We are Socioecological: health carers and advocates

Feb 21, 2021

Our Socioecological interdependence requires us to be in effective relationship with each other and our environment. Who we are, on what we depend, and what we can do to maintain a habitable, healthy, and sustainable place for all now matter more than ever.

As medical graduates involved in clinical practice and public health our experiences have been multiple, challenging and rewarding, but not without fault. Personally, and professionally we now confront seemingly overwhelming threats and opportunities.

Individually and collectively, we face a confluence and interconnectedness of major challenges and threats to human health and existence.

  • Climate change crisis and environmental degradation
  • The Covid-19 pandemic and resurgence of infectious diseases alongside mental health disorders especially in young people
  • Chronic diseases that are preventable, intergenerational, progressive, and terminal
  • Increasing geopolitical and social conflict with societal breakdown, displacement, and inequality
  • Emerging intergenerationally transmissible health risks

Human behaviour, science and technology simultaneously contribute to these problems and offer solutions.

The failure of our profession and wider society to see ourselves as an integral part of an ecosystem that sustains our health and wellbeing is the fundamental underlying issue now demanding our urgent attention.

Socioecological awareness can help us explore our interdependence, the interaction of the existential threats and their predeterminants. It also highlights opportunities for developing collaborative actions to create a more habitable, healthy, and sustainable place for all on our planet.

As authors of this paper, we see ourselves as individuals, healthcare professionals, members of wider society and an integral part of ecosystems.

Carers and livelihood providers

Health services with their workforce provide the spectrum of preventive to therapeutic and palliative care. Care systems need to commence with the twin goals of self-determination and equity of outcomes, as well as be intersectorally wide-ranging with community members, policymakers, legislators, agriculturalists, town-planners, architects, engineers, sociologists, environmentalists, economists, lawyers, transport-workers, educationists, textile workers, communication, media and information scientists, industrialists, and others. This should facilitate equitable and sustainable livelihood orientations in resource utilisation and distribution.

The pandemic has accelerated a shift in health system delivery to a more digital mode, proving both opportune and disruptive for many health practitioners. Precision medicine, cyber-practice, algorithms, robotics, artificial intelligence (AI) and quantum computing are changing our roles and identities. They are altering the benefit-risk-cost ratios of health care and its socioecology, with less flexibility and room for healthcare finesse. However, if it enables more choice (eg Telehealth to home) it can endorse personalised medicine as the health practitioner can observe and better appreciates the location whole context of the patient/health participant. As well as more choice, Telehealth enables better access and distribution of health resources to people in underserved and remote communities.

The health care work force is a reference point for health-seeking behaviour with a size often in the thousands in medical centres. For example, in Australia, that virtually no doctor smokes is a powerful health signal to the community.

On what we depend

Connectedness to others and to the natural world characterises who we are and makes us both social and ecological beings. Health is dependent on these connections. The notion that we have evolved as a species is somewhat misleading since our evolution and biology are ecologically dependent.

Professional encounters can identify and encourage more effective and less economically onerous livelihood approaches to healthy living and management. These can focus on having the essentials when time, resources and cash flow are limited, and avoid the stigma of unemployment. Those who are suffering disadvantage remain sensitive to perceived exploitation as opposed to caring, hence often prefer to be seen in a culturally safe public system (if indeed it is) rather than one that expects out of pocket expenses as an obligation. With climate change and its health consequences, the demand for planetary ecosystem services and resources is already excessive and must be constrained.

An impressive and rapidly growing body of work is emerging from many fields and locations (including health, permaculture, indigenous communities, economics, law) that illustrate our interdependence and practical examples of how a socioecological perspective can be applied in practice to address major challenges.

Health and human nutrition: The International Union of Nutrition Sciences IUNS) has reconceptualised its science to be biological, environmental, societal, and economic. Each of the seven fields of Nutritional Biology has ecological connectedness (Section in ‘Food and Nutrition and Nutrition Biology figure reproduced in benefit-risk-cost ratios). The reconceptualisation of health in ecological terms supports the international recommendation that the most important dietary guideline, aside from breast-feeding in infancy, is to have a biodiverse diet. This, in turn, depends on sustainable ecosystems and their biodiversity, the principle of econutrition. The pandemic of 2020 underscores the critical importance of ecosystem preservation for our health, innate immunity, and well-being.

Being in nature: walks, social activity, public open space, and gardens and confer physical and mental health advantage as articulated by Sue Stuart-Smith in ‘The well-gardened mind’ and by Shane O’Mara, ’In Praise of Walking’. Japanese health-workers recommend ‘forest bathing’ (shinrin-yoku), as a therapy for hypertension, mental stress, and immunotherapy (Kotera et al 2020).

It is axiomatic by oath or agreed ethical principles that medical practice should not be discriminatory in any way. This can be enfolded into our socioecological self. For one of us (MLW) this was stunningly evident in a Vietnamese colleague, Dr Tu Giay, who came to be known as the people’s doctor for how he innovatively and empathetically developed socioecological survival strategies in the face of conflict.

During the Franco-Vietnamese war, he encountered a former Professor-teacher, now foe, while tending the French wounded. During the Vietnam War he developed food security for North Vietnamese combatants and civilians. These improved rice storage and quality; developed ecological gardening for green vegetables even where water was scarce; produced dried food for survival rations; identified 420 species of wild edible vegetables; promoted fish from pond-farming as animal-derived food; and invented new smokeless cooking methods. When MLW first met Tu Giay in Vietnam, notwithstanding Australia’s prior military enmity, he was received as a medical colleague and friend. There was no emotional or social baggage.

Beyond Vietnam, in Australia and elsewhere, health services (Malik et al, 2018 ) and food systems ( Dasgupta Review,2021 ) have unrealised potential to reduce their carbon foot print, and to be players in socioecologically driven health and economic gains.

The Aboriginal definition of ‘health and wellbeing’ is fundamental to the socioecological view of health. It means not just the physical wellbeing of an individual, but refers to the social, emotional, and cultural wellbeing of the whole community in which the individual is living including caring for the Country or common ground to which they belong. Only looking through this lens in the Uluru dialogue alongside the Leaders and Elders in this strengths-based view can we begin to repair the damages of dispossession and support self-determination of ‘whole health’.

The oldest living culture is showing us the way forward. We are all invited to and embrace the generous wisdom and courage of our Aboriginal and Torres Strait Islander Leaders and Elders who are working with government and community post the Uluru Statement of the Heart to enshrine in the constitution the Indigenous Voice to Parliament through the Marrakata Commission. Motivations vary but rights of self-determination, justice, and a wish to eradicate the pervasive racism of our legal, employment education and health institutions so that future generations should not suffer. They are powerful forces, best summarised in Voice, Treaty, Truth. The truth speaks to the oldest living culture who managed land and peoples with ceremony and respect long before socioecology was recognised. They now require endorsement via the constitution to ensure a permanent seat at the table of all matters affecting First Peoples.

These examples illustrate how the socioecological perspective can help us explore our interdependence, and to understand the interaction with amplification of current existential threats, conscious of their predeterminants. They highlight how to build this into clinical and public health, and provide opportunities for collaborative actions directed towards a more habitable, healthy, and sustainable place for all on our planet.

Imagination, creativity, innovation, and scenario planning are needed. Public health, and clinical practice, can mitigate the mounting and ever-present threats to health of greed, affluence, ecological dysfunction, misnutrition and food insecurity. As we encounter new health patterns and crises, many of them nutritional, socioecologically aware partnerships are required in their resolution.

Economy: A livelihood frameworkcan address our basic needs of land, food, shelter, clothing, fuel, education, health, transport, and communication. To operationalise it will inevitably require us to minimise the quest we make beyond our basic needs. As father and son, Skidelsky and Skidelsky, have shown, we can and should acquire the mindset which knows and behaves socioecologically so that that enough is enough- for a life that is good. In other words, be directed to prefer the meeting of need rather than want. The planet cannot afford otherwise as Tony McMichael demonstrated decades ago in his 1993 book, Planetary Overload!

Sharing the Commons: Monetisation can be avoided with semi-quantified Liveability Units (LU) for community-based transactions and be a currency for future sustainability. This is consistent with sustainable socio-ecological systems and Elinor Ostrom’s framework for The Commons. An expectation of such systems is that, with basic socio-ecological measures in place and protected, there is room for innovation and entrepreneurship, in support of the common good. At the same time, sharing reduces the planetary cost. Ostrom identified, however, the need for sanctions of activities not conducive to the welfare of The Commons.

Based on the work of Rockstrom and colleagues, the City of Amsterdam is encouraging a circular economy referred to as a ‘doughnut economy’ which conceptualises social and ecological resource management, a regenerative and distributive economy. It encompasses livelihood needs across the entire citizenry.

Permaculture was conceptualised by Australians Bill Mollison and David Holmgren in 1974 as “The conscious design and maintenance of agriculturally productive systems which have the diversity, stability, and resilience of natural ecosystems”. David Holmgren has made available online his latest book ‘Retrosuburbia: The downshifter’s guide to a resilient future’. It is based on a socioecological understanding, permaculture principles, and is a response to climate change and reducing resources, in order to help people, households and communities live better with less, create abundance and thrive in an energy descent future.

The slowness, reluctance, and resistance to embrace our socioecological reality, whatever its functionality, dysfunctionality or health consequences has been plain for decades. It is undoubtedly a situation where planetary exploitation has exceeded socioecological capacity, where we have been ill-informed about who we really are and what we have needed to do to protect ourselves and the planet in which we are biologically embedded. There is now only a narrow window for us to heal and restore our socioecological well-being. There is a reckoning to be had for failure, and certainly for malevolent assault on or disregard for this plight. On this account, consideration might be given to at least an NGO such as an International Court of Environmental Justice which could hold transgressors to account. There is a proposal in development to have ecocide scheduled as a crime with the International Court in the Hague.

We sometimes feel overwhelmed by the large scale of current challenges, uncertainty, and rapid change. Our response is that we can be emboldened by the strong tide of individuals and groups committed to collaborative action. As well as by hope and opportunities to apply the socioecological perspective.

What we can do?

As societal and ecosystems undergo rapid and accelerating change, loss, and dysfunction, we ask the question ‘Understanding ourselves to be socioecological beings, who can we become in an uncertain and increasingly fragile future world?”. Even more telling, “what if we ceased to be socioecological and without an earthly home of which we are obligatorily part?”. The answer is to be those who strive inescapably to prevent such an outcome as the highest priority.

Much is under way. And there is more we can do as healthcare professionals, not least:

1. Understand that we are socioecological beings, this being the ultimate basis of our health and well-being. Engage with and become guardians of the natural world and its disappearing and dysfunctional ecosystems.

2. Advocate for climate action and amelioration of adverse health impacts in public health and clinical practice.

3. Re-orient clinical and public health systems and practices to address the social and ecological threats. Employ social and clinical epidemiology to inform context, interpretation, and benefit-risk-cost management principles to health care practice and intersectoral collaboration.

4. Acknowledge and respect the traditional Owners of Country throughout Australia and recognise their continuing connection to land, waters, and culture. Support a First Nations Voice to Parliament.

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