Table of Contents
Introduction: Health and the Environment
A plant reflects the quality of its environment in the way that it grows, the amount and condition of flowers that blossom from it, and the fruit that it bears. We see the growth of certain weeds as a sign of the soil conditions. For instance, daisies, dandelions, and moss grow when the soil pH is low. Nettles, thistles, and pigweed grow in dry soil.
The same holds true of all living things, including humans. We do not exist in a vacuum. We are surrounded by an environment with which we interact. The food we eat, the water we drink, the air we breathe, and the environment we live in shape our health. Some parts of this we may be able to control, while other parts we may not.
A person seeking care for a condition without addressing their environment gains little more therapy than a band-aid. A patient came to me recently for a refill on a medication for anxiety. He requested clonidine, which he says he takes 4 times a day for anxiety. Meanwhile, he had recently been homeless, and the current home is temporary. He asked me to give him a three months supply. I only approved it for one month. I later discovered that clonidine, which is not a controlled substance, has some value on the black market for its effect.
How does a pill change someone’s life if the environment stays the same? Our medical system is operating in a sick care mode. Doctors are prescribing pills to treat a chronic condition that in essence is a result of the environment (e.g. food, alcohol, cigarettes, exposures, stress,). All the while, those persons return to the same setting. The search for health, and away from disease, requires a look upstream for the “cause of the cause.” At the crossroads of disease is the body with the environment.
A plant reflects the quality of its environment in the way that it grows, the amount and condition of flowers that blossom from it, and the fruit that it bears.
What does health mean?
According to the World Health Organization (WHO), health is a “state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Secondly, in the WHO’s preamble to its constitution, it declares, “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic, or social condition.”
The Dahlgreen-Whitehead rainbow model provides a schema for viewing the microcosm of factors, or determinants, that contribute to an individual’s health (Dahlgreen and Whitehead, 1991). These factors include social and community networks, socio-economic, cultural, and environmental conditions. The model’s outer band has public health and social care services, access to healthcare, community infrastructure, agriculture and food production, education level, water and sanitation, transport policies, and work environment.
If there is any question of these systems’ impact, consider that more than a quarter of the world’s population has no access to safe drinking water. By 2025, an estimated half of the world’s population will be living in water-stressed areas. Unsafe drinking water contributes to the death of 829,000 people from the diarrheal illness each year (WHO).
Health and Social Environment: The ACE Study
Often, when we look deeper into the cause of behaviors, we find some startling associations. A study by Viana et al. (2018) in adolescent smoking risk factors in Brazil found an association with domestic violence, male gender, and early sex initiation, with odds ratios (OR) of 2.34, 2.11, and 6.56. An odds ratio calculates the association of risk of a variable with a known, in this case, smoking. The degree of religiosity of a person also appears to influence smoking behavior, with religion being protective in a by Martinez et al. (2015).
A critical study in health determinants was published in 1998 by Dr. Vincent Felitti et al. It was known as the Adverse Childhood Experience (ACE) Study. It found a relationship between childhood abuse and household dysfunction to many of the leading causes of death in adults. The researchers used a questionnaire to follow a standardized medical evaluation of a panel of 9,508 adult Health Plan members to determine factors described as “ACEs.” Questionnaires cannot discern the degree of recall bias, i.e., how someone looks back at their childhood and decides on “frequency of abuse.”
More than half had experienced at least one hardship, while a quarter experienced two or more. The experience of an adverse childhood event, such as physical, verbal, sexual abuse, death of a parent, or a divorce, led to increased risk of conditions such as alcoholism, drug abuse, depression, suicide attempt, increased sexual partners, sexually transmitted infection, cancer, ischemic heart disease, chronic lung or liver disease, and severe obesity. Although the risk for severe obesity (1.4 to 1.6-fold) in those with four or more categories of adverse experiences was less than conditions such as alcoholism, drug abuse, depression, or suicide attempt (4-12-fold increased risk), the association of adverse events and disease is significant (Felitti et al., 1998).
The ACE study also showed a correlation with a higher ACE score, smoking, and chronic obstructive pulmonary disease (COPD). Convincingly, this study upheld that a person’s state of physical health may be a barometer of their emotional adjustment to past traumatic experiences. There are important implications in the ACE Study and how we may better approach the health and disease model (Felitti, 2002). In the figure below (from the CDC), trauma sets in motion a cascade of events beginning with disruptions in the brain’s development. Various impairments develop that lead to maladaptive behaviors. These are the risk factors to the development of disease.
The Role of Socioeconomic Factors on Health
It has been well established that with better socioeconomic status comes better health (Graham H, 2007). The country realized significant changes in life expectancy during the early part of the twentieth century because of improvements in public health infrastructure, clean water, and sanitation advances. By 1941, even before Ernst Chain and Howard Florey mass-produced penicillin, the United States’ mortality rate had dropped from nearly 800 people per 100,000 to 200 people per 100,000. It now hovers at a rate of about 25 per 100,000. A child born today can expect to live for 79 years (2016 data) when he or she only lived until 30 years in the early 1900s. However, this is not the care everywhere in the world.
The trend from high infant birth rates and high infant death rates to low birth rates and death rates is the demographic transition. It is commonly seen when a country becomes more industrialized. Unfortunately, there are still countries, such as the Central African Republic, where the life expectancy (53 years in 2019) is closer to the US life expectancy in the early 1900s (47 years in 1900).
One tool to assess a country’s development combines life expectancy, education, and per capita income. It is known as the Human Development Index (HDI). It illustrates that developed countries, such as the US, Canada, Europe, Australia, Japan, and New Zealand, have a higher life expectancy. In contrast, less developed countries such as Africa, Nepal, and East Asia, have a lower life expectancy. Life expectancy increases with a country’s wealth. Factors such as infrastructure, food availability, a cleaner environment, and social services contribute to these differences. Where these systems are limited or incapacitated, such as in war-torn countries, life expectancy decreases.
However, the HDI does not factor in the patchwork of socioeconomic disparities within a country. There are wide income gaps within some countries, from which emerge differences in chronic disease risk and longevity. Poverty correlates directly to unhealthy behaviors, such as improper diet and decreased physical activity. These associations contribute to the increased incidence of chronic diseases such as obesity, diabetes, and hypertension. Unfortunately, there are also higher rates of mental health problems and tobacco consumption in lower-income areas. Consequently, there is a reduced lifespan and healthspan (Stringhini et al.).
Whether a county is poor or affluent may predict the prevalence of chronic disease risk, such as hypertension, arthritis, and poor health, with higher rates in poor counties. There are also differences in education level between the poor and affluent communities, less in the poor counties. A higher education level comes with a lower risk of chronic disease. Aside from income difference, within these poor counties are often greater access to fast-food restaurants and convenient stores (“food swamps”), less access to healthy food options, like natural foods (“food deserts”), and a relative lack of green space (Shaw, K et al.).
These findings have important health policy implications for these counties, many of which are neighboring more affluent areas, which may significantly differ in the rates of chronic diseases and cancer (O’Connor et al.).
Neuroplasticity and Future Directions for Health
A person can successfully change behaviors as long as they can change their environment. Sometimes the more radical changes are, the better.
The dogma of the past was that the brain’s development was fixed after a certain age. Fortunately, while there may be some truth regarding the difficulty of behavior change with “you cannot “teach an old dog new tricks,” the brain does continue to develop throughout life and even in advanced age. These changes come from vascular fitness, neurotransmitter signaling, and Brain-Derived Neurotrophic Factor (BDNF). “Radical” learning often has the greatest neuronal benefits.
A study found that when people with an advanced age take a dance class over time compared to routine sports training, they have higher levels of BDNF, improved benefits in cognition and coordination, and MRI changes showing increased gray matter volume. This brain growth and remodeling with more extensive circuitry is referred to as neuroplasticity.
These types of studies provide much support to the conclusion that repercussions of trauma can be mitigated. Furthermore, the message of how stress and trauma affect the mental and physical health can empower families, and the communities they live in, to provide a network of protection and resilience. This is akin to a nourishing environment for a plant or even adding fertilizer to the soil. Humans, too, may flourish in an accepting and supportive environment.
Most of the high-impact measures to promote health occur outside of the clinic. The healthcare system is mostly a reactive setting. The onus of control falls on entities that can exert the greatest influence on the environment: the federal, state, and local levels; community and grass-roots movements; churches and places of worship; libraries and civic groups; schools; and the family.
Below are a few examples of ways to foment a healthy environment:
- The government can develop policies to protect citizens from exposure to pollution, unsafe city planning, and poor living conditions with no recreational areas or green space.
- Communities and grass-root programs can create an enriching environment for health. They can organize community gatherings, volunteer programs, and betterment efforts (e.g., trash pick-up, playground updating, etc.).
- Churches and places of worship can develop support groups and workshops for parents, young children, and adolescents. Churches can provide community support for their members, such as job training resources and health promotion workshops.
- Schools can ensure education programs are implemented that discuss the ACE study, neuroplasticity, the importance of the environment on health. Parents can receive information about this material while their child is learning about it.
- Families can ensure that their children have a balanced amount of time to play outside and ample time in nature. This can assist in stress management. Parents can work toward resolving past traumas in their lives and develop positive approaches to dealing with parental stress, such as exercise, outdoor time, and scheduled family time for activities. Parents and children can keep an open dialogue on the issues of emotional intelligence and stress reduction.
Here is the Journey to Health Podcast, where I interviewed public health officer Dr. Jennifer Vines. She provides a bird’s eye perspective of health that is intriguing and informative.