Chapter 7 New developments in environmental health
In October 2005, following discussions between colleagues in SEHD, Scottish Executive Environment and Rural Affairs Department ( SEERAD) and the NHS, the Deputy Health Minister announced an initiative to create a Strategic Framework for Environment and Health in Scotland.
The initiative is a clear affirmation of the continuing importance of the environment for the health and well-being of the Scottish population, a recognition which drove some of the most powerful and effective public health measures of the 19th and 20th centuries.
Further detail on the Strategic Framework, its emphasis on creating and co-ordinating effective systems, on evidence for action and on improved inter-sectoral working, will emerge in the coming months as the basis for a wide stakeholder consultation. However, in its explicit reference to the concept of health-promoting environments and its linkage of environmental issues to the health inequalities agenda, the October 2005 announcement signalled an intention to exploit environmental factors more fully and effectively for Scotland's health.
Scoping work has highlighted some areas where the fresh thinking and more strategic approach heralded by the new initiative may offer particular advantage.
Addressing Complexity in the Relationship between Environment and Human Health
The link between the health and well-being of humans and their physical environment is seldom straightforward. Physical factors in the home, the places where people work, play and study and in the wider community combine continuously and interact with other factors to create and destroy health and well-being. For clarity and convenience, the traditional practice of environmental health has disregarded much of this complexity, focussing instead on the challenge of understanding and tackling individual hazards in particular environmental compartments such as toxins or infectious agents in air, water, soil or food. A continuing programme of research, monitoring and enforcement is today directed towards controlling environmental hazards, exploring new threats and securing standards that are safe even for the most vulnerable in society.
This compartmentalised approach has proved pragmatic and effective and, aided by increased general prosperity, has significantly diminished the direct toxic and infectious threat from the environment. However, there is now a need to augment traditional ways of working with new approaches that recognise a more subtle and complex dimension to the relationship between human health and the environment.
Whether individuals and communities are exposed to health-determining influences in their environment and indeed whether such exposures impact on health is invariably influenced by social, economic, behavioural and other factors that may vary significantly according to context.
The traditional approach which expresses the relationship between environment and health essentially as one of simple cause and effect has some important limitations. Notably it is ill- suited to exploring and addressing situations where the primary health threat derives from an interaction of physical, social and behavioural elements within a complex mixture. Such complexity characterises the situation with inequalities in health between affluent and less well off social groups. Because it is hard to sustain an argument that less well off Scots consistently live in environments that are more toxic, infectious or allergenic, a subordinate role has been accorded to the environment in Scotland's health inequalities. At the same time the limited impact of measures to influence health relevant behaviours amongst the less well off may derive in part at least from an underestimation of the importance of physical context.
The new initiative, by framing the relationship between environmental and human health with reference to all the factors that bear upon it and also to the higher level drivers and pressures which shape and influence the quality of environments, offers a chance to assemble evidence in ways that are more likely to point to solutions. Importantly too, by accepting complexity in the relationship between environment and health it can be a vehicle for creating a greater sense of common purpose amongst the wide cast of institutional, professional and other players whose input is necessary for success.
Health Promoting Environments
A further problem of reliance of a traditional hazard-based view of environment and human health is the impediment it creates to considering the health-promoting potential of the environment. Whilst it is not new to think of healthy environments in terms other than simply an absence of toxic, infectious and other hazards, the idea of actively creating and maintaining environments to promote health and well-being is certainly underexploited in public health.
Questions exist about what characteristics would define a health-promoting environment, whether these would remain consistent for different groups and how they might be pursued in practice. There are implicit challenges, too, in moving beyond traditional enforcement-based approaches to environmental control and in engaging in a dialogue with those in the public and private sectors whose actions shape Scotland's environment.
The emphasis of this work is likely to be the built environment, internal and external, public and private. However, evidence that contact between human beings and nature is good for health reinforces importance of stewardship of the natural environment and the pursuit of sustainability. There is a need for a more complete understanding of the value of nature contact and how this might be achieved in shaping the built environment and particularly urban areas.
For buildings themselves, traditional public health concerns over issues such as indoor air quality, amenity provision, occupant safety and, more recently, sustainability issues must extend to embrace a wider definition of what makes a building healthy. Many factors including lighting, acoustics, aspects of design and access, recognised as important in other ways may simply require to be explored in a more specifically public health context, e.g. in terms of relevance to physical activity or psychological well-being.
The potential of making Scotland's public places more suitable to promote social interaction and physical activity is also clear. This is not only about good design of streets and pavements and provision of parks, cycle paths and open spaces, it is also about ensuring non-threatening physical access to facilities for everyone. Good maintenance of public areas is part of this.
Finally, there are issues such as land use policy, transportation and urban design. These operate at a larger spatial scale to determine the form of towns and cities. Health promoting environments cannot be considered without reference to these issues yet, for the most part, they seem disarticulated from public health concerns.
The Strategic Framework for Environment and Health can be a mechanism for framing research questions and giving effect to insights which emerge.
The Environment as a Stressor
A concern echoed throughout this report is the fact that Scots in socially disadvantaged areas live shorter, less healthy lives and confront chronic disease, on average much earlier than society as a whole. Medical science is now considering the role played by the stresses of social disadvantage in the disease processes underlying inequalities in health which persist even after differences in health-relevant behaviours are taken into account.
A contribution from physical environment to these stresses is certainly plausible, given the correlation between disadvantaged social circumstances and environments which are damaged, visually unappealing and threatening, yet residents are often largely unable to affect change.
Research commissioned by the Scottish Executive to contribute to the evidence base for work on environmental justice offers some important insights into these issues. ( http://www.scotland.gov.uk/Publications/2005/10/2791230/12351). This was conducted by the Scottish Centre for Social Research, the MRC Social and Public Health Sciences Unit at the University of Glasgow and Health Protection Scotland.
As part of the annual Scottish Social Attitudes Survey, a representative sample of the Scottish population were asked about so-called "incivilities" in their local environment. Incivilities are aspects of environment about which respondents might feel negatively, ranging from issues at street level such as graffiti, litter and animal mess to larger infrastructural issues including power stations, wind farms or overhead power cables. Incivilities can also take the form of absence of positive features such as a safe place to walk and sit. The information obtained was analysed in terms of age, gender, socioeconomic circumstances, self-reported health and well-being.
Those who believed the environment in their neighbourhood is poor were more likely to report anxiety, depression and a generally poor state of health. They were less trustful of others, more resigned about difficulties in their area and more likely to live in fear of crime. People were more likely to express concern about, and be affected by, everyday street-level incivilities than they were about higher profile infrastructural features.
The study showed that, irrespective of socioeconomic circumstances, people tend to worry about the same things, but those in less well off areas were far more likely than those in less deprived areas to report that street level incivilities were a problem in their area.
The work introduces the possibility of developing an objective measure of the capacity of the environment to engender stress. This has clear implications for the future management of the environment for health and addressing the environmental contribution to inequalities in health. Building a healthier Scotland will require attention to detail in environmental design and maintenance. In developing its Strategic Framework for Environment and Health, Scotland has taken on a new challenge which offers intriguing possibilities for improving health and well-being.