by Kevin Starr

The following article was written by Kevin Starr for our Newsletter. Kevin has an exceptionally broad and holistic view of health, especially for a doctor. He is a board member and project mediator for the Mulago Foundation. As such, he has devoted the last several years to promoting the development of healthy communities, in which people in difficult situations learn to collectively care for their own health, improve their wellbeing, and protect the environment. The meeting of leaders from Mulago-assisted projects, described at the beginning of this newsletter, was organized by Kevin. He also played a key role in a gathering of Mulago-assisted programs at PROJIMO, in Coyotitan, Mexico, in May, 2001. In both these recent get-togethers, Kevin encouraged the project leaders to formulate a clear vision for working toward an equitable and sustainable future.

Like most doctors, my formal training had little to do with health. I learned a lot about diseases, but little about the things that prevent illness and create well-being.

It was only as I traveled to new places and encountered some wise teachers that I began to see that there was much more to health than simply treating disease. I learned about the importance of things like nutrition, poverty, and sanitation, and the role of less obvious factors like culture, public policy, and the ways in which communities can organize to bring about change. As my education progressed, it became clear that the medicine I’d been taught was only a small piece of the picture of health.

Helping people get to real, lasting health requires that we see the big picture. It takes an ecological way of thinking, a realization that everything is connected to everything else. For example, nutrition—the single most important factor in any individual’s health—is influenced by economic status, agricultural practices, cultural beliefs, educational level, weather, and the marketing practices of multinational corporations, just to name a few things. Narrowly focused approaches just don’t work.

Coming to a more ecological view led me to look at the relationship between the natural environment and human health. Again and again, I saw examples of how changes in the environment affected people’s health, usually for the worse:

  • Crop yields shrinking as thin mountain topsoil washed away.

  • Overpopulation forcing succeeding generations to divide their farmland into plots too small to support a family.

  • Devastating floods from deforestation.

  • Protein malnutrition endemic in coastal villages after over-fishing the local fishing reef.

  • Rivers and wells poisoned from mercury, oil, and pesticides.

  • Changes in forests helping to spread disease.

And of course, in every place I went, the effects of environmental destruction were harder on children than anyone else. It became more and more obvious to me that human health-especially the health of children-depends on the health of the natural environment. Conservation of our life support systems of air, water, soil, and local ecological balance forms the foundation of an effective and lasting approach to health.

Now, some people think that conservation is a luxury, something that only rich people can afford to think about. Nothing could be farther from the truth. Local conservation matters much more to cash-poor people living off their own lands. Rich people are insulated from their effects on the local environment; they can import food and export wastes. For example, the United States, the average piece of food travels over 1500 km. From where it is grown to where it is eaten. The water I drink in my city in California comes from lakes 300 km. away. The city of New York ships its garbage over 800km. to the state of Ohio. Cash-poor people can’t do that: they have to rely on their local environment for water, food, building materials, and other basic commodities. They can’t send away their waste products or afford expensive solutions to make up for environmental damage. They have to live with-or suffer with what they do to their local environments. So, more than anyone else, people without a lot of cash have to be conservationists.

While it is true that poor people have a bigger stake in local conservation, to be able to achieve conservation requires that you be able to think about the future-and to think about the future requires that the needs of today be met. People can’t think about the future when they are hungry, sick, impoverished or oppressed. Who could care about conservation when it’s not certain that there will be anything to eat tomorrow?

So I say to my friends working in health: “Lasting health depends on conservation.” At the same time, I say to my friends working in conservation: “Lasting conservation depends on health.” Human health and environmental health are forever intertwined-as two sides of the same coin, one cannot happen without the other.

People always list health issues as one of the things they’re most concerned about. Participatory community-based primary health care programs are an excellent place to begin integrating health and conservation, for several reasons. First, they provide an effective way to deal with the urgent problems of today and begin to achieve health with equity. Second, the participatory problemsolving methods create an opportunity to introduce environmental factors into discussions of community issues. Third, participatory community activities provide a forum for people to envision together the kind of future they want. And finally, the process of participating in well-designed community health activities can provide a model for making good decisions based on good information and then taking effective collective action toward specific goals.

It’s important for those working in both conservation and health to realize that the process of decision-making is central to lasting change for the better. People don’t destroy their environment because they are stupid or greedy; nor do they live in unhealthy squalor because they are lazy. It’s usually because they are acting out of desperation or on the basis of incomplete or misleading information. As a friend of mine working in international development says, “When people do dumb things, it’s usually because they had bad information.” Rarely do people have the opportunity to deliberately think about the future they want. People given the chance usually express the desire for a healthy environment-they don’t say “Hey, I think I’d like a future without any trees and with a river full of pesticides.” And even i people can express their vision of the future, they may not have an effective community process to solve problems and take action together.

Once people have these things—good sources of information, a vision of the future they want, and good community process—seeing and acting on the links between health and conservation become much simpler.

Examples of Connections Between Health and Conservation

Here’s an example of how obvious the connections can be. Suppose that a rural community surrounded by forest wants to address the issue of children’s diarrhea. The most important factor in preventing diarrhea is achieving a clean, safe water supply. The best way to ensure clean water is to protect the watershed area, which means leaving forest intact. This has the added benefit of helping conserve topsoil, which will help maintain good nutrition. Good nutrition is essential to helping children fight off the infections that cause diarrhea. And around it goes.

The connections can spin on and on. Here are some examples of how conservation and health have affected each other in some of the places that I happen to have seen:

In the Solomon Islands of the South Pacific, people were offered what seemed like huge sums of money from loggers for the right to cut down their trees. It seemed like a great windfall, but when it was all over, they found themselves much worse off than before. The resulting deforestation meant that instead of dripping off trees and soaking into the earth, the rains beat down directly on the exposed ground, carrying off topsoil and polluting the rivers. The ground became hard and rocky. Water ran off it in a torrent, causing devastating floods. Where the ground was flat, puddles formed and mosquitoes bred, leading to outbreaks of malaria. The loss of fish and birds from the ruined forests and rivers meant less protein in people’s diets. There was nothing to replace traditional forest-based livelihoods, something that contributed to cultural upheaval and alcoholism. In short, people were impoverished and sickened by selling their forest.

The Kayapo Indians of the central Brazilian Amazon also suffer from malaria. Rates of acute illness are 120% per year; everyone gets malaria and 1 of 5 get it twice. Studying the problem, it became clear that a number of factors are at work. Changes in the ways the forest is exploited may have shifted the mosquito population to a species more likely to spread the disease. Plastic trash scattered about collects rainwater and provides ideal mosquito breeding sites. Loggers and miners allowed into the area act as a continuous source of the malaria parasite. Whatever is done medically, any approach to rid the Kayapo of malaria will have to address these environmental factors. Dealing with malaria is leading to constructive changes in the way people are thinking about economic, cultural and ecological issues.

In a small village in the Fijian Islands, a medical survey team found shockingly high rates of high blood pressure and diabetes. Looming large among the suspected causes: destructive harvesting and fishing practices had destroyed the local reef as a primary food source. For this and other reasons, people replaced traditional foods with modern processed foods full of salt and sugar. Without good information, they had no idea these foods were bad for their health and no way to connect the destruction of the reef to their emerging health problems. In endless rounds of discussion, the village elders started laying a foundation for a return to the Fijian way.

In rural Costa Rica, vegetable farmers influenced by multi-national chemical companies adopted the intensive use of pesticides. The jungle insects proved very good at developing resistance to these chemicals. Farmers ended up using higher and higher amounts of pesticides, to the point where Costa Rican farmers were using more pesticides per hectare than anywhere on earth. With all these chemicals in the environment, the rate of poisonings skyrocketed. People knew the pesticides were bad—one farmer I met wouldn’t let his kids eat his own vegetables—but once the ecological balance had been lost, they felt trapped. Returning to organic farming methods and the introduction of new ecology-based methods of pest control offered farmers a way out of the mess they found themselves in.

For the San people of Botswana, supportive conservationists managed to address an important health issue in a way that led toward conservation. For centuries, the San had lived in the Kalahari desert, developing the skills that allowed them to thrive in unforgiving place. When their ancestral lands were confiscated for cattle ranches and fences were put up that stopped the migrations of game, the San lost their traditional way of life and became dependent on government handouts. The men, famed as hunters and trackers, had nothing to do. A depressed apathy set in; many turned to alcohol. Outside conservationists, thinking about both human and environmental well-being, came up with a number of integrated solutions. Presenting the results of good research, they persuaded the government to remove at least some of the fences. Advocating for the San, they helped them get their ancestral lands back in the form of parks where they could pursue some of their traditional activities. And after studying the potential of tourism, the project began training men as nature guides, using their hunting and tracking skills in a new way. Just a few months into the project, one could see a marked improvement in the morale of the villages.

From the Himalayan mountains of Tibet comes our final example. Living on a desert plateau at 4000 meters, people there have trouble finding adequate sources of fuel and are depleting the native juniper trees. Solar ovens provide an obvious answer, since Tibet has a high percentage of sunny days. As it turns out, though, there is an important potential health benefit of solar cooking. Traditional Tibetan kitchens are full of wood smoke, something that contributes to the high rate of respiratory infections there. A conservation solution is a health solution at the same time.

Start Integrating Health and Conservation

These examples demonstrate just a few of the connections between health and conservation. As community groups and committees work to address health issues there are a number of ways that they can bring conservation into the process. Here are a few suggestions (this is by no means a complete list):

  1. Help your community imagine the future that it wants. As a part of your annual health surveys, organize ways to bring the community together for discussions of their vision for the future. As with the health survey, these discussions can lead to the establishment of priorities and work plans to begin making the vision a reality.

  2. When addressing health problems, ask “What environmental factors are playing a role here?” It may be that the answers are obvious, or the question may provide a stimulus to gather more information.

  3. Ask the question, “How are environmental changes that we notice affecting our health now and in the future?” Local people notice change and they usually have an opinion about what it means. Giving them the chance to express what they have observed and felt can lead to big changes in community awareness.

  4. Collect and present good information. The best information is often local data, gathered by local people. It is immediately relevant, tends to be more complete, and most importantly, it is owned by local people. Other sources are outside experts, the world literature, and local lore and tradition. All of these have their place in decision making; the job of the committee member is to find good information and present it in useful fashion.

Summing it up

Sooner or later, human health depends on the health of the environment. To provide health care in a sickening environment is like oiling the door hinges while the house burns down. Health care is enriched and deepened by bringing in a conservation ethic: it brings optimism, as though we mean to get healthy and stick around for a while. A health care process that is by the people and for the people provides a natural way to integrate conservation into a long-term vision of well-being. Common sense, good information, and a bit of creativity can turn perplexing problems into a chance for a hopeful future.