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RF_DEV_14_SUDHA
HEALTH PROMOTION INTERNATIONAL
C Oxford University Press 1991
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Vol. 6. No. 1
Printed in Great Britain
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Econology: integrating health and sustainable
development. Part One: theory and background
RONALD LABONTE
Community Health Consultant, Ontario, Canada
SUMMARY
Environmental sustainability is rapidly becoming the
most critical public health issue. Prevailing notions of
health in environmental decision-making do not
embody concepts inherent in health promotion and die
new public health. Health promotion emphasizes the
importance of incoipe and power eqiiiry, and socipT
siipport/connecteaness (health-economy relationstup).
alongside direct and indirect human health threats
posed by environmental toxins (health-environment
relationship], Health promotion also acknowledges the
inherent limitations of scientific research, and the need
for value-based decision-making in the absence of
definitive information. Twelve principles are developed
from brief reviews of the hedtili-Hlviroiimeni-ecsnomy
relationships. While fear for personal health underpins
increasing public concern over environmental degrada
tion, persons with expertise or a constituency in public
health are not members of any of Canada’s federal and
provincial Round Tables on Environment and Econ
omy. Health promotion professionals should not wait to
be invited to participate yi~sustainable development
debates; they should invite themselves. I heir discipline
specific roots in epidemiology and clinical public health
practice will significantly enrich the vocabulary of the
debate. Their current a-disciplinary generalism may
allow them to function as effective and necessary cross
discipline translators.
Key words: healtfPand economy: health afijenvironment: sustainable development
INTRODUCTION
This article comprises two parts. Part One
reviews basic concepts inherent in sustainable
development, and explores their health implicatiOnTusing three sets of relationships: health and
environment, health and ecgnamv. economy and
envjZoSmctLt. ParTTwo explores thejjt-belween
tfie'new public~heaTth and sustainable development~criteria7and describe:? 1Z principles that can
be-"usecl to guide sustainable development
decision-making, such that the fullness of human
health is nurtured.
John Maynard Keynes once wrote that ‘Words
ought to be a little wild, for they are the assault of
thoughts upon the unthinking.' The language of .
both health promotion (the new public health)
ancTsustainable development ate certainly ‘wild1,
ahcTperhaps suffer from the effortof integrating
knowledge and information from a variety of
disciplines. A few starting definitions are in order.
Health is derived from the Old English ‘haelth’,
from which we have three entwined concepts:
'hello', whole and health. Health is thus intrins
ically holistic, and we violate its richness when we
focus only on biomedically defined conditions
(morbidity and mortality). Health is inherently a
social phenomenon, embodying the quality of our
relationships with one another. (The root of
'health' doubles as a social greeting in many other
languages as well as in English.) While health and
disease are often considered to exist on a continu
um, persons with chronic diseases or poor health
behaviours often regard themselves as being in
excellent health. (Toronto Comunity Health
Survey, 1988; Blaxter, 1990) This indicates that,
while related, health and disease are not contig
uous. This fact is recognized within a health
49
31
50
R. Labonte
promotion paradigm, but not within a health
protection paradigm. The latter paradigm, which
predominates in environment-health decision
making, is based upon reductionist methodo
logies that assess morbidity and mortality risks.
While providing important information, this
paradigm must be broadened to incorporate and
give inherent validity to individual and commun
ity experiences of health that are qualitative and
subjective.
Sustainable development is '.. . development
that meets the needs of the present without
compromising the ability of future generations to
meet their own needs' (World Commission on
Environment and Development, 1987) At face
value, this definition adequately captures the
environmental imperative to cease exhausting
natural resources. But it is a vague definition.
open to multiple interpretations. According to
Daly and Cobb (_1989), sustainable development
•should refer to the qualitative'change of a physi
cally nongrowing economic system in dynamic
equilibrium with the environment.' In simpler
terfns,”sustainable development recognizes that
the earth is not growing. Sustainable economic
activities develop the sufficiency and quality of
our relationship with planetary ecosystems. Sus
tainable development is not something that can be
tagged onto existing economic practices: it
requires learning how to live and produce in
dramatically different ways, particularly for First
World citizens (Trainer. 1990).
Econology is a neologism that combines econ
omy and ecology. Economy foikonomos ) des
cribes the management of the house, the house
being the planet and the human social systems
(cultures, modes of production) that depend upon
the planet's resources. It shares the same root as
ecology, which in turn describes the science of the
house, the 'rules' of interdependence that bind
planetary ecosystems into a whole. Econology is
'thes.ciencg.or rules of managing the housek or the
principles of sustainable development. The rea
son for a neologism, to paraphrase Foss and
Rothernberg (1988. p. 290). is that our reduc
tionist. determinist language militates against
joining together what 17th century Cartesian
dualism and 19th century industrialization rent
asunder? Ecology and economy still tend to be
seen as separate systems; witness the pheno
menon of 'environmental blackmail', in which
economic development and jobs are viewed as
competing with environmental protection (Kazis
and Grossman, 1982).
32
The role of health in sustainable development
decision-making
Although Canada was the first country to initiate
WCED-recommended Round Tables on En
vironment and Economy, none of its federal and
provincial Round Tables include members with
specific interest, expertise or a constituency in
health. Sustainable development is still largely a
matter ofTtalancing environmental protection
witFTsustained economic growth. Environment
Canada's sustainable development framework.
Into the Mainstream, refers to health only insofar
as 'a healthy environment is required for a healthy
economy' (Environment Canada, 1988). Re
peated opinion polls show that Canadians are
willing to pay higher taxes and higher commodity
prices if it would protect the environment, and
base their desire for environmental protection on
fears for their personal health. Health thus has a
potential moral and community level currency in
prodding economic decision-making that is en
vironmentally sustainable. The new public health,
by emphasizing the psychosocial, cultural and
economic dimensions of health, can significantly
enrich the vocabulary of sustainable development
decision-making.
/lk< *
-(j
The co-option of sustainable development
Sustainable development is often interpreted by
politicians and economists to mean continued
economic growth with the added challenge that
this growth no longer imperil the environment. To
many, this is a contradiction, a variation of
'trickle-down' theories of wealth and equity com
mon to the 1960s' various 'wars' on poverty.
(Kneen, 1989) The Bruntland report is partially
to blame for this perception by accepting a global
economic 'growth imperative’ so long as growth is
sustainable (MacNeill, 1989). Sustainable growth
is an ecological oxymoron; ecosystems do not
grow indefinitely (Daly and Cobb, 1989).
According to the President of the Royal Society
of Canada, sustainable development as sustain
able growth is little more than 'an excuse to carry
on our current practices’ (McLaren, 1989).
The notion that sustainable development is
having our cake (a healthy, resource replenished
planet) while eating it, too (economic growth,
increased purchasing parity, no decline in con
sumer goods or choices) is pervasive. Green
products fertilize this belief. One Canadian
grocery chain vaunts its 20 or so green products
(about 0.1% of the stores’ total merchandise) in
Integrating health and sustainable development
advertisements that claim 'You can write to
government or industry, but frankly it won't make
a difference. The only way you can make your
■<> initiate
voice heard for the environmenLJS_(.O_ bu.y_.pur
' on Engreen products.' Whilemost of these products
deral and
represent a less toxic alternative, there is an
ibers with
absurd meta-message that we can consume our
tuency in
way into a healthier environment. Despite the
largely a
pressure, consumer purchasing can apply to
'rotection
corporate practice, lobbying government and
ironment
industry are also necessary and effective means of
imework.
promoting healthier public and private sector
iy insofar
behaviours?
a healthy
More seriously, a Canadian task force on
88). Regreenhouse gas emissions concluded that 1988
lians are
\ emission levels could only be maintained by 2005
mmoJfeand not reduced by the international target of
ter Wi
20%. In the name of sustainable development, the /
.ction on
i task force's mandate was that emissiorTcuts be
tus has a
1 made ‘without any loss of economic benefit, with- '
rency in
out reducing real income, without affecting our
it is enstandard of living.' (Federal, Provincial, Territor
c health.
ial Task Force on Energy and the Environment,
tral and
1989).
ificantly
The rhetoric of sustainable development pla
opnient
cates many into the belief that a green economy
can be achieved without pain, or that our environmental debt is more acceptable than our fiscal
debt (Mclnnes. 1989). The public health field
eted by
over the past century has learned that meaningful
itinued
health.gains ar.ejot made without some hardship^
_ie that
Ourdominant biomedical model, with its promise
ent. To
of a quick, painless cure for most maladies, is
ion ofL ,
quite ineffective against the chronic afflictions of
v com-/
c -hearl disease and cancer. Only the public health
ovens. F'&i £*2prevention model offers some success, and it is a^/
irtialli
complex, socially 'painfu£_model: changing lifeolobd
cc» styles, chan gi ng_pnb licqJJItcies (e .g. anti-lotiafctvO
(7A^<x^'t^lt-T,slal!£,n- nutritiotppolicies).). and. more recently.
.row‘^*2
-.^attempting
-.-(^attempting to change social ccu
conditions
Ui.iU>» supportive
u>u
:o
a$of 'dis-ease' (poverty, isolation, the sundry '-isms'
989). v’r ‘ of structural and interpersonal prejudices that
ociety
reinforce self-blame).
.stain
Illich characterized the third level of 'iatrocarry
genesis' (medically induced illness) as cultural.
our collective inability to accept the 'healing
.■nt is
qualities' of pain (Illich. 1976). Sustainable
ished
development decision-making that embraces the
owth.
learnings of public health will also embrace as
conhealing the necessity of painful personal and
<reen
social dislocations, the amount of pain being
adian
equivalent to the degree to which we have person
■ducts
ally benefited by past, non-sustainable economic
se) in
practices.
lopment
33
51
The sustainable hierarchy
A fundamental question of any reasonably largescale economic activity is: Does the product it
produces, or the process by which it is fashioned:
O replenish the planet?
® replace what is taken?
• reduce energy consumption and the production/consumption of toxics?
• reuse (or allow for the reuse of) constituent
materials? or
® recycle (or allow for the recycling of) consti
tuent materials?
Any given activity may have attributes of all of the
above, but the five Rs are listed as a hierarchy
because planetary, and hence human, sustaina
bility depends on our abilities to replenish and
replace.
Replenish means that the activity puts more
into the planet (energy, renewable resources)
than it takes out. We have depleted our natural
capital to such an extent that it can scarcely sus
tain our current levels of economic activity.
Neither can we expect population growth to ease
suddenly; simply to maintain a ‘steady-state’ of
human demands on environmental capital we
must now replace more than we take.
Replace is at the core of most government
definitions of sustainable development. It is not a
new idea. In 1915, Canada's Commission on
Conservation noted that 'each generation is
entitled to the interest on the natural capital, but
the principal should be handed on unimpaired.'
(cited in Keating. 1989) Since we have failed
remarkably to do so, replenishing of some form is
required or we would find ourselves damned by
our past even as we 'steady-state' our present.
Reducing our use of natural capital is often
considered the base of environmentalism. It is.
insofar as individual actions are concerned. First
world citizens must consume less, and differently.
As Rees (1989) put it, 'the family’s second car
may represent capital that was not ploughed back
into silviculture, soils management and waste
control,’ or, for that matter, into international
efforts to re-balance global inequities in resource
allocation, and the population growth these
inequities foster. The global epigram for the
1990s may well be ‘live much more simply, so that
others might simply live.’ Reducing our use of
natural capital is also imperative with respect to
non-renewable resources (e.g. minerals) which
cannot be humanly replenished or replaced.
52
R. Labonte
Reusing materials is one method of reduction.
as in recycling. Both are very low-tiered options.
particularly recycling. As with green products.
however, recycling is often promoted by
politicians and industry as a major strategy for
environmental protection/ primarily because
recycling is an individually premised option, and
not one that deals with systemic problems of
production and consumption. , i> A BASIC HEALTH-ECONOMYENVIRONMENT FRAMEWORK
Hancock (1989) in a background conference
paper provided a simple framework for discus
sing the interrelations of health-environmenteconomy/ He positioned health and environment
above economy since 'economic activity must be
subservient to the need for health for all and a
secure environment (while it also) underpins our
health and well-being and our environmental
security'. Figure 1 re-casts Hancock's inverted
triangle of relationships as a simple circle flowing
in both directions.
In general, our understanding of the links
between health and environment has depended
on epidemiology, toxicology, clinical (animal)
controlled trials and molecular biology. Our
understanding of the links between environment
and economy has relied principally on economic
theory, and the natural and applied sciences.
(Although economic theory is, strictly speaking, a
social science, it has successfully aspired to the
status of a natural science and is alone among the
social sciences to be granted a Nobel prize.) Our
understanding of the links between health and
economy have found gi eatest expression in politi
cal economy, sociology, social psychology and
social epidemiology. This is not an exhaustive or
necessarily exclusive listing, but it indicates that
there is no singular way into understanding these
relationships. Also, while the grammar (the scien
tific foundation arguments) of many of these
disciplines is converging, many disciplines remain
committed to certain assumptions about know
ledge. scientific fact and causality. Their lan
guages are very different.
Interdisciplinary work will only partially miti
gate the problems inherent in discipline specific
enquiries. Each discipline engages in a largely
unconscious process of abstracting reality. These
abstractions must be made self-conscious if we
are to develop a sustainable economy (Daly and
Cobb. 1989), which may require the 'nondiscipline' of multisectoral workers whose major
task is to translate across existing disciplines
(Nelson. 1989).
Biomedical Sciences
Social Sciences
’ epidemiology
• toxicology
1 molecular biology
social epidemiology
political science
social/commumty
Natural Sciences
• economic theory
• geology
• natural/opplied sciences
Fig- 1
34
Integrating health and sustainable development
■ ironment
economic
sciences.
’caking. a
-‘d lo the
mong the
ize.) Our
■tilth and
in politiogy and
□stive or
Our institutional forms of organization, built
upon and reinforcing professional disciplines, are
also major barriers. There is often interministerial
jurisdictional conflict. Government treasury,
energy and economic development departments
are generally more powerful than environment,
health or welfare departments. This conflict begs
for a series of publicly debated, legislated prin
ciples that can be used to cut across the narrowly
expressed concerns of different government
ministries.
lies that
ng these
ie scien>f these
' remain
e^W
ly initi'pecific
larsels
These
s if we
ily and
non
major
iplines
Health and environment
Assessing health and environment relations
usually means determining disease risk to humans
from environmental toxics. This can take three
different forms (Figure 2).
• Estimated effects of large-scale environmental
changes (greenhouse effect, foodstock reduc
tions).
• Implied effects using biological markers
(health effects in other species in our immed
iate environment) or experimental studies
(animal research on carcinogenic, mutagenic,
immunotoxic, teratogenic or acute effects; or
bioassay studies).
• Direct evidence of toxic effects (acute and
chronic) on humans.
53
Large-scale planetary changes are the most
important and problematic. Some indicators are
available, for example, the global population
affected by drought and flooding doubled during
the 1960s and there are now more en
vironmental than political refugees. The effects
of enhanced global-warming, however, cannot be
quantified with any precision, and will only be
known as they are experienced. Biological and
ecosystem change differs from linear forms of
mechanical change (Foss and Rothenberg, 1988;
Broecker, 1987). Whereas mechanical change is
generally smooth, ecosystem change may come
in sudden jumps. After a long period of near
equilibrium, or homeostasis (which essentially
describes the ‘health’ of an ecosystem), a slight
rise in global temperature, a small decrease in
stratospheric ozone or a fractional net increase in
toxic contamination of ground water may cause a
massive disruption (‘disease’) within the eco
system with rapid and catastrophic consequences
for human life. A simple analogue is the chemi
stry experiment, in which one liquid is titrated
into another. The clear, receiving liquid (the
ecosystem) can incorporate hundreds of drops of
the new substance (CO2, CFCs, etc.) without
demonstrating any system-wide change. It
remains clear. But a point is reached in which a
single drop turns the receiving liquid milky; the
Fig. 2
35
54
R. Labonte
Table 1
Probable Disease Effects,
Enhanced Global Warming
•
•
•
•
•
increased mortality (young, frail, elderly)
due to high heat
increased infectious disease mortality due
to flooding of sewage vectors, increased
insect vectors
increased genetic damage, cancers,
neurological, immunotoxic and
reproductive damage due to flooding of
toxic waste dumps
increased skin cancers and immune
system damage due to increased UV
radiation, due to ozone-depleting
greenhouse gases
increased overall mortality due to
desertification and flooding of
agricultural gases
entire system is fundamentally and irrevocably
altered. A new system is created.
We know theoretically that this analogue holds
for the planet. We do not know the point at which
the planetary ecosystem will demonstrate such a
•quantal' shift. We are also confounded by the lag
time phenomenon well known to epidemiology.
The time-scale of the planetary ecosystem is
much longer than for test-tubes or humans. It
may take decades before -the perturbations
of enhanced global-warming are indisputably
recognized. Unfortunately, by the time we recog
nize system-wide changes, the momentum of
enhanced greenhouse gas build-up will be irre
versible. (This is sometimes called ‘the Titanic
effect'; the momentum of the ship prevented it
from avoiding the iceberg even when it was
known that a collision was inevitable.)
We are literally staring up from the bottom of
our planetary test-tube watching large, lazy drops
of toxic emissions roll towards us, uncertain of
which one will turn our ecosystem 'milky', and not
knowing if this new ecosystem will be capable of
supporting human life.
In contrast to the intrinsic uncertainty of
ecosystem change (Rees, 1990), biological and
bioassay markers offer evidence that comes
closer to fulfilling the certainty criteria of main
stream science. One researcher scraped industrial
pollutants off the bottom of a creek which
contained fish suffering cancerous tumors; he
placed this effluent on healthy fish, and produced
the identical cancers (cited in Labonte and
Davies, 1986). Beluga whales in the Canadian St
Lawrence River have decreased in number from
over 5000 at the beginning of this century to
fewer than 400 today. Most Belugas suffer from
cancers, birth defects, skin disorders and other
life-crippling diseases. When their carcasses wash
ashore they are so contaminated with toxic pollu-
36
Integrating health and sustainable development
55
Table 2
Human Health Effects of Environmental Damage
Problem
Erred
ground level ozone
accumulation
atmospheric ozone
depletion
chronic lung disease
basal/squamous cell
carcinomas, cataracts
and immune system
dysfunction
respiratory morbidity and
mortality
colon and female breast
cancer
various cancers
SO,/ground level ozone
emissions
SO,/emissions
steelwork, petrochemical
plant processes/emissions
tants flowing from the Great Lakes, or from
primary industrial plants operating near the river,
that they are declared hazardous substances.
Direct inference to human health is moot; how
ever. cancer and birth defect rates increase as one
moves west to east along the Great Lakes towards
the St Lawrence River, and are highest amongst
residents living on the river shores upon which the
belugas beach themselves in death (Israelson.
1987 cited in Small et al.. 1988). Another study
found that children of women who ate a diet high
in Great Lakes fish during pregnancy are suf
fering higher rates of growth retardation and
learning disorders. The same effects are found in
laboratory animals fed a high Great Lakes fish
diet.'
Despite the ethical and practical necessity of
using biological markers as human proxies, many
policy-makers are reluctant to restrict economic
practices unless some direct human evidence is
also available. That evidence is slowly accumulat
ing. for example, ground level ozone accumula
tion and chronic lung disease: atmospheric ozone
depletion and basal/squamous cell carcinomas.
cataracts and immune system dysfunction (Grant.
1988); sulphur dioxidc/ground level ozone emis
sions and respiratory morbidity and mortality
(Bates. 1990); sulphur dioxide and colon and
female breast cancer (Gorham etal., 1989); steel
work and petrochemical plants and cancer, not
ably leukaemias; and magnetic fields emanating
from electromagnetic transmission lines and cer
tain cancers, especially amongst children (Small et
al., 1988)?
Much of the data remain equivocal, and there is
little neutral ground in assessing the risk of toxics
exposure. Apart from trauma or acute disease,
scientific methods are inadequate to capture the
reality of multiple exposures to multiple and often
ubiquitous toxics that occur within a social
context that creates its own health risks (poverty,
isolation, unemployment, unhealthy lifestyles,
etc.). It is extremely difficult to determine ex
posure levels, except in animal experimental
situations. There is really no longer an unexposed
control group. Many toxics produce the same
effects, a single toxic may produce multiple
effects, and many effects caused by specific toxics
are also caused by other chemicals or non
chemical events. This renders unicausal deter
minism somewhat specious?
We lack toxicological data on both acute and
chronic effects of over 80% of the 45 000100 000 odd industrial chemicals in common
use; data on chronic effects are particularly
limited. Toxicologists disagree over inter
pretation of the heuristically high doses to
which test animals are exposed, the inter-species
37
56
K. Labonte
significance of the results, and of the extrapola
tion models/assumptions used for imputing
human health risks.
The net result is that there are very few
quantitative data upon which policy-makers can
rely. Unfortunately, this results in policy inertia.
The chairman of the Canadian Petrochemical
Association expressed relief when the 1990-91
Canadian federal budget did not include a fossil
fuel ('entropy') tax, by contending that 'politics is
too far ahead of the science on these issues'.
Hancock (1989) argues that ‘our decision-making
must be informed by science, to the extent that we
have or can plausibly expect to have scientific
evidence; but where that evidence is unlikely to be
forthcoming, our decision-making must be
informed by our values, chief among which is the
need to err on the side of caution'. This point can
be stated even more strongly: for scientific data to
contribute in a meaningful way to sustainable
development decision-making, they must exist
within a policy framework comprised of value
based principles for decision-making.
This position can be criticized as biasing scien
tific enquiry, or turning science into acts to 'prove'
predetermined judgements. This is not the intent
of advocating for the integration of science within
value-based principles but. rather, a recognition
that public policy already is determined more by
values than by data. These values are usually
unconsciously held, not made public and not
appraised alongside the information science can
provide Moreover, all scientific enquiry pro
ceeds from values (e.g. the decision to study one
problem' rather than another, and how that
problem' is defined) even it researchers do not
recognize this fact (Ratcliffe and Gonzalez-DelValle. 1988).
As Rees (1990) summed it up. 'Environmentrelated decisions will be based more on political
judgement calls than objective technical ai.
Economy and health
The predominant economic argument goes that
we can be healthy only in a healthy economy:
continued economic growth is a prerequisite for
individual well-being. Historically, life expec
tancy and infant mortality rates (the biomedical
bellwether indicators of population health) have
improved as per capita GNP levels have risen
(Daly and Cobb. 1989: Hertzman, 1989). The
best bellwether indicators today belong to Japan
and Sweden, respectively, both 'full employment'
economies. Conversely, life expectancies de
clined in certain parts of the Soviet Union and
Poland. Czechoslovakia and Hungary during the
1970s. a period of gross economic stagnation.
Improvements in industrialized nations' GNP.
however, usually come at the expense of poorer
countries. Economic adjustments conditional for
refinancing of the $1.3 trillion Third World debt
has led to export cash-cropping and less food selfsufficiency. higher unemployment. lower wages.
poorer housing, less health care and less educa
tional services in many poor countries. UNICEF
(1989) directly attributes 500 000 infant deaths a
year to these economic policies, and estimates
that, in 1988. there was net capital outflow of S60
billion from poor to rich countries. Much of this
capital outflow represents interest payments on
the debt, and much of this debt was incurred for
economic development that accrued benefits
principally to First World investors and a very
small proportion of the indebted country's popu
lace. One estimate is that only 6% of Brazil's S121
billion debt went to development that improved
the quality of life for Brazilians; 14% was lent to
transnational corporations for mega-project
development. 17% disappeared into Swiss bank
accounts. 34% was incurred due to lower export
and higher import prices arising from debt refin
ancing provisions, and 28% constituted interest
rate increases on the debt (Tomlinson. 1989).
These economic policies are distinct from
those of environmentally unsustainable mega
projects (e.g. the Polonoroeste Colonization Pro
ject in Brazil; the Botswana Beef Production
Project) which, according to oft-quoted World
Bank president. Barber Conable, are becoming a
thing of the past. These practices embody an
unsustainable environment-health relationship.
Economic reforms imposed by the World Bank
and the IMF produce an unsustainable economyheahh relationship wl-"-h in turn, ta'-'- the envi............. . . , ,anh = excessive
.iculture.
wood-fuel burning, over-grazing and below sub
sistence poverty that fuels population growth.
Despite the growing income gaps between rich
and poor nations the net health gap between rich
and poor nations is actually shrinking. Some attri
bute this trend to the 'invisible hand' of industrial
development, to which McKeown (1976) attri
buted the decline in 19th century infectious
disease rates in industrializing England. There is
some evidence to support this claim. But just as
the bulk of 19th century infectious disease decline
was achieved through a series of intentional
health and social reforms, to which aggregate
38
Integrating health and sustainable development
57
the income or wealth generated by a nation’s
economy is shared by its people. GNP measures
economic value, but is not a reasonable measure
of economic welfare (Daly and Cobb, 1989).
Moreover, the association between GNP growth
and improved population health may be spurious
or, at least, has a ceiling (Shirlow, 1990). Female
life expectancy flattens once per capita GNP
(1985) reaches S3000 — a mere l/5th of the US
1985 per capita GNP!
Steady-state economists have long criticized
the use of GNP for ita failures to encompass the
underground economy, to credit social expendi
tures as wealth-creating (albeit indirectly through
healthier, more productive people), to deduct
environmental or disease-producing activities,
and to internalize fully the costs of production
externalities (Victor, 1989; Ekins, 1986; Robert
son, 1988, cited in Hancock, 1989). This criticism
has not become a part of popular culture. Rather,
the business sector continues to argue for contin
ued GNP growth, lower social spending and other
indicators of economic ’welfare’. This thinking
becomes popular myth. Developing alternatives
to the GNP and similar economic indicators as
measures of social well-being is another requisite
to sustainable development decision-making
(Figure 3).'
economic growth was the context rather than the
cause (Szreter. 1988), so. too, have recent health
achievements in the Third World resulted from
specific interventions: potable water, oral rehy
dration therapy, immunization.h
The same phenomenon exists for First World
countries such as the US, although here the effect
is in the other direction. US infant mortality rates
tn the early 1980s rose in 11 states and many
inner city neighbourhoods. This rise, associated
generally with the economic downturn and
Increased poverty of the 1982 recession, was
directly attributed to intentional cutbacks in wel
fare payments and nutritional supplement pro
grams (Miller, 1985; Brown, 1987). Aggregate
economic change was the background; specific
policies (welfare reductions) was the ’cause'.
‘Health without wealth" challenges the simplis
tic rendering of lifespan as a function of GNP, or
other ’trickle down’ measures of economic health.
Many Third World countries with low GNPs have
much better health indicators than countries with
high GNPs. and have sustained these benefits as
their enlarged cohort of surviving babies grew to
be adults. Even the US. which has the highest per
capita GNP. ranks low amongst OECD nations in
its health indicators. The reason is simple: GNP
savs nothing of economic distributive justice, how
1. Absolute poverty
i 2. Relative poverty
(Wealth inequity)
I 3. Power inequity
4. Social isolation
5. Community
Fragmentation
i
Fig. 3
39
58
R Labonte
The relationship between economy and health
in first world countries is best captured using
socio-economic status (SES), since SES measures
(income, occupation, education) essentially
define one’s relationship to the economy. Transnationally, those OECD countries having the
greatest after-tax income equality (the best gini
coefficient for income) have the best bellwether
health indicators (Wilkinson, 1986). This effect is
independent of the absolute level of income.
Inequalities in income distribution, and what they
represent in terms of the experience of power,
may be more important to health and welfare than
income itself. The health gains in Japan over the
past two decades (Japan ranks first on life expec
tancy and infant survival) are attributed partly to
its economic growth and relatively equitable
income distribution, and are as great as Britain
might achieve if it 'abolished heart disease and
most cancers’ (Marmot and Smith. 1989).
The SES 'health gradient generally holds across
time, geography, relative income increases and
population-level improvements in health. Neo
conservative economists attribute differentials
such as these to a 'selection process'. The sick are
unemployable and economically unproductive.
hence they are also poor. Several longitudinal
studies refute this explanation. I inding that a drop
in income predicts poorer health after controlling
for such health-related behaviours as smoking or
exercise (Hirdes. 1986). Canadian men in the
bottom 5"(> tn earnings in the two decades before
retirement, as another example, are twice as likely
to die before 70 compared with men in the top 5%
of earnings (Wolfson. 1989).
Even more compelling evidence is offered by
the Whitehall study of British civil servants (cited
in Wilkinson. 1986). This study found more than
3-fold differences tn mortality between the lowest
ami highest grades in the male civil service. None
of the employees was living in poverty and all had
good job security. They all worked in the same
location (London) and were not exposed to
industrial hazards. For nearly every cause of
death, there was a clear relationship between civil
service grade and mortality. Another British
study (Marmot and Theorell. 1988) concluded
that work conditions, and in particular the free
dom to make decisions, are the basts for the
strong association between social class and heart
disease; and that 'above a threshold of poverty.
position on the social hierarchy may be a more
important determinant of health and disease than
material conditions.’
40
Economic and workplace organization become
as important criteria for suitable development as
what is produced, emitted and consumed by the
act of work. Garden's research into occupational
stress and well-being found that of all workplace
factors influencing health, the degree of worker
decision-making was the most powerful (Gustavesen, 1988). Social interaction at work was also
rated as more important than remuneration in a
study of Canadian workers (Canadian Mental
Health Association. 1985).
Similar findings emerge from research on social
support/community connectedness and health.
There are two ways in which this connectedness
seems to predict health: the quantity of one’s
social/community networks, and the quality of
support these networks provide (Cohen and
Wills, 1985). Among the key elements of health
enhancing social support are proximity (people
are near to us) and symmetry (the relationship
tends towards equality in power). These findings
have implications for the health-economy
relationship that go well beyond usual environ
mental assessment parameters. Industrial econo
mies are well known for breakingapart traditional
extended families which for centuries provided
much of the social support that researchers are
busy studying today. (The sexism in many of these
extended families and what it did for women is
another matter.) This has been a general trend
and is unlikely to be reversed. But social support
and health findings imply that economic decision
making must embody some accounting for how it
will foster (or at least not destroy) community
social networks of support.
The collapse of certain resource sectors may be
unavoidable and even desirable for environmen
tal sustainability. Such collapses lead to the
demise of many resource-based rural communi
ties. Assuming that environmental sustainability
can be assured, these collapses can be partly off
set by changes in regional economic policies that
embody community sustainability principles in
the planning stages. Up-front capital reserves
before resource extraction can allow the com
munity to create economic activities beyond the
lifespan of the resource, or to relocate and retrain
workers and their families. It could also be requi
site that, before any resource extraction is permit
ted to proceed, an economic diversification and
job re-training strategy is articulated and capital
ized. (Such requirements would represent an
internalization of external social costs. Internali
zation of externalities is discussed in greater detail
Integrating health and sustainable development
'» become
■pment as
:ed by the
upational
workplace
9 worker
il (Gustawas also
ition in a
> Mental
on social
•' health.
etedness
of one's
uality of
ten and
f health-
•
tn. mp
tindings
conomv
nvtroneconoditional
rovided
:ers are
ifthe.se
■men is
I trend
upport
eisionhow it
nunitv
es m
er\ es
mm.1 the
train
.■qui'nutand
■ital: tin
nalietail
below and in Figure 4.) Regrettably, the trend in
Canada is towards the opposite. Resource work
ers in the Maritimes once qualified for paid job
retraining programs [hat. among other things, saw
them construct community theatres, rebuild com
munity wharves, and perform other community
sustaining activities. These programs now will
only support job re-training in a primary resource
occupation — despite the fact that these resource
industries can no longer support the unemployed
labour force. This is not a community sustaining
policy, and it is arguably environmentally un
sustainable by encouraging terminal resource
depletion.
Finally, low levels of social support in First
World countries tend to be greatest amongst
poorer people (Auslander. 1988: Ruberman et
al. 1 984; Berkman 1 986). This finding speaks to
a process through which low-income or lowstatus people internalize their 'real' powerless
ness. creating a psychological 'surplus
powerlessness' (Lerner. 1986). This powerless
ness (both real and surplus') fosters apathy and
cynicism which, in turn, promotes isolation and
withdrawal, a de-construction of community.
Economic activities that increase real powerless
ness (through low-income jobs, isolation, res
tricted choices, community dislocations and so
oh) are unsustainable in human health terms
Fig-4
41
59
Environment and economy
Environment Canada's deputation to the World
Commission on Environment and Development
(Environment Canada, 1986) noted simply that
'we can no longer sell off and pollute the capital
on which our lives and livelihoods are based'.
Whereas in past generations this capital could be
exploited either regionally or nationally without
apparent loss or damage, 80% of the world’s
economic growth has taken place since 1950
(Keating, 1989). This phenomenal growth has
extracted energy and resources and produced
global toxics beyond the resilient adaptability of
the planetary ecosystem. Most of this growth has
occurred within a few industrialized countries.
We are now witnessing global industrialization,
and it is those very industrial activities that extract
the greatest and pollute the most that are expand
ing most rapidly in Second and Third World
countries.
Industrial and post-industrial economic activi
ties have been predicted on two powerful myths,
the first being that of technological beneficence.
Mass media regularly imply that the pollution
caused by economic activity can be resolved by
technology, just as biomedicine will (eventually)
cure all cancers. There has been a beneficial
boom for pollution control and clean-up
industries in recent years; some 3000 Canadian
AO
/?. Labonte
firms employing 200 000 workers are estimated
to contribute between S7 and $10 billion to the
economy (Hansen, 1990). But clean-up indust
ries, and to a lesser extent pollution control
technologies, represent a downstream strategy.
Just as the escalating costs of disease treatment
cannot be sustained indefinitely as a health
strategy, technologically driven pollution clean
ups may be unworkable over the longer, economic
term. If nothing else, we continue to produce new
synthetic chemicals al a rate outstripping our
capacity to assess their health or ecosystem
impact, to say nothing of our relatively paltry
knowledge of those already in our midst (Keating.
1989; Labonte and Davies, 1986).
Our second economic myth is that ofjhe
necessity of continuous economic growth, which.
as Ekins (1986) points out, is ‘as if economists
had never heard of cancer'. The problem may not
be with 'growth' perse (which is a characteristic of
all living organisms and the systems they create
and exist within) but with how economists.
business leaders and politicians consider econo
mic growth. If economic growth means increasing
the scale of economic activities, it is unsustain
able. economic grow th is used in a more biologi
cal sense, that of changing, maturing and
developing, it may be sustainable (Daly and
Cobb. 1989). The Ontario Round Table on Envi
ronment and Economy describes this as an atti
tudinal shift, from economic growth as 'quantity'
(more = better) to economic growth as ’quality'
(doing better with less) (Ontario Round Table on
Environment and Economy. 1990). Daly and
Cobb (1 989) describe it as a shift from economy
as ‘chrematistics’ ('the manipulation of property
and wealth so as to maximize short-term
exchange value to the owner') to economy as
‘oikonomia’ ( the management of the household
so as to increase its value to all members of the
household over the long run.'). Chrematistics
characterizes neoclassical economic theory and
current political decision-making. Oikonomia
differs from chrematistics by taking’ a long-run
view, considering costs and benefits to the whole
community, and focusing on 'concrete use value
and the limited accumulation thereof, rather than
on abstract exchange value and its impetus
towards unlimited accumulation.' (Daly and
Cobb. 1989).
The value of integrating economic-environ
ment-health decision-making lies primarily with
what the latter two might say about the unsustain
ability or pathology of chrematistic economic
practice. This does not mean that economic sjw
theory is secondary to environment and health.
Indeed, market theory and practice offers a vjS
language for valuing human activities and natural
resources that is strategically important in sustain- 31
able development decision-making. This language
can be criticized for ‘reifying’ social relationships -3
and, unamended by community or humanistic a
values, leading to human self-alienation (Marcuse, 5
1964). Nevertheless, it offers a means of beginning )
to transform unsustainable to sustainable eco- 5
nomics. As Victor (1989) points out, a good >
economic analysis should identify market failures ■
to take full accounting of ‘the value people attach
to improvements in environmental quality... ';
These market failures may be much easier to s
respond to (change) than fundamental, ethical
challenges to our existing values.’
Victor's comments reflect a key principle of the
’
new economics’(Ekins, 1986) and of sustainable
development (Daly and Cobb, 1989; Keating,
’
1989), that all ‘externalities’ must be fully costed
,
and internalized into the prices of commodify
J
production. An 'externality' occurs when econo
mic activity affects the welfare of persons not
J
directly involved in that activity, where directly
means that the effect is not mediated through any
market mechanism and thus lacks a price (Daly
and Cobb, 1989). For example, consumers in
market economies currently enter supplyI
demand relationships with producers in which
;
most of the external costs of the product do not
appear in the price, but are hidden in environ
mental degradation and socio-economic inequi
ties. In the short-term, the producer benefits by
essentially depleting social and natural capital
that is collectively ‘owned’ and collectively
indebted. This increases economic inequities
through public clean-up costs. In the long-term,
the producer is failing to renew the very capital
upon which his or her enterprise is based.
Internalizing externalities is sometimes
referred to as full-cost accounting, which requires
that we cost (price) the natural capital that
economic activity uses, and estimate the remedia
tion costs of negative natural and social environ
mental changes arising from economic activity.
When natural capital remains external to econ
omic accounting, it is exploited and depleted to
the point that massive government inputs are
required to stave off the collapse of whole econo
mic sectors. This has certainly been the case with
Canadian fisheries and forestry; concern now
exists over the immediate future of the Atlantic
42
Inlegrating health and sustainable development
fishbanks. Canada's failure to internalize the costs
of water to business and residences has also been
cited as a major factor in its 'abuse' of this
resource. Doubling residential water taxes would
not only decrease consumption, but also generate
sufficient revenue to overhaul antiquated water
treatment and sewage disposal systems. Increas
ing water costs to business would also lead to a
decrease in consumption, without a decline in
economic productivity, and create capital that
might be used to develop better toxic treatment
facilities (Sustainable Development, 1989).
Full-cost accounting requires that inventories
of renewable and non-renewable resources be
developed and maintained. It also requires more
political judgement calls, since it is reasonably
simple to cost localized effects (e.g. preventing or
mitigating occupational health risks, replacing
renewable resources such as trees) but difficult to
cost pervasive effects (e.g. long-range transport of
air pollutants, social and health impacts of the
enhanced greenhouse effect, future costs asso
ciated with depletion of non-renewable
resources). How full-cost accounting might be
integrated into the market system is also subject
to intense debate. Socialists and social democrats
historically have urged government intervention
and tax measures to adjust for social inequities
arising from market economics. Certainly, gov
ernment intervention through legislation and
trade agreements will be necessary to begin the
process of full-cost accounting.
However, taxation policies may be an ineffi
cient and inequitable means of internalizing exter
nalities (Daly and Cobb. 1989). First, most taxes
are regressive and place greater burden upon the
poor. Second, introducing a third party (the
government) into the market relationship
between producer and consumer does not pro
vide a direct incentive to the producer to use his
or her natural resources wisely, since the costs of
unwise use will have been ’socialized' through
general taxation measures.
It is beyond the scope of this article to review in
anv detail the many suggestions advanced to
achieve full-cost accounting. Because full-cost
accounting is compatible with market economies
and with entrepreneurial practices, it offers a
significant ’breakthrough' in the current conflict
between economy and environment, noted earlier
in this article. Full-cost accounting, however, is an
insufficient economic strategy to ensure a sustain
able environment-health relationship. The mar
ket is efficient in allocating resources, when there
61
is enough collective action to 'maintain competi
tion, restrain self-interest and deal with public
goods and externalities." (Daly and Cobb, 1989).
But the market cannot address the fundamental
question of economic scale, that is, it cannot and
will not tell us when our economic activities have
reached the limit of our planetary ecosystem. Nor
can the market deal with the question of equitable
distribution of goods and services.
Internalizing externalities, whether through
market forces or government taxation ('tied tax')
policies, will increase socio-economic inequities
within and between nations. These inequities are
not sustainable in human health and community
terms, and indirectly reinforce unsustainable
environment-economy practices. Some form of
government taxation and fiscal policy will be
necessary to mitigate this problem.
In closing Part One of this article three basic
political imperatives can be stated.
• The scale of human economic activity must be
decreased.
• Population growth must cease.
• Equity within and between nations must be
enhanced.
NOTES
(a) It is important to acknowledge that both
capitalism and socialism are premised on ab
stracting the environment as something external
to economic production. This abstraction attains
absurdity in certain economic theories that main
tain that capital (the built environment and the
wealth created by human economic activities) can
always substitute for natural resources or, as
influential neoconservative economist, George
Gilder, once wrote, '(We) must overcome the
materialistic fallacy, the illusion that resources
and capital are essentially things which can run
out. rather than products of the human will and
imagination which in freedom are inexhaustible'
(cited in Daly and Cobb, 1989. p. 109). Similarly.
the Canadian government has projected various
social, economic and environmental impacts of
population growth to the year 2036, largely
arising from increased immigration. These pro
jections reveal a slight increase in per capita GDP
(gross domestic product), a quadrupling in the
overall scale of the economy and a loss of 5/6ths
of the nation’s remaining forests (Health and
Welfare, Canada, 1990). This enormous finding
62
R. Labonte
is glossed over in the observation that ’the larger
the economy, the more stress we can expect to
place on the environment, even though we should
have more resources for dealing with that stress.’
However, no amount of human resources or capi
tal can compensate for the loss of the ’source and
sink’ functions of Canadian forests!
(b) Many Canadian green products have been
endorsed by environmental non-governmental
organizations (NGOs) with portions of sales
revenues from these products being donated to
environmental NGOs. Greenpeace, however,
refuses to compromise on the issue of green
product endorsement. It refuses to endorse them.
Indeed, so uncompromising is its environmental
advocacy that the Canadian government refuses
to give it charitable tax status. Nevertheless, it is
Canada’s largest environmental organization.
with over 200 000 members; this represents a
4-fold membership increase in the past 2 years
alone.
One of the concerns of sustainable develop
ment in practice is that it may neutralize the politi
cal effectiveness of marginality. In other words.
consensus decision-making (a premise of en
vironment and economy Round Tables in
Canada, and presumed by most reformers to be
an inherently positive value) might only work
'.'■hen politically marginal communities have gone
through a developmental process of opposition to
and conflict with more powerful communities,
that is. they prod and goad policy discourse from
the self-righteous position of ’marginality'
(Labonte. 1990). Within environmental circles,
Greenpeace (despite its membership) is ’margi
nal’. until recently given more to singular, rather
than coalition-style, direct actions. It is to en
vironmental change what the Alinsky mode! of
community organization is to social policy
change: confrontational and power-brokering,
using the size of its membership and its provoca
tive actions as chips in the game of politics. Yet.
without this ’vanguard’ pressure, the ’chips’ taken
to consensus making Round Tables by other.
more reform-minded environmentalists may be
fewer and less potent (Keating, 1989).
(c) In Ontario, start-up costs for curbside re
cycling programs are covered by the soft drink
industry. This came about through a political
agreement to reduce the quotas for refundabledeposit glass bottles, which are environmentally
’friendlier' but less profitable to the industry.
Ongoing costs for curbside recycling must be
borne by municipalities. The sale of recyclables
was presumed to cover these costs, but the market
glut of recyclables has driven down prices.
Municipalities are left bearing the burden of an illconceived system designed to increase the mono
poly of large bottlers, while consumers feel
environmentally friendly about their unsustain
able level of consumption.
(d) The term, ecosystem, is preferable to environ
ment. Environment literally means that which
surrounds or encircles. This reduces discussion of
the health-environment fit to ‘the combination of
external or extrinsic physical conditions that
affect and influence the growth and development
of organisms', as the word environment is defined
by the American Heritage Dictionary. So defined,
the environment is that which exists beyond
humans rather than that which contains humans.
This concept of environment is consistent with a
health protection paradigm, and the reductionist
scientific method of assessing, estimating and
managing the risk of ‘external’ toxics. Political,
cultural and other social phenomena are recog
nized more as confounds that must be accounted
for. than as inherent factors in the health
environment relationship.
The concept, ecosystem, in contrast, implies a
systems approach to understanding relationships.
An ecosystem is comprised of multiple systems,
including human systems (social, cultural, econo
mic). The stability (autopoeisis) of human systems
is dependent upon the stability (autopoeisis) of
the ecosystem at its planetary level (the Gaia
hypothesis). Accepting this systems approach, an
open-pit mine both analogizes and directly repre
sents an open-body wound; as we practise
thinking in this way, we may be less likely to
rationalize biocidal acts in the future. Also, an
ecosystem approach is more compatible with the
health promotion paradigm, in which the inter
relationships of physical, social, economic and
spiritual domains are considered basic to health.
For simplicity’s sake, I will continue to use the
word ’environment' for ’ecosystem’ throughout
the remainder of this article.
(e) Katherine Davies, Ecosystems Consulting,
Ottawa; personal communication, (1990). This
particular study used what are called ‘subtle’
health effects, i.e. neurological damage producing
behavioural changes. Immune system change is
another subtle effect. At present, the health
protection paradigm (risk assessment, estimation
and management) tends to use gross markers,
Integrating health and sustainable development
such as cancers or birth defects. Given the syner
gistic nature of toxic exposure and the concept of
a human body’s ’total carrying capacity' many
researchers are now arguing for greater use of
subtle effects. These effects may signal greater
risk for gross effects and. in the case of neuro
logical damage, may have more profound social
impacts than frank morbidity or mortality. ’Total
carrying capacity' is a notion that combines prin
ciples of biological loading and systems theory
with ecotoxicity: that at a certain point, exposure
to a tiny amount of a particular toxic ’loads' the
body's complex interacting subsystems (immune,
circulatory, endocrine, etc.), causing a .systemwide disruption magnitudes greater than what
one might otherwise expect from an experimen
tally induced exposure to that toxic (Foss and
Rothenberg. 1988; Hall and Chant, 1979).
63
Development Indicator incorporate four dimen
sions: a measure of environmental damage and
resource use, a measure of human health, a
measure of economic distributive justice and a
measure of population. Such an indicator might
look like the following;
sum of per capita energy use (kg coal equivalent), CO,,
NO,. SO, and particulate emissions
divided by
Physical Quality of Life Index (which combines literacy.
infant mortality and life expectancy at age one)
multiplied by
1/the gini coefficient for income
multiplied by
births and immigrations/dcaths and emigrations
In keeping with important numbers being good
news w'hen they are low (e.g. inflation rate.
unemployment rate, interest rate), the smaller the
(f) The relationship between cancer and exposure Sustainable Development Indicator the more
to magnetic fields from transmission lines is parti
likely we will sustain our social and physical
cularly controversial. In general, there is agree
ecosystems. Such an indicator is easy to compute
ment that something seems to be happening, but
using existing databases, and can readily assume
no firm evidence of exactly what.
the same newspaper prominence as the GNP. one
(g) Foss and Rothenberg (1988) argue that of the few figures that is ’better' when ’bigger'.
although that, of course, is an arguable point.
unicausal determinism is no longer scientifically
A much more comprehensive discussion of
tenable. Conflicting research results based on this
alternative economic welfare indicators can be
paradigm should not be surprising. Differing
found in Daly and Cobb (1989) Appendix 1.
results may reflect differences in study design or
methodological error. More importantly, how
ever. they may arise simply because ’different
ACKNOWLEDGEMENTS
qualitative and quantitative mixes of the agent.
host and environment may result in the same (or
This article is based on an address to Integrating Health
different) clinical and pathological disease under
and Environment. Institute of Applied Environmental
different circumstances'.
Research. Griffith University. Canberra. Australia.
(h) By net health gap. I mean IMR. under five April 1990.
mortality and life expectancy at birth. The quality
Correspondent e address'.
of life is another matter. Moreover, this shrinking
Ronald Labonte
„r »be he;t,,h °an **■
-t---- - *• r:- •
world economic policies mat continue to imimsVi) toady Avenue
erate many Third World countries, and in which a
Toronto
Ontario
minority of elites hold power. Surviving infant
Canada M4M 2Y8
cohorts strain ever harder against the persisting
poverty of adulthood. Population grows; environ
mental stresses worsen. This devastation will not
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47
i /<■ /) S
S''(
Op (Po’/l <. / (-/
HEALTH PROMOTION INTERNATIONAL
C Oxford University Press 1991
Vol. 6. No. 2
Printed in Great Britain
•pEV^^
Econology: integrating health and sustainable
development
Part two: guiding principles for decision-making
RONALD LABONTE
Community Health Consultant. Toronto. Canada
SUMMARY
Part One of this article explored three relationships
(health-environmeniyhealth-economy and economvenvironmept) inherent in integrating health and sustain
abledevelopment
Information
about
these
relationships (and in some instances the lack of infor
mation or intrinsic uncertainty tn the relationship) give
rise to a number of principles that can be used to guide
sustainable development decision-making. The 12
principles developed in this article are not exhaustive.
but do capture the essential imperatives emanatingfrom
each of the three key relationships. The 12 principles.
which comprise a mutually reinforcing packaged set.
are: thenecessity of principle-based decision-making,
the inclusiveness of information, shrinking global
inequities, shrinking national inequities, empowering
equally, producing fairly and healthily, sustaining com
munities. replenishing and replacing, internalizing all
costs, sustaining diversities, nurturing the intangibles,
and planning across the generations. An interpretive
commentary accompanies each principle. The article
concludes with a discussion of the role of health promo
tion professionals jn sustainable development policy
debates qiufprogram developments.
Key words: health and environment; sustainable development; health and economy
INTRODUCTION
Health has been embedded in the concept of
sustainable development since its inception. Until
recently, however, the health sector, and more
specifically the public health sector, has not been
actively engaged "Tn decisiofFnfaking or policy
setting discussions on sustainable develdpffieht.
Three unique patterns of relationships emerge
when health is placed alongside the two major
dimensions of sustainable development, the
environment and economy.
The health-environment relationship is
described by research on the human health
impact of environmental hazards. Traditional
public health has focused on protecting indi
viduals from environmental hazards; this com
prises one set of health-environment relations.
The obvious shift herein is from toxins (biological
hazards) to toxics (chemical hazards). However,
Part One of this article identified environmental
sustainability as the most critical emerging public
health issue. The concept of sustainable development fdeveIopment_lhatjmeets the needs of the
present without compromising the ability of
future generations to~ meet tTieif~own need?.
World Commission on Environment and
Development, 1987) is becoming central to
political and economic discourse in most coun~
tnes, and in international fora. As with many
broadly stated ’ concepts, interpretation and
policy implementation of sustainable develop
ment has taken many forms, sometimes contra
dictory and often with the erroneous premise that
minor changes in environmental protection
policies or ‘green' consumerism can permit
continued economic expansion with negligible
ecosystem impacts.
147
48
148
R. Labonte
data on the human health effects of toxics is rarely
unequivocal and largely absent. Environmental
protection policy must begin to use biological
markers (health effects in other species and
experimental animal research) as proxy human
measures where human data are equivocal or
absent, and must begin to study subtle effects (e.g.
immunotoxic, developmental) as well as gross
effects (e.g. £ancer, reproductive failures). At a
paradigmatic-shift level, public health must also
shift its emphasis from protecting humans from
environmental hgzardsftb protecting the etrCnronmenFfforn human hazards. The rnostlhreatening,
and least quantifiable or certain, threats to human
(jP health are those relating to global ecosystem^
•L> change, notably the enhanced greenhouse effect. /I
■y-^jTh'e health ectynorrtyTelatiohship pertains to
'+3''the well documented relationship between
poverty and disease. Less well known is research
•"
linking improved health status to social’support
1 VVv
^systems, psychosocial emotional states and relalively flat_income or power hierarchies. When
' . “ C •
human health in its broadest sense becomes the
endpoint forSbstainable development decision—making, 'trickle-down' theories of wealth creation
~
,
and continuous economic growth become far less
important than the equitable distribution of
- t
wealth related resources_within a community or
a ' V'f c' ' nation. Indeed, the-rifbst powerful amendment
S. '■z'l'SrLf hn.- public health can make to the concept of sustainable development is the fundamental relationship
between social justice, environmental protection
n, , .
and economic development.
The final relationship, that of economyenvironment, represents both a value shift from
/
v. hat Daly and Cobb (1989) describe as ‘chrematr-.. r
istics’ ('the manipulation of property and wealth
so as to maximize short-term exchange value to
pH^-ftlhe owner') to 'oikonomia' (‘the management of
the household so as to increase its value to all
_
members of the household over the long run');
<e; tG.and a correction in market economics so that
-.J
‘externalities' such as the costs of pollution
W
control and resource renewal are internalized in
tz.-w (iczi,i4l/.,£<(,omrnocjjty pnces> thus sending consumers a true
price of consumption while generating the
I
revenues necessary to invest in environmental
V'
protection.
Respectively, these three relationships can be
'L'to'iv. 4aPtured by the imperatives to consume less,
j ^"ihare more equitably end account more accu
rately.
It is possible now to articulate a set of principles
for sustainable development that give full ex
[U{i
49
pression to human health and its social and
environmental underpinnings. Before doing so, it
is useful to clarify the importance and the function
of pnnciples.
Principles are normative and ethical. They
reflect basic assumptions and valuesTPrinciples
may derive from empirical knowledge about the
world and human societies, but they do not
depend upon such knowledge. Principles are
usually general and humanistic in articulation.
This ’parenthood' quality is both their strength
and their weakness. A degree of unity amongst
conflicting social groups is often created through
a process of developing principles or ‘shared
value statements’, (Gray, 1989). Community
groups and coalitions often unite around prin
ciples. Principles, however, are blunt instruments
for policy development. They represent the
beginnirig bTa’social change process, and not a
completion. Significant disagreements over the
most appropriate economic and political
strategies to achieve the intent of principles are
likely to occur. Principles must therefore be
translated into policy, legislation and regulation,
if they are significantly to alter economic practice.
At the same time, clearly stated and agreed upon
principles possessing some degree of political and
economic specificity are considered requisite to
multi-party conflict resolution (Gray, 1989,
pp. 8-9).
The principles offered below are intended to
provide ethical and health-biased guidelines for
addressing the most fundamental question: When
conflicts arise within the environment-healtheconomy triad, what values will guide the process
of conflic* resolution? These principles are not
given in any order of importance, nor are they
separate from each other. One might increase
intranational equity while worsening trans
national inequities and increasing pollution, or
vice versa. Neither situation is sustainable, nor
healthy. The principles are a packaged set.
Principle 1: The necessity of principle-based
decision-making
Principles are fundamental to the process of
sustainable development decision-making. Scien
tific data can only inform, but neither predict nor
dictate, sustainable development decision
making.
Comment
Greater support for scientific research into the
health implications of sustainable development is
0
Econology: integrating health and sustainable development
al and
ig so, it
inction
. They
nciples
out the
io not
es are
ilation.
:rength
nongst
Trough
>hared
munity
.1 prinnt W
: not a
er the
olitical
les are
>re be
.tation,
-actice.
i upon
.-al and
.site to
1989.
ded to
res for
When
ealthrocess
re not
e thev
■"“'’I
on. or
e. nor
-ed
ess of
Scien.ct nor
.ision-
:to the
ment is
required. Nevertheless, decisions on global-scale
environmental effects (greenhouse gas emissions,
stratospheric ozone depletion, loss of carbon sink
capacity and increased appropriation of net
primary product) cannot await scientific
certainty. The Ontario Round Table on Environ
ment and Economy (ORTEE) states its first
principle as ‘anticipate and prevent'. (1990) One
can prevent what is known. To anticipate, how
ever, is to make best guesses about what might
happen, and to act upon those guesses.
Principle 2: Inclusiveness of information
Scientifically generated data should encompass
as broad a pattern of complex relations as
possible: environment-health (risk assessments);
economy-health (equity assessments); environ
ment-economy (full-cost accounting). It should
not be restricted to only one set of relationships.
Comment
With respect to environment-economy relation
ships. an ecosystems approach is required, and
not one that separately assesses environmental
impacts on air. water, flora, fauna, etc. An eco
systems approach accepts 'the tyranny of tininess'
(that very small toxic emissions or system-wide
perturbations may be sufficient to create
profound and health damaging changes) and the
need to integrate ‘total carrying capacity' for
ecosystems and humans into risk assessments.
Whenever disputes over data interpretation arise.
particularly concerning environment-health
effects, the most health-conservative findings or
models should be used, that is, any benefit of
scientific doubt should be given to human health.
Principle 3: Shrinking global inequities
Sustainable development,globally, requires that a
proposed activity increase global equity, that is. it
lessen the wealth (income) gap between nations.
Comment
The Third World debt is the global economy’s
current greatest threat to sustainable develop
ment. It was largely incurred for the benefit of few.
It must be forgiven or postponed, and not simply
through debt-equity swaps such as rainforest
preservation which, by themselves, are in
adequate to meet the population growth and
resource depletion crises faced by most poor
nanons. This is a radical suggestion, though not
without precedent. (It also begs an interesting
question: what is more important, the health of
the species and sustainability of the planetary
149
ecosystem, or colourful pieces of paper with the
faces of dead politicians and rulers?) At the very
least, the implications of monetary policy on
environmental sustainability must be made
explicit.
There are several ways in which this principle
can be implemented. In the case of transnational
projects, international agreements could require
the retention and reinvestment within the poor
country of more earned income than is re
patriated. In the case of strictly national projects
within a rich country, this might~be_achieved
through a combination of national taxation
policies and untied foreign^aid, or specific trading'
and“sharing policies for poor countries related to
the project’s goods or production technology. A
requisite to new national project development, as
an example, may be a specific agreement to
transfer at low or no cost any new and susfaincjale
technological achievement to poorer countries,
possibly through an international agency such as a .
World Round Table on Environment ancr^
Economy. One suggestion would have each'-'
nation pay a carbon tax based on consumption,
with revenues collected by an international body
and used, in part, to fund clean technology
transfer to poorer countries. This would amount
to an ‘ecological redistribution of income’ from
rich to poor, given the vastly greater per capita
carbon consumption of rich nations (Flavin,
1990).
Lowering First World trade barriers to
products from Second and Third World countries
may also assist in increasing global equity, but
only if the exporting country is committed to the
principles that follow. Also, thg^environniental
and occupational conditions under which the
products are manufacturer! should equal those
required for First World production. Increased
foreign aid to Second and Third World countries
could be dedicated to supporting these countries
in achieving this equity in sustainable develop
ment.
These are tenuous, interim suggestions only.
Daly and Cobb (1989), among others, have
argued cogently that only nationally self-sufficient
economies can be ‘managed’ (by market dynamics
and government policy) to be sustainable. While
rejecting both free trade and national selfsufficiency in their extreme, they point out that
current economic policy tends unsustainably
towards the former. Emphasis should be placed
not on international trade, but on intranational,
bioregional market development. This approach
50
150
R. Labonte
would foster, rather than remove, trade barriers.
Daly and Cobb argue that free trade, by allowing
capital to move wherever labour is cheapest,
lowers living standards for most of the world’s
wgjdcers, creating a global 'rush towards poverty'.
This stimulates unsustainable economic activities
in rich countries in order to compete with the
cheap labour productivity of poor countries.
Most of this poor country industrialism, in mm.
takes place in demarcated zones cut off from the
rest of the nation, and contributes to national
economic welfare only to the extent that it creates
a modicum of employment and earns foreign
currency with which some of the nation's debt
interest can be repaid.
Principle 4: Shrinking national inequities
Sustainable development, nationally, requires
that a proposed activity increase national equity.
that is. it lessen the wealth (income) gap between
have and have-not citizens.
Comment
This principle might be achieved through taxation
policies (e.g. negative income tax), and equity
oriented development permits. Some Canadian
municipalities now require new office or
condominium developments to create a specified
number of affordable housing units as a develop
ment permit requirement. These costs are inter
nalized into the price of office rental or
condominium sale, representing an indirect
income transfer from the corporate sector and
upper-incomed groups to the relatively poor. This
principle might also be achieved through various
forms of employment equity policies (regarding
the hiring of women, ethnic minorities, disabled
workers, and so on) and legislation supporting
more equitable forms of remuneration.
Taxation and other fiscal policy instruments
will need to be used to offset the income inequities
that will arise as full-cost accounting of environ
mental resource use is achieved.
Principle 5: Empowering equally
Sustainable development, both globally and
nationally, requires that a proposed activity
increase equity in power.
Comment
Power is not quite the same as wealth, although
the two are certainly related. Empowerment
requires an increase in access to decision-making
by less powerful individuals, groups and com
51
munities. This might be achieved through pro
vision of resources (economic, technical,
organizational) to such groups to assist them in
participating in the decision-making on the pro
posed activity. It takes as fundamental the partici
pation by all interested parlies and requires
regular environmental audits and reporting by the
private and public sectors, including reports of
international activities.
Principle 6: Producing fairly, healthily
Sustainable development requires that each pro
posed activity increase worker control and work
place democracy relative to past practices.
Comment
Increasing workplace democracy may include,
but is not restricted to, unionization of the labour
force; specific agreements regarding health and
safety measures that comply with, or exceed.
legislated minimums; worker-ownership agree
ments; voting worker representation on manage
ment boards and committees; and the existence of
workplace policies reflecting Emery's six basic
criteria for hqalthfu 1 work (cited in Levi, 1983).
0 The job should be reasonably demanding in
terms other than sheer endurance, and should
provide variety.
<• The worker should be able to learn on the job.
and to go on learning.
• The job should include some area of decision
making that the worker can call his or her own.
o There should be some degree of social support
and recognition in the workplace.
• The worker should be able to relate what he or
she does or produces to social life (that is, feel
that his or her labour contributes to improved
social welfare).
• The worker should feel that the job leads to
some sort of desirable future, at a personal and
collective level.
Principle 7: Sustaining communities
Sustainable development requires that each pro
posed activity create, sustain or re-create 'com
munity'. This means that the activity, at a
minimum, must address how it will:
• increase opportunities for social interaction
and development of social networks;
• diversify the community's economic base;
• increase proximity between production, con
sumption and disposal;
• support a more active, democratic participa-
Econology: integrating health and sustainable development
tion of community citizens in political and
economic decision-making, including that per
taining to the proposed project.
Comment
This principle, together with principles 3 through
6, comprise a social contract between capital
(business, economy) and community. This prin
ciple also requires novel methodologies to
capture community perceptions and future
scenarios that draw heavily on participatory
learning theories, ethnographic research and
sociology.
The notion of increasing proximity between
what is produced, consumed and disposed is
sometimes dismissed as urging a return to pre
industrial, agrarian forms of economic and social
organization. This is not so. Rather, the need to
increase proximity recognizes the absolute
necessity of decreasing fossil fuel use and green
house gas emissions. This requires a dramatic
decline in the scale of transport, and in the energy
inputs for food production. (Increased proximity
in food production and consumption also
increases human health directly by increasing
freshness and decreasing agrichemical use and
red meat consumption.) Sale (1986) points out
that a community of less than 10 000 is capable of
producing for itself all of its requirements.
including most modern comforts. Cities intro
duce a larger scale of community (Jacobs, 1960)
and many policy suggestions and strategies for
urban ecological sustainability and self-reliance
exist (Gordon. 1990). Relatively self-sufficient
communities form the base of relatively selfsufficient nation-states.
151
This is a hierarchy of sustainable development.
Human sustainability is commensurate with any
given activity's ability to address higher tiered
concerns. Any proposed activity that does not, at
a minimum, replace what it takes (the notion of
’living off the interest') is not, by definition,
environmentally sustainable.
Comment
Implementation of this principle includes a ‘best
available' precept, in which the best available
technologies, legislation, tegulations and
standards, conditions, enforcement practices and
policies internationally are incorporated into
proposed activity decision-making.
Principle 9: Internalizing all the costs
Sustainable development requires that each
proposed activity employ full-cost accounting.
and internalize all of its externalities to the fullest
extent that these externalities can be estimated.
Comment
Externalities are effects that create costs outside
of the market-mediated relationship between
producer and consumer, e.g. replacement of
natural resources, clean-up of pollution. The
costs of these externalities are to be borne by the
proposer(s) of the activity. Since full-cost
accounting is a novel activity and subject to
debate over value estimates, preference should be
given to those estimates most conservative in
terms of human health and environmental
integrity. Full-cost accounting must take place in
public, and be accompanied by an ‘open-book'
policy by government and industry.
Principle 8: Replenishing and replacing
Sustainable development locates a proposed
activity along a hierarchy that asks if the product
the activity produces, or the process by which it is
fashioned:
Principle 10: Sustaining diversities
Sustainable development requires that each
proposed activity respects, by not actively or
passively decreasing, ecosystem (including
genetic stock) and human system (cultural)
diversity.
• replenishes the planet, putting in more
resources (i.e. ’carbon sink ) than it extracts?
• replaces what is taken, achieving a steady-state
economy-environment systems relation?
• reduces energy and renewable/non-renewable
resource consumption, and reduces the
production/'consumption of toxics?
• reuses (or allows for the reuse of) constituent
materials (’resources')?
• recycles (or allows for the recycling of) con
stituent materials?
Comment
Environmental impact assessments may provide
the scientific data regarding ecosystem diversity;
human system diversity requires that such assess
ments and decision-making fora incorporate and
utilize other forms of cultural knowledge. Social
impact assessments offer some potential to do so,
although such assessments tend to be positivist
and to accept a priori certain impact categories
which reflect certain cultural biases (Rickson and
52
152
R. Labonte
Chu. 1990). How problems are defined and
economic activities selected, and the relationship
between information and political decision
making, may be more important issues than
impact assessments perse.
debates. The Canadian Public Health Associa
tion, a voluntary professional organization,
recently cosponsored consultations on the Cana
dian federal government’s ‘Green Plan’. The
Ontario Public Health Association, a provincial
level voluntary professional organization, is an
Principle 11: Nurturing the intangibles
intervenor in environmental hearings reviewing a
Sustainable development requires that each
22 year energy plan for over 9 million Canadi
proposed activity include statements about how it
ans. Ontario Hydro, the energy plan’s proponent,
will nurture the intangible quality of life for the
failed to estimate human health outcomes and to
citizens affected by it.
project risk estimates of toxic emissions in its
environmental analysis. The OPHA, with the
Comment
International Institute of Concern for Public
There are many things besides a healthy planet
Health, intends to create a human health analysis
and a healthy body that create the self-actualizing
(at both the individual and population level) for
experience of human well-being. These things
the energy options presented by the crown
might include aesthetic experiences, feelings of
corporation, and for those not considered (more
history or continuity in one's family or com
massive const, ration efforts, decentralized
munity, cultural identification, respect for and
smaller scale generation, renewables such as
feelings of oneness with nature, and other
solar, wind and geothermal). A recent decision to
spiritual phenomena. The ORTEE noted in one
open up half of the province of Alberta’s forests
of its guiding principles that 'nature represents the
to 'development' has met with staunch health
spiritual essence of many Ontarians'. This intan
opposition. Until the advent of new pulp tech
gible requires 'the notion that the environment is
nologies, Alberta's aspen forests were regarded
an entity unto itself... be considered in reaching
as unproductive 'weeds', their economic value as
any settlement ... where perspectives, lifestyles
a carbon sink absorbing greenhouse gases to this
and value systems . .. differ'.
day going unrecognized. Almost half the pro
As intangibles are identified they become
vince's population, including the Alberta Medi
tangible, but never in quite the same way as events
cal Association, is opposed to the pulp forestry
that can be represented by data. (An intangible
plan, fearing that the six new kraft-style pulp
may exist, but may simply be 'hard to precisely
mills would pose unacceptable human health
define or identify', as the American Heritage
risks.
Dictionary defines the word.) These intangibles <- Health professionals should not wait to be
will vary across cultures and communities.
invited into sustainable development discussions.
They must invite themselves. As they do so, they
Principle 1 2: Planning across the generations
should consider that, just as principles are only as
■' ■ "loo—
r........ •>’■>> """h
’ " 'he actions they generate and th?
proposed acti>ny sta>^ ..»<» n .
..
uecisions they inform, increased puonc neaun
future generations, that is. how it will maintain the
participation in sustainable development fora will
natural capital and the sustainability of human
only be as good as the degree to which health
cultures. It demands that economic activity
professionals are clear about their unique con
extend the notion of full-cost accounting across
tributions. These contributions can be summed
time, as well as across the resource base.
as:
The Iroquois Nation (an indigenous polity
existing before European settlement of Canada)
• the limitations of scientific data, and the ethics
adopted a principle for making important tribal
of decision-making when epidemiological data
decisions; how will this improve our people now.
are equivocal:
and for the next seven generations?
• a broad construction of health, particularly the
role of political/economic equity in creating
individual and population health;
CONCLUSION: THE ROLE OF HEALTH
• the limitations of ‘lifestyle’ (individual) based
PROMOTION PROFESSIONALS
strategies;
• the concept of empowerment, its relationship
Many Canadian health organizations are now
to personal and community health, and its
participating in sustainable development
53
implication for sustainable development
skills in community organizing, policy advocacy,
^socia
decision-making processes.
political decision-making andother forms of
lization.
participatory democracy that constitute the larger
e CanaHealth promotion has emerged in recent years as
personal responsibility of citizenship. (Hancock,
n’. The
anjutempt io synthesize the relative interplay of
ovincial
1989; Labonte, 1989) It intersects nicely with the
biomedical, behavioural and socio-environmenn, is an
rhetoric of broader community participation in
tal systems in creating health or disease. It repre
ewinga .
sustainable
development
decision-making.
sents to the health sector what sustainable
CanadiBecause health promotion and sustainable
I development represents to the environmentponent.
development share several key concerns, dis
> and toJyfo'-T-' . . economy sectors: an effort to articulate valueciplines and overlapping sectors, initiatives under
s in itst-^-''Tp,'=J based strategies that sustain humans. The Ottawa
these two rubrics should be-deliberately re
ith therp£^\- fcj~harter f°r Heallh Promotion (WHO, 1986)
inforcing to avoid overwhelming ‘communities’
Public ii.
identifies several strategies that health promotion
with action agendas that trip over one another
malysis %.iyt-'ick“eiVnust address: reorient health services, develop
and dissipate citizen energies.
vel) for/, 0. t. A- personal skills, build healthy public policy, create /£) Developing healthy public policies means
crown~ suPP°rtive environments and-strenp.theh_£pm- ^incorporating hitman health criteria into all policy
1
munitv action. These can be, and have been.
sectors. It is a new public health truism that indi
:ra
applied to sustainable development; they have
vidual and community well-being are determined
uch
ajs0 raised political challenges that any sustain
more by social, environmental and economic
bion to
able development decision-making process must
systems than by Health care provision. Policies in
such sectors as transportation, energy,_econQmy,
forests,- /
face.
healtlft'/AjU u/l) Reorienting health services speaks to the need
food and agriculture, waste_management and
t techdevelop more effective and efficient comurban design can either increase, or_decrease
garded '
mumty-based systems of health care. Large health
human health, just as they are“either sustainable
alue aSj,^^
care institutions, predicated on a narrow bioof nor Health promotion and sustainable
to this Su/y^.Ti'/Tnedical model of disease, often lose the human
development policies intersect in many areas. A 4
e pro.Wo^^uality of caring in their relationships with ill
low meat, low cholesterol, high fibre diet now
Medi^^’^^F^r people- There is also declining marginal utility in
recommended as a means of preventing cardio
irestrv>°.'y-'”‘<^'1^,disea.se treatment, and the amount of public
vascular disease and, perhaps, cancer, requires
pulp
revenue «k.t»
that currently goes into k«.»l»k
health care
far less land per capita than do current diets in
services may now be unsustainable. In Ontario
health
western industrialized countries. Health concerns
health care institutions consume 35% of govern
are also driving increases in more sustainable,
ment budgets. Ontario’s Ministry of Health.
organic forms of agriculture that use fewer toxic
to be
currently spends as much on subsidized prescrip
petrochemical inputs. Decreasing urban car use
-stons.
tion drugs (largely for elderly persons who are
and__________
fossil fuel ___
consumption by making bicycle --U.
>, they
hazardously overmedicated) as it does on the^j) commuting easier also promotes personal fitness.
inly as
entire Ministry of the Environment. Stated some
Using high density decentralized cores in new'
d the
what differently, the annualized costs of reducing
town planning and urban redevelopment
acid aerosol emissions by 60% by 1994 at
enhances opportunities for social interaction.
Ontar;o's four largest point sources equals less
allows for more proximate food production,
nealth
than 5% of the province’s expenditures on health
decreases per capita energy use and allows for
concare.
easier access to natural settings. And so on1.
mmed
X-In this context, continuing health care ex
The, .danger in the concept of healthy public
poftcy i.s_thatjLrnight imperiailize existing forms of
penditures represent unsustainable wealth con
hr.
sumption To borrow from Rees (1989). what
environmental decision-making, and risk further
ethics
may be most important about a nuclear reson
confusion rather than more concerted pro
.1 data
ance imaging device is that its costs represent
fessional actions. The_Australian state of Victoria
a failure to invest limited public revenue in
recently introduced legislation requiring health
iy the
health creating, and environmentally sustaining,
impact statements of ‘any activity which may
.•ating
activities.
constitute a danger to human health’. There is
Developing persona! skills can be narrowly
some concern that these assessments may com
construe? as promoting healthy lifestyles. How
pete with existing, more stringent and legally
ever, it is being more broadly interpreted by many
binding environmental impact assessments. It is
•nship
health promotion practitioners as encouraging
likely of greater strategic value for public health
nd its
54
‘A
154
R. Labonte
advocates to expand the parameters of existing
environment-economy decision-making fora
(such as environmental assessment procedures)
to encompass a rigorously broad, social model of
health, than to create cumbersome parallel
structures.
Creating supportive_environments essentially
means ensuring that human social organizations
enhance well-being. Health promotion pro
fessionals have learned, for example, that
personal behaviour choices are far easier to
sustain if they are supported by an individual’s
immediate_ social network (family, friends,
groups) and by the broader community (e.g.
workplace supports for smoking cessation.
healthier cafeteria foods). Choices are never
simply "personal'. One significant lesson from
health promotion has been the_importance of
public policies in stimulating personal change.
Legislated-workplace smoking bans are asso
ciated with markedly greater smoking cessation
and maintenance rates; the carrot without the
stick is simply a dangling vegetable.
Creating supportive environments also pre
sumes the existence of a positive experience of
community, something that many sociologists
argue has been seriously eroded by 20th century
industrial capitalism. (Marcuse. 1974; Oilman,
1975; Milofsky. 1988) The final strategy,
"strengthening community action", is conceived as
addressing this fact. It derives from the rich inter
national literature on community development
and community organizing, and is fundamentally
about the re-creation of. community. Much has
been written on this subject (e.g. Kendrick el al..
1983; Labonte. 1986; Milofsky. 1988; Lamou
reux el al.. 1989); it is beyond this article’s scope
to review critically the implications of this
strategy.
These ideas have become driving forces behind
the several hundred healthy city/healthy com
munity projects worldwide. Several of the
Canadian healthy community projects are speci
fically
addressing
physical
and
social
environmental__considerations, In Sherbrooke,
Quebec, pesticide use in parks and open spaces
was reduced by 50% in one year and is now being
phased out entirely. Sherbrooke is also sponsor
ing "urban reforestation'_projects, on the funda
mental community organizing premise that
activities must be immediate, short-term (respect
ing volunteer time) and do-able. In RouynN’oranda. Quebec, a community forum decided to
establish a waste recycling program and demand
dramatic reductions in waste emissions from the
copperjxfiner.y_that dominates its local economy.
Dartmouth, Nova Scotia, initiated a paper recyling program. Edmonton and Toronto have
both established local food policy councils. The
Edmonton Food Policy Council is researching
food issues affecting low income people in
Edmonton. The Toronto Food Policy-Council is
exploring issueCrangmg from pesticides- and
additives in jpod,-to-the_£ffects_of_packaging
materialFand food irradiation.on_th_c_quaJily of
food, to policies to eliminate-hunger, to research
on how our Toodjiulture’ of advertising, market
ing and fast foodT"contributes to such health^’
problemsasTancemnd heart'disease. Another
Sherbrooke, Quebec, project is seeking to inte
grate housing concerns for the elderly into urban
planning and development proposals. In the longterm, new architectures for healthy aging will be
developed; in the short-term, parks (summertime
public places) will become more accessible for
older persons with the addition of comfortable
chairs, shade trees and playing tables.
Community development successes in health
promotion (partly exemplified by many health
city/healthy community projects) speak to a point
salient to sustainable development decision- '
making. Not only must actions accompany words;
local actions are required. It is not accidental that, i
in Canada, healthy community projects have
worked best in smaller localities. When people i
can truly meet their neighbours "a-Round-a- %
Table’, human sustainability (social interaction,
social support, value-based decision-making) can '
break through institutional or structural inertia.
Citizens can see, speak with and feel less intimi
dated by their municipal politicians and business
leaders. They can also see directly the results of
their participation in decision-making political
processes.
There is. however, an important caveat to this
finding; that of localizing globaljoroblems, and
mystifying macro-level systems of power and
decision-making. Local decision-making may be
a vital countervailing to the disempowering
aspects of state-centralism, but most economic
decision-making is national and.transnational in
nature. Local decision-making at present can only
be within narrow parameters at best, and is
unlikely to include substantial control over eco
nomic resources. As Lester Brown (1989) of the
Worldwatch Institute commented in his 1989
State of the World report, ‘Small may be beautiful,
but it may also be insignificant’. Daly and Cobb
Econology: integrating health and sustainable development
15 5
(19S9) are more direct: Political decision-making
It incorporates theory and practice from dis
must exist at the level of economic decision
ciplines as diverse as social marketing, education,
making. Until economic decision-making is re
sociology, psychology, social work, anthropol
directed towards more localized communities,
ogy, ecology, statistics, administration/manageand from thence outwards towards the nation
ment, to name only a few. The same might be said
state, political decision-making perforce must
for the ‘new’ public health which, by focusing on
remain centralized.
the determinants of health, lyzes itself from the
Unless local actions are integrated with
discipline boundaries of medicine and traditional 1
advocacy and political action strategies directed
infectious disease control. Few other profes
towards higher level government policies, our
sionals participating in sustainable development I
drive for decentralized decision-making and
debates share this vague yet liberating generalism. ,
community development may unwittingly
The mosLpotent role of health promotion pro
"privatize', by rendering local, what are much
fessionals in sustainable deyelopment decision
larger issues. We risk mystifying the actual
making, then, may be that oCa cross-discipline
exercise of political power, just as green products
interpreter. Using the metaphor of health, which
mystify the sustainable limits of consumption.
shares its etymology with ‘hello’ and “whole’, the
Local actio ns and green p roducts a re starting
interpreter does not colonize the other disciplines
points only, and represent the community organ
or sectors with public health imperatives so much
izing rule 'to begin where the people are'. But
as seeks and seeds the commonalities, while
where people are is not necessarily where they
raising to the conscious level the conflicts.
should be. The environmental motto to ‘Think
globally, acl locally' may well need amending to
'Start locally, acTgjobally.'.
NOTES
Empowerment, the ability to exercise choice.
increasingly informs the individual and com
I. There is one ready conflict between sustainable develop
munity work of health promotion professionals. It
ment and health: energy-efficient closed buildings. The 'sick
does not lack for problems of definitiorTof*co
building' syndrome is now well documented. When contem
optation. but it speaks to an emergent knowledge . .plating. this trade-off (energy
__ conservation is ultimately more
that the very act of organizing to alter conditions 'ffiAT11 'by minimizing infectious disease spread or migraines) it
is important to consider that most sick building problems arise
of relative powerlessness enhances individual
"from faulty
""""
temperature and humi_dity_contror,~and the re
health. 'Empower' is usually used transitively, as
circulation of internal and external toxics (outside smog;
in we (health professionals) need to empower
inside tobacco' smoke, carpet fumes, office work-related
chemicals, etc.) The problem may not lie with energy
others (poor, marginalized individuals orgroups).
efficiency so much as with the organization, materials and
Empower is also a reflexive verb; the most
products of work done in the closed building.
enduring power (choice) is that which is taken.
2. This article is based on an address to integrating Health
not that which is given. Health promotion pro
and Environment' conference. Institute of Applied Environ
mental
Research. Griffith University. Canberra, Australia.
fessionals possess a power not yet seized, one that
April 1990.
builds upon a discipline specific credibility while
capitalizing on the relative lack of boundaries
Address for correspondence:
Ronald Labonte
defining health promotion.
Community Health Consultant
Health promotion utilizes the traditional dis
90 Coady Avenue
cipline theory and methodology of epidemiology
Toronto. Ontario
and clinical (direct-service) practice. Public
Canada M4M 278
health professionals _(.'new'_ or 'old') jtre often
organized in voluntary associations. These asscTl^j
ctations can_bring_the collective knowledge of the KCtraditional disciplines_t.Q_sustainable deyelopment . / REFERENCES
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