Tag: health

Why do we do what we do? The poverty of individualist explanations

Why do we do what we do?  The poverty of individualist explanations.

 

Photo by Sofiya Levchenko on Unsplash

We all like cake don’t we? Oh, and beer…and yes wine…and…and

 

In common talk around health issues, we hear and read a great deal about ‘taking individual responsibility for health’ or the need for ‘helping people to make better choices’  and we hear explanations for ill health based on people’s choice of unhealthy lifestyles. Papers like the Daily Mail like to focus unhealthy working class ‘chav’ cultures in a bid to promote outrage and to garner support to reduce the Welfare State. Every New Year, gym membership rises, dry January is embarked upon and resolutions to quit smoking are made. Failure often follows. The UK population is getting fatter, it drinks excessively and takes little exercise. We are also a nation consuming antidepressants as if they were smarties. Some individuals of course are ‘paragons of virtue’ in terms of health and the question is asked “if they can do it, why don’t the rest of us?”  Often this is framed within personal success stories as “I did it, so you can too (you fat lazy bastard)”. Celebrities are often promoted as role models for a “leaner, fitter, healthier you”.

Most people probably know that eating better and taking more exercise is better for health. So why do we see continuing patterns of chronic ill health, patterns which show social class differences, i.e. the  ‘social gradient’, and unequal health outcomes. Those in the lower socio economic groups die younger, experience more chronic illness and have fewer disability free years.  Is it really all down to individual moral failure? Why don’t millions of us get up off our fat arses, do something positive and take responsibility for health? Why don’t we as a population exercise our agency to act for better health? After all, we are all free autonomous people able to choose courses of action.

The complete freedom to think and act may be more complicated than adherents of the ‘autonomous sovereign individual’ may have us believe. The model of the ‘free sovereign individual’, so beloved by libertarians, neoliberals and most hues of conservatism in their political stances, is a flawed and incomplete model of human behaviour. It is a model of human behaviour that arose in Enlightenment modernity, and results in the creation of ‘homo economicus’, the free instrumentally rational being, who weighs up the pros and cons of action independently of social or cultural influences or internal psychological drivers,  and is 100% result responsible therefore for the consequences of their action.

Max Weber introduced the word ‘Verstehen’ (German for understanding, perceiving, knowing) to describe the sociologists’ attempt to grasp both the intent and context of human action. While the ‘man of modernity’ was increasingly using instrumental rationality to guide action, Weber described 4 ‘types’ of social action:

 

  1. Zweckrational – means/ends rationality
  2. Wertrational – values based rationality
  3. Affective action – emotion based
  4. Traditional action – based in custom and practice.

 

Today, many ignore or forget all but ‘zweckrational’, assuming that is our only way of thinking. We know from experience however, that we choose courses of action not because they are always meeting a certain goal, but because of a mixture of all 4 types of reasoned action. Many also think about these types (if at all) as existing independently of society. Weber’s insight was to link these types to changing social conditions. He argued that modern societies differed from those of the past because of the shift to zweckrational thinking rooted in the growth of bureaucracy and industrialism. This might explain why today, in bureaucratised, industrialised societies, that instrumental, technical, means ends thinking came to dominate. The error for many is that the ‘is’ of the dominance of zweckrational becomes the ‘ought’, the only way to think and it becomes the assumed method of human thinking. I suggest that those trained in scientific, technical and logical (means-ends) occupations are apt to think using ‘zweckrational’ but assume that is how everybody else does and ought to think. They then become one dimensional in their own thoughts, unable to grasp the complexity of human decision making.

The social theorist Margaret Archer also describes this ‘man of modernity’ as “a being whose fundamental constitution owes nothing to society” (2000 p 51) and (following Weber) who is increasingly driven by instrumental rationality or ‘means-ends’ thinking. This is the ‘ready-made man’ who turns up out of nowhere to impose his own order on the world and applies rational thought to social concerns. It is a view of humanity that believes that our ‘self’, our individuality,  exists totally separate from society, that it is not constituted at all by society or culture. The free acting self is an independent of society and culture free thinking and rational being. We will hear echoes of this man’s voice when we hear such statements as “only the individual should and can take responsibility for health”, “there is no such thing as society, just individuals and families” and “eat less  – move more” injunctions to reduce weight. Any idea of social structure or social forces is completely denied. In this view there are no social mechanisms operating ‘behind our backs’ that might be guiding free choices.

 

This model of the self assumes the primacy of agency devoid of social structure or cultural or language contexts. It not only assumes the primacy of agency, but elevates it into a core aspect of the political project (neoliberalism) to reduce any action on poverty or welfare beyond that of individuals, families and charities. If there is no society, then there is nothing society can or should do.

 

Those who adhere to this model might think that obese and overweight people merely freely choose to eat more than they need, that their inability to lose weight is down only to their weak moral character and lack of will power. The obese should “just say no” to a second pork pie. Against this I suggest that they eat and move within the structures and cultures of the ‘obesogenic environment’ (Foresight 2007) and within cultural practices around food that becomes aspects of who they are, that they build into their self-concept. Veganism for example has been seen as the preserve of a slightly effete (?) minority and for many men especially, just cannot be built into their own notions of self as ‘red meat eating males’. Their self-concept as a man excludes this food choice as viable. They are of course free to act as a vegan but the structural and cultural context militates against men many doing so. Some men will be able to draw upon their material, psychological, biological, social, cultural, spatial and symbolic assets to exercise their agency to become vegan. Many others will not be able to exercise the same degree of freedom to do so.

 

There is not the space to fully explore this idea of the ‘free, pre-existing, independent from society’ view of self, other than to suggest that extricating human agency and the ‘self’ completely out of the effects of language, culture and social structure is erroneous. I emphasise however, the pernicious persistence of this idea in current culture, politics and health policy as it underpins much understanding of, and pronouncements about, human behaviour towards health.

 

I also suggest that those whose knowledge is non-existent, or superficially grounded, in philosophy, the humanities or social sciences cannot exercise their agency to begin to understand this argument. Their ‘ways of knowing’ and sense of self  is in violent opposition to it. They will be so embedded in certain social structures and cultural assumptions and values that the self they experience is unable to grasp the concepts. They will read the words but will feel an instant visceral hatred of the challenge to sovereign individuality because it shakes the very foundations of who they think they are and the basis for success and failure. Current ideal types would be Boris Johnson, Peter Thiel the PayPal billionaire, Rupert Murdoch, Donald Trump, many in Silicon Valley and the alt-right. In fact most of the powerful world leaders would fall into this category including Putin, Erdogan and Modi. They all feature varying degrees of narcissism and the assumptions of what Graham Scambler calls the ‘Greedy Bastards’.

 

Part of the answer to understating why we do what we do,  will be found by exercising our sociological imaginations to gain a fuller understanding of human behaviour. We need to think beyond the action of an individual, to consider the wider actions of society and culture that provides the context for individual choices at this point in history..

Take the choice to eat insects. In the UK we are free to do so. We could exercise our ‘free agency’ as sovereign individuals. There is no biological reason why we don’t. There is no legal barrier to doing so. There is no trade barrier, tariffs or taxes in importing insects as food. What prevents us eating insects is a combination of cultural barriers with a lack of social institutions that values eating insects, no social institutions providing access to insects. Psychologically we might think that the eating of insects is not part of our ‘self-concept’, there is no social learning going on because no one is doing it, the mental short cuts bypass rational appraisal and go straight to the ‘yuk’ factor. We live in an obesogenic environment and not an ‘insectivorous’ environment.

Why do fat people eat pork pies? Why don’t thin people eat insects?

Graham Scambler in wishing to establish a theory of agency in sociology argues:

 

Humans…are simultaneously the products of biological, psychological and social mechanisms while retaining their agency…socially structured without being structurally determined

 

I think this means that if you want to know why some people can resist eating the pork pie and most in the UK resist eating insects, you have to think holistically rather than individualistically. You have to avoid the temptation to be reductionist and instead think ‘systems’.

A biologist would focus on physiological processes and raise the importance of body chemicals such as leptin, dopamine, serotonin and endorphins in stimulating behaviour. They might acknowledge the physiological role of sugar and processed carbohydrates in providing very satisfying, but unhealthy, eating habits. This is perhaps the first hurdle that ‘will power’ has to overcome.  ‘Willpower’ is of course the ‘go to’ mechanism for those with individualist understandings.

A psychologist might explain eating patterns from a variety of perspectives: cognitive psychology might outline the role of mental short cuts that bypass rational thinking; behavioural psychology emphasising the conditioned nature of responses; social psychology which asks us to consider the power of social learning upon choices and psychodynamic psychology which would raise deep seated emotions as drivers for behaviour e.g. food playing the ‘comfort’ role. All have explanations that down play the power of rationality.  Key concepts within psychology which could be linked to why we eat as we do include:

  • Self-Efficacy.
  • Body Image.
  • Locus of Control.
  • ‘What the hell’ effects.
  • Future Discounting.
  • Classical/Operant Conditioning.
  • System 1 and System 2 thinking.
  • Self and self-awareness.
  • Adult, Child, Parent Ego States.

 

Both biology and psychology examine the individual body and mind. They seek explanations for human agency within ourselves. For some people, that is enough. Yet both disciplines cast huge doubt on the idea of ‘free thinking sovereign individuals’ who use rational thought, and the exercise of sheer willpower in achieving their aims.

If you have not eaten for three or four hours, and you pass a shop selling freshly baked bread or pasties, or foodstuffs you very much enjoy, your will power to lose weight is severely challenged first by your biology as the body reacts to sight and smell of delicious food and then by your psychology as the ‘what the hell effect’ kicks in supported by ‘future discounting’. Your future self as a slim lean athlete is discounted by your immediate self’s need for food.  As you go through your day you are immersed in social and cultural invitations and opportunities to eat and to eat too much. Against this is will power, unless you can actively design your social and cultural environment every single day to support will power, you may well crack. Do you have the material, psychological, social, cultural, spatial and symbolic assets to do this day after day after day for years? For the rest of your life? Some also have poor biological health assets in this regard as in utero processes may well have pre-set a certain weight for you that your body will always want to get to.

We are not completely free autonomous agents beloved of neoliberal ideology. Our lives are highly structured, but not determined. We are the result of a complex interplay of our biology, our psychology and the social. Underpinning much of the common discourse in our media is the idea of the ‘liberal human self’, and failures to live healthy lifestyles are to be found in the individual. This belief, and it is a belief not a scientific fact, often leads to a ‘Moral Underclass Discourse’ (MUD) to explain health inequalities. The MUD focuses on cultural and behavioural explanations, rather than sociological, for health inequalities. It is a discourse that leads easily to victim blaming.

We need to think a little more critically about this explanation, particularly as it has a great deal of political and social force in terms of policies we design to tackle health. We need to bring the social (structure) into the individual (agency). We need to ask to what degree are we free agents who can take 100% responsibility for our lives, we need to examine what social structures exist in which that agency operates.

Margaret Archer has published a series of books on this central problem of structure and agency, i.e. the relationship between our personal actions as free agents and the societies and social structures we are born into.

We know that smoking is linked to illness and disease, we also know there are patterns to smoking which show prevalence is not spread equally across class or age. If we want to more fully understand smoking behaviour we require not only the sociological imagination but also why people as ‘free agents’ continue to smoke despite knowing the consequences. The answer is of course complex, situated in and mediated by a matrix of the biological, social and psychological. Smoking occurs in a social context in which people are enabled or constrained in their behaviours by the structures of society and mediated by their and others’ ‘reflexive deliberations’ and to a degree, their biology (the ‘substance’ (nicotine) theory of addiction).

Archer’s theory suggests that our individual actions are predated by the existence of social structure of, for example, class relationships. Class structure, and the culture associated with it, are transmitted to individuals. In smoking’s case, the culture of smoking was once widespread across all social classes and therefore to take up the habit was not to be seen as a social pariah. Quite the opposite. George Orwell in both ‘Homage to Catalonia’ and ‘The Road to Wigan Pier’ describes vividly the valued place of tobacco in people’s lives. Today however, smoking has a class characteristic to it, the middle classes apparently are more open to health warnings than those lower on the social scale. This ‘predates’ any individual coming into puberty today. The ‘cachet’ associated with smoking, or its status as a rite of passage, has to be factored in to understanding why some people shun the habit while others embrace it.

Archer however does not wish to over emphasise how such social structures affect action, rather there needs to be a focus on how agents respond and act to those circumstances. There is a causal efficacy to agency, we are not automatons responding to class structures or obesogenic environments. We can make choices to act in certain ways to not buy the pork pie.  We do so by having internal conversations which are mediated by our ‘mode of reflexivity’ which at this point in history is particularly salient.

You and I are confronted in our daily lives by social circumstances, and we have a choice of action. We bring to that choice of action our own priorities, our ‘projects and concerns’. What we then do is mediated by the type of internal conversation, or reflexive deliberation,  we have. Archer’s thesis is that in the past social structures were such that little self reflexivity occurred. We ‘knew our place’, we knew what our role was and what status we had.  However, as societies modernised, cultures and structures confronting us are far more open to change and critique, and are so by the actions of the people involved. Women for example, no longer took for granted that their place was to rear children and to engage in domestic labour. They thought about the franchise and employment and some decided to act differently to ‘break the mould’. Why do some act to challenge social structure and why do others conform and thus replicate social structures?

“The subjective powers of reflexivity mediate the role that objective structural or cultural powers play in influencing social action and are thus indispensable to explaining social outcomes’ (Archer, 2007: 5).

In other words, your inner voice is confronted by the facts of the obesogenic environment or of social class or of gender relationships in the work place, but that fact can be acted upon so that action can for example be fatalistic towards that circumstance or instead might confront it in an attempt to overcome any perceived or actual disadvantage.

Agency is necessarily contextualized, it occurs in a context of social structure and culture. That is the objective fact the people confront every day.

Archer’s (1995, 2003, 2007) way of articulating this is in terms of a three-stage model.

  • Structural and cultural properties objectivelyshape the situations that people confront involuntarily; the structural and cultural possess powers of constraint and enablement in relation to
  • People’s own constellations of concerns, as they define them.
  • Courses of action are produced through the reflexive deliberationsof subjects who subjectively determine their practical projects in relation to their objective

 

Think about the social structures that produce, advertise and market and then distribute food  – how that this currently characterised by the industrial production of delicious, tasty and cheap foodstuffs packed with sugar, salt and calories. The objective cultural context might include aversion to walking and cycling as we perceive these as impractical, dangerous or too slow.  Think about the culture of eating food and the sociability that surrounds certain foodstuffs. What currently does wine play in the cultural life of many women and beer for men? These objective conditions provide ‘enablements’ to eating easily too many calories. It is made easy to do so. What constraints do we have in eating too much? Well, against the above we have health injunctions not to do so, we have body images that emphasise thinness with attractiveness. If the various constraints to eating too much are not as strong as the enablements, then the individual has to work hard  on clearly identifying their ‘concerns’ – one of which is to lose weight. This has to be turned into a project, something that they focus on every day to combat the many opportunities to fail at achieving the goal. People will tell themselves if the daily project of losing weight is achievable given the reality of their working and social lives. They will draw upon their health assets to help them do so. If their health assets are very poor across the board success is not impossible (they are after all free agents) but it will be harder.

 

Agency operates within certain social and cultural contexts, so consider how agency operated by an A list actress and a struggling in debt mother. What social ‘forces’ propelled them into two very different circumstances and how much is down to personal achievement, luck or circumstance? Consider they now give birth to daughters. What are the chances of either girl using personal agency to radically alter their circumstances. Yes, it happens (e.g. Oprah Winfrey) but who will have the easier path?

 

The following table are ideal types to illustrate just some of complexity of the interplay between biology, psychology and sociology in understanding health choices and health outcomes. These factors are not be thought of as a simple cause effect relationship, there are feedback loops and emergent properties from the whole. Nothing is predestined, all is possible. The list is not exhaustive either. There may be other confounding variables that will change outcomes. The actress may develop a cocaine habit, Vicky may become an ‘Educated Rita’.

 

Asset A list celebrity Actress Vicky Pollard “yeah but no”
Biological Ectomorph

Non variant FTO gene

No chronic illnesses

Endomorph

Variant FTO gene

Diabetic

Psychological High self-efficacy

High self esteem

High body image (body reality matches body ideal

Internal locus of control

Emotional and sexual support

Depression free

Positive outlook

Low self-efficacy

Low self esteem

Poor body image (body reality far from body ideal)

External locus of control

Emotional and sexual abuse

Bouts of depression

Suicidal ideation

Social Similar looking thin peer group

Network effect positive

Social support for domestic needs

Child care easily affordable

Food prepared by nutritionist

Supportive parents and spouse

Socially popular

Wealthy successful peers

The 0.01% Global elite

Private School and Drama school paid by parents

Similar looking fat peer group

Network effect negative

No social support for domestic needs

Child care expensive

Food prepared by Greggs

Parents both dead, absent partner

Social pariah

Poor just about managing peers

The local Precariat

Left at 16 with no qualifications.

Cultural Ambitious

Health high priority

Non smoker

Gym membership

Non violent

Survivalist

Health discounted

Smoker

Daytime TV

Emotional, verbal and physical violence common/expected

Spatial Beverly Hills, Sunshine, Sea View and palm trees Concrete high rise, Rain, Industrial Units and burned cars
Symbolic ‘A’ list Chav
Material

This asset is paramount as it feeds into the others

High Net worth

 

In debt.

 

 

 

 

 

Graham Scambler, emeritus professor at UCL, has written a series of blogs based on the work of Margaret Archer. His work can be found here: http://www.grahamscambler.com/sociological-theorists-margaret-archer/.

Archer,M (1995) Realist Social Theory: The Morphogenetic Approach. Cambridge; Cambridge University Press.

Archer,M (1998)  Realism in the social sciences. In Eds Archer,M, Bhaskar,R, Collier,A, Lawson,T & Norrie,A: Critical realism: Basic Readings. London; Routledge.

Archer,M (2003) Structure, Agency and the Internal Conversation. Cambridge; Cambridge University Press.

Archer,M (2007) Making our Way Through the World. Cambridge; Cambridge University Press.

Archer,M (2012) The Reflexive Imperative in Late Modernity. Cambridge; Cambridge University Press.

Archer,M (2014) The generative mechanism re-configuring late modernity. In Ed Archer,M: Late Modernity: Trajectories Towards Morphogenetic Society. New York; Springer

 

 

 

Climate Change, Health and Capitalism

Climate Change, Health and Capitalism The debate on climate change and health in the context of Ecological public health: A necessary corrective to Costello et al’s ‘biggest global health threat’, or co-opted apologists for the neoliberal hegemony?

Abstract

The threat posed to global health by climate change has been widely discussed internationally. The United Kingdom public health community seem to have accepted this as fact and have called for urgent action on climate change, often through state interventionist mitigation strategies and the adoption of a risk discourse. Putting aside the climate change deniers’ arguments, there are critics of this position who seem to accept climate change as a fact but argue that the market and/or economic development should address the issue. Their view is that carbon reduction (mitigation) is a distraction, may be costly and is ineffective. They argue that what is required is more economic development and progress even if that means a warmer world. Both positions however accept the fact of growth based capitalism and thus fail to critique neoliberal market driven capitalism or posit an alternative political economy that eschews growth. Ecological public health, however, appears to be a way forward in addressing not only social determinants of health but also the political and ecological determinants. This might allow us to consider not just public health but also planetary health and health threats that arise from growth based capitalism.

 

Keywords Ecological Public health, climate change; risk discourse; capitalism; neoliberalism;

The health impacts of climate change have been much discussed internationally1,2,3,4  however there is some disagreement about the magnitude of those effects, when they will occur and what the right course of action is. Underpinning those disagreements is a tacit and sometimes uncritical acceptance of the fundamental structure of the political economy of growth capitalism – neoliberalism5 , with the differences being around whether climate change requires more immediate public policy and health professionalintervention6 or whether capitalism will address the health issues though economic development. In other words, both use the frame of reference of capitalism to argue for either more market freedom or statist intervention based in a risk discourse. This paper seeks to outline the arguments over the health effects of climate change while rooting that discourse within wider often background taken for granted political economy. Two writers, Indur Goklany and Daniel Ben Ami will be used to represent the critical camp in riposte to Costello et al’s 2009 UCL-Lancet paper on climate change and health. While the focus is on climate change, other factors such as biodiversity loss, chemical pollution, ozone depletion, ocean acidification, all threaten the ecological systems we depend on7. These issues are also associated with our current growth based economic structures.  The ecological public health discourse will not be discussed at length here, but might provide a newer perspective linking global political structures, critiques of growth based capitalism and public health.

The Climate change ‘debate’

 

The Intergovernmental Panel on Climate Change 5th Assessment Report (AR5)8 argues that scientists are 95% certain that humans are the ‘dominant cause’ of global warming since the 1950’s9,10 . Despite this, there is continuing doubt, denial and a focus on uncertainty,11,12,13,14,15   that Climate Change is human induced and that it requires radical shifts in public policy.   This doubt sits in opposition to many in the medical16and public health domain17. The World Health Organisation18,19  accepts IPCC assessments and considers climate change to be a ‘significant and emerging threat’ to public healthwhile previously ranking it very low down in a table of health threats20,21. In the United Kingdom, Costello22 et al argue that climate change is a major potential public health threat that does require major changes such as action on carbon emissions. In addition, Barton and Grant’s health map23 has in its outer ring ‘Climate Stability, Biodiversity and Global Ecosystems’ as key determinants of health and supports the WHO view that alongside the social determinants of health, health threats arise from large scale environmental hazards such as climate change, stratospheric ozone depletion, biodiversity losses, changes in water systems, land degradation, urbanisation and pressures on food production. WHO24  argues:   “Appreciation of this scale and type of influence on human health requires a new perspective which focuses on ecosystems and on the recognition that the foundations of long-term good health in populations rely in great part on the continued stability and functioning of the biosphere’s life-supporting systems”.

 

It is this call for a ‘new perspective on ecosystems’ that indicates why there is a backlash, one that underpins critiques of the link between climate change, environmental issues and human health. Many of those critical are libertarian, anti-state conservatives defending the neoliberal hegemony of free market dogma which ‘new perspectives’ may threaten.  For example, Stakaityte25 argues:   “Free market proponents are quick to point out that the whole climate change issue has been used to stifle freedom and to expand the nanny state – and they are right. If the climate is changing, and if humans really are responsible, the market will adapt”.

 

The WHO call for a ‘new perspective’ however is not a radical critique of neoliberal capitalism or a call for its replacement by other political economies. It sits within an overarching acceptance that growth25 capitalism is the only economic model, and that only its particular current form requires changing, for example by investments in green technologies.   Critical discourse over such an important issue is crucial. Argument should proceed over matters of empirical facts, within discourses of risk and an understanding of scientific uncertainty27 .  Attention also should turn to philosophical positions on political economy in which the dominant neoliberal hegemony28,29 attempts to build and maintain a sceptical view30,31  in the media on climate change and on alternative, including no growth, economic models32,33,34  because neoliberalism is antithetical to ‘nanny state’ intervention implicit in public health ‘upstream’ analysis.

 

Health Impacts of climate change and the policy response.

Indur Goklany and Daniel Ben Ami respectively are noted writers on the topic and both are in the sceptical camp regarding what to do about climate change. Both however appear to accept the fact of climate change, they just don’t agree with the focus on carbon reduction targets.   For the health community that makes decisions on what the main threats to health are, there is a need to carefully weigh up the evidence for threats to population health in the short, medium and long term, or what Goklany calls the ‘foreseeable future’ defined as 2085-2100. This means addressing Goklany’s argument, especially, on the ranking of health threats and Ben Ami’s argument on progress. For Goklany the health threats this century are not from climate change, nor will they be. For Ben Ami, the answer lies in any case of more progress based on economic growth and development.   In this there is some support from the latest IPCC report 35 (p3)  which states   “the present worldwide burden of ill health from climate change is relatively small compared with other stressors and is not well quantified”.   The report also states that rapid economic development will reduce health impacts on the poorest and least healthy groups, with further falls in mortality rates.  In addition, they argue36 (p4), alongside poverty alleviation and disaster preparedness, the most effective adaptation measures are:   “basic public health measures such as the provision of clean water, sanitation and essential healthcare”.   A key point is that climate change and extreme weather events affects the poor disproportionally and that37 (p3)   “until mid century climate change will act mainly by exacerbating health problems that already exist”   So there is an emphasis on economic development and poverty alleviation by the IPCC, thereby accepting the basic tenets of growth capitalism, alongside mitigation and adaptation, to deliver them.   However, McCoy38  et al points out that by 2100,  ‘business usual’ emissions growth will see increases in levels of CO2 in the atmosphere giving a 50:50 chance that global mean temperatures will rise by more than 4 degrees, which they argue  is   “incompatible with an organised global community”.   However, they stop short of a critique of the political economy of growth capitalism that drives C02 emissions39,40,41.   Both Goklany and Ben-Ami’s faith in human progress is based on inductive reasoning, ignores the key statistical problem of exponential growth on a finite planet, and may be over confident that limits have been correctly identified or can be overcome. Goklany might turn out to be empirically correct that in the ‘foreseeable future’, climate change will not be the major threat to public health, however this line of reasoning might support the denial of climate change in particular and obscures the requirement of addressing the sustainability of current economic structures. It also sidesteps addressing the language and discourse of risk42,43 which includes considering that human action should not be based on total certainty but on the assessment of the probabilities of high and low impact events. However, the position taken by both writers is that humanity needs more capitalist economic and technological development even if that results in a warmer world.   Goklany44 argues that humanity, in developing and using fossil fuels, both freed itself from the vagaries of nature’s provision and also has saved nature from humanity’s need to turn more of it into cropland. The inference from this argument is that we ought to continue to use fossil fuels to further human progress and to save nature from ourselves. Increasing global GDP, i.e. a wealthier world, would also be better equipped to deal with future global warming issues45.   Daniel Ben-Ami46 forwards this argument. He points out that we are living longer and healthier lives than ever before thanks to economic development and growth. Therefore, inductively, we need more growth. Humanity should strive to achieve more in terms of economic development so that everyone should have access to a Ferrari if they want it.   Those who suggest climate change is a health threat do not address this economic and development argument head on.  There may be implicit acceptance of the current economic models of development. Instead there is a focus on the magnitude of climate change per se as a health threat rather than the economic structures which may drive climate change and other unsustainable practices such as deforestation.       Costello v Goklany.   In 2009 Costello et al 47(p1693)  argued that ‘climate change is the biggest global health threat of the 21st century’ . Goklany48,49 in the same year replied and argued that climate change is not the number one threat to humanity, and questioned whether it is the defining challenge of our age. Goklany50  pointed out that climate change was ranked only 21st out of 24 global health threats. Goklany’s rebuttal data comes from the World Health Organisation51 ‘World Health Report 2002’ and the Comparative Quantification of Health Risks 200452and he used results from “Fast Track Assessments” (FTAs) of the global impacts of global warming53,54 .   Costello, Maslin and Montgomery 55  in reply to Goklany argued that     “The ranking of climate change at 21st out of 24 risk factors was made at a time when global temperature rise was only 0·74°C, and when the effects of climate change on the other risk factors was unclear”   …and they claimed that there has since been substantial changes in our understanding of climate change risks. They cite two papersshowing that about 1 trillion tonnes56 is probably the cumulative limit for all carbon emissions if we wish to stay within the 2°C “safety” limit57, and that, without action, we shall exceed this limit before 2050.  They also cite a paper by Schneider58 who raised the prospect of worst case scenarios: warming at 3°C gives a 90% probability that Greenland will melt, raising sea levels by many metres, and that on present evidence and trends there is a 5—17% chance that temperatures will go up by 6·4°C by 2100. They argue that this a risk threshold, way beyond which people would buy insurance.   Goklany59  in 2012,  argued Costello et al made their claim about climate change in 2009 without a comparative analysis of the magnitude, severity and manageability of a range of health threats at that time and therefore ranking it as the No 1 threat is untenable.  His position in 2012 is that the 2 degree target is irrelevant in any case and he seems happy to accept a 4 degree rise.   The 2013 IPCC report AR560, while accepting a pause in warming over recent years, argues that climate change is a continuing very serious issue and now post dates this difference in Goklany and Costello’s arguments which are based on data from 1999 to 2009. The report makes it clear that even if greenhouse gas emissions are stopped right now climate change will persists for many centuries, much of it will be irreversible characterised by impacts such as sea level rises and argues that the last time the world was 2 degrees warmer, sea levels were 5 -10 metres higher.   On what to do, Goklany61 (p69)  argued in 2009 that   “Societal resources devoted to curb carbon dioxide and other greenhouse gas emissions will be unavailable for other…more urgent tasks including vector control, developing safer water supplies or installing sanitation facilities in developing countries….”   However this sets up a false dichotomy. The decision to spend on carbon reduction is not an either/or one. There are myriad spending decisions being made, and those choices are made from a raft of competing priorities. One could equally argue that resources devoted to nuclear armaments and other military spending is unavailable also for these other urgent tasks. So to focus on emissions reduction as the spending that diverts funds away from addressing other pressing health issues is a biased view. Goklany could argue for an end to subsidies for the fossil fuel and nuclear industries, reductions in military spending, changing the international tax regimes to access wealth deposited in offshore accounts, or the introduction of a Tobin tax on financial transactions. These are admittedly biased positions and may be seen to be too left wing, and ideologically incompatible with current growth capitalism and neoliberal hegemony62.   Whether funding spent on carbon reduction actually works in terms of human welfare and is less expensive than alternatives, is a valid question but has to be seen in a wider political discourse about spending decisions. His points regarding the need for poverty reduction via sustainable economic development and advancing our adaptive capacity would possibly bring broad agreement. In any case some63 consider that it is too late for mitigation and that adaptation to a warmer world is now needed. Goklany64  uses the term ‘focused adaptation’ meaning taking advantage of the positive benefits of warming. If sea levels are to rise by 5-10 metres this is beyond the foreseeable future and so we should focus on economic growth and development to adapt to those future scenarios rather than wasting time resources and energy on emission curbs. However, this seems somewhat an anthropocentric view taking in little regard for biodiversity loss and ocean acidification, both of which are also threats to human health.   Ben Ami and Goklany put faith instead in ‘secular technological change’. This believes that   1) Existing technologies will become cheaper or more cost effective. 2) New technologies that are even more cost effective will become available.   They may well be correct. They argue the potential health threats may be addressed through human ingenuity based on economic progress and economic progress is best served by accepting the IPCC worse case scenario which would result in greater per capita GDP and thus release capital for adaptation (figure 1).   Goklany argues that if humanity has a choice, it ought to strive for the developmental path corresponding to the richest IPCC scenario (A1FI  – 4 degrees C above 1990 by 2085), notwithstanding any associated global warming, because this increases adaptive capacity and poverty would be eliminated. Other health risks that rank higher than global warming are also associated with poverty and would thus also be eliminated. Poverty related diseases contribute to mortality and morbidity 70 to 80% more than warming. Mitigative capacity would be increased, therefore health improves with economic and technological development, and development encourages the ‘environmental transition’.   This is a very risky strategy which future generations will have to judge the merits of. There is gathering evidence beyond climate change suggesting that humanity is already transgressing other environmental limits65, transgressions which will not support a ‘safe operating space’ in the new era, the ‘anthropocene66,67 .   Risk Discourse.   Goklany68 argued in 2012   “This paper does not address hypothesized low-probability but potentially high consequence outcomes such as a shutdown of the thermohaline circulation or the melting of the Greenland and Antarctica Ice Sheets, which have been deemed unlikely to occur in the foreseeable future by both the IPCC and the US Global Change Research Program, among others”,   …although the IPCC69(p22) has since written that it is     “very unlikely that the Atlantic Meridional Overturning Circulation (part of the global thermohaline) will undergo abrupt transition or collapse…however, a collapse beyond the 21st century…cannot be excluded”.   Goklany, in not addressing these risks, appears to dismiss the need for ‘risk discourse’ to frame public debate relying on ‘kicking into the long grass’ serious future consequences of climate change.   ‘Risk’ is already an essential part of everyone’s experience, including in the world of insurance, health and investment. It is not uncommon for people to insure against low probability but high impact events, e.g. house fires, and for the long term, e.g. pensions. It is thus arguable that the thermohaline shutdown and ice sheets melts may well be just the sort of low probability but high impact events that humanity ought to be insuring against and taking measures to prevent through carbon emissions reductions. Painter70 suggests therefore that elements of risk discourse would provide a better frame for debate than disaster and uncertainty frames, which are both more prevalent in news media.   Space precludes an examination of the concept of exponential growth and the requirement to produce resources to meet the needs of potentially 9-10 billion people by 2050. Costello et al’s position seems to be that climate change will stress ecosystems before we have time to adapt and that both direct and indirect affects will adversely impact on global health. They are not so sanguine about our ability to live within our limits.         Goklany is correct to point out that currently health threats arise from poverty and underdevelopment. In this assessment he is in accord with the WHO social determinants of health approach and the IPCC AR5 WGII71.  Costello et al have not dismissed this and public health experts would probably accept a similar position. A focus on the social determinants of health and the political determinants of health72 needs to run alongside mitigation or else the good work could be undone by a low probability, according to Goklany,  but high impact event such as the melting of the Arctic Ice. They differ on when climate change will be a health threat and importantly on how to address it. Goklany and Ben Ami appear to be on the market driven economic development model as the answer whereas Costello et al argue for more immediate state and public intervention in addressing climate change. All however do not critique the fundamental neoliberal growth economic model or call for alternative economic ‘no growth’ or circular models73,74. There is little doubt that we are running an experiment with the climate, there is agreement that this will impact on global health but the dominant discourse of political economy seems to be either more or less tweaking with capitalist growth models rather than a sustained examination of alternatives.There are voices, now however, pointing public health in another direction. Horton et al75 call for a new social movement in a ‘manifesto from public to planetary health’, to support collective action on Public Health, introducing the concept of ‘planetary’, rather than just ‘public’ health.  As with Lang and Rayner’s76  discussion of Ecological public health, there is a strong focus on the unsustainability of current consumption. Interestingly,  an overt political statement is introduced in the ‘manifesto’: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”77 p847. They attack the idea of progress, and thus implicitly growth based neoliberalism, for deepening this ecological crisis and for being socially unjust. The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, and a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests. In the same vein, Ottersen et al78 are explicitly political on the links between health inequity, globalisation and the current system of global governance, including the actions of ‘powerful global actors’ and while they do not use the term ‘growth based capitalism’ or ‘neoliberalism’, the tone of the report makes it quite clear that there is a need to address global governance and an analysis of power. The domains of Public Health, Medicine and Nursing may be insufficiently politically aware of the scale of the issues, and the sheer force and dynamics of capitalism79, that impacts on human health. This might be due to the (necessary?) ‘ahistoric’ and ‘apolitical’ education of health care professionals, resulting in a lack of a sociological or political imagination underpinned by a critical theory of capitalism. However, adopting the perspective of Ecological Public Health or seeing the world through a ‘sustainability lens’80 might move more health practitioners and policy makers into critique and action on current economic and political structures that result in health inequities, and indeed, if some are to be believed, that threaten western civilisation81,82.

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Figure 1: net GDP per capita, 1990-2200 for 4 IPCC scenarios. The warmest is A1FI (4 degrees C) and the coolest is B1 (2.1 degrees C)       Author’s statement

Funding: none

Competing Interests: None declared

Ethical approval: Not required. This is a review paper.

 

“NOTICE: this is the author’s version of a work that was accepted for publication in Public Health. Changes resulting from the publishing process, such as peer review, editing, corrections, structural formatting, and other quality control mechanisms may not be reflected in this document. Changes may have been made to this work since it was submitted for publication. A definitive version was subsequently published in PUBLICATION, [VOL#, ISSUE#, (DATE)] DOI

The Corporate University, Health as commodity and the citizen as customer.

 “As universities mirror the increasingly unequal nature of English society … their role in advancing social equality, or minimising embedded disadvantage, will be traduced in a ‘meritocratic’ game of spotting talent and ensuring that it is slotted into the appropriate tier.” So writes Andrew McGettigan on the the discoversociety.org website in 2014. This comment on the ‘corporate university’ indicates that universities have functions that go beyond only meeting the needs of student consumers in their quest for a job, that indeed Universities should address aims beyond producing  ‘cognitive capitalism‘.

Should we care at all about this, or should we encourage even more market discipline?

For some, education is a commodity which should be bought and sold in a free market.  If a student wishes to borrow money to study literature or sociology then that is their choice, the State has no business in supporting study that has little direct economic benefit for individuals or society. So goes the free market apologists who places trust in the individual rational action of the student/consumer when buying the commodity of education. This is not new. Logan et al in 1989 argued in the context of the provision of health care that

“…services should be treated just like any other commodity that can be efficiently produced and consumed under market conditions”.

David  Willetts, Minister for Universities and Science, told a fringe event at the most recent Conservative party conference: unleashing the forces of consumerism is the single best means of improving the quality of undergraduate provision.

Student tuition fees have turned students into customers. This is seen as a ‘good thing’. Students will vote with their money and desert courses and institutions that they feel will not fulfill their hopes and aspirations. Competition for Elite universities will thus increase and only the best survive – a bit like the Premier League. Since its inception we have seen the loss of 50 football clubs as well as a sense of the club representing the local community values. Does that matter? Not if you are the winner – a Manchester City/Utd or a Chelsea – or a winner’s fans.

A clearer statement of the ideology of free market capitalism you will find hard to beat. Consider that this thinking has, not as yet, boldly reared its head for health. How would you feel upon hearing:

“unleashing the forces of consumerism is the single best means of improving the quality of health care provision”.

What do you think about  this:  Individuals should pay for their own health and social care needs at the point of delivery, as they are best placed to know what their needs are and how much they value health and social care. If they value beer and fags more, then that is their choice and the state should not intervene in that decision.  Individuals and families could pay for insurance for that ‘rainy day’ of dementia, cataracts or a broken leg. Hospitals and GP practices would be forced to compete for customers and those with poor reputations would have to close. Public Health England could be disbanded as a wasteful state cost base and instead individuals could be nudged to take responsibility for their health.

Well, if you have swallowed market ideology wholesale, that might sound like nirvana.

If universities are turning into warehouses for the production of cognitive capitalism in which education is a commodity to be bought and sold for instrumental purposes (“its the economy, stupid”), then their social role diminishes. Likewise, is health care a commodity to be bought and sold or does society also need a health sector that addresses the social and political determinants of health as well?

Individual rights and liberties balanced with social solidarity?

At root this is the difference between a social democratic political philosophy and a market driven neoliberal agenda. Its your choice, but remember ‘some animals are more equal than others‘ and they have the clout to ensure they stay ‘more equal’.

Planetary and Public Health – its in our hands ?

From public to planetary health: a manifesto.

The Lancet (Horton et al, 2014) has just published  a manifesto for transforming public health.

You can read the full one page easy to read manifesto here.

This is a call for a social movement at all levels, from individual to the global, to support collective action for public health. Public Health has been widely defined in this manifesto and draws upon the ideas of Barton and Grant’s health map which has climate change, biodiversity and global ecosystems as the outer ring of the determinants of health.

The current definitions of public health, for example from the Faculty of Public Health,  draw upon Acheson’s 1998 definition “The science and art of promoting and protecting health and well-being, preventing ill-health and prolonging life through the organised efforts of society”.  However this definition may now be outdated as there is no mention of environmental or ecological determinants of health and no express action on planetary health at all.

Therefore this manifesto is an implicit call to redefine what public health means. Currently you can read the FPH’s approach to public health and fail to consider issues around climate change, biodiversity loss or the crossing of planetary boundaries which delineate a ‘safe operating space for humanity‘. This needs changing.

The main points within this manifesto  include a definition of ‘planetary’ , rather than ‘public’ health which they argue is an “attitude towards life and a philosophy for living… emphasising people not diseases, and equity not the creation of unjust societies”.  There is a strong focus in the manifesto on the unsustainability of current consumption patterns of living, based on the harms this has on planetary systems. They argue “overconsumption…will cause the collapse of civilisation”. Jared Diamond is worth a read on the collapse of civilisations,  and this argument is in line with his analysis.

Interestingly, an overt political statement is introduced: “We have created an unjust global economic system that favours a small wealthy elite over the many who have so little”. They attack the idea of progress, and of neoliberalism  including ‘transnational forces”, for deepening this ecological crisis and for being socially unjust. There is also a hint of the ‘democratic deficit‘ in which trust between the public and political leaders is breaking down.

The call is for an urgent transformation in values and practices based on recognizing our interdependence and interconnectedness, a new vision of democratic action and cooperation.  A principle of ‘planetism’ is invoked which requires us to conserve and sustain ecosystems upon which we rely.

Finally they suggest that public health and medicine can be independent voices of conscience who along with ’empowered communities’ can confront entrenched interests.

So far so good, and in a one page document the detail is necessarily missing.  The principles outlined in this manifesto and the analysis focusing on neoliberalism and ‘entrenched interests’ point us in a direction. However, there is now a need for a map.

I am not convinced that public health, medicine and certainly not nursing, is sufficiently politically aware of the scale of the issue and the sheer force and dynamic of capitalism to even begin constructing the map. That may be an unfair criticism because the education of health care professionals is ‘ahistoric’ and ‘apolitical’ by nature,  they simply lack a sociological or political imagination underpinned by a critical theory of capitalism. And for good reasons.

However, if doctors and nurses are to engage with this manifesto and to debate and argue for an alternative world view, then there is an urgent need to understand the forces railed against them. This manifesto rightly points out the political nature of the issue and the authors no doubt have a clear idea what they mean, however I doubt very much if the majority of healthcare professionals really understand, or even perhaps care about,  the concept of neoliberalism.

In the UK we will be having an election in 2015, in which we will be offered similar versions of the system that is causing the mess. There will be little in the way of mainstream reporting or argument on radical alternatives to consumption or finance capitalism. Indeed parties will be arguing over who can best manage the system.  The only exception will be the Green party who are a fringe party, in terms of votes.

As an example of the scale of the problem, consider Bill McKibbens’  ‘three numbers‘ argument: 2 for two degrees, the threshold beyond which we should fear to tread; 565 gigatons of CO2 we might be able to put into the atmosphere and have some hope of staying below or around 2 degrees; 2795 gigatons which is the amount of carbon in current reserves, but is the the amount of carbon we are planning to burn!  Further, the wealth of investors is tied up in this number and would evaporate like petrol in a hot day should we globally decide that this reserve should stay in the ground. This is an example of an entrenched interest backed by neoliberal politics which is antithetical to global and governmental regulations. The current TTIP negotiations which is trying to establish a free trade area between the US and the EU,  possibly exemplifies the powerlessness of states in the face of lawsuits by corporations if George Monbiot is correct. TTIP is a public health issue and forms part of the backdrop to this manifesto.

I welcome this manifesto, and would urge public health bodies to become overtly political in their statements about public health, perhaps revisiting Acheson and redefining public health to include planetary health.

Following that observation, a new publication published in February 2014, appears to address the politics in an overt way. The Lancet – University of Oslo Commission on Global Governance for Health argues in a document called ‘The political origins of health inequity: prospects for change’ : “Although the health sector has a crucial role in addressing health inequalities, its efforts often come into conflict with powerful global actors in pursuit of other interests such as protection of national security, safeguarding of sovereignty, or economic goals.”

This then sets up political determinants of health which sit alongside the social determinants of health. Whether it goes as far as critiquing the underlying dynamic of various forms of capitalism remains to be seen.

Sustainability, Health and Cycling ‘on yer bike’

Sustainability, Health and Cycling.

 

Following the success of cycling at the London Olympics, which has propelled Chris Hoy and Victoria Pendleton into the limelight, and two successive Tour de France wins by British based Chris Froome and Bradley Wiggins, the Great British public are getting back on their bikes and not just to find work. At the mass cycling event ‘Ride 100’ held in London this summer,  even London Mayor Boris Johnson (17 stone) took part, commenting that he was no “chiselled whippet”. Boris is of course also known for the introduction of the Boris bike in the capital. He stated: “The truth is it’s not that hard, and I’m here to prove it. I am 17 stone, I’m by no means fit, and I got myself round that (100 mile) course in a perfectly respectable time. Not supersonic, but perfectly respectable…The message we’re trying to get over is this is for everybody”.

The Department of Transport has produced figures on walking and cycling by local area based on a survey in 2010/11. The key findings include 10% of adults cycle at least once per week but this varies a great deal by area (from over 50% to less than 5%), 11% of adults cycle for at least half an hour at least once per month but again with huge variations (35%-4%). Perhaps unsurprisingly, Cambridge  reports 52% cycling at least once per week and the highest rates are reported in cities and boroughs within cities. Why do we cycle? The survey suggests that 16% do so for utility purposes and 77% for recreation. The Cycling Touring Club (CTC) reports cycling is up by 20% in the last 12 years from 4 billion kms in 1998 to 5 billion kms in 2011.

So this is good news. For society, a shift from cars to cycling may bring about reduced air pollution, reduced greenhouse gas emissions and increased physical activity. For the individual there is an increase in exposure to air pollution and risk of road accidents. The health benefits of cycling are well understood. According to the NHS choices website these include helping you to lose weight, reducing stress and improving fitness. The example of calorie burning is given: someone weighing 80kgs (12st 9lbs) will burn more than 650 calories in an hour’s riding. As a keen road cyclist I can burn 1500 calories on a weekend ride. Of course there are concerns about death and injury on the roads, even Bradley Wiggins has been involved in a collision back in the UK after winning the Tour de France. Department of Transport figures for 2011 indicate that 107 cyclists were killed, but this figure is declining from 2004. However, combined figures for deaths and injuries show these steadily rising to 19,215 in 2011. What of course we really need to know is the relative risk of cycling compared to say horse riding, other forms of motor transport or any other activities. We need to know how many deaths per 100,000 kms of cycling and then to ask, whatever the number is, is cycling beneficial despite the risk?  Depending on who you ask, the health benefits of cycling do seem to outweigh the risks. Hartog et al in their study (2010) argue “on average the estimated health benefits of cycling were substantially larger relative to car driving for individuals shifting their mode of transport”.

Cycling is not just an individual issue, it is a social issue and perhaps a political issue as well. Both Denmark and the Netherlands have higher rates of cycling than the UK. This might be obvious given the geography, but the story is not as simple as the relative lack of hills, it is also down to political and urban planning decisions taken and active policy decisions by politicians over decades to make the countries cycle friendly, to get people back on their bikes.

In ’The Energy glut – the politics of fatness in an overheating world’ Roberts and Edwards (2010) argue that fossil fuels are making whole populations fat/obese. We have replaced food with fossil fuels as our main energy source while at the same time we are eating, if not less than we did, then certainly no more. We have become sedentary, replacing walking and cycling as active transport with mechanical modes of transport, mainly the motor car. Whole societies are using the energy oil has given us to replace physical labour. The upside is the construction of advanced civilizations and huge increases in food production, and the ability to buy stuff, the downside is that as countries develop and begin to increase their car use, whole populations get fat, and experience death and injury on the roads that make cycling injury statistics seem small. Did I mention the contribution to climate change?

Cycling as active transport is a positive sustainability issue, but it is also complicated in that in achieving positive health gains and reducing carbon emissions on the one hand, we have to also consider the carbon footprint of cycling. This includes the manufacture of cycles and  their transporting around the world. Raleigh manufactures in the Far East and my own Bike, a ‘Merida’, was shipped to the UK from overseas. Then of course there are the clothes and accessories and the taking part in weekend ‘sportives’ which may involve driving to events across the country. I have not calculated the carbon footprint of my own cycling interests nor have I calculated yet how many car miles I have not done as a result of cycling. I have to confess that I am one of the 77% who cycle for recreation, having not yet bitten the bullet on commuting. My only excuse is a 20 mile round trip to work on an A road in West Cornwall at , yes even in Cornwall, ‘rush hour’ where far too many drivers seem not have yet woken up and speed by far too closely.

My value system approves of cycling, I believe it has health benefits as well as risk but the risks could be far better managed if UK policy makers went even further in their plans for cycling. Am I about to sell the car though….?

 

 

 

Human health on a dying Planet?

Barton and Grant’s (2006) health map has an outer ring. In this ring sits ‘Biodiversity’, ‘global ecosystems’ and ‘climate change’. The implication here is that all of human health rests on these ultimate foundations. All human systems rely on these ecosystems remaining functionally sustainable. If we lose or degrade these three foundations for human health, then we lose our ability to survive. Modern city systems, in which 50% of humanity currently lives, would collapse. Alongside the idea of these three foundations is the idea of ‘planetary boundaries’, which map out a ‘safe operating space for humanity’ (Rockstrom et al 2009). If we transgress these boundaries, we take human civilisation into unsafe territory. We may have already done so.

 

The planetary boundaries are also known as biophysical thresholds and relate closely to Barton and Grant’s outer ring:

 

1.                     CO2 emissions for climate change (this boundary has been transgressed).

2.                     Biodiversity loss (this boundary has been transgressed).

3.                     Biochemical boundaries – the nitrogen cycle (the phosphorous cycle has not yet been transgressed).

4.                     Ocean acidification.

5.                     Stratospheric ozone depletion.

6.                     Global fresh water use.

7.                     Change in land use.

8.                     Atmospheric aerosol loading (not yet quantified).

9.                     Chemical pollution (not yet quantified).

 

 

They argue that the first three of the nine boundaries above have already been overstepped. They also argue:

 

In the last 200 years, humanity has transitioned into a new geological era—termed the Anthropocene—which is defined by an accelerating departure from the stable environmental conditions of the past 12,000 years into a new, unknown state of Earth”…..“In order to maintain a global environment that is conducive for human development and well-being, we must define and respect planetary boundaries that delineate a “safe operating space” for humanity. We must return to the long-term stable global environment that nurtured human development”.

 

The return to the long term stable environment may not now be possible.

 

Evidence that we have degraded these determinants of human health and which makes such a return to stable climate conditions improbable, come from ‘The Economics of Ecosystems and Biodiversity (TEEB), the OECD (2008), Millennium Ecosystem Services Assessment (2005a, 2005b, 2005c) and a series of reports in the New Scientist (2012) and even the accountancy firm PricewaterhouseCoopers (2012).

 

The TEEB study aims to link ecology and biodiversity to economics with a view to highlighting their importance to human wellbeing. An aim is to try and quantify the costs of inaction on the loss of biodiversity and ecosystem services. This includes assessments on water and air quality, nutrient recycling and decomposition, plant pollination and flood control. These are what are known as ‘public goods’ which do not have a market price and their loss fails to show up in the accounts of conventional economics. Thus without this accounting, companies continue to operate as if these things do not matter, as if they are provided freely. TEEB aims to provide analysis, tools and a methodological framework to assist decision makers in their quest to assess and undertake an analysis of ecosystem services and biodiversity. The 2008 Interim report sets out the many challenges facing us (food, fresh water, loss of forests, coral reefs and species extinction). The report argues “60% of the earth’s ecosystems services that have been examined have been degraded in the last 50 years” (p12). TEEB is clear that current economic approaches are just not tenable.

 

A series of articles in the New Scientist (2012) makes for grim reading. For arctic warming the suggestion is that summer sea ice could be gone in a decade or two and not by the end of the century and that the loss of Greenland’s ice could mean a rise of sea levels by 1 metre by 2100 and possibly by more. As for ‘planetary feedbacks’, changes (for example, the albedo affect in which white ice reflects heat, while dark seas absorb it) means that the planet’s ability to absorb CO2 will reduce accelerating the rate of heating. The PwC (2012) report suggest that we should expect not 2 degrees of heating but 4 or possible 6 degrees by the end of the century. If this figure does not mean much, Mark Lynas (2007) outlines what this could mean for humanity. It will not be a picnic.

 

One ray of hope (for food production only) is a farm in Australia using technology developed in the UK. Using seawater and sunlight, Sundrop farms are producing fruit and vegetables in the desert (Margolis 2012). It is this sort of technology that would have to be scaled up to feed the world as climate shifts adversely affect current food production. This development is ‘adaptation’ to climate change and thus may be an exemplar of the way we have to go in the coming decades.

 

It is becoming increasingly clear that the current experiment of a fossil fuel based civilization allied to extractive practices that pay little regard to the planet’s ability to renew itself or its ability to absorb often toxic wastes, means that Barton and Grant’s outer ring propping up human health is severely degraded. The climate change battle may already be lost. The IPCC target of safety, 350 ppm to keep us down to 2 degrees of warming, has been missed. We are at 391 ppm in November 2012, see http://co2now.org/. The biodiversity threshold has been crossed (Rockstrom et al 2009) while ecosystem services are under severe stress (TEEB 2008). The plan now is to continue to prevent further warming (mitigation) by reducing carbon emissions, then consider the many adaptations we will have to make to a very changed world (for example changes in resource use for health care practices) and finally to build community resilience in the face of major changes. This will include work on mental health and well-being as old habits and expectations are swept away. This will not be easy. Evidence from Greece and other austerity hit countries indicate that societies faced with rapid changes often exhibit manifestations of social unrest and stress.

 

A dying planet? No, the earth will carry on as it always has, limited only by cosmological changes in its nearest star, the Sun. The holocene era of stable climatic conditions conducive to human development as we know it, is passing very quickly before our eyes. Welcome to the Anthropocene.

 

 

References:

Barton, H. And Grant, M (2006) A health map for the local human habitat. Journal of the Royal Society for the Promotion of Public Health. 126 (6) pp 252-261.

Lynas, M. (2007) Six Degrees. Our future on a hotter planet. Fourth Estate. London.

Margolis, J. (2012) Growing food in the desert: is this the solution to the world’s food crisis? The Observer. 24th November. [online] http://www.guardian.co.uk/environment/2012/nov/24/growing-food-in-the-desert-crisis accessed 26th November 2012

Millenium Ecosystem Services Assessment (2005a) Global Assessment report 1: Current state and trends Assessment. Island Press. Washington

Millenium Ecosystem Services Assessment (2005b) Living beyond our means: Natural Assets and Human well-being. Island Press. Washington

Millenium Ecosystem Services Assessment (2005c) Ecosystems and human well-being: Synthesis. Island Press. Washington.

OECD – Organisation for Economic Cooperation and Development (2008) OECD Environmental outlook to 2030.

PwC – PricewaterhouseCoopers (2012)Too late for two degrees? Low carbon economy index 2012. PwC  [online] http://www.pwc.co.uk/sustainability-climate-change/publications/low-carbon-economy-index.jhtml accessed 24th November 2012

New Scientist (2012) Climate Change: its even worse than we thought. November [online] http://www.newscientist.com/special/worse-climate accessed November 26th 2012

Rockström, J. Steffen, W., Noone, K. et al (2009) A safe operating space for humanity. Nature. 461. Pp 472-475. 24th September.  http://www.nature.com/nature/journal/v461/n7263/full/461472a.html accessed 8th January 2011

TEEB – The Economics of Ecosystem services and Biodiversity (2008) An Interim report [online] http://www.teebweb.org/teeb-study-and-reports/additional-reports/interim-report/ accessed 26th November 2012

A sustainability-climate change-health triad

I have previously suggested (with my colleague Janet Richardson) that there is a sustainability-climate change-health triad  which needs to be addressed more explicitly in nursing.

 

I further suggest that health at both individual and population levels will be more and more based upon both sustainable living and mitigating and adapting to climate change as global temperatures continue to rise.

 

In addition to the biological basis for health, human health is based on the fundamentals of physical environment such clean air, clean water, sufficient food and safe waste disposal, and also upon good psycho- social-political environments. For example, low unemployment and absence of military conflict. A sense of aesthetics and the need ask what constitutes the ‘good life’ for human happiness cannot be ignored when assessing human health and well-being. Health is also founded upon on social and environmental factors that transcend national boundaries. Therefore, as the determinants for health are social and often global, one way of addressing the issue is through developing a sense of global citizenship. In addition, because sustainability, climate change and global health are inextricably linked, health has to have sustainability at its core.

We know, as much as we know anything, that climate change is largely resulting from increasing carbon dioxide and CO2 equivalent emissions as a result of fossil fuel energy consumption. Unsustainable economics and lifestyles based on current economic structures also contribute to this process and to ecological degradation. Thus addressing carbon emissions and climate change cannot be achieved without addressing sustainable living.

 

Sustainable living entails ensuring that current patterns of consumption and lifestyles do not endanger the physical and non physical resource base for coming generations. Climate change threatens health as it threatens both the physical environment and the psycho-social-political environment the latter, for example, as water becomes a scarce commodity and replaces oil as a source for conflict.

 

Environmental pollutants, radioactivity and toxins also affect the health of current generations and future generations by increasing the likelihood of passing on genetic defects.

 

 

Understanding that our individual lives are interconnected systems, bound up with the planetary ecosystems, is a first step to helping us heal ourselves. The planet will survive human predation upon current living systems and the geo-bio-chemical systems, when this current ‘anthropocene’ era that we have started will comes to an end.

Global Citizens for Health

 

Global Citizens for Health.

 

 

Aims: 

 

 

1.              To discuss the concept of the ‘global citizen’

2.              To discuss the implications for the curricula and student experience.

3.              To develop plans for further work.

 

 

Introduction.

 

Health is founded upon on social and environmental factors that often transcend national boundaries. This is not to ignore biological influences (such as genetic diseases) but rather to focus activities on those factors that health workers may influence in individuals and populations. Therefore, as the determinants for health are social and often global, one way of addressing the issue is through developing a sense of global citizenship. Global citizenship, as we define it and argue below, has to have sustainability at its core because sustainability and global health are inextricably linked (Goodman and Richardson 2010).

 

In addition to the health focus, other drivers for global citizenship are clear and many of the most pressing issues facing us must be addressed internationally. The policy context includes the WHO Millennium Development Goals, the G8 Gleneagles Communiqué on Africa (2005) and the COP 15 Accord (2009). In addition to these policy statements which sets out the context, there are global threats to well being from a wide range of economic, environmental and political issues:

 

   climate change and its concomitants e.g. ocean acidification, climate migration.

   unsustainable practice such as deforestation, soil erosion, overfishing.

   water, food and energy shortages (peak oil).

   mineral and other resource depletion.

   population growth.

   toxic chemical and nuclear waste disposal.

   international terrorism.

   shifts in the power base of the global economy (Rosling 2009).

   unsustainable GDP growth as a policy objective (Jackson 2010).

   post (?) ‘Washington Consensus’ economics (Rodrik 2006)

   inequalities in health and wealth.

   alcohol and substance abuse.

 

……and of course ‘globalisation‘ in its various guises.

 

Climate change has been identified as the biggest threat to global health of the 21st century (Costello et al 2009) and health workers have been urged to take action (BMA 2008). International nursing organisations have highlighted this as an imperative (ICN 2009, CNA 2009, 2010, AAN 2008).

 

Global citizenship can be seen as an emergent concept in this context. 

 

 

Graduates from UK universities will not be insulated from these global trends. However there are opportunities as well as threats. Adopting global perspectives also offers opportunities for large-scale beneficial change. For example, the transition to a low carbon economy provides new opportunities for innovation and creativity in energy use, production and distribution. For health, the message is that a low carbon lifestyle is also good for health.

 

Graduates from UoP must be encouraged to think as widely as possible about the future world they are going to inherit and eventually help shape. Sustainable development (or contraction) and the limits to growth as currently defined (Meadows and Meadows 1972, Jackson 2009) may be the defining context for the coming graduate generation. If so, an insular inward looking mindset will not serve us well.

 

Having an idea of what it is to be a global citizen, living in world where prosperity is  meaningless when 80% of humanity live on less than $10 a day (Chen and Ravallion 2008), may be a necessary first step to foster a global consciousness and willingness to engage with these challenges.

 

Higher Education Institutions have a responsibility to encourage graduates to think about their roles and responsibilities as global citizens in the world they will help to shape. 

 

 

 

 

In this presentation, we will address the following issues in relation to students in the Faculty of Health:

 

1.  What is global citizenship?

2.  How can we encourage students to develop their identities as global citizens?

3.  Existing good practice in the curricula and student experience 

4.  Future opportunities.

 

 

A note on the challenge in HEI funding:

 

According to Paul Marshall, chief executive of the small research intensive universities group, there has been an announcement of a £135 million cut and a drive £180 million in efficiency savings. Lord Mandelson’s announcement (Dec 2009) of further budget restraint mean HEFC’s annual budget would fall from £7.291 billion in 2010-11 to £6.376 billion in 2012-13. This would be a 12.5% cut in its annual funding over three years. The December (2009) pre budget report had already announced £600 million in cuts. Therefore any initiative will need to come within existing and reducing funding.

 

Therefore to address the third aim we will need to be very creative.

 

 

 

 

 

 

 

 

What is global citizenship?

 

Global citizenship (GC) applies the concept of citizenship to a global level. Citizenship entails rights and responsibilities in civil society, is active as well as passive. GC can be defined as a moral and ethical orientation which can guide the understanding of individuals or groups of local and global contexts. As an ethical endeavour it reminds us of our responsibilities within and to various communities.

 

Activism, as the translation of this theoretical understanding of the world into actual practice, and appears to be a core idea.

Thomas Paine (1727- 1809) in the ‘Rights of Man’  could be thought to be an early exponent of global citizenship:

 

            “My country is the world, all mankind are my brethren, to do good is my religion”

 

So GC could mean:

   Respect for all human beings regardless of race, religion or creed (that does not mean respect for their ideas).

   Reaching beyond national barriers to act on inequalities, ecological degradation and the promotion of well being.

 

 

Therefore GC has both and an ethical and an action dimension. One follows from the other. It involves both rights and responsibilities.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Falk (1994) identifies five potential categories of global citizens. He describes these as:

 

            “a series of overlapping images of what it might mean to be a global citizen at      this stage in history.”(p132).

 

According to Lagos (2002), except for the example of elite global business people, the majority of Falk’s categories

 

            “have grassroots activism at their core”(p6).     

 

Falk’s five categories are:

 

1.   Global reformers

 

“[A]n individual that intellectually perceives a better way of life of the planet and favours a utopian scheme that is presented as a practical mechanism.”(p 132).

This may entail some form of centralised world government or organisation in order to avoid global turmoil and maintain some form of unity.There may be a tendency for reformers to filter their visions through the cultural and political outlook of their own “political community” (p 133), and thereby impose their framework on the rest of the world.

This ‘centralised world government’ of course could be interpreted as dictatorship. Stalin and Hitler may have had  their own ideas for global reform that went beyond their own borders. In their own terms they may have thought of themselves a ‘reformers’ ushering in a ‘new world order’ (be it a Thousand Year Reich or a Communist utopia). The ‘Washington consensus’ could be seen in this manner – a new world order based on neoliberal capitalism and the dominance of US foreign policy.

Falk summarises the global reformers’ “spirit of global citizenship”(p132) with the statement:

 

            “It is not a matter of being a loyal participant who belongs to a particular political community, whether city or state, but feeling, thinking and acting for the sake of the     human species, and above all for those most vulnerable and      disadvantaged.”(p132).

 

It may be the focus on the ‘disadvantaged and vulnerable’ (with a nod to the universal declaration of human rights to help identify who that group is) that makes GC objectively different from national socialist dictatorship. This is still problematic. The definition of who is disadvantaged and vulnerable may seem self evident but a moments thought suggests subjective definitions alter membership of that group. In Palestine today who thinks of themselves as disadvantaged – jew or arab, who is oppressed and who oppressor? Islamists and Jihadists may also have a wish to create a global muslim brotherhood based on sharia law. The muslim brotherhood transcends national boundaries and could be seen as a way of establishing a new global order. Global citizenship for Islam may have its own meaning.

 

 

 

2.   A man or woman of transnational affairs.

 

This category of global citizens could also be described as elite global business people.Falk also points out that the vast majority of these people are men. He writes:

 

            “This second understanding of global citizenship focuses upon the impact on     identity of globalization of economic forces. Its guiding image is that the world is        becoming unified around a common business elite, an elite that shares interests and experiences, comes to have more in common with each other than it does with the more rooted, ethnically distinct members of its own particular civil society: the    result seems to be a denationalized global elite that at the same time lacks any   global civic sense of responsibility”(p 134).

 

This description is similar to those that inhabit ‘Richistan’ a term coined by Frank (2007) in a book of the same name who argued:

 

            “The wealthy weren’t just getting wealthier — they were forming their own            virtual             country. They were wealthier than most nations, with the top 1% controlling $17 trillion in wealth. And they were increasingly building a self-contained world, with its            own health-care system (concierge doctors), travel system (private jets, destination     clubs) and language. (”Who’s your household manager?”) They had created their             own breakaway republic — one I called Richistan.”

 

 

The difference is that Richistan’s elite may see themselves as apart from other citizens and not members of global citizenry, although their actions are self justified on the basis that their actions are good for the world.

 

 

3.   Managers of environmental and economic global order.

 

This perspective focuses more on environmental needs but also looks at economic concerns. This view is exemplified by the Bruntland Commission’s report, which:

            “stress[es] the shared destiny on the earth as a whole of the human species …    [and] argues that unprecedented forms of cooperation among states and a      heightened sense of urgency by states will be required to ensure the sustainability of industrial civilization”(p135).

 

This perspective is often concerned with:

 

            “making the planet sustainable at current middle-class lifestyles.”(p136)

 

Key thinkers in this perspective would be Rachel Carson (1962), Aldo Leopold (1949), Eric Schumacher (1979), David Orr (1994) and those involved in the ‘green movement’, sustainability and environmentalism. Environmentalism and green politics however, is not about establishing a global political order rather that the current dominant economic models need revolution to be replaced with a world based on economic localism (Wood and Lucas 2004). Frank’s ‘middle class lifestyles’ in this analysis may not survive the greening of the new world order especially if it is based on current economic models.

There are of course divisions, Bruntland has been criticised as merely greening the status quo (Sinclair 2009) while others argue for more thoroughgoing reform of Sustainability (Sinclair 2009, Selby 2007). This perspective suggests that ‘industrial civilisation’ is not  worth saving.

 

4.  Regional political consciousness.

 

Within Europe, the birthplace of the modern state, “The Euro-federal process is creating a sufficient structure beyond the state so that it becomes necessary, not merely aspirational, to depict a new kind of political community as emergent, although with features that are still far from distinct, and complete.”(p137)

Falk asks,

            “Can Europe … forge an ideological and normative identity that becomes more    than a strategy to gain a bigger piece of the world economic pie? Can Europe             become the bearer of values that are directly related to creating a more peaceful        and just world?”(p137)

 

To state that  this sort of regional project is not without its critics is self evident to most people in the UK. Eurosceptics in all major parties plus UKIP argue that this movement is undemocratic and dissolves national sovereignty.

 

5. Trans-national activists.

 

Amnesty International and Greenpeace are examples of transnational activism, in part because they transcend national boundaries.Falk writes of the emergence of transnational activism:

 

            “the real arena of politics was no longer understood as acting in opposition          within a particular state, nor the relation of society and the state, but it            consisted more and more of acting to promote a certain kind of political             consciousness transnationally that could radiate influence in a variety of        directions, including bouncing back to the point of origin.”(p138)

 

This kind of activism became important to social movements during the 1980’s. Falk also emphasises that:

           

            “this transnational, grassroots surge, is not, by any means, just a Northern            phenomenon.”(p138)

Linked with this is the idea of the ‘multitude’. Hart and Negri’s idea is that ‘the multitude’ is a new model for resistance to global capitalism. However this does not imply any organised connectedness between members (except perhaps in the digital world) or a transnational organisation. The idea of the multitude can be traced back to Machiavelli, Hobbes and Spinoza who argued in Tractatus Theologico-Politicus;

‘Every ruler has more to fear from his own citizens […] than from any foreign enemy, and it is this “fear of the masses” […that is] the principal brake on the power of the sovereign or state.’

Global citizenship may take the form of activism at grass roots level using digital technology with individuals forming (online) groups ad hoc around emergent issues. Facebook is a platform may may be used by these ‘global citizens’ to get their message over. Note the response on twitter to comments made by a Daily Mail journalist’s comments on Stephen Gatley’s death. See  Twitter and Facebook outrage over Jan Moir’s Stephen Gately …   Though national in nature it demonstrates the potential for activism using digital technologies.

 

Falk’s 5 categories of GC

1.   Global reformers

2.   A man or woman of transnational affairs.

3.   Managers of the environmental and economic global order.

4.  Regional political consciousness.

5.  Trans-national activists.

 

 

 

 

Activism

 

 

Lagos (2002) relates the concept of activism to citizenship:

            “Global protest activity is on the rise. Demonstrations in Seattle in 1999, Genoa in           2001 and at dozens of other sites, brought activists together from around the world   and localized global issues in unprecedented ways. These and other activities          suggest the possibility of an emerging global citizenry. Individuals from a wide             variety of nations, both in the North and South, move across boundaries for different      activities and reasons. This transnational activity is facilitated by the growing ease   of travel and by communication fostered by the Internet and telephony”.  (p3)

then again:

            “A visible expression of global citizenship is the many global activists who debuted             spectacularly at The Battle in Seattle (1999). These protests continue at other       venues, such as at meetings for the World Bank and the IMF, and most recently at    the Summit of America in Quebec City. Other activists fight for environmental        protection, human rights to the impoverished and the unrepresented, and for       restrictions on the use of nuclear power and nuclear weapons . Freedom from    bureaucratic intervention seems to be a hallmark of global citizenship; the lack of           a world body to sanction and protect these citizens also means to a certain             degree freedom from bureaucratic control”.(p4)

 

Lagos then elaborates:

            “Scholars have already noted the emerging power struggle between corporations           and global activists who increasingly see the nexus of de facto governance taking     place more and more within the corporate world (and as mediated by            communication technologies like the Internet) and not in the halls of representative government. Hence, the tendency on the part of activists to promote rallies and     events like the protests at WTO, as more effective means of citizen participation and democratic accountability(p 13).

 

So clearly from this perspective global citizens not only think about the connectedness of their world transcending national boundaries, but are also spurred to action. There is an echo of Marx (1845, 1888) who argued “the philosophers have hitherto only interpreted the world in various ways; the point is to change it” (11th thesis:  Theses on Feuerbach).

 

Globally Orientated Citizenship

 

Parekh (2003) advocates what he calls globally oriented citizenship, and states:

            “If global citizenship means being a citizen of the world, it is neither practicable nor             desirable”(Parekh 2003 p12).

He argues that global citizenship, defined as an actual membership of a type of worldwide government system, is impractical and dislocated from one’s immediate community. He also notes that such a world state would inevitably be:

            “remote, bureaucratic, oppressive, and culturally bland.”(Parekh 2003 p12).

Parekh (2003) argues:

            “Since the conditions of life of our fellow human beings in distant parts of the world       should be a matter of deep moral and political concern to us, our citizenship has an inescapable global dimension, and we should aim to become what I might call a           globally oriented citizen.” (p12).

Parekh’s concept of globally oriented citizenship consists of identifying with and strengthening ties towards one’s political regional community (whether in its current state or an improved, revised form), while recognising and acting upon obligations towards others in the rest of the world.

 

 

 

 

 

 

 

A Multi dimensional concept

 

Falk’s 5 categories above may illustrate the multi-dimensional nature of GC and the various ways it could be defined. This is supported by Byers (2005 and 2008) who questions the assumption that there is one definition of global citizenship, and suggest that we could unpack aspects of all the various potential definitions. He argued:

            “Global citizenship’ remains undefined. What, if anything, does it really mean? Is           global citizenship just the latest buzzword?”

Byers notes the existence of stateless persons, whom he remarks ought to be the primary candidates for global citizenship, yet continue to live without access to basic freedoms and citizenship rights.  He does not oppose the concept of global citizenship, however he criticizes potential implications of the term depending on one’s definition of it, such as ones that provide support for the:

            “ruthlessly capitalist economic system that now dominates the planet.”

 

 

 

global citizenship

An ethical imperative.

An action imperative.

 

But whose ethics and whose action?

 

But it may be conservative upholding the current order or radical challenging the current order. Change could be advocated within the system to (make it fairer) or to change the system itself as this is the root of inequity.

 

Health care workers will  need to construct their own ideas for GC based on their understanding of ethics of caring, professional philosophies and the foundations for health.

 

 

 

 

 

 

 

 

 

 

 

 

Implications for Education.

 

The challenge for HEIs then is to decide if they should take a stance or be neutral and let the students decide. Each discipline may (will) have their own ideological or philosophical underpinnings that guide their educational practice. These may have to articulated more clearly in addressing ideas around GC. For example, an economics course that teaches within the frame of reference of capitalism (e.g. growth as a given) ignoring other political economies would proffer particular solutions to global finance within its own definitions of what it is to be a GC.

Thus GC is a contested space, but one view within nursing is that nursing is an ethical practice orientated towards health and well being. However this view says nothing about the political and social dimension of nursing. nothing about what is ‘ethical’. One may (‘must’ according to the NMC) act ethically towards our patients and clients but this does not automatically mean an international orientation challenging power structures as acting ethically is open to interpretation. So to what degree should students of nursing be orientated towards socio-political and international activism? Does being a GC mean challenging and overturning  or (merely?) mitigating the effects of the current global order? Working for an NGO in a health clinic in Africa could be seen to fulfill one’s responsibilities as a GC and for some this will be enough. For others being a GC will mean more radical action.

 

Raising awareness

A starting point could be to outline global disparities in health and well being such as that found on Gapminder.org – For a fact based world view., and poverty such as Poverty Facts and Stats — Global Issues   and then to encourage discussion about the remedies (which according to one’s ethical standpoint) may be many and varied. A focus on action needs to stressed if one wants to be a GC, however the nature if that action is debatable. The question arises should and to what degree should lecturers and the HE sector provide leadership in a particular direction?

A response is to argue that given the global crises facing humanity, academia cannot be neutral and objective researching and charting current trends and processes. However each discipline will articulate its own standpoint(s) in response. For health the challenge is to encourage a global outlook within the context of training an NHS workforce. The NHS itself will not look beyond its own borders and the training needs of its own staff.

 

Biomedicalism and Individualism v GC

Whatever GC may mean in terms of actual action, it is clear that the idea takes one out of narrow contexts bounded by local, regional or national UK boundaries and forces one to think about the health and well being of people living outside of the UK. In this task, we would need to move beyond individualistic bio-medical models of health and illness and draw upon more ecocentric paradigms (Kleffel 1996 and 2004, Goodman and Richardson 2010). We would have to examine current curricula to identify where we are focused on disease and illness in the individual and to where we adopt more a SOCIAL DETERMINANTS OF HEALTH model.  A public health (WHO | The public health approach) and a social determinants approach supports and is supported by the concept of GC as both address the environment and human activity as foundations for health.

 

Current and developing educational practice.

 

We argue there is a ‘sustainability-climate change-health’ triad (Goodman and Richardson 2010) that GC may assist in addressing:

 

Sustainability-Climate Change-Health Triad

       

                                                                                               

Positive feedback                                                  

·          Keeping healthy will assist sustainability and climate change.

·          Sustainable living mitigates climate change and improves health.

Negative feedback

·          Unsustainable living causes climate change and poorer health.

·          Climate change negatively affects health and sustainability.

 

This theoretical model needs testing and evidence, but may act as a framework for promoting the idea that good health results from unsustainable living and will be affected by climate change. Thus the payoff of adapting current lifestyles is twofold. Increased health, promoting sustainable living and mitigating climate change.

This task has begun in Faculty of Health modules where the embedding of sustainability has begun. Sustainability is unrelated to GC in terms of defining GC but is a very important policy and philosophical driver not just for developing global citizens but also for the HE sector as a whole (HEA 2009,  HEFCE 2009). The Centre for Sustainable Futures has produced guidance for curriculum planners and developers which may prove useful starting points. In addition, the principles underpinning Education for Sustainable Development (ESD) (Sterling 2001) and ecological (Orr 1994) and sustainable literacy (Stibbe 2009) would enhance discussion around global citizenship and its meanings.

For example , Stibbe (2009) emphasises ideas such as the interconnectedness between people and planet and ‘being in the world’ whereby people have the:

 

“ability to think about the self in interconnection and interdependence with the surrounding world”  (Danvers 2009 p185)

 

and the ‘systems thinking’ ability:

 

“to recognise and analyse interconnectedness between and within systems” (Strachan 2009 p84).

 

Both ‘being in the world’ and ‘systems thinking’ are concepts which are congruent with nursing theory which focuses on holistic care.

 

Comparing concepts embedded in Education for Sustainable development principles and those that may be found in some interpretations of GC indicates some common ground. 

 

GC

ESD

internationalism

internationalism

activism

participation

interconnectedness

interconnectedness

global community

community

reform

futures thinking

 

systems thinking

people centredness

student centredness

ecology

ecology

equity

equity

 

 

 

The link between ESD and Global Citizens (ESDGC) has been made explicit in Wales (leadership from both Welsh assembly and the HEFCW ) at both secondary school and in higher education. The argument is made:

“The role of Higher Education Institutions within ESDGC is pivotal in that they education a great number of the professionals and leaders of tomorrow’s society. They have a large role to play within the environmental management of their institutions and procurement policies, ensuring that globally aware, ethically sound and environmentally balanced processes are introduced. They also have potential for influencing others outside the university through professional development and training opportunities”.

(Welsh Assembly 2009  and ESDGC 2010)

 

 

The Global citizen within Nursing Education and Education for Sustainable Development/Contraction:

Because there is a pending planetary crisis, education (and nurse education) should attempt to challenge and prepare students for a not so brave new world. Selby (2007) suggests 10 Propositions for education:

1. Confront denial by challenging learners’ base assumptions, knowledge and responses. Get them to feel unease at the current situation: Nursing education attempts to develop the personal as well as professional competencies and thus challenges individuals’ world views. Therefore this approach would not be out of place.

2. Given the threat, education needs to address despair, grief, loss. Student nurses have to address loss in personal and individual patient cases: These concepts are already in many curricula (see the work of Kubler Ross for example) but the perspective may have to shift to embrace wider loss and grief issues that flow from climate change.

3. Shift to a holistic dynamic understanding of the relationship between humans and nature is an end in itself not a means to an end: Again this would not be necessarily a radical departure for nursing philosophy in any discussion regarding the value of humanity and the goal of nursing

 

4.Cultivate a poetic understanding alongside a rational understanding – we need to develop awe, celebration, enchantment, reverence as well as classification, prediction, evaluation and exploitation of nature: This mirrors the ongoing debate within nursing education concerning the art science dichotomy and would provide another useful lens to address the need for scientific competence and artistic appreciation and application in nursing praxis.

5. Marginalised ‘educations’ will be important (e.g. the field of non -violence): Rather more challenging for some fields of nursing such as acute hospital care but may well be core to therapeutic approaches within mental health.

6. Given the heating – sustainable and emergency education need to come together. Social dislocation, hunger, environmental disaster, tribalism etc necessitates an education that can respond (e.g. global citizenship, peace education, conflict resolution, anti discriminatory education etc): Nurses may well be key professionals in dealing with emergencies and disaster management with other healthcare professionals and thus education and training that explicitly addresses these skills may well be valued and developed.

7. Alternative ideas of what ‘the good life’ means need exploring: Again this could be core to nursing philosophy especially within the contexts  of mental health and palliative care and living with long term or life limiting conditions.

8. Rethinking notions of democracy, citizenship and sustainability could be  part of the professional responsibilities of the registered nurse.

9. Shift from atomistic/reductionist thinking to holistic ways of mediating reality. This is not an unknown concept for nursing, but may require further exploration and development.

10. “Everyone has to understand and come to terms with the fact that we are threatening our own existence. To confront this requires a Copernican revolution in aims, structures, processes of education and perhaps in the loci of learning ... as the heating happens, education and educational institutions ... will be deeply disrupted and if unresponsive to the need for transformation, will disintegrate as people find other more relevant loci for learning what they have to learn”.  (Selby 2007).

10 propositions for education

1. confront denial

2. address loss and grief

3. human-nature relationship

4. poetic understanding

5. marginalised education

6. sustainability and emergency education

7. alternative good life

8. democracy and citizenship

9. holistic thinking

10. accept we are threatening our own existence

 

Flowing from and building upon Selby’s suggestions, we could apply the following principles  for a  Nurse Education for Sustainable Wellbeing (NESW).

1. Wellbeing

Recognises that human well being depends on foundations of biological, emotional, cognitive, politico-social, and environmental existence which are transient, inter-dynamic and coexistent.  This involves understanding that a goal of nursing is to recognise which current state is achievable, acceptable, manageable and desirable by the individual, society and the environment and to support the movement of existence towards wellbeing. Sustainable Wellbeing rests on a relationship between the five but also recognises that the individual’s ultimate existence is non existence.

 

2. Interdependence

Involves an understanding about the connections and links between all aspects of people’s lives and places at a local and global level, and that decisions taken in one place will affect what happens elsewhere. Nurses should develop an understanding that living things depend on each other and should acquire a sense that all living things have value. This should lead to an understanding that what people do elsewhere affects them, the places they live, other people, and plants and animals. They should become increasingly aware of the global context within which health, trade, industry and consumption operate.

3. Citizenship and stewardship

Recognises that people have rights and responsibilities to participate in decision making and that everyone should have a say in what happens in the future. This involves a willingness to act as responsible global citizens while developing the ability to engage with and manage change at individual and social levels. Nurses are expected to know and understand the connection between personal values, beliefs and behaviour and how the hospital, health centres and community can be managed more sustainably. The choice agenda explicitly recognises this value but may focus too narrowly on choices regarding treatment options rather than choices regarding health inputs (for example – choices around sustainably developed food sources).

 

4. Needs and rights of future generations

This concept is about learning how we can lead lives that consider the rights and needs of others and recognising that what we do now has implications for what life will be like in the future. This involves nurses in discussing the way they live and the products and services they use, to distinguish between actions and products which are wasteful and those which are sustainable. This should enable nurses to begin to assess the sustainability of their own lifestyle.

 

5. Diversity

This concept is about understanding the importance and value of diversity in people’s lives – culturally, socially, economically and biologically – and realising that all our lives are impoverished without such diversity. Through learning, Nurses should appreciate cultural and biological diversity in the hospital and community and eventually be able to reflect critically on, and engage in, debates and decisions on political, technological and economic changes which impinge on diversity and sustainability. Diversity is recognised as a key concept with the NMC professional code of ethics

 

6. Quality of life, equity and justice

Recognises that for any development to be sustainable, it must benefit people in an equitable way. It is about improving everybody’s lives. At a basic level this involves understanding the essential difference between needs and wants and developing a sense of fairness. It involves understanding the difference between quality of life and standard of living and seeks a good quality of life for all people, at local, national and global levels and an appreciation of why equity and justice are necessary to a sustainable society. These concepts are addressed in quality healthcare provision frameworks and ought to be  part of the nurses’ understanding of the management of quality services. It should challenge the funding of some high tech-high cost (big pharma?)  treatment options for the (rich) few .

7. Sustainable change

Promotes an understanding that there are limits to the way in which the world, particularly the richer countries, can develop. The consequences of unmanaged and unsustainable growth in health provision for the rich might include increasing poverty and hardship and the degradation of the environment, to the disadvantage of everyone. This involves nurses in understanding how their hospital and community may be managed more sustainably and beginning to question decisions, practices and processes that affect sustainable development issues. Health care practices and delivery systems which result in inequities on a global scale should be challenged.

8. Uncertainty and precaution

Involves a realisation that because people are learning all the time and that their actions may have unforeseen consequences, they should adopt a cautious approach to the welfare of the planet. This implies understanding that different people want to do things in different ways and are able to listen to arguments and weigh evidence carefully. Nurses should thus be able to think critically, systematically and creatively about sustainable development issues, solutions and alternatives.

(these 8 key concepts are adapted from the Sustainable Development Education Panel 2000).Taking the first step forward towards an education for sustainable development (PDF)

 

Principles for a Nurse Education for Sustainable Well Being

1. well being

2. interdependence

3. citizenship and stewardship.

4. needs and rights of future generations

5. diversity

6. quality of life, equity and justice,

7. sustainable change

8. uncertainty and precaution

 

 

Conclusion

The challenges facing humanity in the 21st century require a radical rethink of ‘business as usual’. Education is important, but is not the only game in town. There are other agencies and ideologies shaping the future. However, education is the HEI’s sphere of immediate influence and although it may be morally questionable to ask the next generation to clear up after our own mess we may have little choice. The principles for educational programmes are enunciated above but they may be seen to be mediated through some notion of global citizenship that has to have a moral and political dimension if we are to move civilisation towards moral, economic and environmental sustainability.

 

 

References.

 

American Nurses Association (2008) ‘Global Climate Change’,http://www.nursingworld.org/  [online]    accessed 25th March 2009 

Byers, Michael (2005), The Meanings of Global Citizenship, UBC Global Citizenship Speaker Series,   [online]   accessed 10th January 2010.

British Medical Association (2008), ‘Health professionals taking action on climate change’, http://www.bma.org.uk/ap.nsf/Content/climatechange   [online]  (accessed 25th March 2009)

 

Canadian Nurses Association (CAN) (2008) ‘The role of nurses in addressing climate change. A background paper’, www.cna-aiic.ca/   [online]  accessed 14th January 2010

Canadian Nurses Association (CAN) (2010) ‘Climate Change and Health’ a postion statement. , www.cna-aiic.ca/    [online]  accessed 14th January 2010 

Carson, R. (1962) Silent Spring. Penguin. London.

 

Costello, A. et al  (2009) Managing the effects of Climate change. Available online at http://www.thelancet.com/climate-change    [online]  accessed 15th December 2009)

 

Chen, S., and Ravallion, M (2008) , The developing world is poorer than we thought, but no less successful in the fight against poverty, World Bank, August 2008  http://www.globalissues.org/article/26/poverty-facts-and-stats   [online]  accessed 10th january 2010.

 

Falk, R. (1994), “The Making of Global Citizenship”, in Bart van Steenbergen, The Condition of Citizenship, London: Sage Publications

 

Frank, R. (2007) Richistan. A journey through the American wealth boom and the lives of the new rich. Random house. New York.

 

Goodman B (2008) Sustainability, Consumption or Contraction:  A discussion paper published on the Centre for Sustainable Futures website: http://erdt.plymouth.ac.uk/csfwiki/index.php/Sustainability%2C_Consumption_or_Contraction%3F  [online] accessed 12th January 2010

 

Goodman B., Richardson J. Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing (forthcoming). In: Jones P., Selby D., Sterling S.(2009)Sustainability Education: Perspectives and Practice Across Higher Education. London, Earthscan

 

Hart, M., and Negri, A. (2000) Empire.

 

Higher Education Academy (2009) HEA Sustainability Project http://www.heacademy.ac.uk/ourwork/learning/sustainability    [online]  accessed 25th March 2009

 

HEFCE (2009)

 

International Council of Nurses (2008) ‘Nurses, climate change and health.  A Position statement.’ http://www.icn.ch/PS_E08_Nurses%20Climate%20Change.pdf  [online]   accessed 25th March 2008

 

Kleffel  (1996)  Environmental paradigms: moving toward an ecocentric perspective.   [online]     accessed 12th January 2010.

 

Kleffel, D. (2004)  ‘Advocating the Ecocentric paradigm in Nursing’ Journal of Holistic Nursing, 22 (1), pp 6-10

 

Lagos, T.G. (2002), “Global Citizenship – Towards a Definition”. [online]   accessed 12th January 2010

 

Leopold, A. (1949) A Sand County Almanac. Oxford University Press. Oxford.

 

Marx, K. (1845) published by Freidrich Engels in 1888 as ‘Theses on Feuerbach’. http://www.marxists.org/archive/marx/works/1845/theses/index.htm  [online]   accessed 10th january 2010.

 

Orr, D. (1994) Earth in Mind. On Education, Environment and The Human Prospect.. Island press. Washington

 

Jackson, T. (2009)  Prosperity without growth. economics for a finite planet. Earthscan. London.

 

Parekh, B (2003), “Cosmopolitanism and Global Citizenship”, Review of International Studies 29: 3-17

 

Rodrik, D. (2006) Goodbye Washington consensus: Hello Washington confusion. Journal of Economic Literature, December. pp 973- 987 http://ideas.repec.org/p/voj/wpaper/200821.html  [online]  accessed 12th January 2010

 

Rosling, H. (2009).  Hans Rosling: Asia’s rise – how and when (TEDIndia)    www.gapminder.org. [online]  accessed 10th January 2010

 

Schumacher, E. (1974) Small is beautiful. Economics as if people mattered. Vintage. London.

 

Selby, D. (2007) As the heating happens: Education for sustainable development or education for sustainable contraction? Discourse, Power, Resistance Conference, Talking Truth to power http://www.esri.mmu.ac.uk/dpr_07/abstracts_07/index.php[online]

 

Sinclair, F. (2009) ‘What is sustainability?’, http://ecohearth.com/eco-news/eco-op-ed/300-what-is-sustainability-.html  [online] accessed 25th March 2009

 

Sterling, S. (2001) Sustainable Education – Revisioning Learning and Change, Schumacher Briefings 6. Green Books, Dartington.

Stibbe, A. (ed) (2009) The handbook of sustainable literacy. Green Books. Dartington.

 

Sustainable Development Education panel (2000)Taking the first step forward towards an education for sustainable development (PDF)     [online] accessed 12th january 2010.

 

UBC (March 28 2008), “The Meanings of Global Citizenship – Dr. Michael Byers”, Global Citizenship Speaker Series, University of British Columbia. [online] accessed 12th January 2010.

Welsh Assembly (2009) ESDGC http://www.esd-wales.org.uk/english/higher_ed/higher_ed.htm [online] accessed 14th January 2010

ESDGC (2010) ESDG within Continuing Professional Development  http://www.esd-wales.org.uk/english/higher_ed/Continuing_Professional_Development.htm

 

Woodin, M. and Lucas, C. (2004) Green Alternatives to Globalisation. A manifesto. Pluto press. London.

 

 

 

Class divide in health widens

Class Divide in Health Widens

http://gu.com/p/3av95

 

What is the mechanism at play which prevents poor people from changing their lifestyles? Why do many not ‘take responsibility’ for unhealthy choices? The structural issues (e.g. unemployment which leads to sickness which leads to unemployment; another is long term low pay and part time work) are some mechanisms. Try living on <£12,000 pa on a monthly rent of £450 to see just how hard it is…so why smoke and drink and eat junk food then, all activities which eat into the funds that are available?? The evidence suggests that relative social status is a key mechanism (Wilkinson and Pickett 2010), i.e. living in a social group means also comparing oneself to those around us, a negative appraisal results in stress and physiologically this means corticosteriod release as well as adrenaline.  It sets up anxiety (physical stress as well – it makes the body unwell), now it just so happens that smoking, drinking and high sugary junk foods are great at hitting the pleasure centre in the brain, and giving us a shot of the pleasure hormone dopamine (the same hormone that ecstacy floods your system with). The advertising industry and corporate activity manufactures demand in the population, it needs you to buy stuff and one mechanism it subliminally uses is social comparison, you are invited to consider how your present self is and how your future self could be if you had this product. This also involves comparison with other social groups. So a lack of resources to engage in that activity advertised as a ‘good thing’ paradoxically leads to precious resources going into activities that relieve the stress and provide instant gratification. Smoking, drinking a junk food are excellent at instant gratification. Add to that mix a sense of fatalism, long term sickness, poor education, a lack of ‘self efficacy’, poor social capital and a perceived and often actual lack of a means to address these issues and hey presto you have an underclass mired in poor health and the cycle begins again. These are just some of the mechanisms at play. We are living in an insane society (see Erich Fromm ), which also creates this underclass and ensures this class has the mechanisms to self defeat. Social mobility in the UK has all but halted, so my advice is: choose your parents very carefully.

 

http://www.guardian.co.uk/news/datablog/2012/may/22/social-mobility-data-charts

http://www.dailymail.co.uk/news/article-2137585/Britain-worst-social-mobility-Western-world.html

http://www.guardian.co.uk/politics/blog/2012/may/30/milburn-social-mobility-politics-live-blog#block-10

Defining Health

Defining Health

 

WHO definition of Health

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948.

The Definition has not been amended since 1948.

This is a pretty idealistic view of health and does not take into account people with a mental or physical disability, who by the above definition are not healthy. Athletes who took part in the Paralympics in London in 2012 may disagree with the above as perhaps would Stephen Fry, who publicly discussed his own Bipolar disorder. The word ‘complete’ is controversial

However it allows us to list the:

Physical

Mental

Social

These 3 aspects of health take us beyond a biophysical definition.

 

There are other classificatory systems in existence such as the WHO Family of International Classifications, including the International Classification of Functioning, Disability and Health (ICF) and the International Classification of Diseases (ICD). These are commonly used to define and measure the components of health.

The WHO’s 1986 Ottawa Charter for Health Promotion further stated that health is not just a state, but also “a resource for everyday life, not the objective of living. Health is a positive concept emphasizing social and personal resources, as well as physical capacities.”

So in this charter, health is seen as a ‘resource’.

The WHO also defines mental health as “a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community”.

Again this might sound a bit too idealistic in that people with a mental illness can also live ‘normal’ (whatever that is) lives. Why are they not healthy then?

The New Economics Foundation (Aked and Thompson 2011) argue that there are 5 ways to well-being (‘well-being’ is a component of health):

1. Connect…

With the people around you. With family, friends, colleagues and neighbours. At home, work, school or in your local community. Think of these as the cornerstones of your life and invest time in developing them. Building these connections will support and enrich you every day.

2. Be active…

Go for a walk or run. Step outside. Cycle. Play a game. Garden. Dance.Exercising makes you feel good. Most importantly, discover a physical activity you enjoy and that suits your level of mobility and fitness.

3. Take notice…

Be curious. Catch sight of the beautiful. Remark on the unusual. Notice the changing seasons. Savour the moment, whether you are walking to work, eating lunch or talking to friends. Be aware of the world around you and what you are feeling. Reflecting on your experiences will help you appreciate what matters to you.

4. Keep learning…

Try something new. Rediscover an old interest. Sign up for that course. Take on a different responsibility at work. Fix a bike. Learn to play an instrument or how to cook your favourite food. Set a challenge you will enjoy achieving. Learning new things will make you more confident as well as being fun.

5. Give…

Do something nice for a friend, or a stranger. Thank someone. Smile. Volunteer your time. Join a community group. Look out, as well as in. Seeing yourself, and your happiness, linked to the wider community can be incredibly rewarding and creates connections with the people around you.

Social Determinants of Health

The approach that has gained influence is that of understanding health as having social determinants (WHO 2008), while Barton and Grant (2006) have developed a health map illustrating the complex interplay of the physical and global environment, social relationships and individual biology.

The social determinants of health approach (WHO 2008) suggests ‘Social justice is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death. We watch in wonder as life expectancy and good health continue to increase in parts of the world and in alarm as they fail to improve in others’.

Thus we clearly see a link between ideas about what health is and social justice. Health is therefore inextricably bound up with how we organise our societies. It is no longer to be understood as a bio-physical concept only. WHO argues:

‘The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels. The social determinants of health are mostly responsible for health inequities – the unfair and avoidable differences in health status seen within and between countries’.

See http://www.who.int/social_determinants/en/  (Commission on Social Determinants of Health 2008).

The Health Map

see: http://eprints.uwe.ac.uk/7863/2/The_health_map_2006_JRSH_article_-_post_print.pdf

Barton and Grant at about the same time produced a ‘health map’ and argued:

‘The environment in which we live is a major determinant of health and well-being. Modern town planning originated in the nineteenth century in response to basic health problems, but in the intervening years has become largely divorced from health. We have been literally building unhealthy conditions into our local human habitat.

 

Recent concerns about levels of physical activity, obesity, asthma and increasing environmental inequality have put planning back on the health agenda. It is widely recognised that public health is being compromised by both the manner of human intervention in the natural world and the manner of development activity in our built environment (Larkin, 2003). However, taking action is not necessarily simple. The links between health and settlements are often indirect and complex. A tool to improve understanding and foster collaboration between planning and health decision-makers is badly needed’.

The health map was inspired by theories about how the eco system interacts with biological species, which is clearly seen in the outer ring. An implication of seeing health in this manner is that the individual’s health is caught up in a web of complex systems and requires the ‘health’ of all manner of interacting physical and non-physical phenomena.

Healthy Planet, Healthy Lives?

Another view firmly connects the planet to people as a unitary whole arguing that as a result an individual is not healthy if the planet is not. This critiques a dualist view of reality in which we can separate physical human bodies from the physical universe, seeing them as two distinct entities. This may seem obvious to those of us living in western societies, as this is how we are brought up to consider how the world is. This has a long tradition but other philosophical traditions make no distinction between ‘man’ and ‘nature’:

“In this century it has become clear that the fundamental social problem is now the relationship between humankind as a whole and our global environment” (Loy 1988 p 302).

David Loy (1988 p140) argues, when contrasting Eastern traditions (nondualist) with mainly Western (Cartesian) dualism, that

“….there is no distinction between “internal” (mental) and “external” (physical), which means that trees and rocks and clouds, if they are not juxtaposed in memory with the “I” concept, will be experienced to be as much “my” mind as thought and feelings”.

This then is a non-dualist viewpoint in which ‘us’ includes the biosphere, we are indivisible as human beings from all life forms and all matter.

Industrialization has required the control of nature to serve humanities purposes. This control is based upon seeing ‘the self’ in opposition to nature, which Yagelski (2011) calls  ‘the problem of the self ‘:

“My argument here is that the prevailing Western sense of the self as an autonomous, thinking being that exists separately from the natural or physical world is really at the heart of the life-threatening environmental problems we face”.

 

These problems include: Ocean acidification, fertile soil erosion, species loss and the loss of biodiversity, fish species depletion, imbalances in the nitrogen and phosphorous cycles, fresh water scarcities, chemical pollution and stratospheric ozone depletion.

Rockström et al (2009) suggest that we need to urgently consider these issues to ensure there is a ‘safe operating space for humanity’.

Another view on health stemming from philosophers such as Aristotle who discussed eudaemonia or ‘flourishing’, or Amartya Sens’ views on ‘capabilities’ as an aspect of human health welfare:

Sen argued for five components in assessing ‘capability’:

1. The importance of real freedoms in the assessment of a person’s advantage.

2. Individual differences in the ability to transform resources into valuable activities.

3. The multi-variate nature of activities giving rise to happiness.

4. A balance of materialistic and nonmaterialistic factors in evaluating human welfare.

5. Concern for the distribution of opportunities within society.

This really stretches definitions of health to include ideas around welfare and the social and economic conditions for it.

Summary

Health involves our physical selves, the biology of our bodies which does not have to ‘perfect’. However health also involves our mental well-being, our abilities to cope with the world. Health involves social relationships and communities. Health involves our relationship to eco systems and other species. Health is therefore a complex concept that can be defined in various ways according to the perspectives we care to take on it.

Aked, J., and Thompson, S. (2011) Five ways to wellbeing. New applications, new ways of thinking. New Economics Foundation. London http://www.neweconomics.org/sites/neweconomics.org/files/Five_Ways_to_Wellbeing.pdf

Barton, H. and Grant, M. (2006) A health map for the local human

habitat.  The Journal for the Royal Society for the Promotion of

Health, 126 (6). pp. 252-253. ISSN 1466-4240

Larkin, M., (2003), Can cities be designed to fight obesity, The Lancet, 362, pp1046-7

Rockström, J., W. Steffen, K. Noone, Å. Persson, F. S. Chapin, III, E. Lambin, T. M. Lenton, M. Scheffer, C. Folke, H. Schellnhuber, B. Nykvist, C. A. De Wit, T. Hughes, S. van der Leeuw, H. Rodhe, S. Sörlin, P., K. Snyder, R. Costanza, U. Svedin, M. Falkenmark, L. Karlberg, R. W. Corell, V. J. Fabry, J. Hansen, B., Walker, D. Liverman, K. Richardson, P. Crutzen, and J. Foley. (2009). Planetary boundaries: exploring the safe operating space for humanity. Ecology and Society 14(2): 32. [online] URL: http://www.ecologyandsociety.org/vol14/iss2/art32/

World Health Organization. (1986) The Ottawa Charter for Health Promotion. Adopted at the First International Conference on Health Promotion, Ottawa, 21 November 1986 – WHO/HPR/HEP/95.1.

World Health Organization (2004). Promoting Mental Health: Concepts, Emerging evidence, Practice: A report of the World Health Organization, Department of Mental Health and Substance Abuse in collaboration with the Victorian Health Promotion Foundation and the University of Melbourne. World Health Organization. Geneva

Yagelski, R. [online] Computers, Literacy and Being. Teaching with technology for a sustainable futurehttp://www.albany.edu/faculty/rpy95/webtext/

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