The increasing challenge for determinants of health approach is the creeping trends of small government and minimal regulations that have subverted the plans for sustainable environmental and social conditions that would bring enduring and equitable health gains. The modern economic theory of trickle down economics is a major obstacle to people’s quality of life. The harshest costs of modern economic practices fall upon ecosystems and populations with little current economic power or value, including generations not yet born. What are the primary components for sustainability? There are four pillars of environmental sustainability commonly recognized: ecology, economy, society, and government.
Ecological sustainability is concerned with the health of the natural environment, the conservation of natural resources, and the preservation of ecosystem functions performed by individual members and the ecosystem as a whole. It requires that use of natural resources not exceed the capacity of an ecosystem to regenerate those resources, known as the carrying capacity. Ecological sustainability also includes preservation of biological diversity, which includes genetic, species, and ecosystem diversity.
The economy has an important role to play in sustainability. Capitalism is based on individualism and making free choices. Western thinking looks at the world in terms of what can be done today to satisfy the growing wants and needs of self that is endemic of a consumer-oriented society. Through globalization more goods and services are made available at lower cost to a wider group of people, and more access leads to rising consumer demand and improved standards of living. Globalization is about the maximizing corporate profits through the promotion of consumerism. The media and advertisers drive consumerism and the cult of individualism that has created the culture of entitlement to consume. Materialism and consumerism have joined together to create individuals with high expectations. Re-education using messages on proper self-esteem will have a significant role in countering such a culture.
The problem is not the mining of heavy metals, or the use of chemicals or compounds produced by society, or disruption of natural process, or even temporarily interfering with people’s capacity to meet their basic needs (unemployment). It is, rather, our industrial system, which has developed so that substances extracted from the earth and produced by society will continue to build up indefinitely in natural systems. This means a progressive build up of pollutants and substances that not only harm us directly but damage natural processes that have taken billions of years to develop.
It is necessary to introduce processes to minimalize the depletion of non-renewable resources. This can be achieved by extending life by recycling, using fewer resources to make a product, as well as switching to renewable substitutes when possible. Economic sustainability uses the construct known as the triple bottom line, as opposed to the traditional ‘bottom line’, which only concerns itself with monetary success. The triple bottom line considers economic profitability compared to environmental harm or profitability compared to societal harm or profitability.Governmental sustainability primarily pushes for legislation that furthers the other three components of sustainability, acting as a steward of common resources and the public well-being for many generations, not only the present constituents.
Milton Friedman claims that policies that support laissez-faire capitalism helps poor people by the trickle-down effect, and that economic growth flows from the top to the bottom, indirectly benefiting those who do not directly benefit from the policy changes. It is believed this is best achieved through minimal government taxes and regulation. This economic theory advocates letting businesses flourish, since their profits will ultimately trickle down to lower-income individuals and the rest of the economy. When this economic model was developed, illness was based on the genetic model of disease, that is, disease originates in changes or mutations in the DNA that take place slowly over time. With the completion of the human genome project in 2003, there was the demise of the genetic paradigm and the revival of the epigenetic approach. From believing that our biological fates were written in our genes, it is now recognized that the environment, and more specifically our perception of the environment, directly controls our behavior and genetic activity. The human genome project did not find a diabetes gene, however, the rapid appearance of diabetes is consistent with epigenetic changes.
Through the lens of individualism, complex and multi-faceted issues are oversimplified allowing self-responsibility to become the dominant issues, and life-style change the response. This type of dialogue sucks all the oxygen out of the room, suffocating debate about the common good. What is known now is that policies aimed at the individual do little to address the social determinants of health, thus fail to promote the health of all.
The precautionary principle to protect the environment was defined in 1992 as one of the principles of the Declaration of the Rio Conference on Environment and Development. The accepted principle includes the premise that, even if full scientific certainty does not exist, that shall not be used as a reason for postponing cost effective measures to prevent adverse health impacts or environmental degradation. That means an activity or product should not be used if it can reasonably be predicted that it will lead to unacceptable consequences. In this instance, the cost effective measure is proportional to the harm. As the scientific certainty of the risk goes up, the justification for costlier measures is similarly increased.
A sustainable society improves the quality of human life process that allows human beings to realize their potential, build self-confidence, and lead lives of dignity and fulfillment. The Chilean economist, Manfred Max-Neef, identifies nine fundamental human needs that are consistent across time and cultures: subsistence, protection, affection, understanding, participation, leisure (time to reflect), creation, identity, and freedom. These needs are constant in all cultures – what varies is how we satisfy the needs, and it is in the satisfaction of needs that cultural diversity can be found. Max-Neef points out that these fundamental needs cannot be substituted for one another, and that a lack of any of them represents a poverty of some kind. Indeed, in Max-Neef’s theory, unsatisfied needs are seen as poverties, broadening the concept of poverty to more than a lack of income and beyond monetary measures. Following this reasoning, development means the alleviation of multiple poverties and becomes the social analogue of individual self-realisation or flourishing.
For the most part society needs to change personal attitudes and practices. People must re-examine their values, and later their behavior. Individualism is such a value, the view that the individual, rather than society as a whole, is the most important entity. During the 1980s, school systems lowered educational standards to protect children from failure. This self-esteem movement had a significant impact on the school system – in order to ensure positive self-esteem education standards were lowered creating a milieu for extreme individualism. The world would be saved from crime, drug abuse and under-achieving through bolstering self-esteem. When there is too much self-esteem, there are problems with tolerance, entitlement and narcissism. Self-tolerance leads to a sense of entitlement and a belief that the world owes them something. With the cult of entitlement many social problems seem to be the result of ‘what’s missing.’ This value system can be changed. Promoting self-esteem that comes from achievement and from service to others, over time, reduces extreme individualism.
The realization that the epigenome is highly sensitive and responsive to environmental influences, including toxic exposures, dietary factors, and behavioral impacts, serves to focus priorities on the future state. In particular, epigenetic harms have the potential to affect every aspect of our lives. The scope of the challenge in epigenetics is illustrated by the discussion around environmental chemicals with hormone-like properties, called endocrine disrupters, which are believed to have a significant effect on an individual’s health. There is a link in animal experiments between endocrine disruptor chemicals and obesity, metabolic syndrome and insulin resistance.
Normal endocrine signaling involves very small changes in hormone levels, yet these changes can have significant biological effects. This means that subtle disruption of the endocrine signaling is a plausible mechanism by which chemical exposure at low doses can have effects on the body. Endocrine signals govern virtually every organ and process in the body. The persistence of effects can be seen long after the actual exposure has ceased. The ubiquity of exposure – hundreds of compounds can be considered.
Epigenetic marks or ‘imprinting’ affect gene expression without actually changing the DNA sequence. There is substantial evidence from animal and man demonstrating that both transient and more long-term epigenetic mechanisms have a role in the regulation of the molecular events governing adipogenesis and glucose homeostasis. The dynamic nature of epigenetics means this is not written in stone – healthy eating, moderate exercise and minimizing stress will have a positive epigenetic effect. Epigenetic marks are reversible. The World Economic Forum says that productivity losses associated with workers with chronic diseases are as much as 400% more than the cost of treating chronic diseases. Productivity costs (indirect costs) are projected to increase as chronic disease rates rise in the working population. These economic measures can be reversed.
Chronic disease is the double-edged sword in the health-care cost debate, that is, it has both a favorable and an unfavorable consequence. The unfavorable consequence is the obesity epidemic that will translate into more chronic disease unless significant action is taken. The favorable consequence is that 70% of chronic disease is preventable. Public health messaging has a role in achieving sustainability of the system. It will still be necessary to change the focus from health protection issues related to air pollution and restaurant and swimming pool inspections, to issues of poverty and social exclusion.
The primary factor that shapes the health of Canadians and Americans is not medical treatments or lifestyle choices, rather the living conditions they experience. Individuals are unlikely to be able to directly control many of the social determinants of health. Public health interventions need to include the social determinants of health. This means adding the social and economic environment, as well as the physical environment to lifestyle and behavior factors, to programs. The social and economic environment includes issues around poverty and exclusion. The physical environment is the source of much epigenetic harm.
Sustainability is something that we do not even know how to directly measure. Agreeing to standards of sustainability is key to holding people accountable. Even though most people can agree that sustainability includes managing our environment, social, and economic impacts on the world so that we meet present needs, while ensuring the ability of future generations to meet theirs, the precise measure of sustainability remains elusive. The main stumbling block to develop measurements is how to calculate ‘soft’ costs, such as the health burden created by such things as fossil-fueled power plants, which have been linked to the increased incidence of cancer, lung disease and asthma. Such costs are not included in the cost of such commodities as electricity generation and distribution.
The real definition of sustainability is about optimizing the human experience, especially well being, allowing the individual to reach their full potential. This requires a change in social and political mindset, along with reformatting economic and environmental policy decisions to ensure that these issues incorporate the social determinants of health into solutions in general, and epigenetic harms in particular. Sustainability will be within reach when we close the gap between recommended care and actual care for those at risk for or living with chronic disease, and act further upstream to modify the environmental and occupational sources that put individuals at risk for chronic disease.
Adapted from On Reaching Full Potential or the false promise of the market, Chapter 8, Sustainability, 2015, by Greg Horsman.