1. Ecosystem Health Restoring the Health in Health Care Healing the Planet - PGS John Howard MD, FRCPC Professor of Paediatrics and Medicine Schulich School of Medicine University of Western Ontario Chair, Canadian Association of Physicians For the Environment

2. Objectives To define Ecosystem Health from a health care perspective To look at some of our societal beliefs from “outside the box” To look how the health of the environment is being eclipsed by “individual human health” Describe an Ecosystem Health model for Ontario, and elsewhere

3. What is Ecosystem Health??

4. What does Ecosystem Health mean to me? The UWO Definition How can it form the basis for medical education and for health care?

5. The Evolution of the Doctor-Patient relationship 1) Traditional Medical Model 2) Patient-Centered Model 3) Ecosystem Health Model

6. Traditional Medical Model Where we were Patient Disease 1.What is the disease? 2.How do I fix it? HEALTH

7. Patient-Centered Model where we are trying to be Patient Disease Illness Context 1.What is the disease? 2.How do I fix it? 3.What is my patient's unique illness?? 4.How do I help my patient? HEALTH

8. Ecosystem Health The health of the “context” and the interaction of the “context” with human health - the physical, social, economic and political environment

9. Ecosystem Health Model Where we want to go Patient Disease Illness Home Community Region World 1.What is the disease? 2.How do I fix it? 3.What is my patient's unique illness?? 4.How do I help my patient? 5.Why is this patient here? 6.What can I do to prevent others from having the same illness? HEALTH

10. Ecosystem Health - Mission To train professionals to work with other professions to create a healthier world. – Transdisciplinary thinking

11. Ecosystem Health Model Patient Disease Illness Home Community Region World Something we care about 1.What is the problem? 2.How do I fix it? 3.What are the unique cultural needs? 4.How do I meet those needs? 5.Why did this problem occur? 6.What can I do to prevent similar problems HEALTH

12. So what? Does it make one think any differently? Some thoughts about health, health care and the practice of medicine in Canada

13. What is Health?

14. Health PhysicalMental Nutritional Community Personal Health EnvironmentalSocial PoliticalEconomic SpiritualMoral Societal Health Ecosystem Health

15. Spiritual Health - Aboriginal The Earth is our Mother, the female giver of Life to all her children, some of whom are human beings. Decisions must respect 7 generations of our ancestors and 7 generations of our children to come

16. Moral Health?

17. $150B$/yr for 15 years would provide safe water and effective sanitation to every person in the world - UNEP Bailout US $833B EEC $2,000B

18. Moral Health 6.450 Provide safe clean water 19.1150.5 TOTAL 0.65 Eliminate illiteracy 1.310.5 Stabilize population 1.915 Provide health care 2.419 Eliminate starvation and malnourishment 2.721 Provide shelter 3.830 Retire developing nation’s debt Percent of current military spending Annual cost in billion dollars Cost of global human need programs

19. A Modest Proposal: Alternative Security Security is better achieved by trying to establish equity rather than dominating

21. 3-4 kilometers per litre Wilderness Capabilities EH Health Care System?

22. Is our society’s attitude to the environment morally healthy? Let’s describe Health in its widest sense: include moral health and spiritual health!!

23. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

24. Revelations Many/all diseases have an ecosystem health component? We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

25. Crohn’s Disease

27. Other Diseases Rheumatoid Arthritis – 2% of the population Asthma – 30% of SW Ontario children on puffers at some point in their lives Diabetes – massive increase in Type II Diabetes Mellitus –1997 – 5.8% of US population diagnosed Is it the environment?? Immunologic disruptors??

28. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care! Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

30. 37%/5years 7.4%/year

31. Sickness Land, Air, Water!!

32. Where are we going? 2010 2016 2044 = 100% Year % of Provincial Budget

33. Health Care NOT a determinant of health “The majority of the health care dollar is spent in the last 6 months of one’s life” - 1993 Average health expenditures on people who are in their last year of life is between 50 and 100 times more than expenditures on those who are not. - Health Canada -2005

34. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

35. Uncertainty not part of our vocabulary Obsession with certainty –Double blind trials, critical appraisal –Evidenced based medicine The present scientific method is about reductionism –Inclusion, exclusion criteria, controls

36. Uncertainty - not part of our vocabulary EH - Can’t find appropriate controls, system has many interactions, etc. –Don’t study it –Absence of data implies no effect Complexity ≡ Uncertainty Complexity ≠ Complicated

37. Which is the More Important Question? Have pesticides used on land been proven to lead to illness in humans? Might pesticides cause illness in humans? Or both!

38. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

39. Systems Thinking The Perspective for the 21 st Century

40. 10/10/201540 Need to study big issues!!

41. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

42. Things can be done Smoking – a once-attractive pastime Automobile take-back So much potential we can be/are opinion leaders

43. 3-4 kilometers per litre Wilderness Capabilities EH Health Care Institution? Advocate health

44. Revelations Many/all diseases have a significant Ecosystem Health component We need to put less money in sickness care Uncertainty is more important than certainty Bigger is better! Things can be done! Accountability should be replaced by responsibility

45. Accountability Meet minimal standards –Health care: Single use instruments Insurance issues, legal departments –Much $$ spent on non-medical issues Limits boundaries One-way accountability Focus on practices

46. Responsibility Striving for excellence –Health Care-responsible for health Health in its greatest sense –Single use recyclable /Multiple use –Decisions to improve health –Bidirectional Public has a responsibility – behaviour, resources –Focus on Values

48. Learning Knowledge Skills Attitudes (perspectives)

49. Learning in University Knowledge Skills Attitudes (perspectives)

50. Global/Ecosystem Health Learning Knowledge Skills Attitudes (perspectives)

51. How might Ecosystem Health be the basis for a Health Care System?

53. A balance

54. Ecosystem Health Model for Health Care Patient Disease Illness Home Community Region World 1.What is the disease? 2.How do I fix it? 3.What is my patient's unique illness?? 4.How do I help my patient? 5.Why is this patient here? 6.What can I do to prevent others from having the same illness? People es s 1.What are the regional diseases? 2.How do we fix them? 3.What are the unique regional problems?? 4.How do we best help our people? 5.Why are the diseases happening? 6.What can we do to prevent the diseases/ improve health? HEALTH Political EnvironmentalSocial Economic Ecosystem Health Model

55. EH Health Care System Disease → Disease + Health Focus on the Population/Region Consider health in its broadest sense Responsibility for health

56. Is there a crisis? If so what is the crisis?

57. Sickness Health