that, due to an increased awareness of pollution, people reduce their trips. Chapter 2 studies the effects of regional exposure to extreme temperatures on credit delinquency rates for firms in Mexico. Our exposure variable is defined as the number of days in a quarter that minimum and maximum temperature are below 3°C and above 36°C, respectively, which correspond to the bottom 5 percent and top 5 percent of daily minimum and maximum temperature distribution in the country. We find that extreme temperatures increase delinquency. This effect is mostly driven by extreme heat, and it is concentrated on agricultural firms, but there is also an effect on non-agriculture firms. The impact on non-agricultural firms seems to be driven by general equilibrium effects in rural areas. Chapter 3, provides the first estimation of child penalties in the Mexican labor market. Using an event study approach and an instrumental variable as a robustness check, we estimate the impact of children on employment and wages, unpaid labor, and transitions between informal and formal sectors. We are the first to show that a child’s arrival significantly affects mothers’ paid and unpaid work, and it impacts members of the extended family unevenly, reinforcing traditional gender roles. While low- and middle-income women account for most of the effect of childbirth on wages, all mothers increase time spent on unpaid work.

Geographic Areas

• Mexico--Mexico City
• Sustainable development
• Sustainable agriculture
• Air--Pollution
• Working mothers
• Wages--Working mothers

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Original research article, understanding local perceptions of the drivers/pressures on the coastal marine environment in palawan, philippines.

• 1 College of Fisheries and Aquatic Sciences, Western Philippines University, Puerto Princesa, Philippines
• 2 European Centre for Environment and Human Health, University of Exeter Medical School, Truro, United Kingdom
• 3 Cognitive Science HUB, University of Vienna, Vienna, Austria

The Philippines, as a tropical archipelagic country, is particularly vulnerable to environmental changes affecting coastal and marine settings. However, there are limited studies investigating how these changes are perceived by the local populations who depend directly on the marine environment for their livelihoods, health, and well-being, and who are the most vulnerable to such changes. To explore these issues, we conducted an in-home face-to-face structured survey in 10 coastal communities in Palawan, Philippines ( n = 431). As part of the survey, respondents were asked to comment on how important they believed a list of 22 drivers/pressures (e.g., “land-use change”) were in affecting their local marine environment. Statistical analysis of this list using Exploratory Factor Analysis suggested the 22 drivers/pressures could be categorized into 7 discrete groups (or in statistical terms “factors”) of drivers/pressures (e.g., “urbanization,” “unsustainable fishing practices” etc.). We then used ordinary least squared regression to identify similarities and differences between the perspectives within and across communities, using various socio-demographic variables. Results suggested that among the seven identified factors, four were perceived by the local communities as making the marine environment worse, two were perceived as having no impact, and one was perceived to be making the marine environment better. Perceptions differed by gender, education, ethnicity, and study site. A subsequent survey with 16 local coastal resource management experts, suggested that public perceptions of the most critical drivers/pressures were broadly consistent with those of this expert group. Our findings highlight how aware local coastal communities are of the drivers/pressures underpinning the threats facing their livelihoods, health, and well-being. Ultimately, this information can support and inform decisions for the management of local marine resources.

1 Introduction

The ocean plays a critical role in supporting human well-being; from relatively proximal goods/services such as providing food, livelihoods, and recreational opportunities, to more distal services such as diluting pollution and regulating the global climate ( Halpern et al., 2012 ; Moore et al., 2013 ; Fleming et al., 2014 , 2015 ). The Philippines, as a tropical, archipelagic country, is particularly dependent on the goods and services provided by the marine environment. However, the ocean is increasingly facing cumulative direct and indirect threats that alter marine ecosystems locally and worldwide ( Inniss et al., 2016 ; Lotze et al., 2018 ). The management and governance of coastal marine resources is complex. To ensure the sustainability of the marine environment, conservationists and researchers are increasingly recognizing the importance of the knowledge, involvement, and stewardship of local communities and community-based resource management more broadly ( Castilla, 1999 ; Winther et al., 2020 ).

Originating in the small-scale fisheries sector, community-based resource management has become a key strategy for small-scale fisheries and coastal marine conservation ( Evans et al., 2011 ). In the Philippines, the systematic management of coastal resources began in the mid-1970s using community-based management approaches to address coastal environmental degradation, and the over-exploitation of aquatic resources ( Pomeroy and Carlos, 1997 ; Alcala, 1998 ). This strategy is composed of several essential features, and inherently takes place in a highly complex social-ecological environment influenced by external factors as well as community-specific conditions ( Rivera and Newkirk, 1997 ; Beyerl et al., 2016 ). Stakeholder misunderstandings, lack of participation, non-compliance, or conflict, are frequently encountered problems in this type of management ( Eder, 2005 ; Bloomfield et al., 2012 ; Glaser et al., 2018 ). According to Beyerl et al. (2016) , most of these problems are largely driven by the varying perceptions of environmental changes, coping strategies, and social processes of local communities. Thus, understanding how local communities perceive the marine environment is an essential component of the ecosystem approach, and can be partially attributed to the success or failure of environmental management goals ( Potts et al., 2016 ). The ecosystem approach is a strategy for the integrated management of natural resources that promotes conservation and sustainable use in an equitable way ( CBD, 2021 ). However, empirical evidence in the understanding of the linkages between local communities’ knowledge, perceptions, and collective actions have been limited, but is needed to achieve sustainable marine resource management ( Kitolelei and Sato, 2016 ).

Individual perceptions are the product of a complex interaction between an individual, their material and non-material circumstances, and their surroundings ( Beyerl et al., 2016 ). Understanding public perception is widely recognized as key to the management of the coastal marine environment. However, to date, most of these studies have been focused in high-income continents, e.g., Australia ( Cvitanovic et al., 2014 ; Clarke et al., 2016 ) and Europe ( Gelcich et al., 2014 ; Aretano et al., 2017 ; Tonin and Lucaroni, 2017 ; White et al., 2017 ; Carpenter et al., 2018 ). Although there have been numerous studies on perceptions of the marine environment conducted in the Global South, these were mostly site-specific on a case-by-case basis ( Slater et al., 2013 ; Chaigneau and Daw, 2015 ; Gehrig et al., 2018 ; Glaser et al., 2018 ). Furthermore, differences in perceptions can relate to socio-demographic characteristics ( Wright and Lund, 2003 ; Safford and Hamilton, 2012 ; Cvitanovic et al., 2014 ; Halkos and Matsiori, 2018 ). These socio-demographic variables typically include gender ( Smith et al., 2015 ; Chakraborty et al., 2017 ; Ensor et al., 2018 ), age ( Arcury and Christianson, 1990 ), income ( Van Liere and Dunlap, 1980 ), education ( Sparrevik et al., 2011 ), location (country and village level) ( Chaigneau and Daw, 2015 ; Buckley et al., 2017 ; Carpenter et al., 2018 ; Gehrig et al., 2018 ) and ethnicity ( Jones, 2002 ). Although their findings are variable, some potential trends emerge, suggesting that women, higher educational attainment, younger people, those with a higher income, ethnic minorities, and urban residents show greater environmental concern compared to their counterparts ( Liu and Mu, 2016 ; Ergun and Rivas, 2019 ).

In particular, studies are needed which aim to understand the drivers and pressures of changes to the coastal marine environment, incorporating the views of the local community. Thus, the current study aims to explore these issues in the context of several relatively small coastal communities on the Island of Palawan in the Philippines. To understand local community perceptions of the drivers/pressures affecting their coastal marine environment, we developed the following objectives: To explore coastal communities’ perceptions toward the perceived drivers/pressures facing their marine coastal environment and compare these to those of experts; and to assess the interrelationship between these perceptions with socio-demographic characteristics.

To do this, we used data collected as part of the GCRF (Global Challenges Research Fund) Blue Communities 1 project. The GCRF Blue Communities project aims to investigate the complex impacts of changes in the regulatory backdrop of marine spatial planning for coastal communities located in and around UNESCO Biosphere Reserves and Marine Protected Areas (MPAs) across Southeast Asia. The current work was formed as part of Project 6 of this program, which assessed the well-being benefits and risks of coastal living. For the current study, we used data from a bespoke survey co-created with local stakeholders and administered to three coastal communities (Aborlan, Taytay, and Puerto Princesa) in Palawan, Philippines.

2 Materials and Methods

2.1 study area.

Palawan forms an elongated strip, oriented in a north-southwest direction, between a latitude of 7°C and 11°N and a longitude of 117° and 199°E, with the Sulu Sea bordering the eastern coast and the South China Sea on the western coast ( Figure 1 ; Förderer and Langer, 2019 ). The province has an area of 14,896 km 2 in total, comprising around 1,780 islands ( Itano and Williams, 2009 ). Including its marine area, it occupies almost one-fifth of the country’s territory and has a population of approximately one million people ( PSA, 2016 ). The Presidential Proclamation 2152 of 1981 declared the entire province of Palawan as Mangrove Swamp Forest Reserves and a UNESCO Man and Biosphere Reserve (MAB) in 1991, in recognition of its rich natural resources and high biodiversity. The key economic sectors and major sources of employment in Palawan are agriculture, fisheries, forestry and tourism ( PCSD, 2015 ).

Figure 1. Map of Palawan showing an inset of the Philippines, with Palawan highlighted with a red box. Aborlan, Puerto Princesa City, and Taytay, the study sites where the coastal communities were located, are highlighted in light and dark gray.

Three coastal areas were selected as study sites (village location): Aborlan, Taytay, and Puerto Princesa ( Figure 1 ). The provincial capital, Puerto Princesa City is located in the central part, Aborlan is a municipality located 69 km south of the capital; and Taytay is located 206 km to the north ( Figure 1 ). All these areas have extensive coastal ecosystems and the local communities are highly dependent on fisheries ( Salao et al., 2013 ; WWF, 2016 ). In the last decade, there has been a substantial increase in the human population and a deterioration of major marine ecosystems across Palawan ( PCSD, 2015 ). A climate change exposure map has been created for the Philippines ( HDN, 2013 ; The Climate Reality Project, 2016 ). This map shows how specific geographical factors contribute to the vulnerability of different zones of the country and identifies specific risks of climate change. Northern Palawan, including the municipality of Taytay, falls under cluster III of the climate change exposure map: vulnerable to extreme heating events, unstable water supply, and sea-level rise. The rest of mainland Palawan, including Aborlan and Puerto Princesa City, fall under Cluster XI (i.e., sea-level rise). This makes Palawan an ideal area to study both community and environmental changes in the coastal marine environment.

2.2 Developing the Survey Instrument

The survey, which was administered to the local communities, was designed using a co-creation process. Focus group discussions and workshops were conducted with local stakeholders in three local government units (LGU) of Aborlan, Taytay, and Puerto Princesa. Each focus group involved 12–15 participants. Participants included representatives from provincial, municipal, and barangay (the latter the smallest government unit in the Philippines, similar to a village) LGUs for the environment, fisheries, health, and legislative offices, as well as non-government organizations (NGOs) and private stakeholders. Representatives from the fishing communities, healthcare workers, environmental officers, and community leaders also participated.

The findings that emerged during the focus group discussions, along with relevant academic and gray literature, suggested an emerging structure of complex causes affecting marine ecosystems, whose effects on health and well-being outcomes would be mediated by the extent to which people were exposed to the affected ecosystems. Following discussion as a team, we recognized that, although unplanned, these issues closely mirrored the structure of an existing framework which linked changes in ecosystems to human health and well-being. The ecosystems-enriched Drivers, Pressures, State, Exposure, Effects, Actions, or “eDPSEEA” model ( Reis et al., 2015 ) builds on earlier frameworks such as DPSIR (Drivers, Pressures, State, Impact, Response) ( Kristensen, 2004 ; Patrício et al., 2016 ), but focuses on ecosystem services in operationalizing “State,” and unpacks “Impact” but separating “Exposure” and “Effects” in line with a public health (rather than just an environmental) focus.

Subsequently, we developed the survey to contain all aspects of the eDPSEEA model, but given the complexity of the data that emerged, the current study focuses primarily on the first two aspects—Drivers and Pressures. For the purpose of the survey and analysis that follows we use the term “drivers/pressures” to describe the environmental issues identified by local stakeholders that have changed or could change the quality of the coastal marine environment. We recognize that in some senses ‘Drivers’ are more distal causes of changes to states (in our case changes in ecosystems and the services they provide) than “Pressures,” which tend to be more proximal. However, in reality, assigning environmental issues to discrete categories is complex ( Oesterwind et al., 2016 ), thus we have chosen the joint term of “drivers/pressures.”

2.3 Overview of the Community Survey

The community survey was structured into six sections (see Supplementary Materials 1 ). Section 1 sought to explore how Palawan has changed over the last 10 years and what the local people think will happen in the next 10 years, using a list of 16 items related to resources, habitats, and water quality. Their perceptions were measured on a seven-point scale with anchor points (1) “much worse” to (7) “much better.”

The key section for the current paper was Section 2 which contained a list of 22 marine-based, land-based and environmental management issues (i.e., our drivers/pressures) and asked participants to evaluate the impact of that activity on the quality of the coastal marine environment using the same seven-point scale.

Section 3 sought to explore the interactions of local people with the coastal marine environment by asking the respondents how often they had engaged in marine activities relating to their livelihoods, day-to-day activities, and environmental management in the last week, using an eight-point scale with anchor points (0) “zero days” to (7) “7 days.” Section 4 focused on individual-level health outcomes with respondents asked if they experienced any of the 15 health outcomes as a result of spending time in/on/around the coastal marine environment using three choices; (1) “no,” (2) “yes, but did not talk to health workers” and (3) “yes and talked to health workers.” Section 5 focused on the importance of health services, infrastructure and facilities, and land/coastal management factors to local people’s health and well-being using a scale from (1) “not important at all” to (7) “very important.” An option of (99) “don’t know/prefer not to answer” was also provided for each of the questions in all of the sections. Finally, Section 6 of the survey was about the socio-demographic data of the respondents, and included age, education, ethnicity, income, location, and gender.

For this study, only the data of Section 2 (drivers/pressures) and 6 (socio-demographics) were used to understand local perceptions of the drivers/pressures on the coastal marine environment (other aspects will be explored in subsequent publications). The community survey was piloted by the research staff from the Western Philippines University and received ethical approval from the National Ethics Committee of the Philippines (2019–002-Creencia-Blue) and the University of Exeter Medical School Research Ethics Committee (May19/B/185).

2.4 Survey Participants

The target population were households within coastal marine areas in our three selected geographic regions; and the respondents were restricted to 18 years old and above. A total of 431 respondents participated (see Table 1 ) from 10 barangays: two barangays in Aborlan, four in Taytay, and four in Puerto Princesa City, with a higher number of females than males [ n = 257/431 (60%)]. The higher percentage of female participants was in part due to the time of day the interviews were conducted (morning and afternoon), as many male household members would have left home for work at sea. For the groupings of income from marine activities, we used the income cluster of the Philippine Institute of Development Studies ( Albert et al., 2018 ; see Table 1 for further description).

Table 1. Socio-demographic profile of adult participants in Palawan, Philippines.

2.5 Procedure

Face-to-face surveys were conducted between June 2019 and July 2019 in the 10 barangays. A Computer-Assisted Personal Interviewing (CAPI) program was used to record answers on a tablet device, with a pre-loaded questionnaire available in Filipino and English (see Supplementary Materials 1 ). Interviews were carried out by 10 experienced and trained research staff from Western Philippines University, who were divided into five teams. In a procedure agreed with local Barangay leaders and stakeholders in advance, each team selected a starting point within each barangay and randomly chose a household to be interviewed. Only one member per household was interviewed, with a preference for the head of the family. Where the head of the family was not available, any adult member of the household present during the visit was recruited for the interview. If any of the members in the chosen household did not want to complete the survey or were unavailable, the interviewer would proceed to the next household until the target sample of 40–60 households per barangay was reached. Before starting the face-to-face interviews, the survey participants were provided with information sheets explaining the background of the study, and informed consent was obtained.

2.6 Expert Survey

To collect data on the perceptions of local coastal resource management experts on the “drivers/pressures” that have changed the quality of the coastal marine environment in Palawan, a Delphi technique interview ( Okoli and Pawlowski, 2004 ; James et al., 2009 ) with slight modification was conducted in April 2020. Experts were identified based on their involvement in marine conservation (e.g., working in NGOs, government offices, research, and academic institutions) ( Easman et al., 2018 ). A pre-selected list of experts were contacted personally via email, with a link to the survey which included the seven grouped pressures/drivers, as identified by the participants in the community surveys (grouping methods are outlined in Table 2 ). Experts were asked to rate how the issues have changed the quality of the coastal marine ecosystem. Sixteen local experts in Palawan participated in this survey. Their perceptions were also measured using a 7-point Likert scale, ranging from (1) “made much worse” to (7) “made much better.”

Table 2. Local perceptions from the community survey of the drivers/pressures on the coastal marine environment of Palawan, Philippines.

2.7 Data Analysis

Data were analyzed using SPSS version 25. Values from the community and expert survey were converted from the original one (“much worse”) to seven (“much better”) scale to an easier to interpret bi-polar scale of –3 (“much worse”) to + 3 (“much better”). Descriptive statistical analysis were used to understand the profiles of the respondents in our survey, and the mean and standard deviation was calculated for questions relating to individual perceptions of the drivers and pressures.

An Exploratory Factor Analysis (EFA) using principal component analysis was used to reduce the 22 potential drivers/pressures to a reduced set of “factors” ( Finch, 2013 ; Chen et al., 2018 ; Goretzko et al., 2019 ) indicative of each participants “mental model” ( Binder and Schöll, 2010 ) of the perceived core underlying drivers/pressures in the coastal marine environment.

To conduct the EFA, the oblique rotation method with direct oblimin rotation ( Jennrich and Sampson, 1966 ) was applied. This rotation method was selected because we assumed that variables are correlated. The number of the retained factors was based on the criterion of the eigenvalue (> 1.0) and examination of the scree plots ( Costello and Osborne, 2005 ); items with factor loading and corrected item-total correlations below 0.3 were considered too small to be of consequence ( De Vellis, 2003 ; Field, 2013 ). The factor loading patterns and meaningful relationships for the grouped items were used to determine the ideal factor structure ( Gabriel et al., 2019 ). Acceptable internal consistency for the items in the respective factors was set at Cronbach’s alpha values > 0.70 ( Field, 2013 ).

The individual perceptions of the drivers/pressures on the marine environment from the community survey demonstrated a good index for factor analysis as indicated by the Kaiser-Meyer-Olkins test measure (0.80) ( Table 2 ). Bartlett’s test of sphericity also showed a significant value for factor analysis to be appropriate with a p -value lower than 0.05 ( p < 0.01). We concluded that the sample available here was suitable for EFA despite not being firmly structured. A total of 22 variables were used for EFA analysis.

The result of the analysis defined six groupings with eigenvalues greater than one. However, on closer inspection the items in one grouping did not make conceptual sense, so we decided to split this into two (i.e., “unsustainable farming practices” and “urbanization”) in order to keep logical internal consistency resulting in seven factors in total ( Table 2 ). Finally, we used ordinary least squared regression (OLS) analyses to measure and predict driver/pressure grouping scores based on socio-demographic variables. The perceptions of drivers/pressures based on EFA groupings served as dependent variables and socio-demographic as independent (predictor) variables (see Table 2 for groupings). A total of three models were created after running the OLS regressions, to fully understand the interrelationships between perceptions and socio-demographic characteristics of the participants. However, due to limited space, only the first model is presented below. The other two models are presented in Supplementary Materials 2 .

3.1 Local Perceptions of the Drivers/Pressures on the Coastal Marine Environment: Results From the Factor Analysis

Seven driver/pressure groupings were identified: unsustainable fishing practices, coastal risks, urbanization, unsustainable farming practices, fisheries livelihoods, fisheries livelihood support, and environmental management ( Table 2 ).

Among the seven identified factors, four were perceived by the local communities as making the marine environment worse, two were perceived as having no impact, and one was perceived to be making the marine environment better ( Table 2 ). The factors identified as having negative impacts on the marine environment, in order from most to least harmful were: unsustainable fishing practices (mean ± SD) (–1.41 ± 1.19), coastal risks (–1.27 ± 1.37), urbanization (–1.05 ± 1.63), and unsustainable farming practices (–0.98 ± 1.29). The participants did not perceive that fisheries livelihoods (0.34 ± 0.97) and fisheries livelihood support (0.72 ± 1.41) had any impact, either positive or negative, on the coastal marine environment of Palawan. Environmental management (1.78 ± 1.22) was the only factor perceived positively by the participants.

With regards to the perception of individual drivers/pressures, destructive fishing practices (–2.08 ± 1.55), illegal fishing (–1.67 ± 1.48) and mangrove harvesting (–1.52 ± 1.53) were the top issues perceived by the local community to have negatively affected the coastal marine environment in Palawan. In contrast, research by non-government organizations (1.78 ± 1.3), enforcement of environmental laws and ordinances (1.82 ± 1.40), and the local communities and stakeholders calling for better protection (1.89 ± 1.36) were perceived as the most positive.

The result of the survey with the coastal management experts generally showed a similar pattern with the perceptions of the local communities on the drivers/pressures in the coastal marine environment ( Figure 2 ). The coastal management experts also demonstrated negative perceptions of the effects of unsustainable fishing practices, coastal risks, urbanization, and unsustainable farming practices on the marine environment. Similarly, fisheries livelihoods and fisheries livelihood support were perceived as having no impact, while environmental management was perceived positively.

Figure 2. Mean scores (± 95% Confidence Intervals) of local people ( n = 431, orange circle) and experts ( n = 16, blue triangle) for the perceived drivers/pressures on the coastal marine environment in Palawan, Philippines.

However, there were differences between the experts and local communities in which drivers/pressures were perceived to be worst for the marine environment. Unsustainable fishing practices were perceived as the worst by local people, whilst urbanization was perceived as the worst by the experts. Despite this difference, their views were most similar for unsustainable farming practices and fisheries livelihoods, with communities perceiving fisheries livelihood support as having a much greater positive impact on the coastal marine environment. Similarly, both groups perceive environmental management as positive but local people perceived it more positively.

3.2 Associations Between the Socio-Demographic Variables and Local Perceptions

Table 3 presents the results of the OLS regression, exploring the relationship between socio-demographic variables and the seven driver/pressure groupings. By and large, we see relatively high consistency and homogeneity in perceptions across the socio-demographic variables for all seven drivers/pressures, which could help in establishing common support for certain policies. Nonetheless, some differences did emerge.

Table 3. Results of ordinary least square regression model predicting perceptions of the drivers/pressures in the coastal marine environment of Palawan, Philippines from key socio-demographic variables (standard errors in parentheses).

Women perceived urbanization as being worse for the marine environment compared to men ( B = –0.53, p < 0.01; Table 3 ). Although not significant, women also had more negative perceptions of the effects of coastal risks, unsustainable farming practices, and fisheries livelihood support compared to men ( Table 3 ).

In terms of education, participants in the coastal communities with a college education had significantly more negative perceptions of unsustainable fishing practices ( B = –0.46, p < 0.05) and unsustainable farming practices ( B = –0.56, p < 0.05) compared to participants with elementary education ( Table 3 ). Although the relationship was not significant, college participants also had more negative perceptions of coastal risks, urbanization, fisheries livelihoods, and fisheries livelihood support compared to participants with elementary education. Similarly, participants with secondary education had negative perceptions of unsustainable fishing practices, coastal risks, unsustainable farming practices, and fisheries livelihood support, although the relationships are not significant.

With regard to the effect of study sites on participants’ perceptions of the drivers/pressures, there were clear similarities in the perceptions between the municipalities of Aborlan and Taytay ( Table 3 ). Coastal risks were generally perceived negatively by locals, but participants in Aborlan ( B = 0.56, p < 0.01) and Taytay ( B = 0.78, p < 0.001) had relatively neutral perceptions, compared to participants from Puerto Princesa City. In addition, although unsustainable fishing practices were generally perceived as the worst driver/pressure affecting the coastal marine environment, participants from the municipality of Taytay had relatively neutral perceptions ( B = 0.39, p < 0.01) compared to participants from Puerto Princesa City ( Table 3 ). Participants from Aborlan perceived unsustainable farming practices and fisheries livelihoods more negatively compared to participants from Puerto Princesa City, although these associations were not significant.

When study sites were excluded from exploratory models, ethnicity was also found to be a significant factor associated with perceptions. Visayan participants perceived unsustainable fishing practices ( B = –0.36, p < 0.01) and coastal risks ( B = –0.28, p < 0.05) more negatively than non-Visayan participants ( Supplementary Materials 2 ). That this only emerged when the location was not included reflects the fact that less Visayan’s lived in Aborlan and Taytay than Puerto Princesa. Although not significant, Visayan participants had more negative perceptions of urbanization, unsustainable farming practices, and fisheries livelihood support. Income and age were not found to be associated with people’s perceptions of various drivers/pressures across all models.

4 Discussion

4.1 drivers/pressures affecting the coastal marine environment in palawan.

In this study, we sought to (a) identify the main drivers/pressures affecting the marine coastal environment as perceived by local communities, (b) assess how these perceptions are affected by communities’ socio-demographic characteristics, and (c) compare these perceptions to those of local experts. Unsustainable fishing practices were perceived as the worst driver/pressure by the local communities ( Figure 2 ). We found that gender, education, and study site were associated with perceptions of specific drivers/pressures in the coastal marine environment ( Table 3 ). Overall, the perceptions of the local communities and local experts were generally similar. We discuss these findings in more detail below, with a focus on how understanding perceptions can help to improve the management of coastal marine environments.

Unsustainable fishing practices (overfishing by the local community, illegal fishers, fishing by commercial large-scale fisheries, and destructive fishing practices) were perceived by the local communities as the driver/pressure that has most negatively impacted the quality of the coastal marine environment in Palawan. These results were consistent with the perceptions of local experts, as well as previous research conducted in the Philippines more generally ( Courtney and White, 2000 ; Eder, 2005 ).

Coastal risks such as storms, floods, coastal erosion, and mangrove harvesting were perceived by local people as the second biggest risk to the coastal marine environment. Developing countries in Asia are one of the most natural-disaster prone regions in the world ( Jha et al., 2018 ), and extreme events like storms and flooding regularly put coastal communities at risk ( Cochrane et al., 2009 ). The Philippines is an archipelagic island state located within the typhoon belt; natural disasters are coupled with other hazards such as landslides, active volcanoes, and earthquakes, making the Philippines one of the most vulnerable countries in the world ( Bollettino et al., 2018 ; UNDRR, 2019 ). The social, economic, and environmental impacts of these disasters are significant, directly affecting the livelihoods of coastal communities like those explored here. Despite these risks, local experts did not perceive coastal risks as one of the biggest threats to the marine environment, having a more neutral perception. This mismatch could be due to local people and experts viewing drivers/pressures on differing scales, with local people experiencing the direct effects of such risks, whereas experts perceive these risks at a wider scale. In the Philippines, fishers are deemed to be amongst the poorest of the poor and are most affected by the coastal risks. In turn, this is likely to undermine poverty reduction in fishing communities ( Jha et al., 2018 ; PSA, 2020 ). Therefore, despite local experts not perceiving this as a key issue, coastal risks must be addressed. Reducing the effects of coastal risks can be achieved through prevention, mitigation, and preparedness measures ( Sperling and Szekely, 2005 ).

Compared to other major marine ecosystems, mangroves have suffered the earliest and greatest degradation in the Philippines because of their relative accessibility and long history of conversion to aquaculture ( Primavera, 2000 ). In our study, mangrove harvesting was perceived as the most negative coastal risk ( Table 2 ). Unsustainable mangrove harvesting in the Philippines has seen mangroves decrease from 500,000 hectares in 1920 ( Brown and Fischer, 1920 ) to just 120,000 hectares in 1994–1995 ( Primavera and Esteban, 2008 ). Thus, mangrove replanting programs became popular, from community initiatives to government-sponsored programs to large-scale international sponsored projects. Despite all these initiatives, the survival rates of mangroves are generally low, which could be attributed to inappropriate species and site selection ( Primavera and Esteban, 2008 ). Laws and regulations governing the conservation of mangrove areas in the Philippines were also created. However, it is difficult or impossible for some coastal communities to comply because many of them are dependent on mangroves for fuel, wood, housing materials, and other uses ( Primavera, 2000 ; Parras, 2001 ; Primavera and Esteban, 2008 ). Thus, the negative perceptions toward mangrove harvesting in our study could reflect that unsustainable mangrove harvesting is still being practiced by the coastal communities. It also shows that communities understand the negative environmental impacts caused by mangrove harvesting, but due to their potential dependence, they are not willing/able to stop even though they know it is bad.

In this study, both fisheries livelihoods (aquaculture, live reef fish trade, gleaning) and fisheries livelihood support (alternative livelihoods, infrastructure development, tourism) were perceived as having no impact on the coastal marine environment. This could be due to lack of public knowledge on these issues because some of these, such as tourism, are not present in our study sites. This finding is further supported by our results that participants with higher levels of education had more negative perceptions of these drivers/pressures.

Previous research on public knowledge concerning ocean conditions revealed that while there is a general realization that the ocean and coastal areas are at risk due to pollution, overfishing, etc., the public have little knowledge about ocean functioning and ecology ( Steel et al., 2005 ). This was supported by Buckley et al. (2017) who found that people felt quite well informed about highly publicized issues such as pollution and overfishing, but are less knowledgeable about more complex issues such as ocean acidification or impacts on wildlife. In the case of mangroves, while it is widely known that their destruction for pond conversion is one of the negative impacts of aquaculture, other potentially more subtle ecological impacts such as eutrophication ( Martinez-Porchas and Martinez-Cordova, 2012 ) are less well known. Therefore, despite our findings showing communities are concerned about the drivers/pressures affecting the marine environment, increasing their knowledge could lead to even greater concern.

Environmental management was the only factor that was perceived positively and included activities such as national political will, environmental laws and policies, community support for protection and management, and further research. These can be viewed within the “social license concept.” Social license is an unwritten social contract that reflects the opinions and expectations of the community toward the impacts and benefits of industry and government practices, including research on the environment (including the ocean) ( Kelly et al., 2018 ). Improving social license among stakeholders could further strengthen the conservation of the coastal marine environment by allowing communities to engage with the issues and voice their opinions and views ( Kelly et al., 2018 ).

As stated above, coastal resource management in the Philippines works as a group of behaviors involving various stakeholders. Our results showed consistencies between the perceptions of experts and local communities for the various coastal drivers/pressures. This suggests good communication between locals and policymakers/experts, and shows that the various government programs which support the management of coastal and marine resources in Palawan are effective at the grassroots level.

However, although they have a similar pattern of perceptions in general, local communities and experts had different perceptions of negative drivers/pressures on the coastal marine environment. Their differences could suggest that these issues are happening at different scales. For example, unsustainable fishing practices are a very local issue, impacting the local people directly, whereas urbanization is a broader issue happening at a higher scale possibly across the whole of Palawan/the Philippines. Therefore, it highlights that these two groups (experts and locals) can sometimes operate at different scales.

Another possible explanation of this gap may be related to the different levels of awareness or sources of information. While experts are more likely to get information from scientific research and data, the public uses fewer and less reliable information sources to gain information about the marine environment ( Potts et al., 2016 ; Lotze et al., 2018 ). Previous studies found a clear gap between public and marine expert perceptions of the top threats to the marine environment ( Potts et al., 2016 ; Lotze et al., 2018 ). Another study found a significant difference in the level of perceived impact of coastal threats between professionals and the public ( Easman et al., 2018 ).

These discrepancies in findings may be due to experts’ perceptions sometimes not aligning with specific local issues ( Deng et al., 2017 ). With regards to management, varying perceptions between experts and local people, as is the case with coastal risks perceptions in our study, could raise concerns regarding the prioritization of action. This highlights the importance of transparent discussions around issues between local people and all concerned stakeholders, ensuring actions are planned collaboratively with a clear and accepted distribution of responsibilities ( Blake, 1999 ; Sparrevik et al., 2011 ; Beyerl et al., 2016 ).

4.2 Role of Socio-Demographic Factors on Perceptions of Pressures/Drivers on Marine Coastal Ecosystems

To better understand the differences and heterogeneity in the perceptions of participants, we assessed the interrelationships between their perceptions and socio-demographic variables. Our results showed that gender (women vs. men), education (secondary and college level vs. elementary level), and study sites (Taytay and Aborlan (more rural areas) vs. Puerto Princesa City) affected the perceptions of local participants.

With regard to gender, this finding is consistent with previous research that showed women reported stronger environmental concern and attitudes compared to men ( Lai and Tao, 2003 ; Gkargkavouzi et al., 2019 ). A comprehensive survey of European citizens in 10 countries showed that men considered themselves to be better informed about most environmental issues, whilst women expressed higher levels of concern across all issues ( Buckley et al., 2017 ). A review of research by Zelezny et al. (2000) found that women tend to report stronger environmental attitudes and behaviors compared to men because they had higher levels of socialization, were more “other-oriented,” and more socially responsible.

In a small-scale coastal community setting in the Philippines, women are the ones who typically attend community meetings, seminars, and training provided by various government and non-government organizations, and were more likely to participate in the current study, while men usually devote time offshore catching fish. Likewise, the participation of women in fisheries in the Philippines is mostly limited to beach seining, net hauling, and marketing of fish catches, suggesting that they have little direct involvement in offshore capture fisheries ( Lim et al., 1995 ; Siason, 2000 ; Muallil et al., 2013 ). Since women generally spend more time in the community than men, they often develop more richly ramified local social networks which may be the reason for their higher perceptions of selected drivers/pressures in the coastal marine environment ( McGoodwin, 2001 ). Nevertheless, as noted earlier, due to women being more available to take part in our interviews, we need to treat these gender results with caution (i.e., it may be that men who were absent fishing actually have more similar attitudes to women than men not engaged in these activities).

On the relationship between education and perceptions, our finding is consistent with previous studies of Cao et al. (2009) and Shen and Saijo (2008) which showed that people with higher educational attainment tend to have more concern for the environment. In several countries, people with more education, in general, are more concerned about the environment ( Arcury and Christianson, 1990 ; Lai and Tao, 2003 ; Bi et al., 2010 ; Sparrevik et al., 2011 ; Gehrig et al., 2018 ; Guzman et al., 2020 ).

Recent studies have supported the idea that perceptions differ based on location, with individuals within the same community tending to have more similar views ( Cao et al., 2009 ; Buckley et al., 2017 ; Carpenter et al., 2018 ). In Zanzibar, the fishing village was found to be associated with fishers’ perceptions of environment and governance compared to any other variable such as occupational group. This suggests that where people live is a strong predictor for the level of differences in attitudes, understanding, and interpretation among fishers ( Gehrig et al., 2018 ).

A previous study in the Philippines showed that differences between villages significantly predicted attitudes toward Marine Protected Areas ( Chaigneau and Daw, 2015 ). In this study, study site was the strongest predictor for perceptions of drivers/pressures in the coastal marine environment. Participants from Aborlan and Taytay, which are more rural compared to Puerto Princesa, perceived unsustainable fishing practices and coastal risks to be less negative compared to their city counterparts. This may be because these drivers/pressures have been improving in recent years potentially because of the effective government support and interventions at the community level ( PCSD, 2015 ), with residents from Aborlan and Taytay seeing these changes on the ground.

5 Strengths and Limitations

Compared to previous studies on environmental perceptions, the current research has the following advantages. First, instead of using existing survey questionnaires and theories, we co-created our survey with stakeholders and local communities, supported by existing literature. This allowed us to explore issues in a more localized context. Second, our survey was framed using a standard conceptual model, the eDPSEEA. This research is also part of a larger cross-country project including coastal communities in Malaysia, Vietnam, and Indonesia. As the project progresses this means that cross-country findings from neighboring coastal communities may be used to gain greater insight and learning about the role of the marine environment in creating healthy coastal communities in Southeast Asia. Third, the survey was conducted via face-to-face interviews using a uniquely large sample, maximizing the quality of the data collected. Lastly, although a different survey technique and study design were used for local populations and local experts, the results showed strong consensus on how they perceived drivers/pressures in the coastal marine ecosystem.

However, we also recognize several limitations of our study. First, we felt we could not distinguish between Drivers and Pressures in the current study, despite them being differentiated in the eDPSEEA framework, and indeed other frameworks such as DPSIR. However, we do not see this as a major limitation given that we were primarily interested in lay people’s perceptions toward the marine environment (in relation to experts), and felt that the frameworks distinction was unnecessarily subtle for our purposes. The important point was that in people’s minds, there appeared to be seven key groupings (or statistical factors) of causes driving ecosystem change. Second, we are also aware that we were unable, in a paper of this length, to attempt to piece together all aspects of the survey, since this would have been far too complex for a single paper. Thus, we recognize that several potentially interesting questions remain unanswered as yet, although we intend to address these issues in subsequent papers, such as how perceptions of drivers/pressures are related to perceived States and in turn Effects (depending on the moderating potential of exposures).

Third, we also observed that there was a tendency for participants to select mid-point answers, particularly for critical issues. This could be attributed to recall biases in which the participants cannot remember how they were affected by the issue being asked, or it could be linked to the risk of social desirability bias of face-to-face surveys ( Bollettino et al., 2018 ). This means that participants will answer in a way that makes them feel safe and avoids controversial answers, particularly on sensitive issues. However, the survey instrument was co-created with stakeholders and local communities and was designed to enhance respondents’ cooperation and willingness to answer openly and truthfully.

Lastly, we recognize some gender imbalance in our study. As noted previously, more women participated in the survey compared to men, who had left to work at sea. Thus, we need to treat the gender results with caution.

6 Conclusion and Policy Implications

The current study offers an understanding of how local communities in Palawan, Philippines perceived the drivers/pressures in their coastal marine environment. We found that drivers/pressures affecting coastal marine environments are perceived differently by the local communities. Unsustainable fishing practices, coastal risks, urbanization, and unsustainable farming practices were perceived as having negative impacts on the coastal marine environment. Fisheries livelihoods and fisheries livelihood support were perceived as having no impact, whilst environmental management was perceived positively. The results of the expert survey showed a similar pattern of perceptions to those of the local communities. However, there were differences in how they perceived negative drivers/pressures suggesting that these two groups can sometimes consider things at different scales. Participant’s socio-demographic characteristics such as gender, education, location of study sites, and ethnicity impacted perceptions toward specific drivers/pressures in their coastal marine environment.

To our knowledge, there are no previous studies in the Philippines that used the same methodological approach. However, our results support previous studies ( Combest-Friedman et al., 2012 ; Andrachuk and Armitage, 2015 ; Chen et al., 2018 ; Almahasheer and Duarte, 2020 ) in understanding people’s environmental perceptions. Our results can be useful for policymakers and relevant government offices in designing and implementing strategies for effective management of coastal marine environments in the Philippines, incorporating local people’s perceptions and demographic complexities.

Data Availability Statement

The datasets presented in this article and from the entire survey will be made open access after an embargo period currently under discussion with the international consortium which is collecting similar data in three other countries in South East Asia. Request to access the datasets should be directed to the first author.

Ethics Statement

The studies involving human participants were reviewed and approved by the University of Exeter Medical School Research Ethics Committee (May19/B/185) and Philippines National Ethics Committee (2019-002-Creencia-Blue). The patients/participants provided their written informed consent to participate in this study.

Author Contributions

JM: data collection, development, and design of methodology, formal analysis, writing-original draft, and visualization. LC: data collection, conceptualization, writing-review and editing, and supervision. BR: data visualization and writing, review, and editing. JN: formal analysis, visualization, and writing-review, and editing. MW and KM: conceptualization, development, and design of methodology, formal analysis, writing, review, and editing, and visualization and supervision. LF: conceptualization and writing, review, and editing. All authors contributed to the article and approved the submitted version.

This work has received funding in part from the Global Challenges Research Fund (GCRF) United Kingdom Research and Innovation (UKRI) under grant agreement reference NE/P021107/1 to the Blue Communities Programme.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

We are grateful to various stakeholders and partners involved from the development until the conduct of the survey and all the study participants. Deep gratitude also goes to the Blue Communities Team of the Western Philippines University for participating during data collection.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmars.2021.659699/full#supplementary-material

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Keywords : coastal marine, drivers, pressures, coastal management, fisheries livelihoods, marine environment, public perception

Citation: Madarcos JRV, Creencia LA, Roberts BR, White MP, Nayoan J, Morrissey K and Fleming LE (2021) Understanding Local Perceptions of the Drivers/Pressures on the Coastal Marine Environment in Palawan, Philippines. Front. Mar. Sci. 8:659699. doi: 10.3389/fmars.2021.659699

Received: 28 January 2021; Accepted: 21 July 2021; Published: 14 September 2021.

Reviewed by:

Copyright © 2021 Madarcos, Creencia, Roberts, White, Nayoan, Morrissey and Fleming. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: John Roderick V. Madarcos, [email protected]

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Integrating environmental and ecosystem health into One Health – choices, contexts and communities matter

• Pamela Wairagala
• Peter Ballantyne
• Theo Knight-Jones
• Alexandre Caron

Our societies are facing major challenges, many caused by the ever-expanding human footprint on the planet. These challenges, such as ecosystem degradation, food system failures, biodiversity loss, infectious disease emergence, extreme climatic events and antimicrobial resistance, collectively impact on the health of ecosystems, people, animals and plants across the world, with a disproportionate impact in the least-developed countries.

The One Health approach is seen to deliver collaborative and systemic responses to some of these complex societal threats by promoting more inter-sectoral and inter-disciplinary collaboration across the environment, human, plant and animal health sectors. This is expected to improve the health of humans, animals, plants, and the environment, while contributing to sustainable development.

Most discussions around One Health tend to centre around human and animal health with environmental dimensions rarely unpacked and discussed in detail. In East and Southern Africa, as elsewhere, this is a serious issue as it risks leaving out key actors and agendas, leading to unintended negative outcomes and missed opportunities.

The members of the One Health ‘Quadripartite’ – the Food and Agriculture Organization of the United Nations (FAO), the United Nations Environment Programme (UNEP), the World Health Organization (WHO) and the World Organization for Animal Health (WOAH) – that guide the transformations required to mitigate the impact of current and future health challenges at human–animal– plant–environment interfaces, recognize this challenge and have called for the environment to be fully integrated into the One Health approach. While they suggest several ways to do this – such as integrating environmental experts in One Health fora and platforms, incorporating environmental data into One Health decision-making, fostering a better understanding of environmental issues and ecosystem health in the One Health community, and boosting the capacity of the environmental sector and its institutions to have an equal voice at the One Health table and in decision-making – most countries are yet to make strong progress in this area. 

To advance this agenda, the Capacitating One Health in Eastern and Southern Africa ( COHESA ) project recently brought together representatives of ministries of health, agriculture and the environment, members of country national One Health platforms and academics and international experts in different health components from across the region to brainstorm how best to integrate environment and ecosystem health (EEH) within the wider One Health concept in the 12 project target countries in Eastern and Southern Africa.  This effort aligns with the quadripartite  Action track 6 of the Joint Plan of Action which identified the need to better ‘integrate the environment into One Health.’

Convened in Hwange, Zimbabwe, by the  French Agricultural Research Centre for International Development ( CIRAD ), one of the consortium members of the COHESA project, the three-day workshop mapped and co-defined core dimensions of environment and ecosystem health, articulating intersections, interdependencies, trade-offs and relations among EEH and other One Health components.

On the third day, at country level, participants started to develop strategies to better identify and engage EEH actors, stakeholders and practitioners as well as understand their interests, needs, roles, opportunities and motivations, in order to fully integrate them in national One Health platforms and initiatives.

Field visits to nearby community projects linked to the  Zone Atelier Hwange and the ‘ Production and Conservation in Partnership’ research platform as well as observation of interactions between people and the nearby Hwange National Park also stimulated lively discussion and reflection on the different ‘healths’ – of people, ecosystems, livelihoods – observed trade-offs and the implications of community choices on outcomes. Again, the tension was visible between achieving healthier ecosystems, perhaps at the expense of people’s livelihoods, and creating economic opportunities with minimal environmental damage or negative side-effects. 

For the COHESA teams developing country-level strategies, these points have several implications:

Managing complexity:  The presentations, visits and mapping exercises showed how EEH is characterized by the always evolving nature and  diversity of disciplines, actors, themes and issues that comprise the environment, making its integration and implementation within the One Health context complex. Inclusion of components such as  animal, wildlife, plant, soil, air and water health, forests and rangelands health , and involvement of a wide scope of stakeholders, need to be considered when discussing integration and roles of the environment and ecosystem health into implementation of the One Health approach. 

Whose health : Health was seen to be not only ‘about diseases’ but also about well-being and quality of life – applied to people, animals and ecosystems and indeed the many different components such as wildlife, water, plants and soil. Together, these notions of well-being and health, already present in the WHO definition of human health, were felt to provide a useful overarching and holistic framework with deep roots in systems thinking.

Managing trade-offs : As introduced above, the perceived role of the environment and its health in the One Health approach needs to be revisited; from being considered as a source of exposure or risk to animal and human health, to an outcome of interest when managing human and animal health issues. Participants noted that the environment is associated with both negative and positive impacts from human and animal activities such as  industrialization and production systems, land use practices resulting in positive outcomes like improved livelihoods, research, tourism, recreation, trade and travel, traditional drug production and spiritual well-being. Unfortunately, there is a high impact from the negative outcomes such as climate change, environmental degradation, biodiversity loss, pollution, disease outbreaks, challenges to animal and plant welfare. Human-wildlife conflicts resulting from habitat fragmentation, and civil unrest among other problems are far reaching. 

Contexts are critical : Owing to this complexity, successful implementation of One Health, including the integration of environment and ecosystem health, requires context-specific approaches, and a willingness by all the disciplines and stakeholders to collaborate and make tradeoffs, in order to reach a situation that is most harmonious in terms of balancing the health of humans, animals and environments with a view to maximize the well-being of society and the ecosystems within which society exists. 

Communities matter: People and communities living closest to nature and areas rich in biodiversity often suffer the brunt of conservation efforts. This is particularly true in the savannas of eastern and southern Africa hosting large, protected areas with healthy wildlife populations but also small-scale farmers with limited livelihood options in a semi-arid environment. The people-nature interfaces in these savannas need to be managed for the benefit of people and nature, and not one at the expense of the other. 

Participants proposed the development of protocols to empower and support the socio-economic development of these communities as a way of promoting effective long-term conservation of biodiversity. Indigenous knowledge, beliefs and practices that have been used for generations and passed on through cultural value systems and practices to promote biodiversity conservation constitute a key component of environment and ecosystem health. Unfortunately, this knowledge is at risk  of erosion from factors such as technology and science, globalization, global warming, modernization, religion and forms of communication coming from the developed world, among others. 

Ways forward

Following the mapping exercises, the 12 COHESA target countries will further develop their country EEH strategies focusing on their local contexts; ensuring inclusion of previously misunderstood and under-represented issues, themes and actors. These will be incorporated in the existing country OH strategies and platforms or the ones that are being developed, in countries where they do not exist. The biodiversity conservation, environmental, public health and animal health/veterinary sectors will collaborate to deliver on this. 

Watch video recordings of the plenary presentations  

Download event presentations and country posters here

About COHESA

The project ‘Capacitating One Health in Eastern and Southern Africa (COHESA)’ is co-funded by the OACPS Research and Innovation Programme, a program implemented by the Organization of African, Caribbean and Pacific states (OACPS) with the financial support of the European Union.

COHESA is led by the International Livestock Research Institute (ILRI), the French Agricultural Research Centre for International Development (CIRAD - Centre de coopération internationale en recherche agronomique pour le développement) and the International Service for the Acquisition of Agri-biotech Applications (ISAAA) Africentre.

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The Gazette spoke to students engaged in environmental action in a variety of ways on campus to get their views of the problem today and thoughts on how their activities and work may help us meet the challenge.

Eric Fell and Eliza Spear

Fell is president and Spear is vice president of Harvard Energy Journal Club. Fell is a graduate student at the Harvard John H. Paulson School of Engineering and Applied Sciences and Spear is a graduate student in the Department of Chemistry and Chemical Biology.

FELL:   For the past three centuries, fossil fuels have enabled massive growth of our civilization to where we are today. But it is now time for a new generation of cleaner-energy technologies to fuel the next chapter of humanity’s story. We’re not too late to solve this environmental challenge, but we definitely shouldn’t procrastinate as much as we have been. I don’t worry about if we’ll get it done, it’s the when. Our survival depends on it. At Harvard, I’ve been interested in the energy-storage problem and have been focusing on developing a grid-scale solution utilizing flow batteries based on organic molecules in the lab of Mike Aziz . We’ll need significant deployment of batteries to enable massive penetration of renewables into the electrical grid.

SPEAR: Processes leading to greenhouse-gas emissions are so deeply entrenched in our way of life that change continues to be incredibly slow. We need to be making dramatic structural changes, and we should all be very worried about that. In the Harvard Energy Journal Club, our focus is energy, so we strive to learn as much as we can about the diverse options for clean-energy generation in various sectors. A really important aspect of that is understanding how much of an impact those technologies, like solar, hydro, and wind, can really have on reducing greenhouse-gas emissions. It’s not always as much as you’d like to believe, and there are still a lot of technical and policy challenges to overcome.

I can’t imagine working on anything else, but the question of what I’ll be working on specifically is on my mind a lot. The photovoltaics field is at a really exciting point where a new technology is just starting to break out onto the market, so there are a lot of opportunities for optimization in terms of performance, safety, and environmental impact. That’s what I’m working on now [in Roy Gordon’s lab ] and I’m really enjoying it. I’ll definitely be in the renewable-energy technology realm. The specifics will depend on where I see the greatest opportunity to make an impact.

Photo (left) courtesy of Kritika Kharbanda; photo by Tiera Satchebell.

Kritika Kharbanda ’23 and Laier-Rayshon Smith ’21

Kharbanda is with the Harvard Student Climate Change Conference, Harvard Circular Economy Symposium. Smith is a member of Climate Leaders Program for Professional Students at Harvard. Both are students at Harvard Graduate School of Design.

KHARBANDA: I come from a country where the most pressing issues are, and will be for a long time, poverty, food shortage, and unemployment born out of corruption, illiteracy, and rapid gentrification. India was the seventh-most-affected country by climate change in 2019. With two-thirds of the population living in rural areas with no access to electricity, even the notion of climate change is unimaginable.

I strongly believe that the answer lies in the conjugality of research and industry. In my field, achieving circularity in the building material processes is the burning concern. The building industry currently contributes to 40 percent of global carbon dioxide emissions, of which 38 percent is contributed by the embedded or embodied energy used for the manufacturing of materials. A part of the Harvard i-lab, I am a co-founder of Cardinal LCA, an early stage life-cycle assessment tool that helps architects and designers visualize this embedded energy in building materials, saving up to 46 percent of the energy from the current workflow. This venture has a strong foundation as a research project for a seminar class I took at the GSD in fall 2020, instructed by Jonathan Grinham. I am currently working as a sustainability engineer at Henning Larsen architects in Copenhagen while on a leave of absence from GSD. In the decades to come, I aspire to continue working on the embodied carbon aspect of the building industry. Devising an avant garde strategy to record the embedded carbon is the key. In the end, whose carbon is it, anyway?

SMITH: The biggest challenges are areas where the threat of climate change intersects with environmental justice. It is important that we ensure that climate-change mitigation and adaptation strategies are equitable, whether it is sea-level rise or the increase in urban heat islands. We should seek to address the threats faced by the most vulnerable communities — the communities least able to resolve the threat themselves. These often tend to be low-income communities and communities of color that for decades have been burdened with bearing the brunt of environmental health hazards.

During my time at Harvard, I have come to understand how urban planning and design can seek to address this challenge. Planners and designers can develop strategies to prioritize communities that are facing a significant climate-change risk, but because of other structural injustices may not be able to access the resources to mitigate the risk. I also learned about climate gentrification: a phenomenon in which people in wealthier communities move to areas with lower risks of climate-change threats that are/were previously lower-income communities. I expect to work on many of these issues, as many are connected and are threats to communities across the country. From disinvestment and economic extraction to the struggle to find quality affordable housing, these injustices allow for significant disparities in life outcomes and dealing with risk.

Lucy Shaw ’21

Shaw is co-president of the HBS Energy and Environment Club. She is a joint-degree student at Harvard Business School and Harvard Kennedy School.

SHAW: I want to see a world where climate change is averted and the environment preserved, without it being at the expense of the development and prosperity of lower-income countries. We have, or are on the cusp of having, many of the financial and technological tools we need to reduce emissions and environmental damage from a wide array of industries, such as agriculture, energy, and transport. The challenge I am most worried about is how we balance economic growth and opportunity with reducing humanity’s environmental impact and share this burden equitably across countries.

I came to Harvard as a joint degree student at the Kennedy School and Business School to be able to see this challenge from two different angles. In my policy-oriented classes, we learned about the opportunities and challenges of global coordination among national governments — the difficulty in enforcing climate agreements, and in allocating and agreeing on who bears the responsibility and the costs of change, but also the huge potential that an international framework with nationally binding laws on environmental protection and carbon-emission reduction could have on changing the behavior of people and businesses. In my business-oriented classes, we learned about the power of business to create change, if there is a driven leadership. We also learned that people and businesses respond to incentives, and the importance of reducing cost of technologies or increasing the cost of not switching to more sustainable technologies — for example, through a tax. After graduate school, I plan to join a leading private equity investor in their growing infrastructure team, which will equip me with tools to understand what makes a good investment in infrastructure and what are the opportunities for reducing the environmental impact of infrastructure while enhancing its value. I hope to one day be involved in shaping environmental and development policy, whether it is on a national or international level.

Photo (left) by Tabitha Soren.

Quinn Lewis ’23 and Suhaas Bhat ’24

Both are with the Student Climate Change Conference, Harvard College.

LEWIS:   When I was a kid, I imagined being an adult as a future with a stable house, a fun job, and happy kids. That future didn’t include wildfires that obscured the sun for months, global water shortages, or billionaires escaping to terrariums on Mars. The threats are so great and so assured by inaction that it’s very hard for me to justify doing anything else with my time and attention because very little will matter if there’s 1 billion climate refugees and significant portions of the continental United States become uninhabitable for human life.

For whatever reason, I still feel a great deal of hope around giving it a shot. I can’t imagine not working to mitigate the climate crisis. Media and journalism will play a huge role in raising awareness, as they generate public pressure that can sway those in power. Another route for change is to cut directly to those in power and try to convince them of the urgency of the situation. Given that I am 22 years old, it is much easier to raise public awareness or work in media and journalism than it is to sit down with some of the most powerful people on the planet, who tend to be rather busy. At school, I’m on a team that runs the University-wide Student Climate Change Conference at Harvard, which is a platform for speakers from diverse backgrounds to discuss the climate crisis and ways students and educators can take immediate and effective action. Also, I write about and research challenges and solutions to the climate crisis through the lenses of geopolitics and the global economy, both as a student at the College and as a case writer at the Harvard Business School. Outside of Harvard, I have worked in investigative journalism and at Crooked Media, as well as on political campaigns to indirectly and directly drive urgency around the climate crisis.

BHAT:   The failure to act on climate change in the last few decades, despite mountains of scientific evidence, is a consequence of political and institutional cowardice. Fossil fuel companies have obfuscated, misinformed, and lobbied for decades, and governments have failed to act in the best interests of their citizens. Of course, the fight against climate change is complex and multidimensional, requiring scientific, technical, and entrepreneurial expertise, but it will ultimately require systemic change to allow these talents to shine.

At Harvard, my work on climate has been focused on running the Harvard Student Climate Conference, as well as organizing for Fossil Fuel Divest Harvard. My hope for the Climate Conference is to provide students access to speakers who have dedicated their careers to all aspects of the fight against climate change, so that students interested in working on climate have more direction and inspiration for what to do with their careers. We’ve featured Congresswoman Ayanna Pressley, members of the Sunrise Movement, and the CEO of Impossible Foods as some examples of inspiring and impactful people who are working against climate change today.

I organize for FFDH because I believe that serious institutional change is necessary for solving the climate crisis and also because of a sort of patriotism I have for Harvard. I deeply respect and care for this institution, and genuinely believe it is an incredible force for good in the world. At the same time, I believe Harvard has a moral duty to stand against the corporations whose misdeeds and falsification of science have enabled the climate crisis.

Libby Dimenstein ’22

Dimenstein is co-president of Harvard Law School Environmental Law Society.

DIMENSTEIN:   Climate change is the one truly existential threat that my generation has had to face. What’s most scary is that we know it’s happening. We know how bad it will be; we know people are already dying from it; and we still have done so little relative to the magnitude of the problem. I also worry that people don’t see climate change as an “everyone problem,” and more as a problem for people who have the time and money to worry about it, when in reality it will harm people who are already disadvantaged the most.

I want to recognize Professor Wendy Jacobs, who recently passed away. Wendy founded HLS’s fantastic Environmental Law and Policy Clinic, and she also created an interdisciplinary class called the Climate Solutions Living Lab. In the lab, groups of students drawn from throughout the University would conduct real-world projects to reduce greenhouse-gas emissions. The class was hard, because actually reducing greenhouse gases is hard, but it taught us about the work that needs to be done. This summer I’m interning with the Environmental Defense Fund’s U.S. Clean Air Team, and I anticipate a lot of my work will revolve around the climate. After graduating, I’m hoping to do environmental litigation, either with a governmental division or a nonprofit, but I also have an interest in policy work: Impact litigation is fascinating and important, but what we need most is sweeping policy change.

Candice Chen ’22 and Noah Secondo ’22

Chen and Secondo are co-directors of the Harvard Environmental Action Committee. Both attend Harvard College.

SECONDO: The environment is fundamental to rural Americans’ identity, but they do not believe — as much as urban Americans — that the government can solve environmental problems. Without the whole country mobilized and enthusiastic, from New Hampshire to Nebraska, we will fail to confront the climate crisis. I have no doubt that we can solve this problem. To rebuild trust between the U.S. government and rural communities, federal departments and agencies need to speak with rural stakeholders, partner with state and local leaders, and foreground rural voices. Through the Harvard College Democrats and the Environmental Action Committee, I have contributed to local advocacy efforts and creative projects, including an environmental art publication.

I hope to work in government to keep the policy development and implementation processes receptive to rural perspectives, including in the environmental arena. At every level of government, if we work with each other in good faith, we will tackle the climate crisis and be better for it.

CHEN: I’m passionate about promoting more sustainable, plant-based diets. As individual consumers, we have very little control over the actions of the largest emitters, massive corporations, but we can all collectively make dietary decisions that can avoid a lot of environmental degradation. Our food system is currently very wasteful, and our overreliance on animal agriculture devastates natural ecosystems, produces lots of potent greenhouse gases, and creates many human health hazards from poor animal-waste disposal. I feel like the climate conversation is often focused around the clean energy transition, and while it is certainly the largest component of how we can avoid the worst effects of global warming, the dietary conversation is too often overlooked. A more sustainable future also requires us to rethink agriculture, and especially what types of agriculture our government subsidizes. In the coming years, I hope that more will consider the outsized environmental impact of animal agriculture and will consider making more plant-based food swaps.

To raise awareness of the environmental benefits of adopting a more plant-based diet, I’ve been involved with running a campaign through the Environmental Action Committee called Veguary. Veguary encourages participants to try going vegetarian or vegan for the month of February, and participants receive estimates for how much their carbon/water/land use footprints have changed based on their pledged dietary changes for the month.

Photo (left) courtesy of Cristina Su Liu.

Cristina Su Liu ’22 and James Healy ’21

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Liu is with Harvard Climate Leaders Program for Professional Students. Healy is with the Harvard Student Climate Change Conference. Both are students at Harvard T.H. Chan School of Public Health.

HEALY:   As a public health student I see so many environmental challenges, be it the 90 percent of the world who breathe unhealthy air, or the disproportionate effects of extreme heat on communities of color, or the environmental disruptions to the natural world and the zoonotic disease that humans are increasingly being exposed to. But the central commonality at the heart of all these crises is the climate crisis. Climate change, from the greenhouse-gas emissions to the physical heating of the Earth, is worsening all of these environmental crises. That’s why I call the climate crisis the great exacerbator. While we will all feel the effects of climate change, it will not be felt equally. Whether it’s racial inequity or wealth inequality, the climate crisis is widening these already gaping divides.

Solutions may have to be outside of our current road maps for confronting crises. I have seen the success of individual efforts and private innovation in tackling the COVID-19 pandemic, from individuals wearing masks and social distancing to the huge advances in vaccine development. But for climate change, individual efforts and innovation won’t be enough. I would be in favor of policy reform and coalition-building between new actors. As an overseer of the Harvard Student Climate Change Conference and the Harvard Climate Leaders Program, I’ve aimed to help mobilize Harvard’s diverse community to tackle climate change. I am also researching how climate change makes U.S. temperatures more variable, and how that’s reducing the life expectancies of Medicare recipients. The goal of this research, with Professor Joel Schwartz, will be to understand the effects of climate change on vulnerable communities. I certainly hope to expand on these themes in my future work.

SU LIU:  A climate solution will need to be a joint effort from the whole society, not just people inside the environmental or climate circles. In addition to cross-sectoral cooperation, solving climate change will require much stronger international cooperation so that technologies, projects, and resources can be developed and shared globally. As a Chinese-Brazilian student currently studying in the United States, I find it very valuable to learn about the climate challenges and solutions of each of these countries, and how these can or cannot be applied in other settings. China-U.S. relations are tense right now, but I hope that climate talks can still go ahead since we have much to learn from each other.

Personally, as a student in environmental health at [the Harvard Chan School], I feel that my contribution to addressing this challenge until now has been in doing research, learning more about the health impacts of climate change, and most importantly, learning how to communicate climate issues to people outside climate circles. Every week there are several climate-change events at Harvard, where a different perspective on climate change is addressed. It has been very inspiring for me, and I feel that I could learn about climate change in a more holistic way.

Recently, I started an internship at FXB Village, where I am working on developing and integrating climate resilience indicators into their poverty-alleviation program in rural communities in Puebla, Mexico. It has been very rewarding to introduce climate-change and climate-resilience topics to people working on poverty alleviation and see how everything is interconnected. When we address climate resilience, we are also addressing access to basic services, livelihoods, health, equity, and quality of life in general. This is where climate justice is addressed, and that is a very powerful idea.

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Environmental Public Health Essay

Introduction, code of ethics, standards of practice, ethical decision making.

Public health is a major concern in the world today. The welfare of human beings has been put in the spotlight of major scientific research. As such, the research has emphasized on the need for public health ethics so as to ensure that people’s health is put into consideration. Professionalism within the public health sector has, therefore gained some renewed attention from various agencies.

The need to have professionals who are well equipped with skills and knowledge in environmental health is thus of paramount importance to any nation. The following essay focuses on professionalism in environmental public health raging from the code of ethics, standards of practice, to ethical decision making among other core values.

The code of ethics refers to the manner in which environmental health professionals are expected to conduct themselves while delivering their services to the public. These include the upholding of the rule of law through promotion of justice, accountability, maintaining confidentiality of the public and ensuring competent practice among health professionals (Dawson, 2011).

In Canada, The Canadian Institute of Public Health Inspectors (CIPHI) concerned with environmental public health is the only body that usually regulates and outlines the ethical conduct of health professionals in Canada. As such, the body usually deals with the welfare of people’s health by ensuring that the concerns are put into consideration while still engaging in the diverse world of knowledge and research.

Promotion of Justice

The promotion of justice among health professionals in Canada requires from every health professional to recognize the fact that every person has a right to fundamental rights of health regardless of their race or any other social distinction.

Additionally, Environmental Public Health Professionals (EPHPs) are obliged to promote fairness and equity as well as respect human rights in their different areas of research. With these attributes in mind, the welfare of the public is thus given priority by health agencies.

Accountability

Accountability is a requirement among health professionals so as to ensure that they are held accountable and responsible for their actions. As such, a high degree of loyalty to CIPHI is paramount in ensuring that health professionals safeguard the interests of the public. These obligations have no exceptions or compromise as ignoring them would pose dire consequences to the public. Consequently, the impact on people’s health would be dire consequences.

Maintenance of confidentiality

Maintenance of confidentiality among health experts is another requirement within the code of ethics of the environmental public health. This requirement compels all health professionals within the public sector to safeguard the health secrets of any family or community through the privacy laws that have been established (Dawson, 2011). This ensures that people’s life secrets are protected and their privacy is respected by all health professionals within the country.

Competency is a key requirement among health professionals in ensuring that their knowledge and skills remain relevant to people’s health. As such, EPHPs strive to remain competent and up to date with the various developments in the world of environmental public health.

Competent knowledge and skills are vital in ensuring that their work and service to the public remain competitive and up to date with technological advancements.

The scope of practice has, therefore, been put in place to ensure that every health professional conforms to the standards of quality and competency in the field. The need to keep people fully informed with regard to health issues is paramount so as to ensure competency and delivery of professional services to the public.

A Professional Standard of Practice can be defined as a specific level of performance where an individual must perform various professional tasks and responsibilities while maintaining some minimal standards below which the quality of work is unacceptable (Canada, 2008). As such, any professional activity or task must be performed at a minimum threshold so as to ensure that quality of the work is not compromised at all costs.

Standards will always provide values and a set of principles that must be observed while engaging in research. These standards ensure that professionals in the field of public health remain competitive and knowledgeable in handling pertinent issues within the field. They usually enlighten the public on what is expected of health professionals and also inform the latter of their responsibility and accountability.

These standards of practice serve to achieve the vision of health professionals enabling the professionals to make informed decisions with regard to the welfare of the public, ensure cohesion and conformity of all health professionals with the universally agreed requirements as well as provide a legal framework of understanding the code of conduct of these professionals. The standards include accountability, competency, ethics, application of knowledge, leadership as well as relationships standard.

Accountability standards aim at ensuring that the health professionals conform to the legislative requirements by taking responsibility with regard to their actions (Frumkin, 2010). Additionally, health professionals are also obliged to assist in the development of rules and policies to govern their field and ensure consistent practice of all stakeholders.

With regard to competency standards, EPHPs maintain their proficiency and competency through advancements in research as well as taking regular training programs to advance their knowledge and skills. Additionally, health professionals are obliged to dedicate their time and resources in order to meet certain requirements that are set by the regulatory authority (Frumkin, 2010). These rules are aimed at ensuring delivery of quality services to the public which are in line with universal standards.

EPHPs must maintain their ethical standards which outline their responsibilities to the public as well as inform the public and other health professionals of their ethical commitments to environmental public health concerns. The professionals should also maintain and safeguard the information pertaining to the health of their clients.

Leadership standards compel health professionals to be role models with regard to their professional etiquette and participation in various community development projects. These requirements ensure that there is sharing and dispensation of knowledge and skills to the community and other groups of interest.

Development of adequate conflict resolution skills that are highly effective is paramount to any health professional within the public health sector. This portrays their ability to find effective and workable solutions in the event of a conflict.

Decision making within the environmental public health sector can be defined as the identification of conflicting values within a particular society which can be solved through the employment of a legal moral framework (Frumkin, 2010).

For instance, a law might be formulated by health professionals requiring all children within public institutions to wear leg guards while playing football. However, the parents might oppose the move by arguing that they reserve the rights to make rightful decision regarding the interests of their children.

The ability to recognize and acknowledge an ethical concern is paramount to any health professional who is equipped with knowledge and understanding of pertinent issues that a particular society faces. These decisions are made in steps which include recognition of the ethical problem or concern, identification of conflicting values and putting into consideration the ethical support towards the health program from the society. As such, improvement of the public health is an essential consideration while making decisions pertaining to the public welfare.

From the above discussion, professionalism in environmental public health is paramount to all health professionals, which is due to the fact that the public heavily relies on their services for a healthy life. As such, ethics and various standards of practice cannot be overlooked by the professionals. Should these factors be put into consideration, the results will be visible to everyone, and thus will ensure a healthy and productive nation.

American Public Health Association. (1971). American journal of public health: JPH . New York, N.Y: American Public Health Association.

Benatar, S. R., & Brock, G. (2011). Global health and global health ethics . Cambridge: Cambridge University Press.

Canada. (2008). The Chief Public Health Officer’s report on the state of public health in Canada . Ottawa, Ont: Chief Public Health Officer.

Canadian Institute of Health Inspectors. (2010). Continuing Professional Competencies Program . Canada: The CPC Working Group and Council of Professional Experience.

Dawson, A. (2011). Public Health Ethics: Key Concepts and Issues in Policy and Practice . Cambridge: Cambridge University Press.

Frumkin, H. (2010). Environmental health: From global to local . San Francisco, CA: Jossey-Bass.

Haber, D. (2010). Health promotion and aging: Practical applications for health professionals . New York: Springer Pub.

Public health ethics . (2008). Oxford, UK: Oxford University Press.

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IvyPanda. (2024, April 7). Environmental Public Health. https://ivypanda.com/essays/environmental-public-health-essay/

"Environmental Public Health." IvyPanda , 7 Apr. 2024, ivypanda.com/essays/environmental-public-health-essay/.

IvyPanda . (2024) 'Environmental Public Health'. 7 April.

IvyPanda . 2024. "Environmental Public Health." April 7, 2024. https://ivypanda.com/essays/environmental-public-health-essay/.

1. IvyPanda . "Environmental Public Health." April 7, 2024. https://ivypanda.com/essays/environmental-public-health-essay/.

Bibliography

IvyPanda . "Environmental Public Health." April 7, 2024. https://ivypanda.com/essays/environmental-public-health-essay/.

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Environmental Issues Essay for Students and Children

500+ words essay on environmental issues.

The environment plays a significant role to support life on earth. But there are some issues that are causing damages to life and the ecosystem of the earth. It is related to the not only environment but with everyone that lives on the planet. Besides, its main source is pollution , global warming, greenhouse gas , and many others. The everyday activities of human are constantly degrading the quality of the environment which ultimately results in the loss of survival condition from the earth.

Source of Environment Issue

There are hundreds of issue that causing damage to the environment. But in this, we are going to discuss the main causes of environmental issues because they are very dangerous to life and the ecosystem.

Pollution – It is one of the main causes of an environmental issue because it poisons the air , water , soil , and noise. As we know that in the past few decades the numbers of industries have rapidly increased. Moreover, these industries discharge their untreated waste into the water bodies, on soil, and in air. Most of these wastes contain harmful and poisonous materials that spread very easily because of the movement of water bodies and wind.

Greenhouse Gases – These are the gases which are responsible for the increase in the temperature of the earth surface. This gases directly relates to air pollution because of the pollution produced by the vehicle and factories which contains a toxic chemical that harms the life and environment of earth.

Climate Changes – Due to environmental issue the climate is changing rapidly and things like smog, acid rains are getting common. Also, the number of natural calamities is also increasing and almost every year there is flood, famine, drought , landslides, earthquakes, and many more calamities are increasing.

Above all, human being and their greed for more is the ultimate cause of all the environmental issue.

Get the huge list of more than 500 Essay Topics and Ideas

How to Minimize Environment Issue?

Now we know the major issues which are causing damage to the environment. So, now we can discuss the ways by which we can save our environment. For doing so we have to take some measures that will help us in fighting environmental issues .

Moreover, these issues will not only save the environment but also save the life and ecosystem of the planet. Some of the ways of minimizing environmental threat are discussed below:

Reforestation – It will not only help in maintaining the balance of the ecosystem but also help in restoring the natural cycles that work with it. Also, it will help in recharge of groundwater, maintaining the monsoon cycle , decreasing the number of carbons from the air, and many more.

The 3 R’s principle – For contributing to the environment one should have to use the 3 R’s principle that is Reduce, Reuse, and Recycle. Moreover, it helps the environment in a lot of ways.

To conclude, we can say that humans are a major source of environmental issues. Likewise, our activities are the major reason that the level of harmful gases and pollutants have increased in the environment. But now the humans have taken this problem seriously and now working to eradicate it. Above all, if all humans contribute equally to the environment then this issue can be fight backed. The natural balance can once again be restored.

FAQs about Environmental Issue

Q.1 Name the major environmental issues. A.1 The major environmental issues are pollution, environmental degradation, resource depletion, and climate change. Besides, there are several other environmental issues that also need attention.

Q.2 What is the cause of environmental change? A.2 Human activities are the main cause of environmental change. Moreover, due to our activities, the amount of greenhouse gases has rapidly increased over the past few decades.

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Understanding the links between health and the environment

Credit: Maridav / Getty Images

The MRC Centre for Environment and Health is doing vital research to advance our knowledge of how pollution and other environmental factors affect human health.

It is no mystery that our environment has a major influence on health, but there is still much that is unknown:

• what exactly are the links between factors such as air pollution, noise, non-ionising radiation and ill-health?
• how do these links work?
• what does this mean for society?

Many of these questions are poorly-understood, but are essential if we are to make the right decisions for our environment and our wellbeing.

The Centre for Environment and Health (CEH), funded by the Medical Research Council, has been working to address these gaps since 2009.

Based at Imperial College London, the Centre has over 30 research groups and around 200 associated research staff and students. Led by Centre Director Professor Paul Elliot CBE, they work to:

• detect and quantify associations between environmental factors and health
• understand impacts on society
• inform policy.

Research ranges from detailed analysis of disease pathways and mechanisms through to large-scale population studies.

The air that we breathe

The recent death of Ella Adoo Kissi-Debrah in South London, linked by the coroner to local air pollution, starkly highlighted the issue of air quality, an increasing concern for cities worldwide.

Imperial College’s Environmental Research Group , led by Professor Frank Kelly, Deputy Director of the CEH, have been at the forefront of research guiding air pollution policies. Including the ultra-low emission zone (uLEZ) in London.

Under the Centre’s Environmental Exposures programme, they work closely with the Greater London Authority, providing advice and policy input, and are researching the health benefits of the uLEZ to help other UK cities developing plans for clean air zones.

Making cities healthier

More than half of the world’s population lives in cities. The CEH Healthy Cities, Healthy People programme is working to advance knowledge of how social, economic and technological developments affect the environment and health in urban areas, from air quality to flood risk.

This research is helping cities worldwide to maintain healthy urban environments, develop sustainably, and support healthy lives.

Pollution-effect pathways

The centre also has a focus on the biochemistry and toxicology of pollution, through the Molecular Signatures and Disease Pathways programme. For example, working with the MRC Toxicology Unit , researchers have explored how brake dust exacerbates inflammation and compromises the work of white blood cells.

Other work looks at the effects of wood smoke and diesel particulates. By understanding the specific pathways by which different pollutants affect human health, we can design better policy to regulate specific emissions.

Multiple disciplines, new frontiers

The centre’s priorities include:

• growing capability and expanding the frontiers of environmental health research
• developing new methods in biostatistics, data science and related disciplines.

Centre members have been awarded funds from the UK Research and Innovation Strategic Priorities Fund Clean Air Programme. This is a £42.5 million multidisciplinary investment to explore near-term and emerging air pollution challenges and health risks, with vulnerable populations at its core.

Describing the work of the MRC CEH, Professor Paul Elliot emphasised that:

A proper understanding of the health impacts of environmental exposures depends on many scientists from different disciplines working closely together. With such a team, working from the molecular scale through to whole populations, our Centre continues to help inform policy and public practice at what is a critical time for our society and the planet.

Last updated: 15 October 2021

This is the website for UKRI: our seven research councils, Research England and Innovate UK. Let us know if you have feedback or would like to help improve our online products and services .

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What is environmental health?

Examining a massive influence on our health: the environment..

We've been reporting on environmental health for 20 years. But what is environmental health? You've got questions, and we have answers.

Environmental health is a branch of public health that monitors the relationship between human health and the environment, examining aspects of both our natural and human-made environment and their effect on human wellbeing.

What is an example of environmental health?

Living near factories or heavy traffic worsens air quality and leads to health impacts on the lungs and heart.

Credit: Kouji Tsuru / Unsplash

Environmental health is a broad area of study — everything from the climate to the food we eat to the air we breathe plays into environmental health. A few specific examples include:

• Air pollution: Living near factories or heavy traffic worsens air quality and leads to health impacts on the lungs and heart such as asthma and increased risk of heart attacks or stroke.
• Water contamination: Drinking lead-contaminated water can cause IQ loss, behavioral issues, learning disabilities and more. Infants and young children are most at risk.
• Toxic chemicals in consumer products: Phthalates, a class of chemicals that are widely used in consumer products, are known endocrine-disruptors, meaning they hijack your body’s hormones and can cause a wide array of health impacts including increased risk of cancer and fertility issues.

What is the role of environmental health?

The role of environmental health research is to examine areas of the environment that impact our health so that we can make personal and policy changes to keep ourselves safe and improve human health and wellbeing.

Why is environmental health important?

Credit: Viki Mohamad / Unsplash

Environmental health impacts every one of us.

We reap the benefits of clean air, clean water, and healthy soil. If our environment is unhealthy, with toxic chemicals saturating our resources and pollution abundant, then our health also suffers.

It is also an important field of study because it looks at the “unseen” influences on your health.

Many individuals may not associate their health problems with air or water quality, or with what clothes they wear, makeup and household goods they use, or food they eat.

That’s because not every example of environmental health problems are obvious: some chemicals, for example, build up slowly over time in your body: a small dose may not seem to bring harm, but repeated small doses can lead to later impacts.

• BPA absorbed through plastic containers, cans, receipts, etc. lingers in the body and the build-up over time increases risk of cancer, diabetes, liver failure, and more.
• PFAS are known as ‘forever chemicals ’— they don’t break down and are widely used, so small exposures are frequent and contribute to immune system and reproductive damages, heightened cholesterol levels, and more.
• Mercury from eating seafood and shellfish can impact neurological development of fetuses in the womb, and populations that regularly consume mercury-heavy seafood have shown mild cognitive impairment.

Also, individual susceptibility can differ: for example, one member of a household can experience illness, asthma, migraines, etc. from chemicals found in their water supply while another member of the same household is just fine, such as the case in a young girl’s reaction to benzene in her water from living near fracking wells.

Certain variables play a role in susceptibility and level of adverse health effects such as age, gender, pregnancy, and underlying health conditions. Studies suggest fetuses, infants and children are much more at risk to experience lifelong health problems from toxic chemical exposure.

Rate, duration, and frequency of exposure to toxic chemicals and other influences from our environment all factor into our health.

Good environmental health = good human health.

What environmental health problems affect our health?

Two women extracting from a well in Senegal.

Credit: JordiRamisa

There are many environmental health issues that affect human health. These include:

Air pollution — nine out of 10 people currently breathe air that exceeds the World Health Organization’s guideline limits for air pollution worldwide. This mainly affects people in low and middle-income countries, but in the United States, people that live in cities, or near refineries or factories, are often affected as well.

Air pollution also ramps up during wildfire season.

Read more: Breathless: Pittsburgh's asthma epidemic and the fight to stop it

Water pollution — as of 2014, every year more people die from unsafe water than from all forms of violence, including war. Water is the ‘universal solvent’, meaning it can dissolve more substances than any other liquid on Earth. Thus, it is too easy for toxic chemicals to enter our water supply.

Read more: Sacred Water: Environmental justice in Indian Country

Lack of access to health care — yes, this is an environmental health issue! Having an accessible health care system is part of one’s environment. Difficulty getting health care can further impact one’s health.

Poor infrastructure — from “food deserts” to lack of transportation services, living in an area with poor infrastructure can impact your health.

Read more: Agents of Change: Amplifying neglected voices in environmental justice

Climate change — climate change-induced heat waves, increased frequency and severity of large storms, droughts, flooding, etc. have resulted in health problems and even death.

Chemical pollution — chemical pollution can be sneaky: the chemicals in your everyday products, from shampoo to deodorant to your clothing to the food you eat, can directly affect your health. These chemicals are often not on the label or regulated at all.

Read more: Exposed: How willful blindness keeps BPA on shelves and contaminating our bodies

How can we improve our environmental health?

Credit: instaphotos

Educate yourself. Environmental health is a broad topic, so this can seem overwhelming. Start by taking stock of your own personal environment. Look up air pollution monitoring in your area. Get your water tested to see its chemical makeup. Evaluate the products you use in your life — personal products like shampoo and deodorant, household cleaners, air fresheners, the foods that you eat — and see what you’re bringing into your home.

Explore the Environmental Working Group's guides to check your products for toxic chemicals.

We have additional guides to help you learn more about environmental health. Find guides to plastic pollution , environmental justice , glyphosate , BPA , PFAS and more in the Resources tab at the top of our website.

As individuals we have the power to improve some of our environmental health, but there is a pressing need for systemic change and regulation on a policy level.

We’re actively working with scientists to share their research and knowledge with politicians to advocate for science-backed policy change. But we need your help. Contact your representatives to let them know that environmental health is important to you — whether it’s air pollution in your area, contaminated water, plastic pollution, food deserts in your area, or chemicals in consumer products.

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What is Environmental Health and What Critical Issues Impact Our Health?

What is environmental health, areas of environmental health, global environmental health, how you can help protect and improve environmental health.

Water quality, safe housing, healthy food access, and pollution -free transportation all contribute to human health, along with many other factors. Where people live and how they're connecting to the world can affect their health. The environmental health field—with its professionals, policies, and programs—is focused on these factors.

Your health is determined by personal choices (like whether you exercise or get vaccinated ) but also factors like local industry, the age of your home, food deserts , green space in your community, and more. Environmental stressors and advantages help to shape your options.

This article explains what environmental health is and how it can affect you and your community. It describes the work done by professionals and what you can do, too, to improve environmental health.

Environmental health is the  public health  field that monitors and addresses physical, chemical, and biological factors that impact your health though they're not always within your direct control.

Simply put, environmental health is the area of public health that deals with all the different ways the world can impact physical and mental well-being. Examples of impacts include:

• Lead toxicity (poisoning) from the paint or water pipes in older homes and neighborhoods
• Obesity and type 2 diabetes risk in food deserts and food swamps (communities with limited access to grocery stores and healthy food options, but often home to fast food stops)
• Cancer and the impacts of air pollution, heat, ultraviolet radiation, and other carcinogens and climate factors
• Stress, sleep disruptions , hearing loss , and other impacts due to traffic and other environmental noise
• Depression, cognition, and other brain health factors can be affected by green space

If you live in an urban heat island with few trees, it may be hotter than other neighborhoods— affecting a range of issues, from heat-related illness to asthma and heart disease. It's harder to get outside and exercise, too. When your home was built and the materials used, what insects live nearby, and what food you can access affect your health and the health of your family.

Environmental health is one of the largest fields within public health because of the myriad ways external forces can impact how people eat, live, and grow. These forces can be about addressing the natural environment (as in the case for clean water or sanitation), but they can also be the consequence of human beings' actions—including societal norms.

There are a number of initiatives focused on environmental health in the United States. Among them is the Healthy People 2030 agenda, which highlights six key areas that encompass the various ways environmental health is crucial to the health of communities.

Air Quality

Air is non-negotiable for humans. It's needed to survive and air quality can have a significant impact on health.

Poor air quality has been linked to a wide range of health issues, including SIDS, lung cancer , and chronic obstructive pulmonary disease ( COPD ). Air pollution is also linked to low birth weight.

One2019 study found that people exposed to high levels of air pollutants in the early and late states of pregnancy were more likely to have babies with lower birth weights, or with preterm births, than their non-exposed peers.

The Clean Air Act

The Clean Air Act of 1970 marked the first time the federal government took responsibility for protecting the air quality for all U.S. citizens by regulating harmful emissions from things like cars and factories. The act was later expanded in 1990 to address acid rain and ozone depletion.

Water and Sanitation

According to the Centers for Disease Control and Prevention, an estimated 780 million people worldwide don’t have access to safe drinking water, and a jaw-dropping 1.7 billion (or roughly a fifth of Earth’s population) lack adequate sanitation services like clean bathrooms.

The simple act of filtering and chlorinating water systems in the United States has resulted in significant declines in once-common diseases like typhoid . Historically, clean water is responsible for the bulk of the decline in childhood mortality in the country.

The environmental health impact of safe water can't be overstated. An estimated 2,200 children die every day worldwide of diarrheal diseases linked to improper water and sanitation. The United Nations estimates a return of $4.30 in medical and social costs for every dollar spent on clean water.

Toxic Substances and Hazardous Wastes

Toxicology—that is, the area of science devoted to understanding how chemicals and substances can affect people and their surroundings—is an important field in environmental health. Many of the materials needed to advance industries and technology, like heavy metals or even some plastics, can also hurt the human body and even lead to serious medical conditions.

The Flint, Michigan, water crisis is an example of lead poisoning effects in a community that can lead to long-term health complications, including brain damage in children. Economically disadvantaged kids are often most affected.

The Flint crisis, which exposed more than 100,000 people to unsafe lead levels in drinking water, was a prime example of how environmental health issues often hurt those whose health status is already most at risk.

Homes and Communities

Home and neighborhoods are at the core of environmental health. When a neighborhood has a lot of violence, for example, families or older people might not go outside to exercise. When roads aren't properly maintained, it can result in more car crashes. When sidewalks are in poor condition, people may avoid walking for fear of accidents.

An emerging field of environmental health is that of food access. In neighborhoods without full-service grocery stores, people rely on convenience stores, gas stations, and fast food restaurants. This limits fresh produce options—a vital part of a healthy diet. These food deserts contribute to health disparities for low-income and minority populations especially.

Environmental health professionals are urging communities to establish public gardens where residents can grow and harvest their own fresh produce, improve access to public transportation to full-service grocery stores and farmers markets, and change zoning laws to incentivize retailers to offer healthier food options.

Infrastructure and Surveillance 

A primary piece of any public health strategy is information to identify risks and guide the resources and responses to prevent them. This includes investigating and responding to diseases—a field called  epidemiology —as well as screening for hazards and establishing surveillance programs.

Surveillance activities involve either going out and looking for particular health concerns (active surveillance) or by asking professionals in other fields, such as medicine or agriculture, to alert environmental health agencies when they encounter them (passive surveillance).

An example of this in action is mosquito surveillance and abatement activities. These programs test mosquitoes for certain things, including the presence of dangerous infections like  Zika virus , as well as monitor populations to ensure control measures are working. This information can help health officials know what to watch for in doctors' offices, direct local governments on where and how best to spray for mosquitoes, and alert the public if a mosquito-borne illness is spreading in the area.

In the coming decades, environmental health professionals are bracing for a warmer, wetter climate that will likely prompt or exacerbate threats to public health across the globe.

Disease-carrying mosquitoes can live in areas previously too cold for them to survive, upping the number of people impacted by vector-borne illnesses like dengue and malaria . As sea levels rise, whole coastal cities and island nations face flood risks and disease due to displacement.

Even though health outcomes have improved significantly over the past century—in wealthy nations like the United States in particular—environmental hazards and infectious diseases know no geopolitical boundaries. People today are traveling farther and more often than ever before, and conflicts in areas like Syria, Afghanistan, and South Sudan cause millions to flee their homes.

These increases in cross-border and cross-continental movements have the potential to threaten disease prevention efforts and overextend existing infrastructure. That's why it's crucial that countries look beyond their borders to improve the health of the global population overall.

Environmental health is supported by trained experts who assess nutrition and community health, test water for heavy metals, and do research on how rising heat might change where insects are likely to spread disease. They develop laws, policies, and programs at all levels of government.

And while environmental health doesn't focus on individual impacts and footprints, there's much you can do to help. Consider protecting environmental health and safety by:

• Improving air quality. You can ride your bike, take mass transportation, or work from home instead of driving a car to and from work.
• Testing for toxins. You can test for radon gas, lead paint, or heavy metal exposure in pipes to prevent toxicity. Don't forget your cooking stove, which can be a source of indoor air pollution.
• Cooling your home. You can plant trees, install roofs designed for cooling, and make lifestyle choices (like closing off rooms or running certain appliances after dark) to limit heat impacts.
• Promoting healthy food choices. Plant gardens, shop at local farmer's markets, join a food co-op, and consider eating less meat when opting for a diet that's friendlier to environmental health.

Keep in mind that visibility helps to drive environmental health policy. Talk with your government and local businesses about investing in environmental health to ensure every neighbor has the chance to live, work, and play in a healthy and safe community.

Environmental health professionals focus on factors like industrial air pollution, water quality, healthy food access, and safe housing that impact public health. In many cases, these factors (unlike the personal risk of genetics, for example) are preventable or can be changed to improve public health and overall health equity .

Most communities in the United States are served by environmental health agencies, whether at the local and state level or through federal authorities. You can help to improve environmental health by working closely with these professionals, local businesses, and other stakeholders.

But there's much you can do personally to make lifestyle changes, like limiting plastic waste and reducing energy use, that can limit environmental health risk both for you and the planet.

Neta G, Martin L, Collman G. Advancing environmental health sciences through implementation science . Environ Health . 2022 Dec 23;21(1):136. doi:10.1186/s12940-022-00933-0. 

Centers for Disease Control and Prevention.  Sources of lead exposure .

Bevel MS, Tsai MH, Parham A, Andrzejak SE, Jones S, Moore JX. Association of Food Deserts and Food Swamps With Obesity-Related Cancer Mortality in the US . JAMA Oncol . 2023 Jul 1;9(7):909-916. doi:10.1001/jamaoncol.2023.0634. 

Hiatt RA, Beyeler N. Cancer and climate change . Lancet Oncol . 2020 Nov;21(11):e519-e527. doi: 10.1016/S1470-2045(20)30448-4. 

• American Academy of Pediatrics. New AAP policy, technical report offer advice on reducing harms from excessive noise exposures .

Jimenez MP, Elliott EG, DeVille NV, Laden F, Hart JE, Weuve J, et al .  Residential green space and cognitive function in a large cohort of middle-aged women .  JAMA Netw Open.  2022;5(4):e229306. doi:10.1001/jamanetworkopen.2022.9306

Sampath V, Shalakhti O, Veidis E, Efobi JAI, Shamji MH, Agache I, et al . Acute and chronic impacts of heat stress on planetary health . Allergy . 2023 Aug;78(8):2109-2120. doi:10.1111/all.15702. 

Department of Health and Social Services. Healthy People 2030 .

Lee JT. Review of epidemiological studies on air pollution and health effects in children . Clin Exp Pediatr. 2021 Jan;64(1):3-11. doi:10.3345/cep.2019.00843

Liu Y, Xu J, Chen D, Sun P, Ma X. The association between air pollution and preterm birth and low birth weight in Guangdong, China .  BMC Public Health . 2019;19(1):3. doi:10.1186/s12889-018-6307-7

Environmental Protection Agency. Progress Cleaning the Air and Improving People's Health .

Centers for Disease Control and Prevention. Assessing access to water and sanitation .

Centers for Disease Control and Prevention. The water people drink .

Alsan M, Goldin C. Watersheds in child mortality: the role of effective water and sewerage infrastructure, 1880–1920 .  Journal of Political Economy . 2019;127(2):586-638. doi:10.1086/700766

Center for Disease Philanthropy. Water, sanitation and hygiene .

• United Nations. Every dollar invested in water, sanitation brings four-fold return in costs .

World Health Organization. Lead poisoning .

Brown J, Acey CS, Anthonj C, Barrington DJ, Beal CD, Capone D, et al . The effects of racism, social exclusion, and discrimination on achieving universal safe water and sanitation in high-income countries. Lancet Glob Health . 2023 Apr;11(4):e606-e614. doi: 10.1016/S2214-109X(23)00006-2. 

Economic Research Service, U.S. Department of Agriculture. Access to affordable, nutritious food Is limited in “Food Deserts” .

Centers for Disease Control and Prevention. Zika virus .

World Mosquito Program. Explainer: How climate change is amplifying mosquito-borne diseases .

U.S. National Library of Medicine. The impact of globalization on infectious disease emergence and control: Exploring the consequences and opportunities: Workshop summary .

Environmental Protection Agency. Radon .

Kiefner-Burmeister A, Heilman CC. A Century of Influences on Parental Feeding in America . Curr Nutr Rep . 2023 Dec;12(4):594-602. doi: 10.1007/s13668-023-00499-4. 

Centers for Disease Control and Prevention.  What Is Health Equity?

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Healthy People.gov. Environmental Health . Office of Disease Prevention and Health Promotion.

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By Robyn Correll, MPH Correll holds a master of public health degree and has over a decade of experience working in the prevention of infectious diseases.

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Institute of Medicine (US) Committee on Using Performance Monitoring to Improve Community Health; Durch JS, Bailey LA, Stoto MA, editors. Improving Health in the Community: A Role for Performance Monitoring. Washington (DC): National Academies Press (US); 1997.

Improving Health in the Community: A Role for Performance Monitoring.

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2 Understanding Health and Its Determinants

W hat is health? Multiple definitions of health exist, ranging from a precise biomedical or physical definition such as the absence of negative biologic circumstances (altered DNA, abnormal physiologic states, abnormal anatomy, disease, disability, or death) to the broad definition of the World Health Organization: "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" (WHO, 1994). The former definition offers the advantages of easy measurement and relatively clarity of the causal connections between the medical and public health care systems and the measured outcomes. The latter definition views health more broadly but risks assigning to the "health" system full responsibility for the economic and social welfare of members of society. Neither definition explicitly takes account of how individuals experience disease. Individuals can feel ill in the absence of disease and vary dramatically in their responses to a disease. Indeed, what matters to individuals is not simply the absence of disease, disability, or death, but also their responses to symptoms or diagnoses; their capacity to participate in work, family, and community; and their sense of well-being in many spheres (e.g., physical, psychosocial, spiritual).

• A Broader Definition of Health

The successful implementation of initiatives to improve community health requires an understanding of the complex and diverse processes that produce health in communities. For both individuals and populations, health can be seen to depend not only on medical care, but also on other factors including individual behavior and genetic makeup, and social and economic conditions. The committee has adopted a broad definition of health, echoing a WHO (1986) health promotion perspective, that acknowledges multiple possible goals for the health system and underscores the important contributions to health that occur outside the formal medical care and public health systems. The committee definition allows improvement efforts to target not only the reduction of disease, disability, or death, but also an improvement in individuals' response to and perceptions of their illnesses; their functional capacity both now and in the future; and their overall sense of physical, emotional, and social well-being. The value of a broad measure thus rests in part upon the value attached to it by the population. Working within a definition of health that explicitly relies, in some measure, on community values is particularly important in a context of decision making for the allocation of limited resources.

Committee definition of health: Health is a state of well-being and the capability to function in the face of changing circumstances. Health is, therefore, a positive concept emphasizing social and personal resources as well as physical capabilities. Improving health is a shared responsibility of health care providers, public health officials, and a variety of other actors in the community who can contribute to the well-being of individuals and populations.

As Syme (1996) notes, viewing health as a biomedical construct has limited our ability to integrate processes that produce health and to address the underlying causes of disease. Death, disability, and disease incidence—ascertained by using traditional biologic or epidemiologic measures—are all important and valid indicators of the health of a population. A broader definition, however, allows efforts to measure community health to go beyond traditional public health measures, incorporating measures of functional status and general health perceptions. Communities embarking on health improvement initiatives should consider carefully their definition of health and ground their work in an evidence-based conceptual model of the determinants of health. Three arguments supporting such action are discussed below.

The origins of good health are multiple and cross-sectorial . Origins of good health include factors such as genetic makeup, environmental conditions, nutrition and exercise, access to health care, social support systems, and many others. Some of the factors, such as genetic makeup, are nearly impossible to alter whereas others are amenable to change. In addition, some of the factors influence a variety of health outcomes (e.g., on a population basis, dietary habits and education are known to influence multiple health outcomes). Careful consideration of what is known about the determinants of health highlights the tension between factors that are easily measurable now (e.g., hospitalization rates) and factors that may be equally or more important in the long run (e.g., teenagers' perception of their future) but are much more difficult to measure and monitor. Grounding community health improvement in a broad model of the determinants of health can remind communities to consider multiple and cross-sectorial influences when selecting health issues to target and when designing possible interventions.

A focus on the origins of health emphasizes the need for cross-sectorial assumptions of responsibilities . For various stakeholders to be accountable, the roles of those stakeholders in producing illness or health must be defined. A broad conceptual model of the determinants of health includes the full spectrum of possible influences on health. Such a model provides a valuable framework for communities to use as they consider the roles (and potential contributions) of the various stakeholders and thus each stakeholder's responsibility for health improvement in the community.

A focus on the origins of health creates multiple options for intervention . A conceptual model of the determinants of health can serve as the starting point for communities to identify what is known about issues they wish to address. Options for intervening can reflect the unique characteristics of the community vis-à-vis available resources, cultural norms, and target populations. Performance measures can then be developed as the basis for strategic actions.

The rationale for adopting a broad definition of health lies not only in its value to the population served by the health system and its usefulness in identifying measures of the origins of health. A broad definition of health also is appropriate for the changing nature of the "health care system," reflects the interconnectedness of health and social systems, and is consistent with current scientific evidence about how health is produced in communities (Aguirre-Molina, 1996; Warden, 1996).

Changing Nature of the "Health Care System"

Many Americans view health as a simple biomedical construct in which health is determined by the provision of health care (Lamarche, 1995). This perspective on health developed during this century, beginning in the 1930s with well-baby clinics and services for "crippled children" and expanding in the 1950s with national investments in biomedical research facilities such as the National Institutes of Health and construction and funding of hospitals through the Hill-Burton program (Guyer, 1990). With advances in medical science and increases in the number of hospitals, policymakers and health care providers became concerned about differential access to health care resources, especially for underserved and hard-to-reach populations. Poverty and geography were viewed as barriers to health care and thus to good health.

Beginning in the 1960s, programs designed to improve access to health services were created, including Medicare and Medicaid. These programs markedly reduced financial barriers for the poor and elderly, and they also ensured a supply of well-trained physicians by providing funds for medical school and residency training programs.

The biomedical model of health has fostered the development of a personal health care system centered around technologically advanced hospitals and highly trained medical specialists. However, the high cost of maintaining these resources is the subject of current public debate. In addition, questions have been raised about the overall contribution of the biomedical model to improvements in health status. Although important, health care has probably been overemphasized as a determinant of health. Of the 30-year increase in the life expectancy achieved this century, only 5 years can be attributed to health care services (Bunker et al., 1995).

The roles of the public sector in managing the health care system and in providing clinical and personal preventive care services as well as public health services are undergoing dramatic changes. Historically, public health departments have provided population-based services and, together with public hospitals and community health centers, have delivered clinical and personal preventive services to poor and uninsured populations. For many public health departments located in the South and in large metropolitan areas, the delivery of clinical and personal preventive services is a primary focus. In the late 1980s, however, the activities of public health departments were reexamined, and the Institute of Medicine (IOM, 1988) recommended a focus on three core functions—assessment, policy development, and assurance. In this framework, the direct provision of clinical and personal preventive services is only a small portion of the assurance function of public health departments. In many states, this transition is in progress. Public hospitals and community health clinics, however, remain important providers of these services.

Currently, most local public health departments do not play a significant role in assuring the quality of personal health care services that they do not purchase or provide. the quality assurance roles of state agencies have also been limited. Private-sector organizations, however, have developed complex and sophisticated quality assurance systems, often more in response to market forces than to demands of the public sector. As more public health departments become involved in quality assurance activities, providers and health plans can be expected to experience the influence of more public-sector demands via standard setting and licensure requirements as well as market forces.

The recent surge in the growth of managed care organizations has taken place in an environment that seeks to continue the delivery of high-quality clinical and personal preventive health services while constraining the costs of care. Managed care organizations are viewed as more capable of responding to the demands of third-party payers for performance and accountability than are clinicians practicing independently. Market forces, which spurred the recent growth of managed care organizations, have influenced the structure of the health care system (Rodwin, 1996). The experience of the Pacific Business Group on Health illustrates the changing relationships in the health system vis-à-vis new roles for purchasers and providers (see Box 2-1 ).

THE PACIFIC BUSINESS GROUP ON HEALTH. The experience of the Pacific Business Group on Health, a private-sector employer purchasing coalition based in the San Francisco Bay Area, demonstrates how "purchasers can shift the focus of the health care system (more...)

Interconnectedness of Health and Social Systems

It has long been recognized that the health of a community has a tremendous impact on the function of its social systems and that the condition of the social and economic systems has a significant impact on the health of all who live in a community (Patrick and Wickizer, 1995). For example, a healthy workforce is more productive, a healthy student body can master lessons more readily, and a healthy population is better able to make progress toward societal goals. Working conditions, economic well-being, school environments, the safety of neighborhoods, the educational level of residents, and a variety of other social conditions have a profound impact on health. Only recently, however, has substantial attention been devoted to understanding and acting upon the interdependence of health and social systems (Ashton and Seymour, 1988).

Health is a growing concern of employers, community-based organizations, schools, faith organizations, the media, local governmental bodies, and community residents, even though their roles are not viewed as part of the traditional domain of "health activities." As communities try to address their health issues in a comprehensive manner, all parties will have to sort out their roles and responsibilities. By reaching out to new partners in the community, traditional partners in health can ensure that all relevant sectors are engaged in efforts to improve health. A recent IOM report on primary care (IOM, 1996) also emphasizes the need for better collaboration among the diverse groups that can influence health. The Health Care and Community Services Project in Escondido, California, illustrates this kind of collaboration among diverse groups and the interconnectedness of health and social systems (see Box 2-2 ).

ESCONDIDO HEALTH CARE AND COMMUNITY SERVICES PROJECT. The Escondido Health Care and Community Services Project aims to reduce the harmful effects of alcohol and other drug use in the community of Escondido, California (population, 120,000; county population, (more...)

• A Model of the Determinants of Health

A resurgence of interest in broader definitions of health and its determinants is, in part, a response to the growing realization that investments in clinical care and personal preventive health services were not leading to commensurate gains in the health of populations (Evans and Stoddart, 1994). In the early 1970s, an ecologic or systems theory approach to understanding health and its determinants generated a multidimensional perspective. Some grouped the factors influencing health into four principal forces: (1) environment, (2) heredity, (3) lifestyles, and (4) health care services (Blum, 1981). A Canadian government white paper, often referred to as the Lalonde Report (Lalonde, 1974), brought wider attention to this "force-field" paradigm.

Initial responses tended to focus on individual behavior as the target of both responsibility and clinical and policy interventions. In the United States as well, the broadened emphasis on health promotion was aimed primarily at modifications of individual behavior that could be, and often were, undertaken as clinical and community interventions (USDHHS, 1991).

Responding, in part, to this focus on individuals largely to the exclusion of the communities in which they live. Evans and Stoddart (1994) proposed an expanded version of this model, illustrated in Figure 2-1 , that identifies both the major influences on health and well-being and the dynamic relationships among them. In developing a model that is consistent with current knowledge about the determinants of health, they identified nine components of interest:

A model of the determinants of health. Source: Reprinted from R.G. Evans and G.L. Stoddart, 1990, Producing Health, Consuming Health Care, Social Science and Medicine 31:1347–1363, with permission from Elsevier Science Ltd, Kidlington, UK.

social environment,

physical environment,

genetic endowment,

individual response (behavior and biology),

health care,

health and function,

well-being, and

prosperity.

Unlike a biomedical model that views health as the absence of disease, this dynamic framework includes functional capacity and well-being as health outcomes of interest. It also presents the behavioral and biologic responses of individuals as factors that influence health but are themselves influenced by social, physical, and genetic factors that are beyond the control of the individual. The model emphasizes general factors that affect many diseases or the health of large segments of the population, rather than specific factors accounting for small changes in health at the individual level. It takes a multidisciplinary approach, uniting biomedical sciences, public health, psychology, statistics and epidemiology, economics, sociology, education, and other disciplines. Social, environmental, economic, and genetic factors are seen as contributing to differences in health status and, therefore, as presenting opportunities to intervene. It is important to note, as Evans and Stoddart (1994) have done, that each component of the model represents complex sets of factors that can be examined in greater detail (see Evans et al., 1994).

The committee found the model proposed by Evans and Stoddart—which is referred to in this report as the field model —broad enough to encompass its vision. Although not yet widely tested, the model has been adapted for health policy and community planning in several Canadian provinces (Roos et al., 1995). Several features of the model were important to the committee. The model

• emphasizes the importance of considering the origins of health and the underlying causes of disease in individuals and populations;
• encourages explicit hypothesizing about the production of health in the community;
• underscores the interdisciplinary and multisectorial efforts often required to achieve health improvement in communities;
• makes explicit the possible trade-offs and benefits that occur across sectors; and
• encourages communities to identify possible performance and outcome measures from all of the categories.

In selecting indicators for performance monitoring, the determinants of health approach is useful in expanding the potential universe of indicators that should be considered. In addition to these practical reasons for adopting a model of the determinants of health such as that proposed by Evans and Stoddart, the field model provides an accurate representation of the complex contributions of physical environment, social environment, individual behavior, genetics, and health services to the well-being of communities.

Components of the Field Model: Some Examples

The components of the field model were discussed at the committee's second workshop. 1 the material below has been drawn from the summary of that workshop (see Appendix D ).

Social Environment and Prosperity

Among the elements of the social environment that have been linked to health are family structure, the educational system, social networks, social class, work setting, and level of prosperity.

Family structure, for example, is known to affect children's physical and mental health. On average, children in single-parent families do not do as well on measures of development, performance, and mental health as children in two-parent families. Children's relationships with their parents, social support, nurturance, and sense of self-efficacy have been shown to be related to their mental and physical health and even to their future economic productivity (Schor and Menaghan, 1995).

Education has an effect on health status separate from its influence on income. Years of formal education are strongly related to age-adjusted mortality in countries as disparate as Hungary, Norway, and England and Wales (Valkonen, 1989). Although most research is based on years of formal schooling, evidence suggests a broader relationship that includes the preschool period. An assessment at age 19 of participants in the Perry Pre-school Study, which randomized children into a Head Start-like program, showed that participation in the preschool program was correlated with better school performance, attending college, and avoiding involvement with the criminal justice system (Weikart, 1989). Critical periods for education, particularly at young ages, may prove to be important in determining health. In addition, studies show that maternal educational attainment is a key determinant of child welfare and survival (Zill and Brim, 1983).

"Social networks" is a term that refers to an individual's integration into a self-defined community and the degree of connectedness to other individuals and to institutions. There is a strong inverse correlation between the number and frequency of close contacts and mortality from all causes, with odds ratios of 2:1 or higher and a clear "dose-response" relationship (Berkman and Syme, 1979). Other aspects of physical and mental functioning also appear to be influenced by the quantity and quality of social connections (Seaman, 1996). Although it is possible to see the impact of social networks on health, the pathways responsible for those effects are not yet known.

Social class is another well-described determinant of health, independent of income. Major studies have been done in Britain, where social class is defined more explicitly than in the United States. In the Whitehall study of British civil servants, Marmot and colleagues (1987) demonstrated a clear relationship between social class (based on job classification) and mortality. The relationship persists throughout the social hierarchy and is unchanged after adjusting for income and smoking. The effect of social class may raise uncomfortable issues in the United States but is important to consider in dealing with issues of health and equity.

The health effects of work-related factors are seen in studies of job decision latitude, autonomy, and cardiovascular mortality (Karasek and Theorell, 1990). Involuntary unemployment negatively affects both mental and physical health. Economic prosperity is also correlated with better health. Throughout history, the poor have, on average, died at younger ages than the rich. The relationship between prosperity and health holds across the economic spectrum. For every decile, quintile, or quartile of income, from lowest to highest, there is a decline in overall age-adjusted mortality. In international comparisons by the Organization for Economic Cooperation and Development, the difference in income between the highest and lowest deciles of income shows a stronger relationship with overall mortality rates than does median income (Wilkinson, 1992, 1994).

Physical Environment

The physical environment has long been recognized as an important determinant of health. The public health movement of 1840–1870 emphasized environmental changes as a successful strategy for reducing the epidemic rates of infectious diseases, which flourished in the overcrowded housing with poor sanitation in industrial cities in Europe and North America (Ashton and Seymour, 1988).

The physical environment affects health and disease in diverse ways. Examples include exposures to toxic substances, which can produce disorders such as lung disease or cancers; safety at home and work, which influences injury rates; the design of vehicles and roadways, which can alter crash survival rates; poor housing conditions and overcrowding, which can increase the likelihood of violence, transmission of infectious diseases, and mental health problems; and urban-rural differences in cancer rates.

Genetic Endowment

The contribution of genetic makeup to the health of an individual is a new and emerging area of scientific inquiry. As scientific knowledge about genetics increases, this component of the field model is likely to become increasingly important.

For the most part, genetic factors are currently understood as contributing to a greater or lesser risk for health outcomes, rather than determining them with certainty. One area of particular interest is the link seen between genetics and behavior. Studies of twins separated at birth demonstrate a high concordance rate in alcoholism, schizophrenia, and affective disorders (Baird, 1994). Even so-called voluntary behaviors such as smoking and eating habits may be subject to genetic predispositions (e.g., Carmelli et al., 1992; de Castro, 1993; Falciglia and Norton, 1994). Health behaviors are complex, and the influences that determine them are likely to be extremely complex.

Genetic factors also interact with social and environmental factors to influence health and disease. It will be important to understand these interactions to learn why certain individuals with similar environmental exposures develop diseases whereas others do not (e.g., why most smokers do not develop lung cancer).

In the field model framework, behavior is seen as a response to other factors and can be treated as an intermediate determinant of health. Rather than a voluntary act only amenable to direct intervention, behavior is shaped by multiple forces, particularly the social and physical environments and genetic endowment. At the same time, behavior change remains a goal. Behaviors related to health care, such as adherence to treatment regimens, are influenced by these forces as are behaviors directly influencing health, such as smoking.

Health Care

Health care is an essential determinant of health. In the United States, however, its contribution has probably been over-emphasized. As noted above, about 5 years of the 30-year increase in life expectancy achieved in this century can be attributed to health care (Bunker et al., 1995). The greatest share of this gain can be attributed to diagnosis and treatment of coronary heart disease, which contributes 1 to 2 of these additional years of life.

Linking the Determinants

The committee was impressed by several implications of the field model's theoretical perspective. First, the model clearly reinforces the interrelatedness of many factors. Health outcomes are the product of complex interactions of factors rather than of individual factors operating in isolation. Indeed, these interactions are probably as important as the actions of any single factor. Currently incomplete, however, are descriptions of mechanisms underlying the linkages among the various determinants and full characterizations of the interactions among factors. The committee encourages the continued research needed to gain a better understanding of these mechanisms.

Second, not all of the determinants, viewed as causes, act simultaneously. The effects of some determinants, in fact, may be necessary antecedents to others, and some may have their primary influence by modifying the effects of others. Some may also differ in their relationship to health according to when they are present in the life cycle. Evidence suggests that there are certain times in the human life cycle that are critical for future health and well-being. During infancy and early childhood, crucial neurologic, cognitive, and psychosocial patterns are established (Carnegie Task Force on Meeting the Needs of Young Children, 1994; Entwisle, 1995). Experiences in childhood and adolescence may also have a critical influence on adult health risk factors such as weight and smoking (Dietz, 1994; IOM, 1994).

Another Perspective

Patrick and Wickizer (1995) have extended the field model framework by focusing on factors in the social and physical environments that operate at the community rather than the individual level. These two components are seen as affected by cultural, political, policy, and economic systems. In turn, they influence elements such as community response, activation, and social support, and ultimately community outcomes including social behaviors, community health, and quality of life. For example, establishing a smoke-free workplace policy exerts an influence on exposure to tobacco smoke separate from the smoking practices of individuals. This perspective points both to the influence of community-level factors and to the opportunities for community-level interventions.

• Interventions to Improve Health

Many factors can influence the impact of interventions to improve health. It is possible to target various determinants of health to produce change at an individual level, a community level, or both. All aspects of each broad determinant of health are not equally amenable to intervention, however. For example, the social environment of isolated senior citizens can be improved by increasing contact with others, but their genetic makeup is not amenable to change.

Time frames for measuring health changes vary widely, from days to decades. Some successful interventions will produce observable results within a year or two, but others may be followed by long latency periods before significant changes in health status can be observed. The impact of an intervention may also be influenced by when it reaches an individual because, as noted above, there appear to be "critical periods" in human development. Certain interventions in childhood may have long-delayed yet long-lasting results. In addition, the population effects of interventions are also important to consider. Small changes at the individual level may have important ramifications when applied to a whole community (Rose, 1992).

The traditional targets for intervention have been specific diseases or behaviors, and categorical funding streams for both research and the delivery of services encourage this approach. The field model of the determinants of health encourages consideration of a wider array of targets. For example, if adolescents' sense of well-being can be improved by reducing their feelings of alienation and hopelessness, can unintended pregnancies, alcohol and other drug use, crime, and the school dropout rate all be reduced? A multidimensional approach would be required, focusing on education, social and community involvement, family preservation, and improved social networks for teens and their parents. Community-level interventions might include after-school programs, athletics (e.g., midnight basketball), and church-based programs.

Whether focused on individuals or the community as a whole, health improvement efforts should be targeted at specific causal pathways or should employ interventions that have been proven effective. There is an obvious tension between what is now known and what we need to know to improve health. For example, the biologic pathways through which poverty or low social class influence health have not been adequately elucidated. A tension also exists between what is now measurable with valid and reliable indicators and what is not measurable, but may be important.

The multidimensional approach may be unfamiliar to health professionals because it is new and relies on partnerships with people from fields beyond those traditionally encompassed by a medical model. It is, however, consistent with the field model and may provide expanded opportunities for performance monitoring and improving the community's health.

• Implications for Communities

An examination of the field model points to the importance of considering both individual- and community-level data. Performance monitoring should include measures of inputs, process, and outcomes for health and health improvement activities. It may prove useful to monitor some key determinants, regardless of whether they are amenable to change at the local level, so that communities can understand the range of important factors. In addition, qualitative data may contribute important information about community needs. For example, information on social support, perceived barriers to service utilization, and attitudes toward the community and its resources are all relevant to performance monitoring and can be obtained from community surveys.

Performance monitoring provides an opportunity for a community to define and articulate expectations for organizations' contributions to the population's health. Although organizations might disagree with the appropriateness of the expectations, a useful dialogue may ensue. Communities may want to focus special attention on expectations regarding managed care organizations (MCOs) and the business sector. MCOs, for example, have generally defined "community" as their enrollees and not considered the entire community or public health as their area of concern. A community expectation that the health of the entire local population is part of an MCO's corporate and social responsibility could lead to their broader involvement in public health activities. Businesses, including MCOs, that have strong ties with a city or region may have a history of interest in local health issues. As corporations expand to multiple regions, however, they may require added encouragement to become involved and accountable in the local communities where they have a presence.

• Conclusions

Contributing to the interest in health improvement and performance monitoring is a wider recognition that health embraces well-being as well as the absence of illness. For both individuals and populations, health can be seen to depend not only on medical care but also on other factors, including individual behavior and genetic makeup, and social and economic conditions for individuals and communities. The field model, as described by Evans and Stoddart (1994), presents these multiple determinants of health in a dynamic relationship. The model's feedback loops link social environment, physical environment, genetic endowment, an individual's behavioral and biologic responses, health care, disease, health and function, well-being, and prosperity. The committee found this model to be an effective basis for its work.

This multidimensional perspective reinforces the value of public health's traditional emphasis on a population-based approach to health issues. It also provides a basis for looking to segments of the community beyond those traditionally associated with health to address factors affecting health and well-being. Some of the additional parties who can be brought to the table as interested stakeholders and accountable partners include, among many others, schools, employers, community-based organizations, the media, foundations, and public safety agencies. A performance monitoring program can promote the articulation of roles and responsibilities among these participants.

The committee has concluded that entities engaged in performance monitoring for community health improvement should

• adopt a broad definition of health;
• adopt a comprehensive and conceptual model of the way in which health is produced within the community; the field model, as elaborated by Evans and Stoddart, is a good starting point; and
• develop a concrete and specific hypothesis of how the multiple sectors of the community and individual stakeholders in each sector can contribute to the solution of a health problem.

In addition, federal agencies and foundations should provide support for further research on the determinants of health to clarify pathways, to develop reliable and valid measures useful for performance monitoring related to these pathways, and to identify community programs and clinical and public health interventions that are successful in addressing the underlying causes of ill health in communities.

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The workshop discussion was based on a presentation by Jonathan Fielding.

• Cite this Page Institute of Medicine (US) Committee on Using Performance Monitoring to Improve Community Health; Durch JS, Bailey LA, Stoto MA, editors. Improving Health in the Community: A Role for Performance Monitoring. Washington (DC): National Academies Press (US); 1997. 2, Understanding Health and Its Determinants.
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January 28, 2011

The Link between the Environment and Our Health

Would people care more about the environment if they had a better understanding of how it affects them personally?

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Dear EarthTalk : Aren’t environmental issues primarily about health? Detractors like to trivialize environmentalists as “tree huggers,” but the bottom line is that pollution makes us sick, right? Wouldn’t people care more if they had a better understanding of that?— Tim Douglas, Stowe, Vt. No doubt many of the ways we harm our environment come back to haunt us in the form of sickness and death. The realization that the pesticide-laced foods we eat, the smokestack-befouled air we breathe and the petrochemical-based products we use negatively affect our quality of life is a big part of the reason so many people have “gone green” in recent years. Just following the news is enough to green anyone. Scientific American reported in 2009 that a joint U.S./Swedish study looking into the effects of household contaminants discovered that children who live in homes with vinyl floors—which can emit hazardous chemicals called phthalates—are twice as likely to develop signs of autism as kids in other homes. Other studies have shown that women exposed to high levels of polybrominated diphenyl ether (PBDE) flame retardants common in cushions, carpet padding and mattresses—97 percent of us have detectable levels of these chemicals in our bloodstreams—are more likely to have trouble getting pregnant and suffer from other fertility issues as a result. Cheaply produced drywall made in China can emit so much sulfur gas that it not only corrodes electrical wiring but also causes breathing problems, bloody noses and headaches for building occupants. The list goes on and on.... But perhaps trumping all of these examples is the potential disastrous health effects of global warming. Carbon dioxide emissions may not be directly responsible for health problems at or near their point of release, but in aggregate they can cause lots of distress. According to the Center for Health and the Global Environment at Harvard Medical School, climate change over the coming decades is likely to increase rates of allergies, asthma, heart disease and cancer, among other illnesses. Also, it is quite likely that, as global temperature rises, diseases that were previously found only in warmer areas of the world may show up increasingly in other, previously cooler areas, where people have not yet developed natural defenses against them. And the loss of rain forest that accompanies increases in temperature means less access to undiscovered medicines and degradation of the environment’s ability to sustain our species. Given the link between environmental problems and human health, more of us are realizing that what may seem like exorbitant up-front costs for environmental clean-up may well pay us dividends in the end when we see our overall health care costs go down and our loved ones living longer, healthier lives. To help bridge the understanding gap between environmental problems and human health, the nonprofit Environmental Health Sciences offers the free website, Environmental Health News , which features daily reports on research showing how man-made environmental problems correspond to a wide range of individual and public health problems. Even your local TV station or newspaper likely carries an occasional story about the health effects of environmental pollution. We don’t have to look very hard to find examples of environmental neglect leading to human suffering. But with newfound public awareness and the commitment of younger generations to a cleaner future, we are moving in a good direction. CONTACTS : Harvard Medical School Center for Health and the Global Environment, http://chge.med.harvard.edu ; Environmental Health News , www.environmentalhealthnews.org .

SEND YOUR ENVIRONMENTAL QUESTIONS TO: EarthTalk® , c/o E – The Environmental Magazine , P.O. Box 5098, Westport, CT 06881; [email protected] . E is a nonprofit publication. Subscribe : www.emagazine.com/subscribe ; Request a Free Trial Issue : www.emagazine.com/trial .

Human Impacts on the Environment

Humans impact the physical environment in many ways: overpopulation, pollution, burning fossil fuels, and deforestation. Changes like these have triggered climate change, soil erosion, poor air quality, and undrinkable water. These negative impacts can affect human behavior and can prompt mass migrations or battles over clean water.

Help your students understand the impact humans have on the physical environment with these classroom resources.

Earth Science, Geology, Geography, Physical Geography