Ecosystems, Society, and Health: Pathways through Diversity, Convergence, and Integration 9780773583122

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e c o s y s t e m s , s o c i e t y , a n d h e a lt h

   

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Ecosystems, Society, and Health Pathways through Diversity, Convergence, and Integration

Edited by lars k. hallström, nicholas p. guehlstorf, a n d m a r g o t w . pa r k e s

McGill-Queen’s University Press Montreal & Kingston • London • Ithaca

   

© McGill-Queen’s University Press 2015 ISBN ISBN ISBN ISBN

978-0-7735-4478-9 (cloth) 978-0-7735-4479-6 (paper) 978-0-7735-8312-2 (ePDF) 978-0-7735-8327-6 (ePUB)

Legal deposit second quarter 2015 Bibliothèque nationale du Québec Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication   Ecosystems, society, and health : pathways through diversity, convergence, and integration / edited by Lars K. Hallström, Nicholas Guehlstorf, and Margot W. Parkes. Includes bibliographical references and index. Issued in print and electronic formats. ISBN 978-0-7735-4478-9 (bound). – ISBN 978-0-7735-4479-6 (pbk.). – ISBN 978-0-7735-8312-2 (ePDF). – ISBN 978-0-7735-8327-6 (ePUB)   1. Human ecology. 2. Environmental health. 3. Biotic communities. 4. Ecosystem health. 5. Ecological integrity. I. Hallstrom, Lars K., 1973–, editor II. Guehlstorf, Nicholas P., editor III. Parkes, Margot W., editor GF41.E26 2015   304.2 C2015-900310-5 C2015-900311-3 Typeset by Jay Tee Graphics Ltd. in 10.5/13 Sabon

   

Contents

Tables and Figures  vii Acknowledgments ix 1 Convergence and Diversity: Integrating Encounters with Health, Ecological, and Social Concerns  3 Lars K. Hallström, Margot W. Parkes, and Nicholas P. Guehlstorf

Section one: Socio-Ecological Approaches to Health, Environment, and Community 2 Strengthening Communities with a Socio-Ecological Approach: Local and International Lessons in Whole Systems  33 Nancy Edwards and Colleen Davison 3 Using Research and Restoration to Re-Imagine Safe Places in a Technologically Colonized Health Care World  68 Patricia Marck 4 Engaging with Nature in the Promotion of Health  99 Patti Hansen-Ketchum

Section two: Deliberation, Policy, and Collaboration as Pathways to Integration 5 Deliberative Rule-Making for Human Health and the Environment: Making Administrative Discretion Safe for Democracy 135 Robert V. Bartlett and Walter F. Baber

   

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6 The Social and Environmental Outcomes of Market-Based Wetland Regulations in the US Midwest  159 Nicholas P. Guehlstorf and Traci Lichtenberg 7 “Just Add Water”: Dissolving Barriers to Collaboration and Learning for Health, Ecosystems, and Equity  184 Margot W. Parkes

Section three: Linking Ecosystems, Society, and Health through Learning and Local Knowledge 8 Situated Learning, Community Development, and Ciguatera Fish Poisoning in Cuban Fishing Villages  227 Karen Morrison, John Fitzgibbon, and David Waltner-Toews 9 Religion, Environment, and Health  256 Anne Marie Dalton 10 Integrative Science and Two-Eyed Seeing: Enriching the Discussion Framework for Healthy Communities  280 Cheryl Bartlett, Murdena Marshall, Albert Marshall, and Marilyn Iwama Contributors 327 Index 331

   

Tables and Figures

Tables 6.1 Analysis for atrazine concentration vs number of banked wetlands within measured radius and within watershed  172 7.1 Distinguishing and dissolving boundaries between integration, participation, and collaboration: a typology  188 7.2 Integration, participation, and collaboration as components of research design  192 7.3 Type, mode, and place of participation in the Taieri Catchment and Community Health Project  197 7.4 Linkages between integration, participation, and collaboration in the TCandCH Project  202 8.1 Relative toxicity to mice of a variety of toxins  231 8.2 Summary description of case study communities and study results 243

Figures 7.1 Type, mode, and place of participation: three axes influencing the design of participatory processes  198 8.1 Percentage total outbreaks by municipality, La Habana 1995–98 236 10.1 Spirit of the East, painting by Basma Kavanagh  292 10.2 Trees Holding Hands, computer graphic by Integrative Science Research Assistants Sana Kavanagh and Nadine Lefort  293 10.3 Trees Holding Hands, photo by Integrative Science  295 10.4 Two-Eyed Seeing “Old,” computer graphic by Kristy Read  297

   

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10.5 Two-Eyed Seeing “New,” with jigsaw puzzle pieces, computer graphic by Kristy Read  298 10.6 Integrative Science Vision, painting by Basma Kavanagh  308 10.7 Two-Eyed Seeing – Big Pic #1, Ontologies, computer graphic by Integrative Science  310 10.8 Two Eyed Seeing – Big Pic #2, Epistemologies, computer graphic by Integrative Science  312 10.9 Two-Eyed Seeing – Big Pic #3, Methodologies, computer graphic by Integrative Science  314 10.10 Two-Eyed Seeing – Big Pic #4, Knowledge Objectives, computer graphic by Integrative Science, including part of the “First Nations Holistic Lifelong Learning Model” from the Canadian Council on Learning, Aboriginal Learning Knowledge Centre (http://www. ccl-cca/CCL)   315

   

Acknowledgments

This book originated in 2005 as a result of a series of conversations, meetings, conferences, grant applications, and new teams that were created across Atlantic Canada. At the same time that faculty in Nursing at St. Francis Xavier University were beginning to collaborate on research and funding related to the social determinants of health, other faculty from Prince Edward Island, the University of New Brunswick, and St. Francis Xavier University were starting a concurrent set of conversations about linking health-based research to the social and applied sciences, including informatics, mathematics, religious studies, and environmental research. Following a series of fits and starts as new projects came and went, and as new contributions and contributors emerged, what always rested at the heart of this project, and those conversations, was the idea that the thinking about how social, health, and environmental systems were linked could be pushed forward. Since that time, different research streams and initiatives (such as ecohealth and one health) gained some traction, but our intention has always been to continue to push beyond questions of method and discipline, and instead to try to find a way that recognizes and incorporates such work, but does not leave it there. Instead, our goal has been to speak to a wide range of audiences, including practitioners, researchers, decision-makers, and students, to both reflect and inspire the wealth and diversity of perspectives available to us. As a result, while this book is rooted in three basic streams (social, health, and environmental systems), its particular interest lies in, and with, those who are working at this interface, and perhaps wrestling with

   

x Acknowledgments

the intellectual, methodological, professional, and even personal challenges such work can present. One of us, Lars Hallström, began his work in environmental and comparative public policy, but has spent the past ten years examining and working on questions of integration, decision-making, and complexity in these different, yet intimately linked systems. He is indebted to all of the partners, collaborators, and participants who have contributed to the success not only of this book, but of the different projects that have helped to inform its development: the original members of the Healthy Communities Research ­Cluster (Patti Hansen-Ketchum, Patricia Marck, Keith De’Bell, Brenda Appleby, and Donna Murnaghan), the Gender, Race, Class and Health Research Group at StFX, the Canada Research Chairs program, the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, the original applicant team for the National Collaborating Centre for Determinants of Health (and the Atlantic Health Consortium), the National Collaborating Centres for Public Health, the members of the Network for Ecosystems Sustainability and Health, faculty in multiple departments at both StFX and the University of Alberta, and the numerous students who have (often unwittingly) helped explore, shape, and validate the approach and key questions that helped spark the creation, revisions, and editing of this book. He is particularly thankful to Roxanne Harde at the University of Alberta, who provided a second eye during a critical period of finalizing the manuscript. Margot Parkes’ interest in the integrative themes of this book began in New Zealand, fuelled by training, research, and experience with clinical medicine, human ecology, public health, and  – for the last decade – an explicit engagement with the emerging field of ecohealth. Her contributions to this book are a direct result of learning and exchange with groups in a range of contexts including, but not limited to: the founding co-editors of the journal EcoHealth; the founding board of the International Association for Ecology & Health; the Ecohealth Program initiative of Canada’s International Development Research Centre; and past institutional ‘homes’ supportive of integration, including the University of Otago’s Ecology & Health Research Centre; the Division of Ecology and Health at the John A. Burns School of Medicine, University of Hawaii; and the College of Health Disciplines, Department of Family Practice and Global Health Research Program at the University of British Columbia.

   



Acknowledgments xi

Margot is especially grateful to the funding, conceptual, and practical contributions that have supported her editorial contributions more recently, including: the Canada Research Chairs program; the Canadian Institutes of Health Research; the Canadian Community of Practice in Ecosystem Approaches to Health; the National Collaborating Centre for Aboriginal Health; the Network for Ecosystem Sustainability and Health; and related, integrative initiatives at the University of Northern British Columbia, including the Ecohealth Knowledge to Action Research Group. Margot is indebted to a range of inspiring students and colleagues who have helped expand, provoke, refine, question, and consolidate the orientation and perspectives in this book. Her willingness to engage in the integrative challenges, tensions, and opportunities reflected in this book is the result of a long-term collective process, indebted to many years of dynamic and ongoing connections, conversations, encouragement, guidance, and good humour shared, in particular, with Will Allen, Kerry Arabena, Rachel Brown, Valerie Brown, ­Martin Bunch, ­Dominique Charron, Sarah de Leeuw, Maya G ­ islason, Lars Hallström, Pierre Horwitz, Karen Houle, Sophie Jerram, Karen ­ ­Morrison, Homaida (Robbie) Razack, Johanne Saint-Charles, Céline Surette, Carolyn Stephens, Craig Stephen, Rachael Trottman, David Waltner-Toews, and Robert Woollard. Nicholas Guehlstorf has been examining questions of environmental policy and democracy for over a decade. This book is a cooperative effort and he is thankful for the valuable contributors in this edited volume who are attempting to build a necessary bridge, fill an important gap, or destroy silo’d thinking in the scholarship of environmental sciences. He gives special thanks to Margot Parkes, who was responsive to the persistent suggestions of a novice coeditor, and he hopes to someday put a face to her endurance, intellect, and humour. Finally, Nicholas would like to express his appreciation to one of his best friends and colleagues, Lars, who had a synoptic view of the intersection of academic work on the environment, social assessments of government, and the human health industry he was willing to share. A book of this size, scope, and length is far more than a simple intellectual and authorial undertaking. Its many authors have been not only persistent, but consistently supportive, conscientious, and sometimes even graciously indulgent of the various editorial requests that have been made along our journey. We are particularly

   

xii Acknowledgments

grateful to the people who have read some, or all, of the manuscript. This includes not only the reviewers recruited by the Press (who have been constructive and professional almost to a fault) but also those who offered a second set of eyes, opinions and editorial skills, and even financial support. This list includes Erin Yulka, Roxanne Harde, Erika Heiberg, Naomi Finseth, Devin Keay, Aubrie Duncan, Juillane Epplin, and Jennifer Stonechild. Similarly, we are also appreciative of the institutional support provided by our respective institutions and departments. This book has been a long time in the works, and has required some patience and understanding at the departmental level. Finally, this book could not have come to fruition without the insight and professional guidance of Kyla Madden at McGillQueen’s University Press. She has been engaged, constructive, and timely – all highly desirable attributes in an editor. At the same time, as editors we must take full and final responsibility for this volume, its content, and its omissions – there is much more to be said, and more ways to say it, than can be contained within one book. Our most important thanks are to our partners and families: to Kristin Guehlstorf, Regina, Joseph, Maria, and Elizabeth; to Robbie, Win, Ross, Karen, Derek, Paul, Josephine, and Angus; and to Erin Yulka, Logan, Freya, and Willow. Our partners know how this work has worn upon us, while we hope that our friends and our children (thankfully) may never know. We thank them all for their love, their support, their encouragement, their patience, their engagement, and their companionship.

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1 Convergence and Diversity: Integrating Encounters with Health, Ecological, and Social Concerns l a r s k . h a l l s t r ö m , m a r g o t w . pa r k e s , a n d nicholas p. guehlstorf

This book brings into conversation three vast subject areas: environment, health, and society. Although their issues and concerns are deeply interconnected, their research and policy agendas are frequently confined to disciplinary, administrative, sectoral, and knowledge-based silos. Both public media and academic publications have tended to portray significant problems (and their solutions in particular) as falling into only one domain: environmental risk, public health, or social science. Given the scope of each area, the prospect of identifying convergence and connection among them can seem daunting and unmanageable. Despite this challenge, acknowledging and respecting the complexity of contemporary issues has also led to recognition that integrative approaches to ecosystems, health, and society are not only possible, but increasingly necessary. This interdisciplinary collection of research is brought together to explore or reconstruct a story of a convergence that respects this diversity. As research on environment, health, and society continues to expand – as is happening in this text – it is important to identify and systematize our knowledge of the embedded connections and relax the desire for shortterm solutions. The issues and patterns we identify in this chapter, and the works included in this book, offer a narrative of the interlinked, cross-national, and interdisciplinary research that is now in progress.

   

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In keeping with all of the chapters in the book, this introduction begins with an acknowledgment of the diverse interests and research concerns of the authors, which have provoked the need for this book. As co-editors, it is notable that our interests are rather different but have emerged, respectively, from environmental, health, and social concerns. Recognition of the neglect of the societal complexities of science, especially in relation to issues of environmental democracy, was a key driver for Hallström. For Parkes, a health-driven concern with the emergence of water-related diseases related to intensive agriculture fuelled attention to watersheds, intersectoral governance, and the social-ecological context for health. The risks associated with genetically modified organisms was one of the issues that prompted Guehlstorf to navigate scholarly terrain spanning environmental hazards, product-based health risks, and an awareness of the political and legal ramifications of industrial legacies that now bridge continents. The range and scope of contributions to this book lay bare the deeply embedded connections and narratives that link social, health, and environmental concerns. Drawing on a range of scholarly backgrounds and approaches, the book spans contexts from Cuban fisheries, to Canadian and Chinese health care services, to watersheds from North America to New Zealand. As co-editors, we continue to learn from each of these contributions and we encourage the reader to encounter, explore, and engage with the diversity, convergence, and integration at the interface of health, ecological, and social concerns.

Introduction The past decade has seen a number of events move health and environmental policy concerns forward on the political stage, as well as into the public eye. Environmental and health-related issues ranging from avian influenza, global mercury accumulating in Arctic food sources, sars, and trans-boundary land and water conflicts have all prompted public scrutiny. These issues have also challenged trust and confidence in the public institutions and the science that assist in determining public policy. Such issues demonstrate the critical social dimensions of environmental and health policy, and not least the fact that the risks, costs, and benefits of environmental and healthrelated challenges are not distributed evenly throughout society.

   



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This introductory chapter offers a lens for viewing such issues with patterns of convergence and diversity about the developments, approaches, and practices that have informed our understanding of the linkages among health, ecosystems, and society over recent decades. The intention is to provide the reader with a starting point from which to consider the subsequent chapters and a broader context that reflects contemporary approaches to understanding human health in relation to both society and the environment. This emerging social context includes an emphasis upon dynamic change and the movement away from a focus on traditional scientific, practical, or policy-based delineations. At the heart of this book, therefore, is the recognition of the expanding range of questions (and indeed answers) being posed, considered, and sometimes accepted by an increasingly diverse range of scholars engaged with concerns spanning health, environmental, and social agendas. Indeed, the problems resting at the interface of health, environment, and society have come to exemplify the uncertainty and complexity of the modern era (Beck 1998; Janicke 2008; Waltner-­ Toews et al. 2008). These problems pose real challenges for expertise defined by traditional science, rationalism, and sectoral and disciplinary domains. Environmental, health, and social policy researchers and practitioners are increasingly being tasked with navigating multiple disciplines to seek out best practices, scholarly insights, and relevant experience from complementary, but quite foreign, spheres or silos of knowledge. The ongoing debates around issues spanning health care, public infrastructure, resource extraction, genetically modified foods, Indigenous governance, global climate variability, and the spread of infectious diseases share a similar set of characteristics. These include transferability or potentially international dimensions in terms of scope and effect; high levels of complexity and uncertainty; public demands for political and legal, as well as social, mechanisms to control or manage them; and considerable controversy over the provision of advice and knowledge on which political decision-making and public policies are based. Despite the ubiquitous public and political rhetoric about interrelated health, ecological, and social concerns, there has not been a corresponding response in public policy or research. This book responds to a growing need for boundary-crossing among all three agendas and forms of praxis that explicitly consider health,

   

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e­ nvironment, and society together, rather than as distinct or unrelated agendas, approaches, and priorities. Acknowledging this need is particularly important when considering the place of human beings within a larger planetary and ethical context, which can be seen in public health, societal economics, and juridical decision-making about the environment. These considerations echo recurring calls to consider health in its social-­ ecological context and the relevance of the powerful yet elusive idea of “reciprocal maintenance.” This is, quite profoundly, the need to take care of each other, our communities, and our natural environment that has remained unrealized since the Ottawa Charter for Health Promotion in 1986. This book considers the benefits of creating a space to explore and learn from commonalities, differences, and juxtapositions, and offers a complementary response to proposals by Parkes (2012), Aguirre et al. (2012), and Charron (2012) that ecohealth  – including social-ecological orientations to health, conservation medicine, and ecosystem approaches to health – may offer spaces for this kind of convergence. This book emphasizes that demands for integration will never be fully addressed by any one field or development and in particular argues the merits of exploring convergence and diversity without the constraints of potential orthodoxies arising from any new field. Research and policy have tended to focus upon the nexus of health and environment, but this book goes beyond this to explicitly engage with the merits and opportunities of seeing the three policy agendas of health, environmental, and social issues as explicitly interrelated. Given the overlap in terms of ethical, cultural, restorative, and power dynamics, we consider synthesis and integration as guiding imperatives. These imperatives, in turn, lead to reflection on governance, intersectoral policy, and decision-making that traverse health, sustainability, and equity concerns, as well as the interactions between knowledge, legitimacy, and power (Maasen and Weingart 2005; Van Der Plaat and Barrett 2006; Brown 2007; Janicke 2008; Kickbusch et al. 2008; McMichael 1993; Parkes et al. 2010; ­Raphael 2004, 2008). For scholars and practitioners alike, this array of concerns and issues is characterized by interconnected causes and conflicting interests which are typically not amenable to a simple cure or complete resolution (Brown et al. 2010). Churchman’s description of “wicked problems” in 1967 offered explicit recognition of these

   



Convergence and Diversity 7

c­ haracteristics and was later reinforced by the critical social school of the 1980s (see for example Beck 1992, 1995, 1998), which recognized that ecological risks are intimately linked together with the social, economic, and health risks generated by late or post-­ modernity (Mol 1996). This recognition came about in response to issues that: (1) are “embedded” in society; (2) display complex interdependency that escapes simple definition; (3) are not solvable by “taming” or addressing “manageable” sub-problems; and (4) often result in unintended consequences (Churchman 1967; apsc 2007; Brown et al. 2010). Wicked problems also challenge us to assess how knowledge is reliable, valid, and useful for contemporary politics and society at large. As a series of encounters with the challenges present at the interface of health, ecosystems, and society, this text is composed of three broad sections that reflect such adaptive characteristics. Hajer and Wagener, for instance, characterize these characteristics as: (1)  interpretative; (2) participatory and deliberative; and (3) practical (2003). While each section speaks to all three of these characteristics, the emphasis varies between them. Section I: SocioEcological Approaches to Health, Environment, and Community highlights the reality that local context, settings, and the integration of different approaches to knowledge have important roles to play at the epistemological, theoretical, and methodological levels for all three domains. Section II: Deliberation, Policy, and Collaboration as Pathways to Integration is primarily concerned with how questions of social engagement and environmental deliberation interact with the dynamics of engaging with health and social concerns. Section III: Linking Ecosystems, Society, and Health through Learning and Local Knowledge speaks to the practical implications of growing calls for partnership, learning, and the incorporation of local knowledge when addressing issues that span health, environmental, and community concerns. Each section begins with a brief summative text that explores the section themes in more detail and introduces each of the subsequent three chapters. This volume embraces these different perspectives in a way that respects their diversity. It can be seen as a collection of diverse but convergent responses to a particular suite of wicked problems and pressing integrative challenges that are manifesting as the twentyfirst century unfolds. These intersections demand we consider how to best understand the interconnections among policy problems

   

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and solutions, collaboration across diverse forms of knowledge and knowledge acquisition, and the emancipatory opportunities for social movements capable of engaging with complex and interdependent concerns. As the myriad social, environmental, and health issues faced today demonstrate, singular or disciplinary approaches to problem-solving tend to create different and additional issues from those they address, and demand innovation, integration, and an acknowledgment of these issues’ complexity.

Understanding Convergence through D i v e rs i t y: A dva n c e s o n I n t e g r a t i o n The “territories” of the health, environmental, and social policy domains have not only grown respectively, but can increasingly be understood as both overlapping and convergent (Parkes et al. 2003, 2010). However, as the chapters in this text show, this convergence is not guided, nor consistent, nor agreed upon. While some researchers may point to the rise of ecohealth, one health, or the determinants of health as linking or integrative approaches to work in this area, there are also broader realities of research, practice, management, and collaboration that, to date, are defined by limited interaction. The contributing authors reinforce an important consideration that underpins their contributions to this book, whereby the multiple perspectives associated with health, ecological, and social concerns may lead in multiple and not obviously unifying directions. Researchers, practitioners, and educators are, therefore, challenged to think in nuanced and critical ways about the nature of the convergences we see and some of the incongruities of the diversity that is the foundation of this book. The initial spark for this book was a conversation among a collection of researchers funded by Canada’s Social Science and Humanities Research Council in 2005–06. This group maintained that although environmental and health considerations were far from new, they tended to be framed in ways that are now being challenged from multiple directions. Specifically, the biomedical emphasis on viewing the environment as a simple, proximal cause of ill health was seen as particularly limited and the need was expressed to expand that view. What was originally discussed and envisioned through a series of meetings, conversations, and individual projects with different contributors was the value of attempting to better

   



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frame the relationships between ecological factors, social processes, and institutions and the health and well-being of both individuals and communities. This led to invitations to authors not directly working within “environment and health” and/or Canada, yet who self-identified as thinking in either theoretical or practical terms about the ways in which these complex interrelationships ought to function. Recognizing that human beings, our communities, other species, and the larger ecosystems within which we live are intimately connected is not necessarily a new idea. Accordingly, the diverse but converging perspectives that contributed the founding themes of this book should be considered in their historical context. Hippocrates, for example, is often noted for his urging of physicians to consider the “airs, waters, places” where their patients lived 2,500 years ago (see Waltner-Toews 2011, 7). Likewise, the recognition of the importance of interrelationships among individuals, communities, and ecosystems, and the benefits of an holistic view of social, ecological, and health factors, not only echoes Indigenous teachings across millennia but is being rekindled as an essential consideration for the health and well-being of Indigenous peoples, with growing relevance to all populations (Raphael 2004, 2008; Greenwood and de Leeuw 2009; Loppie-Reading and Wein 2009; Parkes 2011). This kind of integrative thinking has, however, tended to be marginalized throughout the twentieth century as many leaders and scholars were lured by the vision that infectious disease had been conquered (WaltnerToews 2011). After the Second World War, the exponential growth of technology and communications (Barber 1996) and the expansion of the positive state (Hallström 2008) all helped to deify what ­Ehrenfeld (1981) termed “The Arrogance of Humanism” and Frank Fisher (1990) termed the “politics of expertise” or technocracy. This is not to diminish the benefits that have been associated with the rapid progress of the twentieth century, as significant advances have been made in medicine, engineering, agriculture, computing, communications, public administration, and the “management” of conflict. Despite these advances, scrutiny of environmental issues at a multitude of scales has continued over the last decades (Carson 1962; Caldwell 1990), along with increased recognition of the significant adverse events triggered by, linked to, and associated with “progress.” Since the late 1980s, the linkages between environmental, social, and health domains have become increasingly apparent,

   

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influenced by the work of the Frankfurt School in particular (Beck 1992, 1995, 1998; Habermas 1987a, 1990, 1987b). From the early effects of chlorofluorocarbons (cfcs) on the ozone layer, to increasing antibiotic resistance and globalization with interspecies transfer of infectious disease, the human species is exacting a toll on the ecosystems upon which it relies. Moreover, the causes, effects, and scope of that toll are complex, variable, dynamic, and interrelated across the structures of politics and society, across ecosystems, and across the different policy domains on which they touch. In contrast to this dynamism and interrelatedness, both science and policy studies have rationally and administratively sought to break down issues into their “component” parts. While this disciplinary and practical compartmentalization has generated a great understanding of process and causation in many fields, such an approach tends to neglect the inherent and necessary interconnections present. That said, as we look back on the past twenty years of research, practice, and policy-making, multiple concomitant streams have sought to address this gap, each recognizing and working amidst the complexity and connections. Four notable converging examples include: (1) ecohealth (creating an umbrella for lines of thought that includes ecosystem approaches to health, one health, and ecology of infectious disease) (Charron 2012; Webb et al. 2010; Nguyen 2011; Wilcox et al. 2012); (2) socially based approaches to health and wellbeing (such as the social determinants of health and health equity as presented by the who Commission on the Social Determinants of Health, csdh 2008); (3) socio-ecological and restorative approaches to health, communities, and ecosystems ­(Bronfenbrenner 1986, 1995, 2000; Bronfenbrenner and Morris 1998; Evans and Stoddart 1990; Dahlgren and Whitehead 1991; Stokols 1996); and (4) public policy and politically grounded approaches such as risk (Beck 1992, 1995, 1998), health society (Kickbusch 2007, 2008), and deliberative democratic theory (Dryzek 2000; Baber and ­Bartlett 2005, 2010). Corresponding with these developments, the theme of complexity and in particular its application to an ecosystemic understanding of the environment began to emerge in the 1990s (Allen et al. 1993; Waltner-Toews et al. 2008). The notion that a truly complex system defies capture or representation from any singular perspective is of key importance to this book. As Waltner-Toews et al. (2002, 2) describe it, “The sheer diversity of elements and ­interactions requires a plurality of perspectives … Not only can complex

   



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s­ ystems be described from a variety of perspectives, but new properties emerge into view as one considers these systems at different scales.” What results from this pluralism is the acknowledgment of the need for and the benefits of multiple perspectives, along with the realization that solutions are limited and that some perspectives will still be obscured, invalidated, or not acknowledged. From a health standpoint, many early efforts to address complexity, systems, and integration grew from community-based initiatives such as Healthy Communities and the founding efforts of health promotion expressed by the Ottawa Charter in the 1980s (who 1986; Hancock 1985, 1993). Early examples of cross-fertilization between systems-oriented health and environmental approaches can also be found in the subtle interplay between international health-oriented documents such as the Alma Ata Declaration, the Ottawa Charter, and strongly ecosystem-oriented regional initiatives such as the International Joint Commission of the Great Lakes (Allen et al. 1993) or the emergence of the international conversation around sustainable development represented by Our Common Future (Brundtland 1987) and the Rio Declaration (unced 1992). Building from these ideas in the 1980s and 1990s, a next generation of more explicitly integrated approaches is indicated by the development of health programs with an ecosystems approach, exemplified by the several cycles of Canada’s International Development Research Centre on ecosystem approaches to human health (Forget and Lebel 2001; Lebel 2003; Charron 2012). Parkes et al. (2012) note the cross-­fertilization among a range of related integrative efforts including the Network for Ecosystems Sustainability and Health (nesh), several international Communities of Practice for Ecosystem Approaches to Health (copeh), and the International Association for Ecology and Health (iaeh). These developments have also been associated with the emergence of new fields with integrated and synthesized names  – such as “ecohealth” (the semantic origins of which could be attributed to Ecosystem Health, Ecology and Health, and Ecosystem Approaches to Health) and “one health” (generally agreed to link human and animal health, with varying degrees of connection with ecosystems and sometimes associated with the trademarked phase “One World – One Health”). Having emerged across several decades of work among networks of researchers and practitioners ­internationally, efforts to consolidate and reflect on these contributions and their convergence

   

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are starting to emerge (see for example Webb et al. 2010; WaltnerToews 2011; Dakubo 2011; Zinnstag 2011; Charron 2012; Parkes 2012; Aguirre et al. 2012). Ecosystem approaches to health, for example, are hailed as systemic, participatory approaches to understanding and promoting health and well-being in the context of complex social-ecological interactions (Waltner-Toews 2009), but as Nguyen (2011) points out, they have tended to emphasize social dynamics with less attention to ecology and ecosystems than the names of these approaches would suggest. It remains to be seen how explicit efforts to connect the social and ecological in relation to health, such as Bunch (2003) and Neudoerffer et al. (2005), in the application of an Adaptive Methodology for Ecosystem Sustainability and Health (amesh), will influence the long-term development of ecohealth and one health scholarship and practice. These efforts will be fuelled by parallel critiques and developments, such as those arising in conjunction with the twenty-fifth anniversary of the Ottawa Charter’s claim for a socio-ecological approach to health. Other notable examples include Hancock’s recent challenge “It’s the Environment, Stupid!” (2011) and Poland et al.’s (2011) call for a “Sociology of Transformation” in order to secure “supportive environments” for health in the face of ecosystem collapse. While reflection on the evolution of integrative effort is important, a critical point for this text is that links between the developments above and the majority of the works in this book are implicit at best. In fact, with a few exceptions, the diverse “conversations” represented in this book emerged almost entirely in parallel with the emergence of integrative fields such as ecohealth. Simultaneously, this book is an earnest effort to better connect the lines and pathways of commonality, of complementarity, and of convergence in the face of ecological, social, and health challenges.

D i v e rs e y e t C o n v e r g e n t A p p roac h e s to Wicked Problems Notable responses to developing legitimate knowledge and actions for interrelated health, environmental, and social equity issues are the calls to work together across disciplinary, sectoral, and cultural boundaries (Brown 2007; Capon 2007; Kickbusch et al. 2008; phac and who 2008; Parkes et al. 2010). These calls have emerged in

   



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parallel with a growing attention to the social and/or biophysical “determinants of health” on the international stage, and a range of extensive international initiatives that have tended to reflect a biophysical or a social orientation to understanding and responding to complex interrelated phenomena. Thus, despite calls for integration, incomplete efforts to link health, environmental, and social agendas are common, and are exemplified by the disconnects between the efforts of the World Health Organization (who) Commission on Social Determinants of Health (csdh 2008) and the Millennium Ecosystem Assessment (mea 2005). The who Determinants of Health report (csdh 2008, 1) focuses on the social factors that determine why some people are healthy and others are not, with analyses of the causes and health consequences of social disparities and the key message that “inequities are killing people.” This work views socially determined health inequities as equally significant with, if not more important than, medical care and personal health behaviours (Evans et al. 1994; Wilkinson and Marmot 2003; Marmot 2007; csdh 2008). The growing attention to social determinants of health often emphasizes that responsibility for population health improvement often lies outside the health sector, and has rekindled calls for innovative, integrated, and intersectoral approaches to promote health and reduce health inequities, including Health in All Policies and Intersectoral Action (Bangkok Charter 2006; Barten et al. 2007; Kickbusch et al. 2008; phac and who 2008; Beckfield and Krieger 2009). The Millennium Ecosystem Assessment (2005) provided a concomitant, but largely parallel international effort to understanding and responding to ecological determinants of health. By focusing on the relationships between health, well-being, and ecosystems, the Millennium Ecosystem Assessment (mea) challenges the traditional framing of environment and health relationships as linear “cause and effect” interactions of exposure to biophysical hazards and resulting disease. Drawing on diverse international expertise, the mea lays out the complex and systemic relationships between cultural, provisioning, and supporting ecosystem services and their direct and indirect influences on health through provision of or disruption to material minimums, social relations, and security (see for example Corvalan et al. 2005). The mea has provided an impetus and profile for several decades of prior scholarly effort to highlight how health and well-being, and the social dynamics that determine

   

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them, are all embedded within and dependent on the life-support of ecosystems at local, regional, and global levels (McMichael 1993; Matsumura 1996; Rapport 1997; Cole et al. 1999; Rapport et al. 2003; Waltner-Toews 2004). The Commission on Social Determinants of Health and the Millennium Ecosystem Assessment reports make valuable and complementary contributions to decades of conceptual work regarding the social and ecological context of health. Yet, when viewed together, these two reports are notable for the absence of linkages to each other. They exemplify an ongoing failure to realize the imperative of a social-ecological perspective on health (Parkes et al. 2003; Waltner-­ Toews 2009; Bunch et al. 2011) and our collective reluctance to engage with the Ottawa Charter’s call for reciprocal maintenance (who 1986). They also reinforce a policy bias toward intersectoral action that may take steps to foster links among different aspects of social or environmental agendas, but rarely addresses both at the same time, especially when it comes to health and well-being. Social awareness and academic calls to overcome these disconnects have been highlighted by the recent international processes of seminars, webinars, conferences, and reports leading up to the Rio+20 Conference (see for example paho 2011; Patz et al. 2012). As the preamble to the who submission to the Rio+20 Conference notes, “the last 20 years has seen limited progress in the integration of economic, environmental and social policy … So despite a growing recognition that progress in health depends on trade, intellectual property, agriculture, employment and many other aspects of international and domestic policy – coherence across sectors remains elusive” (paho 2011, 1). Related themes have come to the fore in the official international consultation to reconsider the role of health in the post-2015 agenda associated with the end date for the Millennium Development Goals in 2015 (Horwitz et al. 2012) with a summary of findings that highlights the reciprocity of “healthy planet – healthy people” and frames health in the context of sustainable development (who and unicef 2013). Despite their integrative tone, a recurring point of weakness of these international statements is the lack of explicit and critical reflection on the policy, social-political, and cultural dimensions of issues at the interface of health and environment (Parkes, de Leeuw, et al. 2010; Brisbois and Ali 2010). It could be argued that growing attention to the language of integration, participation, and ­collaboration

   



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in health and environmental issues indicates increased attention to social dilemmas and dynamics. However, there has been little recognition of how the human dimensions and power dynamics of these processes are compounded when taken together. Recognizing the complexity of social dynamics  – in terms of how power is manifested and decision-making is implemented – is a new endeavour for those who have entered the health or environmental worlds from a more biomedical or biophysical orientation. The resulting social and political “mess” of health and environmental issues can pose daunting and often overlooked obstacles to progress in research and policy (Beck 1992, 1998; De-Shalit 1995; Light and De-Shalit 2003; Kickbusch et al. 2008; Hancock 2011). A conventional response to the “social mess” of health and environmental issues has been to engage with the more easily definable “parts.” Focusing on examples relating to existing programs for specific diseases or environmental issues will result in a recurring failure to address the combined social, environmental, and health dynamics. In contrast, meaningful innovation in environment and health issues challenges us to engage in the messy socio-­political context that will ultimately be the stage on which these issues are addressed. As Brown (2010, 62) succinctly states, “since wicked problems are generated by the society in which they are set, their resolution will necessarily involve changes in the society that produced them.” Accordingly, this book examines new ways to understand and engage with the combined contexts of these problems and to pursue the “coupling” of mutual references (Maasen and ­Weingart 2005), where democratic and social inputs are integrated and where the scientific and practical dimensions of the health/environment/ social nexus become a point of explicit focus. Scholarly attention to wicked problems has helped to highlight a new generation of questions about knowledge, power, and decision-making. Issues that span health, ecological, and social concerns present notable examples of such wicked problems, as they are not easily amenable to being addressed in isolation, or by any particular sector, discipline, or approach. Such issues are exemplified by complex, multi-sector, and scientifically tough issues such as climate change, obesity, land degradation, and Indigenous disadvantage, each of which poses significant challenges to the model of public policy as a linear, rational problem-solving process (apsc 2007). These types of issues demand new insights into the political,

   

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c­ ognitive, and broader “problem-solving” approaches adopted by society and its political institutions (Folke et al. 2005). In a recent revisiting of wicked problems, Brown et al. (2010) highlighted the value of collaborative processes and transition science, which is characterized by boundary-crossing and knowledge synthesis. This type of thinking and approach to problem-solving offers a timely contrast and challenge to the push toward technocratic decision-making that tends to dominate contemporary health, environmental, and even social policy (Beck 1998; Beckfield and Krieger 2009; Fisher 1990). The awareness of the complexity and “wicked” nature of so many issues in the twenty-first century is, therefore, drawing a more systematic and nuanced attention to the diverse range of actors, organizations, and conceptual descriptors seeking to affect, and being affected by, both national and inter/supranational policies and decisions. Examples include adaptive governance (Folke et al. 2005; Dietz 2003); global civil society (see Kaldor 2003; Keane 2003); individual, community, specialist, organizational, or holistic contributions to “collective decision-making” (Brown 2007); and the multiple actors influencing decision-making, identified by Janicke (2008) as civil society, government, and industry. Attention to these socio-political processes, and not just the socially mediated context for health, becomes especially important when considering the linkages between what happens at the local or community level with broader or international events such as pandemics of infectious disease (sars, avian flu, or the most recent swine flu) or environmental events such as the transnational effects of Chernobyl, the Gulf of Mexico bp debacle, the Danube cyanide spill, or contaminant dumping in and around Nova Scotia (Hallström 2002). Authors such as Janicke (2008), Parkes et al. (2010), and others (Kiefer, Frank, et al. 2005; Kickbusch 2007) have pointed to emerging patterns of governance in public health, social policy, and environmental politics. Within this work, however, there is little to guide the integration of the three with each other, nor to link them back to local and regional social, economic, cultural, and ecological systems. Although public consultations and panels are often an integral procedural component of the “new” public health in Canada and the Food and Drug Administration advocacy review boards in the United States, it is questionable whether such involvement is a gesture toward the appearance of inclusion, or an actual attempt at participatory problem-solving. There is evidence for the creation of

   



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new social movements focused on health and the increasing pressure at both national and global levels to frame and orient public health and health policy toward the social determinants of health. This development is an important one, since the emphasis on “causes of the causes” (per Marmot [2007] and who Commission on Social Determinants of Health [2008]) has created increased potential for the shift to what Illona Kickbusch (2007) has termed “health society,” which, in its fullest sense, may have the potential to address the imperative of integrating health determinants with both their ecological and social drivers. Informed by these consistent patterns of diversity and convergence, this book is significant and timely in a number of respects. It brings together a diverse collection of scholars and practitioners who, despite the commonalities of their work, would rarely gather under the same roof (let alone in the same book). It does so from a standpoint that deliberately seeks to engage and inform theory, policy, and practice in a variety of domains. While the 1980s and 1990s saw both a theoretical and applied response away from public policy as “problem-solving” as a primary orientation (see for example Hajer and Wagenaar 2003), the movement toward governance, deliberation, and networked collaboration is only one part of the story. As the chapters included here demonstrate, the intersection of social, ecological, and health considerations presents an embodiment of the policy sciences that is interpretive and socially based, practical and deliberative. Not only is this approach consistent with the broader movement toward post-positive policy analysis, but as the recognition of wicked problems demonstrates the need for researchers and decision-makers to situate both policy and practice within the complexity, dynamism, and uncertainty behind social, economic, health, and ecological systems (Swanson and Bhadwal 2009; Homer-Dixon 2006).

Conclusion In this chapter, we have tried to lay out the “big patterns” (Bartlett et al., chapter 10 below) present at the intersection of the environmental, social, and health domains. This overview is a response to the fact that the “big problems” of today push for, if not require, the acknowledgment and insight gained from working in and across multiple perspectives, multiple domains, and multiple settings. While

   

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we do not put forward integrative or interdisciplinary perspectives as a panacea for the wicked problems and uncertainties of our time, there is strong evidence to suggest that there are benefits to recognizing and learning from the adaptive and integrative approaches we have introduced. Contributors to the book were selected in order to fit the broad categories of the three sections of the text, but perhaps more importantly to exemplify the themes of convergence and diversity. To reflect this, and in the same way as this chapter commences, authors were asked to provide a brief statement as to the origins, development, and “pathway” of their work leading to their respective chapters. This approach is intended to provide a sense of the academic, intellectual, and practitioner context for each contribution, but also the wide breadth of work available to inform our thinking on the social-ecological-health nexus. These statements, found at the onset of each chapter and this introductory contribution, are not intended as authorial biographies. Instead, they offer insights into the pathways the contributors have followed to engage with the themes of the book. Within each section the reader will encounter diverse starting points, orientations, and insights into the boundary-crossing present at the interface of health, ecological, and social concerns. One particularly notable point of convergence are those chapters that emphasize Indigenous and Aboriginal perspectives as being of both historical and contemporary relevance to our pressing health, environmental, and community concerns. In addition to Bartlett et al.’s final chapter (for whom this theme is central), it is also noted in chapter 4 by Hansen-Ketchum on community health and chapter 7 by Parkes on water. Within sections, ideas, and orientations may also diverge, as authors may draw insights from a single research project in a specific place and time, or from multiple examples. Contributions that share a focused approach on one example include the work of Guehlstorf et al. (chapter 6) and Parkes (chapter 7) on public policy and water and Morrison et al.’s (chapter 8) focus upon Cuban fisheries. In contrast, the work on socio-ecological approaches to health (Edwards et al. – chapter 2) and ecological restoration and community-based perspectives on health (chapters 3, 4, and 5) tend to draw on ­multiple examples to make their contributions. As is noted in Bartlett and Baber’s chapter below, such perspectives confirm that “[g]eography

   



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no longer constrains culture and technology … Both health and environmental risks are distributed inequitably in a world in which politics is increasingly organized around risk allocation.” In turn, such perspectives explicitly acknowledge the ambiguity, complexity, and diversity of our world, but also recognize that such inequities require approaches that are both integrative and socially based. Viewing these contributions together, it is apparent that this is not a text with a single question or problem, nor is it a book with a unified, over-arching approach, method, or paradigm that has guided the authors. Instead, it is an attempt to capture some of the diversity that is taking place across the ecological-social-health complex, and to situate that scholarship alongside fields that have an integrative focus. Indeed, a common insight across most chapters is the need to “work together” across boundaries – a need that has been reinforced by the recent run of international reports that highlight connections across ecosystems, health, and society (Patz et al. 2012; Horwitz et al. 2012; who and unicef 2013). This same need is embedded in ongoing calls for new approaches to research, education, and practice at the nexus of health, sustainability, and equity, and the associated language of multi-stakeholder governance, cross-sector policies, and new levels of coordination among diverse agendas (Barten et al. 2007; Brown 2007; Capon 2007; Orozco and Cole 2008; phac and who 2008). As numerous authors working in public policy, governance, ecological modernization, and social theory will attest, the emergence of new terminology and concepts that attempt to capture these dynamics reflects a broader dissatisfaction with “set solutions” for difficult issues. This speaks not only to the integrative, collaborative, interdisciplinary, and participatory impetus behind this book, but also to the broader socio-political reality emerging from “network society” (Hajer and Wagenaar 2003). In this reality, not only is an expanded political and practical reality present, but perhaps more importantly, there are revised and dynamic models of socio-political relations whereby established institutions and practices are “less stable and solid than we assumed and are less well positioned to keep risks at bay” (Hajer and Wagenaar 2003, 5). These instabilities are core elements to understanding the themes of convergence, diversity,and integration driving this book. As much of the work in deliberative and participatory policy analysis has demonstrated, complex ­problems are too unstable, dynamic, contested, and integrated to

   

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allow for uni-linear, schematic problem-solving and regulation. As the chapters included here demonstrate, the practical experiences of working in these contested and complex domains represent an inherently interactive and integrative process. The uncertainty of public health, political rationalization, and social knowledge is a reality, but so too is the realization that uncertainty extends beyond policy and practical domains (the “Law of Unanticipated Consequences,” Merton 1936). The over-arching goal of this book is not to make a contribution to a singular field, discipline, or sub-discipline, but rather to highlight the political and practical spaces in which so many of us find ourselves now working and researching. We have brought together diverse theoretical, applied, and integrative perspectives that illustrate the breadth of perspectives and approaches now informing how we might think about, and work at, the interface of social, health, and environmental challenges and that also provide a sense of the commonalities and differences that inform this work. Beyond demonstrating examples of different forms of work, this book recognizes and values a wealth of alternative pathways for their contributions to the challenges of complexity, participation, evidence, and equity, and the opportunities they create for (re)integrating health, ecosystems, and society.

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Swanson, D., and S. Bhadwal. 2009. Creating Adaptive Policies: A Guide for Policymaking in an Uncertain World. Thousand Oaks, ca: Sage Publications. unced. 1992. The Rio Declaration on Environment and Development. Rio de Janeiro, Brazil: United Nations Conference on Environment and Development. Van Der Plaat, M., and G. Barrett. 2006. “Building [Canadian] Community Capacity in Governance and Decision Making.” Community Development Journal 41 (1): 25–36. Waltner-Toews, D. 2004. Ecosystem Sustainability and Health: A Practical Approach. Cambridge: Cambridge University Press. – 2009. “Food, Global Environmental Change and Health: EcoHealth to the Rescue?” McGill Medical Journal 12 (1): 85–9. – 2011. “Ecohealth: A Primer: Veterinarians without Borders/Vétérinaires sans Frontières.” https://www.vetswithoutborders.ca/get-involved/ resources/fbli (accessed 3 September 2014). Waltner-Toews, D., J.J. Kay, and N.-M.E. Lister. 2008. The Ecosystem Approach: Complexity, Uncertainty and Managing for Sustainability. New York: Columbia University Press. Waltner-Toews, D., J. Kay, T. Murray, and C. Neudoerffer. 2004. ­ “Adaptive Methodology for Ecosystem Sustainability and Health (amesh): An Introduction.” In Community Operational Research: OR and Systems Thinking for Community Development, edited by G. Midgley and A. Ochoa-Arias. New York: Kluwer Academic / Plenum Publishers. Webb, J., D. Mergler, M.W. Parkes, J. Saint-Charles, J. Spiegel, D. WaltnerToews, A. Yassi, and R.F. Woollard. 2010. “Tools for Thoughtful Action: The Role of Ecosystem Approaches to Health in Enhancing Public Health.” Canadian Journal of Public Health 101 (6): 439–41. who. 1986. “Ottawa Charter for Health Promotion.” Geneva: World Health Organization. who and unicef. 2013. “Health in the Post-2015 Agenda: Summary of Findings.” http://www.worldwewant2015.org/health (accessed 3 September 2014). Wilcox, B.A., A.A. Aguirre, and P. Horwitz. 2012. “Connecting Ecology, Health and Sustainability.” In New Directions in Conservation Medicine: Applied Cases of Ecological Health, edited by A.A. Aguirre, R.S. Ostfeld, and P. Daszak. New York: Oxford University Press. Wilkinson, R., and M. Marmot. 2003. The Solid Facts. Copenhagen: World Health Organization.

   

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Zinzstag, J., E. Schelling, D. Waltner-Toews, and M. Tannera. 2011. “From ‘One Medicine’ to ‘One Health’ and Systemic Approaches to Health and Well-Being.” Preventive Veterinary Medicine 101 (3–4): 148–56.

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section one

Socio-Ecological Approaches to Health, Environment, and Community As the introduction to this book notes, a core element of contemporary policy issues lies in the (both perceived and often real) failure of conventional governmental institutions to adequately address their symptoms and their causes. As the ever-­expanding literature on network governance, collaboration, partnership approaches, and interdisciplinarity demonstrates, there are new and changing networked approaches to identifying, managing, and approaching these complex issues. Socio-Ecological Approaches to Health, Environment, and Community presents three complementary chapters, with each contribution combining social and ecological approaches to health in relation to both environment and community. These chapters draw lessons from the importance of systems-level thinking, the possibilities of restorative thinking and practice, and the opportunities for health and well-being created by engagement with the natural environment. Each chapter illustrates a shift toward including both socially and ecologically grounded perspectives and knowledge, in health-based research and practice. In addition to stressing the importance of integrative perspectives across health, environment, and communities, this section highlights the importance of citizen engagement and social processes when addressing environmental and health issues, and the value of integrative research and approaches oriented to local systems and settings. A critical element of these networked and collaborative approaches lies in the realization that the historical emphasis upon

   

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epistemological, disciplinary, and practitioner-based boundaries is a problem. Whether approached from the standpoint of argumentation in public policy analysis, or the importance of place-based, local, and traditional forms of knowledge and decision-making, interpretive, post-positive perspectives challenge the traditional, positivist conception of government and problem-solving. Where issues are highly contested, complex, and variable (as is almost always the case in the social, health, and environmental policy domains), not only is there no longer a simple “knowledge for policy and action” strategy available, but the acknowledgment of action in the face of complexity and uncertainty is still unavoidable. In turn, these chapters mark the importance of how action (i.e. individual and community behaviours) can work with and restructure knowledge, and how we approach problem-solving. Chapter 2, Strengthening Communities with a Socio-Ecological Approach: Local and International Lessons in Whole Systems, by Nancy Edwards and Colleen Davison describes socio-ecological models in order to critique their application in the community health field. This is grounded in six principles: (1) dimensions of well-being are reciprocally related and linked to diverse conditions in the sociophysical environment; (2) individual and community well-being are contingent upon many characteristics of the person or population; (3) health is an outcome of the quality of the person-­environment fit; (4) certain individual or environmental conditions exert a disproportionate amount of influence on health and well-being; (5) physical and social environments are interdependent; and (6) a more comprehensive understanding of health results from multidisciplinary approaches. Canadian and international examples are presented as a basis for discussion of the limitations of socio-ecological models to inform community health research and intervention. The chapter concludes with an examination of these limitations in terms of: the tendency to focus on proximal rather than distal levels of influence; the over-simplification and under-estimation of the dynamic nature of different system influences; the lack of explicit attention to historical contextual influences on health; and the failure to adequately address the differential effects and inequity of environmental influences across populations. Systems thinking and systemic approaches are identified as an area of development that is increasingly relevant to understanding problems in the context

   



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of their larger whole, and is potentially able to better address the complexity of today’s wicked problems. Chapter 3, Using Research and Restoration to Re-Imagine Safe Places in a Technologically Colonized Health Care World, by ­Patricia Marck examines the relationship between cultural and ecological health. The author argues that safe places in health care and in our world are both culturally and ecologically healthy and whole. If we want to foster and sustain the health and wholeness of places and their inhabitants into the future, we need to nourish critical ethical, political, scientific, and practical connections between culture and ecology. She supports the notion that societies are characterized by a technological “colonization of the imagination” which oppresses questioning and thus increases societal tendencies to settle for a manufactured nature rather than real experiences. This estrangement leads us to artificial places and “quick fix” health care. To solve this problem, a restorative approach is offered that leads us to engage in three vital projects: collective moral imagination, place ethic, and ecological citizenship. Ecological restoration is the main focus in this chapter, with implications for reform in health care that could benefit from restoration, despite numerous roadblocks. Most health care communities fail to recognize that they are part of nature, accompanied by a related ethical deficit in how those working with health care treat each other and the places we share. In order to both fix health care and improve cultural and ecological health, the author suggests that we leave a world of consumption for a healthier ecological future and open our minds and hearts to alternative pathways toward a healthier community and world. Chapter 4, Engaging with Nature in the Promotion of Health, by Patti Hansen-Ketchum uses the results from a community-based study on nature-based health promotion to examine key elements of ecologically emancipated communities. This study was designed to examine citizen engagement with nature in the promotion of health, and the barriers and facilitators to the same, in two phases. First, the study examines how parents of young children care for and engage with nature to promote their individual and family health. Second, it addresses how health practitioners and decision-makers use evidence of the health benefits of engaging with nature to design community-based health promotion interventions. Respondents’ views are presented and discussed in relation to four

   

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overarching themes: (1) restorative outdoor places are valued as health-promoting; (2) restorative experiences in nature are simple, profound, and enriching; (3) engaging with nature develops ecological citizenship; and (4) access to nature is shaped by multi-level barriers and facilitators. The chapter then moves to consider ecologically emancipated communities and three key elements derived from the study: equitable access to restorative outdoor places, opportunities for ecological citizenship, and communal efforts for change. The study highlights the untapped potential and reciprocity between nature-based health promotion and communities, with a combined emphasis on citizens as engaged parts of a community ecosystem that generates health.

   

2 Strengthening Communities with a Socio-Ecological Approach: Local and International Lessons in Whole Systems nancy edwards and colleen davison

Our interest in socio-ecological models stems from disciplinary backgrounds of nursing, epidemiology, education, and public health and our efforts to address a wide range of health-related priorities in health and other sectors. In each of these domains, it is apparent that many levels of influence are at work and that successful interventions will necessarily reflect these influences. Although a socio-ecological framework is explicit in our respective programs of research (Edwards, Mill, and Kothari 2004; Davison 2007), the theoretical underpinnings of these models have been challenging to fully realize. These underpinnings call for complex interventions and pertinent research designs that are not necessarily supported by existing research or funding models (Edward 2001; Hawe, Samis, DiRuggiero, and Shoveller 2011; Whitehead 2010). It has been tempting to delimit our research projects to a single system level, yet this obfuscates the essence of socio-ecological thinking. This chapter has been written in the hopes of inspiring other researchers to fully integrate the promising theoretical foundations of socioecological models in their own work.

Introduction Socio-ecological models have been used as a framework for health interventions for decades. They describe the interplay of varying system influences on the health of individuals. Implicitly reflecting a whole systems approach, they are inclusive of those factors and ­conditions

   

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which are concurrently more or less immediate, and more proximal or more distal, to the individual. These models capture multiple system levels and represent the nestedness, reciprocal interactions, and feedback loops that occur within complex systems. Drawing on various fields of health and social sciences inquiry, socio-ecological models have formally been used as the basis for both assessing communities and implementing and evaluating intervention programs since about the 1980s. The 1990s was a decade when, in the health sciences, there was the “develop[ment of] a more environmentally explicit version of the ecological approach” (Stokols 1992, 7). The purpose of this chapter is to describe and critique the application of socio-ecological models in the field of community health. Early in the chapter we discuss the origins and strengths of socioecological models while reviewing some of the most prominent iterations. We then examine the use of socio-ecological approaches in the field of community health, providing a brief review of the literature and four practical examples from Canadian and international situations. In the latter part of the chapter, we bring to light our critique of the historical and current use of socio-ecological models in community health, arguing that their optimal use in both community health programs and the research of health determinants and interventions has been compromised in a number of ways. We argue that: (1) there has been a tendency to focus on proximal rather than distal levels of influence; (2) the nestedness of different system influences and the dynamic interactions among these influences have been over-simplified and under-examined; (3) historical contextual influences on health determinants have often been overlooked; and (4) the differential effects and inequity of environmental influences across populations are often ignored or prematurely dismissed. These compromises have limited our perspective and ability to understand and work within natural systems of influence, which are inherently highly complex (see chapter 1 above). They have also hampered our explorations into system-level influences that serve to promote social disadvantage. We consider reasons for these gaps and, returning to the literature and to the local and international examples, illustrate the potential for a socio-ecological approach to more effectively address contemporary environmental and health issues. Finally, we consider the potential for a socio-ecological approach to engage and strengthen communities, and explore future directions for program and research development.

   



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B a c k g ro u n d : S o c i o - E c o l o g i c a l T h e o ry Ecology and the ecosystem, concepts from biology and the natural sciences, have deep roots by analogy in other fields of study, including social work (Oetzel and Duran 2004; Schneiderman 2004; Atzaba-Poria, Pike, and Deater-Deckard 2004), sociology (Twombly and Holtz 2008; Duran and Walters 2004; van Dam 2003), education (Tissington 2008; Seginer 2006; Davison 2007), international development (Corbin 2008), geography (Oishi et al. 2007), psychology (Cummings, Goeke-Morey, Schermerhorn, Merrilees, and Cairns 2009; Maton 2000; Steele, Nelson, and Cole 2007), anthropology (Schensul and Trickett 2009; Trueba, Spindler, and Spindler 1989), community development (Yoo et al. 2004) and community health (Green, Richard, and Potvin 1996). Ecological theory is grounded in the following principles (as outlined by Grzywacz and Fuqua 2000, 102): different dimensions of well-being are reciprocally related and linked to diverse conditions in the socio-physical environment; • individual and community well-being are contingent upon many characteristics of the person or population, as well as multiple dimensions of the environment; • health is an outcome of the quality of the person-environment fit; certain individual or environmental conditions exert a disproportionate amount of influence on health and well-being; • the physical and social environments are interdependent; and • a comprehensive understanding of health results from multidisciplinary approaches. •

From this perspective, determinants of individual and community health are multi-dimensional, multi-level, interactional, and interdependent (see also Bartlett et al., chapter 10 below). Health is influenced via complex pathways and the differential health effects of specific causal agents may be mitigated or exacerbated by other social and environmental conditions. “People-environment transactions are characterized by cycles of mutual influence, whereby the physical and social features of settings directly influence their occupants’ health and, concurrently, the participants in settings modify the healthfulness of their surroundings through their individual and collective actions” (Stokols 1992, 8).

   

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Although socio-ecological models are the focus of this chapter, some introductory remarks about systems theory are warranted here, since the latter helps delineate the nature and mechanisms for interacting system levels. Systems theory is interdisciplinary and describes the nature of complex systems in nature, society, and science (see also Bartlett et al., chapter 10 below). One significant origin was in biology in about the 1920s, where it helped define the interrelatedness of organisms in ecosystems. Austrian biologist Ludwig von Bertalanffy then wrote his influential General Systems Theory (gst) in 1968 (Bertalanffy 1968). Systems thinking is grounded in the idea that in order to understand problems or phenomena, we must understand them as component parts (holons) of a system or the larger whole. Parts of systems can be best understood by examining them in the context of the relationships they have with other parts and with other systems, rather than considering them in isolation (Banathy 1996). Thus, while socio-ecological theory and systems theory are generally considered distinct from each other, the social-ecological perspective incorporates a number of concepts that are derived from systems theory, such as interdependence (influences are dynamic and can rely on one another to produce outcomes), homeostasis (influences tend toward equilibrium), and feedback loops (influences can be in iterative relationships) (see for example Cannon 1939 or Katz and Kahn 1978).

A Review of Prominent Models Socio-ecological models attempt to capture complexity while acknowledging the interdependence and dynamic interactions among factors at different system levels. Models by Bronfenbrenner (1986, 1995, 2000), Bronfenbrenner and Morris (1998), Evans and Stoddart (1990), Dahlgren and Whitehead (1991), and Stokols (1996a) are among the most widely referenced in the community health literature. Bronfenbrenner Urie Bronfenbrenner’s ecological model is frequently cited as a foundation for community health interventions. This model describes how individuals are linked to a dynamic social system (Schensul and Trickett 2009). Bronfenbrenner hypothesized that in addition to factors that are associated with the individual (sex, age, health status, etc.), human behaviour and individual development are impacted

   



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by factors in five environmental systems: the microsystem (family, peers, school, neighbourhood, church, etc.); the mesosystem (relationships among microsystems and influences at the organizational or institutional level); the exosystem (environmental factors, which originate largely beyond the immediate realm of the individual, such as the mass media, social welfare, or legal services); the macrosystem (cultural and political ideologies, regulatory and constitutional frameworks); and the chronosystem (socio-historical conditions or patterns of events and transitions over a life course). The application of the system levels described in the model has been quite variable. Some have labelled spheres of influence more intuitively: identifying the individual, the family, the community, the institution, and the society (Gregson et al. 2001); others have differentiated levels as intrapersonal (within individuals) and interpersonal (between people), along with other system layers (Edwards, Etowa, and Kennedy 2008; Kok, Gottlieb, Commers, and Smerecnik 2008; Schensul and Trickett 2009). Richard, Potvin, Kishchuk, Prlic, and Green (1996) have attempted to bring more coherence to this field by developing a typology for socio-ecological levels. Two propositions summarize Bronfenbrenner’s (1986) discussions of his model (as cited in Watt, Ayoub, Bradley, Puma, and LeBoeuf 2006, 109). P r o p o s i t i o n 1   Human development takes place through processes of progressively more complex reciprocal interaction between an active, evolving organism and the persons, objects, and symbols in its immediate environment. To be effective, the interaction must occur on a fairly regular basis over extended periods of time. Such enduring forms of interaction are referred to as proximal processes. P r o p o s i t i o n 2   The form, power, content, and direction of the proximal characteristics affecting development vary systematically as a joint function of the characteristics of the developing person; of the environment, both immediate and more remote, in which the processes are taking place; and the nature of the developmental outcomes under consideration. These propositions, and the literature surrounding this model, surface three important and common weaknesses in its application – a delineation and oversimplification of system levels, a focus on proximal influences, and a very limited use or inclusion of the chronosystem. These limitations will be discussed later in this chapter.

   

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Stokols A second, often-cited scholar who has critically examined socioecological theory in the field of community health and health promotion is Daniel Stokols (1992, 1996a, 1996b; Stokols, Allen, and Bellingham 1996; Stokols, Misra, Runnerstrom, and Hipp 2009). Stokols’ 1996 articles discuss three distinct, yet complementary, theoretical perspectives on health promotion: behavioural change, environmental enhancement, and social ecological models. Using the core principles of social ecological theory, Stokols derived practical guidelines for designing and evaluating community health promotion programs and described implications for future research. Stokols’ socio-ecological model brought into focus both physicalmaterial and social-symbolic environmental influences that impact the physical, social, and emotional well-being of individuals and groups. Stokols’ model extends Bronfenbrenner’s work since he addresses “health” as it relates both to individuals and to larger aggregates and populations. Stokols’ conceptualization of healthpromoting environments more explicitly draws our attention to the role of intermediaries (e.g., corporate decision-makers, legislators) in promoting well-being. Studies in the fields of tobacco control and physical activity promotion (Kothari, Edwards, Yanicki, and Hansen-­Ketchum 2007; Richard et al. 2004; Riley, Garcia, and Edwards 2007; Sallis et al. 2006) provide particularly rich illustrations of how these intermediaries in health and other sectors can support or mitigate efforts to influence change. They reinforce the importance of more distal influences on health. Thus, Stokols’ model is more explicit in its integration of theory from the fields of population health and environmental science. The identification of intermediaries is illustrative of an important mechanism of influence across system levels and between sectors. However, like Bronfenbrenner’s model, Stokols’ model is largely silent on the chronosystem and does not profile global system influences. Dahlgren and Whitehead The model put forward by Goran Dahlgren and Margaret Whitehead (1991) focuses on levels of influence across the lifespan, a focus that is implicit, rather than explicit, in the two previous models. These influences range from innate individual characteristics through individual

   



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behaviours, social, family, and community networks, and living and working conditions, all the way up to very broad societal and global conditions and policies. This model reflects the diverse and interconnected nature of health determinants within and outside of the individual and acknowledges their importance over the lifecourse. The authors depict their most distal ring as the general socio-economic, cultural, and environmental conditions and policies that exist at the global, national, state, and local levels. This refinement of macro levels of influence is consistent with a political science orientation and better reflects governance and jurisdictional boundaries. More recently, authors such as Labonté, Schrecker, Packer, and Runnels (2009) and Galea (2007) have added considerable specificity to the influences portrayed in this distal ring. The strengths of this model are that it recognizes health influences across the lifecourse and includes a specific focus on inequities as they relate to health influences and outcomes in society. Like Stokols’ model it acknowledges distal influences on individuals; however, while the lifecourse is an underlying element of the model, biological endowment is not as explicit. Evans and Stoddart A model that reflects earlier conceptualizations of the social determinants of health by Robert Evans and Greg Stoddart (1990) includes the individual’s behaviours and genetic endowment or biology as they interact with features of their social and physical environments. The authors also include individuals’ current health and function, levels of disease or injury, access to health care, and levels of prosperity and well-being in the model. One strength of this model is the explicit link to the health care sector and to health care services, an element that is not prominent in the previously described models. Thus, the Evans and Stoddart model has been widely cited, particularly in the medical and health care literatures. It specifically includes “access to the health care system” as one of a number of key health determinants, and this has been focused upon in scholarship around health-systems strengthening and primary health care. However, the model is somewhat dated in two ways. First, although the identification of genetics is an important defining feature of this model, this conceptualization reflects the nascent state of environmental and genetic science in the late 1980s. The emerging discipline of epigenetics will undoubtedly further our ­understanding

   

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of this interface and how this endowment plays out over the life course. Second, in the decades since the development of this model, scholars have advanced our understanding of income distribution and the effect of an individual’s relative income level (Wilkinson and Pickett 2009), suggesting that the model should be revised to capture the concept of relative prosperity.

Application of a Socio-Ecological A p p roac h i n t h e F i e l d o f C o m m u n i t y Health While the preceding models are prominent, there has been an important diversity of models and approaches across different disciplinary traditions. In community psychology and some areas of population health, for example, scholars have evolved and refined their thinking significantly from earlier models (O’Donnell, Tharp, and Wilson 1993), as shown by the more recent models of Greenfield, Maynard, and Childs (2003), Saunders and Goldenberg (2005), and Trumbull, Greenfield, Rothstein-Fisch, and Quiroz (2001). Currently, these scholars are examining how social interactions and ultimately individual health are modified by our daily exposure not only to people but also to resources, routines, hierarchical reporting structures, and symbols. This is the basis for activity settings theory in community psychology, for example. There is evidence of recent use of systems theory and of “systems thinking” in health services and public health (World Health Organization Alliance for Health Policy and Systems Research 2009; ­Rothschild et al. 2005; Homer and Hirsch 2006; Leischow and ­Milstein 2006; Atun and Menabde 2009), and in the fields of health promotion and community psychology (Naaldenberg et al. 2009; Hawe, Shiell, and Riley 2009). Aspects of the theory have emerged in the health field partly as a response to the predominance of reductionism in the health sciences (Flood 2001), but their use is still relatively underdeveloped. Best, Stokols, Green, and colleagues (2003, 168) recognize and promote the potential of systems thinking in health disciplines, but state that “systems theory has been relatively ignored both by the health promotion field and more generally, by the health services.” They note that systems theory adds value to our current thinking in health promotion and community health because it provides an important holistic, integrative p ­ erspective that is in

   



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line with, yet distinct from, socio-ecological modelling (Best, Stokols, Green, et al. 2003). Within the broad field of community health, there has been extensive application (both explicit and implicit) of some form of socioecological model. The models are most often derived from those outlined above (Bronfenbrenner 1996a; Stokols 1992; Dahlgren and Whitehead 1991; or Evans and Stoddart 1990). They are used to inform research and the development of programming in many areas, for example: stigma and hiv/aids (Holzemer et al. 2007; Mill et al. 2009); vulnerability to sexually transmitted infections among migrant workers (Bronfman, Leyva, Negroni, and Rueda 2002; ­Webber 2007); heart health (Riley 2003; Riley, Edwards, and d’Avergnas 2008); dietary environments (Lytle and Fulkerson 2002); smoking and tobacco control (Richard et al. 2004); parenting, child development, and school health (Smith, Edwards, Varcoe, Martens, and Davies 2006; Deschesnes, Martin, and Jomphe-Hill 2003); mental health (Watt et al. 2006); active living (Sallis et al. 2006); and obesity prevention (Raine 2004). What stands out in research and community health interventions tackling these substantive issues over the last thirty years is the person- and family-centred behavioural focus of the 1970s and 1980s, which has shifted only somewhat to a more thorough socio-ecological orientation (Edwards and Di Ruggiero 2011; Schensul and Trickett 2009). The following examples illustrate how socio-ecological approaches have been used to strengthen community health interventions. These examples are drawn from Canadian and international initiatives in which the authors have been involved. The local examples illustrate the usefulness of a socio-ecological approach in community health research and the importance of considering contemporary and historical meso, macro, and exo influences on community planning and interventions. The international examples demonstrate the dynamic nature of socio-ecological levels and the concept of positioning community interventions within the model.

Canadian Examples Built Environments and Fall Prevention Early work in the field of fall prevention among seniors focused on mitigating individual risk factors for falls (Edwards 1999; Edwards

   

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2011; Edwards, Etowa, and Kennedy 2008). Although the environment was one of the known risk factors, accounting for approximately one third of all falls (Rubenstein et al. 1988; Edwards, Birkett, Nair, et al. 2006), it was addressed as a micro (intra-personal) determinant that happened to interact with the meso environment (Edwards 2011). In our early intervention studies in Ottawa, for example, seniors were encouraged to complete home hazard environmental assessments and to identify environmental risks for falls that they were ready to tackle (e.g. removing scatter rugs and increasing the amount of lighting on stairs). However, qualitative descriptions of falls and field notes kept by the public health nurses who conducted home visits pointed to other levels of the socio-ecological model that needed to be targeted. For example, seniors identified rules imposed by landlords that prevented them from installing grab bars in bathrooms and described indoor and outdoor stairs in the community that were particularly difficult to navigate. Through the work of a local fall prevention coalition, we began to identify regulatory policies that influenced the construction of the built environment. Over an extended period, our team reviewed national building code recommendations and provincial building code legislation, examined how the codes were enforced by local building inspectors, identified key stakeholders who were particularly influential in revisions to building codes, considered how Canada’s provincial building codes compared to those of other jurisdictions, and explored how human rights legislation intersected with the codes. We also learned what processes and time periods were involved in the development and enforcement of new building codes through reviews of the literature, discussions with key informants, and through the first author’s experience of sitting on a technical review committee that considered revisions to some of the national building code recommendations. As we learned more about the code development process, suggestions for local action were brought back to the fall prevention coalition and helped to guide their policy-related initiatives. This broader examination of the influences on falls significantly extended the priorities of our regional fall prevention coalition from a primary focus on building community awareness about falls and supporting seniors’ individual behaviour change to avert falls, to a focus that included local policy action on building codes. This exploration of meso and macro influences on falls also had a significant impact on the focus of our research with a

   



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redirection of our efforts to contribute to the evidence base that was required to inform code changes, specifically related to grab bars in bathrooms (Edwards, Birkett, Nair, et al. 2006). Environmental Influences on School Engagement in Northern Canada Between 2004 and 2007, the second author worked in partnership with the Tlicho First Nations community of Behchoko, Northwest Territories, to examine the school engagement of their youth, as it related to the ever-changing northern environment with self-­ governance and land claim settlements, burgeoning natural resource development, and decreased physical isolation of communities (Davison 2007). Activity settings theory and the social determinants of health, both grounded in a socio-ecological approach, informed the work. This meant that from the beginning, the researchers were interested in examining influences at various environmental systems levels (micro, meso, macro, chrono) on youth and the dynamic interactions that existed among influences. The scope and focus of the approach was determined primarily as a reaction to gaps in previous literature, which had focused much more heavily on individual and lifestyle influences; the approach was also a reaction to recognized needs and local understanding that existed about youth and educational decision-making. A regional high school in the community was the centre of the study. Influences more immediate or proximal to the individual were considered, including such things as the people who interacted in the school and the roles or positions they held, their routines and use of time in the setting, the lack of – or availability of – funds and other resources in the school, and symbols used in the setting such as the school motto and mascot, physical artefacts on display, or a specific list of “golden rules for life.” More distal influences were also considered including those at a meso level (such as institutional policies, or how the school interacted with other institutions) and those at macro levels (such as the place of the school in the community, the influence of the opening of the diamond mines in the region, and the signing of the self-governance agreement). Also key were influences associated with historical factors (such as colonialism or the residential schools era) and cultural factors (such as the Tlicho cosmology or traditional approach to education).

   

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The work highlighted the complexity of influences at play in school engagement for Tlicho youth and informed the development of some specific programs to mitigate influences at various levels. In this work, the socio-ecological approach allowed an examination of “the degree to which students persist in educational pursuits as well as the degree to which schools are successful in retaining students” (Barnaby, Shimpo, and Struthers 1991, 17). It helped focus attention on the environmental factors that influence school engagement, not just the within-child factors. In this sense it confirmed that “[e]ducation must pay more attention to the economic, political, historical and organizational factors that profoundly influence individuals” (Shapiro 1983, 93). While the research supported a multifactorial model for influence on students’ school engagement, it was still limited in its ability to clearly explain the dynamic of these relationships and the interaction and nestedness of influences. The literature base to guide this kind of theoretical development and then practical application is small. The task is not a simple one. In this particular study, the researchers found the complex and organic nature of natural systems difficult to effectively capture. We continue to build a conceptualization of school engagement that is not just an issue of individual strengths or deficits, but rather a phenomenon linked to features of settings and contexts. However, questions remain: how do we effectively study and explain the dynamic nature of influences at varying systems levels? How can we study and understand the differential effects of influences across individuals in a population? What role do chronosystem influences, such as the historical oppression of a people, play in the dynamic of health influences and outcomes found in a society? While socio-ecological approaches present one way forward in answering these kinds of questions, we feel we are still early in this process.

International Examples Reducing Maternal and Child Mortality in Yunnan Province, China An international maternal and child health development project undertaken in Yunnan Province, China, illustrates the importance of reciprocal and dynamic influences across socio-ecological levels. Edwards was the Canadian Project Director for this bilateral project. Funded by the Canadian International Development Agency

   



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and the government of the People’s Republic of China, this sixyear initiative aimed to reduce maternal and child mortality in ten poor ethnic minority counties located in Yunnan Province in southwest China (Edwards and Roelofs 2006). The project began with an extensive consultation process that engaged Ministry authorities at local, provincial, and national levels and key stakeholders at various levels of the health care system. These stakeholders ranged from traditional midwives and village doctors to highly trained health professionals and health care system administrators. Our assessment also captured the voices of those in the target communities, as we met with community leaders and those who were using health care services. We used a socio-ecological orientation to guide our assessment and developed a solid understanding of meso, macro, and exo influences on the training of health care workers and the delivery of maternal and child health care services. We took into account both contemporary influences on health workers and the health care system, such as the introduction of social market economic policies; and historical influences such as the early training received by village health workers during the Cultural Revolution and the gradual dismantling of a cooperative system that had provided social security at the village level for decades. Briefly, the cascade training program that was introduced involved preparing key trainers, who in turn prepared county trainers, who then trained village health workers across the participating counties (Edwards and Roelofs 2006). Trainers were equipped with many new skills and approaches, which were oriented towards problemsolving, critical analysis, and reflection and community engagement processes. The initial set of key trainers came from various parts of Yunnan province and underwent a three-month training program in the provincial capital, which included fieldwork. These trainers were extremely enthusiastic about the training approach and described the learner-centred and problem-based teaching strategies as highly relevant and engaging. The key trainers returned to their communities, eager to begin work with county trainers. This was a critical point in the project. Key trainers did not find the transition easy. We did not fully appreciate how these multi-level influences would interact with the introduction of new expectations and approaches the key trainers brought to their work. For instance, we had a commitment from the key trainers’ work units to allow the trainers the release time they required to train and supervise county trainers.

   

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However, there was also an emerging set of financial incentives for health workers that reflected the sharp intrusion of social-market policies into county and township hospitals. Among these incentives was a bonus received by workers in each work unit, and this bonus was becoming an increasingly large portion of their monthly income. The source of this bonus was from clinical earnings for which health workers were permitted to charge fees. With key trainers fully engaged in non-clinical work, they were not contributing to the collective bonus and were, therefore, excluded from receiving their usual share of this bonus. This seriously jeopardized their earnings and prevented some of them from continuing the training work. Although we found ways to resolve this and other issues and we did meet the health impact goals of the project, this example reminds us that a socio-ecological assessment needs to include a thorough examination of governance and incentives within a system, and that dynamic forces within system layers are constantly at work. Furthermore, the introduction of an intervention into the system becomes part of the system and creates an additional set of multi-level interactions and influences that go well beyond what one might aim to achieve or expect to happen as a result of a planned intervention. Mining, Health, and Health Equity in Mongolia Davison has been part of a Canadian-Mongolian team of researchers and practitioners, led by Dr Craig Janes and affiliated with the Canadian Coalition for Global Health Research (ccghr), the Health Sciences University of Mongolia, and the Ministries of Health and of Mining in Mongolia since 2007. Over the past decade, there has been an explosion in mineral development in Mongolia, and currently, mining accounts for more than 70 percent of industrial output and 78 percent of export revenues and employs tens of thousands of people informally and formally (Mongolian Mining Association 2009). The team undertook a health research and health equity impact assessment exercise in the mining sector in Mongolia. This project was funded by the Canadian Institutes of Health Research and the who Alliance for Health Policy and Systems Research and is part of an emerging program of research and intervention around mining and health in Mongolia. Grounded in ecological theory, the initial stage of the work was to build a strong team and then construct a map of stakeholders in mining and health

   



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in Mongolia. This was followed by an international meeting held in Ulaan Bataar, Mongolia, in May 2008, entitled “Assessing the Health Impacts of Mining in Mongolia: Strengthening the Public Health System Response.” Stakeholders were engaged in this initial meeting to brainstorm ideas and identify potential avenues to move the initiative forward in the field. A steering group was convened to lead a priority-setting exercise with a group of mining and health experts and a number of groups of community-based representatives. Mining presents both a promise and a risk with respect to economic growth, health, and health equity in Mongolia (World Bank 2006). Mining has the potential to provide rural employment, finance improvements to rural infrastructure, and support local community development; but it also poses environmental, social, and cultural risks that could exacerbate, rather than mitigate, social inequalities. Within this context, the research team worked with local stakeholders to develop, disseminate, and feasibility-test a health impact assessment process that clearly integrated the concepts of health equity and social determinants of health for mining development in Mongolia. The progress in Mongolia has been gradual but continued. The team is bolstered by strong research and knowledge-translation capacity among the Canadian and Mongolian members. The project uses an integrated form of knowledge translation (Canadian Institutes of Health Research 2004), which involves the engagement and integration of those who will need to act on the findings (knowledge users) into the research process. It requires partnership and collaboration between researchers and research users (International Development Research Centre 2009; Davison 2010). Indeed, a key to the success thus far, and we believe a strong component of the work that may improve its future success, has been the inclusion of stakeholders, particularly from government, that come from different sectors and system levels. Through the use of integrated knowledge translation, input from various stakeholders is included at all stages of research and intervention. In Mongolia, members of affected communities, mining companies, and academic and government representatives each have a role in informing and critiquing the work. In this program of research, the varying stakeholders “represent” different parts of the socio-ecological model, particularly different institutions at the meso system level. There are also the stakeholders who speak loudest for proximal influences, such as the health

   

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impacts of unsafe drinking water or mercury-contaminated soil, as well as those who are more closely associated with potentially distal forces, such as government representatives who work to set health impact assessment policies for the country or who are primarily considering the broader social and cultural impacts of large-scale mining in Mongolia. The aim is for the project to be responsive to the very real and pressing needs of the Mongolian people as they enter into a potential boom for mineral development. This is an ongoing and evolving project that, thus far, has worked to effectively use a socio-ecological approach that emanates from a commitment to integrated knowledge translation. The approach has purposefully conceptualized influences in a socio-ecological manner and has maintained a focus on the engagement of stakeholders, who exist within different systems and at different levels and are influenced by environments in different ways. We believe that the potential interplay between socio-ecological approaches and knowledge translation is an area for future exploration. Indeed, Best, Stokols, Green, and colleagues (2003) have argued for socio-­ ecological approaches that are centred on collaborative health promotion and more effective community partnering. “Systems-thinking has the potential to improve synthesis, translation and dissemination of research findings in health promotion initiatives” (Best, Moor, et al. 2003, S206; see also Parkes, chapter 7 below). We believe that researchers who use socio-ecological approaches may also be prone, or receptive, to considering knowledge translation issues and effective approaches across systems or levels. This is because as in a socio-ecological approach, effective knowledge translation hinges on an understanding and appreciation of the multiple factors in systems, such as actors, places, and events. The partnership in Mongolia has led us to further examine the relationship between socio-ecological theory and knowledge translation. The specific use of a socio-­ecological model to underpin the design and facilitation of the work has also helped us appreciate that it is necessary to engage and understand actors, places (including institutions), and events at various levels in different sectors or systems in Mongolian society. This has had to be done in order for the research to be effectively undertaken in the first place, and hopefully as we continue, for the research and partnership to have maximal positive impact. In this project, a socio-ecological approach has married well with the theoretical and practical components of integrated knowledge

   



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translation, and we believe that this duality may help us further consider influences at various systems levels as well as how the transition from knowledge to action may be most effectively undertaken.

Current Limitations of Socio-Ecological A p p roac h e s i n C o m m u n i t y H e a lt h While a review of the literature and a look at some Canadian and international examples have demonstrated that there is significant potential for socio-ecological models to effectively inform community health research and interventions, at present, this opportunity is compromised in a number of ways. In general, there has been a trend towards an oversimplification of the socio-ecological approach, both conceptually and analytically. Conceptually, this has resulted in an under-emphasis of the historical, dynamic, nested, and multi-level features of determinants of health in complex community health interventions. Analytically, the approach used in multi-level interventions is often constrained or oversimplified, since the individual is most often used as the only unit of analysis (Schensul and Trickett 2009; Smith and Petticrew 2010). Thus far the use of socio-ecological models has been compromised in four significant ways: (1) the tendency has been to focus on proximal rather than distal levels of influence; (2) the dynamic nature and nestedness of different system influences have been over-­ simplified and under-examined; (3) historical contextual influences on health determinants have often been overlooked; and (4) the differential effects and inequity of environmental influences across populations have at times been ignored or prematurely dismissed. These two final compromises have resulted in a lack of attention to systemic factors that may perpetuate social disadvantage (Adler and Stewart 2010; Edwards and Di Ruggiero 2011). As noted in the introduction, these compromises and oversimplifications have limited our perspective and ability to understand and work within natural systems of influence, which are inherently highly complex. We examine these limitations further here. 1. A Focus on Proximal Health Influences It has been argued that well-established research methods, program planning frameworks, and evaluation requirements continue to

   

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­ rivilege approaches that focus on proximal determinants (Beckfield p and Krieger 2009; Edwards and DiRuggiero 2011; Krieger 2008). As Schensul and Trickett (2009, 234) point out, deep philosophical and methodological traditions within the social sciences have kept researchers focused on more proximal health influences. For instance, they observe that despite a variety of standpoints within the field of anthropology, the approach in this field has been primarily “local and generally involves local communities in collaboration with outsiders working towards desired community level change.” Similarly, in the field of community psychology, they conclude that “the history of community intervention research in psychology has struggled to broaden its conceptual frameworks in the context of this individualistic history and the laboratory tradition of psychological science” (Schensul and Trickett 2009, 234). A gap in the community psychology literature around activity settings, for example, is the relative lack of theoretical development associated with activity settings and their relationship either to larger contextual factors, or to the dynamics of the interaction between the inside and outside spheres of this model. Perhaps in an effort to minimize the inherent complexity of socio-ecological models, many scholars have simplified the original models to include, for example, only the micro and meso systems (Corcoran, Franklin, and Bennett 2000; Voisin, DiClemente, ­Salazar, Vrosby, and Yarber 2006). This focus on proximal determinants is inconsistent with compelling evidence on the effects and importance of macrodeterminants of health such as regulations, policies, laws, conventions, and treaties (Beckfield and Krieger 2009; M ­ erzel and D’Afflitti 2003; Subramanian, Belli, and Kawachi 2002). In her analysis of this concentration on proximate influences, Krieger (2008) forcefully argued that distal position does not denote lack of importance. Labonté, Schrecker, Packer, and Runnels (2009) make a strong case for the addition of a global system level, since the operationalization of the exo and macro systems has tended to focus on influences that are within nation-states. Schensul and Trickett (2009) point to the constraints that have been created by those averse to methodological pluralism and by the dominant perspective that the individual is the appropriate unit of analysis in intervention research. Various evaluation designs and approaches – such as institutional ethnography, intersectional analysis, social network analysis, interstitial ethnography (“at the

   



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sites where activities at each level intersect,” [Schensul and Trickett 2009, 236]), mixed methods, and comparative case study designs – extend the methodological tools required to make other system levels the analytical entry points for community studies. Thus, the next phase of socio-ecological research will require transdisciplinary approaches to inquiry and methodological pluralism. It is the research questions that emerge from slices through all levels of the socio-ecological model that require future emphasis. 2. Limitations in Explaining the Nestedness and Dynamic Interaction of Influences Such nestedness concerns interactions between system levels. It requires an understanding of mechanistic pathways between system levels and a treatment of contextual influences that goes beyond identifying variables that are merely aggregated descriptions of individual characteristics. Nested influences are inherently dynamic rather than static. The dynamic nature of context is both dependent on and independent of the community-level intervention. While the intervention may shape individuals, social ties, community engagement, and social capital, these changes in turn feed back into the intervention itself, reflecting the interdependence of intervention and context. Community-level interventions never take place in isolation from other programs, events, or community partnerships. As these environmental influences evolve, they too may influence how the program is delivered and “received” (Edwards and Clinton 2008). In this view, “the environment is seen as a collection of ‘force-fields’ that are constantly changing and never remain static” (McCormack et al. 2002, 96). While the introduction of multi-level modelling techniques has provided a means to examine how system influences are nested within each other (Schensul and Trickett 2009), these techniques do not take into account the dynamic nature of change processes at each system level, nor the fact that these changes are often occurring at different time scales (Gunderson and Holling 2002). That is, individual behaviour change is not only reciprocally influenced by changes in the meso- and macro-environments, but also influenced by different rates of change in other system levels. These differential time scales are visible, for instance, when we compare the rapid pace of change that may be seen in the distribution and uptake of

   

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new products with the slower pace of change that is often observed in efforts to introduce new government policy (see also Baber and Bartlett, chapter 5 below). Managers of community health programs describe the opportunities for community action that are provided through shifting environmental or contextual influences (Edwards 2007). In contrast, quantitative researchers who are trying to implement standardized interventions using randomized controlled trial designs are plagued by these same environmental perturbations. For the researcher who is aiming to answer an attribution question, these dynamic influences are typically viewed as a problematic source of co-intervention(s), which may muddy research findings (Edwards and Clinton 2008). Thus, these dynamic and unpredictable environmental influences challenge standard approaches used in the design of intervention studies (Hawe and Shiell 2000; Smith and Petticrew 2010). The future of socio-ecological inquiry must be able to embrace the dynamic nature of context and of environmental influences on individual and population health (Hawe, Shiell, Riley, and Gold 2004; Smith and Petticrew 2010). Hawe, Shiell, and Riley’s (2009) conceptualization of interventions as “events in systems” goes some distance towards an approach that is consistent with nestedness, in part because the interventions being introduced by researchers are seen as system intrusions that are superimposed upon a dynamic set of community interfaces that are already at play. It is essential that we begin to more consistently examine these dynamic and nested contextual influences. They may help to explain some of the variability in responses to community health interventions that have been observed within studies using cluster sample selection and analysis. It is time for us to move beyond a more constrained use of socio-ecological theory, perhaps mitigated by a need for a more narrowly defined “researchable question” and manageable datasets that can be analyzed using traditional methods. This will require adjustments in both the research approach used by teams of scientists and the funding mechanisms provided by research councils. 3. Historical Influences Have Been Largely Overlooked The pervasive and challenging nature of person-environment interactions is also reflected in the fact that environmental influences are

   



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not only contemporary, but also historical. Environmental influences exist before the formal beginning of a community health program and they continue after a program or intervention is actively finished. It is essential to understand what has gone on before and to consider the nature of sustainability. “Natural” environmental influences, for example, are inherently more sustainable than imposed formal programs or interventions might be, because many of them are systematically rooted or insinuated in social institutions ­(Hofrichter 2006). Cultural influences, social norms and values, power structures in society, and specific regulatory and governance structures are powerful contextual forces that can be particularly challenging to influence through health intervention (see also Baber and Bartlett, chapter 5 below). This is especially true given the relatively short funding time periods often allotted for community health intervention programs. Similarly, the omnipresence of established built environment infrastructure – as seen in existing housing stock, urban design, and transportation networks – also reflects historical influences on today’s environment. Despite these historical influences, few studies have maintained a distinct chronosystem. Consequently, health determinants have become conceptualized as “ahistorical” (Altenbaugh, Engel, and Martin 1995). Failures to acknowledge the influence of residential schools on Aboriginal families in Canada (Smith et al. 2006), apartheid on patterns of hiv and aids in South Africa (Sachs 2002), or slavery and subsequent racial segregation laws on health status in the southern United States (Subramanian, Jones, Kaddour, and Krieger 2009) illustrate the importance of including a distinct chronosystem. This is also the case for global levels of influence as shown by structural adjustment policies, which have contributed to the migration of health workers from African countries (Labonté, Schrecker, Packer, and Runnels 2009), and economic globalization policies, which have disproportionately restricted the access of the poor to wealth derived from ecosystem resources, including timber, aquaculture, minerals, and oil (Labonté et al. 2009). Capturing and understanding these historical influences in terms of both intervention design and evaluation require an acknowledgment of these influences, a deeper understanding of how they exert their influence, and a reduction of the dismissive attitude that these influences can and should be ignored because we cannot undo history. Emerging research in several fields points to the shift in

   

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i­ntervention approaches that can be considered when these types of historical influences are taken into account. The application of decolonizing approaches to both interventions and scholarly inquiry (Bartlett, Iwasaki, Gottlieb, Hall, and Mannell 2007; Bhattacharya 2009; Mundel and Chapman 2010) is illustrative of this point. 4. Differential and Inequitable Influences Are Not Sufficiently Examined An underlying premise of socio-ecological models is their ability to address the many levels of influence on health. Accordingly, these models should assist us in thinking about ways to tackle widening disparities, both within and between countries. A paper by Adler and Stewart (2010) outlines five eras of empirical research on health disparities with a focus on socio-­economic status and health. The fourth and fifth contemporary eras are described as those periods when multi-level influences are being examined and interactions among factors are being tested, respectively. Our review suggests that researchers are appropriately adding depth and complexity to earlier studies in this field. However, as Adler and Stewart infer, there is a larger paradigmatic shift required to support more fulsome examinations of interactions among inequities and between inequities and community health interventions. We know that it takes much more than the mere introduction of new research designs and analytic tools to shift patterns of research. The prevailing conceptualizations and analytic tools of science are tenacious. For example, hierarchical multi-level regression models were used in the field of education for at least a decade before they found their way into health sciences. The notion of an ecological fallacy tenaciously began to take hold in the field of epidemiology in the 1960s, arguably tarnishing our views about the relevance of social influences on health and their estimation in studies. Interestingly, thinking about ecological fallacies followed from observations of discrepant findings that emerged during an analysis of individual and aggregated variables examining literacy rates among whites and blacks in the Southern United States (Robinson 1950). A recent re-analysis of the data used in this seminal paper (Subramanian et al. 2009) took into account the Jim Crow segregation laws that were in place at the time, demonstrating a dramatic difference in the interpretation of findings from the original a­ nalysis. The re-analysis

   



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­ ighlighted the inherent limitations of not taking into account hish torical and multi-level contexts when choosing study variables and analysis techniques to examine disparities. The authors observed that there are perils in thinking about both ecological and individualistic fallacies, and they concluded that “multilevel thinking, grounded in historical and spatiotemporal context, is thus a necessity, not an option” (Subramanian et al. 2009, 355). Thus, the application of socio-ecological models to the examination of disparities must be accompanied by a set of appropriate analytic tools that do not over-simplify the complexity of forces that serve to create and reinforce health inequalities and inequities. Hyper-vigilance is required within each of our disciplines to ensure that we are not blinded to the obvious when following well-accepted methodological traditions.

Discussion of Current Limitations There are many examples of research that demonstrates the practical and methodological constraints on or limitations of fully using socio-ecological theory. Practical constraints such as access to multilevel data, sample size limitations (particularly at macro-system levels), and lack of technical know-how in the use of more sophisticated analysis techniques are all pertinent. More troubling are constraints that arise from under-theorizing multi-level influences and from the strength of disciplinary traditions that may also be driving the under-utilization of socio-ecological models. The way researchers have approached intervention design for experimental and quasi-experimental research studies has thwarted efforts to fully apply socio-ecological models. For example, with respect to intervention studies, reductionist disciplinary traditions are dominated by efficacy and effectiveness research questions with an underlying focus on attribution. That is, does the introduction of a specific intervention lead to a particular outcome? Answering attribution questions has traditionally called for the rigid use of standardized protocols, strict adherence to intervention fidelity, and the control of confounders (Hawe, Shiell, and Riley 2004). Two understandable but problematic offshoots of this approach have been decisions by researchers not to engage community members in the design of interventions, and failures to adequately contextualize interventions before and during their implementation.

   

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In a comprehensive review of multi-level and multi-strategy programs, Merzel and D’Affliti (2003) concluded that lack of community engagement in planning interventions at the design phase was a key factor differentiating effective and ineffective programs. In contrast, within other disciplines and among various groups of scholars, interventions are being re-theorized as events in systems (Hawe, Shiell, and Riley 2009; Beckfield and Krieger 2009) rather than as discrete entities that are bounded by definitions imposed either by research protocols or by funding parameters for community health programs. Critical realists, therefore, have begun to consider and define environmental and contextual influences in all of their complexity: The local mix of conditions and events, social agents, objects and interactions which characterize open systems … whose unique confluence in time and space selectively activates, triggers, blocks or modifies causal powers and mechanisms in a chain of reactions that may result in very different outcomes depending on the dynamic interplay of conditions and mechanisms over time and space. (Poland, Frolich, and Cargo 2009, 10) This perspective is echoed by Pawson (2006) and Pawson and Tilley (1997, 69), who state that “the relationship between causal mechanisms and their effects is not fixed but contingent … it is the contextual conditioning of causal mechanisms which turns (or fails to turn) causal potential into causal outcome” (emphasis in original). Researchers have begun to delve into the complexity of community interventions, examining in detail the interactions that take place between features of programs and characteristics of dynamic social and physical environments in which programs are placed (Hawe, Shiell, Riley, and Gold 2004). Similarly, new institutionalism in the fields of political science and sociology and structural functionalism in the field of economics have both theorized a broader set of influences on organizations and political structures. These approaches and theories are consistent with socio-ecological models.

S u m m a ry a n d F u t u r e D i r e c t i o n s In our discussion of limitations associated with current, mainstream usage of socio-ecological models in community health, and using the

   



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lessons learned from the case studies, we make four points. First, we note that influences more proximal to the individual have garnered more research attention and application than those more distal. While this is not necessarily always a problematic imbalance, it has led to the design and testing of interventions that ignore underlying systemic factors that may be producing and continually reinforcing poor health outcomes and health disparities among those in different social strata (Edwards 2010; Edwards and Di Ruggiero 2011; Schensul and Trickett 2009). Second, we argue that contextual influences are not static and that any model must be able to accommodate dynamic interactions among system levels. This points to the necessity of monitoring the implementation of community health interventions for both expected and unintended effects, and making subsequent adjustments so the intervention fits better within a shifting context. Next, we have stated that environmental influences are not ahistorical and that we believe that scholars ignore historical and future contexts at their peril. And finally, we assert that environmental influences do not act on all individuals in the same way and these influences may create and reinforce inequities. We must be able to take into account differential contextual effects and different mechanisms by which these influences occur over time if we are going to successfully understand and address health disparities. There is a shift towards health promotion and community health programs that is crossing disciplinary and institutional boundaries. In a ten-year follow-up to an ecological model of health promotion published by Richard et al. (1996), Kok and colleagues (2008, 441) concluded that over the past decade, “health promotion practice may have changed to include more multilevel programs.” Thus, community health researchers must have models for intervention development and evaluation that can adequately inform and guide action as well as providing ways of examining intervention effectiveness in this evolving health promotion environment. While the socio-­ecological model is relatively robust, the exact makeup, function, and interaction of its core elements have too often been overlooked, misunderstood, or oversimplified in community health. The community health literature reflects a constrained use of the socioecological model that does not take into account dynamic, historically mediated, and differential person-environment interactions. The model should go well beyond reminding us of the different system levels at work as influential characteristics. It needs to be able to

   

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assist us in conceptualizing multi-level nested factors with levels of influence that vary over time and across individuals and populations. We must reiterate that in order to improve the overall level and distribution of health in society, complex community health interventions are required. Any socio-ecological model used to inform these interventions must be able to assist us in conceptualizing and grappling with this complexity. We are entering into an era of trying to address “wicked” problems such as climate change, social violence, and food insecurity. These problems have no borders. They call for mature and sophisticated applications of socio-ecological thinking that should continue to challenge research and scholarship in this field.

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Corcoran, J., C. Franklin, and P. Bennett. 2000. “Ecological Factors Associated with Adolescent Pregnancy and Parenting.” Social Work Research 24 (1): 29–39. Cummings, E.M., M.C. Goeke-Morey, A.C. Schermerhorn, C.E. ­Merrilees, and E. Cairns. 2009. “Children and Political Violence from a Social Ecological Perspective: Implications from Research on Children and Families in Northern Ireland.” Clinical Child and Family Psychology Review 12 (1): 16–38. Dahlgren, G., and M. Whitehead. 1991. Policies and Strategies to Promote Social Equity in Health. Stockholm: Institute for Future Studies. Davison, C.M. 2007. “Engagement and the Northern School Setting: A Critical Ethnography among the Tlicho First Nation of Behchoko, nwt.” PhD diss., University of Calgary, Department of Community Health Sciences. – 2010. “Understanding Knowledge Translation and Its Implications for Evaluation.” New Directions in Evaluation 124: 75–87. Deschesnes, M., C. Martin, and A. Jomphe-Hill. 2003. “Comprehensive Approaches to School Health Promotion: How to Achieve Broader Implementation?” Health Promotion International 18 (4): 387–96. Duran, B., and K.L. Walters. 2004. “hiv/aids Prevention in ‘Indian ­Country’: Current Practice, Indigenist Etiology Models and Postcolonial Approaches to Change.”aids Education and Prevention 16 (3): 187–201. Edwards, N. 1999. “Prevention of Falls among Seniors in the Community.” In Community Nursing: Promoting Canadians’ Health, 2nd ed., edited by M. Stewart, 296–316. Toronto: W.B. Saunders. – 2007. “Perspectives in Context.” Paper presented at the Multiple Intervention Programs Invitational Symposia Series’ Inaugural Symposium: Changing Contexts. Ottawa. – 2009. “Revisiting Our Social Justice Roots in Population Health Intervention Research.” Canadian Journal of Public Health 100 (6): 405–6. – 2011. “Preventing Falls among Seniors: The Way Forward.” Journal of Safety Research 42 (6): 527–41. Edwards, N., N. Birkett, R. Nair, M. Murphy, G. Roberge, and D. Lockett. 2006. “Access to Bathtub Grab Bars: Evidence of a Policy Gap.” Canadian Journal on Aging 25 (3): 295–304. Edwards, N., and K. Clinton. 2008. “Context in Health Promotion and Chronic Disease Prevention: Community Level Interventions.” Background document prepared for Public Health Agency of Canada.

   



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Edwards, N., and E. Di Ruggiero. 2011. “Exploring What Context Matters in the Study of Health Inequities and Their Mitigation.” Scandinavian Journal of Public Health 39 (Supp. 6): 43–9. Edwards, N., J. Etowa, and M. Kennedy. 2008. “Community Health Planning, Monitoring and Evaluation.” In Community Health Nursing in Canada, 2nd ed., edited by L. Stamler and L. Yiu, 212–26. Toronto: Pearson. Edwards, N., J. Mill, and A. Kothari. 2004. “Multiple Intervention Research Programs in Community Health.” Canadian Journal of Nursing Research 36 (1): 40–54. Edwards, N., and S. Roelofs. 2006. “Developing Management Systems with Cross-Cultural Fit: Assessing International Differences in Operational Systems.” International Journal of Health Planning and Management 21: 55–73. Evans, R.G., and G.L. Stoddart. 1990. “Producing Health, Consuming Healthcare.” Social Sciences and Medicine 31: 1347–63. Flood, R.L. 2001. “The Relationship of Systems Thinking to Action Research.” In Handbook of Participatory Research: Participative Inquiry and Practice, edited by P. Reason and H. Bradbury, 133–44. Thousand Oaks, ca: Sage. Galea, S. 2007. Macrosocial Determinants of Population Health. New York: Springer. Green, L., L. Richard, and L. Potvin. 1996. “Ecological Foundations of Health Promotion.” American Journal of Health Promotion 10 (4): 270–81. Greenfield, P., A. Maynard, and C. Childs. 2003. “Historical Change, Cultural Apprenticeship and Cognitive Representation in Zinacantec Maya Children.” Cognitive Development 18: 455–87. Gregson, J., S.B. Foerster, R. Orr, L. Jones, J. Benedict, and B. Clarke. 2001. “System, Environmental and Policy Changes: Using the SocialEcological Model as a Framework for Evaluating Nutrition Education and Social Marketing Programs with Low-Income Audiences.” Journal of Nutrition Education 33 (S1): S4–15. Grzywacz, J.G., and J. Fuqua. 2000. “The Social Ecology of Health: Leverage Points and Linkages.” Behavioural Medicine 26 (3): 101–15. Gunderson, L.H., and C.S. Holling. 2002. Panarchy: Understanding Transformations in Human and Natural Systems. Washington, dc: Island Press. Hawe, P., S. Samis, E. Di Ruggiero, and J.A. Shoveller. 2011. “Population Health Intervention Research Initiative for Canada: Progress and Prospects.” nsw Public Health Bulletin 22 (1–2): 27–32.

   

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Hawe, P., and A. Shiell. 2000. “Social Capital and Health Promotion: A Review.” Social Science and Medicine 51 (6): 871–85. Hawe, P., A. Shiell, and T. Riley. 2004. “Complex Interventions: How Far ‘Out of Control’ Should a Randomised Controlled Trial Be?” British Medical Journal 328 (7455): 1561–3. – 2009. “Theorising Interventions as Events in Systems.” American Journal of Community Psychology 43 (3–4): 267–76. Hawe, P., A. Shiell, T. Riley, and L. Gold. 2004. “Methods for Exploring Implementation Variation and Local Context Within a Cluster Randomised Community Intervention Trial.” Journal of Epidemiology and Community Health 58 (9): 788–93. Hofrichter, R., ed. 2006. Tackling Health Inequities through Public Health Practice: A Handbook for Action. Washington, dc: The National Association of County and City Health Officials and the Ingham County Health Department, Lansing, Michigan. Holzemer, W.L., L. Uys, L. Makoae, A. Stewart, R. Phetlhu, P. Dlamini, et al. 2007. “A Conceptual Model of hiv aids Stigma from Five African Countries.” Journal of Advanced Nursing 58 (6): 541–51. Homer, J.B., and G.B. Hirsch. 2006. “System Dynamics Modeling for Public Health: Background and Opportunities.” American Journal of Public Health 96 (3): 452–8. International Development Research Centre (idrc). 2009. “Research ­Matters Knowledge Translation Toolkit.” http://www.idrc.ca/researchmatters/ev-128908-201-1-DO_TOPIC.html (accessed 7 April 2010). Katz, D., and R.L. Kahn. 1978. The Social Psychology of Organizations, 2nd ed. New York: Wiley. Kok, G., N.H. Gottlieb, M. Commers, and C. Smerecnik. 2008. “The Ecological Approach in Health Promotion Programs: A Decade Later.” American Journal of Health Promotion 22 (6): 437–42. Kothari, A., N. Edwards, S. Yanicki, and P. Hansen-Ketchum. 2007. “Socio-Ecological Models: Strengthening Intervention Research in Tobacco Control.” Drugs, Health and Society 6 (1): iii1–24. Krieger, N. 2008. “Proximal, Distal and the Politics of Causation: What’s Level Got to Do with It?” American Journal of Public Health 98 (2): 221–30. Labonté, R., T. Schrecker, C. Packer, and V. Runnels. 2009. Globalization and Health: Pathways, Evidence and Policy. New York: Routledge. Leischow, S.J., and B. Milstein. 2006. “Systems Thinking and Modeling for Public Health Practice.” American Journal of Public Health 96 (3): 403–5.

   



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Lytle, L.A., and J.A. Fulkerson. 2002. “Assessing the Dietary Environment: Examples from School-Based Nutrition Interventions.” Public Health Nutrition 5 (6A): 893–9. Maton, K.I. 2000. “Making a Difference: The Social Ecology of Social Transformation.” American Journal of Community Psychology 28 (1): 25–57. McCormack, B., A. Kitson, G. Harvey, J. Rycroft-Malone, A. Titchen, and K. Seers. 2002. “Getting Evidence into Practice: The Meaning of Context.” Journal of Advanced Nursing 38 (1): 94–104. Merzel, D., and J. D’Afflitti. 2003. “Reconsidering Community-Based Health Promotion: Promise, Performance and Potential.” American Journal of Public Health 93 (4): 557–74. Mill, J., N. Edwards, R. Jackson, W. Austin, L. MacLean, and F. Reintjes. 2009. “Accessing Health Services While Living with hiv: Intersections of Stigma.” Canadian Journal of Nursing Research 41 (3): 168–85. Ministry of Foreign Affairs and Trade in Mongolia and United Nations Development Program in Mongolia. 2008. “Trade Policy and Human Development in Mongolia: Way Forward After a Decade in the World Trade Organization.” Ulaanbaatar: Author. Mongolian Mining Association. n.d. “About the Sector.” http://www. ­miningmongolia.mn/en/index.php?option=com_contentandtask= viewandid=20andItemid=38 (accessed 7 April 2010). Mundel, E., and G.E. Chapman. 2010. “A Decolonizing Approach to Health Promotion in Canada: The Case of the Urban Aboriginal Community Kitchen Garden Project.” Health Promotion International 25 (2): 166–73. doi:10.1093/heapro/daq016. Naaldenberg, L., U.R. Wageningen, M. Koelen, A.-M. Wagemakers, H. Saan, and K. de Hoog. 2009. “Elaborating on Systems Thinking in Health Promotion Practice.” Global Health Promotion 16 (1): 39–47. O’Donnell, C., G. Tharp, and K. Wilson. 1993. “Activity-Settings as the Unit of Analysis: A Theoretical Basis for Community Intervention and Development.” American Journal of Community Psychology 21 (4): 501–20. Oetzel, J., and B. Duran. 2004. “Intimate Partner Violence in American Indian and/or Alaska Native Communities: A Social Ecological Framework of Determinants and Interventions.” American Indian and Alaska Native Mental Health Research 11 (3): 49–68. Oishi, S., A.J. Rothman, M. Snyder, J. Su, K. Zehm, A. Hertel, et al. 2007. “The Socio-Ecological Model of Pro-Community Action: The Benefits

   

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of Residential Stability.” Journal of Personality and Social Psychology 93 (5): 831–44. Pawson, R. 2006. Evidence-Based Policy. A Realist Perspective. London: Sage Publications. Pawson, R., and N. Tilley. 1997. Realist Evaluation. London: Sage Publications. Poland, B., K. Frohlich, and M. Cargo. 2009. “Context as a Fundamental Dimension of Health Promotion Program Evaluation.” In Health Promotion Evaluation Practice in the Americas: Values and Research, edited by L. Potvin, D.V. McQueen, M. Hall, L. Anderson, L. DiSalazar, and Z. Hartz, 299–317. New York: Springer. Raine, K. 2004. “Obesity and Overweight in Canada: A Population Health Perspective.” In Canadian Population Health Initiative, edited by Canadian Institute for Health Information. Ottawa: Author. Riley, B.L. 2003. “Dissemination of Heart Health Promotion in the Ontario Public Health System: 1989–1999.” Health Education Research 18 (1): 15–31. Riley, B., N. Edwards, and J. d’Avergnas. 2008. “People and Money ­Matter: Investment Lessons from the Ontario Heart Health Program, Canada.” Health Promotion International 23 (1): 24–34. Riley, B.L., J.M. Garcia, and N. Edwards. 2007. “Organizational Change for Obesity Prevention – Perspectives, Possibilities and Potential Pitfalls.” In Obesity Epidemiology and Prevention: A Handbook, edited by S. Kumanyika and R.C. Brownson, 239–61. New York: Springer. Richard, L., P. Lehoux, E. Breton, J.L. Denise, L. Labrie, and C. Leonard. 2004. “Implementing the Ecological Approach to Tobacco Control Programs: Results of a Case Study.” Eval Program Plann 27 (4): 409–21. Richard, L., L. Potvin, N. Kishchuk, H. Prlic, and L.W. Green. 1996. “Assessment of the Integration of the Ecological Approach in Health Promotion Programs.” American Journal of Health Promotion 10 (4): 318–28. Robinson, W.S. 1950. “Ecological Correlations and the Behaviour of Individuals.” American Sociological Review 15 (3): 351–7. Rothschild, A.S., L. Dietrich, M. Ball, H. Wurtz, H. Farish-Hunt, and N. Cortes-Comerer. 2005. “Leveraging Systems Thinking to Design PatientCentered Clinical Documentation Systems.” International Journal of Medical Information 74 (5): 395–8. Rubenstein, L.Z., A.S. Robbins, B.L. Schulman, J. Rosado, D. Osterweil, and K.R. Josephson. 1988. “Falls and Instability in the Elderly.” Journal of the American Geriatric Society 36 (3): 266–78.

   



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3 Using Research and Restoration to Re-Imagine Safe Places in a Technologically Colonized Health Care World pat r i c i a m a r c k

In the moral (the ecological) sense you cannot know what until you have learned where. Not knowing where you are, you can lose your soul or your soil, your life or your way home. Berry 1983, 103

As someone who has extensively practiced, then taught and managed, and now studies and consults on ethics and safety within developed health care systems, it has been a long journey from emergency nurse to skeptical scholar to aging activist for ecologically driven systemic change. To navigate this eventful transformation in my understanding of the world, I have had to work with many colleagues across multiple disciplines to draw meaningful links between critical theoretical schools of thought in nursing and elsewhere, several philosophical analyses of technology, and the interdisciplinary fields of health care ethics, ecological restoration, ecosystems management, and safety science. In struggling with these questions, I have come to realize that the current agreement between for-profit biotechnology and high-tech health care operates at the expense of mobilizing our resources to build robust public and environmental health systems. In short, I have had to recognize that we currently perpetuate a visibly failing health care system in Canada for very select subsets of our population when what we need to create is a sustainable, ecologically viable health system for all.

   



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Introduction My goal in this chapter is to stimulate critical debate on how we need to reach better outcomes for our health and the health of our world. I seek to contribute to these deliberations by raising and exploring several questions. Specifically, I wonder: Is it possible for health care communities to “imagine together” better ways to treat each other and the places we share? Generally I hope to discover ways that are more ecologically and therefore also more ethically, scientifically, and practically sound. Can we foster such communal creativity and collective ecological citizenship within health care environments and within all of the places that matter to our shared environmental and human condition? And, if we cannot meet this challenge, can we realistically expect to competently envision, develop, and sustain ecologically and socially healthy communities? That is, can we heal ourselves or our world? My questions arise from ongoing efforts to adapt thinking and methods from the field of ecological restoration to a program of health systems research focused on the ethics and safety of health care (see also Edwards and Davison, chapter 2 above, and HansenKetchum, chapter 4 below). These questions also link with calls from other contributors in this book to explore new forms of governance that address the intersections of social, ecological, and human health and to exercise ecological citizenship in service of environmental and human health (Hansen-Ketchum et al. 2011, 2009). The specific objectives I will pursue in this chapter to address these questions are as follows: I will integrate thinking from the fields of ecological restoration, environmental ethics and bioethics, and health care safety research to re-examine the notion of safe places in health care; • I will delve into how restorative thinking in health care can help communities, practitioners, and decision-makers to rediscover and nourish fundamental links between ecological and human health; and • I will explore how the deliberate use of restorative thinking to attend to place ethics, moral imagination, and ecological literacy can engage us as ecological citizens to counter a problematic technological colonization of our imaginations in health care. •

   

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To pursue this line of inquiry, I make several arguments that have emerged over the past decade from a program of research and restoration which I have led with colleagues and students in health care. First, I argue that safe places, in health care and in our world, are ones which are both culturally and ecologically healthy and whole (Marck 2012, 2006, 2004). By healthy, I mean places that demonstrate vital attributes of ecological and cultural integrity, and by whole, I mean that culture and ecology co-evolve in ways that enable places and their inhabitants to thrive. Second, I assert that to foster and sustain the health and wholeness of places and their inhabitants into the future, it is essential to nourish critical ethical, political, scientific, and practical connections that support us to treat each other and the places we share in ways that are more ethically and ecologically sound (Hofmeyer and Marck 2008; Higgs 2005; Marck 2006, 2004, 2000; Marck et al. 2006). Third, I support the arguments of restoration scholars Jennifer Cypher and Eric Higgs (1997, 107), who contend that our consumer-oriented societies are characterized by a technological “colonization of the imagination.” This process effectively oppresses our inclination to question increasing societal tendencies to settle for, if not prefer, manufactured facsimiles of nature rather than actual experiences of real wilderness (Higgs 2003, 1999, 1997; Cypher and Higgs 1997; Strong 1995; Borgmann 1984). These technological thinking patterns fuel the disconnect between man and nature that contributors to this volume and others critique (Borgmann 1984; Hansen-Ketchum et al. 2009; Higgs 2003, 1999, 1997; Strong 1995; Whitehouse 1999). In turn, our self-imposed estrangement from nature fuels an increasing consumption of artificial places such as Disney World (Higgs 1999; 1997; Cypher and Higgs 1997) or quick-fix health care, to the detriment of attending to real places, real communities, and real people in common need of our thoughtful stewardship and care (Marck 2012, 2004, 2000a). I then argue that a restorative approach to health care issues offers hope for an alternative path because its principles and practices lead us to engage in three vital, linked projects. These projects, which I have come to view as equally relevant for health care and for our technologically over-determined, ecologically under-stewarded twenty-first-century world, are: to develop the kind of collective moral imagination we need to grasp what Berry (1983) notes: that ecological questions are

•

   



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f­undamentally ethical questions of how we share knowledge, power, and resources in more democratic, equitable ways; • to marshal our ecologically enlightened moral imagination to enact a place ethic that informs our treatment of each other and the places we share in ecologically literate (and therefore ethically sound) ways; and • to promote synergies between moral imagination, place ethic, and ecological literacy that support us to exercise the ecological citizenship required to create ecologically emancipated communities in health systems and across our world. By the development of sufficient collective moral imagination, I am referring to the generation of the communal intellectual and moral capacities that our communities need to envision a range of better to worse potential futures for the integrity, health, and sustainability of ourselves and the places we inhabit together around this world. With this imaginative capacity, I argue, Canadians and their fellow global citizens can find the inspiration we need to enact an ethic of place where we collaboratively design, implement, study, and refine policies, practices, and laws that treat each other and the places we share in more ecologically literate ways. Establishing these connections between the moral and the ecological promotes the exercise of good ecological citizenship, supporting people to work with human and natural systems in a participatory, place-aware, sustainable manner that maintains a shared, ecologically sound, moral imagination at the forefront of our decisions and actions (see also Bartlett et al. and Baber and Bartlett, chapters 10 and 5 below). Within this context, I envision engaged, democratically driven networks where as ecological citizens, we use our collective moral imagination, a committed stewardship of places, and an ecologically literate approach to health system management to liberate ourselves and our strained Earth from the consumptive mindset that characterizes our technologically colonized, ecologically threatened world (Borgmann 2000, 1999, 1992, 1984; Feenberg 1991; Higgs, Light, and Strong 2000; Marck 2000a, 2000b; Strong 1995). Within that colonial mindset, our separation from nature fundamentally distances us from a critical awareness that, as Howard Frumkin (2003, 1451) observes in his discussion of place sense and public health, “place matters.” Places that are liberated from such colonization, I assert, are potentially emancipated communities where human

   

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s­ystems and natural systems democratically co-evolve in healthy, equitable, sustainable ways. These realizations fit, of course, with the consensus within the ecological sciences that not all current ecosystems are equally desirable, nor is it our task to unreflectively squander finite resources on every existing socio-ecological system (see Bartlett et al., chapter 10 below; Higgs 2003). To the contrary, ecological wisdom forces us to make deliberate choices that favour some kinds of living systems over others if we hope to effect sustainable, whole systems change. What follows is my attempt to illuminate key turning points for me that have shaped my trajectory thus far along this challenging restorative path.

S t u dy i n g a n d M a n ag i n g H e a l t h S ys t e m s : Why Restoration? Ecological restoration is described as helping the land heal … what you are trying to do is set up a situation where it can restore itself … creating conditions for adaptation. sshrc study1

It is fair to ask: How can restoration usefully inform the way we approach health systems issues related to ethics and safety? The tenets of my restorative approach and the rationale for its use in health care are quickly grasped by the majority of practitioners, managers, and other front-line health care workers with whom I collaborate,2 but many funding agencies, health system leaders, and other thoughtful skeptics have questioned the link.3 While this ongoing disconnect between environment, society, and health fits the thesis of this book, this chapter hopes to highlight some early successes at making the marriage. Unfortunately, I and my research collaborators work with health systems where concepts such as technological colonization of the imagination, place ethics, ecological literacy, democratic decision-making, ecological citizenship, and most of the other ideas that are deliberated in this book are little known and even less discussed. As the first researcher in health care to attempt this kind of theoretical cross-fertilization between the health, restoration, and philosophy fields, I am heartened to be part of this volume. With its emphasis on nurturing stronger connections between nature, culture, and health, restoration seems

   



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one ­promising path towards achieving this imperative if persistently elusive goal. Since the majority of my health care colleagues have never heard of ecological restoration, I start with offering the Society for Ecological Restoration International (ser) (2004, 3) definition, which is “the process of assisting the recovery of an ecosystem that has been degraded, damaged, or destroyed.” I then invite them to recall the last urban emergency department, inner-city shelter, contaminated river, tar sands, industrial farm, neglected First Nations community, or other overburdened region of our society that they visited. With that exercise in imagination, it is a short step for most to recognize the considerable commonalities between our management of ecosystems and how we currently manage health systems. These commonalities include: a persistent emphasis on the production and consumption of services rather than the generation and maintenance of health; related tendencies towards reactive cycles of excess waste and short-sighted cost-cutting rather than longer-term strategies for eco-efficiency and sustainability; a penchant for superficial, hightech quick fixes over deeper, long-term reforms; and ongoing failures to develop and exchange general scientific knowledge and local, place-based indigenous knowledge in democratic, participatory, and contextualized ways (Marck 2006, 2000; Marck et al. 2006a; see also Bartlett et al., chapter 10 below). How to develop and share knowledge to enact better policy for the closely coupled concerns of environmental and human health leads to my next argument for applying restoration thinking to health system issues, which is a methodological one. Specifically, the science needed to intelligently manage ecosystems, health systems, or any complex living system is shaped by ethical and methodological challenges which encompass, but also exceed, those found in the analytic science of controlled trials (Marck et al. 2006a; Marck 2005; Gunderson and Holling 2002; Holling 1998; see also Baber and Bartlett, chapter 5 below). Perhaps most problematically for the scientific status quo in health care, a restorative approach to health systems research dissolves the myth that any form of science can be successfully isolated from the influences of politics, profit, and culture in a technologically shaped world (Higgs 1997; Light and Higgs 1996; Feenberg 1995; see also Guehlstorf and Lichtenberg, chapter 6 below). To the contrary, Higgs (2005, 2003, 1997) asserts that accomplishing good restorations requires

   

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us to comprehend that cultural and ecological integrity go hand in hand. Unlike good clinical trials, good restorations are local rather than generalizable by intention and are deliberately characterized by participatory rather than controlled designs (Marck et al. 2006a; Higgs 2003). Accordingly, rather than seeking replicable results with similar populations, a central goal of good restorations might be more usefully thought of as generating replicable principles for managing cultural and ecological recovery and care that are translatable to widely different places and the diverse communities which call those places home (see also Hallström et al., chapter 1 above). These participatory, democratic attributes of restorative science remind us, as Berry (1983) does, that when we lose touch with the fundamental wisdom of place sense, we ethically and literally lose our way. We fail, for instance, to imagine and mount effective resistance to industrial farms owned by offshore corporations or to advertisers who urge us to perpetually acquire and discard “stuff” (Borgmann 2000, 1992, 1984; Higgs, Light, and Strong 2000). It is reasonable to argue that such colonization of our intellectual commons also explains why so many politicians, policy-makers, and citizens favour easily digested and equally disposable sound bites about human and environmental health over more difficult, open-ended intellectual debates about our values, obligations, and most pressing ecological problems (Higgs, Light, and Strong 2000; Marck 2000a; Borgmann 1999; see also Baber and Bartlett, chapter 5 below). As one senior administrator observed in recent research while discussing her efforts to problem-solve with health care executives following health care regionalization and downsizing, “they have nature-deficit disorder due to the demands of their job and their jobs within the systems as currently constructed” (sshrc study). In her experience as a senior manager, it was almost impossible within these technologically complex environments to get even five minutes of any decisionmaker’s time to discuss pressing safety issues. The numbing of the moral imagination that hampers better health systems management may also explain how contemporary societies manage to persistently manufacture and successfully market fast food, consumptive lifestyles, and high-tech health care fixes in the face of rampant rates of obesity, asthma, and other contemporary epidemics, rather than turn our attention to the determinants of health and a host of urgently needed health system and environmental reforms (Marck 2000a, 2000b). With the exception of a

   



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growing literature on greening modern hospitals in order to lessen their ecological footprint (Baldwin 2009; Canadian Coalition for Green Healthcare 2008; Coller and Grunseth 2008; Hancock 2005, 2003; Harris et al. 2009; Kaiser et al. 2001; Mazurkewich et al. 2004; Mejia and Sattler 2009; Moore 2005; Schulte 2008; Serb 2008; Topf 2005), thoughtful conceptual links between ecosystem and health system management in the extant health system literature remain few and far between. Given the problematic relationship between the consumptive conquest of our imaginations and our consumptive way of life, it becomes difficult to challenge Higgs’ (1999, 31) contention that our consequent loss of place sense and its ecological moral compass have enabled a state of affairs where “[m]ost of the planet now qualifies as freak landscape.” Certainly, the hospital environments that characterize “weak modern” health systems, with their cluttered hallways of admitted patients awaiting beds amid piles of outdated or dirty equipment, display several features of a freak landscape. As one of the sshrc research participants observed: we don’t have any storage for anything; we have commodes that are being used that no one wipes down, that no one knows whether they are fresh, clean, dirty … you have four beds in every room, well on top of that, you don’t just have four beds, you got wheelchairs, you got four walkers, you got four IV poles, so the rooms are so cluttered there is no ability to move people around freely – so nurses are hurting themselves, patients are falling, tripping over things, so that is [a] safety issue. (sshrc study) These freak hospital environments reflect a consumer model of health care that has spawned successive waves of system restructuring, workforce downsizing, and “business process re-­engineering”; and an attendant preoccupation in the current literature with moving higher volumes of people through increasing numbers of technologically complex treatments and procedures in shorter times with fewer human and material resources holds sway (Carter and ­Chochinov 2007; Farrell et al. 2008; Leddin et al. 2008; Lessard 2008; ­MacLeod et al. 2008; Morley-Forster 2007; Patrick and ­Puterman 2008; Woodend 2008). As another health professional research participant wryly observed about this state of affairs d ­ uring the same

   

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study: “Hospital environments are not healing places.” Rather, with their current emphasis on volume and throughput, health systems and hospitals in today’s “developed world” embody technological patterns of production and consumption that suggest a deep colonization of our collective health care mindset. They are places full of deepening paradoxes where fewer qualified practitioners and other health care workers strain to provide increasingly technologically sophisticated care to greater numbers of sicker people in more and more complex and cluttered surroundings (Marck 2012, 2004b, 2000a, 2000b, 2000c). In Canada and elsewhere, as this unsustainable pace of our overburdened health care environments escalates, fundamental steps in the oversight of infection control, medication safety, inter-­ professional communication, and other aspects of safe, healing care are routinely violated at the individual, team, and organizational levels, with consequent significant preventable harm (Amalberti et al. 2005; Backman et al. 2008; Baker et al. 2010; Baker et al. 2004). Managers, practitioners, and policy bodies have expressed ongoing distress at the state of contemporary health care environments (Canadian Healthcare Association 2002; Canadian Health Services Research Foundation 2006; Canadian Nursing Advisory Committee 2002; Institute of Medicine 1999; National Health Service 2000; National Steering Committee 2002; O’Brien-Pallas et al. 2008; Registered Nurses’ Association 2004; Storch et al. 2012) and there is a deepening international shortage of professionals as the health care workforce registers record rates of attrition from illness, injury, or just plain loss of heart for work that seems further and further removed from healing care (Canadian Institute of Health Information 2008; Canadian Health Services Research Foundation, International Council of Nurses 2006; Wilkerson 2006). Outside the doors of these overburdened industrial zones of hospital care at a broader system level, the costs of drugs, biotechnology, and information technology escalate, conflicts of interest between industry and research accumulate, and reporting and regulating bureaucracies proliferate. Provincial, regional, and local layers of governance are restructured every couple of years with profoundly disruptive and recurrent waves of layoffs, leadership changes, mergers, and other upheavals. In just one current example of the phenomenal human and material waste that this ongoing system turmoil produces, the n ­ umber of

   



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new registered nurse graduates doubled in Alberta in 2010 due to government-mandated increases to nursing program enrolment in 2004–05. As of 15 May 2010, the majority of these same graduates could not find employment in Alberta due to recent health system restructuring and cutbacks to nurse staffing within the same province (Belford 2010). By 18 May 2010, Alberta Health Services board chair Ken Hughes announced on cbc Radio that they would be able to hire “a fairly good percentage of the graduating class this year” (cbc 2010). This ongoing system turbulence arrives on the heels of several years of expensive overseas recruiting of registered nurses to fill shortages that governments of the mid-90s induced across Canada with massive nurse layoffs in the last wave of health system restructuring and cutbacks. Meanwhile, our neglect of community and environmental health continues, with episodic, shortlived spikes in resources for public health campaigns whenever sars, h1n1, or another pandemic looms, and transient headlines on oil spills, water shortages, or other news of our present follies. As we survey the over-industrialized environments and overburdened health systems that characterize our world, freeing ourselves of the consumptive mindset that colonizes our contemporary culture assumes the proportions of an urgent emancipatory endeavour. A meaningful ecological turn in health care begins with decolonizing our nature-deficient imaginations in a technologically colonized world. Since restoration forces us to re-examine our relations with nature and with each other, it seems up to this decolonizing task. In other words, the purpose of conducting research and restoration within health care environments is to try to imagine or construct together the ways health, natural, and human social systems are interrelated in an ecologically threatened world (see also chapter 1 of this volume).

Using Restoration to Re-Imagine Health Care: A Decolonizing Task The antidote to colonization is discovery. We need to discover how the world works to know better our place in it. Jackson 1987, 27

In contrast to our impoverished current approaches to both environmental and human health (see also Hansen-Ketchum, chapter 4

   

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below, and Edwards and Davison, chapter 2 above), the foundations of good restorative thinking are perhaps best exemplified in the original, pre-colonial character of many First Nations communities in North America and other parts of the world. As scholars have noted, the first restoration practitioners were Aboriginal peoples who self-organized and self-regulated their work, communities, and lives around a central goal of sustainable relations with each other and the land (Higgs 2005, 2003; Tuhiwai Smith 1999). The traditional ecological knowledge (tek) that First Nations people gathered, preserved, and transmitted in their daily activities, rituals, and stories guided their relations with nature and amongst themselves. The issues that First Nations people take with Western concepts of science and ethics are ones which have only begun to change health and social sciences research policy and practices in the recent past and are vitally linked to honouring and nourishing these traditional, life-giving sources of knowledge about harmonious co-evolution with nature. The value of this indigenous knowledge is evident in the primary goals of the ser International Indigenous Peoples’ Restoration Network (iprn) (1995), which are to develop and use restoration to enhance the survival of Indigenous peoples and their cultures and  to incorporate the tek of Indigenous tribes and Native communities into newly emerging models of sustainable agro-ecosystem management. Many restoration practitioners argue that the role and importance of traditional knowledge for Indigenous peoples should reshape our thinking about what matters to any given community and its members with whom we seek to work (Turner et al. 2000; Higgs 2005). The work of Molzahn and colleagues (2004) to explore Aboriginal people’s beliefs about organ donation reinforce this claim, as it becomes clear that health choices and treatment choices are often rooted in community knowledge and values that are not always respected and accounted for in the provision of care. The local knowledge, rituals, and practices of any practice community we work with are vital pieces of knowledge that I and my co-researchers seek when we are trying to learn how to effect enduring improvements in the delivery of care (see also Bartlett et al., chapter 10 below). With this context for my collaborative research and related restorative work, the foundations that guide my research relationships, priorities, and activities are relatively few, but essential. These fundamentals are to use research to foster place ethics, conduct c­ itizen

   



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s­ cience, illuminate and support engaged practice, and generate adaptive learning and growth (Marck et al. 2008; Marck et al. 2006a). The role of each of these cornerstones for decolonizing an ailing health care world is described in some detail below.

Fostering Place Ethics A research participant from the ecological sciences incisively noted that “the first thing about a restorative eye is that it is open” (sshrc study). That is, one does not prejudge what is important or how things actually work when one begins a new research relationship with a new community (see also Bartlett et al., chapter 10 below). One of the first challenges at the outset of any of our projects is to question, as Higgs (1997) urges those in restoration to ask: What are we after in doing this work together? What do these places mean to us, what are our commitments to them, and in service of what healing goals? These questions remind us that good restoration begins with moral matters, matters of what it is that we seek to restore and in service of what moral ends (Higgs 1997; Buell 1995; Mills 1995; Leopold 1974). How will our acts of restoration bring about more ethical relations with one another and with the land, we are challenged; what rituals and actions can spark the deeper moral commitments that are needed between humans and their surroundings, if we are to truly heal a place and be healed? In working to restore damaged ecosystems, Higgs (1999, 31) counsels, these moral questions must be pursued if we are to “renovate the public imagination” in ways that sustain deeper and more ethical relations with the land as our home place. Re-understood in this deeper sense of place, Higgs argues, good restorations teach us that well-tended places respond to practices with a lasting capacity to heal. If the aim of fostering place ethics is to improve the way we treat each other and our surroundings, it becomes necessary to exercise a deep, respectful curiosity about the Indigenous history, culture, knowledge, and rituals of our fellow research participants and partners. In understanding who we work with, we can open up our individual and communal moral imaginations to different possible future stories about the places we share. The decolonizing exercise of gathering local knowledge and re-connecting with the places we inhabit creates those opportunities to recognize what a place means to us, how it is thriving and not, and what we want to do about it.

   

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This need to gain a historical context of the safety issues we study requires us to work together with participants to establish the narrative continuity or “the story” on each place we enter. As Higgs (2003, 148) notes, places become important to us “through narrative continuity, mainly through accounts of [their] significance and presence in the life of the community.” To construct rich narratives of the places that I and my coresearchers study, we use a variety of participatory visual approaches to engage managers, practitioners, students, faculty, and patients in the design, data collection, analysis, and dissemination aspects of our research. The visual research methods that we employ include participant-led photographic walkabouts, repeat photography, photo elicitation in communal forums, and photo narration, and are adapted from work by Eric Higgs and colleagues, first in the Rocky Mountain Repeat Photography Project (Higgs 2003; MacLaren et al. 2007; MacLaren et al. 2005; Rhemtulla et al. 2002) and more recently in the Mountain Legacy Project (Higgs et al. 2009). These joint experiences of data collection and analysis enable us to capture and tell stories about how safe this place is, how safe it once was (or was not), and more importantly, how safe we might be able to make it for the future (Marck et al. 2006). With this narrative continuity, we seek to effect changes that bring what is vital about the past forward (Higgs 1997) as we work to effect affordable, useful repairs. The images and related visual narratives that we gather in our research also provide a potent entry point to share available evidence on safety issues in a format that is equally user-friendly for patients, students, practitioners, managers, and policy-makers. As Higgs (2003, 147) notes about the use of photo elicitation and photo narration in community forums: “Stories nurture places and give weight to restoration.” For my program of research, this means that the power of reviewing images together with communities of practice lies with the capacity to elicit each other’s stories about, and potential ethical commitments to, the places we share. As researchers, practitioners, care recipients, managers, educators, and students listen to each other’s knowledge and perceptions of safety in these forums, we exchange wisdom that strengthens our capacity to care about these places and imagine how to make them safer in concrete, tangible ways (Marck 2012; Marck et al. 2008; Marck et al. 2006b). We can then set about trying to make viable improvements that we can also capture, wherever possible, in repeat post-­ intervention

   



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photographs. These improvements may be practitioner-­led changes to their surroundings, practices, delivery systems, or monitoring methods. In all instances where changes emerge from the research approach, though, the principles which remain constant are that members of the community lead them and take ownership of their effects.

Conducting Citizen Science A variety of methodological perspectives in health care incorporate the mixed methods of data collection (observation, survey, photographic, interview, focus group, and statistical data – see for example Hansen-Ketchum, chapter 4 below) that are characteristic of our work. What becomes important in restorative forms of data collection, as with other aspects of this research approach, including problem identification, proposal development, data analysis, and knowledge exchange, is an underlying drive for democratic design. That is, as citizen scientists, I and my fellow team members work with practitioners, managers, patients and clients, funders, communities, governing bodies, and others to collaboratively study and manage safety issues with methods that are deliberately participatory, contextual, and iterative (Marck et al. 2008; Marck 2006; Marck et al. 2006b; Gunderson, Holling, and Light 1995; Walker et al. 2002). If the goal of a good restoration is to actively work with a community to discover and strengthen what matters about a place in service of its long-term well-being, the science is only as sound as the extent to which collaborative inquiry starts from and continues within a shared intellectual commons. The democratic spirit of citizen science does not mean that every team member needs to know the same things about the problem in question or the research methods. It does mean that considerable ongoing effort must be concentrated on understanding, exchanging, and respecting local expert and generalized research knowledge about the issues under study as the research progresses. Research problems are therefore chosen and prioritized collaboratively; proposals are jointly designed; data are collected and reviewed together; and findings are translated into policy and practice through ongoing negotiation and relationship-building before, throughout, and after the completion of projects. Within those relationships, some of the most invaluable interactions are with those who question received

   

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wisdom about how things are and how they should be. These “loyal heretics,” as Gunderson and colleagues first described them in 1995, accelerate the potential for adaptive systems change by moving beyond popular trains of thought to create alternative perspectives and partnerships that enhance system sustainability rather than reinforcing hierarchical system control of a failing status quo. As with any form of science, research projects begin and end, but discoveries and their accompanying decolonizing power are not bound by grant deadlines. As one research participant observed, “Restoration is work in progress  – never finished, never correction” (sshrc study). In this sense, researching with a restorative eye encourages community awareness and communal self-correction as we monitor and care for our surroundings together, both while and after the official scientific work of a given project is “done.” For example, this kind of ongoing self-correction was recently evident when a practitioner member of our infection control research team informed us that she used the photo walkabout images she helped to collect during the project as inspiration to develop pictures instead of written signs to convey isolation precautions to the hospital’s multilingual visitors.

Supporting Engaged Practice While the development of a place ethic and the conduct of citizen science are useful restorative goals for health care in their own right, their shared deeper purpose is to nourish the emergence of engaged practice where what we value and what we know can reach fruition in what we do and how we do it. At its roots, engaged practice encompasses the rituals, practices, and habits of being that support organizations, teams, and individual practitioners to use their moral imaginations and ecological knowledge or place sense to create safer places in which to deliver and receive care (Marck et al. 2008; Marck et al. 2006a). Whether this is how practitioners hand off care to each other, how leaders and practitioners monitor their environment for safety hazards together, how teams remind each other to wash their hands correctly, or how patients are invited to exercise decisions about their care, the hallmark of engaged practices is that they are always tied to deeper ethical and scientific goals. In my experience to date, the larger challenge for research and restoration lies with fostering healthier organizational and system

   



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­ ractices. That is, we have experienced several times in our research p that individuals, teams, and units can effect tangible concrete changes to how they approach and manage their delivery of care. What remains problematic is that, with a few notable exceptions, we have seldom seen similar transformations in culture or practice at the organizational or system levels to date. Nonetheless, images and stories and niches of wholeness and integrity are powerful change agents in their own right whose potential to spur further future developments remains unknown. As with other kinds of restoration, time indeed will reveal the ongoing legacies of our initial work.

E n c o u r ag i n g A da p t i v e L e a r n i n g a n d G row t h Restorative cycles of study and practice are characterized by learning throughout rather than at the end of projects and natural experiments alike and at all levels of the system, including individual, team, organization, and system levels. The goal is to use what is learned across levels to monitor how health systems co-evolve and respond to (adaptively manage) the findings that emerge from selfmonitoring in sustainable ways. This conception of adaptive learning and growth speaks to the hope that over time, changes which demonstrably help communities to function better will spread as the number and variety of people, communities, and partners we work with grows. Horizontal spread is clearly evident already, with students and colleagues using restoration thinking and methods to study nature-based health promotion (Hansen-Ketchum, chapter 4 below), infection control in Canada and the Netherlands (­ Backman et al. 2012), medication safety in Canada (Domm 2011) and in ­Brazil (Raduenz et al. 2010), medical waste and environmental and public health in Brazil (Brites et al. 2010), and other topics. Droplets of vertical spread are also emerging as I and other research team members field requests from health authorities and other regional, national, and international institutions or organizations about restorative methods and potential applications to fostering health systems change. In concrete terms, a commitment to restorative research in modern health systems is a demanding labour of building communities of hope. Emancipation is a long journey; it is also a constant intellectual and moral stretch for those of us who have been educated and socialized in the corporate colonies of

   

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modern health care and a daily exercise in humbling, dogged persistence. Neither health care nor restoration work are for the faint of heart, and in both endeavours, much of the vital knowledge we need to move forward is found in backcountry that can be difficult for researchers to reach (Marck 2006). For health care, this terrain includes practitioners’ work in hospitals, long-term care settings, clients’ homes, and other communities, where it takes considerable mutual will and trust to examine intractable safety and ethical issues together. There are far easier routes to a flourishing research career, but for our teams, there seems no justifiable alternative in light of the problems we seek to tackle. Higgs (2003, 182) asserts that the “power and the promise of ecological restoration” lies with its capacity to “regenerate old ways or create new ones that bring us closer to natural processes and to one another.” I believe that the power and promise of restoration which Higgs envisages is as real and compelling for health care as it is for our world. In my estimation, there is potential for restorative thinking and practices to transform the way we understand and inhabit our health care communities. In fact, it is why organizations, patients, practitioners, managers, and students actively seek out and readily take part in our research, despite all the competing demands on their attention and even as we too often uncover discomfiting findings about the safety concerns we study together. However painful and prolonged a lasting decolonization and reformation may be for health systems, each new discovery brings us closer to better treatment of each other and the creation of healing places that we can safely call home.

R e s to r at i o n a n d E m a n c i pat i o n : A r e T h e y A c h i e va b l e G oa l s ? What we need to do is help maintain the processes and the elements of the systems and they are going to become something new in the future from their own roots, they are the source of their own future. sshrc study

The notion that health care communities and all kinds of communities can synergistically develop our capacities for place ethics and creative ecological thinking to better our world, within and beyond health care, is tangible in my view. It seems we should just get on

   



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with this urgent task. I can only speculate from what my colleagues and I have learned to date how we will progress in our work. It is not possible to discuss all of the methodological, theoretical, and practical insights in one sitting, which I optimistically read as a sign of the promise of this approach. In my view, though, some of the most rewarding discoveries are that practitioners can readily understand and articulate ecological thinking when discussing their practice and practice environments, and that they are deeply ecologically literate field guides in their own backcountry. It is also gratifying to confirm my original intuition that researchers, senior leaders, managers, practitioners, educators, students, and patients can work well together on difficult safety issues when the problem selection, data collection, and data analysis are genuinely democratized. Perhaps most gratifying of all has been watching health care communities take up research findings as their own to voluntarily make changes to their practices and care environments within their own resources, and watching clinicians and students take inspiration from restoration to lead the way with their own research ideas. A wide array of funders have also come on board one by one, and our research teams and students now benefit from diverse local, provincial, and national funding sources. I have also witnessed real, lasting changes in at least one medication delivery system (Marck et al. 2006) and in our joint model of clinical teaching and learning;4 there have been several successful summer studentship programs (Marck et al. 2007); and the Ethics-in-Practice sessions which began for students and practitioners in 2002 (Marck 2006) have spread to community forums (Scott et al. 2012). And, as we intended from the outset and gradually turned into reality, research projects and relationships have grown from one acute-care hospital site to projects across Canada and internationally and across the continuum of care, from hospital to home care, continuing care, and public health. At the same time, it is clear that like restorations of ecosystems, restoration projects in health systems face formidable ongoing cultural obstacles. In my experience, at any rate, these barriers are not in evidence at the coal face, where students, practitioners, educators, managers, and the people they serve readily work with us to improve care. Although it is probably the most demanding kind of research to ask busy clinicians and other colleagues to take part in, there is no lack of committed participants. Instead, I face the unfortunate scenario of having to turn potential research partners

   

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away through sheer lack of additional capacity. Neither do most of the senior ­leaders at the local institutional, regional, provincial, or federal levels who work with my teams present obstacles to studying the thorny research problems that our clinical partners select for study, nor do they suppress the dissemination of findings about present practices and conditions that reveal serious problems. Rather, the barriers that challenge the collective resolve of my teams and their clinical partners often seem to be rooted at much broader and more intractable layers of the health, social, financial, and political systems. For example, we cannot address medicationlabelling issues that lead to selection error without the cooperation of pharmaceutical companies that resist uniform labelling because they want to distinguish their respective brands from each other in a competitive marketplace. Nor can we address infection control issues related to outsourcing linen services without discussing historical decisions to eliminate in-house laundry services during previous rounds of system restructuring. It is also often difficult to sustain research relationships or emerging practice changes when clinical and managerial leadership change every few years through cutbacks, layoffs, and organizational or system restructuring. In addition, even though so many nurses, pharmacists, physicians, and others support and want to take part in restorative research, and even though some professionals attend walkabouts, focus groups, data analysis, or other research activities (using their scarce time off to do so), the sheer volume of demands on clinicians’ and managers’ time limits access to their expertise. As a result, my teams frequently face hard choices about which findings to prioritize for follow-up with strained colleagues and which potential insights to defer to a future day. I try to support wise choices in this regard by ensuring that there are clinicians from the affected health care communities on each of our research teams. Despite the considerable roadblocks to restorative work in health care that I have listed, it seems justifiable to pursue restoration thinking as one viable path for developing a more robust communal imagination about what needs reform in health care. When people work together to actually understand the nature of a given place, they are more able to envision a range of healthier or less healthy futures for it, and commensurately more motivated to replace illconsidered measures for the immediate term with more responsible actions on behalf of the long view (Marck et al. 2006a; Higgs 2005;

   



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Marck 2004; Leopold 1974). What remains to be seen, however, is whether the restorative approaches that we and kindred communities mount in the coming years will expand enough to effectively counter the technological patterns of a consumptive society, in health systems or in our world. Can leaders throughout our society move a reluctant public, which prefers continued access to quick health care fixes over making difficult personal changes, to go beyond the greening of hospitals to re-imagine a health system whose raison d’être is ecological integrity? If we can collectively imagine it, will we make it a reality? The answers to those questions, of course, are uncertain, but I take my own evolution of personal and accompanying professional growth since starting this work as an encouraging case in point. I must shamefacedly admit that before I started my PhD work in 1991 on technology and nurses’ work in acute care, I seldom gave the environment the attention it merited. Ecology was not part of my everyday lexicon, and as middle-aged working parents, my husband and I ferried our young children everywhere by car and fed them more fast food than I care to acknowledge on the way to soccer, hockey, and basketball. We threw away packaging with no lingering guilt and there was no compost at home for our organic waste. As I began my doctoral studies in technology and ethics and became aware of works by Borgmann (1992, 1984), Feenberg (1995), Higgs (1997, 1999, 1991), Strong (1995), and others that would eventually transform so much of my life, I still maintained most of my consumptive life habits, even as I began to critique them. By the time I completed the doctoral research that led me to restoration, however, I was too decolonized to stay comfortable with my consumptive ways. The packaged cookies and other junk food were replaced with home- and locally baked goods; recycling became our conscious practice; I shopped less than ever (which was never really a predilection of mine anyway, though, unless it was books or music); and I knew that we had to keep changing, so much more. Several years into this work, neither my husband nor I drive anywhere that we can reasonably reach by other means. We garden; we compost; we shop with cloth bags; we support local markets; we do not drink bottled water; and we have learned to pay attention to the energy efficiencies of the places we call home. He has volunteered on neighbourhood transportation planning committees and related student thesis work, and we vote for political candidates who offer

   

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credible environmental platforms for change. We have rediscovered walking in the woods, cross-country skiing, and many other naturebased activities that we lost sight of during the early years of parenting and work, and we have ongoing discussions about ecological citizenship with our grown children, who did not receive from us in their youth what we are now belatedly trying to impart. Despite our parental shortcomings, though, our vegetarian daughter bicycles to work and our athletic son buses to school and refills his water jug from the kitchen tap. We have a long way to go, but we have come far from the ecological illiteracy we displayed just a few decades ago. More and more, restorative thinking and practices at work and at home are teaching us that we are the source of our own future.

F i n d i n g O u r W ay H o m e i n H e a lt h C a r e a n d in Our World To be at home means asking ourselves about our intentions of staying on, about care of the furnishings and their maintenance, about sympathy for the other occupants and their welfare  – all matters with the power to initiate a fundamental revolution in the practice of our arts and sciences, in time, practices that become our second nature (Rowe 1990, 157). In this chapter, I have advanced several arguments which inform an ongoing program of health systems research where we use a restorative approach to critically examine some of the pressing safety and quality issues in twenty-first-century health care. These arguments have several implications for how we go about achieving ecologically emancipated communities. First, that the ecological concerns and commitments of a growing body of scientists, citizens, and communities outside of health care attract scarce attention within today’s technologically oriented health care workplaces is legitimate cause for alarm. Second, this serious failure of most twenty-first-century health care communities to recognize themselves as part of nature is accompanied by a related ethical deficit in how those of us who work in them treat each other and the places we share. Third, this deficient place ethic works against the creation of safe places, places in health care and in our communities where we can conceive of and conduct ourselves in ways that reliably sustain our collective ecological health. Yet, safe places are arguably essential for nurturing the values of social justice and ecological integrity, which ­characterize

   



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e­cologically emancipated communities. Fourth, the absence of an adequate place ethic within health care is tied to a collective failure of “ecological imagination” that I join others to argue is characteristic of a technologically colonized health care world. Within health care, this colonization phenomenon translates into a prevailing tendency to view health and health systems from a socio-technical perspective that privileges a hierarchy of theories, methods, and practices drawn from the health, social, and engineering sciences as well as the business literature to the continued neglect of vital literature in the ecological, environmental, and political science literature. As Higgs notes (1991, 97), when it comes to leaving a world of consumption behind for a healthier ecological future, “a quantity of engaging work” awaits. We know that good, lasting restorations are difficult enough to achieve (Higgs 1999) and they are even more challenging to sustain. Accordingly, the research insights and accompanying theory that I propose here are works in progress that are intended to contribute to a much larger and likely never finished task. This research approach should help health care practitioners, managers, policy-makers, and the public to jointly come to terms with something that far too few of us seem to take into account: that as part of nature, there is no form of health that we need worry about other than ecological health and no viable future health system except one where ecological emancipation is its central goal. In summary, I only reiterate rather than improve on Frumkin’s observation about the profound moral weight of place. To wit, I believe that those who guide today’s health systems largely fail to recognize, and urgently need to realize, that where ecological health (and therefore all environmental-human health) is concerned, the particular purpose and character of each place in which healing work is carried out (whether in health care or restoration) matters and matters most fundamentally. My colleagues and I proceed with our restorative work in health care on the hope that we can use some of the more robust thinking, methods, and practices that are found in the fields of ecological restoration and ecosystems management to “decolonize our imaginations” and open our minds and hearts to alternative ways forward into healthier communities and a healthier world. No doubt we have several lifetimes of work ahead of us. But we work in hope that our children’s children will reap the rewards as rehabilitated members of a healthier Earth that they know and cherish as their home.

   

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notes 1 The theoretical content for this chapter stems primarily from work supported by Social Sciences and Humanities Research Council Grant # 410-2006-2163 ($128,192.00), Through the Eyes of Practitioners: ReImagining and Restorying Medication Safety with Photographic Research. Quotes in this chapter that are cited as “sshrc study” relate to the analysis of data from the first phase of the research, which was conducted at the University of Victoria School of Environmental Studies with fourteen participants including restorationists, biologists, botanists, ecologists, health care managers, nurse educators, practicing nurses, and educators, researchers, and graduate students from both the health and environmental sciences. External critiques of the initial working paper produced during this phase of the research were provided by a physician researcher in patient safety, a practicing icu physician, an operating room nurse, and two additional health care researchers not associated with the study. These critiques were integrated with independent team member analyses and subsequent team analyses of the data to generate the findings reported here. In addition, many of the observations in this chapter arise from a synthesis of findings from both the sshrc work and related research in home care, continuing care, and public health in Canada and Brazil. For more information on the sshrc study and other projects, see the Safer Systems research program website at http://nurs.ualberta.ca/safersystems/ Publications_files/HEPS2008_Marck%20etal_11April2008.pdf (accessed 20 January 2015). 2 For example, a service aide on one of the medical units where we currently study infection prevention and control recently walked me through the unit to point out a wide range of infection-related issues, and then animatedly discussed our unit poster on a restorative approach to health care safety research, saying repeatedly “This makes so much sense.” It is arguable that no other team member knows that place like the service aides do, and in so many ways that matter to its overall function and well-being. 3 While ecological language remains foreign in the everyday parlance of health care, health systems and particularly hospitals are fraught with military language such as “front line,” itself an intriguing phenomenon when trying to introduce notions of socio-ecological integrity. The further removed the party in question is from the “coal face” (another popular term in health care safety language that seems more apt than “front line” when critiquing its current consumptive direction), the more challenging it seems to explain the ecological lens.

   



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4 Grant # N12100032 HREB#121009 Transforming Clinical Learning Environments for Undergraduate Nursing Students: The Piloting and Evaluation of a Collaborative Clinical Learning Unit (2008–2011). P.B. Marck, Principal Investigator, S. Barton, Co-Principal Investigator, and K. Bulmer-Smith, R. Day, L. Kemp, K. Martin, K. Peterson, and J. Worrell, Co-Investigators. Funding: University of Alberta, Teaching and Learning Enhancement Fund ($147,962.69).

References Amalberti, R., Y. Auroy, D. Berwick, and P. Barach. 2005. “Five System Barriers to Achieving Ultrasafe Healthcare.” Annals of Internal Medicine 142: 756–65. Backman, C., P.B. Marck, N. Krogman, G. Taylor, A. Sales, and V.R. Roth. 2011. “Barriers and Bridges to Infection Prevention and Control: Results of a Case Study of a Canadian Surgical Unit.” Canadian Journal of Infection Control 26 (4): 233–42. Backman, C., P.B. Marck, N. Krogman, G. Taylor, A.E. Sales, V. Roth, M.J.M. Bonten, and A.C.M. Gigengack-Baars. 2012. “Barriers and Bridges to Infections Prevention and Control on a Surgical Unit at a Netherlands Hospital and a Canadian Hospital: A Comparative Case Study Analysis.” bmj Open. 2012 (2): e000511. Backman, C., D.E. Zoutman, and P.B. Marck. 2008. “An Integrative Review of the Current Evidence on the Relationship between Hand Hygiene Interventions and the Incidence of Healthcare Associated Infections.” American Journal of Infection Control 36 (5): 333–48. Baker, G.R., J.L. Denis, M.P. Pomey, and A. MacIntosh-Murray. 2010. “Designing Effective Governance for Quality and Safety in Canadian Healthcare.” Healthcare Quarterly 13 (1): 38–45. Baker, G.R., P.G. Norton, V. Flintoft, R. Blais, A. Brown, J. Cox, E. ­Etchells, W.A. Ghali, P. Hebert, S.R. Majumdar, M. O’Beirne, L. Palacios-Derflingher, R.J. Reid, S. Sheps, and R. Tamblyn. 2004. “The Canadian Adverse Events Study: The Incidence of Adverse Events among Hospital Patients in Canada.” Canadian Medical Association Journal 170 (11): 1678–86. Baldwin, G. 2009. “How Green Was My Hospital.” Health Data Management 17 (4): 82–6. Belford, T. 2010. “Nurses on Slow Track of ‘Roller Coaster.’ Up-andDown Demand for New Grads Bottoms out Again in Alberta after Healthcare Cuts.” Edmonton Journal. http://www.edmontonjournal.

   

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com/business/Nurses+slow+track+roller+coaster/3032376/story.html (accessed 17 May 2010). Berry, W.E. 1983. Standing by Words. San Francisco, ca: North Point Press. Borgmann, A. 1984. Technology and the Character of Contemporary Life: A Philosophical Inquiry. Chicago, il: University of Chicago Press. – 1992. Crossing the Postmodern Divide. Chicago, il: University of ­Chicago Press. – 1999. Holding On to Reality: The Nature of Information at the Turn of the Millennium. Chicago, il: University of Chicago Press. – 2000. “The Moral Complexion of Consumption.” Journal of Consumer Research 26: 418–22. Brites, A.S., I.E. Cabral, and R.C.B. Aguiar. 2010. “Analise imagetica da produção de residuos derivados do uso da insulinoterapia infantile: Uma contribuição da enfermagem (Visual Analysis of the Production of Residues Derived from the Use of the Pediatric Insulin Therapy: A Contribution from Nursing).” Revista de Pesquisa Cuidado e Fundamental 2: 305–8. http://www.seer.unirio.br/ index.php/cuidadofundamental/ article/view/930/pdf_138 (accessed 3 February 2012). Buell, L. 1995. The Environmental Imagination. Thoreau, Nature Writing and the Formation of American Culture. Cambridge, ma: The Belknap Press of Harvard. Canadian Coalition for Green Healthcare. 2008. “Building Green Hospitals Checklist.” hfm (Healthcare Financial Management) 62 (5): 93–5. Canadian Healthcare Association. 2002. Patient Safety and Quality Care: Action Required Now to Address Adverse Events. Ottawa: Author. Canadian Health Services Research Foundation. 2006. “What’s Ailing Our Nurses? A Discussion of the Major Issues Affecting Nurse Human Resources in Canada.” Canadian Health Services Research Foundation. http://www.chsrf.ca/research_themes/pdf/What_sailingourNurses-e.pdf (accessed 15 May 2010). Canadian Institute of Health Information. 2008. “Regulated Nurses: Trends, 2003 to 2007.” Canadian Institute for Health Information. https://secure.cihi.ca/free_products/nursing_report_2003_to_2007_e.pdf (accessed 12 September 2014). Canadian Nursing Advisory Committee. 2002. “Our Health, Our Future: Creating Quality Workplaces for Canadian Nurses.” Health Canada. http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/2002cnac-cccsi-final/2002-cnac-cccsi-final-eng.pdf (accessed 12 September 2014).

   



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Carter, A.J.E., and A.H. Chochinov. 2007. “A Systematic Review of the Impact of Nurse Practitioners on Cost, Quality of Care, Satisfaction and Wait Times in the Emergency Department.” cjem: The Journal of the Canadian Association of Emergency Physicians 9 (4): 286–95. cbc News Edmonton. 2010. “Alberta to Hire Most New Nursing Grads.” cbc News, 18 May. http://www.cbc.ca/canada/edmonton/ story/2010/05/18/edmonton-alberta-hiring-december.html. Coller, J.G., and A.L. Grunseth. 2008. “Demonstrating Reverence for the Earth.” Frontiers of Health Services Management 25 (1): 11–23. Cypher, J., and E.S. Higgs. 1997. “Colonizing the Imagination: Disney’s Wilderness Lodge.” Capitalism, Nature, Socialism. A Journal of Socialist Ecology 8 (4): 107–30. Domm, E.L. 2011. “Exploring Medication Safety with a Restorative Approach.” PhD diss., University of Alberta (AAT NR70866). Farrell, S., C. Roye, J. Crane, D. Davis, M. Heywood, A. Lalonde, N. ­Leyland, V. Senikas, C. Menard, and G. Lefebvre. 2008. “Statement on Wait Times in Obstetrics and Gynaecology.” Journal of Obstetrics and Gynaecology Canada: jogc / Journal D’Obstétrique Et Gynécologie Du Canada: jogc 30 (3): 248–70. Feenberg, A. 1991. Critical Theory of Technology. New York: Oxford University Press. Frumkin, H. 2003. “Healthy Places: Exploring the Evidence.” American Journal of Public Health 93 (9): 1451–6. Gunderson, L.H., and C.S. Holling, eds. 2002. Panarchy: Understanding Transformations in Human and Natural Systems. Washington, dc: Island Press. Gunderson, L.H, C.S. Holling, and S.S. Light, eds. 1995. Barriers and Bridges to the Renewal of Ecosystems and Institutions. New York: Columbia University Press. Hancock, T. 2003. “The Healthy Hospital.” Hospital Quarterly 6 (4): 68–9. – 2005. “Greening Healthcare: Looking Back, Looking Forward.” Healthcare Quarterly 8 (1): 40–1. Hansen-Ketchum, P., P.B. Marck, and L. Reutter. 2009. “Engaging with Nature to Promote Health: New Directions for Nursing Research.” Journal of Advanced Nursing 65 (7): 1527–38. Hansen-Ketchum, P., P.B. Marck, L. Reutter, and E. Halpenny. 2011. “Strengthening Access to Restorative Places: Findings from a Participatory Study on Engaging with Nature in the Promotion of Health.” Health and Place 17 (2): 558–71.

   

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Harris, N., L. Pisa, S. Talioaga, and T. Vezeau. 2009. “Hospitals Going Green: A Holistic View of the Issue and the Critical Role of the Nurse Leader.” Holistic Nursing Practice 23 (2): 101–11. Higgs, E.S. 1991. “A Quantity of Engaging Work to Be Done: Ecological Restoration and Morality in a Technological Culture.” Restoration and Management Notes 9 (2): 97–103. – 1997. “What Is Good Ecological Restoration?” Conservation Biology 11 (2): 338–48. – 1999. “The Bear in the Kitchen. Ecological Restoration in Jasper Park Raises Questions about Wilderness in the Disney Age.” Alternatives Journal 25 (2): 30–5. – 2003. Nature by Design: Human Agency, Natural Processes and Ecological Restoration. Boston, ma: mit Press. – 2005. “The Two Culture Problem: Ecological Restoration and the Integration of Knowledge.”Restoration Ecology 13 (1): 159–64. Higgs, E.S., G. Bartley, and A.C. Fisher. 2009. The Mountain Legacy Project, 2nd ed. Victoria: Backus North Books. Higgs, E.S., A. Light, and D. Strong, eds. 2000. Technology and the Good Life? Chicago, il: University of Chicago Press. Hofmeyer, A.T., and P.B. Marck. 2008. “Building Social Capital in Nurses’ Workplaces: Thinking Ecologically to Strengthen the Safety and Integrity of Health Care Organizations.” Nursing Outlook 56 (4): 145–51. e2. Canadian Health Services Research Foundation (Hofmeyer pdf) and Social Sciences and Humanities Research Council (Marck pi). Holling, C.S. 1998. “Two Cultures of Ecology.” Conservation Ecology 2 (2): 4. http://www.consecol.org/vol2/iss2/art4 (accessed 1 May 2010). Institute of Medicine. 1999. To Err Is Human. Washington, dc: The National Academy Press. International Council of Nurses. 2006. “The Global Nursing Shortage: Priority Areas for Intervention.” http://www.icn.ch/global/report2006. pdf (accessed 1 May 2010). Jackson, W. 1987. Altars of Unhewn Stone. Science and the Earth. San Francisco, ca: North Point Press. Kaiser, B., P.D. Eagan, and H. Shaner. 2001. “Solutions to Healthcare Waste: Life-Cycle Thinking and ‘Green’ Purchasing.” Environmental Health Perspectives 109 (3): 205–7. Leddin, D., D. Armstrong, A. Barkun, Y. Chen, S. Daniels, R. Hollingworth, R.H. Hunt, and W.G. Paterson. 2008. “Access to Specialist Gastroenterology Care in Canada: Comparison of Wait Times and Consensus Targets.” Canadian Journal of Gastroenterology 22 (2): 161–7.

   



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Leopold, A. 1974. A Sand County Almanac: With Essays on Conservation from Round River. New York: Ballantine Books. Lessard, S. 2008. “Elderly Face Longer Bed Wait Times in Hospitals.” cmaj : Canadian Medical Association Journal 178 (1): 18. Light, A., and E.S. Higgs. 1996. “The Politics of Ecological Restoration.” Environmental Ethics 18 (Fall): 227–47. MacLaren, I.S., E.S. Higgs, and G. Zezulka-Mailloux. 2005. Mapper of Mountains; M.P. Bridgland in the Canadian Rockies, 1902–1930. Edmonton, ab: The University of Alberta Press. MacLaren, I.S., M. Payne, P.J. Murphy, P. Reichwein, L. McDermott, C.J. Taylor, G. Zezulka-Mailloux, Z. Robinson, and E.S. Higgs. 2007. Culturing Wilderness in Jasper National Park; Studies in Two Centuries of Human History in the Upper Athabasca River Watershed. Edmonton, ab: The University of Alberta Press. Macleod, H., R.S. Bell, K. Deane, and C. Baker. 2008. “Creating Sustained Improvements in Patient Access and Flow: Experiences from Three Ontario Healthcare Institutions.” Healthcare Quarterly 11 (3): 38–49. Marck, P.B. 2000a. “Nursing in a Technological World: Searching for Healing Communities.” Advances in Nursing Science 23 (2): 59–72. – 2000b. “Recovering Ethics after Technics: Developing Critical Text on Technology.” Nursing Ethics 7 (1): 5–13. – 2000c. “Technology and Registered Nurses’ Work in Acute Care: A Healing Inquiry.” PhD diss., Faculty of Nursing, University of Alberta. Alberta Heritage Foundation for Medical Research Incentive Grant and University of Alberta Dissertation Fellowship, 1998–2000. – 2004. “Ethics in Hard Places: The Ecology of Safer Systems in Modern Healthcare.” Health Ethics Today 14 (1): 2–5. – 2005. “Theorizing about Systems: An Ecological Task for Patient Safety Research.” Clinical Nursing Research 14 (2): 103–8. – 2006. “Discourse. Field Notes from Research and Restoration in the Backcountry of Modern Healthcare.” Canadian Journal of Nursing Research 38 (2): 11–23. – 2012. “Building Moral Community: Fostering Place Ethics in TwentyFirst-Century Healthcare Systems for a Healthier World.” In Toward a Moral Horizon: Nursing Ethics for Leadership and Practice, 2nd ed., edited by J.L. Storch, P. Rodney, and R. Starzomski, 215–35. Toronto: Pearson Education Canada. Marck, P.B., G. Coleman-Miller, C. Hoffman, B. Horsburgh, S. Woolsey, A. Dina, T. Dorfman, J. Nolan, N. Jackson, J. Kwan, and K. Hagedorn. 2007. “Thinking Ecologically for Safer Healthcare: A Summer Research

   

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Student Partnership.” Canadian Journal of Nursing Leadership 20 (3): 42–51. Marck, P.B., E.S. Higgs, N. Edwards, and A. Molzahn. 2006a. “Generating Adaptive Health Systems: An Emerging Framework of Research and Restoration for a Safer World.” Social Science and Humanities Research Council Working Paper 1. http://www.nurs.ualberta.ca/safer systems/Publications_files/SSHRC2006_Working%20Paper%20Series_ Paper1_U%20Vic20Workshop_with20bib_27apr07.pdf. Marck, P.B., E.S. Higgs, E.R. Vieira, and K. Hagedorn. 2008. “Through the Eyes of Practitioners: Adapting Visual Research Methods from Ecological Restoration to Integrate the Ethics, Science and Practice of Safety in Healthcare.” Paper presented at the Healthcare Systems Ergonomics and Patient Safety International Conference, Strasbourg, France, June. http://nurs.ualberta.ca/safersystems/Publications_files/HEPS2008_ Marck%20etal_11April2008.pdf (accessed 20 January 2015). Marck, P.B., J.A. Kwan, B. Preville, M. Reynes, W. Morgan-Eckley, R. Versluys, L. Chivers, B. O’Brien, J. Van der Zalm, M. Swankhuizen, and S.R. Majumdar. 2006b. “Building Safer Systems by Ecological Design: Using Restoration Science to Develop a Medication Safety Intervention.” Quality and Safety in Healthcare 15 (2): 92–7. Mazurkewich, C., J. Houghton, and T. Hancock. 2004. “How British Columbia Is Greening Health Systems.” Healthcare Quarterly 7 (2): 29–30. Mejia, E.A., and B. Sattler. 2009. “Starting a Healthcare System Green Team.” aorn Journal 90 (1): 33–40. Mills, S. 1995. In Service of the Wild. Restoring and Reinhabiting Damaged Land. Boston, ma: Beacon Press. Molzahn, A.E., R. Starzomski, M. McDonald, and C. O’Loughlin. 2004. “Aboriginal Beliefs about Organ Donation: Some Coast Salish Viewpoints.” Canadian Journal of Nursing Research 36 (4): 110–28. Moore, A. 2005. “Going Green.” Nursing Standard 19 (31): 24–6. Morley-Forster, P. 2007. “Tomorrow and Tomorrow and Tomorrow: Wait Times for Multidisciplinary Pain Clinics in Canada.” Canadian Journal of Anaesthesia / Journal Canadien D’Anesthésie 54 (12): 963–8. National Health Service. 2000. An Organization with Memory: Report of an Expert Working Group on Learning from Adverse Events in the nhs. London: Department of Health. National Steering Committee on Patient Safety. 2002. Building a Safer System. A National Integrated Strategy for Improving Patient Safety in Canadian Healthcare. Ottawa: Author.

   



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O’Brien-Pallas, L., G. Tomblin-Murphy, and J. Shamian. 2008. “Understanding the Costs and Outcomes of Nurses’ Turnover in Canadian Hospitals (Nursing Turnover Study).” http://www.hhrchair.ca/research. cfm (accessed 2 January 2010). Patrick, J., and M.L. Puterman. 2008. “Reducing Wait Times through Operations Research: Optimizing the Use of Surge Capacity.” Healthcare Quarterly 11 (3): 77–83. Raduenz, A.C., P. Hoffmann, V. Radünz, G. Teresinha, M. Dal Sasso, I.C. Alves Maliska, and P.B. Marck. 2010. “Nursing Care and Patient Safety: Visualizing the Organization, Storage and Distribution of Medication with Photographic Research Methods.” Revista Latino-Americana de Enfermagem / Latin American Journal of Nursing 18 (6): 1045–54. Registered Nurses Association of Ontario. 2004. sars Unmasked: Celebrating Resiliency, Exposing Vulnerability. Ottawa: Author. Rhemtualla, J.M., R.J. Hall, E.S. Higgs, and S.E. MacDonald. 2002. “Eighty Years of Change; Vegetation in the Montane Ecoregion of Jasper National Park, Alberta.” Canadian Journal of Forest Research 32: 2010–21. Rowe, S. 1990. Home Place. Essays on Ecology. Canadian Parks and ­Wilderness Society Henderson Book Series No. 12. Edmonton, ab: NeWest Publishers Ltd. Schulte, M.F. 2008. “Green Hospitals: Improving the Workplace, Saving MoneyandHealing the Earth.” Frontiers of Health Services Management 25 (1): 1–2. Scott, S.L., P.B. Marck, and S. Barton. 2012. “Exploring Ethics in Practice: Creating Moral Community in Healthcare One Place at a Time.” Canadian Journal of Nursing Leadership 24 (4): 78–87. Serb, C. 2008. “Think Green.” HandHN: Hospitals and Health Networks 82 (8): 22–35. Society for Ecological Restoration International Science and Policy Working Group. 1995. “Society for Ecological Restoration International Indigenous Peoples’ Restoration Network Founding Mission Statement.” http://www.ser.org/iprn/default.asp (accessed 10 January 2010). – 2004. The ser International Primer on Ecological Restoration. Tucson, az: Society for Ecological Restoration International, Version 2. http:// www.ser.org/pdf/primer3.pdf (accessed 10 May 2010). Storch, J.L., P. Rodney, and R. Starzomski,eds. 2012. Toward a Moral Horizon: Nursing Ethics for Leadership and Practice, 2nd ed. Toronto: Pearson Education Canada.

   

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Strong, D. 1995. Crazy Mountains. Learning from Wilderness to Weigh Technology. New York: suny Press. Topf, M. 2005. “Psychological Explanations and Interventions for Indifference to Greening Hospitals.” Healthcare Management Review 30 (1): 2–8. Tuhiwai Smith, L. Decolonizing Methodologies: Research and Indigenous Peoples. Dunedin, nz: University of Otago Press. Turner, N.J., M.B. Ignace, and R. Ignace. 2000. “Traditional Ecological Knowledge and Wisdom of Aboriginal Peoples in British Columbia.” Ecological Applications 10 (5): 1275–87. Wade, J., et al. 2002. Building a Safer System. A National Integrated Strategy for Improving Patient Safety in Canadian Healthcare. Prepared by National Steering Committee on Patient Safety (Ottawa). Walker, B., S.R. Carpenter, J.M. Anderies, N. Abel, G.S. Cumming, M. Janssen, L. Lebel, J. Norberg, G.D. Peterson, and R. Pritchard. 2002. “Resilience Management in Social-Ecological Systems: A Working Hypothesis for a Participatory Approach.” Conservation Ecology 6: 14. Whitehouse, P.J. 1999. “The Ecomedical Disconnection Syndrome.” ­Hastings Center Report 29 (1): 41–4. Wilkerson, B. 2006. “An Agenda for Change: Global Business and Economic Roundtable on Mental Health.” 2006 Business and Economic Plan for Mental Health. Ottawa: Mental Health Round Table. http:// www.mentalhealthroundtable.ca/20060328/2006BusinessPlan.pdf (accessed 9 January 2010). Woodend, A.K. 2008. “Cardiovascular Nurses Speak Out on Wait Times.” Canadian Journal of Cardiovascular Nursing / Journal Canadien en Soins Infirmiers Cardio-Vasculaires 18 (1): 3–4.

   

4 Engaging with Nature in the Promotion of Health pat t i h a n s e n - k e t c h u m

I first noted the systemic impoverishment of our connections to each other and to the natural environment in my work in health care in Canada. The way we chose to care for individuals, families, communities, and populations was and continues to be characterized by individual-level medical interventions and lifestyle education within the confines of institutions, facilitated by hierarchical relationships between patients and health professionals. The focus in health care is steeped in health problems treated downstream using costly measures. Even health promotion strategies more often than not focus on patient education, which, although important, does not necessarily help people to be healthy, particularly if they do not have access to the resources needed to eat well or be active, for instance (Alvaro 2012). Often missing are the more broad interdisciplinary and citizen-engaged strategies aimed at creating community conditions and accessible resources that are relevant to people and that support health in everyday ways.

Introduction In this chapter, the findings from a community-based study on nature-based health promotion are used to provide valuable insight into how an aggregate group of citizens in rural Atlantic Canada connects with their local and shared outdoor natural places. The knowledge generated from the study fills a knowledge gap on citizen, practitioner, and decision-maker perspectives about engaging with nature to promote health in local contexts. A grassroots

   

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­ erspective on everyday access to nature raises critical and necesp sary questions about equitable and community-based opportunities and conditions for restorative experiences and ecological citizenship. As such, the findings critically inform an inclusive vision of health that links directly to the social, political, and cultural processes that simultaneously influence human and ecosystem health. This vision of health develops when people are able to participate in ecologically sound and everyday ways of promoting human and ecosystem health, commensurate with equitable access to conditions for healthy living. We are in the midst of a broad societal crisis stemming from a reductionist focus on disease, technology, and economic progress that is disconnecting us from one another and nature; a crisis that is rooted in culture and is permeating practice, policy, and research across disciplines and communities. Hope rests, in part, on research evidence about engaging with nature as a resource for health, including the risks and fears of being in nature and the barriers and facilitators to accessing natural places, which can inform and potentially strengthen current work in health and other disciplines. The theoretical and research literature across many fields provides evidence to substantiate the health-promoting benefits of interacting with nature (Dunkley 2009; Ewert et al. 2005; Berger and MacLeod 2006; Burns 1998; Hartig et al. 2001; Kingsley and Townsend 2006; Kuo 2001; Kuo and Sullivan 2001; Lundgren 2004; Milligan et al. 2004; ­Wakefield and McMullan 2005; Wells 2000; Williams 1999; Wilson 2003; Ulrich 1984). Spending time in nature has also been shown to increase the likelihood of being active, eating well, and adopting pro-environmental behaviours for the health of the planet (Ewert et al. 2005; Carrus, Passafaro, and Bonnes 2008; Hartig, Kasier, and Bowler 2001). The challenge of our modern time is to create opportunities for people to come together to re-envision health and our connection to the Earth and to re-establish our roles in creating healthy communities and a healthy world. I begin this chapter with a paean to nature-based health promotion and ecologically emancipated communities. I follow with an overview of the study design as segue into key findings relating to the analytic themes of restorative outdoor places, restorative experiences, access to nature, and ecological citizenship. These findings link to the vision noted above by drawing on fundamental elements of health, nature, and community, particularly related to equitable

   



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access to restorative outdoor places, ecological citizenship, and communal efforts for change.

Nature-Based Health Promotion and E c o l o g i c a l ly E m a n c i pat e d C o m m u n i t i e s Nature-based health promotion is an integrative approach to human and environmental health that unites people with the natural world in diverse and ecologically sound ways (Hansen-Ketchum et al. 2009). Health, framed in this context, is generated through individual, collective, and ecologically sound practices that are simultaneously “good” for people, “good” for the planet, and relevant to communities. Although human communities are socially defined, they are fundamentally composed of relationships among people and natural ecosystems in varied and interconnected local and global contexts (see Edwards and Davison, chapter 2 above). As McMurray (2007) points out, communities are “ecological in that the relationships within the community not only connect people to the community, but give back to the community what it needs to sustain itself and both sides benefit. Where there is a relatively healthy environment and a sense of communal sharing or civic pride, people tend to work together to make sure their community or society is sustainable” (13). Adding “emancipation” to this ecological sense of communities helps us recognize that in equitable societies, citizens are not dependent on but rather part of a community system that generates health. In other words, such communities are ideally composed of everchanging social, cultural, and political processes and conditions that enable people to connect with and care for one another and their built and natural environments and live in equitable, ecologically sound, and health-promoting ways. Similarly, Capra (1996) suggests that sustaining our planetary web of life requires that we nourish the health-sustaining relationships within our local and global ecological communities, recognizing that, at varying degrees, each of us is intricately tied to everyone and everything else. By way of contrast, discrimination, racism, and inequitable allocation of resources are examples of social and political processes that contribute to social exclusion, poverty, ill health, and unjust living and working conditions (McGibbon 2009; Reutter et al. 2006). For instance, lower-income groups often carry an inequitable burden of

   

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exposure to harmful contaminants for a variety of reasons, including lack of affordable healthy food and housing, lack of access to restorative places, and close proximity to polluted areas; all of which are situated within a broad social, cultural, and political context that enables these conditions to happen (Schulz and Northridge 2004). In preventing and addressing such health inequities, we need to continue to address the patterns of associations within and between communities that contribute to unhealthy living conditions, while also shifting attention to processes that create healthy conditions. Current work on the social determinants of health is a means toward addressing some of the health inequities, and toward creating just and equitable societies (Raphael 2006; cmdh 2008; ­Wilkinson and Marmot 2003). However, often missing in these efforts to address the social determinants of health is the “nature matters” connection, where the health of surrounding ecosystems and the linkage between citizens and nature are fundamental to equitable and healthy living conditions that support and sustain health and quality of life: Based on the understanding of ecosystems as autopoietic networks and dissipative structures, we can formulate a set of principles of organization that may be identified as the basic principles of ecology and use them as guidelines to build sustainable human communities. The first of those principles is interdependence. All members of an ecological community are interconnected in a vast and intricate network of relationships, the web of life. (Capra 1996, 298) Ideally, then, members of these communities are liberated in the sense that they are able to connect with each other and the world in ways that uphold and protect the rights of humans and their shared ecosystems, where economic gain and development do not trump the health and welfare of all people or the natural environment. Hence, we can benefit from examining how people engage with the natural world in ways that are health-promoting for themselves, for others, for their community, and for nature itself. Approaches such as this stem from the foundational themes of health promotion laid down in the Ottawa Charter, not least the central ideas of creating healthy environments stated as follows: “Health cannot be separated from other goals. The inextricable links between people and their

   



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e­ nvironment constitute the basis for a socio-ecological approach to health. The overall guiding principle for the world, nations, regions and communities alike is the need to encourage reciprocal maintenance – to take care of each other, our communities and our natural environment” (who 1986).

S t u dy D e s i g n : M e t h o d o l o g y a n d M e t h o d s An integrative view of human and environmental health (see Hansen-­ Ketchum et al., 2009) guided me to examine nature-based health promotion in a study involving community citizens, practitioners, and decision-makers from diverse sectors1 to better understand the complexities of the local experience, the barriers and facilitators of engaging with nature in a local community, and the implications for change in practice and policy across such domains as health, education, recreation, community services, environment, and community planning and design. This community-based participatory study was informed by critical realism, socio-ecological thinking, and principles of ecological restoration. From a critical realist perspective, knowledge development is neither subjective nor objective but is rather the interplay of variant standpoints (McEvoy 2006; Proctor 1998). Community is understood as a socio-ecological system of relationships and influences on people and their environment (McLeroy 1988; McMurray 2007; Stokols 1996). Hence, knowledge relevant and useful to community citizens requires citizen engagement in examining varied perspectives and experiences to address the socio-ecological complexities impacting people and their shared places (Israel et al. 1998; Viswanathan et al. 2004; Wallerstein and Duran 2003). The principles of ecological restoration (Higgs 2003, 2005) and its application to health care (Marck 2004a, 2004b, 2005, 2006; Marck et al. 2006a, 2006b) augment socio-ecological thinking with a focus on the reciprocity between people and their natural environment. These influences and related notions of ecological sensibility (Bookchin 2005) and ecological citizenship (Engel 1998) provided the methodological foundations for the design and implementation of the study. The study was conducted in a rural town and county in Atlantic Canada with a population of approximately 20,000 inclusive of 5,000 families (Statistics Canada 2006). The population was primarily English-speaking. Agriculture, fishing, retail, health care,

   

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trade, and educational services were the main economic stimulators. Visible minorities comprised 1.8 percent of this population with lower-income families at 7 percent (Statistics Canada 2006). The geographic area was an expanse of approximately 1,500 square kilometers characterized by natural outdoor environments such as woodlands, beaches, fields, and parks. Winters were cold with moderate amounts of snow and summers were warm. Data collection occurred in the spring, summer, and fall and therefore influenced the types of experiences described by participants. The setting was purposively chosen because it provided ample potential access to local and everyday natural outdoor environments. In part, the aim of the study was to examine nature-based health promotion with a sample of people who had potential access to experiences in common outdoor places in the area. The study consisted of two phases, each guided by a corresponding research question: (1) How do parents of young children care for and engage with nature to promote their individual and family health? (2) How do health practitioners and decision-makers use evidence on the health benefits of engaging with nature to design community-­based health promotion interventions? In phase one, parents of young children (n=8) were recruited from the local town and county. Young parents were chosen as an aggregate group of community citizens, particularly because of their gatekeeper role through which “society transmits to individuals its social norms, roles and responsibilities” (McMurray 2007, 108). It was understood that parents’ values and lifestyle practices would influence their own and their families’ health and have an impact on the environment in which they lived (McMurray 2007). Phase two participants (n=16) were selected from multiple sectors such as public health, education, and community planning. Specific selections were based on the findings and recommendations from participants in phase one. Findings from phase one were then shared and discussed with phase two participants and used to facilitate discussion on practice and policy. For this chapter, I focus on the analysis and interpretation of phase one data of parents’ experiences. However, Figure 4.2 at the end of this section provides a hint of the processes that phase two data revealed. In phase one I used photo narration2 and photo elicitation3 in interviews and focus groups to examine how the parents of young children cared for, and engaged with, nature to promote their

   



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own and their families’ health. Parents were recruited through local day care centres and other community places accessed by people with varying demographics. The sample included six female and two male parents. All participants were between the ages of 31 and 43 with varying levels of education and incomes. All were literate, Caucasian, spoke English, and had either one or two children. Six participants worked full-time and two participants worked part-time. Data saturation was reached with the eight participants when repetition in the codes and themes occurred. Sample size in qualitative research is not determined a priori for purposes of generalizability; rather, it is determined by data saturation and the richness of the findings (Maxwell 2005; Sobal 2001). The findings are not meant to represent the experiences of all community members, and instead provide an emic view of participants’ experiences. A limitation of the study is the possibility that those who chose to participate were likely to have had bias in their interest in nature and health promotion and therefore may have had limited data on the negative aspects of engaging in nature. Future studies should include participants of varying ages and backgrounds living in rural and urban settings to expand our understanding of nature-based health promotion in diverse local places. The data presented in the following section emerged from the experiences of participants who, in this case, did not necessarily perceive their outdoor places as frightening or scary but who provided insight into the restorative value of nature within their local community. It is these data and the interplay of four key emergent themes that offer profound insights into core elements of naturebased health promotion and ecologically emancipated communities. 1 Restorative outdoor places are valued as health-promoting 2 Restorative experiences in nature are simple, profound, and enriching 3 Engaging with nature develops ecological citizenship 4 Access to nature is shaped by multi-level barriers and facilitators

Phase 1 Findings: Overview of Select A n a ly t i c T h e m e s In this section I describe select analytic themes derived from a community-­ based study on nature-based health promotion as

   

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groundwork for a discussion on ecologically emancipated communities. Select themes relate to notions of restorative outdoor places, restorative experiences, ecological citizenship, and access to nature and are rooted in the perspectives and experiences of participants. Participant quotes are used to exemplify select data. In subsequent sections the themes identified are discussed in relation to relevant literature. Restorative Outdoor Places Are Valued as Health-Promoting Restorative outdoor places were the locations in nature that participants described as having favourite or preferred qualities such as wooded areas, views of the water, open space, and peace and quiet. These restorative places were natural outdoor environments that provided conditions for restorative experiences. They connected participants to nature and contributed to a sense of well-being. For instance, one participated recounted that “just as important as being on our bicycle is where we were riding. This is the only bicycle friendly trail and, fortunately, is quiet, scenic and natural” (Photo narration). Another participant described a restorative place as “a place like, if I’m stressed out about something I’ll go for a walk up there and it clears my mind, makes me refocus on the important things and forget the trivial things [in] life and it’s also a great place” (Interview). Restorative Experiences in Nature Are Simple, Profound, and Enriching Restorative experiences for participants were those that occurred in outdoor places, that connected parents and children to the natural world and to each other, and that were health-promoting. One participant asserted: I was saying to my husband that  … first of all walking and using some of the trail systems and just having that time in between, I call it like a segment, so say, if I’m going to the University and, I’m walking to the University, I use that walking time out in nature to just segment and wind down and really get clear and focused for myself mentally and being more focused on my task. So it gives me that clarity. (Interview)

   



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Participants in phase one suggested that engaging with nature fostered a sense of mental, spiritual, and physical well-being, helped them focus on their priorities, created opportunities to talk and connect with others, and enabled them to understand and appreciate the natural world in simple, profound ways. Outdoor activities such as walking in the woods, field, or beach, picking berries, growing gardens, looking for pollywogs, stacking wood, and sitting by the fire were examples of restorative experiences that took families away from the stress of work or at-home duties and provided opportunities to talk, imagine, play, and learn. The activities of engaging with nature were also described as very feasible for families and for the community: It shows that we don’t always need fancy playground equipment  … kids see a pile of dirt as a mountain to climb  … and then it turns into a slide  … children’s imaginations come alive in nature  … Fresh air and physical activity usually means the kids will eat a good supper and have a good sleep. (Photo narration) Nature-based health promotion was depicted in an array of everyday activities that did not pose an economic burden for participants or the community; activities that did not require a membership to a gym, a wellness centre, or other built structures, as stated by a participant during a phase one focus group discussion: If you’re out in nature, there’s lots of things that you can do for free that don’t cost anything and I think, you know, to see the health benefits, for maybe lower income, if that was a challenge, you know, for paying for swimming, paying for skating. Those types of things really don’t even have to come into effect. Not only are such actions economical for participants, but engaging with nature was also described as having minimal, if not positive, environmental impact. Examples of other sustainable practices described by participants included using the clothesline, walking instead of driving, growing vegetables, buying local food, picking up garbage, and visiting local farms. Several participants shared the following examples: “Our whole family helped prepare the soil, plant the seeds and harvest the vegetables this fall. Our kids were more likely to eat more vegetables because they helped grow them” (Interview) and

   

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it’s all a mindset right, like in my opinion I’m helping the environment and I’m showing my kids that its everybody’s responsibility to take part and clean it up and, like the beach that we went to for the bonfire, I mean there’s tons of broken glass and stuff like that and you know it’s part of our education. (Interview) Engaging with Nature Develops Ecological Citizenship Coupled with the analytic themes of restorative places and experiences described in the previous sections, is the notion of developing ecological sensibilities and citizenship (see also Marck, chapter 3 above). Ecological citizenship is tied to how we connect to, experience, and care for the natural world including our shared outdoor places. It involves the sustainable ways we can protect both the planet and the lives of future generations. Not only did participants point to sustainable practices in describing their engagement with nature as indicated previously, they also considered these practices as important pieces to understanding the need to care for and protect the natural world. As was made evident in participant data, engaging with nature in everyday ways fostered ecological citizenship by (a) developing ecological sensibilities and (b) using and caring for shared resources. Ecological sensibilities refer to participants’ ecological understandings and values about nature and health. Data on participants’ restorative experiences in nature provided insight into the interconnection between human and ecosystem health. As examples in the context of everyday life, ecological sensibilities influenced participants’ choice to use “environmentally friendly” cleaning products, to engage with their children in a fossil hunt on the beach, to share ideas and stories about nature-based health promotion with other families, and to offer recommendations for ecologically sound playgrounds and walking paths. An example of pro-environmental behaviour was evident in the following statement: But it’s just knowing that we live right by a river and  … since we’ve moved to  … our house, we’ve changed our cleaning products and dish wash products to vegetable based  … And when I buy those things, I’m thinking of my immediate surroundings at what’s going through the drain  … So I’m thinking of the ground

   



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water and future generations  … valuing where you live and feeling a part of what you live, does have an impact  … I’m adding globally too  … I was reading a label on dishwashing liquid and it said  … if every household changed one bottle of their oil based dish soap to vegetable leaf dish soap, they would have enough oil to heat 5,000 homes for a year. (Phase one, focus group one) In addition to individual-level experiences in nature and proenvironmental behaviour, participants also saw the need to foster equitable access to restorative places for others in the community. For instance, a participant recounted: I think at schools too, I look at the elementary school and just because my son is there now but it’s so barren  …The playground  … why don’t they have fruit trees, I mean there’s apples for the kids, right? You know once [the trees] get bigger and you know a few years down the road  … it would provide shade  … Which is great because on the sunny days they are totally exposed, right  … It would be good learning for them to be part of it, or and then community gardens  … I mean to have them in on community gardens just in and around the town, there’s lots of space. (Phase one, focus group two) Access to Nature Is Shaped by Multi-Level Barriers and Facilitators Access to restorative places and experiences such as community gardens or green playgrounds was described in relation to a complex array of barriers and facilitators. At the individual and family level, participants described engagement with nature as influenced by factors such as the individual/family’s understanding of and desire to be in the natural environment, having restorative places nearby, knowing where to go, having the ability to get there by vehicle, bicycle, or on foot, prior life experiences, having networks of family and friends with similar interests, and a match between the qualities of accessible natural places and the individual/family’s desire for solitude, view, or activity. Other barriers included road safety, fear of wildlife, and polluted areas:

   

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I mean that little stream here in town is disgusting sometimes, you know you’re like wow there’s a lot of pollution in there, you know and it’s up to  … some of the downtown businesses and, corporate you know  … whatever to do some kind of initiative where people get out and raise money or do clean up crews, right, I mean that also builds pride in the community doesn’t it? The barriers and facilitators to creating equitable community-based access to nature were described by participants as multi-sectoral and related to the need for sharing knowledge and concern about nature-based health promotion among those in practice and policy from varied sectors such as education, community planning, transportation, and health while garnering adequate human and financial resources for community-based change. As an example, a participant emphasized the need for knowledge integration and collaboration among diverse sectors to create safe roadside walking conditions, particularly in rural areas: I was going to say if like you’re building a road, how much more is it to really add a little side slab, right, off the side of the road to build [for walking and biking]. Especially when you’re moving dirt. And a lot of times they are taking that extra fill and looking for places to dump it because they have nowhere to put it  … Yeah, it does take community initiative, for something like that. (Phase one, focus group one) Another participant emphasized that nature-based health promotion was economical and not dependent on incumbent incidental funding: Sometimes I think places that we are promoting more – rather than look at building some big fancy public 28 million dollar project, I mean, to me like our town and county, it’s small, it’s relatively small, right? So we have great places already. To promote just the basic trails that are there or beaches or  … Potential, but [people] don’t realize that that’s an option. Simple ideas that don’t cost much. You know, close by. And just in conversation I feel that maybe people don’t realize that. (Phase one, focus group one)

   



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Community-based access to walking and biking paths was described as an equitable means to connect people with nature and to simultaneously promote health and nurture natural ecosystems. Participants suggested opportunities for trails that would enable and encourage children to walk to school in an environment not only free of traffic but also, ideally, full of focal things in nature: a path that meanders by a brook with pollywogs and edged with raspberry bushes and apple trees that offer blossoms in the spring, berries in the summer, and fruit for foraging in the fall. Community gardens, farmers’ markets with local produce and products, nature-based curricula for children, public health messages about the value of nature, and parks and green space for free play were other examples of accessible community-based resources and opportunities. Taken together, creating equitable access to these types of restorative places and experiences in nature and enabling ecological citizenship are fundamental cornerstones for ecologically emancipated communities and key facilitators of nature-based health promotion. Although not the focus of this chapter, two additional themes emerged from phase two data from practitioners and decision-­ makers in relation to the changes needed across sectors to enable access to restorative places for all people. 1 Examining norms in practice and policy is an important first step in creating access 2 Inter-sectoral governance can facilitate community-based change for human and ecosystem health In short, the first theme from phase two related to the norms across sectors such as recreation, transportation, community planning, public health, community services, and education which hinder change toward ecologically emancipated communities. Creating access to restorative places was perceived to be a critical component of healthier communities but not a current norm within participants’ respective sectors. Community development initiatives were described as happening in silos even if the issues transcended departments in their interrelationship between human, community, and ecosystem health. There seemed to be very little room for shared responsibility in creating community contexts to support health, and instead, more internal foci toward priorities such as technological advancements, economic gain, and structured programming.

   

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Highway restructuring was an example from participants of a provincial initiative that proved missed opportunities for the local community by the lack of walking and biking paths incorporated along rural roads already under reconstruction. The second theme, intersectoral governance, captured the processes needed to create connections between sectors in the development of equitable access to health-promoting restorative places within communities. Participants described the need for better processes and decision-making tools that would enable practitioners and decision-makers to “think health” and to “think healthy environments” in their work and in their collaborations with each other and with community groups, to understand shared environmental and health assets, to create opportunities for ecological citizenship, and to better support access to health-promoting resources for human, community, and ecosystem health. For other details on phase one and two data please refer to Hansen-Ketchum et al. (2011).

F u n da m e n ta l E l e m e n t s o f H e a lt h , N at u r e , and Community This section helps to contextualize the study findings by drawing connections between health, nature, and community through critical notions of equitable access to restorative outdoor places, ecological citizenship, and communal efforts for change. In describing these linkages, I reinforce the reciprocity between nature-based health promotion and the creation of healthy and emancipated communities. Equitable Access to Restorative Outdoor Places Analytic themes about restorative outdoor places and experiences described in the previous section raise questions about the linkages between health and place. The idea that place affects health is not new (see Collins et al. 2009; Crooks and Andrews 2009; ­Fitzpatrick and MaGory 2000; Frumkin 2003; Jackson 1994; Potvin and Hayes 2007; Eyles 1985; Speldewinde et al. 2009; Ulriche 1981) yet the focus in research and practice has largely been on the built environment or the place-based contributors to disease. There is, however, another body of substantive research that corroborates the restorative qualities of natural environments (Cimprich and Ronis 2003; Hartig et al. 2001; Kingsley and Townsend 2006; Kuo 2001; Kuo and

   



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Sullivan 2001; Moore et al. 2006; O’Brien et al. 2011; O ­ gunseitan 2005; Pretty et al. 2005; Schaefer and Higgs 2007; Wells 2000; see also Marck, chapter 3 above). Other related literature concerns the notion of therapeutic landscapes (see Dunkley 2009; Gesler 2003; Gesler et al. 2004; Milligan, Gatrell, and Bingley 2004; Wakefield and McMullan 2005; Williams 1999; Williams 2008; Wilson 2003) where the focus is on the health benefits of places, built and natural. In contrast to the analytic theme of restorative outdoor places described earlier, literature on the health effects of places tends, overall, to focus on the therapeutic benefits of place for humans rather than the reciprocal benefits for nature, a critical piece in understanding nature-based health promotion. Philosophies of humanism and anthropocentrism (Bonnicksen 1988; Eckersly 1992; Ehrenfeld 1981; Engel 1998; Tribe 1972) typify the cultural values that contribute to the marginalization of nature. The belief that human needs are separate from the needs of healthy ecosystems still permeates the Western world. Ehrenfeld’s (1981) sentinel warnings about lack of ecological foresight in economic and technological progress are now increasingly evident in the depletion of natural resources, climate change, and changing trajectories of vector-borne disease, for instance (Routledge and Ayrese 2005; ­Watterson et al. 2005). This ecological crisis is a simultaneous crisis of culture, rooted in our inherited values, beliefs, and knowledge, now fast becoming agents for social action and change ­(Eckersly 1992). More often than not, what our Western society fails to recognize is that ecological problems are “symptomatic of a fundamental rupture of human emotional and spiritual relationship with the natural world” (Kellert 1993, 46). Restoring our connections to the natural world may require that we experience moments in nature that liberate us from what ­Borgmann (1984, 35) describes as the “deeply engrained pattern” of technological production and consumption that populates modern life. This cultural discourse is exemplified in the work of Higgs (2000, 2003) and Marck (2000) stemming from Borgmann’s philosophy of technology (Borgmann 1984, 1992, 1999) and is a barrier to engaging with nature in everyday ways. Participant data from the study on engaging with nature in the promotion of health attest to this technological discourse, with participant narratives and photographs highlighting commodities such as the internet, cell phones, and computer games as luring family members away from

   

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the ­natural world, from experiencing the profound restorative benefits of walking a forest path or harvesting garden vegetables. In this sense, nature stands in counterpoise to technology; yet it is the contrast between the two that “heightens rather [than] denies the radiance of genuine focal things” (Borgmann 1984, 196). Focal elements, such as a path in the woods or a campfire, provide opportunities to connect to the simple abundance that still remains in the precincts of a predominantly technological world (Borgmann 1984). This imbalance permeates all sectors and, as Marck (2000) indicates, the health system is suffering from a disconnection of both focal practices and communal engagement. Technocracy prevails even in environmental health sectors, where, for instance, an orientation to technology for wind and solar energy, although critical to sustainability as well, takes precedence over more focal practices and therefore threatens “our very capacity to develop ecological sensibility” ­(Bookchin 2005, 409). Higgs (1999, 2005) similarly describes the cultural challenges of using technology to recreate nature in unnatural forms. Disney World’s nature excursion is an example: a market-driven and romanticized culmination of technology and culture drawing people further from focal and restorative experiences in our natural world. Yet, dichotomizing technology and nature creates a discourse that awakens a renewed view of focal practice. The contrast exposes the domination of humans over nature and accentuates the need for restoration of everyday focal practices as central to our lives. At the other extreme is the lack of ecological thinking evident in various forms of environmentalism. Hay (2002) and Light (2002) describe environmentalism as a political identity that can exclude people and create a biased view of nature. For instance, in extreme environmentalism nature is cast as a romanticized place of maltreatment external to our local communities, treated without deliberation on social, cultural, economic, or political consequences. Furthermore, claims that some people are closer to nature or more environmental than others takes a privileged view that can only work as yet another barrier to engaging with nature. Contrary to this type of exclusionary view of saving nature in faraway places, participant data from the study on nature-based health promotion reveals diverse sensibilities directed at local outdoor places as influenced by participants’ earlier life and learning experiences and everyday opportunities to access nature in the rural context (see also Guehlstorf and L ­ ichtenberg, chapter 6 below, and Morrison et al., chapter 8 below).

   



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In conjunction with understanding the local context and the social and cultural values and norms that influence our relationship with nature, there is the need to consider the broad determinants of health that have an impact on citizens’ ability to engage with nature in everyday feasible and health-promoting ways. While there is research to suggest that negative experiences and perceptions of nature may contribute to a lack of interest in or even a discomfort with being in nature for some people (Bixler and Floyd 1997; ­Milligan and Bingley 2007), other scholars suggest that citizens may not be comfortable with or able to engage with nature, participate in local decision-making processes, or adopt certain sustainable lifestyle practices due to a variety of broad system-level influences such as social and cultural values and norms and economic and infrastructure restraints (Melo-Escrihuela 2008; MacGregor 2006; see also Baber and Bartlett, chapter 5 below). The identification of barriers and opportunities to engagement with nature parallels advances in human health promotion and the social determinants of health over the last several decades, in a move from addressing individual- to system-level influences affecting health, such as income and social status, social support networks, education, employment and working conditions, physical environments, healthy child development, and health services (Epp 1986; Health Canada 2002; Raphael 2006; cmdh 2008; who 2003). Much is still to be learned about how these determinants and related multi-level multi-strategy interventions that target individuals, groups, community organizations, institutions, and policy development (Edwards et al. 2004; McLeroy et al. 1988) can contribute to the creation of sustainable environments that support engagement with nature. Although ecological models have been integral to the policy sciences, public health, ecology, and many other disciplines for decades, they are now becoming particularly useful in understanding and framing the complexities of promoting and protecting human and ecosystem health.

Opportunities for Ecological Citizenship: Access to and Connecting with Natural Outdoor Places Can Encourage Ecological Citizenship Ecological citizenship is place-based (Engel 1998) and ties to how we connect to, experience, and care for each other and the planet.

   

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At varying levels, ecological citizenship involves acting on the right and responsibility to live sustainably (Bell 2005; Dobson 2003; Melo-Escrihuela 2008) in communities where, ideally, people work together to “satisfy its needs and aspirations without diminishing the chances of future generations” (Capra 2002, xiii). Ecological citizenship is a term that emerged out of the work of a number of environmental and policy scientists in the 1990s. Van Steenbergen (1994) and Christoff (1996) were some of the first to coin the term, yet elements of ecological citizenship have been guised in other constructs such as “stewardship,” “green citizenship” (Barry 1996, 1999), “environmental ethics” (Hay 2002), “participatory rights” (Bell 2005), and “ecological footprint” (Dobson 2003). The 1998 Hasting Center Nature Polis and Ethics Project created particular energy and dialogue on ecological citizenship, with further evolution in the more recent works of Light (2002, 2003, 2006), Dobson (2003, 2006), Bell (2005), and Bookchin (2005). Moreover, many of the underlying principles of ecological citizenship have been practiced for centuries by Indigenous populations who often hold a deep respect for nature and identify their relationship to the Earth as a determinant of their well-being (Yotti Kingsley 2009; Adelson 2006). Aboriginal people have developed and used traditional ecological knowledge to sustain natural ecosystems (Higgs 2003, 2005; see also Bartlett et al., chapter 10 below). They have long recognized the reciprocal connections between health and nature based on a fundamental understanding that that whatever they do to the Earth they do to themselves. As such, many Aboriginal peoples have modelled ecological citizenship for centuries in a Western world that is only now beginning to realize the wisdom of their teachings. Engel (1998a) suggests that ecological citizenship occurs when people are concerned about nature and its role in the human experience and when they understand communities as living ecosystems. Yet can someone who does not understand communities as ecosystems be an ecological citizen? Is someone who is not concerned about engaging with nature, excluded from being an ecological citizen? It is evident in participant data on nature-based health promotion in this study that participants had varying levels of concern about the environment and engaged in a variety of proenvironmental behaviours, from picking up garbage in caring for their favourite outdoor places, to using eco-friendly cleaning products. These types of behaviours were possibly influenced by a broad

   



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range of factors such as ability to afford environmentally friendly products, or participant knowledge about the related benefits for the health and environment. The multiplicity of citizenship practices reflects an inherent and necessary diversity in society. Ecological citizenship, therefore, has the potential to embrace and support a variety of practices whereby as many people as possible can see the ends of environmental sustainability as part and parcel of their own personal interests or within their broader communal interests. After all, we do not only want environmentalists to recycle and the like, we want everyone to, preferably without having to coerce them to do so. (Light 2002, 158) In this sense, ecological citizenship is not exclusionary because humans are inescapably inhabitants of shared ecosystems and, as such, are all ecological citizens in unique and valuable ways. However, to create opportunities that foster ecological citizenship and that enable engagement with nature, many would argue that we must challenge traditional patriarchal systems to better balance power struggles between people and nature (Cuomo 2001; ­Bookchin 2005; Hay 2002). From an eco-feminist perspective, this means advocating for participatory approaches that embrace a diversity of perspectives and practices (Cuomo 2001; Bookchin 2005). Fostering ecological citizenship requires that we bring together and trust the pluralistic array of perspectives from multiple sectors and citizens and encourage knowledge-building and action at the intersection of views (Engel 1998b; Latta 2007).

Communal Efforts for Change Melo-Escrihuela (2008) and Dobson (2003) both advocate for an ecological citizenship that changes how we live and function in the world. Engel (1998a) suggests that society “reshape political and economic structures so as to extend the power of ownership to all persons and to remove the obstacles keeping others from full engagement in civic life” (S29). Ophuls (1977), too, provides a sentinel call for a policy of scarcity to promote the sustainability of life on Earth. Ophuls describes a need to “move away from the values of growth, profligacy and exploitation  … toward sufficiency, frugality and stewardship” (229). This requires a change in mindset and

   

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practice for all citizens and sectors within society even from “social justice advocates convinced that ever-greater utilization of natural resources is necessary to improve the living standards of the poor as well as by environmental activists who sometimes seem oblivious to the ways environmental policies and economic inequalities can adversely affect the welfare of people, including their capacity to care for the environment” (Engel 1998b, S38). Nature-based health promotion involves creating everyday and ecologically sound ways of enabling people to connect with each other and with nature within their own communities. It is tied to the socio-ecological notion of health promotion: that the health of people and the planet is engendered by people (McMurray 2007) through intrapersonal, interpersonal, family, community, and political processes (McLeroy et al. 1988; Nutbeam 1999; see also Edwards and Davison, chapter 2 above). As Dobson (2005), ­Valencia Sáiz (2005), Dobson and Bell (2006), and Melo-Escrihuela (2008) suggest, ecological citizenship requires a deep and fundamental cultural shift among citizens and multi-sectoral practitioners and policy-­makers. Kellert (1993, 1997), Orr (1993), and others (Frumkin 2001; G ­ ullone 2000; Kahn 1999) encourage us to consider these “roots of motivation and understand why and in what circumstances and on what occasions we cherish and protect life” (Wilson 1984, 138). In remembering our tendencies toward the technological and humanistic visage in Western society, our duty to our natural places is as much about the processes for communal engagement and decision-­making in nature-based health promotion as it is about the technologies and crisis-oriented action for reducing carbon emissions, slowing climate change, countering environmental degradation, and combatting disease. Examining the local experience of nature-based health promotion legitimizes community-level change, rooting it in the experiences and perspectives of those whose lives it affects. It is clear that although engaging with nature has healthpromoting benefits at the individual level, whole-systems change requires that multidisciplinary representatives from various sectors such as health, education, agriculture, natural resources, recreation, and urban planning adopt participatory approaches and work with each other and community citizens to strengthen more proactive and everyday opportunities for healthy living for the betterment of longterm human and ecosystem health.

   



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Conclusion This chapter offers insight into central constructs of nature-based health promotion and raises vital questions about equitable and community-based opportunities and conditions for restorative experiences and ecological citizenship in local settings. Analytic themes of restorative outdoor places, restorative experiences, ecological citizenship, and access to nature are juxtaposed with the literature and linked to equitable access to restorative outdoor places, opportunities for ecological citizenship, and communal efforts for change. These elements constitute a very broad and inclusive view of environment and health that relates to the social, political, and cultural conditions that enable people to engage with nature in ways that simultaneously influence human and ecosystem health. Using the terms “ecological” and “emancipated” to describe communities in this way helps us recognize that in equitable societies, citizens are not dependent on but rather part of a community ecosystem that in its entirety generates health. These findings from a community-based study with citizens living in rural Atlantic Canada provide a grassroots perspective on how people in this setting can engage with nature in local and everyday ways to nurture their health and well-being. Such results highlight the need for community-based conditions and opportunities that enable people to reconnect with the Earth in their everyday lives and in ways that sustain natural ecosystems, which, in turn, sustain people. Although experiences in nature and the barriers and facilitators to accessing restorative places may vary extensively from rural to urban settings and from place to place, it is possible that by being in nature, people can come to know their embedded place in the web of life and use that fundamental knowledge to inform their everyday decisions and actions (Capra 1996, 2002; Orr 2004; Smith and William 1999). As such, restorative places and experiences can help create vital ecological knowledge and sensibilities that foster ecological citizenship as people “come to see their duties to that place as co-extensive with their duties to their fellow citizens” (Light 2006, 154). Participant data extends the literature on health and place, therapeutic landscapes, restorative experiences and places, health promotion, and ecological citizenship, and situates the connections between nature and people within a complex system of influences

   

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and relationships. Equitable access to nature as a health resource, opportunities for ecological citizenship, and communal efforts for community-based change are necessary and primary undercurrents to creating just, inclusive, healthy communities. Our systemlevel work in addressing the social determinants of health needs to broaden to include the notion that “nature matters.” We need to foster the connection between citizens and nature in creating conditions that support and sustain health and quality of life. As Engel (1998a) asserts, “neither the democratic freedom, equality and community nor the ecological well-being of the planet can be realized separately” (S31). Using research to examine the local experiences of citizens, practitioners, and decision-makers from multiple sectors is commensurate with repositioning science as a tool of dialogue, understanding, and local change rather than a tool for asserting objective certainties. In this context, it is the research process in conjunction with the findings that best influences community-based change whereby research becomes an opportunity to create theory and action with participants toward “what could be” (Weaver and Olson 2006, 461). Select findings from this study on engaging with nature in the promotion of health help us envision ways to simultaneously care for the health of people and the planet, and in doing so, contribute to ecological health, well-being, and the emancipation of communities. Ongoing community-based participatory research is needed to engage citizens, together with practitioners and decision-makers from diverse sectors, and advance knowledge and interventions in the promotion of human and ecosystem health. Creating such communities requires communal efforts in sharing perspectives and working together to use knowledge, resources, and infrastructure in ecologically sound and sustainable ways, commensurate with creating equitable access to conditions for healthy living and everyday opportunities to care for and engage with nature in local contexts.

notes 1 The sectors involved in the study included: community health, recreation, nutrition, public health, education, community planning and development, daycare centres, community services, municipal sustainable development, and various community advocacy groups.

   



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2 Photo narration in this case was a participant-led method for collecting data. Participants were provided with cameras and, over a period of two weeks, photographed and narrated their experiences using a digitally recorded or written log. 3 Photo elicitation was used to elicit discussions during interviews and focus groups. Select photographs were used, upon participant consent, to facilitate discussions. In phase two, I used photo elicitation via focus groups with sixteen community practitioners and decision-makers from public health, recreation, community services, community planning, education, and other sectors to examine how they used evidence on the health benefits of engaging with nature in their work. The two-phase approach was useful in examining the individual and systemic features of and possibilities for engagement with nature in the promotion of health. I also used an iterative process of dialectical analysis to critically examine the multiple perspectives and analyze for themes (Dunning 1998; Thompson 1995). These types of photo methods have roots in visual anthology and restoration science. For other detailed examples see http://bridgland.sunsite. ­ alberta.ca/. u

References Adelson, N. 2000. Being Alive Well: Health and Politics of Cree Well Being. Toronto: University of Toronto Press. Barry, J. 1996. “Sustainability, Political Judgement and Citizenship: Connecting Green Politics and Democracy.” In Democracy and Green Political Thought. Sustainability, Rights and Citizenship, edited by Brian Doherty and Marius de Geus, 115–31. London: Routledge. –1999. Rethinking Green Politics. London: Sage. Bell, D. 2005. “Liberal Environmental Citizenship.” Environmental Politics 14 (2): 179–94. Berger, R., and J. McLeod. 2006. “Incorporating Nature into Therapy: A Framework for Practice.” Journal of Systemic Therapies 25 (2): 80–94. Bixler, R., and M. Floyd. 1997. “Nature Is Scary, Disgusting and Uncomfortable.” Environment and Behaviour 29 (4): 443–67. Bonnicksen, T. 1988. “Restoration Ecology: Philosophy, Goals and Ethics.” The Environmental Professional 10: 25–35. Bookchin, M. 2005. The Ecology of Freedom: The Emergence and Dissolution of Hierarch. Oakland, ca: ak Press. Borgmann, A. 1984. Technology and the Character of Contemporary Life. Chicago, il: University of Chicago Press.

   

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section two

Deliberation, Policy, and Collaboration as Pathways to Integration This second section offers perspectives derived from public policy and participatory politics. Its goal is to demonstrate the opportunities that community-based and participatory approaches hold toward identifying, categorizing, and dealing with or managing complex and intractable issues, as well as noting the challenges and difficulties that come with this approach. While engagement and participation are themes that run throughout this book, the chapters in this section are primarily concerned with how questions of environmental deliberation interact with health and social concerns. Although technological advances in medicine, communications, engineering, and agriculture have abated some environmental and human issues, there is still a strong disconnection between people, place, and environment. A responding framework – combining ecological factors, health, and social institutions – is very uncommon, but has also faced opposition on several fronts due to the integrated and confusing nature of approaches and solutions. The convergent and overlapping processes that are derived from these factors require non-traditional or creative viewpoints and cannot be solved without a holistic approach, as this framework demands cooperation among distinct and separate agendas, administrations, and approaches. Taking a common-sense approach to environmental decisionmaking, reasonable scholars questioned the maintenance of democracy with cost-benefit analyses and pluralistic services, and suggested that what is needed instead is inclusive policy-making that considers long-term maintenance of both biodiversity and human well-being, and that operates by process not product. The

   

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concept of a deliberative approach that includes ecosystem components, economic processes, and political services characterizes holistic decision-making, which takes into account multiple stakeholders who use different ideas, are in different institutions, and have different issues to debate. Limitations to this approach have included frustration over the processes of slow consensus and mudd­ling consent. Politically grounded approaches such as risk, health society, and deliberative democratic theory must, therefore, be merged without losing their disciplinary rigour. Section two highlights political initiatives and deliberation that address the typology in chapter 7, and create a necessary bridge to the next section. Specifically, it seeks to further our understanding of how public policy must interact with the sciences of the environment, health, and society by drawing on the effects deliberative efforts have on engaging the public and managing problems. Chapter 5, Deliberative Rule-Making for Human Health and the Environment: Making Administrative Discretion Safe for Democracy, by Robert V. Bartlett and Frank W. Baber presents the importance of scientific information in the creation of environmental protection policies. The authors note that sustainability becomes more difficult as modernization, globalization, and urbanization produce higher levels of consumption. They state that it is additionally challenged by modern governance because democracy complicates existing regulatory approaches to the protection of the environment and human health. Due to the tedious work involved in legislation, broad standards and controls are often proposed, with administrative agencies using their discretion to adjust the demands of the policy to varying circumstances. Bartlett and Baber offer a hypothetical problem of environmental protection to be considered by average people, involving thermal pollution of a river that acts as the border of three countries, to model the issue of global warming. Their results demonstrate the difficulty in relating issues of human health to environmental protection and managing the relationship between the two. Chapter 5 then argues that administrative discretion has strong anti-democratic tendencies, but is inevitable in the modern governance of health and environment matters. As globalization continues, administrative rule-­making will grow, and in order to be successful, policy juries must be brought into democracies’ institutional procedures.

   



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Chapter 6, The Social and Environmental Outcomes of Market-­ Based Wetland Regulations in the Midwest United States, by Nicholas Guehlstorf and Traci Lichtenberg discusses an emerging style of legislation intended to enhance public participation in the environmental policy process. As administrative agencies become overloaded, citizen involvement becomes more appealing. Combined with public awareness of participation in the policy process, citizen involvement has greatly increased. To assess this unprecedented increase, a survey of the relationships between government, communities, and watersheds is offered. Watersheds are of specific importance for this topic due to the failure of their preservation through command and control regulations. To illustrate this, challenges involved in watershed governance and management are discussed, along with issues surrounding environmental democracy and mitigation banking. A study of wetland losses in Missouri is presented to evaluate whether current banking mitigation policies for urban and suburban wetland losses have negatively affected water quality; more specifically, the presence of the herbicide atrazine and its health effects are discussed. Guehlstorf and Lichtenberg use this study as an example of how citizen interest and participation may rise as a result of increased realization of the impact of wetlands on water quality. Chapter 7, “Just Add Water”: Dissolving Barriers to Collaboration and Learning for Health, Ecosystems, and Equity, by Margot Parkes examines the importance of working together across disciplinary, sectoral, and cultural boundaries to improve health in the context of a river catchment (or watershed) and the management of water resources. The chapter begins with an examination of integration as a goal that can only be achieved through participation and attention to the processes of learning and collaboration. Integration, participation, and collaboration are then examined and discussed in the context of a case study of the Taieri Catchment and Community Health Project. Findings from this case study suggest that multi-stakeholder catchment initiatives provide an opportunity to link ecosystems with the combined goals of equity and health. This highlights the importance of three “axes of participation,” all of which inform a more nuanced approach to partici­ pation, whether in research, practice, or policy. The Taieri case study also identifies multiple axes of integration, combining horizontal and vertical interactions across and between different

   

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stakeholder groups and providing the impetus for ongoing multistakeholder processes. The case study demonstrates how a combination of integration, participation, and collaboration creates opportunities to engage people and places influenced by the Taieri River in ways that reconnect health, ecosystems, and society.

   

5 Deliberative Rule-Making for Human Health and the Environment: Making Administrative Discretion Safe for Democracy r o b e r t v . b a r t l e t t a n d w a lt e r f . b a b e r

Drawing on our decades of scholarly background in law, environmental policy analysis, and public administration, we explore the necessities of administrative rule-making and the challenges involved in promoting human health by protecting the environment. These necessities and challenges share a similar legal, managerial, and political architecture, and ought, in fact, to serve as mutually supportive structures. Drawing further on our more recent work on deliberative environmental democracy, we argue that using disinterested citizens drawn together as juries can allow for the aggregation of perspectives that serves the cognitive objectives of democratic deliberation about health and environment without surrendering the impartiality of administrative adjudication.

Introduction There is a growing awareness among both physicians and public health experts that global environmental degradation should receive more of their attention. This awareness is grounded upon three insights: that the human habitat (which encompasses much more than the built environment) is an important determinant of human health; that prevention of human illness must involve protection of the environment; and that physicians can and should communicate with the public and with policy-makers about the seriousness of environmental hazards (McCally 2002). By the same token, there is a growing awareness that many environmental protection p ­ olicies

   

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that have been primarily justified on human health grounds  – air pollution, hazardous waste, and toxic substances policies, for example – must also be both ecologically sound and politically sustainable if human health is to be maintained for the long run. For policy to be ecologically sound requires a great deal more than political will or sustained public opinion. Many environmental problems cannot even be perceived as such without a great deal of scientific information and technological sophistication, so public discourse must appropriately integrate technical and scientific expertise. Political sustainability, in turn, depends on continuing pragmatic judgments that must be both broadly and deeply democratic (Baber and Bartlett 2005; see also Hallström et al., chapter 1 above). These emerging perspectives have converged in the realization that modernization and globalization are pushing the boundaries of human existence in ways that are endangering both human survival and our ability to respond to that danger. Geography no longer constrains culture and technology. Aggressive agriculture, urbanization, and growing life expectancies strain Earth’s carrying capacity. Both health and environmental risks are distributed inequitably in a world in which politics is increasingly organized around risk allocation (Beck 1992). Social modernization and the increasing levels of consumption it encourages tax resource bases. All of these developments create mismatches between our biological needs and our ways of life that adversely affect both ecology in general and human health in particular (McMichael 2001). In the meantime, the globalization of democratic expectations and the disempowering of conventional governmental institutions are rendering the political challenges associated with sustainability all the more intractable (Baber and B ­ artlett 2009). Institutions of governance  – which include not only the formal structures of government, but also public and civil society actors including corporations, networks, non-governmental organizations, and hybrid partnerships  – have everywhere proven inadequate to these challenges. At the international level, in particular, the lack of effective legislative institutions has led to a dependence upon networks of policy specialists that promise greater opportunities for the development of ecologically sound policy than do conventional “legislative” strategies. But this trend also exacerbates the problems of political sustainability in an increasingly disaggregated system of governance (Slaughter 2004). Not only are policy specialists

   



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appointed rather than elected, their work presents special problems of oversight for those public officials who do serve in elective office. As an example, the advent of risk assessment and environmental cost-benefit analysis in the 1970s and 1980s did a great deal to enhance the ability of public officials to make more rational choices about regulatory issues. By one estimate, however, a typical risk assessment relies on at least fifty empirical assumptions (each open to some level of doubt) and, moreover, incorporates an uncertainty factor containing everything that we do not know, cannot know, or simply cannot measure (Raffensperger and Tickner 1999). As a consequence of this accumulated uncertainty, decision-­makers increasingly rely upon decision rubrics (rules of thumb) such as the widely discussed “precautionary principle.” This reliance may be a reasonable compromise between the ideal and the real. Or it may be a dangerous act of self-delusion because the precautionary principle itself is incoherent, since risk is omnipresent and precautionary measures have their own (often imponderable) risks (Sunstein 2005). Adjudicating conceptual conflicts of that nature, in addition to performing the inherently complex and uncertain research that underlies risk assessment, involves a significant and unavoidable element of administrative discretion. These are precisely the sorts of tasks that we would expect even the most capable legislatures to delegate to administrative agencies. The fact is that, in the modern governance of health and environmental matters, administrative discretion is inevitable. Our desire to contrive new regulatory approaches to the protection of the environment and human health, and to do so democratically, will ultimately require us to understand this problem in some detail.

The Inevitability of Administrative Discretion The major premise underlying the idea that administrative discretion is unavoidable is the proposition that no legislature has the insight or vision necessary to regulate all of the details of administration nor to render in the form of unconditional commands the rules necessary to express the collective will of those whom it represents (Goodnow 1905). Even if the cognitive assets necessary to achieve that level of specificity in legislation existed in a legislative institution, any procedure that requires legislators to debate such minute

   

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details would raise the decision costs in the legislative process to a level sufficient to deadlock the entire process (Landis 1938). Likewise, even if greater specificity at the legislative stage were possible, there are reasons to believe that it would be undesirable. Detailed standards and controls imposed early in the process of developing any administrative regime may do more to obscure than to reveal the intent of the legislature, and may constrain the administrator’s ability to develop a program that will ultimately achieve that intent (Sofaer 1972). Beyond those general problems, any conceivable regime for regulating environmental health – however broadly or integratively the relationship of environment and human health might be conceived – must rely upon a foundation of technical and scientific expertise that would shift and grow more quickly than any legislature could respond. Only a specialized administrative agency could command the resources to initiate and sustain the pursuit of so elusive a form of the public interest. Administrative discretion makes it possible for regulatory regimes to individualize the application of governmental power over private interests. This permits governing bodies, if it they are so inclined, to adjust the demands of the policy to varying circumstances and to avoid most of the unjust and otherwise undesirable results of standardized restraints and particularized requirements (Freund 1928). The arguments for the unavoidability of administrative discretion are thus both political and functional. Our political institutions and the individuals who populate them are both unable and unwilling to legislate with greater specificity. Moreover, our governing processes would work less well if our elected officials tried to legislate with greater precision and we would be less satisfied with the results in any event. This last observation serves as a useful bridge to a second point of consensus regarding administrative discretion: that it must be subjected to some measure of democratic control if it is to be tolerable in a system of popular government. In Kenneth Culp Davis’s (1969a, 25) colourful description, administrative discretion can be a useful tool, but “like an ax, it can be a weapon for mayhem or murder.” So vivid a simile should serve to remind us that when we allow our elected officials to stop short of saying precisely what they mean, we also allow them to escape much of the moral and political heavy lifting that goes into establishing behavioural norms in a complex society.

   



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Living with Administrative Discretion What should be done about administrative discretion depends in large measure on what one takes it to be and what interest one assumes that it might threaten. If emphasis is placed upon the inability of the legislature to be more specific than it usually is, then administrative discretion appears to be a shortcoming in our effort to achieve what is often characterized as the “rule of law.” If, however, this specifically legal perspective is taken to suggest that the objective of law is to leave no indeterminate space in which details must be filled in by bureaucrats, then we have been sent on a wild goose chase. An apparent gap in the law is real only if one assumes that authorization for some official body to fill the gap is not also part of the structure of law (Kelsen 2006). Moreover, even those who are generally identified as political conservatives are often willing to admit that the notion of the rule of law as the mechanical application of standards that require no interpretation, no fleshing out, is a profoundly silly idea (Posner 2008). If taken to be an empirical proposition, it can only refer to a halcyon past that never was. If it is a normative prescription, it summons a legalistic (even rigidly authoritarian) future that we should all hope will never be. But a more modest and sensible “rule of law” critique of administrative discretion is available. In this view, the public and public officials should attempt to give guidance to private individuals, administrators, and judges on lower courts through clear, abstract rules laid down in advance of their actual application (Sunstein 1996). The point of the exercise is not to reduce discretion to zero. It is, rather, to lend a higher degree of predictability to the exercise of that discretion by describing (in general terms) the patterns that it should follow. This process is not presumed to be the exclusive domain of the legislator. It is at the heart of both the modern reliance on administrative rule-making and the general preference for rulemaking over adjudication as a means for defining the restraints and obligations that government places upon individuals. The only clear alternative to rule-making (if one dismisses arbitrariness or chaos as options) is case-by-case adjudication of administrative issues – the creation of law at its point of application. The long-term trend is to avoid this alternative. Rule-making is preferred because, it is argued, the promulgation of rules enhances efficiency (Cooper 2007; Warren 1996). It provides a widely deployable

   

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standard for decision and leaves a documentary record that aids in both interpretation of that standard and long-term policy development. Rule-making also reduces the likelihood of arbitrary treatment of individuals and enhances the general sense of fairness in the administrative process. Finally, rules go beyond protecting the interests of individuals. They encourage a regularity, a predictability, and a transparency in the operation of administrative agencies that allow elected officials and citizens generally to more easily understand administrative action and to hold administrators accountable (Cooper 2007). Beyond “rule of law” perspectives on administrative discretion, it is possible to approach the subject from a managerial point of view. This approach emphasizes the role that discretion plays in allowing administrative decisions to more effectively utilize our technical, scientific, and social scientific (especially economic) understanding of the empirical content of regulation. The role of expertise, in whatever discipline it is based, has long been a subject of debate in the policy sciences (see Hallström et al., chapter 1 above). It has been argued that human activities are normally organized by one of three different techniques: markets, politics, or expert analysis (Munger 2000). Both markets and politics are the subject of extensive literatures. But we have a much thinner foundation for our discussion of expertise. Happily, pursuing a better understanding of the managerial dimension of administrative discretion does not require us to develop a full theory of expertise. It requires only that we understand in broad terms what claims to expertise are and how they can be integrated into administrative rule-making. Expertise refers to either of two sorts of knowledge claims. Knowledge claims of the first sort are based upon the expert’s membership in a specially trained group that can contribute valuable advice to administrative decision-makers. Knowledge claims of the second sort are claims to a form of tacit knowledge that allows the expert to puzzle out the underlying dynamics of a problem by combining both systematic knowledge and personal intuition and experience in a unique perspective that allows the expert to assert knowledge claims that are personally authoritative (Baber and Bartlett 2005). It matters a great deal which sort of claim one takes a claim to expertise to be. If we adopt a “group knowledge” perspective, then we may deprive ourselves of the most flexible and creative perspectives on our problem because of the inherently cautious and c­ onservative

   



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character of scholarly practice (Munger 2000). But expertise grounded in “tacit knowledge” is problematic for a different reason. Tacit knowledge, even when it appears to be objective and factual, may be subject to resistance because of the personal quality of the perspective that it legitimizes. Citizens, policy-makers, and even other experts may reject this form of expertise because of their attitudes about its source or because of the challenge it presents to their own tacit knowledge (Stone 2002). But either interpretation poses a problem in deploying our supposed knowledge upon the field of administrative practice. The leading solution to the problem of integrating expertise into the practice of administrative rule-making is the use of the public hearing. Ideally, hearings allow both experts and interested parties to challenge each other’s knowledge claims in an open process of rational give and take. Administrative hearings have evolved rules of procedure that are more permissive than those found in judicial hearings. Decisions about who may participate and what kind of information may be introduced are made with the idea of maximum feasible participation in mind. As a general matter, most of the evidence proffered in administrative hearings is accepted because to do otherwise increases the risk having the ultimate ruling overturned (Cooper 2007). This tends to be true both in administrative rule-making and in administrative adjudication. The potential burden of holding open the agency door to all comers in this way has been ameliorated in the rule-making process by the frequent (in the United States, nearly universal) resort to informal rule-making – also known as notice and comment rule-making. Notice and comment rule-making retains the broadly adversarial qualities typical of both adjudication and formal rule-making. However, it is far less restrictive on the issue of who may participate in the process and how extensively the agency must justify its exercise of discretion. As a general matter, to have standing in notice and comment rulemaking, one need only have an opinion (what it takes to gain actual influence for that opinion is another matter). A third perspective on administrative discretion is neither specifically legal nor narrowly functional. It is, rather, an unapologetically political argument that administrative discretion has strong antidemocratic tendencies. As an extension of interest group liberalism, administrative discretion is unavoidably suspect on this score. It has no internal mechanism to insure that worthy arguments are heard,

   

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especially when their advocates lack the resources and special access of well-organized interest groups. One recent development designed, in part, to address this problem is the process of negotiated, sometimes called collaborative, rule-making. Negotiated rule-making involves the creation of a committee or task force (consisting of a maximum of about twenty-five parties) whose membership is determined by a facilitator to represent all of the relevant stakeholders in a given rule-making situation. A second facilitator, in the process designed to reach a general consensus which contours the form that the ultimate rule should take, then leads the committee. The product of the committee’s work becomes (with agency approval) a notice of proposed rule-making which is then subject to the normal hearing and decision process (Weber 1998; O’Leary 1993). Negotiated rule-making works best where the number of interests affected by the rule is manageable in size and reasonably well organized to begin with. There has to be at least some clarity as to the issues involved, and those issues must be ripe for decision. The parties involved must have interests sufficiently complex that they can be effectively traded off against one another without requiring any group or individual to surrender something that is of fundamental importance to them (Cameron et al. 1990; Weber 1998). And, of course, the agency itself must be prepared to live with the decision of the committee. Although it is always within its rights to do so, walking away from the consensus of a stakeholder committee is a political disaster for any administrative agency. This further limits the range of application for negotiated rule-making. It should be obvious, therefore, that negotiated rule-making is no panacea. Though it has the potential to be more inclusive and representative than other approaches to the use of administrative discretion, there is no guarantee that it will be. Even assuming that a given issue has only two sides, there will often be a large number of different groups that adopt each position. They may have little in common with one another other than a shared position on the issue at hand. If all are included, how are their different priorities traded off against one another? If some are to be excluded, how will that choice be made and defended? Exclusion of anyone from the process is illegitimate (from a democratic perspective). An excluded party may find it difficult to contest the final rule itself because showing a nexus between that party’s exclusion and the violation of a legal right in which it has a concrete interest will usually be quite difficult

   



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(Cooper 2007). Thus negotiated rule-making appears to have the same potential to exclude disadvantaged or historically marginalized interests that plagues other forms of rule-making. These potential flaws in negotiated rule-making are not, however, unique to that approach. They are imported, as it were, from the basic characteristics of notice and comment rule-making. Forcing a rule-making process intended to be open and responsive into the bleak choice between an excessively demanding formal procedure (formal rule-making) on the one hand and an informal process that is susceptible to only the most limited judicial review (notice and comment) on the other was problematic from the start. In response to the problems inherent in this forced choice, judges in a series of cases have developed a third alternative. Intermediate between formal rule-making and the notice and comment process, this approach is referred to as “hybrid rule-making.” The general thrust of hybrid rule-making is to allow administrative agencies to continue using the flexible and open procedures of notice and comment rule-making but to require them to generate a substantial record in support of their exercise of discretion that demonstrates the thoroughness of their analysis and the completeness of their attention to the arguments of the stakeholders (Williams 1975). Under this approach, agency decisions are required to state the basis and purpose of the rule as well as the data and methodology upon which the agency relied. Furthermore, the agency is required to show that adequate notice was given to all potentially interested parties, that sufficient time to respond was allowed, that challenges to agency data were entertained, and that the agency examined and responded to all relevant public input (Pederson 1975). Although this approach originally emerged from the judiciary, it has been reinforced and expanded (particularly with respect to opportunities for public participation) by executive orders and statutes, in particular pollution statutes addressing human health issues. For example, in the United States, the Clean Air Amendments of 1997 (42 U.S.C. 7607 (d)) specify a “hybrid” procedure to be followed by the epa in setting emission standards, a process previously governed only by Section 553 of the Administrative Procedures Act. The amendments require the Agency to prepare a “rulemaking docket” containing the notice of proposed rule-­making, a statement of the basis and purpose for the proposal, all written comments and documents received by the Agency, transcripts of any

   

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public ­hearings, proposed draft rules, inter-agency comments, and all other documents of central relevance to the rule-making that become available after the proposed rule has been published. The Agency is also required to hold hearings involving oral presentations and to hold the records of those hearings open for thirty days to permit the filing of rebuttals and supplementary information. The final rule is required to include a second statement of basis and purpose, explaining any changes from the rule originally proposed, as well as Agency responses to all “significant” comments, criticisms, and new information. When the more demanding record-of-decision requirements of hybrid rule-making meet the consensus standard of negotiated rulemaking, the establishment of a network of mutual vetoes creates new potential for democratic responsiveness. But many questions regarding negotiated rule-making remain. Can it really be sufficiently representative and inclusive, given the complexity of modern society? Can a stakeholder committee (regardless of its size or composition) meeting over a protracted period of time be genuinely open in a democratic sense? Will the notice and comment process that follows the development of a consensus add anything to the outcome, and should it? And will the agency genuinely conform itself to the will of the stakeholder committee, both when the rule is adopted and when the time comes to apply it to concrete circumstances (Cooper 2007)?

Making Discretion Safe for Democracy Identifying distinctive legal, managerial, and political perspectives on administrative discretion does more than simply provide us with a general analytical framework for organizing our ideas and concerns on the subject. It also suggests a developmental trend in administrative and regulatory law. The general preference for rule-making over the adjudication of particular cases, the development of negotiated regulation, and the advent of hybrid rule-making as an alternative to both formal and notice and comment rule-making all present themselves as signposts on the road to a more effective and fully democratic role for administrative discretion in modern government. The questions, of course, are how far along that road we have come and whether we are headed in the right direction. ­Kenneth Culp Davis (1969a; 1969b) framed the debate by issuing a call for a new approach to administrative discretion.

   



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Davis observed that both our statutes and our administrative rules have always taken the form of abstract generalizations, but that there is no reason why they must. A rule, he argued, can be limited to hypothetical cases and can contain no generalizations at all. What Davis imagined was that an agency could enlarge its capacity to serve the interests of affected parties if, instead of generalizing in a rule, it issued rules that contained a hypothetical set of facts, a statement of the problem raised by the facts, and a statement of the agency’s answer to the problem and the reasons for it. In so doing, the agency would be able to extend the advantages of rulemaking (clarity, predictability, and reviewability) into areas where generalizations are not yet possible but where an appropriate exercise of administrative discretion is capable of answering the questions that the agency is prepared to answer while avoiding questions that it is not yet prepared to answer. On this account, an agency that added rules in the form of hypothetical adjudications to rules in the form of generalizations and actual adjudication would be far better equipped to serve the public interest than one which limited itself to only the latter two of these techniques (Davis 1969a; 1969b). It should be noted, however, that Davis’s notion about rules in the form of hypotheticals is not meant to resolve all of the problems associated with the exercise of administrative discretion. It is a specifically legal solution to a specifically managerial problem. Where administrators have only administrative discretion (rather than an unambiguous legislative requirement) at their command and where their understanding of the social and economic facts underlying a problem are uncertain, rule-making via hypotheticals gives them an opportunity to provide guidance to interested parties without risking the inefficiency and unfairness that often attends case-by-case adjudication. But this technique, in the form in which Davis presents it, holds out little hope for a type of administrative discretion that is more responsive and accountable from a democratic perspective.

Discretion as an Opportunity for Democratic Deliberation In fitting Davis’s suggestion for administrative rule-making as the adjudication of hypotheticals into the context of negotiated regulation and hybrid rule-making, one is immediately struck by the fact that we would still be dependent upon judges (both ­administrative

   

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judges and those in the judicial branch) to define the rights and protect the interests of citizens. It is also apparent that the citizens who are allowed into the process would still be of a very particular sort. They would be either litigants or representatives of interest groups. Their particular stakes in those issues would determine their orientations to the questions of regulatory discretion they confront. Moreover, most of them would have won their roles in the administrative process as a consequence of their privileged positions in the political system within which that process is taking place. This is not to say that negotiated regulation, hybrid rule-making, and rulemaking through hypotheticals are not (or would not be) improvements in the control of administrative discretion. It is only to say that their advantages are most apparent from the legal and managerial perspectives. From a more thoroughly political perspective, it is clear that what is lacking is not popular participation but, rather, fully public participation. The distinction, obviously, is between those outside of government who have a direct stake in the issue at hand and those outside of government who have only that interest in the issue that all other citizens have. The resolution of a particular issue by a committee of stakeholders may be reasonably stable. It may also be immediately defensible as a reasonable modus vivendi. If it is the result of a process of hybrid rule-making, there may be a record of the decision sufficient to allow a court to subsequently evaluate whether the action has harmed the interests of persons not party to the discretionary process. Given the way “stakeholder” is commonly understood and defined in these processes (Whitman 2008), none of these advantages (over unrestrained exercises of discretion) are sufficient to satisfy the demands of democratic legitimacy – namely, that all decisions result from fair and open participatory processes, that the majority of the broad community be the source of sovereign power, and that outcomes give citizens reason to continue to participate (Baber and Bartlett 2005; Whitman 2008). These demands have become more acute as the decline of the notion of divinely ordained natural law has left lawmakers clothed in little more than their own skins and a common law grounded (apparently) in nothing more than judicial fiat. Our challenge, then, is to develop a mechanism of administrative rule-making that will address its democratic deficit without compromising the advantages it enjoys over the option of regulation by detailed legislation.

   



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The Next Step: Deliberative Rule-Making We have already seen that one response to the expanding discretionary power of modern governance has been to build new forms of participation and arenas for deliberation into the decision-making process of administration itself, so as to avoid the dangers of administrative discretion tethered only to normative premises of its own devising (Habermas 1996, 191). But to constrain acts of discretion, normative premises must be “formulated with sufficient abstraction and not just independently of their varying institutional forms.” Regulatory norms must not simply be the work of some actor other than the agency whose discretion is to be limited, but they also must be “abstract” in that they are not derivative of the case in which the discretion is to be exercised. But the “semantic concept of a general norm” prejudges too much by straying into the realm of “discourses and negotiations in which the legislature’s will is formed” ­(Habermas 1996, 191). Thus, the norms that an administrative agency’s participatory and deliberative processes might generate to constrain its discretion must be abstract (inasmuch as they would not speak to a particular case), but not general (inasmuch as they would not apply to cases of other types). They would not require the development of later “exceptions” because they would not claim to apply beyond the fact pattern presented. They must be generated in a form that speaks directly to, but is not distorted by, the discretionary objectives and interests of the agency. Therefore they would deal with the matter at hand, but they would view the objectives and interests of the agency as contestable parts of the matter at hand. Bureaucratic conditions would be regarded as bureaucratic contingencies rather than bureaucratic imperatives. They would be, necessarily, norms of a “reflexive” sort. The implications for the administrative practices discussed above are reasonably clear. Davis’s rule-making by the adjudication of hypotheticals is obviously suited to the development of norms that are abstract but not general. The process relies upon what administrative agencies do well. It allows the administrator to identify the most relevant characteristics of frequent parties to actual disputes that the agency must resolve, structure a hypothetical scenario capturing those (and only those) characteristics and contestations, and apply to them the agency’s expertise in order to arrive at what would be an adjudicatory conclusion were the case a real one but

   

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is instead, in this instance, a rule that applies prospectively to cases of that sort (and of that sort only). The flaw in Davis’s existing formulation is that the deliberator is the administrator or, perhaps, an administrative law judge. The problem is that this fails produce a norm for the exercise of discretion that is independent of the interests of the administrator. Insofar as the implementation of programmatic goals in modern government requires administrators to perform tasks that require a further development of the law than the legislature has so far achieved, the legitimation basis of existing administrative structures is insufficient to so political a task (Habermas 1996, 193). Fortunately, the process of negotiated regulation offers a solution to this shortcoming. Replacing the single administrator as deliberator with a group of citizens, such as a committee of stakeholders, produces a constraint on the exercise of administrative discretion that is independent of the administrator. But in the case of rule-­ making by the adjudication of hypotheticals, we have no stakeholders because no real-world dispute is yet at hand. This is, however, more a strength of the approach than a weakness. When stakeholder committees are used to resolve actual disputes in concrete circumstances, the results are always open to criticism resulting from the fact that parties have been allowed to serve as judges in their own cause. If, however, we use disinterested citizens drawn together in another way, as juries similar to those employed in trial courts, we can allow for the aggregation of perspectives that serves the cognitive objectives of democratic deliberation without surrendering the impartiality of administrative adjudication. This form of administrative adjudication by policy juries would capture institutionally the distinction that Habermas (1996, 273) alludes to when he observes that there is “a structural difference between the communicative power that political communication brings forth in the shape of discursively formed majority opinions and the administrative power available to the government apparatus.” In the last analysis, it is only the former that can genuinely legitimate the later. Finally, hybrid rule-making provides an appropriate framework within which to situate this use of policy juries to formulate administrative rules through the adjudication of hypotheticals. Hybrid rule-making shifts the focus of our attention from the rule-making outcome to the record of deliberation that generated the outcome. The original purpose of this shift, of course, was to enhance the

   



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a­ bility of courts to review the use by agencies of their administrative discretion and thereby to better protect individual citizens whose interests might be overlooked by the agency or overwhelmed by the organized groups that dominate conventional agency procedures. That function would remain, and remain important, in a regime of rule-making through the adjudication of hypotheticals. But a wider process of approximating justice in the use of administrative discretion would be set into motion. This would allow us to address several persistent issues that undermine the legitimacy of administrative rule-making: problems of accountability (or reviewability), problems of democratic representation, and the problem of reconciling administrative rule-making with the separation of powers. Justice is administered (or denied) outside of the courts more than it is inside them. Particularly when we shift our thinking from justice to injustice, our institutional focus shifts with it. The largest cluster of injustices in any modern society resides not in the courts of law, nor even in the administrative courts where the use of administrative discretion is reviewed by administrative law judges. The greatest injustice occurs in the theatre of the mundane, where government officers who are not judges exercise discretionary power without the kinds of procedural protections that courts customarily employ and in ways that are largely unreviewable (Davis 1976). Administrative discretion is largely unreviewable for three reasons. One is that the parties involved often lack the resources, or even the basic knowledge of their rights, that would be required to challenge an administrator whose actions have frustrated their interests. Another reason is that when a society’s administrative actions number in the millions each year and the matters that existing institutions of administrative and judicial review can take up number only in the hundreds or thousands, often there simply is no opportunity to be heard. But most significantly and perversely, many (if not most) of the exercises of administrative discretion that aggrieve individual citizens are in their nature unreviewable because they are decisions to refrain from exercising discretion. The practical implications of this are profound. Every day, every administrator knowingly or unconsciously does nothing – an infinite number of times – on matters involving the environment and health. Generally speaking, decisions of that kind (non-decisions) are unreviewable both as a matter of law and because they would usually leave no record for a reviewing authority to examine.

   

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When a policy jury adjudicates a hypothetical and issues its ruling, a rule for cases of that sort is pronounced. If the hypothetical has been properly structured and the reasons for the ruling have been elicited, an administrative law judge or a court of law would be quite capable of evaluating the ruling for its logical consistency, reasonableness as a matter of policy, compatibility with other existing legal norms, and legality within the statutory boundaries of the agency whose discretion the rule is intended to guide. Legal scholars would be capable of collecting rulings of this sort and subjecting them to the same kind of analysis that has produced the restatements of law that have proven so important in the development of the common law in those countries that inherited legal systems from Great Britain. Ultimately, this kind of ruling can become the raw material for the creation of model codes that would eventually allow for the codification of law that would have a uniquely democratic provenance (Baber and Bartlett 2009). The deliberative discourse described here would thus take place in an arena that is administrative, employ procedures that are judicial, and produce results that are legislative. It would achieve results that are more fully democratic because they are more representative in a specific sense. They allow for the inclusion of all “discourses” relevant to the issue at hand on a more or less equal basis regardless of the relative support each discourse enjoys in the population at large (Dryzek and Niemeyer 2008). This is consistent with Habermas’s insistence that civil society deliberations have some institutional tie-in, which is needed to turn his “subjectless communication” into administrative power through legislation (Habermas 1996; see also Parkes, chapter 7 below). The use of the model code approach facilitates the process going forward in multiple and varied jurisdictions instead of in just a few isolated locations, consistent with Habermas’s increasing focus on the international arena as a site of democratic legitimation (Habermas 2001). Finally, lest this offend our well-developed sense of the importance to democracy of the separation of powers, we should recall Habermas’s (1996, 192) observation that “the division of powers and responsibilities among authorities that respectively make, apply and implement laws follows from the distribution of the possibilities for access to different sorts of reasons and to the corresponding forms of communication that determine how these reasons are dealt with” (emphasis in original). The purpose, clearly, is not to

   



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render less effective the work of government but, rather, to render more effective the citizens’ control over government. An emphasis on the distinctions between the legislature, the judiciary, and administration promotes an “overly concrete understanding led astray by inherited forms of institutionalization” (Habermas 1996, 193). Democratic rule-making, adjudicating, and administrating are never isolated from each other in separate government branches, and indeed are pervasively intermingled as well in the governance institutions of civil society. If a system of separated powers is to achieve its full democratic potential, the logic of the separation of powers must be realized in new structures that promote citizen participation and communicative action “by introducing quasi-judicial and parliamentary procedures” (Habermas 1996, 193) directly into the administrative institutions where most interactions between citizens and their governments take place and where democratic self-­legislation will likely occur – if it occurs.

A n E x p e r i e n c e i n t h e F i e l d   – P r e l i m i n a ry but Promising To explore the potential for administrative rule-making through the use of citizen juries, we have developed a series of deliberative simulations that subject concrete but hypothetical problems of environmental protection to the considered judgment of average people. The context within which we placed these problems is a simulated continent holding four imaginary countries that find themselves involved in various environmental disputes. Our initial trials of these simulations have involved using them as learning exercises for students at the University of Vermont and the Polytechnic Institute of Turin. The first dispute that simulation participants were asked to adjudicate has to do with thermal pollution of a river that made up the border between three countries. The source of the warm water was a collection of new geothermal electrical generating plants built by one country near the river, into which clean but warm water was discharged. The primary result of the rise in water temperature in the river was the disappearance of a species of fish from part of its normal range. This problem was, in fact, designed to model the issue of global warming. In the hypothetical, one of the countries petitioned the court (the student juries) to impose a judgment that incorporated

   

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the relevant features of the Kyoto Protocol’s regime of “common but differentiated responsibility” (cbdr). Our interest was to see whether Americans, when not associating that concept with Kyoto and their own country’s controversial position, would adopt solutions similar to those chosen by citizens of a country that had supported the protocol. At that level, our suspicions that the logic of cbdr was persuasive (when presented to disinterested deliberators) were confirmed. But an interesting divergence appeared that we had not anticipated. On “initial response forms” completed by participants prior to the deliberative sessions, nearly one third of the Italian deliberators mentioned that the citizens of the country that had petitioned for relief relied on the affected fish species as their primary source of protein. These deliberators grounded their support for the petitioning country, not in the logic of state responsibility to avoid transboundary harms, but in the individual right of citizens to enjoy adequate nutrition and to have that right adjudicated in an international tribunal. Moreover, this rationale found its way into one of the three judgments eventually rendered by the Italian deliberators. It did not, however, emerge in the initial response forms or the final judgment of the American participants. To generalize from these results, of course, would clearly be unwarranted. At this point in our research, we are doing little more than trying to achieve “proof of concept” and to produce results that are interesting enough to encourage others to experiment with similar techniques. Nevertheless, the fact that a fundamental right to adequate nutrition emerged from the Italian deliberations and appeared nowhere in the American trials is highly suggestive  – and relevant to our current concerns in some obvious ways. First, environmentalists have often been frustrated by their inability to press their claims with the same success that other contemporary political movements have enjoyed. In particular, the rights rubric, which has been so successful in other areas, has generally eluded their grasp. This, in part, explains the enthusiasm with which some environmentalists greeted the advent of the environmental justice movement (Baber and Bartlett 2005). Whereas it is often impossible to interest decision-makers in protecting the environment for the sake of people in general, it is sometime easier to instill in them concern about the legal consequences of imposing environmental risks on specific people with specific ethnic and racial characteristics. Health

   



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and environmental inequities extend well beyond the obvious connections between ethnicity, poverty, and pollution; among the other politically sensitive social determinants of health well established by social science are age, employment status, housing, transport access, workplace environment, social organization, employment, family structure, diet, and sexual behaviour (Siegrist and Marmot 2006; Marmot and Wilkinson 2006; who 2008). Extending the logic of rights to confront any of the problems of environmental risks to human health would provide a distinctive legal framework within which to conduct the subsequent debate. If environmental health issues are re-conceptualized as rights issues, the potential for substituting jury-like procedures for legislative processes (or, rather, going through the former to get to the latter) immediately suggests itself. Second, efforts to relate issues of human health to environmental protection often run up against certain conceptual categories that give way only grudgingly. Human health, from a medical standpoint, is generally viewed as an individual attribute. Only with the use of mental quotation marks do most people discuss the health of the planet or the health of a human society. What has been lacking until recently is sustained analysis of ecosystem-based perspectives that would take into account the health-related services that an intact natural environment provides (McCally 2002). Promising emerging perspectives include ecohealth, the health society, and community health (Waltner-­ Toews, Kay, and Lister 2008; McQueen et al. 2007; Di Giulio and Monosson 1996; see also Edwards and Davison, chapter 2 above). Researchers who have self-organized into such groups as the Network for Ecosystem Sustainability and Health and the International Association for Ecology and Health have attempted to identify the relationships among environmental and health variables and to expand that conception to socio-political variables. A non-anthropocentric, holistic worldview is increasingly shared by biological scientists. But the challenge of demonstrating concrete and meaningful links between macro/ecological and micro/medical problems remains. It might be useful to start by connecting the concept of an individual right to an adequate diet to threats to individual plant and animal species so as to concretize the fact that the provision of food is one of the principal links between biodiversity and human health (Sala, M ­ eyerson, and Parmesan 2009). Establishing a clear conceptual structure demonstrating the network of relationships between environmental, social, and health variables would make it possible to more ­effectively ­manage

   

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the risks associated with economic modernization and globalization (see also Guehlstorf and Lichtenberg, chapter 6 below, and HansenKetchum, chapter 4 above). Third, the conjunction of a rights-driven legal framework for describing humans and their environment with a relational perspective on the challenge of managing the relationships between human health and environmental protection suggests a distinctly political challenge that must be addressed – the challenge of risk. There currently exists a widespread enthusiasm for modern techniques of risk assessment. In our present context, that enthusiasm manifests itself in the view that these techniques will allow us to protect human health and promote economic prosperity simultaneously (Rodricks 2006). Yet, although it is undeniable that risk assessment deploys an impressive array of sophisticated analytical tools, these approaches disempower people, such as those suffering from multiple chemical sensitivity, who face environmental health issues that fit poorly within standard rubrics of cost-benefit analysis (Kroll-Smith and Floyd 1997). It is precisely in such circumstances of uncertainty that our ongoing debate over the so-called precautionary principle arises. Is the logic underlying that principle (when in doubt, don’t) a sound guide for environmental policy? Or should that principle be scrapped in favour of an “anti-catastrophe” principle that substitutes improved methods of cost-benefit analysis and a form of “libertarian paternalism” designed to protect people’s freedom while giving them a “nudge” in the direction of making better choices (Sunstein 2005; Thayler and Sunstein 2009)? The political challenge is (of course) not to answer this question but, rather, to describe a process by which an answer could be developed. Who should get to decide, what decision procedure should they employ, and to whom should they be held responsible? As the reader will have already concluded, it is our view that the answers to these questions must enjoy a democratic provenance if they are to provide the foundation for policies protecting the environment and human health that meet the twin standards of ecological and political sustainability.

Conclusion Administrative discretion, which is inevitable in the modern governance of health and environment matters, has strong anti-democratic

   



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tendencies. Addressing this problem is necessary if the protection of the environment and human health is ever to be regulated democratically. One response to the expanding discretionary power of modern governance has been to build new forms of participation and arenas for deliberation into the decision-making process of administration itself, so as to avoid the dangers of administrative discretion tethered only to normative premises of its own devising. Using disinterested citizens drawn together as juries similar to those employed in trial courts can allow for the aggregation of perspectives that serves the cognitive objectives of democratic deliberation without surrendering the impartiality of administrative adjudication (although, of course, there would be very real political and institutional barriers to overcome when implementing such an approach). This would address several persistent issues that undermine the legitimacy of administrative rule-making: problems of accountability (or reviewability), problems of democratic representation, and the problem of reconciling administrative rule-making with the separation of powers. Deliberative juristic rule-making can provide a democratic foundation for administrative discretion without compromising the advantages discretionary rule-making enjoys over the option of regulation by detailed legislation. Administrative rule-making for health and environment confronts a set of legal, managerial, and political questions that all modern democracies face and that become ever more pressing as processes of globalization continue. Policy research that could inform more specific policy design would be invaluable, as would an extensive, systematic program of experimentation and simulation. Institutions charged with environmental and health administrative rule-making can address some of the questions of normative principles that their responsibilities entail by building deliberative mechanisms such as policy juries into their institutional procedures. Although administrative institutions can move in this direction by their own initiative, more likely might be legislative mandates or sieges by civil society producing collaborative partnerships with those ngos that agencies cannot afford to walk away from. The necessities of administrative rule-making and the challenges involved in promoting human health by protecting the environment share a similar legal, managerial, and political architecture. They can, in fact, serve as mutually supportive structures. Policy juries, by deliberating hypothetical disputes over health and environment issues, can serve as the flying buttresses of

   

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the human cathedral, allowing light of myriad colours to illuminate our contemplative efforts.

References Baber, W.F., and R.V. Bartlett. 2005. Deliberative Environmental Politics: Democracy and Ecological Rationality. Cambridge, ma: mit Press. – 2009. Global Democracy and Sustainable Jurisprudence: Deliberative Environmental Law. Cambridge, ma: mit Press. Beck, U. 1992. Risk Society: Toward a New Modernity. London: Sage. Cameron, C., P.J. Harter, G. Bingham, and N.R. Eisner. 1990. “Alternative Dispute Resolution with Emphasis on Rulemaking Negotiations.” Administrative Law Journal 4 (1): 83–111. Cooper, P.J. 2007. Public Law and Public Administration. Belmont, ca: Thomsom Wadsworth. Davis, K.C. 1969a. Discretionary Justice: A Preliminary Inquiry. Baton Rouge, la: Louisiana State University Press. – 1969b. “A New Approach to Delegation.” University of Chicago Law Review 36: 713. – 1976. Discretionary Justice in Europe and America. Urbana, il: University of Illinois Press. Di Giulio, R.T., and E. Monosson, eds. 1996. Interconnections between Human and Ecosystem Health. London: Chapman and Hall. Dryzek, J.S., and S. Niemeyer. 2008. “Discursive Representation.” American Political Science Review 102 (4): 481–93. Freund, E. 1928. Administrative Powers over Persons and Property: A Comparative Survey. Chicago, il: University of Chicago Press. Goodnow, F. 1905. The Principles of Administrative Law in the United States. New York: Putnam. Habermas, J. 1996. Between Facts and Norms: Contributions to a Discourse Theory of Law and Democracy. Cambridge, ma: mit Press. – 2001. The Postnational Constellation. Cambridge, ma: mit Press. Kelsen, H. 2006. General Theory of Law and State. New Brunswick, nj: Transaction. Kroll-Smith, J.S., and H.H. Floyd. 1997. Bodies in Protest: Environmental Illness and the Struggle over Medical Knowledge. New York: New York University Press. Landis, J.M. 1938. The Administrative Process. New Haven, ct: Yale University Press.

   



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Marmot, M., and R.G. Wilkinson, eds. 2006. Social Determinants of Health. New York: Oxford University Press. McCally, M. 2002. Life Support: The Environment and Human Health. Cambridge, ma: mit Press. McMichael, T. 2001. Human Frontiers, Environments and Disease. New York: Cambridge University Press. McQueen, D.V., I. Kickbusch, L. Potvin, J.M. Pelikan, L. Balbo, and T. Abel. 2007. Health and Modernity: The Role of Theory in Health Promotion. New York: Springer. Munger, M. 2000. Analyzing Policy: Choices, Conflicts and Practices. New York: W.W. Norton. O’Leary, R. 1993. Environmental Change: Federal Courts and the epa. Philadelphia, pa: Temple University Press. Pederson, W.F., Jr. 1975. “Formal Records and Informal Rulemaking.” Yale Law Journal 85: 38–88. Posner, R. 2008. How Judges Think. Cambridge, ma: Harvard University Press. Raffensperger, C., and J.A. Tickner, eds. 1999. Protecting Public Health and the Environment: Implementing the Precautionary Principle. Washington, dc: Island Press. Rodricks, J.V. 2006. Calculated Risks: The Toxicity and Human Health Risks of Chemicals in Our Environment, 2nd ed. New York: Cambridge University Press. Sala, O.E., L.A. Meyerson, and C. Parmesan, eds. 2009. Biodiversity Change and Human Health: From Ecosystem Services to Spread of Disease. Washington, dc: Island Press. Siegrist, J., and M. Marmot, eds. 2006. Social Inequalities in Health: New Evidence and Policy Implications. New York: Oxford University Press. Slaughter, A.-M. 2004. A New World Order. Princeton, nj: Princeton University Press. Sofaer, A.D. 1972. “Judicial Control of Informal Discretionary Adjudication and Enforcement.” Columbia Law Review 72: 1293–375. Stone, D. 2002. Policy Paradox: The Art of Political Decision Making, rev. ed. New York: W.W. Norton. Sunstein, C. 1996. Legal Reasoning and Political Conflict. New York: Oxford University Press. – 2005. Laws of Fear: Beyond the Precautionary Principle. Cambridge: Cambridge University Press. Thayler, R.H., and C.R. Sunstein. 2009. Nudge: Improving Decisions about Health, Wealth and Happiness. New York: Penguin Books.

   

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Waltner-Toews, D., J. Kay, and N.-M.E. Lister, eds. 2008. The Ecosystem Approach: Complexity, Uncertainty and Managing for Sustainability. New York: Columbia University Press. Warren, K.F. 1996. Administrative Law in the Political System, 3rd ed. Upper Saddle River, nj: Prentice-Hall. Weber, E.P. 1998. Pluralism by the Rules: Conflict and Cooperation in Environmental Regulation. Washington, dc: Georgetown University Press. Whitman, D. 2008. “‘Stakeholders’ and the Politics of Environmental Policymaking.” The Crisis of Global Environmental Governance: Towards a New Political Economy of Sustainability, edited by J. Park, K. Conca, and M. Finger. New York: Routledge. who (World Health Organization). 2008. Commission on Social Determinants of Health. “Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health (Final Report).” Geneva: Author. Williams, S.F. 1975. ““Hybrid Rulemaking’ under the Administrative Procedures Act: A Legal and Empirical Analysis.” University of Chicago Law Review 41 (3): 401–56.

   

6 The Social and Environmental Outcomes of Market-Based Wetland Regulations in the US Midwest nicholas p. guehlstorf and traci lichtenberg

As authors, we maintain that the potential contribution of the environmental sciences to the academic community is to bridge the rationalist laboratory sciences with the pragmatist social sciences. Like many theoreticians and practitioners of environmental risk who become married to an ambitious project, we have come to respect the learning processes and diversity of health and social issues related to environmental phenomenon. This chapter contains elements of Lichtenberg’s thesis – the only one to date chaired by Guehlstorf that involved a student working in industry on technical issues and the physical sciences – but it attempts to be less abstract than most of Guehlstorf’s work. This work is driven by a co-authorial desire of making a bridge from the certainty of science to the necessary values of democratic policy-making.

Introduction United States regulatory authorities – who have traditionally focused on scientific research and regulations – are beginning to incorporate a myriad of formal opportunities by which lay citizens are able to participate in environmental decisions at the local level. These opportunities are supplementary policy tools for some effective environmental regulations, and may prove to be future management solutions regarding intersectional issues of natural resource pollution and human health concerns. This chapter will explore the theoretical application of public participation with a brief demonstration

   

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of a scientific case study involving water quality and current wetland practices in the United States, which is experiencing some challenges with implementation. It is the general intent of this chapter to examine the deliberative elements involved with legitimizing the mechanisms of inclusive public participation. Specifically, we will look at banking mitigation, its effects on rural water quality, and the potential impact of lay participation in Missouri watersheds. This case study speaks to the geographic dispersion of environmental and health risks with a story about the lost potential of meaningful participation and deliberation as policy stakeholders have failed to understand the importance of space. Although it is perhaps obvious to most spectators and participants that environmental risks about watersheds are spatial, it is our objective to actually illustrate the importance of understanding the complexity of both such risks and related policies, as they link both social (distal) and proximal health concerns. The connection between the deliberative and empirical work in this study will demonstrate not only the lack of deliberation in the Missouri watershed management context, but also the regulatory need for deliberation. When present, deliberation provides a mechanism for bridging different social and policy conceptions of space in order to improve understanding of social/environmental/health implications and risks within mitigation banking as a water policy strategy.

Deliberative Democracy and Environmental Policy in the US In order to understand the context and evolution of public participation, an exploration of the political framework for deliberative democracy and its history in the United States is necessary. The underpinning work for much deliberative innovation is the Administrative Procedures Act (apa) of 1941, as it allows for the public’s right to be informed of, and informally participate in, administrative agency processes. The apa’s most evident contribution to civic engagement is the element of transparency it provides to government activities. Under the Act, administrative rule-making must be published and provide a means for public comment (Blomgren ­Bingham 2006). Critics, however, properly note that participatory expansion is often a performance without substance, as an agency may/can proceed with a public hearing only after a policy proposal has been

   



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decided by experts. This serves as a prime example of the intricacies of environmental policy that are not understood by the average citizen (see also Baber and Bartlett, chapter 5 above). Nonetheless, dual amendments to the apa – the Negotiated Rulemaking Act (nra) and the Administrative Dispute Resolution Act (adra)  – were added in 1996 to foster increased opportunities for public participation (Blomgren Bingham 2006). The nra (1) calls for negotiation in the form of an agency’s arrangement of a group of up to twenty-five stakeholders who partake in conversation prior to notice and comment; and (2) offers agencies the ability to use alternative dispute resolution (Blomgren Bingham 2006). Although the stipulations of the Act do not apply directly to any state or local agencies, many states have made use of the legislation’s general authorization to include rules for informal procedures available to the public. State-based expert programs that respect voluntary participation remain the primary facilitator of public inclusion, but some progressive states have gone as far as mandating formal citizen involvement. The work of Dorothy M. Daley explores the variation among states and the causal factors involved, producing a twofold definition of public participation which includes (1) altering political processes by eliminating bureaucratic arguments and (2) “improving citizen satisfaction with the decision-making” (Daley 2008, 22). This unique approach centres on state agency perceptions of public participation rather than on the individual or community point of view. This distinction is essential, as “informal” or voluntary actions are not the policy recommendation; rather, environmental agencies’ “formal” requirements  – such as citizen forums, public comment periods, and public notices – are endorsed. Carmen Sirianni (2009) helps to answer some questions surrounding Daley’s conclusions. Sirianni’s work focuses on the epa’s rising obligation to foster public participation and the corresponding efforts put forth by the Agency, drawing on analysis from interviews with forty-six current and former epa employees, as well as staff of various environmental groups who have worked closely with the agency. Sirianni’s work explores two cases in which epa funding directly facilitated public participation that can be assumed to fall into Daley’s “informal” category: (1) the Chesapeake Bay Program established in 1983; and (2) the National Estuary Program founded in 1987. Both have funded grant programs invested in supporting local groups, as well as in assisting the establishment of new groups

   

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(Sirianni 2009). These grants are tailored to enhance public participation in a number of ways, such as providing added incentives for civic partnership formation among diverse groups. Additional epa-based legislation further enables federal financial assistance. The Clean Water Action Plan (1998) developed by the epa (along with eight other federal agencies), supports funding for the nation’s premier network of watershed management groups: the River Network. The Watershed Assistance Grants (wag) program, a product of such funding, employed a variety of financial tools designed to enhance participatory watershed partnerships. Although the wag program has now ended, it has been replaced by the epa’s Targeted Watershed Initiative, the Center for Watershed Protection, and the International City/County Management Association. These intermediaries offer training to watershed groups and local officials and provide annual conferences encompassing field-based local leadership development and regional watershed workshops. These and other administrative efforts have played an integral role in the civic goal that many have coined “watershed democracy” (Sirianni 2009). The Clean Water Action Plan mentioned above is an example of an emerging style of legislation intended to enhance public participation in the environmental policy process. Blomgren Bingham et al. understand this political innovation to be an entirely new form of governance in which governance and government are not synonymous. The authors view government as “occurring when those with legally and formally derived authority and policing power execute and implement activities” (Blomgren Bingham 2006, 548). This is not to be confused with governance, which is “the creation, execution and implementation of activities backed by the shared goals of citizens and organizations, who may or may not have formal authority and policing power” (548). Here, governance is directly related to civic engagement insofar as its goal is to share decision-making power and encourage citizen autonomy and independence, while providing a process to reach the common good. The authors expand their interpretation of the new governance by augmenting a standard definition: “the collaborative nature of modern efforts to meet human needs, the widespread use of tools of action that engage complex networks of public and private actors and the resulting need for a different style of public management and a different type of public sector, emphasizing collaboration and enablement rather than hierarchy and control” (549).

   



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As administrative agencies are becoming less capable of bearing the workload, environmental regulators are increasingly incorporating, and relying on, citizen involvement mechanisms. With regard to local health and natural resource issues, this regulatory demand is met with an emerging citizenry, which has resulted in a public that participates because it is aware of its political potential. Unlike Parkes’ chapter in this text, which offers a qualitative case study to demonstrate the value of fostering effective environmental decisionmaking, this chapter offers a case study on the scientific relationships of wetland loss and water quality to illustrate how secondary sources (deliberative citizens or lay stakeholders) can use this data for meaningful governance. Although the epistemological framework provided by Parkes is a richer perspective, the rationale for this piece is more didactic or instructional, as many environmental programs formally engage citizenry, but only in order to seek or provide expert or scientific information, which fails to encourage deliberative action. What is missing from many in the banking mitigation community – both experts and lay participants – is an explicit statement or acknowledgment to regulators of how deliberative efforts are present, and a possible method to critique the loss of biological functionality in current wetlands policy. The simple operations of market-based practices such as banking mitigation have profoundly reshaped watersheds with little to no dialogue about why space is important to rural populations and public health. The policy reforms needed to aid in wetland functionality can, therefore, potentially be realized with some of the participatory “spaces” within which people debate and shape environmental discourse. The opportunities present for expanded discourse around those environmental risks are seen in the Missouri survey, but real action has yet to come to fruition. In order to better explain the underlying conceptual framework and normative import of this piece, the following sections will explore the statistical relationships between water quality and permitted wetland mitigation, as well as possible actions by watershed communities. While traditional command and control regulations are in place for watershed protection, they have fallen short in preserving the United States’ natural resources. Similarly, the success of market-based incentives such as banking mitigation has not been comprehensive. This is not to say that these new-style regulations should be abandoned, but rather that they should include

   

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empowered or emancipated communities, as these will prove to be instrumental watershed stewards by adapting deliberative policies. Not all environmental policy issues can or ought to be addressed by deliberative means, but attempts in wetland practices such as banking mitigation are gaining momentum. It is not difficult to see that much of the American Midwest is less than sufficient when it comes to state wetland policy, hence the need for a more deliberative form of governance. Addressed in the last section of this chapter is the economic standpoint of the “Missouri Wetland Project,” which is unique and may pave the way for more inventive approaches to the atrazine problems in rural areas, which may ultimately result in a solid foundation for surrounding states’ public policy initiatives.

Environmental Democracy and Watershed Mitigation Banking While it has been established that the formal opportunity for participation exists and that the informal presence of deliberation is occurring, this does not mean that successful watershed management, or noteworthy wetland mitigation, will happen. Most state environmental wetland programs, which are both voluntary and non-regulatory, involve temporary conservation easements or restoration agreements that require substantial work for private landowners (Zinn and Copeland 2004). It is because of this that banking mitigation, which requires less overall involvement from the private landowners, is becoming the most popular way of preserving wetlands. A wetland bank is a natural resource depository, or watershed reserve, established for the purpose of selling credits, usually in the form of acres, to developers or farmers who need to comply with requirements. City developers and rural landowners who do not have enough land to satisfy the required offsets, or do not want to maintain a wetland themselves, are increasingly purchasing credits from a wetland mitigation bank. Banks are often located ten or more miles from the permitted watershed development. Normatively, it is our assessment that mitigation banking – with its current market-based mechanisms for encouraging compliance – does little to facilitate the deliberative and environmental health dimensions of wetland management. Environmental democracy (including prior local site planning, stewardship practices, and partnership programs), if incorporated

   



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into wetland mitigation, could improve the process by increasing the deliberation of the few policy stakeholders. As such, it has the potential to increase participation qualitatively, rather than just quantitatively. The key to successful implementation of quality stakeholders is to have public buy-in, where concerned citizens take ownership of the issues at hand. Citizens are more likely to take an active interest in wetland issues once they understand why wetlands are important and how this essential natural resource impacts their public and ergo private health. Forcing public participation is not the answer. Instead, finding a way to relate the importance of wetlands to everyday life must be a priority. This active interest will go much further in improving the efficacy of wetland policies than promoting a passing interest from the entire community. Starting in 1983, the US Fish and Wildlife Service (fws) promoted the first use of wetland mitigation banks. In 1989, Corps permits allowing the destruction of a wetland required offsetting, or compensating for, the wetland losses as a legal condition of the development. By 1993, interim Banking Guidance had been issued by the epa and wetland banking was supported in both the White House Office of Environmental Policy’s Federal Wetlands Plan and the Intermodal Surface Transportation Equity Act (usepa 2009). Between 1999 and 2005, Corps-permitted mitigation banks increased from 46 to 450 banks, with nearly 200 more proposed. In 2008 the epa and the Corps issued revised regulations favouring banking mitigation over other types of compensatory mitigation (usepa 2009). The reports offered by these environmental agencies offer exact dollar amounts for the incentive programs.The lowest estimated costs for mitigation were $3,000 to $4,000 per acre (plus land costs) for non-tidal wetland restoration in Baltimore and the maximum was $350,000 per credit (acre) for estuarine wetland in the Norfolk district (eli 2006, 28). Wetland mitigation efforts can also be broken down by type, as a percentage of total acres of mitigation nationwide. The breakdown is as follows: restoration (35.2%), enhancement (30%), creation (20.2%), and preservation (14.7%) (eli 2006, 27). The report also shows the distribution of sponsors for approved mitigation banks as follows: private companies (72.2%), state agencies (14.2%), local government (7%), non-profit (5%), and federal agencies (1.7%) (eli 2006, 27). Therefore, the majority of mitigation bank sponsors are private companies and the majority of banked wetlands are being altered in the form of restoration, enhancement,

   

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or creation. Preservation, striving to keep the wetland in its original form, is the least used option, which is important when looking at the functionality of the wetland. Whether wetlands are being threatened by agriculture or urban sources, mitigation offers a solution for wetland management issues. With substantial growth in the number of permitted banks, it would appear that the implementation of mitigation banking is successful. Some, however, criticize this law and practice because it causes disparities by restoring wetlands outside their original area. In BenDor et al.’s (2007) article, “Assessing the Socioeconomic Impacts of Wetland Mitigation in the Chicago Region,” 1,058 permitted wetland mitigation transactions between 1993 and 2004 were analyzed in the Chicago region. The study shows that mitigation is moving wetlands not only from urban to rural areas, but also between suburban areas. In turn, it proposed that planners take “relocation and redistributive effects into account in setting up and administering mitigation programs, particularly as responsibility for wetland protection shifts from federal to local regulators” (BenDor 2007, 263). Likewise, other research focuses on determining the factors of successful mitigation. Khalid Saeed (2004) notes that the success of mitigation efforts is only through the development model of mitigation banking operating with a variety of regulatory policies. That study shows that the pricing of environmental credits for the mitigation banking system is a difficult task, but by properly utilizing economic and system dynamic ideas, mitigation banking can establish a desirable market. Simply stated, when mitigation banking is properly institutionalized it can “yield both an optimal price for the environmental credits and an appropriate scale for the regulated economic activity without use of engineering methods connecting price to cost of mitigation” (Saeed 2004, 909). Furthermore, the geographical shift of wetlands resulting from the practice of mitigation banking is far-reaching. Previous studies of wetlands in Virginia and Florida have found that mitigation banks are located predominantly in rural areas with low population densities, while the development projects that purchase credits from them tend to be located in metropolitan areas with high population densities (Ruhl and Salzman 2005; Salzman and Ruhl 2006). Thus, wetland banks, while achieving the 1989 legal responsibilities of “no net acre lost,” are facilitating urban sprawl. Wetland ecosystems are migrating from high to low ­population

   



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c­entres, and regions with significant agricultural runoff are often left with low areas of functioning wetlands. Banking mitigation may have administrative (permits, monitoring, submittals, etc.) successes as low as four percent (banks meeting all of their administrative requirements), but most facilities were meeting only approximately three-quarters of their requirements (Kihslinger 2008). These numbers are even lower when looking at ecological (acres, functions, habitat) successes. Quite simply, this means that wetlands are being created but not conserved. This is troubling, as seventy-five percent of these created watersheds are not functioning properly. Even more importantly, this is occuring without any meaningful conversation about the loss of space by ecological citizens. Although humans are social beings, we tend to perceive health and environmental risks as solitary or individualized. A fundamental social and policy challenge is finding methods for making “the connections” realized by citizens. Thankfully, this is a possibility in Missouri (as demonstrated by the survey results noted below), as many see the benefits of wetlands and can reconcile the social and public health benefits with some personal investment. While the framework exists for banking mitigation to be a successful policy tool for land use with sustainable watershed management, it can be aided by the contributions of deliberative decision-making and increased environmental participation by citizens interested in health. Numerous public health consequences coincide with the environmental destruction of wetlands. While these consequences may be diminished with more ecologically rational citizens and through more environmental democracy, the risk associated with the remaining consequences is high and creative policy solutions are needed. Wetlands harbour remarkable filtering capabilities in regards to both biological and chemical contaminants. As the number and quality of wetlands available to filter out pollutants decreases, the potential for those pollutants to leach into drinking water sources increases. Wetland filtration is especially important in those areas where runoff from crop fields is one of the primary sources of non–point source pollution. This runoff often contains chemical residues from herbicides and pesticides, which have been shown to have detrimental, and sometimes deadly, effects on humans such as lowered sperm counts and cancer (Cone 2003; Swan et al. 2003). These pollutants run into nearby creeks and streams or leach into groundwater, ultimately reaching drinking water sources.

   

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While common methods at water treatment facilities are able to remove many of these contaminants before sending the finished water on to consumers, cases of abnormally high pollutant levels in treated water still exist. Additionally, self-supplied sources such as rural wells may not have any treatment for these contaminants. These sources are likely to be located in agricultural areas that are susceptible to pesticide runoff, compounding the problem. To explore the relationship between wetland function, preservation, and water quality, we compared atrazine concentrations from drinking water sources across the state of Missouri. Atrazine is a synthetic herbicide applied to a majority of crops in the United States and is prevalent across the Midwestern United States, but has been banned in the European Union due to groundwater contamination concerns. For example, studies on laboratory frogs exposed to atrazine levels as low as 40yrs) Co-researchers: See Table 7.4 for details of coresearcher participation, including initiation and types of collaboration. Advisors: Agreed levels of communications, updating, advice and exchange, including written agreement with local M ˉaori regarding processes and procedures. Survey respondents: 13.4% of the target population were sampled and 496 residents responded (47.6% female, 26% over 65 and 19.8% retired. Overall response rate 37.5%)

Public / community spaces: Local community halls, council chambers, library meeting rooms

On University of Otago campus and in catchment communities for crg-researcher meetings Generally in organizational offices or relevant meeting venues

Survey respondents completed the survey in location of their choice (own home, kitchen table?)

Source: Parkes and Panelli 2001, Parkes 2003a, Parkes 2003b

provides an explicit visual depiction of different dynamics and “directions” to be considered when designing participatory processes. ( x ) T y p e s o f pa r t i c i pa n t ( W H O i s i n v o lv e d ? )  This axis takes into account the simple and often pragmatic fact that not all stakeholders will be able to become participants and therefore a

   

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Figure 7.1 Type, mode, and place of participation: Three axes influencing the design of participatory processes. (Adapted from Parkes, Brisbois, et al., 2012, Figure 1.1, published under Creative Commons Licence. http://creativecommons.org/licenses/by-nc-sa/3.0/)

stakeholder-participant transition is required (see axis x, Fig. 7.1). This demands a careful process of identifying, selecting, and justifying which stakeholder groups and types of knowledge are most relevant to ongoing research – including the design of research to best answer research questions and informing important decisions about appropriate modes and places of participation. These decisions may be informed by categories such Janicke’s (2008) differentiation of “different levels of authority,” “types of actors,” and “sectors,” or Brown’s identification of individual, community, organizational, and specialized knowledge cultures (see also Brown 2007, 2008). Explicit attention to types of participant is also consistent with what Charron (2012) has described as a “Participatory Design” phase for ecohealth research, informed by the system, stakeholders, power dynamics, and the nature of the problem.

   



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( y ) M o d e s o f pa r t i c i pa t i o n ( H O W d o t h e y pa r t i c i pa t e ? ) This axis highlights the need to clearly identify in what ways participants will be involved and what roles and responsibilities they will have within the ongoing research process (see axis y, Fig. 7.1). Considerations of importance here include understanding of Arnstein’s Ladder of Participation (Arnstein 1969) and related work highlighting the spectrum of ways to take part and share in research processes, including “consultation,” “cooperation,” “colearning,” and “collective action” (see Parkes and Panelli 2001). Informed by the copar methodology, the modes of participation in the TCandCH Project are summarized in Table 7.3, including explicit negotiation of different roles and responsibilities within the participatory research community (community reference groups, coresearchers, advisors), in addition to more traditional “research participants” participating in primary data-collection methods such as the TCandCH Survey. ( z ) P l a c e o f pa r t i c i pa t i o n ( W H E R E d o t h e y pa rt i c i pa t e ? ) Explicit attention to the locations where participation took place was an essential feature of the TCandCH Project and echoes the focus on re-coupling of people and place (see axis z, Fig. 7.1). Attention to the place of participation does not refer simply to location, but to the rich insights gained from understanding the social-ecological (including ecological, historical, economic, and cultural) context of those who are taking part in and sharing in the participatory process. The places that participants come from in order to participate, as well as the places in which participation, sharing, and exchange occur, inform options for types and modes of participation, as well as opportunities for integration and collaboration. Attention to the type, mode, and place of participation was influential throughout the TCandCH project, and especially as background to the research design decisions that defined the stakeholder-­ participant transition and subsequent participation. Findings during the initiation phase regarding the relative lack of accessibility or profile of “local” place-based and “community knowledge” were very influential in this regard (see Brown 2008; see also Dalton, chapter 9 below, and Morrison et al., chapter 8 below). The awareness and profile of community knowledge contrasted sharply with the relative abundance of catchment-based research and publications available in the public domain, including ecological and limnological research

   

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and the development of cultural impact assessment tools (Townsend, Crowl, et al. 1998; Townsend, Dolédec, et al. 1998; Townsend and Riley 1999; Schallenberg et al. 2000; Schallenberg and Burns 2003; Schallenberg, Burns, and Peake 2003; Townsend et al. 2004; Tipa and Welch 2006). Awareness of these contrasts led to the decision to orient future phases of primary research toward the knowledge and preferences of community reference groups and to view this as a complement to ongoing interaction and research integration with an interdisciplinary team of co-researchers from the University of Otago (Table 7.3). Community participants shaped their relationship with researchers through these reference groups, electing how they wished to become involved (or not) in ongoing phases. Periods of reflection between phases of research (Table 7.2) created opportunities for the types, modes, and places of participation to evolve as the research developed through different stages.

I n t e g r at i o n , P a rt i c i pat i o n , a n d C o l l a b o r at i v e L e a r n i n g “ B e yo n d ” t h e Community Many “participatory” research processes tend to focus on community participants, without explicit attention to the role of researchers (and the academy) in relation to knowledge integration, participation, and collaboration. This section profiles specific insights arising from the explicit involvement of co-researchers as part of the participatory research community and specific collaborative initiatives initiated in the third phase of the copar process (see Table 7.2). In addition to the initiatives selected as a result of interaction with community reference groups (the TCandCH Survey, cross-­catchment community meetings, and specific activities with community reference groups), Phase II also involved the identification and selection of specific cross-disciplinary collaborative projects designed and conducted with co-researchers. Two of these collaborative initiatives involving co-researchers are examined here as a means to highlight the importance of integration, participation, and collaboration “beyond” the catchment residents and community. This section provides additional insights into the central premise “integration is not enough,” noting that knowledge can only be transformed into action through the participation of those involved. Specific attention is given to “second order” (Ewing et al.

   



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1997) and “operational” insights (Gross-Stein et al. 2001) regarding two collaborative projects referred to as “Integration of Ecology and Health at the Catchment Scale (cp1)” and “From TCandCH Project to taieri Trust – A copar Evaluation (cp2).” The overview of the two collaborative research projects provided in Table 7.4 highlights the degree to which knowledge integration within the TCandCH Project is a “social” process between those who take part in and share in the research process throughout the project’s life-cycle. Opportunities for interaction and integration within each project are identified in relation to seeking or establishing funding, conceptual integration, integration of research design, technical and/or practical techniques for data collection and analysis, interpretation, and integration through knowledge dissemination. A key feature of Table 7.4 is an analysis of the two projects in relation to three counterfactual questions developed by Gross-Stein et al. (2001, 33) to assess the “quality” of the operational knowledge generated by the collaborative projects. These questions focus on the process through which knowledge is produced and transferred, rather than making specific judgments about the research itself. The questions also ask: (a) Would we know less if this collaboration had not been created? (b) Would we know differently if collaborators had not had the opportunity to work together? (c) Would we have known what we know more slowly or less widely if the knowledge had not been disseminated by the research? Reflection on the project entitled “Integration of Ecology and Health at the Catchment Scale” (cp1, Table 7.4) highlights informative challenges when initiating collaboration between doctoral researchers, due to the conflicting pressures to generate one’s own (unique) contribution to knowledge while working closely with others. In turn, this required careful (re)negotiation regarding the inevitable overlaps and shared findings, and maintaining clear communication with common supervisors and other co-researchers with whom both doctoral students worked. A different kind of initiation is presented in the project “From TCandCH Project to taieri Trust  – A copar Evaluation” (cp2, Table 7.4). An invitation to the emerging taieri Trust for inclusion as a case study in a national meta-analysis of community action research (Greenaway and Witten 2006) led to the choice to distinguish the evaluation process as a distinct phase of research with the three Community Reference Groups. This research explored the

   

Table 7.4 Linkages between Integration, Participation, and Collaboration in the TCandCH Project Collaborative Project Characteristics

Integration of ecology and health research at the catchment scale1 (cp1, see also Parkes et al. 2004)

From TCandCH Project to taieri Trust – A copar evaluation (cp2, see also Parkes 2002, Parkes 2003)

Establishing collaborative relations with multiple stakeholders Initiation of collaborative Negotiated collaboration Informal collaboration with ­relationship between doctoral students co-researcher and advisory (and supervisors) based on participants, initially focused overlapping research interests on researcher/facilitator, then converged with reference groups to evolve through “partnership,” “alliance,” and “trust” Mode of participation and type - Co-operation and co-learning - Cooperation and co-learning of participant with research colleagues as with community reference co-researchers groups, university co- Cooperation with community researchers reference groups - Consultation and coopera- Consultation with agency/iwi tion with agency and iwi coadvisors researchers C o u n t e r f a c t ua l q u e s t i o n s ( G r o s s S t e i n , 2 0 0 1 ) (a)Would we know less without Perhaps. Both PhD researchers Yes. The collaboration between the collaboration? needed to respond to their crgs and co-researchers own priorities and constraints within the taieri commuand generated complemennity-university partnership tary rather than more findgenerated new findings ings. Without the collaboraregarding multi-stakeholder tion, the lack of integration processes. This data would would have created a knowlnot have been available withedge deficit regarding the out both reference groups links between projects and co-researcher collaboration (b) Would we know differently Yes. Emergent knowledge Yes. The evolution toward the without the collaboration? regarding the links between taieri Trust would not have the biophysical and participabeen possible without coltory research (through both laboration between crgs researcher and community and university participants. interpretation of findings) Different and more limited would not have resulted from perspectives would be availindividual effort able without it (c) Would we know more slowly Yes. The collaboration did Yes. The links between crgs and less widely without the extend the capacity of the and co-researchers and collaboration? two PhD research projects, advisors reflected increased generated shared language learning, research, and “disaround ecology and health semination capacity” across research and created wider the participatory research disseminated of findings community

   



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Table 7.4 continued Multiple Axes of Integration though collaborative learning and actions (Parkes and Panelli 2001; Parkes et al. 2005) Integration between partici- Builds horizontal links - Community-university partpants and projects between researchers nership formalizes vertical - Vertical links for disseminalinks between community and tion through taieri1 Trust university and future reporting - Building capacity for vertical - highlights the importance of and horizontal links (within vertical link with community and between community, for dissemination agency, researcher, iwi) through taieri1 Trust aims 1 The taieri (Taieri Alliance for Information Exchange and River Improvement) Trust (2001–2006) aimed to: enhance existing relationships and partnerships between communities, researchers, and agencies; establish a catchment information exchange system; implement actions for environmental improvement; evaluate and review the catchment approach.

evolution of collaborative relationships among community reference groups, co-researchers, and advisors in the transition from the TCandCH Project to the taieri Trust and resulted in a separate discussion paper (Parkes 2002). The copar evaluation highlighted the benefits of flexibility within a copar process and the capacity to integrate new opportunities arising during the course of collaborative research and activities. In combination, the two projects highlight the different levels of formality that evolved during the TCandCH Project, involving both university co-researchers (formalized through design, implementation, or sharing of specific research projects) and advisory colleagues (less formal, but developed through correspondence, communication, and regular informal meetings with the researcher/facilitator). For both projects, modes of participation also evolved during the course of the research, commencing in most cases with “consultation” or active “cooperation” in the establishment phase and progressing to “co-learning” and in some cases “collective action” as community-university relationships and actions developed (see also Martin 1996; Parkes and Panelli 2001). Gross-Stein’s (2001) three “counterfactual questions” provide a useful guide to reflecting on the two collaborative projects as a catalyst for knowing more, differently, and faster (Table 7.4). When considering whether we would know less without collaboration among co-researchers, both collaborative projects responded to knowledge deficits by generating new (otherwise unavailable) knowledge and

   

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integrating findings that would have otherwise remained separate, thus combining to know more. Since the lack of integration in health and sustainability issues is a form of knowledge deficit in its own right, this integration of knowledge also offers a critical opportunity to know more. Furthermore, Table 7.4 summarizes how both projects generated a different type of knowledge than what would have been achieved in isolation, consistent with what Woollard (2006) describes as the scholarship of integration, application, and engagement (see also Table 7.1). Interaction between co-researchers and within the participatory research community also provided new opportunities for dialogue, discussion, and sharing of results, enabling recognition that results would have been disseminated and known more slowly and less widely without these two collaborative projects. Perhaps most importantly, the ongoing involvement of diverse coresearchers and advisers enabled multiple axes of integration that directly influenced the evolution of the TCandCH Project. Mutual awareness and growing familiarity among the community reference groups and co-researchers were especially influential in the transitions from “community reference group meetings” (Table 7.2, Phase II), to the wider “cross-catchment community meeting” as a step toward a “community-university meeting” in November 2000 (see Table 7.2, Phase III). The subsequent development of community-­ university interactions through phases of “partnership,” “alliance,” and “trust” were also actively encouraged by the “in-kind” and written support of non-academic advisors involved throughout the project. Examining the influence of specific collaborative initiatives within the TCandCH Project helps to debunk the idea of participatory research as being restricted to “communities” and makes explicit the roles, responsibilities, and complexities of academics and researchers as research “participants.” At the same time, the ideas examined here help to reveal the many ways in which collaborative relations formed with community reference groups are different from those formed with co-researchers and advisors, reflecting not least the different power dynamics and different motivations that influenced the evolution of the TCandCH Project.

“Multiple Axes of Integration” as a Basis for Ongoing Collaborative Learning The collaborations of the TCandCH Project not only increase “what we know” (understanding of the problem), but also opportunities

   



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to “know what we know” (through the interactions across and between participants and “knowers”). In the final row of Table 7.4, the interactions across and between co-researchers and community reference groups are described using the terminology of “horizontal” and “vertical” integration (see also Parkes and Panelli 2001; Parkes et al. 2005). Horizontal connections refer to connections and capacity for links across similar stakeholder groups. These horizontal relationships reflect what Pretty and Ward (2001) describe as “Local-Local connections” (horizontal connection between groups within communities, or between communities which sometimes become platforms and new higher-level institutional structures) and “External-­External connections” (horizontal connections between external agencies leading to integrated approaches for collaborative partnerships). As the TCandCH Project evolved, horizontal connections arose across community reference groups from different catchment locations; across researchers in different disciplines working within the Taieri catchment; and across agencies with different sectoral mandates (conservation, environment, health) consistent with insights from other catchment- and watershed-based research (see McGinnis et al. 1999; Mullen and Allison 1999). The latter phase of the TCandCH Project, and particularly the evolution from TCandCH Project to taieri Trust, was characterized by vertical integration. Vertical integration among different types of stakeholders or among several layers of stakeholder involvement is described by Pretty and Ward (2001) as connections between local groups and external agencies or organizations. Vertical integration implies connections to “other,” and can be used to describe initiatives that cross the interface between researchers and policy agencies, that create new partnerships between researchers and communities, or that potentially create a platform for ongoing relationships or actions involving communities, researchers, and agencies. In the TCandCH Project, multiple axes of integration were identified, combining horizontal and vertical interactions across and between different stakeholder groups and providing the basis for ongoing multi-stakeholder processes. The community-­ university meeting in November 2000 exemplified a vertical connection between community reference group representatives and university co-researchers. This interaction led to the formalization of a community-university partnership under the title “The taieri Catchment Forum” (taieri = Taieri Alliance for Information Exchange

   

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and River Improvement). Initial funding from the Otago University Research Committee provided the financial and human resources to support the early stages of this partnership. The initial taieri community-university partnership was viewed as a “stepping-stone” toward the successful application for external (national) funding for the taieri Trust. The community-university partnership effectively built capacity for improved coordination, future partnerships, and multiple axes of integration, without compromising local communities’ sense of autonomy. Participant descriptions of the community-university partnership highlight the multiple and two-way benefits for university and community partners: Although I’ve never really had a lot of time for all these intellectual people at the university, obviously one has to accept that they really can cut through … they know the right areas, the right way to do it. And it just shows that if you work together, how far you can come. (Lower Catchment Evaluation meeting, June 2001) Importantly, community reference group participants could also see advantages for the university from being aligned to a representative community catchment forum. Reference group members felt that university research, which was otherwise overlooked, could gain both credibility and acceptance if channelled through a community vehicle such as the taieri Trust (Cross-catchment meeting, Group 4, October 2000). University co-researchers strongly agreed with this co-benefit, echoing the reciprocal need and motivation for information sharing. Well, if there are mitigating things that happen, that prevent people from being in danger, then that’s got to be good. You know, this is where the information sharing comes in – and the fact that it is, has been studied and you know, it has a sort of official stamp on it, saying “this is what might happen,” – then that is really a good idea. (Lower Catchment Evaluation meeting, June 2001) A recurring theme for reference group participants was inspiration, enthusiasm, and learning generated through contact with r­ esearchers.

   



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A notable example of this was impressions made through efforts to present extensive research conducted in the Waihola–­Waipori Lake– Wetland complex (Schallenberg 1997; Schallenberg and Burns 2003; Schallenberg, Burns, and Peake 2003) to local residents at annual general meetings of local community groups. We are coming to realize how wonderful [the] river is because the University has studied in detail the things that we don’t see. Like we can only see on the surface, but the University people get into the mud and into the fish and the wildlife and stuff like that, you know and it’s a bit like “Our World,” when you see something on TV and it opens all up for you. (Lower Catchment Evaluation meeting, June 2001) Such precedents provide invaluable groundwork for ongoing community-university links within the Taieri. Community impressions of the benefits of working together with the (human, financial, and experiential) resources of the university are indicated by the following lively exchange during the Lower Catchment Evaluation meeting: lce4: And I suppose another thing is that we’ve learned just how much you can do by getting a lot of local people together, that have got common interests and bringing in the people from the university who have, well I don’t know, but I guess they’ve got more knowledge of the systems and the details … And they know how to cut through a lot of the stuff if you are going to get something like this going. So you may say it takes a long time. Well, I suppose it has. But when you look back, we’ve gone a long way. How long have we been going? A couple of years or something? But really to get where you are now with this taieri forum thing virtually up and running. You know if it was just left to just us, as little people who live beside the river, we’d still be sitting around the thing here talking about it … lce1: We probably wouldn’t have had our second meeting! lce4: Right! We would be no further ahead. (Lower Catchment Evaluation meeting, June 2001) Transitions to new phases and cycles of activity create both opportunities and obstacles, with the potential to highlight new or existing conflicts and a variety of vulnerabilities (Goff 1999; Hemmati

   

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2001). During reflection and evaluation, TCandCH Project reference groups highlighted a variety of potential tensions and obstacles that would be faced in an ongoing multi-stakeholder process – reiterating the importance of maintaining communication, feedback, and a focus on people to offset this. My biggest concern is that, yeah you’ve got the people that have an interest in the catchment alongside you at the moment. But, as I said before, if a particular issue comes up, you’ll find you’ve got to deal with other people that haven’t got an appreciation and understanding of the whole catchment … [so] keep the feedback coming. Take care not to focus on political issues such as irrigation. Keep people as a critical element. (Upper Catchment Evaluation meeting, June 2001) Concerns raised about demands on already stretched voluntary services highlight the importance of maintaining the community orientation in order to prevent the process from becoming impersonal or losing the features that made it a “vital alive focus group.” These comments reinforce the importance of the interweaving of social and ecological concerns, with a combined focus on place and people as a critical factor for ongoing collaboration and learning. As the second stage of funding from the Ministry for Environment’s Sustainable Management Fund came to a close, the chair of the taieri Trust in 2004 provided a succinct reminder of the personal, place-based resonance and benefits of linking ecosystems, equity, and health during the TCandCH Project and its future iterations: “from the source to the sea, our use of the river affects others downstream for better or worse. The Trust has shown everyone can help to improve the health of the river; school children, fishermen, farmers, university academics, local bodies, government departments, power companies and recreational users can all play a part in making the river a better place” (taieri Trust 2006, 3).

Synthesis: Collaboration and Learning t h a t L i n k E c o s y s t e m s , E q u i t y, a n d H e a l t h The TCandCH Project case study demonstrates how a combination of integration, participation, and collaboration were woven into an unfolding story that engaged both people and places influenced by

   



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Taieri River. The project highlights the possibilities arising when we “just add water” to overcome barriers to addressing ecosystems, equity, and health in a cohesive manner. This section highlights some overarching lessons from the Taieri case study, including efforts made to dissolve barriers to collaborative learning and research and links to new developments. One way to synthesize these lessons is to reflect on the hazards and challenges that could have arisen in a project such as this if different approaches had been taken. The following questions were identified in the process of TCandCH Project evaluation as useful prompts to reflect on Taieri case-study experiences, yielding not only a range of insights about integration, participation, and collaboration, but also their relevance to concerns that span health, ecosystems, and equity: Could a community-university partnership have been successful if the project had focused on integrating knowledge from researchers and agencies only, with no recognition of the place-based knowledge of the local catchment communities? • Would the sense of ownership and engagement in a cross-­catchment meeting have arisen if the initial community reference group meetings had been held in only one part of the catchment, requiring members from other areas to travel several hours to attend? • Would a diverse, multi-stakeholder taieri Trust have been possible if the collaborative catchment efforts had been designed without attention to the integration of existing knowledge and without spending the time to establish relationships among different members of the participatory research community? •

The combination of horizontal and vertical integration in the TCandCH Project is notable as an effort to “integrate knowledge across and beyond academic disciplines” (Parkes et al. 2005, 259). This approach is consistent with the framing of transdiciplinary research as a collaboration among “academic as well as non-­ academic thought styles” (Pohl 2011, 618) with respect for diverse cultures of knowledge providing a sound conceptual and procedural platform for future cycles of collaboration and collective learning (Brown et al. 2010). Such experiences help to strengthen a sense of trandiscipinarity as a central guiding feature of ecosystem approaches to health (Lebel 2003; Charron 2012).

   

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The evolving participation of community reference group members in the TCandCH Project highlighted a dynamic of people in relation to their place and location within the catchment, and a growing concern for the entire river as a reflection and responsibility of those who lived throughout the river basin. This was especially evident in the community-driven push for a “cross-catchment community meeting” as a first step of learning and exchange among participants from different community reference groups, and the clear orientation to overcoming barriers to linking upstream and downstream concerns. The connections between place and people factored heavily in the clear decision to host the first “communityuniversity meeting” in the community hall in a small central catchment location. The willingness of a group of senior professors to travel several hours to join community representatives in a small catchment community (as compared to the common “default” of community members travelling to the university to meet with professors) was of significant symbolic value. This attention to the place of participation was considered an important factor in the community’s willingness to establish the taieri community-­university partnership. The TCandCH Project case study illustrates a complex, emerging social process (involving diverse community, research, and agency participants) that was continually grounded and referenced to the Taieri River as a place, a metaphor, and a living system. Likewise, concerns for equity manifested throughout the process, not only in relation to traditional power dynamics between types of stakeholders, but also equity between different catchment locations through the explicit choices about where, with whom, and how research interactions took place. Quotes from participants (noted above) highlight the dynamic interplay of equity, ecosystems, and well-being. Notable examples include the description of the pleasure gained from improved access to insights into the ecosystem within which they live and interact (“University people get into the mud and into the fish and the wildlife and stuff like that, you know and it’s a bit like ‘Our World.’”) Similarly, the motivation of working together with university players was seen as a vehicle to preventing future inequities arising, whereby the exchange of information provided a shared focus as a means to prevent future inequities by “mitigating things that can happen, that prevent people from being in danger.”

   



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While the developments during and after the TCandCH Project were not always focused explicitly on health and well-being, a view of integrated watershed (catchment) management as an investment to improve the social and environmental factors determining health continued to feature throughout. In the final stages of project evaluation, the links between ecosystems, equity, and the determinants of health were reflected in community reference group selection of the three integrating concepts of “lifestyles, livelihoods and living systems” as their descriptors of their motivation for engaging with whole-of-catchment activities and involving diverse taieri partners. These themes were echoed in subsequent taieri Trust activities, including the title of the first taieri Trust symposium, which was “Taieri Waterways: Sustaining Our Lifestyles, Livelihoods and Living Systems” (Robertson 2004). The lifestyles, livelihoods, and living systems “trio” provides a succinct reminder of the links between the social and ecological determinants of health and the value of a view of health and well-being that is directly engaged with people and place. In the years following the TCandCH Project, subsequent phases of activity at different scales within the catchment have continued to explore the themes of health, ecosystems, and equity that were central to the TCandCH Project (Parkes et al. 2009, Box 7; Tyson et al. 2005; Robertson et al. 2009; Newman and Roberston 2010). Following two rounds of funding for the taieri Trust from the Ministry for Environment’s Sustainable Management Fund, a series of mutually negotiated and pragmatic decisions saw a return to the priority issues of water quantity and quality in the dry highlands of the upper catchment. In 2007 the Upper Taieri Water Management Steering Group was successful in identifying new opportunities for funding from the New Zealand Ministry of Agriculture and Forestry’s Sustainable Farming Fund. The 2007–2009 project overview for “Effective Community Water Resource Management” states: “This project builds on the existing concept of community-led decentralised irrigation schemes/companies and brings in a new component  – multi stakeholder involvement. The project couples a farmer-led scheme with the formalized involvement of a multi stakeholder ‘Catchment Management Group’. The group will implement project deliverables which will develop better relationships, improved monitoring, smoother Resource Management Act processes, fairer whole-of-

   

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community outcomes, improved environmental outcomes and more efficient use of water” (sff [Sustainable Farming Fund] 2007). The Sustainable Farming Fund initiative points to the ongoing relevance of fairness equity and multi-stakeholder processes in future phases of collaborative initiatives in the Taieri and reiterates the TCandCH Project emphasis on links between health, equity, and ecosystem sustainability. These are reminders of the potential to “just add water” to complex governance processes – dissolving artificial boundaries between environmental, social, and health priorities. A more recent phase of the Sustainable Farming Fund (2009–2011) was entitled “Redefining Upper Taieri Water Allocation and Management for Whole of Community Good” and continued to focus on working with the community, stakeholders, and environmental bottom lines to determine fair, sustainable allocation regimes (­ Robertson et al. 2009). Among other efforts, this project hosted a National Workshop in the Upper Taieri focused on “Community-Led Water Resources Management.” Outputs from this event highlight the importance of management that links water-quality and water-quantity concerns, and of community-led approaches where top-down policies do not override community priorities and where “scientists should be on tap, not on top” (Newman and Robertson 2010, 11). Project coordination continues through the nz Landcare Trust. The initiatives in the Upper Taieri reiterate ways in which “adding water” reconnects fundamental concerns that span water quality and quantity, community identity and stewardship, and concerns regarding safety, supply, and sources of drinking water, as well as “whole of community good” linked with livelihoods, living systems, and lifestyles, extending to include socio-economic well-being and mental health concerns (e.g. during drought or floods). The continued concern about, and commitment to, water quantity and quality issues in the Taieri appear to be providing ongoing motivation and lubricant for future iterations of integration, participation, and collaboration among diverse groups with common concerns for health and sustainability.

Conclusion In the years the TCandCH Project research was conducted (1999– 2001), the field of ecohealth and the particular orientation to “ecosystem approaches to health” were beginning to emerge in literature

   



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and associated international projects, especially those funded by Canada’s International Development Research Centre (Forget and Lebel 2001; Lebel 2003). Since this time, the field of ecohealth has expanded to become explicitly associated with an international journal, its own Association, and a more nuanced understanding of the links between social and ecological interactions, their relationship with human health, and their relevance to sustainability (De Plaen and Kilelu 2004; Waltner-Toews 2004; Wilcox et al. 2004; Aguirre and Wilcox 2008; Boischio et al. 2009; Webb et al. 2011; Parkes 2012). Although the TCandCH Project was not an ecohealth project per se, it resonates with and provided informative lessons for the author’s involvement in this emerging field. The findings in this chapter are part of a growing body of systematic and critical reflection on the purpose, participation, and processes that guide ecohealth and other approaches to addressing health and sustainability concerns. A starting point is the need for conceptual integration that reflects the important, reciprocal interactions between social and ecological determinants of health. This requires approaches that seek the links between ecosystem change and socio-economic well-being (including livelihoods) and the ways in which social processes are coupled with the ecosystems on which they depend. The theme “just add water” was woven throughout the chapter to highlight the place-based nature of the collaborative learning processes and ways in which this case study sought to dissolve unhelpful divides between people and place, equity and ecosystems, society and nature – especially in relation to health and well-being. Insights from the TCandCH Project help inform understanding of  – and strategies to overcome – the persistent biophysical and social biases that can arise in ecohealth and related work. The findings from the Taieri case study highlight the limits of considering conceptual and knowledge integration in isolation from the people, processes, power dynamics, and places that determine the social-ecological context in which we work. Instead, integration is better realized when seen as a result of decisions around what knowledge will be valued; who will be involved in integrating this knowledge; and how and where this participation will take place (the type, mode, and place of participation). Finally, integration attains a whole new potential when seen as part an ongoing process of collaborative learning and actions that manifest, apply, and bring to life the benefits of working together.

   

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A c k n ow l e d g m e n t s I acknowledge the time, enthusiasm, support, and encouragement of individuals and groups throughout the Taieri River catchment who were involved with this project. I am especially thankful to those who attended project events, and for the kind hospitality and generosity that was a continuous feature of my fieldwork, at meetings, in homes, on farms, or at workplaces. The research was supported through funding support from a New Zealand Health Research Council Training Fellowship. Earlier versions of the ideas in this chapter received helpful input and review from my PhD supervisors, Dr Ruth Panelli and Dr Philip Weinstein, as well as from Homaida Razack. The final writing and refinement of this chapter was enabled, in part, thanks to funding support from the Canada Research Chairs program.

note 1 “The community” is a concept that has received explicit attention in other contexts due to its potentially exclusionary and homogenizing t­ endencies, and is acknowledged as both a socio-cultural construct and a powerful rhetorical notion in lay, academic, and policy discourses (Liepins 2000b). COPAR recognizes and supports social diversity, change, and even disagreement within a process of “community” action and research (see Liepins 2000b; Panelli 2001).

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section three

Linking Ecosystems, Society, and Health through Learning and Local Knowledge Section III: Linking Ecosystems, Society, and Health through Learning and Local Knowledge includes three chapters that explore the practical implications of intersecting social, cultural, and ecological values and how these values engage with understandings of, and approaches to, health and well-being. Each contribution provides examples of practical efforts to adapt and respond to changing social-ecological contexts, and each is fuelled by the “bottom-up” drivers of learning, meaning-making, and sharing among different kinds of knowledge and experience. Whereas themes of interpretation, participation, and deliberation are at the foreground in earlier sections, an adaptive characteristic that is especially relevant in this section is “practicality” (Hajer and Wagener 2003). Each chapter pushes us to consider both why integration among different kinds of knowledge may be important to understanding complex contemporary issues, and also provides practical examples of how the integration of social, ecological, and health concerns arises through reciprocal relationships, critical reflections, and learning about the tools and processes we use. Whether through communities of practice, international volunteering, or strengthening capacity for culturally engaged storytelling, each chapter provides practical insights regarding the dynamics and consequences of learning and boundary-crossing among different kinds of experiences and knowledge for individuals and groups. In Chapter 8, Situated Learning, Community Development, and Ciguatera Fish Poisoning in Cuban Fishing Villages, Karen ­Morrison, John Fitzgibbon, Arnaldo Castro Domingues, and Pablo Aquiar examine ciguatera fish poisoning (cfp) as an example of

   

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how actions, attitudes, and behaviours are shaped within a socialecological system experiencing a prolonged absence of scientific information. This chapter, more than many in the collection, demonstrates the practical implications of ‘convergence’ for an issue that spans social, ecological, and health concerns. cfp is a foodborne illness caused by the consumption of toxic fish that have bioaccumulated potent marine biotoxins. Based on research conducted in three Cuban coastal communities on the north shore of La Habana, this study applies situated learning theory, an approach that emphasizes activity, context, and culture, providing a way to interpret empirical data related to a community’s knowledge and action. The results of the study show that both social and ecological factors play a part in determining the level of cfp outbreaks. Whereas many fishery communities did not look beyond the catch of the fish to consider the health of the coral reefs, this project sheds light on the role of community learning and interaction about them that helped to buffer the lack of proactive policies to address the social-ecological context of outbreaks. This chapter stresses the importance of community knowledge – exemplified by the local fishermen whose understanding of the fishing industry and the social and cultural life of the community provides essential insights to address the converging ecological, social, and health dynamics of cfp. Chapter 9, Religion, Environment, and Health, by Anne Marie Dalton argues that religion effectively promotes ecological sustainability and fosters human health, and that this contribution is achieved in two ways. First, nature is protected through institutional and community resources that allow access to considerable numbers of people, in addition to having religious meanings that include ecological meanings that enhance sustainable activity. Second, religious contributions to social capital hold power in society and have developed into a significant academic and socially engaged field. Religion provides opportunities to see that humans are an integral part of nature, rather than a dominant part. Two international case studies are presented as practical demonstrations of how comprehensive religious meaning functions in the practices in which humans engage, including international volunteer efforts. This author proposes that through the production of meaning, religion offers a way to value the environment, as well as highlighting the need for a sustainable world for human health. Religions are

   



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able to capitalize on their social and institutional access to resources and to develop appropriate meaning systems to address the need for hope and purpose in the light of ecological crisis. Chapter 10, Integrative Science and Two-Eyed Seeing: Enriching the Discussion Framework for Healthy Communities, by Cheryl Bartlett, Murdena Marshall, Albert Marshall, and M ­ arilyn Iwama focuses on integrative science (bringing different worldviews together) and two-eyed seeing (bringing together different perspectives) in academia and research in order to facilitate, create, and nurture opportunities for meaningful engagement with perspectives beyond scholarship’s conventional walls. This chapter presents the authors’ co-learning journey in which they learn that research informed by an Indigenous paradigm may start with a research question, but often evolves into conversations and eventually storytelling. The authors push for work that is both integrative and transcultural, and seek to encourage human reconnections with the Earth through organic and visual models, rather than the highly compartmentalized, linear models (e.g. flowcharts) that fail to adequately represent relationships among ideas or people. Three examples informed by the guiding principle of listening to Elders are presented: trees holding hands, two-eyed seeing, and the healing tense. A “pattern smarts” view of science is used with respect to the culturally inclusive view of science developed within Integrative Science. Specifically, this view of science takes the form of “stories” as they hold the information and truth about the past. A “big picture” or “big pattern” understanding of the dimensions of knowledge systems is proposed to expand the discussion framework for healthy communities. The focus on pictures and patterns is applied to examine ontology, epistemology, methodology, and objectives in relation to accessible concepts, actions, languages, and methods and the combined influence in understanding healthy communities in relation to people and place in ways that open new opportunities for the future. Each of the chapters pushes the reader to consider the transition from conceptual integration involved with positioning health and well-being within a social-ecological context, to the practical implications of procedural and methodological integration for both research and practice. These authors all seek to connect with the ecological as well as the social and also the interaction between them, with the degradation of ecological conditions offering a

   

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prompt for different kinds of engagement. We are challenged to consider the social dynamic of learning in all three contributions, with attention to the type, flow, and relationships among different knowledges and experience. Stories and narratives are a priority theme across each of the three contributions, emerging from contextualized community experience of cfp and as a pathway and precedent for fostering values and meaning within religious engagements and also as a manifestation of an Indigenous paradigm of research. By highlighting the power, values, meaning, and motivation invoked by these narratives, each chapter sheds light on approaches that enhance health and well-being by buffering the consequences of rapid social-ecological change. In particular, this final section of the book offers practical insights regarding hope and learning as pathways that can help navigate the challenges of diversity, convergence, and integration that frame the orientation of this book.

   

8 Situated Learning, Community Development, and Ciguatera Fish Poisoning in Cuban Fishing Villages karen morrison, john fitzgibbon, and david w a lt n e r - t o e w s

Contrary to the myths generated by our dominant science-based ideology, when we delve into the science of the vast majority of specific incidences of environmental or health concern, we find that we know very little. We may know little about the particular social-ecological context, little about the concern itself, and/or little about how to solve any problems or move forward. It is this lack of useful knowledge that has driven the theoretical, methodological, and practical elements of this study. This chapter draws on the knowledge that we have gained from a wide variety of disciplines (anthropology, learning, ecology, fisheries, public health, toxicology, epidemiology, etc.) that relate in whole or in part of the topic of cfp. The focus of the study, however, is on generating a holistic understanding that has widespread applicability to Cuban fishing villages and leads to clear multi-level and multi-sectoral recommendations.

Introduction This chapter highlights the connections between social, ecological, and health systems and the need for integrated interventions that recognize the complexity of social-ecological systems (see also Edwards and Davison, chapter 2 above). The notable rise of outbreaks of ciguatera fish poisoning (cfp) in some Cuban coastal communities, but not others, during the Cuban Special Period in Peacetime

   

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(­ 1989–95+), is examined through the lens of situated learning theory (slt). slt creates a framework for understanding the way in which locality and community influence each other in shaping local public health outcomes. It emphasizes the connections within and between communities of practice, different places, authentic activities, and different kinds of knowledge (see also Marck, chapter 3 above). It is our conclusion that slt is well-suited to identify possible areas for integrated policy responses to environmental health challenges. Traditional assumptions about environmental and health policy build on the idea that scientific investigation can promote the development of targeted and effective public policies. In this chapter, cfp is discussed as an example of how actions, attitudes, and behaviours are shaped in the prolonged absence of such “scientific” information. In particular, the goal of this chapter is to investigate the socialecological context of outbreaks of cfp recorded by the Cuban Ministry of Health in three fishing villages on the north shore of the province of La Habana. Its objectives are: 1 To investigate different communities of practice in the three communities, including the perspectives of “just plain folks” living in them (people who are neither fishers nor have been ill with cfp); 2 To develop a conceptual framework for the study based on situated learning theory; 3 To compare the findings from the mixed-methods research in the three case studies; 4 To identify key factors and points of intervention influencing cfp outbreaks in the case study area.

Method The methodological framework guiding the collection of the socialecological data in this study was based on two main approaches: (i) the comparative case study (as per Yin 2003) employing mixed methods; and (ii) the Adaptive Methodology for Ecosystem Sustainability and Health (amesh: Waltner-Toews et al. 2004). In this study, three Cuban coastal communities located on the north shore of the province of La Habana were selected. The communities  – M ­ ariel, Playa Baracoa, and Santa Cruz del Norte – have similar areas (8–18 km2), populations (11–18,000 people), and socio-economic status.

   



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They are all classified by Moliner et al. (2001) as urban and rural-­ industrial, with primarily agricultural activity and some industrial and service activities, and are located in the same province (La Habana) within 140 km of each other on either side of the City of Havana on the northwest shore of Cuba. The amesh approach is a place-based, integrative way to study community health concerns. It takes a systemic approach to identifying the root causes of these concerns and endorses the use of participatory methods. It recognizes that human actions and everyday decisions play a major role in determining the kind of ecosystem we live in through their effects at multiple spatio-temporal scales (Waltner-Toews 2004). The amesh approach complements traditional epidemiological studies and opens the door for a more holistic approach to understanding the relationship between human health and ecosystem sustainability (see also Edwards and Davison, chapter 2 above, and Parkes, chapter 7 above). The amesh methodology falls under the ecohealth umbrella. The ecohealth approach recognizes the interconnectedness of human, wildlife, and ecosystem health, and encourages the development of ideas and approaches that incorporate the ecological and health sciences. It promotes integrated studies that explore the ways in which the drivers of social and ecosystem change ultimately influence human health and well-being (Wilcox et al. 2004). The study benefits from taking an ecohealth approach to the issue of community learning and adaptation to cfp, because, as Forget and Lebel (2001, S4) write: “the relationships among living and inert components of the ecosystem are extremely complex, [and thus] the simple observation of cause-and-effect consequences in these hierarchical, interlocking systems fails to give a proper picture of the impact of human intervention on either the health of the ecosystem itself or the human beings who inhabit it.” To collect information about the social system, thirty-two unstructured interviews with key informants (including historians and Cuban experts on ciguatera), two matrix timeline interviews (Bunce et al. 1994) with the presidents of the local sport fishing federations, and secondary data (including epidemiological data) were the primary sources of information for this aspect of the study. Cuba has a particularly rich history related to the study of, and debate over, cfp dating back to the mid-1800s, and has been collecting epidemiological data specifically on cfp since 1992. With respect to

   

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the ­ecological ­system, the aforementioned unstructured interviews included national coral reef ecologists, national and provincial fishery authorities, and national, provincial, and local environmental representatives. In addition, books, government reports, and journal articles related to ecological stressors and changes affecting Cuban coral reefs (particularly near-shore coral reefs on the northwest coast of the country) were key sources of reef-specific information for this study. The social, epidemiological, and ecological data were interpreted in the context of the rapid increase in cases of ciguatera fish poisoning in some communities but not others that was reported after the collapse of the Soviet Bloc in 1989 (see Morrison et al. 2008). In addition, sixty-three semi-structured interviews were conducted in the three communities, with a minimum of five sports fishers and five men and women in the community who were neither fishers nor had been affected by cfp in each of the study communities (“just plain folks” in Lave’s [1988] terminology). Interviews were also conducted with people in the community who had been sick with ciguatera. Corresponding to the reported epidemiological data, these people were relatively easy to locate in Mariel, where nine interviews were conducted, and there were fewer in Baracoa (four interviews) and Santa Cruz del Norte (two interviews). An additional eight semistructured interviews were conducted in the town of Bauta, located ten kilometers inland from Playa Baracoa and in the same municipality (Bauta), in order to gain additional perspective on the issues (Miles and Huberman 1994). In Santa Cruz del Norte, a survey of the domestic tourists (n=142) at four local camping areas (campismos) was conducted after it became apparent that they were becoming ill with ciguatera from fish they were either catching themselves or buying from local fishers. In addition, participatory workshops were held in each community (due to the destruction of the community health centre’s meeting room by a cyclone, Playa Baracoa’s workshop was held in Bauta), and a two-day final workshop brought together local, provincial, national, and international stakeholders. In the analysis phase, inductive reasoning was used to interpret and structure the data (as per Thorne 2000) and the interview data were coded. The comparisons benefited from the focus of the study on understanding each case in a holistic fashion, which included the insights of multiple perspectives (Functowicz and Ravetz 1993; Waltner-Toews 2004) and a mix of methods (Miles and Huberman 1994; Yin 2003). Emphasis was placed on the triangulation of data

   



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Table 8.1 Relative Toxicity to Mice of a Variety of Toxins Toxin

Source

Toxicity (fold)

Cyanide Muscarin Okadaic Acid Cobra Toxin Saxitoxin Ciguatoxin Tetanus toxin

Fungus, Amanita Muscaria Algae, dinoflagellates (e.g. Dinophysis spp.) Cobra snake Algae, dinoflagellates (e.g. Alexandrium spp.) Algae, dinoflagellates (Gambierdiscus toxicus) Bacterium (Clostridium tetanii)

1 9 50 500 1100 22000 100000000

Zingone and Enevoldsen 2000

and the identification of relationships, patterns, processes, and context (as per Capra 2005; see also Bartlett et al., chapter 10 below).

C i g uat e r a F i s h P o i s o n i n g cfp is a food-borne illness caused by the consumption of toxic fish. These so-called “ciguatoxic” fish have bioaccumulated potent marine biotoxins that are produced by certain genera of marine dinoflagellates (for example, Gambierdiscus, Prorocentrum, and Ostreopsis) (Zingone and Enevoldsen 2000; Pierce and Kirkpatrick 2001). In mammals, ciguatoxins are among the most potent toxins known (see Table 8.1). Ciguatera is naturally occurring and is endemic to tropical ecosystems. Outbreaks of cfp in Cuba were documented as early as the sixteenth century, and in other oceans references to marine biotoxins date back millennia (Olsen 1988; Bruslé 1997). cfp causes gastrointestinal, neurological, and cardiovascular symptoms in humans, and in rare cases can be fatal. It has acute, chronic, and relapsing phases (Van Dolah et al. 2001). cfp is particularly wellsuited to research into complex social-ecological symptoms because, despite many decades of intensive research, there are few definitive “facts” that can help guide decisions about the management of this illness (see also Morrison 2008). Given the lack of “scientific” evidence to support concrete actions and the knowledge that most cases of cfp are not fatal, many countries have not invested significant resources in tracking this illness in their countries. Cuba is an exception to this rule. In Cuba, the verb “enciguatarse” conveys the idea that a person has become ill with ciguatera fish poisoning. Yo me enciguato – “I

   

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poisoned myself by eating ciguatoxic fish” – sums up the idea that fundamentally, becoming ill with cfp is about making an unfortunate food choice. Some people, after eating ciguatoxic fish, refuse to eat any fish again. Ciguatera is a health problem because toxic fish are indistinguishable from those which are not, and more than four hundred species of fish – including herbivores, omnivores, and carnivores – are considered potentially ciguatoxic (Lehane and Lewis 2000). The toxins associated with cfp (ciguatoxins, maitotoxins, scaritoxin, okadaic acid, and prorocentroid; see Park 1994; Chinain et al. 1999) include water- and fat-soluble compounds with different toxicities. There is currently no reliable test to indicate whether or not a fish is safe to eat, although some sophisticated and expensive analytical methods can detect the toxins’ presence (Lewis 2001). Instead, a mouse bioassay is typically used, based on the method described by Banner et al. (1960). The poisons are not affected by cooking, freezing, smoking, or salting and are odourless and tasteless (Lehane and Lewis 2000; Pierce and Kirkpatrick 2001; Perkins and Morgan 2004). Gambierdiscus toxicus is the most studied ciguatoxic species and is present wherever ciguatera occurs (Lewis 2001). The dinoflagellates are biflagellate and will swim if disturbed, but are usually motionless and attached as epiphytes to macroalgae. These macroalgal species are in turn found in and around coral reefs, among other habitats such as sand or macroalgal turf (see Holmes and Lewis 1994; Lehane and Lewis 2000). The dramatic increase of macroalgal populations (at the expense of coral) is a hallmark of a coral-algal phase shift, which is linked to a variety of factors, including overfishing, pollution, and severe weather (McManus and Polsenberg 2004; Hughes et al. 2005). Not all suspected dinoflagellates produce toxins; ciguatoxin production appears to be strain-dependent and the impetus for toxin production is unknown (Ballantine et al. 1985; Holmes and Lewis 1994; Chinain et al. 1999). Some scientists currently hypothesize that bacteria play an as-yet-unknown role in triggering the production of the toxins by the dinoflagellates (Sakami et al. 1999). Ciguatera has been referred to as “a problem in ecology par excellence” (Scheuer 1982, 529). In 1992, in response to a perceived increase in the number of outbreaks of cfp being reported along the coast, the Cuban Ministry of Public Health (minsap) included cfp as a reportable foodborne disease. Cuba is now one of the few tropical countries with

   



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e­ pidemiological surveillance and reporting data about this illness. The system relies on a diagnosis of a history of eating fish, gastrointestinal problems, and one other symptom. This is because, as indicated above, the various toxins (water- and fat-soluble) and toxicities mean that there are over 150 symptoms associated with the illness. To further complicate the matter, the lack of exposure biomarkers in human beings makes acquiring “true” incidence data impossible (Fleming et al. 2001). In many endemic areas, because it is rarely fatal, cfp is not regarded as a serious health issue and most public health departments limit their interventions to publicizing species which are dangerous to consume and, sometimes, restricting marketing of those species (Dalzall 1994). In Cuba, the Ministry of Industrial Fishing (mip, Ministerio de la Industría Pesquería) is responsible for administering the Decree-Law 164 pertaining to potentially toxic marine species. This regulation includes an outright ban on fourteen species of fish, as well as size and weight limitations for seven other species. The law was the first fishery law to explicitly include members of the Cuban Sports Fishing Federation (Federación Cubana de Pesca Deportiva). Claro et al. (2001, 219) note that, in Cuba, for some “underutilized species (e.g. certain groupers, jacks and barracuda), efficient ways to detect ciguatera poisoning could improve their commercial value.” This investigation of outbreaks of cfp in three Cuban fishing communities focused on the fact that the communities, despite their similarities, reported significantly different patterns of cfp outbreaks during the Cuban Special Period. Prior to that time, all of the communities had experienced low-level, sporadic incidences of cfp. In Cuba, studies pertaining to cfp have been published since the days of biologist Antonio Parra y Callado (Parra 1787) and naturalist Felipe Poey y Aloy (Poey 1866). The investigation applied an ecohealth approach complemented by situated learning to better understand this phenomenon.

S i t ua t e d L e a r n i n g T h e o ry Situated learning theory (slt) locates learning firmly in social interactions. Its emphasis on activity, context, and culture provides a way to interpret empirical data related to a community’s knowledge and action. At its foundation is the idea that collaborative

   

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social ­interactions and socially constructed knowledge contribute ­significantly to learning (Brown et al. 1989). Learning is seen as “a way of being in the social world, not a way of coming to know about it” (Hanks 1991, 24). Situated learning is complementary to complex systems approaches which assert that knowledge is contextual, local, and temporal (Lave and Wenger 1991; Bryne 2005). Learning also contributes to transformation in people. Lave and Wenger (1991) emphasize the role of newcomers in situated learning activities and their gradual assimilation into roles as legitimate peripheral participants in local formal and informal knowledge systems. A key question in situated learning theory is: what kinds of social engagements provide the proper context for learning to take place (Hanks 1991)? It considers that the practices of a community are continually renegotiated by its members (Kuhn 2002). The theory of situated learning builds on the results of a study on “cognition in practice” by Jean Lave (1988) which focused on the way in which everyday people (“just plain folks”) acquire and use their knowledge and skills (for example, how they use math skills in a supermarket, or when dieting). Situated learning theory emphasizes the role of social structures and processes in promoting learning, and considers that such social processes are as important, if not more important, than the learning of knowledgeable skills (Lave and Wenger 1991). The theory generally sees learning as unintentional. It is based on the ideas that learning requires social interaction and collaboration and that knowledge needs to be presented in an “authentic context” (Lave and Wenger 1991). Stories and narratives are also considered to be important both in situated learning theory (McLelland 1996) and in the ecohealth approach that informed this and similar studies. The activities of communities may only make sense when they are viewed from within the culture (Brown and Duguid 1996; see also Marck, chapter 3 above, and Dalton, chapter 9 below). In this way, situated learning theory also reinforces the importance of the role of the observer in understanding the system in question (as per ­Checkland 2000). Authentic activities form an important part of situated learning theory. Such activities are the ordinary practices of a culture which have developed in a certain context. They are activities that have been generated, over time, by past and present members of a community and their meaning and purpose are generally understood by

   



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the local community (Brown et al. 1989). Activity provides the participant with experience and this experience helps inform his/her subsequent actions (Brown et al. 1989). This link between present and future activities, which is informed by experience, is a key part of the dynamic nature of a learning “system.” Those who learn, in this framework, are those who participate in the “learning context” (Hanks 1991). In this study, the authentic activities undertaken by the community are quite straightforward, as they involve catching, selling, preparing, and eating near-shore coral reef fish. They also involve activities related to ecosystem understanding and management, as well as community health concerns, such as the identification, treatment, and monitoring of disease outbreaks. Situated learning also recognizes the importance of documented information in supporting new knowledge generation. Wenger et al. (2002) refer to this as “reified” information as it guides learning and practice when it moves from an oral to a documented form. Manuals, articles, paintings, laws, or musical scores are examples of “reified” information resources that can be referred to by a wide range of people in different places and contexts. This presentation serves as a “backstop” that enables people to move forward with creating new knowledge and learning, based on and with reference to previous experience, opinion, and expertise. In this case, the resources include epidemiological and ecological data and relevant articles or pamphlets referring to cfp and fishing regulations. Legitimate peripheral participation is considered by Lave and Wenger (1991) to encompass the fringes of social interaction, where relations that appear at first glance to be disconnected are not. It is related to the larger and better-known concept of communities of practice (cops). cops are groups of people who share an interest in, or a concern for, a particular topic and improve their understanding of it through ongoing interaction (Wenger et al. 2002). The idea of communities of practice originated in anthropology and was adapted by Lave and Wenger (1991) to the area of individual and organizational learning (Kuhn 2002). A cop may be understood as a community that is created over time through the ongoing pursuit of common experiences (Wenger 1998, 2000). For Lave and Wenger (1991), the degree of participation in a cop is very flexible and can be very fluid. The cops may or may not have any formal organization associated with them.

   

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90

80

Percentage of Total (141 outbreaks)

70

60

50

40

30

20

10

0 Mariel

Bauta, Guanajay including Playa Baracoa

Artemisa

Caimito

Bejucal

San Nicolas

Santa Cruz San Antonio del Norte de los Banos

Figure 8.1 Percentage total outbreaks by municipality, La Habana 1995–98. Adapted from Arencibia Mederos, 1999

Results: The Socio-Ecological Systems C o n t e x t o f cfp O u t b r e a k s A summary of the epidemiological data from 1995 to 1998 for the province of La Habana (Figure 8.1) indicates the relative severity of reported outbreaks in three case study communities: Mariel, Playa Baracoa (in Bauta), and Santa Cruz del Norte. The results of the study are summarized in Table 8.2, according to the main themes of situated learning theory. Morrison (2008) contains a more thorough presentation of the results. In Santa Cruz del Norte, the levels of cfp were not considered to have changed during the Special Period. Outbreaks of cfp in the local tourist areas outside of the town (that were not captured by the town’s surveillance system) indicate that ciguatoxins are present in that ecosystem, as expected in an endemic area. The entire northwest coast of Cuba falls into the endemic category which indicates

   



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a relatively stable pattern of toxicity, generally involving the larger carnivores in the area (Bagnis 1994). The coral reef in the area is widely considered to be in good shape, although Cyclone Lily and ­Hurricane Michelle both caused substantial damage to the Santa Cruz area during the 1990s. The Jibacoa-Bacuanyagua coastal and marine protected area was founded in 1986 and encompasses 30,000 hectares of land and water (unep 1989). The mpa may be having positive impacts on the local fish and coral populations (i.e. for larval recruitment) down-current of the area. The fishers noted the presence of sardines, which are present in the protected area, but are rarely found outside of the protected area. Linton et al. (2002) found that Cuban marine protected areas are under-equipped and under-staffed. Studies suggest that a few locations in the area have shifted from a coral- to an algal-dominated state, mainly at the mouth of industrial effluent pipes (Herrera Moreno and Menendez 1986; Herrera Moreno 1991). The social setting related to fishing in the area is robust, with an active and engaged sports fishing population and a wide range of opportunities for authentic activities related to the catch and sale of fish to occur. The federation has 1,300 members and approximately 130–140 boats. The fishers were able to hold onto the title of their clubhouse following the 1959 revolution, and this place provides a vibrant and active hub for fishing activity. This hub includes the apprenticeship of younger fishers in the area (the fishers have given over part of their land to the local youth club) and the socialization of newcomers with an interest in fishing. The sports fishers also host social and cultural events involving the wider community, including fishing derbies and religious festivals. The sports fishers are a robust community of practice, with organization generally provided by the older, more experienced fishers (i.e. the president of the local federation), as well as strong connections to other levels of government and a strong local culture. They have a strong sense of community and share a commitment to protecting the community from ciguatoxic fish. They find it frustrating that illegal fishers sell fish in Havana and Matanzas and tell people that their fish are from Santa Cruz del Norte. The sport fishers resent this because when these fish are ciguatoxic it gives them a bad name. The illegal fishers are not in direct competition with the Santa Cruz fishermen. They come from Havana, fish from rafts late at night, and return to the city to sell their fish.

   

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The Santa Cruz del Norte area has a dominant narrative associated with a local fisher who fell ill with cfp and was in a coma for four months. This story was related to the researcher by a wide range of interviewees, including a City of Havana taxi driver with family in Santa Cruz. The majority of the people who passed on this story had never met the fisher; some people believed that he was of Chinese descent, given his nickname of “El Chino” among the fishermen: “Here there is one [case of cfp] … he ate barracuda and he was accustomed to eating barracuda and … he was on the point of being dead … his name is El Chino” (Male, 69, community member, Santa Cruz del Norte). This story was a cautionary tale about the fact that even a sport fisher, who had fished all of his life, could be at risk of cfp and provided an entry point for conversations about ways one could protect oneself from cfp (including various forms of folklore, such as testing the fish with ants, cats, silver). cfp in Santa Cruz del Norte during the Special Period was not a health priority in the town and little additional activity took place to address it because of the lack of an increase in outbreaks. As in all of the communities studied, with the exception of Mariel, there is next to no “reified” information available to backstop learning about this illness. The fishers continue to believe that it is caused by manzanillo (a plant that grows along river banks that was disproven as a cause of cfp by Felipe Poey in the mid-1800s) and that its toxicity is in some way related to the phases of the moon. In Playa Baracoa, a distinct fishers’ neighbourhood (barrio de los pescadores; see Díaz et al. 2003) runs along the east coast of the Baracoa river. The coral reef is considered to be of good quality, although with some evidence of deterioration (Carrodeguas et al. 2001). Access to the coastline in front of the nearby military facilities and the university is restricted, limiting the impact of fishers. According to the residents, the military uses the area for marine and artillery operations. The area is prone to severe weather events, including cyclones and hurricanes. During the 1990s and continuing to a lesser extent today, cfp became an increasing health concern in the municipality. Between 1996 and 2004, Playa Baracoa was the site of ten of the eighteen ciguatera outbreaks recorded at the municipal level (Bauta). In response to the increase in the number of cases of ciguatera, the Unidad Municipal de Higiene y Epidemiología (umhe) Bauta identified the practice of illegal fishers selling fish to the public and a

   



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lack of knowledge in the community about ciguatera. The ciguatera intervention program of 1994–95 targeted the illegal fishing population and the informal leaders of the community of Baracoa and provided them with face-to-face information about the potential health effects associated with selling contaminated fish. The problem of illegal fishing in Baracoa was referred to by many community members; typical comments include: “They control the boats, but they don’t control the scuba fishers or the illegal [fishers] who are out of control” (Male, 41, community member, Baracoa). The program had excellent short-term results, with only one outbreak of ciguatera in 1999 and none in 2000 and 2001 (Paula et al. 2003). One of the “expected benefits” of the work was to develop positive attitudes in illegal fishers to not catch or commercialize ciguatoxic species of fish. Representatives from the Coast Guard and the Ministry of Fishing Industry were involved in identifying illegal fishers to include in the project. The sport fishing community of practice in Baracoa has a strong corporate focus, as the fishers target “first class” fish (such as blue marlin, swordfish, and skipjack tuna) to sell to the state as well as to other buyers. The emphasis of the community is on the business of fishing and the sport fishers do not organize any community events (e.g. fishing derbies). The sport fishing community is small (approximately 150 members), tightly knit, and well-organized. The fishers interviewed were strongly supportive of the Decree-Law 164 and its regulations, which they feel have little impact on them, given their focus on the catch and sale of high-value fish. The fishers are very cognizant of the penalties associated with breaking the law, in particular the threat that they could lose their boats. Playa Baracoa had the most robust ecological community of practice of the three communities. A wide variety of community groups, including fishers and students, have been – and are – involved in programs and capacity-building exercises on the topic of the environment (for example, Díaz et al. 2003). The local middle school is part of a unesco program with an environmental focus. The students’ work provides a common narrative for the public at large. For example, one man commented that the local environment must be improving because “Those same students are still at the beach picking up garbage, they are always there, cleaning the beach” (Male, 28, community member, Baracoa). This success of the ecological cop in reaching out to the community is apparent in the larger number of

   

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actors working on and supporting environmental initiatives in the community. There are ample opportunities for the apprenticeship and mentoring of youth by more experienced community l­eaders. The president of the local sports fishing federation expressed his organization’s interest in local environmental projects, as did a number of community members. There was a general feeling among those interviewed that the environment was getting better, mainly because of the perception of an increased level of interest in the community. Mariel is best known for the mass exodus of 125,000 Cubans who left the country via a flotilla of boats sent from the US in 1980. In Mariel, the sport fishing federation is run by a small group of approximately ten committed fishers who meet in the house of the president of the local chapter of the Sport Fishing Federation, founded in 1986. The local organization has grown consistently over time, with approximately 500 members in 1986, approximately 800 in the early 1990s, and currently approximately 1,200 members. Opportunities for the group to interact and build relationships are limited. Mariel is located on a large bay and the local sport fishers are distributed all around the bay and the adjacent coastline. The lack of a common meeting place (i.e. a clubhouse) and/or a common docking area also contributes to their limited contact with each other. Some social activities do take place, however. For example, the larger fishing community is involved in some organized events, such as fishing competitions. In the early 1990s, meetings were called to explain the new fishing regulations and to inform fishers about ciguatera, although only a small fraction of the total sport fishing community participated. Mariel is also unique among the case study communities in that it does not have a formal agreement with the state to legally sell fish to the state monopoly store, Aquabana. Between 1997 and 2000 the fishers in Mariel did have such an agreement (with Aquabana’s parent company Mercomar), but due to some problems with that arrangement it was cancelled and the fishers have been without a formal agreement since that time. This lack of a legal outlet for their catch contributes to the problem of the illegal sale of fish. Problems with the fishers’ contract have led to a lack of trust between the local sport fishing federation and its provincial counterpart. The fishing activity in this area more closely resembles a recreational fishery than in the other two communities, in which it is more concentrated and more overtly commercial. Boats fishing in the

   



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large bay are not subject to inspection by the Coast Guard, which is located at the mouth of the bay and only inspects the boats that come in from the open ocean. The local industries attract newcomers to the area. Many of these newcomers are keen to take advantage of their proximity to the bay and the ocean in order to take up fishing. The newcomers often have little to no knowledge of ciguatera or potentially harmful fish. Finding this information is difficult in that there is no obvious place to go in town where fishers congregate. Prior to the late 1980s, ciguatera outbreaks occurred sporadically in Mariel. After the fall of the Soviet Bloc, however, ciguatera outbreaks in Mariel began to increase. Between 1989 and 1991, cases of ciguatera in Mariel were on the increase, and by 1992 the umhe realized that this illness had become an important health issue in the community. In 1995, out of concern for the continuing high levels of ciguatera in the community and following a provincial investigation of this illness (Arencibia Mederos 1999), it was agreed that a focused intervention was needed in the town. As in the Baracoa, the intervention activity centred on the formation of a general dialogue among different agencies. Specifically, the staff working at umhe Mariel were in close contact with other stakeholders in the community. Mariel was the only community to invest its own resources in the 1990s in printing information pamphlets about ciguatera, which it distributed among the population. Given the dire shortage of both paper and ink, this investment is indicative of the health community’s concern over this illness. The local environmental agency was established in the mid-1990s. It has very little information about the state of the local marine environment. Local work is often project-based and is run by specialists from the provincial office, who work in partnership with the local environmental specialist. Unlike the other municipalities, environmental programs are focused on the major industrial polluters and not on community engagement. The town received a rating of “extreme” in a study of ambient air pollution (in contrast, Santa Cruz del Norte received a rating of “low”) (citma 2002). The Maximo Gomez thermoelectric plant is one of the top ten industrial polluters in Cuba (citma 2003). In addition, the nearby hempprocessing plant and sugar refineries contributed significant levels of organic and chemical pollution to the waters in the early 1990s. No local work has been done by the local citma office on the issue of the local coral reef ecosystem, although studies have been

   

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c­ onducted over the years by the Institute of Oceanology. GonzálezFerrer (2004, 83) makes specific mention of the town when discussing various kinds of marine pollution: In Cuba, one could find this type of contamination [thermal] in the coral reefs around the thermoelectric plant of Mariel (La Havana), where a massive death of corals occurred after suffering bleaching from this cause. A notable case of contamination of this type took place on a reef near the Mosquito River, to the east of Mariel Bay. In this location … industry caused the death of innumerable colonies of coral, among other organisms, from the waste of the hemp factory going into the sea. The coastal water at the mouth of Mariel Bay is so polluted that it violates Cuba’s water quality standards for direct contact (citma 2004). In addition to industrial pollution, the coastal area suffers from urban, as well as waste-water, runoff which is contributing to the large inputs of organic contamination. This is causing the eutrophication of the waters as well as their occasional “stench” (fetidez). The runoff is harmful to both marine life and the recreational use of the water (citma 2004). According to Alcolado et al. (2000, 2): “thermal pollution caused by the cooling system of a power plant located east of Mariel Bay has killed a shallow reef area, producing extensive coral bleaching. Mechanical pollution by fibre wastes from a hemp (an agave plant used to produce ropes) fibre processing factory was observed at a shallow reef near Mosquito River (east of Mariel Bay), causing abrasion of stony corals, sponges and gorgonians. The observed increase of ciguatoxic fishes could be a consequence of this general coral reef deterioration” (emphasis added). Table 8.2 summarizes the results of the investigation using categories from slt.

D i s c u s s i o n : T h e I m p l i c a t i o n s o f slt f o r Understanding Local Concerns In this study, both social and ecological factors appear to play a part in determining the level of cfp outbreaks observed in the three communities during the Cuban Special Period. Community organization and empowerment, local environmental changes, and health

   

Table 8.2 Summary Description of Case Study Communities and Study Results Case Study Communities Background Information Location Relative to the City of Havana on the NW shore of Cuba Size (km2 ) Population Outbreaks of Ciguatera (1989–­present)

Santa Cruz del Norte

Playa Baracoa

50 km E

20 km W

50 km W

16 11,000 Very low

8 10–13,000 Low

19 18,000 Very high

Mariel

S i t ua t e d L e a r n i n g T h e m e s Social Setting

Ecological Setting

Stories and Narratives

Legitimate Peripheral Participation

Communities of Practice

Newcomer / Old-timer Relationship

Authentic Activities

‘Reified’ Information Resources

Legend:

Robust

Moderate

Weak

   

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are all intertwined in creating distinctly different opportunities for situated learning and adaptation to take place. Indeed, the connections between social, ecological, and health “systems” have significant repercussions for the health and well-being of citizens and these ­connections need to be addressed by all three sectors. This includes both the local actors and their connections to provincial and national stakeholders. The study found that the departmentalization of the various parts of the cfp issue contributed to the lack of a holistic vision of the possible causes of the illness in the affected communities. This in turn prevented the development of proactive policies that could both address the illness and contribute to building more resilient local social-ecological systems. In the case of cfp, there was no link made at the local level between ecological conditions and public health in the case study communities. It is significant that the public health and fishery communities did not look beyond the catch of fish (i.e. the fish exiting the ecosystem) to the ecological situation in which the fish were living. Had they done so, early warnings from coral reef ecologists – particularly in Mariel – might have led them to call for greater protection of the ecosystem on which the fish, and the fishers, depend. Indeed, it is indicative of the education systems in general, and certainly not only in Cuba, that the public health officials – even those who had spent decades working on the cfp issue – had no knowledge of the environmental determinants of this illness. It is as though the illness “appears” on shore with harvested fish and then is dealt with by a variety of epidemiological and medical interventions. This is one of the key messages emerging from social-ecological systems research: true health prevention goes beyond the identification of primary, secondary, and tertiary public health communities. This is because it is an interdisciplinary science that includes ecological communities of concern. Another theme emerging from this study is the importance of “reified” information, available locally, to motivate, justify, and support behavioural changes among individual and institutional stakeholders. Local environmental changes, in the form of degraded near-shore coral reef ecosystems, were implicated in the high levels of outbreaks in the town of Mariel. That environmental change has human health implications is well-understood and is a key message of the Millennium Ecosystem Assessment (mea 2005). This link between a degraded ecosystem and human health was clearly made by the national ecologists who conducted studies of north shore

   



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reefs. This information was not locally available, however, and had no bearing on subsequent discussions and actions regarding cfp. In contrast to the ecological system, the local offices of epidemiology and hygiene (umhe) in both Mariel and Playa Baracoa, where ­outbreaks were increasing, took full advantage of the data provided by minsap’s epidemiological surveillance and reporting system to convene local stakeholder meetings. In both cases this included legal and illegal sports fishers, community leaders, and local government representatives, as well as provincial epidemiologists who discussed and defined local strategies to reduce the number of outbreaks. These included meetings with fishers and with the community-at-large at the neighbourhood level, as well as (in ­Mariel) the use of very scarce resources to print leaflets to distribute among the community warning them to avoid fish with a higher probability of being ciguatoxic. These measures helped reduce the number of outbreaks reported in the following years. This example highlights the influence that locally available information can have in changing organizations and behaviour. Community organization can be motivated by trusted local data that indicates a problem. In the absence of both quantitative and qualitative data, institutions that can harness and inform action have limited opportunities for community-level organization and empowerment. It is possible that early indicators of the degradation of the near-shore marine ecosystem off the coast of Mariel might have motivated a response by the sports fishing community and other stakeholders. This is entirely speculative, however, since the lack of information, the decline of the reef and its shift into an algal-dominated state, and a collapse of fishing infrastructure (i.e. docks, meeting areas for fishers) in the community are indicative of a social-ecological system that is neither supporting nor being supported by an near-shore coral reef fishery for a long time. Active and vibrant sports fishing communities in Playa Baracoa and Santa Cruz del Norte create a setting for a wide range of community activities, conversations, and learning to occur. Their specific knowledge about fishing can be passed on to apprentices and newcomers to the community in formal and informal ways. This creates opportunities for the legitimate peripheral participation of these groups in the sports fishing community of practice. It also increases the diffusion of knowledge through the community. Where the sports fishers are also actively engaged in the social and c­ ultural ­activities

   

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of the community, the opportunities for information exchange, story­telling, and learning are enhanced. Situated learning theory highlights the connections between local communities and the policies and practices that influence them. In this case, it served to highlight the key differences between three communities that were located very close to each other and were otherwise quite similar. These differences contributed to the very different patterns of cfp outbreaks observed during the Special Period. The study determined that the level of organization and visibility of the sports fishing community was an important factor in raising the awareness of “just plain folks” about the threat of cfp, which helped them to measure, avoid, and/or cope with the illness. In brief, the better organized, more visible, and more engaged socially and culturally the fishers were with the community, the fewer outbreaks of cfp were reported in those communities. In this case, policies related to the strengthening of sports fishers’ communities of practice may well have the added benefit of reducing cfp outbreaks in those communities. The state of the local ecosystem also appeared to be an important factor influencing cfp outbreaks. In the communities where the near-shore ecosystem remains in a predominantly coral reef configuration (albeit with a few algal-dominated areas at industrial outfalls and the like) there were fewer outbreaks of cfp than in communities where the near-shore ecosystem had completely flipped to an algal-dominated state. In this case, policies related to pollution prevention, the reduction of overfishing, and the protection of key ecosystem areas (i.e. marine protected areas – such as the one to the east of Santa Cruz del Norte) may also help reduce the number of cfp outbreaks in a community. In this study, the engagement of “just plain folks” with the fishing industry was limited in communities (such as Mariel) where there was no visible fishing presence, and it was more active in areas with either readily identifiable “fishing neighbourhoods” or readily accessible common docking areas and facilities. In the former case, both people living in the community and newcomers to the community do not have access to the formal and informal conversations about the challenges, concerns, and hopes of the fishing community. Their stories and narratives do not become part of the community’s background knowledge and most people are very unfamiliar with cfp, unless they or someone they know falls ill. In this case,

   



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they rapidly enter the “ciguatera system” and are often frustrated and angry that they had not received more information about this illness. In contrast, the “just plain folks” interviewed in this study in the communities with organized and visible sports fishers (Playa ­Baracoa and Santa Cruz del Norte) – who were neither fishers nor had ever been ill with cfp – knew more about both the fishing industry and cfp and were more likely to know the fishers personally and have a relationship with them (i.e. buying from a trusted source). From their conversations with the fishers, they had become aware – wittingly or unwittingly – of the fact the cfp is a concern and that certain species of fish are more trustworthy than others. In Santa Cruz del Norte, which has the lowest levels of cfp of the three communities, the sports fishers are actively engaged in the social and cultural life of the community and additional opportunities for social and situated learning exist. slt highlights the “unintentional” nature of most social learning. Most of the “just plain folks” interviewed in this study had no interest or intention in becoming experts in cfp because the knowledge they had acquired was part of a broader set of social interactions that made them more or less able to take precautions to protect themselves against this illness. The role of the fishers in educating the public about cfp appeared in this study to be more significant on a day-to-day basis than that of the public health community. This is partly due to the wide range of health issues tackled by the public health officials and cfp’s historically low priority as a health issue. The communities of practice also reflect the ability of new knowledge to permeate local settings. This is a key factor in community learning, development, and adaptation. The amesh approach recognizes that local social-ecological systems are part of a nested hierarchy of interconnected systems operating at different spatiotemporal scales (see also Edwards and Davison, chapter 2 above, and Parkes, chapter 7 above). The connectivity of these systems to those operating at both larger (i.e. provincial, national, international) and smaller (i.e. neighbourhood, household, individual) scales is an important feature of them. In some cases, there are barriers to the connections between communities and larger-scale actors, including communication and interpersonal constraints, as well as significant resource constraints that preclude the active sharing of information. Significantly, this is not an issue for the public health community of practice, where a robust system of information sharing,

   

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both by ­telephone and on paper, integrates local concerns with those of higher levels of government. The ability of local communities of practice to access and share information with higher and lower levels of organization is a key factor that encourages sustainable development. Local actors cannot solve all of the issues that confront them. The factors affecting coral reefs range from local sources of point-source contamination (albeit caused by nationallevel industrial developments such as large industry or hydroelectric plants) and diffuse pollution (such as upstream land-use practices), to overfishing on a local and regional scale, historically lower overall coral reef biodiversity in the Caribbean (particularly as opposed to the Pacific Ocean; see Smith and Buddemeier 1992), and extreme weather events (including more frequent and severe weather, such as cyclones and hurricanes) linked to global climate change. Without local interest and information, the motivation for local communities to advocate, lobby for, and/or demand changes in higher-level systems is limited. In addition, local changes can be motivated by new information brought in from other levels of government and society. Interconnected, multi-level governance is fundamental to the sustainable development of social-ecological systems. This study also highlighted the role of civil engagement in shaping community learning and development possibilities. In one of the communities, Playa Baracoa, the citma office is relatively large and well-established in the community. The office is supporting a variety of programs. This has had the effect of raising “just plain folks’” interest in and awareness of these issues. In other places in Cuba, a globally sanctioned participatory methodology for determining the status of coral reef ecosystems (Reef Check, http://www.reefcheck. org) is being used to monitor reef conditions. Such methodologies could be incorporated into the activities of citma and local schools in coastal communities around the country  – particularly on the north shore where the coral reefs are quite close to shore. Community engagement related to cfp thus can take many forms – engagement with sports fishers as well as engagement with and reporting about both onshore and offshore ecosystem conditions. The role of science in the case of cfp is particularly significant to understanding this issue as a social-ecological system. cfp has proven to be so complex in terms of its chemistry, toxicology, ecology, and epidemiology that there are few “facts” available to guide action in terms of fishery management, law, and public health. As

   



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mentioned above, cfp defies easy analysis or description. Thus, cfp is an excellent example of a complex issue. It highlights the serious limitations that we have in terms of our knowledge of social and ecological systems. In this case, cfp provides us with a glimpse into the importance of other ways of knowing. Some of these ways are socially determined – for example, fishers draw on their knowledge, experience, and intuition to avoid selling potentially toxic fish to trusted customers. Others are informed by folklore – such as testing the fish using ants, cats, or silver spoons, or understanding toxicity as related to the phases of the moon. The sum total of these multiple ways of knowing led to a situation in Cuba where from time immemorial cfp was considered to be a minor health concern with low levels of sporadic outbreaks occurring each year. Only under the very difficult conditions of the Special Period did the social-ecological safeguards previously in place begin to break down. In the absence of clear science, a range of actions – a multi-barrier approach – including expert judgment, apprenticeship, newcomer/oldtimer relationships, vibrant fishing communities, social capital, and trust, as well as myth and folklore, served to maintain the health and well-being of the coastal community. As ecological conditions underpinning this system changed (mainly deteriorated) and larger-scale social dynamics also changed (leading, for example, to a massive increase in the catch and sale of “illegally” caught fish along the coast), these changes manifested themselves to greater and lesser extent in the health of the communities studied.

Conclusion There are a number of implications of these changes for community development. The social and ecological settings are important factors influencing community development and learning. In the social realm, the diffuse, unintentional, and experiential nature of learning is encouraged by a multitude of opportunities for people to engage in the activities of other groups and to hear about their issues and concerns. Encouraging apprenticeship and the integration of newcomers into community events is a form of legitimate peripheral participation that can lead to enhanced local communities of practice. In the environmental realm the setting is also of importance. Publically and locally available information (particularly with respect

   

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to invisible and difficult-to-access ecosystems such as coral reefs) is urgently needed. Without such information, there is little incentive for communities to self-organize to invest scarce resources in proactive, mitigative, or restorative efforts to safeguard the environmental systems on which they depend. In addition to biodiversity and lower levels of the macroalgal habitat preferred by potentially toxic dinoflagellates, healthy coral reefs provide a wide range of ecological services to human populations, particularly coastal communities (see Nyström and Folke 2000). The degradation of these habitats and the potential for them to suddenly and dramatically shift to algal-dominated states (which provide fewer services, such as shoreline protection, to humans) is a vital concern to coastal communities protected by these reefs. In contrast to the public health system and the influence that epidemiological data has on motivating action, a parallel system interested in the environmental determinants of health is sorely lacking. It is also important that civil society and other stakeholders are engaged in, and informed about, efforts to enhance local social-ecological systems, and that these efforts be informed and supported by the efforts of actors at both larger and smaller scales. Local action is not enough to protect and maintain social-ecological resilience. In fact it seems that multi-level governance is a key to environmental and health success. Only where that action is embedded in and enhanced by its connections to larger- and smallerscale actions can community development begin to address the root causes of the challenges they face. The amesh approach, with its focus on the researcher and the embedded context of the research, promoted a mixed-methods design that enabled the collection of wide-ranging data regarding outbreaks of cfp in the case study communities. Its emphasis on system descriptions and narratives provided a methodological framework for integrating the mixedmethod findings. The methodology is well-suited to inform studies that seek to understand community development in a way that integrates social and ecological system dynamics.

References Alcolado, P.M., R. Claro-Madruga, and R. Estrada. 2000. “Status and Prospective of Coral Reef Management in Cuba.” Paper presented at the

   



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9th International Coral Reef Symposium, Bali. http://www.reefbase.org (accessed 3 September 2014). Arencibia Mederos, C. 1999. Ciguatera una enfermedad sin percepción de riesgo. Provincia La Habana 1995–1998. Mariano, Cuba: Unidad Provincial de Higiene y Epidemiologia, Ministry of Public Health. Bagnis, R. 1994. “Natural versus Anthropogenic Disturbances to Coral Reefs: Comparison in Epidemiological Patterns of Ciguatera.” Memoirs of the Queensland Museum 34 (3): 455–60. Ballantine, D.L., A.T. Bardales, and T.E. Tosteson. 1985. “Seasonal Abundance of Gambierdiscus Toxicus and Ostreopsis Sp. in Coastal Waters of Southwest Puerto Rico.” Proceedings of the 5th International Coral Reef Congress (Tahiti) 4: 417–722. Banner, A.H., P.J. Scheuer, S. Sasaki, P. Helfrich, and C.M.B. Alender. 1960. “Observations on Ciguatera-Type Toxin in Fish.” Annals of the New York Academy of Science 90: 770–87. Brown, J.S., A. Collins, and S. Duguid. 1989. “Situated Learning and the Culture of Learning.” Educational Researcher 18 (1): 32–42. Brown, J.S., and S. Duguid. 1996. “Practice at the Periphery: A Reply to Stephen Tripp.” In Situated Learning Perspectives, edited by H. McLelland, 169–74. Englewood Cliffs, nj: Educational Technology Publications. Bruslé, J. 1997. Ciguatera Fish Poisoning: A Review. Sanitary and Economic Aspects. Paris: Les Editions inserm. Bryne, D. 2005. “Complexity, Configuration and Cases.” Theory, Culture and Society 22 (5): 95–111. Bunce, L., P. Townsley, R. Pomeroy, and R. Pollnac. 1994. Socioeconomic Manual for Coral Reef Management. Townsville, qld: Australian Marine Institute. Capra, F. 2005. “Complexity and Life.” Theory, Culture and Society 22 (5): 33–44. Carrodeguas, C., G. Arencibia, and N. Capetillo. 2001. “Consideraciones sobre el estado ambiental de los arrecifes coralinos cubanos.” http:// usuarios.lycos.es/ambiental/ecologia/corales.html (accessed 14 April 2006). Checkland, P. 2000. “Soft Systems Methodology: A Thirty Year Retrospective.” Systems Research and Behavioral Science 17: S11–58. Chinain, M., M. Germain, X. Deparis, X. Pauillac, and A.M. Legrand. 1999. “Seasonal Abundance and Toxicity of the Dinoflagellate Gambierdiscus Spp. (Dinophyceae), the Causative Agent of Ciguatera in Tahiti, French Polynesia.” Marine Biology 135: 259–67.

   

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Claro, R., J.A. Baisre, K.C. Lindeman, and J.P. García-Arteaga. 2001. “Cuban Fisheries: Historical Trends and Current Status.” In Ecology of Marine Fishes of Cuba, edited by R. Claro, K.E. Lindeman, and L.R. Parenti. Washington, dc: Smithsonian Institution Press. Dalzall, P. 1994. “Management of Ciguatera Fish Poisoning in the South Pacific.” Memoirs of the Queensland Museum 34 (3): 471–9. Díaz, E., T. Caram, and S. Porro. 2003. Capacitación en Género para el manejo de recursos costeros en la comunidad Playa de Baracoa. Havana, Cuba: University of Havana. http://www.rifm.net/uploads/ users/10510265640Informe_del_Proyecto_Baracoa_genero.pdf. Fleming, L.E., D.G. Baden, J.A. Bean, R. Weisman, and D.G. Blythe. 2001. “Marine Seafood Toxin Diseases: Issues in Epidemiology and Community Outreach.” http://www.oceandocs.org/bitstream/1834/758/1/ Lora%20E5.pdf (accessed 14 September 2014). Forget, G., and J. Lebel. 2001. “An Ecosystem Approach to Human Health.” International Journal of Occupational and Environmental Health 7 (Supp.): 3–38. Functowitz, S.O., and J.R. Ravetz. 1993. “Science for the Post-Normal Age.” Futures 25: 739–55. González-Ferrer, S.G. 2004. Corales Petreos: Jardines sumergidos de Cuba. Laltabana, Cuba: Institute of Oceanology, Editorial Academia. Hanks, W. 1991. “Foreword.” In Situated Learning: Legitimate Peripheral Participation, edited by J. Lave and E. Wenger. New York: Cambridge University Press. Herrera Moreno, A. 1991. “Efectos de la Contaminación sobre la Estructura Ecológica de los Arrecifes Coralinos en el Litorel Habanero.” PhD diss., University of Havana, Institute of Oceanology. Herrera Moreno, A., and P. Alcolado Menendez. 1986. “Estructura ecológica de las comunidades de gorgonáceos del arrecife de Santa Cruz del Norte.” Academia de Ciencias de Cuba Reporte de Investigación de Instituto de Oceanología 49. Holmes, M.J., and R.J. Lewis. 1994. “The Origin of Ciguatera.” Memoirs of the Queensland Museum 34 (3): 497–504. Hughes, T.P., D.R. Bellwood, C. Folke, R.S. Steneck, and J. Wilson. 2005. “New Paradigms for Supporting the Resilience of Marine Ecosystems.” Trends in Ecology and Evolution 20 (7): 380–6. Kuhn, T. 2002. “Negotiating Boundaries between Scholars and Practitioners: Knowledge, Networks and Communities of Practice.” Management Communication Quarterly 16 (1): 106–12.

   



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Lave, J. 1988. Cognition in Practice: Mind, Mathematics and Culture in Everyday Life. New York: Cambridge University Press. Lave, J., and E. Wenger. 1991. Situated Learning: Legitimate Peripheral Participation. New York: Cambridge University Press. Lehane, L., and R.J. Lewis. 2000. “Ciguatera: Recent Advances but the Risk Remains.” International Journal of Food Microbiology 61 (2–3): 91–125. Lewis, R.J. 2001. “The Changing Face of Ciguatera.” Toxicon 39: 97–106. Linton, D., R. Smith, P. Alcolado, C. Hanson, P. Edwards, R. Estrada, T. Fisher, R.G. Fernandez, F. Geraldes, C. Mccoy, D. Vaughan, V. Voegeli, G. Warner, and J. Weiner. 2002. “Status of Coral Reefs in the Northern Caribbean and Atlantic Node of the gcrmn.” In Status of Coral Reefs of the World 2002, edited by C. Wilkinson, 277–302. Townsville, qld: Australian Institute of Marine Science. McLelland, H. 1996. “Situated Learning: Multiple Perspectives.” In Situated Learning Perspectives, edited by H. McLelland, 5–18. Englewood Cliffs, nj: Educational Technology Publications. McManus, J.W., and J.F. Polsenberg. 2004. “Coral-Algal Phase Shifts on Coral Reefs: Ecological and Environmental Aspects.” Progress in Oceanography 60: 263–79. Miles, M.B., and A.M. Huberman. 1994. Qualitative Data Analysis, 2nd ed. Thousand Oaks, ca: Sage Publications. Millennium Ecosystem Assessment (mea). 2005. “Ecosystems and Human Well-being: Health Synthesis.” Geneva: World Health Organization. Ministerio de Ciencia, Tecnología y Medio Ambiente (citma). 2002. Situación Ambiente Cubana 2001. Havana: Centro de Información, Gestión y Educación Ambiental. – 2003. Situación Ambiente Cubana 2002. Havana: Centro de Información, Gestión y Educación Ambiental. – 2004. Situación Ambiente Cubana 2003. Havana: Centro de Información, Gestión y Educación Ambiental. Moliner, R.B., G.C. Marie, P.F. Cañizares, R.G. Cruz, and D.R. Milord. 2001. “Determinación de estratos para priorizar intervenciones y evaluación en salud pública.” Revista Cubana de Higiene y Epidemiología 39 (1): 32–41. Morrison, K. 2008. Situated Learning, Social-Ecological Resilience and Human Health: Ciguatera Fish Poisoning in Cuba. Saarbrucken, Germany: vdm Academic Publishers.

   

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Morrison, K., P. Aguiar Prieto, A.C. DomÍnguez, D. Waltner-Toews, and J. FitzGibbon. 2008. “Ciguatera Fish Poisoning in La Habana, Cuba: A Study of Local Social-Ecological Resilience.” EcoHealth 5: 346–59. Nyström, M., C. Folke, and F. Moberg. 2000. “Coral Reef Disturbance and Resilience in a Human-Dominated Environment.” Trends in Ecology and Environment 15 (10): 413–17. Olsen, D.A. 1988. “The Impact of Ciguatera Fish Poisoning within a Changing Caribbean Environment.” Population and Environment: A Journal of Interdisciplinary Studies 10 (1): 14–31. Park, D.L. 1994. “Reef Management and Seafood Monitoring Programs for Ciguatera.” Memoirs of the Queensland Museum 34 (3): 587–94. Parra, A. 1787. Descripción de diferentes piezas de historia natural, las más del ramo maritimo, representadas en 75 láminas. Havana: Captaincy General of Cuba. Paula, J.G., L.B. Gamez, N.J. Gonzales, and G.P. Valdes. 2003. Prevención de la ciguatera mediante acciones de promoción de salud en la comunidad de Baracoa. Bauta, Cuba: Unidad Municipal de Higiene y Epidemiología Bauta. Perkins, R.A., and S.S. Morgan. 2004. “Poisoning, Envenomation and Trauma from Marine Creatures.” American Family Physician 69 (4): 885–90. Pierce, R.H., and G.J. Kirkpatrick. 2001. “Annual Review: Innovative Techniques for Harmful Algal Toxin Analysis.” Environmental Toxicology and Chemistry 20 (1): 107–14. Poey, F. 1866. “Ciguatera: Memoria sobre la enfermedad ocasionada por los peces venenosos.” In Repertorio Físico-Natural de la Isla de Cuba, edited by Tomo II, 1–39. Habana: Impr. del gobierno y capitanía general por S.M. Sakami, T., H. Nakahara, M. Chinain, and Y. Ishida. 1999. “Effects of Epiphytic Bacteria on the Growth of the Toxic Dinoflagellate Gambierdiscus Toxicus (Dinophyceae).” Journal of Experimental Marine Biology and Ecology 233: 231–46. Scheuer, P.J. 1982. “Marine Ecology – Some Chemical Aspects.” Naturwissenschaften 69: 528–33. Smith, S.V., and R.W. Buddemeier. 1992. “Global Change and Coral Reef Ecosystems.” Annual Review of Ecological Systems 23: 89–118. Thorne, S. 2000. “Data Analysis In Qualitative Research.” ebn Notebook 3: 68–70. United Nations Environment Program (unep). Regional Overview of Environmental Program and Priorities Affecting the Coastal and Mar-

   



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ine Resources of the Wider Caribbean. Technical Report No. 2, Caribbean Environment Program, 1989. http://www.cep.unep.org/information-services/cep-technical-reports/tr02en.pdf (accessed 12 September 2014). Van Dolah, F.M., D. Roelke, and R.M. Greene. 2001. “Health and Ecological Impacts of Harmful Algal Blooms: Risk Assessment Needs.” Human and Ecological Risk Assessment 7 (5): 1329–45. Waltner-Toews, D. 2004. Ecosystem Sustainability and Health: A Practical Approach. Cambridge: Cambridge University Press. Waltner-Toews, D., J. Kay, and T. Murray. 2004. “Adaptive Methodology for Ecosystem Sustainability and Health (amesh): An Introduction.” In Community Operational Research: Systems Thinking For Community Development, edited by G. Midgley and A.E. Ochoa-Arias. Alphen aan den Rijn, Switzerland: Kluwer. Wenger, E. 1998. Communities of Practice: Learning, Meaning and Identity. New York: Cambridge University Press. – 2000. “Communities of Practice and Social Learning Systems.” Organization 7 (2): 225–45. Wenger, E., R. McDermott, and W.M. Snyder. 2002. Cultivating Communities of Practice. Boston, ma: Harvard Business School Press. Wilcox, B.A., A.A. Aguirre, P. Daszak, P. Horwitz, P. Martens, M. Parkes, J.A. Patz, and D. Waltner-Toews. 2004. “EcoHealth: A Transdisciplinary Imperative for a Sustainable Future.” EcoHealth 1 (1): 3–5. Yin, R.K. 2003. Case Study Research: Design and Methods, 3rd ed. Thousand Oaks, ca: Sage Publications. Zingone, A., and H.O. Enevoldsen. 2000. “The Diversity of Harmful Algal Blooms: A Challenge for Science and Management.” Ocean and Coastal Management 43 (8–9): 725–48.

   

9 Religion, Environment, and Health a n n e m a r i e d a lt o n

You cannot have healthy people on a sick planet. Thomas Berry (Webb 2003, 2)

A number of developments have led religious studies scholars to examine the interdisciplinary nexus of environment, religion, and health. Beginning in the 1970s, the environmental movement that involved many of the same activists involved in the peace movement was calling forth a response from religious groups. Led by scholars such as Thomas Berry, John Cobb, and Rosemary Radford Ruether, an academic field of religion and ecology began developing (Dalton and Simmons 2010, 19–37). More recently, again evoked by public events (9/11 predominantly), but also by the postmodern critique of secularity, interest in religion as an active presence in most societies is increasing significantly. While religious clergy and chaplains have a longstanding presence in the health sector, scientific study of the impact of religion on health is also a comparatively recent phenomenon. This chapter is made possible by the increasing prominence given to interdisciplinary conversations across all these fields. As Vernice Miller-Travis (2000, 570) has observed in his discussion of Christianity, poverty, and ecology, “Isolating issues doesn’t work because nobody lives like that.”

Introduction On the top of a mountain in Appalachia, evangelical Christians gather to protest mountaintop mining and to conduct a ritual of honour to the mountain, both to celebrate it as divine creation and to lament its

   



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devastation. In San Francisco Bay, a Buddhist sangha advocates for the use of recycled paper by major magazine publications (Renewal: http://renewalproject.net/film). In Northern Toronto, a recently built Roman Catholic Church is certified as a leed Gold (Leadership in Energy and Environmental Design) building. In Halifax, a mosque is carefully constructed to meet the highest levels of environmental standards. Globally, the Anglican Church Environmental Network involves local communities worldwide in exploring ways in which their churches and communities can become more environmentally responsible. Quietly and mostly below the radar, religious groups are becoming green. Does this really matter? What difference does it make to society, the environment, and communities? Empirical data on how widespread these efforts are and what real differences the religious efforts are making in stimulating more ecological responsibility have not been systematically compiled. However, in recent years there has been a growing interest among social scientists and religion scholars in what religion-based activity might mean to society at large. At its heart lies the question “What is the social capital of religion?” (some refer to this as spiritual capital). A growing body of research strongly supports the positive role of religions in the larger human society; even more, there is an interest in the relationship of religion to human health.1 What remains to be explored, however, are the interconnections of the social capital of religion to health, specifically through the effective promotion of a healthy environment and what it is that makes this uniquely religious. Hence, this chapter argues (on the basis of research on the social capital of religion) that religion can effectively promote ecological sustainability, which is a basic condition for human health. As a species dependent on the Earth and its other species for the basic sustenance of life, we have quite a large stake in the condition of the physical environment. The cleanliness of air, water, and food are not negotiable if we are to be healthy. Furthermore, both our psychological and mental health are much more dependent than we have previously thought on the quality of our relationship to the natural world and the way in which we understand that relationship (see also Hansen-Ketchum, chapter 4 above).2 There are two different but interrelated ways in which religion’s promotion of ecological sustainability fosters human health: (1) Religious communities foster strong and committed social networks; it has been argued that social networks are the key to p ­ romoting a

   

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more ecologically sustainable society (Dale 2005). (2) Religions often centre on transformation; they contain the motivation and dynamics necessary for changing minds and hearts toward what is considered morally good. Many contemporary religions have already adopted or are striving to incorporate ecological meanings. Some even attempt to transform whole ways of understanding human life based on ecological meanings (Tucker and Grim 1997–2002). The horizon of these changes to the basic worldviews is responsible action for sustainability.

Definition of Terms The meanings of the terms human health, religion (and its relation, spirituality), and nature as well as the concept of social capital are rather fluid, so definitions are in order. For the purposes of this chapter, human health is understood to be a holistic concept of wellness. As such, it is not to be equated with freedom from particular diseases, although that is a component and often (but not always) a good indicator of all-around well-being. However, health is more synonymous with a sense of well-being that includes the mental, psychological, and physical dimensions of the human person. As such it is subject to the influences of the ecological, social, and political contexts within which individuals attempt to flourish. The term religion, like the term health, can have a variety of meanings and is further complicated by its relationship to the term spirituality (Hufford 2003; Larson, Swyers, and McCullough 1997). In this chapter, religion will refer to a system of meaning that includes an assumption of some ultimate divine or sacred reality and has an institutional presence, or has been recognized as a religion traditionally. Those who do not belong to a traditional religious institution, but claim a personal faith in some form of sacred reality, often profess spirituality. The assertion “I am spiritual, but not religious” captures this sense (Zinnbauer et al. 1997). Spirituality can also refer to non-material dimensions of the universe such as consciousness or an unnamed mysterious presence in things, without recognizing the existence of any reality outside the physical universe. In this chapter, the designation religion is used to include spiritualities that have become somewhat institutionalized in that they are a recognizable group; some neo-pagan and Wiccan groups are achieving limited legal recognition, such as the right to

   



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perform marriages. The term religion as used here also includes Taoism, Confucianism, and some forms of Buddhism, which do not profess belief in some divine reality, but which have traditionally been understood as religions. There is no attempt to speak for all individualistic forms of spirituality, although what is said of religion may also apply to these. Nor should it be assumed that all religious groups everywhere contribute in the same fashion to social capital, especially as it relates to sustainable societies. Nevertheless, all the major religious groups of the world are attempting, albeit to different degrees and in various ways, to address the ecological crisis both through a renewal of their belief system and through appropriate moral action (Yale Forum on Religion and Ecology n.d.). The terms nature and natural world have also become contested (Demeritt 2002; Simmons 1993; Latour 2004). They will be used below with full awareness that nature includes human beings and that our knowledge of nature or of the natural world is always mediated. There will also be the assumption, however, that there is a natural world that has existed beyond any human conception of it and that rocks, plants, soil, water, animals, and so on are inherently different from the artificial environments constructed by human beings. While some argue that the humanly constructed world can be understood as natural in the sense that humans are natural animals and therefore their productions are also natural (Simmons 1993), the terms nature and natural world in this chapter will not refer to human-created artifacts. Finally, another key term, social capital, is subject to a diversity of definitions. Jenny Onyx identifies a number of nuances given to the term by various authors. She concludes that the ongoing understanding is likely to be “complex and multi-layered” (Onyx 2005, 3). No clear boundary of meaning has emerged, but there does seem to be agreement that “networks that facilitate collective action” ­(Woolcock 2001, cited in Onyx 2005, 4) lie at the core of what constitutes social capital. Furthermore, Portes claims that there is growing consensus that “social capital stands for the ability of actors (both group and individual) to secure benefits by virtue of membership in social networks or other social structures” (Onyx 2005, 3). The discussion below will assume that social capital is what enables humans as individuals and groups to become agents in promoting well-being for themselves and their societies within networks of dialogue and cooperation.

   

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Religion’s Production of Social Capital Research has shown that religions contribute to more than half of the social capital of the United States (Putman 2000; Alexander 2007; Paxton 1999). While issues such as which religious groups contribute what particular capital, or how religious pluralism affects the overall social capital, do exist, most research confirms a strong contribution of religion to the norms, values, and institutions of a society (Alexander 2007; Finke 2003; Hufford 2003). This is despite the decline in overall church membership and attendance in mainline Protestant Christian groups.3 Moreover, there is growing evidence that religion plays a unique role in the production of social capital. In a study conducted in the public schools in Chicago, one of the authors of Catholic Schools and the Common Good (1995) was hired to produce social capital in the public school system at the levels he had observed in Chicago Catholic schools. The latter had been observably successful in the integration of minority students and in helping the students achieving high levels of academic success. In short, the experiment failed. The experimenters were unable to produce in the public schools the sense of community, the ideological motivation, the committed involvement of parents, teachers, and other key players, and the sense of self-sacrifice that were the key to the success of the religious schools (Coleman 2003, 226). Such case studies are an indication that religions combine, in some particular way, a number of factors that comprise a recognizable social capital. While religion’s contribution to social capital is very much under discussion, there are already a number of helpful reflections and conclusions from scholars working in this area. One obvious way in which religions contribute to social capital is through the social functioning of the institutions established by religions, whether these are schools, hospitals, soup kitchens, recreational facilities, media, family services, summer camps, orphanages, political advocacy groups, or other outreach activities. Through all of these, as well as through the religious community itself, relationships and networks are established which in turn have consequences for the larger society. Because of this functionality of religion through its institutions, some scholars have treated religions as a subset of associational groups in terms of the social capital they actually or potentially contribute (Smidt 2003, 4). However, as the example above illustrates,

   



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religion involves more than association. For one, the association is a result of common faith and ideals. Further study of the social capital inherent in associations of citizens reveals a layering of trust and coherence that depends upon the “thickness” of the association; that is, the level of trust, the manner (face-to-face or internet, for example) and frequency of contact (monthly, weekly, daily), and the commitment to a goal (Smidt 2003, 5). Religious communities are often characterized by this “thickness” of association. Hence, the second way religions contribute to social capital is through systems of meaning within which individuals and communities view their lives and their contributions to society as having an ultimate meaning and purpose. These systems of meaning also engender the creation of such intangibles as attitudes of trust, love, forgiveness, and service, as well as social norms and practices, such as rules against smoking or drinking, for example, or a more responsible ecological practice. Actions are closely associated with an overriding story of the meaning of life; to name a few, we have the gospel life of Jesus, the history of the chosen people, or the life of Buddha. Religion and its institutions have had, and still possess, a lot of power in society. No one denies that this power has been and too often continues to be used for ill purposes, but the conclusion of most research is that most religious groups and individuals have a positive influence on the building, maintenance, and renewal of societies. As research advances, an emerging challenge lies in recognizing different kinds of contributions by religious communities in particular contexts. While one group contributes to capitalistic growth, another may contribute to resistance against such growth. In different contexts, one or the other may be desirable or not. The same is the case for social capital related to ecological wholeness as a basis for human health. Where religions are involved in destructive conflicts, the results are obviously not contributing to human or planetary health, while at the same time the religious faith of individuals or small communities may well be enabling them to cope with adversity and maintain some social integrity. Obvious difficulties and exceptions notwithstanding, the judgment of a generally positive effect of religions on human well-being seems to hold over a broad range of preliminary studies (Hufford 2003; Emmons 2003; Post 2003). Religion and ecology has developed over the past five decades not only as a significant field of study, but also as a socially engaged

   

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field that includes established churches as well as religiously inspired activist individuals and groups (Dalton and Simmons 2010; Forum on Religion and Ecology n.d.). Overall, this is a relatively new way in which religions are present within society, and potentially a new category of social capital. While it is too early to find conclusive studies directly addressing the influence of religion on the ecological crisis, there is no reason to expect that religious influence in this area would differ greatly from religious influence in other areas affecting attitude and behaviour, such as social justice. Certainly the structures and systems within which religions attempt to influence responses to the ecological crisis are the same as those through which religions address traditional moral issues. In other words, religions use their traditional outreach, their evangelical role in preaching and teaching, their networks of charitable organizations, their frequent community gatherings for social events as well as religious ritual, and their emphasis on the moral development of the individual and on the transformation of society. What is distinctly religious is the combination of such activities within a motivational worldview that assumes an ultimate purpose to all of these efforts. For many, the created order has its origin in a divine creation; it is imbued with divine presence and possesses an integrity that is not dependent on its utility as human resources. Furthermore, the protection of that creation is divinely placed in the hands of humankind. Christians refer to this as stewardship; Muslims as trusteeship. Virtually all religions believe in accountability for human behaviour to some ultimate reality; accountability for human treatment of creation is, therefore, one of the key foci of religion and ecology.

Meaning, Religion, and Human Health The effect of religion’s focus on meaning and the relationship of this dimension to human health have warranted special attention. Religions can have a positive effect for ecological sustainability in their functional dimension, such as promoting recycling or vegetarianism, making their buildings more energy efficient, and preaching stewardship of natural resources. Religious communities have become involved in such activities. Given that most religious groups still reach a substantial percentage of the public on a regular basis (and the research noted above testifies to the continuing power of

   



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religions), such an assertion hardly needs much argument (this is not to say that it is insignificant). However, the more intangible effects related to religion as systems of meaning, which account for the “thickness” of association, are less transparent. Much of the investment of religions in creating a more ecologically sustainable world focuses on a new formulation and articulation of traditional worldviews to include human relationships to nature; that is to modify and in some cases radically change traditional systems of meaning (see also Edwards and Davison, chapter 2 above, and Hansen-Ketchum, chapter 4 above). Religions such as Christianity, for example, are moving from a predominantly anthropocentric view of humans as dominators of nature to one of humans as integral components of a sacred creation, or at least of humans as benign stewards of God’s creation. The assumption underlying this investment in changing traditional meanings is that religions are effective in the production of meaning and that these meanings matter for human and planetary well-being. Eric Weislogel (2007) argues for the necessity of a sense of wholeness as basic to human well-being. Weislogel relies on the research of three other scholars: John Caputo (2001), Stanley Rosen (1969), and Karl Vaught (1969). Caputo developed a notion of the unseeable future to which we look forward but which is also impossible to predict or describe. He suggested that there are two futures, one for which we can prepare and one which arrives as a surprise. We live in anticipation somehow between these two futures. For Caputo, such an understanding of the future is essentially a religious view; it belongs to religious stories all of which, Weislogel (2007, 1–2) points out, are but fragments of some whole for which humans reach but which we can never fully attain. From Rosen, Weislogel adapts reflections on the nature of human desire for wholeness and the impossibility of achieving it. Rosen claims that a fulfillment of all human desire would require a complete speech, which is not possible to humans. Hence we exist in the fragmentary accounts of a whole. To be human is to carry the desire for wholeness and to possess that wholeness only in the sense that one comprehends and can speak about completeness. While wholeness is unattainable, it is nevertheless intelligible. It would be a mistake, however, to substitute our fragmentary ways of speaking about wholeness (our stories) for wholeness itself (Rosen 1969, 225–6, cited in Weislogel 2007, 4).

   

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Finally, Weislogel’s third source, Vaught, highlights the inadequacy of thought about wholeness to “encompass the quest for wholeness as it unfolds within direct experience” (Vaught 1969, x, cited in ­Weislogel 2007, 5). Both reflection and action are necessary in a healthy quest for wholeness. Vaught identifies two problems in the human quest for wholeness. One is the “preference for immediacy, for doing rather than saying”; the other is to demand “complete comprehension” (Vaught 1969, 8, cited in Weislogel 2007, 7). Wholeness is neither the immediate intensity of the moment nor the sense of completeness. It is rather human finitude that exists between fragmentation and completeness and opens onto a transcendent, unbounded whole (Weislogel 2007, 7). Humans do, in fact, live a fragmentary existence (as postmodernists continue to point out). That said, as these philosophers argue and as the lived examples cited below demonstrate, we are, in ­Weislogel’s (2007, 8) words, “driven by the whole,” and that is fundamentally religious. It is, in fact, what constitutes meaning in the religious sense. Owen Flanagan (2007) gives a different perspective on the relationship of religion to the quest for meaning. Like Weislogel, F ­ lanagan claims that human flourishing requires a sense of the meaningfulness of life. He bases his claim on the history of philosophical inquiry as well as on recent scientific and neuroscientific research on consciousness. Unlike Weislogel, he speaks from a naturalistic perspective; in other words, there is no necessity for appeal to a supernatural reality to acquire a meaningful life. Given the scientific basis for understanding the human in the twenty-first century, Weislogel (2007, 11–12) posits six spaces with which contemporary humans interact in their quest for meaning: art, science, technology, ethics, politics, and spirituality. While it is possible that some humans may interact almost exclusively with one of those six spaces (or a few), for most humans, a fulfilled and meaningful life requires interaction with all of them, including a crosscutting requirement for “friendship, companionship, family and perhaps passionate love” (Weislogel 2007, 188). Flanagan claims that the reason religion has been a consistent and long-standing system of meaning for many is that it alone can supply all the other spaces. “The space of spirituality and religion is designed, it seems, to function comprehensively for those to whom it is designed to appeal  – in principle to everyone in the vicinity” (Flanagan 2010,

   



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189). More than explaining why we exist or why there is anything at all, religions typically have two common functions: “Providing stories that make sense of things and provide meaning” and “Providing some sort of ‘superglue’ to an ethical conception” (Flanagan 2010, 197). Whether one agrees with Flanagan that religion has a naturalistic explanation or not, it is worth noting that, as Flanagan demonstrates, modern and contemporary scientific understandings of the human support an account of religion as primarily a comprehensive system of meaning. The two case studies that follow, therefore, serve as practical demonstrations of how comprehensive religious meaning functions in the practices in which humans engage. Human activity and meaning are interwoven and influence each other. As indicated above, this may well be the “superglue” that holds together networks and associations, which religions generate. It is not that there is meaning, and actions follow it as a kind of practical consequence, but rather that each enhances and produces the other. Thus, in terms of the ecological crisis, a meaningful understanding of creation as a sacred entity of which humans are an integral part supplies a context for recycling or the protection of biodiversity, while at the same time these activities enhance the meaning of creation as bonded to one’s life and as kin to family and those within one’s circle of care. This again is the identifiable “thickness” that religions can give to social capital.

Case Studies on Religion’s Social Capital as Meaningful Action In the 1980s about 200,000 Guatemalans of Mayan descent were forced to cross the border into Mexico as refugees from the Guatemalan army. The poor people of Chiapas, Mexico, welcomed many of these refugees. They settled in Mexico and some remain there today. A decade later many of the refugees expressed the desire to return to Guatemala. Canadian Christian groups, including the Canadian Task Force on Central America and the Maritimes-­Guatemala “Breaking the Silence” Network, responded to their desire and helped found Project Accompaniment. This project supported the return of the Guatemalans to their homeland by providing accompaniment by one hundred and forty Canadians. The story of this project and its impact not only on the Guatemalans, but also on both the Mexicans who welcomed them and the Canadians who

   

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accompanied them back, is told by Kathryn Anderson in Weaving Relationships: Canada-Guatemala Solidarity (2003). Anderson interviewed many of the people of Chiapas who welcomed the refugees to Mexico and the refugees themselves, as well as the Canadian organizers and accompaniers, about their experience. The results reveal a successful project in terms of the resettling of the Guatemalan refugees in their home country. They also provide an intimate view of the integration of the social functioning of religious institutions and the religious meaning systems of those who participated. The following statements are quite representative of many. One accompanier said, “If you give me $50,000 for a project that is good. But if you offer me spiritual and moral support and we encounter one another as human beings, it is far more than $50,000. If we don’t have this kind of solidarity we are going to destroy the world” (Anderson 2003, 209). One of the refugees observed: “When we left Guatemala and found refuge in Mexico, we felt alone. But the Catholic Church gave us spiritual and pastoral accompaniment. Because of this we said, ‘We are no longer alone. The Church is with us’” ­(Anderson 2003, 38). As the author and interviewer herself comments, The people I interviewed often refer to solidarity as spirituality in action. Many find regular spiritual practices such as prayer, meditation and participation in guided retreats a vital necessity, but do not see these practices as an end in themselves. Essential to their spirituality is both a transformation of their personal lifestyle and participation in struggle for more just, respectable relationships and more equitable economic systems. (Anderson 2003, 218) The witnessings of participants are consistently a testimony to a concrete social action, a religious movement that functions in the establishment of social justice, but is at the same time immersed in a deepening of personal meaning for the participants. In a similar study of Canadian Christian involvement in ecological and justice issues in the developing world, Gabrielle Donnelly (2008, 68) interviewed members of kairos, a task force representing the major churches of Canada. Kairos is a biblical term meaning a critical present time in which there is a call to respond to the issues of the day. One respondent noted,

   



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I think we in kairos Canada do really believe in that … in that our attempts to read the signs of the times and … the issues of the day, choosing where we are going to put time and effort is really an attempt to discern that … is this a situation in which God is challenging us to be active? Just prior to Donnelly’s interviews, kairos was involved in issues surrounding the presence of Canadian mining in countries in the South. Canadian mining companies were accused, quite rightly as it was later determined, of violating the rights of Native communities and destroying natural environments in a manner that would be unacceptable according to standards within Canada. kairos joined the Canadian Network for Corporate Responsibility to advocate to the Canadian government to enforce standards similar to those upheld in Canada on Canadian mining companies. In 2006, kairos groups across Canada made submissions to National Roundtables on Corporate Social Responsibility and the Canadian Extractives Sector in Developing Countries. At the end of the process, the Subcommittee on Human Rights and International Development of the Standing Committee on Foreign Affairs and International Trade submitted its Third Report to the Committee recommending stricter standards on Canadian corporations overseas. While it is difficult to judge the efficacy of particular advocacy groups in influencing policy change, it is noteworthy that kairos along with other church groups was and remains among the most consistent advocates for greater corporate responsibility. kairos’s involvement in obtaining a more robust policy regarding Canada’s corporate presence in developing countries is a good illustration of the roles that religious groups can and do play in directly affecting public policy and action. As was the case with the accompaniment program for the Guatemalan refugees, there is also evidence that the political and social action of kairos members was intimately related to the spiritual meaning held by the institution as well as by the individual members. People were acting out of a relevant religious meaning, as Donnelly’s research demonstrated ­(Donnelly 2008, 86–7). In this case, it was their understanding of the gospel norms of social justice, the new sensitivity to care for nature, and/or the example of Jesus Christ in his attentiveness to the poor that gave a religious context to the action. For some individuals, the actions proceeded from a quest for a more meaningful life; in others,

   

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some vague commitment to justice led them to action that in turn produced personal meaning for them and further clarified their commitment. The sequence of action and meaning is indiscernible; the two dimensions are inseparable. As Lisa Kowalchuk and Jennifer Pierce (2005) concluded about the Anderson study of the accompaniment model of social engagement, the commitment and action for justice is “deeply intertwined with a spiritual quest for purpose in their own lives”(Pierce 2005, 433–4). Pierce also found in interviewing religious activists that their social and political engagement often began not from political stances or commitments but from feelings of mutuality and relationship or senses of humanitarian responsibility or moral duty (Pierce 2005, 435). For Kowalchuk and Pierce, this evidence raises questions about the way in which individualism has been negatively portrayed as destructive of community solidarity and commitment. Evidence from the study of religious activists indicates that the individual search for fulfillment is often associated, both as source and consequence, with community engagement. Clearly the sense of a meaningful life, one of the significant conditions for human health, can be sought and found by means of an engaged religious commitment. In another setting, Robert L. Kinast (2008) draws attention to the incorporation of theological reflection into pastoral activity. Theological reflection, in this case, refers to the explication of the belief system out of which people, such as chaplains and pastors, work, and reflection by these practitioners on their beliefs in the light of their practice. According to Kinast, theological reflection is considered by practitioners to be integral to their work. It is another way of talking about the meaning of what one is doing. Kinast (2008, 275–7) observes that reflecting on the religious meaning of care increases the pastoral workers’ sense of identity, their efficacy, in practice and their relationships with God, with their patients or clients, and with the community of believers to which they belong. As the cases above demonstrate, reflection and practice are interwoven in a meaningful life and religion plays a significant role for many in the production of such a meaningful life. Religion has traditionally influenced both the physical contexts of human life (the construction and operation of social institutions) and the production of meaning through which such contexts are understood; and (if the research on meaning and health is correct) these can work together to contribute to holistic human well-being – that is, to human health.

   



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The recent engagement of religion in responding to the ecological crisis relies on this traditional power of religion. However, it extends that power towards greater protection for the natural world, without which human health is itself in jeopardy. The last section of this chapter, therefore, turns more directly to religion’s engagement with ecology. Religion’s engagement with ecology draws its confidence from the longstanding tradition of meaningful action.

E c o l o g y, R e l i g i o n , a n d H e a l t h The links between ecological health and personal health, especially in relationship to pollution and the use of toxic substances, was certainly controversial when Rachel Carson raised the ire of many agriculturalists and industrialists with Silent Spring in 1962. However, the connection is now well established, and more and more popular accounts (Smith and Lourie 2009) are reaching the public. Research into the relationship of environmental pollution to various forms of cancer, to asthma and other respiratory diseases, to increasing reports of allergies in children, and to other diseases is no longer rare. On the one hand, political and economic concerns still often trump ecological and health concerns. A current Canadian example is the inertia of political action around the health effects of the tar sands in Alberta despite evidence of increasing cancer rates among communities downstream from the tailings ponds (Clarke 2008; Simpson 2009). On the other hand, grassroots involvement has an effect on other fronts such as on the growth of the slow food movement, which is perhaps the best indication of the growing public awareness of the effects of poisoned environments on human health and subsequent action (Andrews 2008). Besides the obvious health issues, the ecological crisis – the threat to the very Earth on which we stand – engenders a sense of anxiety and hopelessness for many. Given the relatively short time in which religions have been involved in responding to the ecological crisis,4 there are no comprehensive studies of the ecological effects of related religious activity. While such empirical studies remain to be done, there are certainly thoughtful arguments for the significance of ecological meaning for human well-being (Rutledge 1993; Clayton and Optow 2003; Swan 1992). Based on personal experience as well as the accounts he heard from others, especially Aboriginal peoples around the world,

   

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­ sychologist James A. Swan (1992) claims that modern peoples sufp fer from a loss of awareness of their physical and psychic connection to nature. He leads his reader in an exploration of traditional forms of healing from the East, from Native North and South Americans, and others. He connects these ancient insights with modern psychological experiments in his argument for paying serious attention to the healing power of the physical world itself. Swan also cites modern studies and programs that provide scientific credence to the traditional claims and practices regarding the healing powers of the natural world. One of these is the program for treating drug addicts by taking them on wilderness exploration (Swan 1992, 173–4). Others include the work of clinical psychologist Jean Acterberg on the use of creative imagery in cancer treatment (Swan 1992, 177), Winslow Anderson’s study that supported the healing power of mineral springs (Anderson 2003, 159), and a Japanese study that showed the positive effects (for eighty percent of patients) of hiking and camping trips on allaying the symptoms of clients suffering from schizophrenia (Ishihari 1973, cited in Swan 1992, 173). Aldo Leopold (1966) associated the formation of the human mind with a lack of consciousness of the natural world when he wrote, “perhaps the most serious impediment to the development of a land ethic is the fact that our educational and economic system is headed away from, rather than toward, a consciousness of the land” (Leopold 1966, 269, cited in Swan 1992, 110). Thus, Swan argues for the reconstruction of meaning systems which encourage human presence to the natural world. Deep ecologists, and those who accept much of their thinking and agenda, claim that an adequate response to the environmental crisis, one that will effectively promote the healing of the planet, calls for a re-examination of the whole cultural context in which humans have come to separate themselves from the rest of the natural world. Many environmentalists have claimed that the devastating ways in which humans have treated the natural world are directly linked to negative perceptions of the natural world inherent in the Bible (White 1967; Santmire 1985; McFague 1987; Berry 1988; Dunn 1990; Ruether 1992). The injunction to dominate the rest of the world, the perception of humans alone as made in the divine image and therefore superior to the rest of creation, and the belief in a heavenly realm separate from and above this world are among the attitudes and

   



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beliefs ­singled out as ideas complicit in the ecological crises of today. Christian eco-theologians5 argue that a corrective to these attitudes within the traditionally dominant religion of the West, Christianity, is a necessary and critical part of an effective response to the ecological crises. Thus, Rosemary Radford Ruether (1998) calls for a “psycho-­cultural conversion” away from an anthropocentric domination of the rest of nature to one of communion with all beings. What is needed, she claims, is a healing culture. She advocates the examining of other cultures for wisdom not so present in Western cultures, such as compassion for all beings and a sense of balance and harmony in society and in the cosmos (13; reference to Tucker and Grim 1994). This is a call for a revision of the meaning system of some, and maybe all, religions. Early in the recent phase of the environmental movement (since the 1960s), Thomas Berry (1988) connected the overall sense of alienation in humans with our separation from the natural world. Whereas Swan (above) examined this phenomenon from a psychological perspective, Berry focused primarily on a cultural perspective. For Berry, humans, especially in the West, had lost their sensibility to the energies provided by the natural world as well as having truncated their worldview by pitting the scientific understandings of the world against humanistic understandings. He advocated for a reuniting of these understandings in a more holistic story of the universe (Berry 1988, 123–37). Such a story would integrate modern scientific evolutionary views of the cosmos with attention to the emergence of consciousness and the spiritual and psychic sensitivities that were active in the lives of pre-modern peoples and to some extent among Aboriginal peoples today (see also Bartlett et al., chapter 10 below). The natural world, Berry claimed, has its own spirituality of which humans are a part. Hence, he argued for a human re-inhabiting of the Earth (Berry 1988, 163–70). By this he meant the development among humans of a realization that we are the Earth, just as all other creatures are. We are better considered a unique kind of presence (i.e., one that is reflectively aware) within the universe rather than a superior creature with inherent rights to dominate the rest of the natural world. Not only is this change of mind and manner of living critical to the future survival of the Earth and its creatures, but it is integrally bound up with the human sense of flourishing and well-being. Critical of the way in which modern humans have

   

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seen the well-being of the human species alone as the norm for all judgments about good and evil, Berry proposed: “we are ourselves only to the extent of our unity with the universe to which we belong and in which alone we discover our fulfillment. Intimacy exists only in terms of wonder, admiration and emotional sympathy when beings give themselves to each other in a single psychic embrace, an embrace in which each mode of being experiences its fulfillment” (Berry 2006, 35). Poulsen (2009), Waldau and Patton (2006), ­Goodall (1988), and Fossey (2000) all present convincing accounts of complex relationships between humans and other animals, which support Berry’s claim of communion and mutuality among living creatures. The call to transform the human relationship to the universe, to all other beings, is a call first and foremost for a meaning system that can ground environmental or ecological ethics. It is also an appeal to the human quest for wholeness to include in a serious manner the meaning of the human presence in the rest of nature (Gibson 2009; Goodall 1990). Chaia Heller begins her book, The Ecology of Everyday Life (1999, 1), with the following statement about the relationship of the environmental crisis to the human desire for a better quality of life: “ecology is as much about desire as it is about need. While the ecology movement of the sixties addressed the need for clean air and water for survival, it also expressed a popular desire for an improved quality of life. People took to the streets in the seventies to fight nuclear power; but many also took to the land to build ecological communities hoping to enrich their social relationship as well as their ties to the natural world … Born out of the call for enough clean water, air and land to survive, ecology is also the demand for a particular quality of life worth living.” For Heller, the human constructions of both nature and desire belong to the realm of the historical and political. What she calls the eco-erotic desire, that is, the desire for nature, has since the 1960s expressed itself most clearly as one that incorporates both social action and human desire for fulfillment. While Heller is not claiming that religions are the basis for such action or the fulfillment of such desire, her account highlights the same quest for human wholeness reflected in the subjects of research presented above. In her conclusion, she claims that ecological or social activist groups work not only because they perform certain actions, but also because they share a common meaning

   



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(Heller 1999, 159–60); hence, her advice to such groups is that they provide access for others not only to their practices, but to their shared meanings. In our time, the paralysis and fear engendered by the ecological crisis (as well as the continual war, violence, and poverty throughout the world) is prevalent. One has only to peruse the shelves of self-help books in large bookstores or to scan the internet for book titles addressing “hope.” Enabling people to engage in meaningful responses to the ecological crisis is one of the major (and arguably the most critical) ways in which to promote holistic health. Religions are not the only institutions needed to accomplish this. As the research on the social capital of religion cited above has shown, however, religions can and do promote human health largely by providing a sense of purpose and meaning that many believe is critical to human well-being.6 Over three decades of work by religious scholars in many different faiths has resulted in a body of research that relates many traditional religious teachings to the ecological crisis.7 These scholars are from many different religious traditions and have committed their expertise to the reinterpretation of sacred texts and a critical examination of their particular religious traditions in the light of the ecological crisis. Several generations of young people have now taken courses relating religion to ecology (Dalton 2008). Much more recently, religious-based actions on behalf of environmental sustainability are both evident and increasing. On 25 January 2009, Roman Catholic Bishop Luc Bouchard of St. Paul’s Diocese, Alberta, released a pastoral letter entitled “The Integrity of Creation and the Athabasca Oil Sands,” addressing the continued development of the tar sands in northern Alberta. ­Bouchard called the environmental devastation and health problems caused by the tar sands a moral issue. He explained within a Christian context the basis for considering environmental and health concerns to be moral issues, summarized the scientific evidence motivating him to write the letter, and insisted that “[p]ersonal, social and political change will be necessary to meet this national challenge” (Bouchard 2009, 1). He addressed his concerns to “oil company executives in Calgary and Houston, to government leaders in Edmonton and Ottawa and to the general public whose excessive consumerist lifestyle drives the demand for oil.” The bishop’s l­etter

   

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is just one example of how official institutional representatives of many religions are turning their attention to the ecological crisis and ­instructing their followers in the relationship of religious understandings to practical action. Religion’s response to the ecological crisis attempts an interweaving of action and reflective understanding. As is the case in the much more studied examples of religion’s involvement in social justice and charity, the religious promotion of ecological sustainability is drawing on the dual action-reflection production of meaning. Social capital is therefore being redirected and/or expanded into a new area of concern.

Conclusion This chapter has argued that religion has the power, through its contribution to social capital, to enhance human health through its response to the ecological crisis. The argument rests on the substantial evidence produced by social science research that religion contributes in its own particular way(s) to the social capital of society. That contribution has been further differentiated to reveal two overall dimensions of religion to social capital: religious communities’ power to create networks and associations of deep trust, and the related dimension of religions as producers of meaning that undergirds such associations. Through the use of case studies, we have demonstrated the ways in which individuals and groups bring together action and reflection in the production of meaning. According to some scholars (Weislogel and Flanagan, for example), religions function well in providing systems of meaning for their adherents. Religious response to the ecological crisis delivers its message and provides occasion for action through the traditional institutional ways in which it has delivered social capital. Thus religion pays attention to the necessity of a sustainable natural world for human health. Case studies also show that religions capitalize not only on their ability to create networks and nodes of action, but also on the production of appropriate meaning systems to address the need for hope and purpose in the light of an overwhelming ecological crisis. Human health in the present, and for the foreseeable future, will depend greatly on systems that engender hope and empowerment.

   



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notes 1 Some researchers are using the term spiritual capital to distinguish specifically religious kinds of contributions to society from those of other institutions. Henceforth in this paper we will use only the term social capital but also maintain that religion offers a unique social capital. 2 The chapter will not argue the case that a healthy environment is essential to human health. It will be assumed that clean air, clean water, and non-contaminated food are basic requirements for health and that access to naturally beautiful environments plays a role in overall physical and psychological health. However, recent research connecting closeness to the natural world with human well-being will be discussed in the section “Ecology, Religion, and Health.” 3 The statistics on religious membership and ritual attendance in Canada does show these trends for United Church of Canada, Presbyterian, and Anglican denominations. However, there is an increase in attendance in particular in evangelical groups, many of which are active in the ecological movement. There is also a large increase in religions associated with major immigrant groups. Cf. commentary on the Canadian statistics at http:// www.religioustolerance.org/can_rel1.htm. 4 While there were a few individuals such as Thomas Berry who were addressing the ecological crisis in religious terms in the 1970s, most involvement can be traced to the mid-to-late 1980s. The Assisi meeting of the network of religions and conservation initiated by the World Wildlife Fund in 1986, the call to action by Ecumenical Patriarch Bartholomew in his environmental seminars beginning in 1994, and the establishment of the Forum on Religion and Ecology (fore) in 1996 are significant markers. All of these events incorporated a call for action with the production of appropriate ecological meaning. fore, for example, invited scholars from the major traditions to reflect on sources from within their traditions that might contribute to or inspire new understandings of the human presence in nature. 5 Eco-theologians are theologians who critically examine their religious tradition in the light of the ecological crisis, both highlighting damaging teachings and reconstructing theology to respond more positively to the ecological crises. 6 Based on an analysis of many studies (over 1,000) that examined the relationship between religion and health (understood comprehensively), ­Harold Koenig and fellow editors of the Oxford Handbook of Religion

   

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and Health (2000) concluded that a significant number of very reliable social scientific studies allow for the general statement that spirituality and religion do contribute to better human health, both psychological and physical. 7 For an extensive bibliography of works on religion and ecology, see the website of the Forum on Religion and Ecology, http://fore.research.yale. edu.

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Ruether, R.R. 1992. Gaia and God: An Ecofeminist Theology of Earth Healing. San Francisco, ca: HarperSanFrancisco. Rutledge, D.W. 1993. Humans and the Earth: Toward a Personal Ecology. New York: Peter Lang Publishing. Santmire, H.P. 1985. The Travail of Nature: The Ambiguous Ecological Promise of Christian Theology. Minneapolis, mn: Fortress Press. Simmons, I.G. 1993. Interpreting Nature: Cultural Constructions of the Environment. New York: Routledge. Simpson, J. 2009. “Broken Hearts, Broken Policies: The Politics of Climate Change.” In Carbon Shift, edited by Thomas Homer-Dixon, 177–202. Toronto: Random House Canada. Smidt, C. 2003. “Religion, Social Capital and Democratic Life.” In Religion as Social Capital: Producing the Common Good, 211–22. Waco, tx: Baylor University Press. Smith, R., and B. Lourie. 2009. Slow Death by Rubber Duck: How the Toxic Chemistry of Everyday Life Affects Our Health. Toronto: Knopf Canada. Spiritual Capital. n.d. “Articles.” http://www.metanexus.net/archive/ ­spiritualcapitalresearchprogram/research_articles.asp.html (accessed 3 September 2014). – n.d. “Literature Review.” http://www.metanexus.net/archive/ ­spiritualcapitalresearchprogram/research_review.asp.html (accessed 3 September 2014). Swan, J.A. 1992. Nature as Teacher and Healer: How to Awaken Your Connection with Nature. New York: Villard Books. Tucker, M.E., and J. Grim, eds. 1994. Worldviews and Ecology: Religion, Philosophy and the Environment. Maryknoll, ny: Orbis Books. – eds. 1997–2002. Religions of the World and Ecology Book Series. ­Boston, ma: Center for World Religions and Harvard University Press. Vaught, K. 1969. Quest for Wholeness. Albany: suny Press. Waldau, P., and K. Patton, eds. 2006. The Communion of Subjects. New York: Columbia University Press. Webb, C. 2003. “The Mystique of the Earth.” Caduceus 59: 1–8. Weislogel, E. 2007. “The Quest of Wholeness.” The Global Spiral. E-publication of Metanexus Institute. 7 December. http://www.metanexus.net/ Magazine/tabid/68/id/10221/Default.aspx (accessed 3 September 2014). White, L. 1967. “The Historical Roots of Our Ecological Crisis.” Science 15 (March): 1203–7. Zinnbauer, B., et al. 1997. “Religion and Spirituality: Unfuzzying the Fuzzy.” Journal for the Scientific Study of Religion 36: 549–64.

   

10 Integrative Science and Two-Eyed Seeing: Enriching the Discussion Framework for Healthy Communities cheryl bartlett, murdena marshall, a l b e r t m a r s h a l l , a n d m a r i ly n i w a m a

The inspiration for the authors draws upon a dream long held by co-author Murdena Marshall (and undoubtedly shared with many other Aboriginal Elders): namely, that one day the educational mainstream will recognize the Indigenous sciences alongside the Western sciences (Bartlett 2011). Our work is grounded in efforts to do exactly that at the post-secondary level within an initiative called “Integrative Science” guided by “Two-Eyed Seeing” even as we acknowledge the “cultural mismatch” that ccl (2007) identified as a major barrier in science education for Aboriginal students and the “irreconcilable beliefs” that Winder (2005) identified as a general challenge for integrative research. We realize that good intentions towards having different cultural knowledges and ways of knowing work together is only one piece, albeit essential, within the exceedingly challenging process of actually doing so, yet we believe that the world’s diverse cultures contain rich insights and approaches that can help address complex issues in today’s world, if appropriately and respectfully recognized, honoured, and harnessed. We emphasize developing shared abilities to respectfully work with our different epistemologies and ontologies, see with the strengths or the best in our different worldviews (i.e. employ Two-Eyed Seeing), find common ground in innovative and meaningful ways, use visuals to complement and extend our word-based concepts, and engage other approaches that enable newer (to the ­academy) forms of research inquiry and community

   



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­ articipation (while continuing to value the more familiar, convenp tional methodologies).

T owa r d s C o l l a b o r a t i o n f o r H e a l t h y Communities: Insights from a Co-Learning Journey of Elders and Academics How can we begin to implement the wisdom of Aboriginal Elders who readily and passionately share their knowledge in hopes for a better future for their children and communities, those around the world, and the Earth herself? In other words, how might the mainstream become more welcoming of “outside the academy” perspectives within discussion frameworks intended to promote healthier communities? Furthermore, recognizing that discussions of healthy communities extend to ecosystems (i.e. that discussions must include both the understanding that humans are members of the natural world and the acknowledgment that both Indigenous and Western scientific knowledges are based in observations of the natural world), what view of science can be adapted to foster transdisciplinary and transcultural collaboration? In an effort to help answer these questions, this chapter is a partial telling of a particular story of the meeting of Indigenous and Western perspectives and the understandings emergent therefrom. It is about Integrative Science (an initiative designed to bring together different worldviews) and Two-Eyed Seeing (a guiding principle in bringing together different perspectives) within a co-learning journey involving a small group of people on the island of Cape Breton (Unama’ki) in northeastern Nova Scotia in the traditional territory of the Mi’kmaw Nation, plus a few individuals from elsewhere in Canada (Bartlett 2011). In sharing our understandings, we concur with those (e.g. Ambler 2003; ccl 2007) who maintain that traditional Indigenous knowledges and ways of knowing have profound and long-established understandings about the value of multiple perspectives and collaboration. We further believe that the academic mainstream should become more involved in creating and nurturing opportunities for meaningful engagement with perspectives beyond its walls, as per the urging of others pursuing integrative and/or transdisciplinary research (e.g. McGregor 2010; Pohl 2010; Bartlett et al. 2012). But participants need to find ways to engage with each other and the diverse knowledges they bring – engage in ways that

   

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are accessible, meaningful, and respectful for both expert and nonexpert while also being conducive to problem framing, to problem solving, to new learning, and to delivering on expectations for productive outcomes (see also Edwards and Davison, chapter 2 above; Parkes, chapter 7 above; Morrison et al., chapter 8 above). The “we” voice used in telling our story denotes group understandings and/or achievements although the words are those of Cheryl, the lead university scientist involved in Integrative Science. In strategic places, the direct words or paraphrased thoughts of coauthors Murdena, Albert, or Marilyn are provided. Our co-learning journey started in the early-to-mid 1990s (Bartlett 2011; Bartlett et al. 2012) and is ongoing; our position is that the journey has been and continues to be the living laboratory in which participants from different sectors and communities are coming to understand how to talk and walk together in an ethical, respectful, and productive manner ... as per the millions of people around the world who desire healthier communities and a healthy Earth Mother. The first three co-authors are the conceptual parents for Integrative Science and remain its “core journey participants.” Murdena and Albert are Elders of the Mi’kmaw Nation and have devoted themselves to the protection, preservation, and promotion of their Mi’kmaw culture, while also advocating the need for transcultural work and thus the need to take down the boundaries between the academy and the community. The fourth co-author and our poet, Marilyn, has been involved in the co-learning journey of Integrative Science since January 2004. We have chosen to use a story genre herein, i.e. to tell about our experiences and, moreover, to configure this as a journey  – journey is the way in which experiences unfold. This format aligns with Aboriginal approaches while breaking with the academic convention of an argumentative format. In regards to Aboriginal approaches, co-author Elder Albert further encourages the understanding that “the foundational basis for any relationship is an exchange of stories.” This is most appropriate as our journey sprang from a vision for a relationship, one in which there would be a “bringing together of the scientific knowledges and ways of knowing from Indigenous and Western worldviews.” Indeed, this is now our definition for “Integrative Science” and its arenas have expanded beyond post-secondary science education where it started to include science research, applications, and outreach to youth and communities. Our journey has

   



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also determinedly sought to help humans reconnect with the Earth and our story approach in that respect sits comfortably with the thoughts of Gregory Bateson (1979, 13) as highlighted by Goodwin (2008, 149): Now I want to show you that whatever the word “story” means ... the fact of thinking in terms of stories does not isolate human beings as something separate from the starfish and the sea anemones, the coconut palms and the primroses. Rather, if the world be connected, if I am at all fundamentally right in what I am saying, then thinking in terms of stories must be shared by all mind or minds whether ours or those of redwood forests and sea anemones. Our co-learning journey has involved dialogues, workshops, projects, conversations, and storytelling within the overall intent that both common ground and differences can be recognized and called upon. The diversity of the people on our journey is rich; over time it has always included Aboriginal Elders, educators, and scientists plus mainstream-educated university scientists and researchers. As opportunities have arisen, Aboriginal and non-Aboriginal post-­ secondary science students and graduates as well as interested others have also been important fellow travellers. Within our journey, we have come to understand very well what Indigenous scholar Jo-ann Archibald clearly articulates in her 2008 book “Indigenous Storywork; Educating the Heart, Mind, Body and Spirit,” namely, that research informed by an Indigenous paradigm may start off with a research question but later such becomes conversation becomes chat becomes storytelling. The guiding principle for our journey is “TwoEyed Seeing” as brought forward by Elder Albert. This is explained later; briefly, it encourages that we learn to see from one eye with the best in the Indigenous ways of knowing and from the other eye with the best in the Western (or mainstream) ways of knowing and, moreover, that we learn to use both these eyes together, for the benefit of all. We use “Aboriginal” herein following Section 35 of the Canadian Constitution Act of 1982, where “Aboriginal Peoples” is the collective name for the original peoples of Canada and it is specified that the Aboriginal Peoples in Canada consist of three groups – Indian (First Nations), Inuit, and Métis. We use “Indigenous” to refer to

   

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knowledge or ways of knowing inherently tied to the natural world (i.e., ecosystems and particular landscapes and landforms within them, plus skies overhead) in traditionally occupied territories. The main Aboriginal participants in our co-learning journey have been Mi’kmaw people, who are First Nations (we use “Mi’kmaw” to denote the adjective and “Mi’kmaq” the noun). However, other Aboriginal peoples and non-Aboriginal peoples have also helped ponder and explore Integrative Science and Two-Eyed Seeing, as, for example, Inuit Elders and educators with respect to land-based camps for youth (Anonymous 2009), diverse workshop participants looking to advance the Species At Risk Act (Williams 2009), attendees at a national science conference (namely, the Canadian Aboriginal Science and Technology Society 2005; see Canadian-­ universities.net website), and participants in global science celebrations (namely, International Year of Astronomy 2009; see iya 2009 Canada website). At all times, the goal for our co-learning journey has been to encourage improved cross- and transcultural understanding, participation, and innovation in science in its various arenas of relevancy (see also Parkes, chapter 7 above; Morrison et al., chapter 8 above). We use “cross-cultural” to mean individuals from different cultures interacting, perhaps collaboratively. By “transcultural” we mean individuals from different cultures working together  – or imagining to – in a way that respects differences, acknowledges common ground, and seeks to co-create new knowledge. We use “transdisciplinary” in the sense of Pohl’s (2010) “Concept B” with the defining features of relating to socially relevant issues, transcending and integrating disciplinary paradigms, and doing participatory research. We use “integrative” to mean individuals from different cultures recognizing and working with the ontologies, epistemologies, axiologies, and methodologies in their different worldviews (especially those in academia working with those outside the academy). It is equally necessary to specify how “integrative” is not being used herein or in Integrative Science. We acknowledge the historical record in Canada of injustice towards Aboriginal peoples and societies; it is our desire to avoid contributing new misunderstandings. “Integrative” is not used in the sense of two knowledge systems merged into one. The latter is not our intent and, moreover, would hold open the door to knowledge domination and assimilation, an undesirable new form of hegemony. “Integrative” is not used in the sense of only taking

   



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bits and pieces from Indigenous knowledges and ways of knowing and then appending them to Western knowledges and approaches. Unfortunately, this easily results when timeframes are hurried and/ or when co-learning has not been part of the process. In addition, we do not use “integrated.” This past tense implies a finished product, whereas our co-learning journey is envisioned as ongoing. Indeed, Newhouse (2004) indicates that the work of grappling with each other’s cognitive universes and learning to see through the minds of others is the work of generations to come. In developing our understandings and sharing them herein, we concur with Watson and Huntington (2008, 276) that the “intellectual traditions we assemble, ‘Western’ and ‘Indigenous,’ are not entirely separable into our individual selves, who are instead a ‘multiplicity of multiplicities.’” We particularly emphasize that our “big picture” approach (explained later) is intended to help orient within “our place of beginnings” for collaborative work that is integrative and transcultural. As Elder Albert indicates, “we need to know who we are and where it is we come from, if we are to envision where we want to go.” We need a place of beginnings. Our Integrative Science journey has shown us that more sophisticated understandings, articulations, and instantiations can and will emerge as participants develop relationships of mutual trust and respect. On the other hand, we have also experienced that when co-learning is not acknowledged or implemented, a collaboration intended to be integrative and transcultural can easily falter, and in dramatic ways. Winder (2005, 299) indicates that “integrative research (i) involves two or more epistemic communities, often with mutually irreconcilable beliefs and (ii) requires small, well-managed, ephemeral groups and sympathetic regulation.” In this regard, our experience shows there is great need, at the outset but continuing throughout the journey of integrative research, to acknowledge and affirm the need to engage in co-learning. Later, we explain how we came to realize that this co-learning requires participants to be able to place the actions, values, and knowledges of their own culture in front of themselves like an object, to take ownership over them and to be able to say “that’s me.” And, as guided by Two-Eyed Seeing, we need these “objects” for both the Indigenous and Western worldviews so that participants can learn both “that’s me” and “that’s you” to foster working together. Thus, “co-learning” involves learning from each

   

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other, learning together, learning our commonalities and differences, and learning to see how to weave back and forth between our cultures’ actions, values, and knowledges as circumstances require. Moreover, we have learned that in order for integrative research to succeed, there is great value in having continued involvement from the same core group of participants until new understandings are strongly rooted or the seeds for such broadly planted. Nonetheless, this core must welcome the participation of others plus nurture their “catch up learning” while continuing to tend to the new learning needs of the group as a whole. Key visuals can assist in this regard, and later we explain some we have developed to convey concepts and enable ongoing and appropriate awareness and application in shifting, evolving, and diverse contexts. Willie Ermine, professor at the First Nations University, who is Cree and from north central Saskatchewan, speaks passionately to the need for different perspectives and cultures to enter into dialogue for the good of all humanity, although he has particular interest in dialogue involving Indigenous cultures and “the West.” He (2007, 201) explains that the fundamental question of cultural encounters is “How do we reconcile worldviews?” He suggests this can occur with implementation of the concept of “ethical space,” a term coined by Poole (1972), in which we make “a venue to step out of our allegiances, to detach from the cages of our mental worlds and assume a position where human-to-human dialogue can occur.” Ethical space is created when two societies, with disparate worldviews, are poised to engage each other. Ermine believes that in this way channels can be opened for new ways of thinking and understanding. Ermine (2007, 202–3) also suggests that “recognizing that the Indigenous-West encounter is about thought worlds may also remind us that frameworks or paradigms are required to reconcile these solitudes ... but attentive work on these issues has not occurred.” The overall context of Ermine’s (2007) article was law and the legal system, although the relevant horizon is broad and inclusive of science. Ermine et al. (2004, 21) indicate: As a process, the fundamental requirements of the ethical space include an affirmation of its existence. The ethical space cannot exist without this affirmation. The affirmation of the space indicates that there is an acceptance of a cultural divide and a direct statement of cultural jurisdictions at play. The ethical space also

   



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requires dialogue about intentions, values and assumptions of the entities towards the research process. As already mentioned, within our co-learning journey of Integrative Science and Two-Eyed Seeing, we have developed a big picture approach (described later) for our knowledges; we believe this is congruent with the dialogue Ermine et al. (2004) encourage. The understandings we use align well with what Schmidt (2008) refers to as the interdisciplinary interaction of several knowledge “dimensions” and for which he then advocates plurality in a philosophy of interdisciplinarity (see also Hallström et al., chapter 1 above). Pluralism is increasingly acknowledged and advocated for interdisciplinarity (e.g. Miller et al. 2008) but spirituality is seldom if ever included. In contrast, our big picture understandings recognize spirituality as central within Indigenous ways of knowing. Elder Albert is adamant that spirituality cannot be separated from the physical within the Mi’kmaw worldview, an understanding reinforced and broadened in the following statement from Ermine (1999, 108) and highlighted by the Aboriginal Education Research Centre (see aerc website): “Aboriginal epistemology is grounded in the self, the spirit, the unknown. Understanding of the universe must be grounded in the spirit. Knowledge must be sought through the stream of the inner space in unison with all instruments of knowing and conditions that make individuals receptive to knowing.” In addition to the understandings that the remainder of this chapter will expound upon, there are others that can help the discussion framework for healthy communities to become open to Indigenous knowledges and ways of knowing. We realize it is beyond the scope of our chapter to explain them at length, but want to mention them nonetheless. First, we emphasize the richness of knowledge and wisdom embedded in Aboriginal languages. In this regard, co-author Marilyn has explored Two-Eyed Seeing and the language of healing based on taped conversations over tea with Elders Murdena and Albert in their home. She (Iwama et al. 2009) writes: In Unama’ki, the English language has so supplanted Mi’kmaq that [the] knowledge Mi’kmaw youth have acquired amounts to, as Elder Albert Marshall explains, “everything from the mainstream and precious little from the Mi’kmaq.” Diminished ­fluency threatens the linguistic matrix that creates and sustains

   

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the health of individuals in community, an optimal state that includes, says Elder Murdena Marshall, “the capacity to be healed in a way that you’re back.” Second, Elder Murdena points to the traditional understandings below. These are her words: Love is the main ingredient in wellness. It is the one and only Sacred Gift with which we are born and thus as humans have no choice but to accept. Whether we choose to manifest it, however, is up to each one of us. • We need to relearn how to talk with and listen to the trees. Such are normal, healthy human capabilities in the Mi’kmaw worldview; trees are part of my family, my living identity ... Ms−i t No’kmaq (all my relations). •

Elder Albert, who speaks passionately at meetings, conferences, dialogues, and workshops, points to the need to (re)awaken our human consciousness to the understanding that the health of humans is tied to the well-being of our Earth Mother. These are his words: If the environment is not healthy, how can we expect to be healthy? If we continue to think the pharmaceutical and biotechnology companies can fix all our problems, we simply continue to foster a dependency on entities external to ourselves. We must acknowledge that each individual has responsibility and we must act upon this to attain collective health and wellness. • Furthermore, we must acknowledge this in a holistic way – all domains must be included in order to be healthy: physical, emotional, cognitional and spiritual ... and the individual, yes, but also the collective. • We keep expecting the pharmaceutical and biotechnology companies to come up with a magic pill to relieve us of our health problems ... what we need to come to better realize is that we are the magic. • Schools need to put “natural science” back into the forefront of curricula at all levels as only this will ultimately give us our good health back ... because only when we come to realize that everything that we do to the water, the air and the earth, we •

   



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also ultimately do to ourselves ... will we treat our environment and ourselves with equal reverence ... and only with the understanding that all must be maintained and that all must be equal, will we be healthy. This is the path of understanding that will lead us to good health and wellness – for humans and all others in our environment and the Earth herself. With respect to (re)learning interconnectiveness with the land, Elder Albert has long said: “it is important to realize that the Mi’kmaw language comes from the land and that if a person speaks their [Aboriginal] language, their spirit can never be captured. Moreover, our language teaches us that everything alive is both physical and spiritual ... that everything is interdependent and interconnective ... and that humans are only a small part of the whole  ... and thus, that everything we do to our Earth Mother, we also do to ourselves.” In this regard, there is increasing research to show how the Indigenous sciences are place-based (e.g. Michell et al. 2008). In the mid-1990s Elder Murdena was already encouraging “sense of place, emergence and participation” for understandings of Indigenous science, congruent with the interconnectiveness and interdependence explained in Cajete (1995, 2000a), a long-time friend of Elders Murdena and Albert. To the above, Marilyn adds: “When we in Integrative Science get impatient for ‘results,’ when we are asked to prove that Two-Eyed Seeing is working, or that Two-Eyed Seeing is ‘Science,’ Elder Albert likes to tell us about the ash tree. Every year, the ash tree drops its seeds on the ground. Sometimes those seeds do not germinate for two, three or even four cycles of seasons. If the conditions are not right, the seeds will not germinate. Sometimes, Elder Marshall says, you have to be content to plant seeds and wait for them to germinate. You have to wait out the period of dormancy. Which we shouldn’t confuse with death. We should trust this process.”

O u r O r i g i n s i n P o s t- S e c o n da ry S c i e n c e : Welcoming the Indigenous Sciences Integrative Science (English) or “Toqwa’tu’kl Kjijitaqnn” (Mi’kmaq) began as a globally unique undergraduate science program created in the mid-1990s at Cape Breton University (cbu) in Sydney, Nova Scotia (Bartlett 2011; Bartlett et al. 2012). The overall vision was and

   

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still is to bring together scientific knowledges and ways of knowing from Indigenous (or Aboriginal) and Western (or Eurocentric, conventional, or mainstream) worldviews. Indeed, the dream that one day the educational mainstream might recognize the Indigenous sciences alongside the Western sciences has been, for Elder Murdena, a long-held, important life aspiration (Hunter 2001; Bartlett 2011). As Murdena is a Spiritual Leader for the Mi’kmaw Nation, it is not surprising that the Integrative Science program came into existence at cbu, the institution where Murdena worked for many years, retiring as an associate professor of Mi’kmaw Studies in the late 1990s. cbu is also home to more Mi’kmaw students than any other postsecondary institution in the traditional territory of the Mi’kmaw people. This ancestral territory is known as Mi’kma’ki and includes the present-day provinces of Nova Scotia, Prince Edward Island, most of New Brunswick, the Gaspé of Quebec, and the southwestern region of Newfoundland, as well as parts of the state of Maine in the United States of America (ncns website). The creation of Integrative Science can be traced to specific interest expressed by Murdena plus a few other key representatives from the Mi’kmaw First Nation community of Eskasoni (Bartlett 2011; Bartlett et al. 2012). They requested university-level innovation and action that would begin to reverse two situations: 1 the almost total absence of Mi’kmaw students in cbu’s science and science-related programs, including the failure or drop-out within a few months by those who did begin (a common situation across Canada among other Aboriginal peoples and universities) and 2 the failure within the mainstream science and science educational communities to acknowledge Indigenous knowledges in science and science-related curricula. Mi’kmaw proponents felt that action towards reversing the second of the above could serve as an essential, concurrent step to reverse the first. That is, it was felt that culturally inclusive curricula would help attract and retain Mi’kmaw students into and within post-secondary science. Community members found the (then) low to nonexistent participation in university-level science by Mi’kmaw students worrisome in the face of the increasing needs in all Mi’kmaw communities

   



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for scientifically educated personnel in sectors such as health and medical services, natural resource planning and management, and elementary through high school education. Furthermore, this low to nonexistent participation in science was vexing in that for thousands of years prior to the arrival of Europeans, the Mi’kmaw people were the scientists of Atlantic Canada – they had rich and complex knowledge about the medicines, plants, and animals in their waters, lands, and skies and they transmitted and enriched this knowledge, generation to generation, via highly effective, traditional modes of teaching and learning within stories, ceremonies, and mentoring (Murdena Marshall, personal communication, 1996). A major challenge immediately faced in the creation of cbu’s Integrative Science program was the “how” in bringing together Indigenous and Western scientific knowledges. With no other Integrative Science models to learn from, we found inspiration in the “Spirit of the East” (in Mi’kmaq: “Wjipenuk Etek Lnuimlkikno’ti”; Bartlett 2011) wherein, as stated by Calliou (1995), “the East is seen, through its association with the sunrise, as a place of beginnings and enlightenment and a place where new knowledge can be created or received to bring about harmony or right relations.” A commissioned painting (Figure 10.1) by Integrative Science journey participant and artist Basma Kavanagh complements these words. Proponents of Integrative Science also found strength in knowing that science as a “way of knowing” (regardless of the culture) is dependent upon transformational consciousness towards thinking in new ways. Further, transformation is a key component in the Indigenous research paradigm (Wilson 2003; Archibald 2008). Thus, with the first students in the fall of 1999 we took heart from Dr Gregory Cajete’s personal advice (offered in 1997) to “just start, have the courage to learn by doing and emphasize creativity” ­(Bartlett 2011). Dr Cajete is one of North America’s leading proponents of Indigenous/Native Science and has published many of his understandings (1995, 1999a, 1999b, 2000a, 2000b). He is Tewa from the Santa Clara Pueblo in New Mexico, a scientist and educator, and currently the director of the Native American Studies Department at the University of New Mexico, Albuquerque. In his doctoral thesis, Cajete (1986, 221) stated: “The teaching of science from only one cultural perspective and in the partialistic manner that dominates science education continues to be the c­ entral dilemma of science

   

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Figure 10.1 Spirit of the East, painting by Basma Kavanagh

e­ ducation today.” It was apparent from the o­utset that Integrative Science needed to address this broad situation and its entailments. Even though Integrative Science was pioneered within the postsecondary science arena, the Indigenous-West encounter in the context of science education has been ongoing in a formal and growing way for a few decades. The encounter is enriching understandings, approaches, debates, and developments (e.g. Battiste 2005, 2008; Aikenhead 2002; Aikenhead and Ogawa 2007; Hatcher et al. 2009; see also the entire 2008 Issue 3 of “Cultural Studies of Science Education” as well as the “Aboriginal Learning Knowledge Centre” on the ccl website).

   



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Figure 10.2 “Trees Holding Hands,” computer graphic by Integrative Science Research Assistants Sana Kavanagh and Nadine Lefort

Our Guiding Principles: Listening to the Elders As the preceding sections indicate, the Integrative Science co-­ learning journey has always included Aboriginal Elders. Their words have guided the overall venture and the projects within it. Three key examples (with accompanying visuals for two) are provided below. Trees Holding Hands When the Integrative Science co-learning journey first emerged from its nursery of post-secondary science education into the garden of science research, we realized a guiding principle was needed to encourage manifestation of the understanding that “only when knowledge is conditioned by respect can it be truly shared.” We chose wisdom

   

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from the late Mi’kmaw Spiritual Leader, Healer and Chief Charles Labrador of Acadia First Nation, Nova Scotia: “Go into the forest, you see the birch, maple, pine. Look underground and all those trees are holding hands. We as people have to do the same.” Our wording comes via an interview (Kierans 2003) with the Chief’s son Todd in which he quotes his father’s wisdom and also says: “Everything I do, I do with respect. Father used to say, believe in all people. It’s not we and them. It’s us.” The Integrative Science research project in question was an Aboriginal community-based, participatory action, health research project funded by the Canadian Institutes of Health Research – Institute of Aboriginal Peoples’ Health (cihr–iaph). It was launched at a workshop in Eskasoni First Nation in January 2004 (Paul 2004) and encompassed many additional workshops, numerous sub-­projects, and countless conversations over the next four years. The project’s title was “Integrative Health and Healing: Co-Learning Our Way to Expanding Wholeness through Restoration of Relationships with the Land” and the overall project objective was to create a co-­ learning journey for different perspectives about health. The steering committee felt that Chief Labrador’s wisdom was ideal for the project and we continue to highlight it today at conferences and workshops. An iconic visual (Figure 10.2) was developed to portray “Trees Holding Hands.” Response among youth audiences suggested, however, that this visual was not helping to convey the intended message. We speculated that this failure may relate to the lifestyles of many young people today, in that they have not had the personal experience of walking in the woods and seeing for themselves how roots of different trees often entangle such that, metaphorically speaking, the trees do hold hands. Upon complementing the iconic visual with a photograph (Figure 10.3), we felt that audiences were better able to grasp the intended message. Two-Eyed Seeing Two-Eyed Seeing was introduced earlier in this chapter as the guiding principle for our co-learning journey; more explanation is provided here. By fall 2004, Elder Albert felt that participants within the above-mentioned Integrative Health and Healing project could benefit from additional encouragement towards the “it’s us”

   



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Figure 10.3 “Trees Holding Hands,” photo by Integrative Science

c­ onsciousness of Trees Holding Hands. With this understanding, he offered Two-Eyed Seeing, indicating that it is the gift of multiple perspective treasured by many Aboriginal peoples. In addition, Bartlett (2011) outlines “eleven lessons learned for co-learning” that culminated in Two-Eyed Seeing; Bartlett et al. (2012) refocus and enrich these as “eight lessons learned.” Albert explains that for Integrative Science, Two-Eyed Seeing refers to learning to see from one eye with the strengths of Indigenous knowledges and ways of knowing and from the other eye with the strengths of Western knowledges and ways of knowing and to using both these eyes together, for the benefit of all. Two-Eyed Seeing adamantly, respectfully, and passionately asks that we bring together our different ways of knowing to motivate people, Aboriginal and non-Aboriginal alike, to use all our understandings so we can leave the world a better place and not compromise the opportunities for our youth (in the sense of Seven Generations) through our own inaction. More recently, on the basis of several years’ experience in explaining the principle, Albert adds: “Two-Eyed Seeing is hard to

   

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convey to academics as it does not fit into any particular subject area or discipline. Rather, it is about life: what you do, what kind of responsibilities you have, how you should live while on Earth ... i.e., a guiding principle that covers all aspects of our lives: social, economic, environmental, etc. The advantage of Two-Eyed Seeing is that you are always fine tuning your mind into different places at once, you are always looking for another perspective and better way of doing things.” In putting forward Two-Eyed Seeing, Elder Albert has passionate concerns for the well-being and future of Aboriginal peoples and Indigenous knowledges, as is evident when he states what happens in its absence: When you force people to abandon their ways of knowing, their ways of seeing the world, you literally destroy their spirit and once that spirit is destroyed it is very, very difficult to embrace anything – academically or through sports or through arts or through anything – because that person is never complete. But to create a complete picture of a person, their spirit, their physical being, their emotions and their intellectual being ... all have to be intact and work in a very harmonious way. Elder Albert’s passionate concern, as outlined above, can also be taken into account when pondering “how might we have proceeded to try to make academic/mainstream views more useable for Indigenous communities?” rather than seeking to have Two-Eyed Seeing bring the best of other knowledge systems (namely, Indigenous worldviews and paradigms alongside those of the mainstream) into play. Albert’s words speak clearly as to why our Two-Eyed Seeing approach seeks to bring the different knowledges together, rather than tweaking one to accommodate bits and pieces of the other. He directs attention to the stress placed on an Aboriginal person when educational (and other) systems deny traditional knowledge a place and a role in today’s times; a concrete example of such stress is provided in Marshall et al. (2015). Also, given that spirit is at the heart of Indigenous knowledge, it would be highly inappropriate if not impossible to ask that mainstream science and much of modern academia  – which have diligently scrubbed spirit out of their overall ontology – somehow reverse this diligence. We additionally want to respect the wishes of the numerous Aboriginal Elders such as those

   



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Figure 10.4 “Two-Eyed Seeing ‘Old,’” computer graphic by Kristy Read

in Atlantic Canada who have recently and formally requested that their traditional knowledges be accorded meaningful positioning both within Aboriginal communities and within university curricula; the Elders’ recommendations have, moreover, been approved by the Chiefs in Atlantic Canada (see apcfnc website for “Elders Research Project” 2011). We also point to the importance in acknowledging that, as creatures with consciousness, humans have options: there are worldviews and paradigms in addition to those of the mainstream. In pondering the above question as to how we might have proceeded differently, we further point to a “lesson learned” early within our journey: “we need to acknowledge that we need each other” (which is in reference to each other’s knowledges) (Bartlett et al. 2012). Finally, in pondering the question from a more theoretical perspective, one can look to Blackstock’s (2007, 2011) articulation of the importance of ancestral knowledge, of traditional knowledge, as the “Breath of Life” that nourishes the health of Aboriginal communities and individuals. Iconic visuals have been developed within the Integrative Science co-learning journey for the guiding principle of Two-Eyed Seeing. Initially we simply used two eyes (Figure 10.4) but around 2007 we switched to a visual in which two eyes are positioned behind two connected pieces of a jig-saw puzzle (Figure 10.5). This followed Elder Albert’s encouragement that we emphasize that “Mi’kmaw First Nations’ understandings are but one view in a multitude of Aboriginal and Indigenous views ... and similarly that of the Western sciences ... and that all of the world’s cultures (which we take to include Western science) have understandings to contribute in addressing the local to global challenges faced in efforts to promote healthy communities.” Thus, one might wish to talk about FourEyed Seeing, or Ten-Eyed Seeing, etc. Furthermore, Albert indicates,

   

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Figure 10.5 “Two-Eyed Seeing ‘New,’” with jigsaw puzzle pieces, computer graphic by Kristy Read

“the two jig-saw puzzle pieces help remind us that, with respect to Aboriginal Traditional Knowledges [Indigenous knowledges], no one person ever has more than one small piece of the knowledge.” Thus, there is a need to recognize that Traditional Knowledges draw upon the community of Elders and other Knowledge Holders, as well as the collective consciousness of the people. So here, too, one might wish to talk about multiple-eyed seeing. The guiding principle of Two-Eyed Seeing further helps us to acknowledge the distinct and whole nature of the Indigenous knowledges and ways of knowing (i.e., they are represented as a whole eye) and the distinct nature of the Western knowledges and ways of knowing (i.e., they are also represented as a whole eye), while asking that these two eyes work together (as they do in binocular vision). Nevertheless, it may be that in a particular set of circumstances we will choose to call upon the strengths within Indigenous sciences, whereas in another set of circumstances we might choose to call upon those within the Western sciences. Thus, Two-Eyed Seeing can require a “weaving back and forth” between knowledges, and this will draw upon abilities to meaningfully and respectfully engage in an informed manner in collaborative settings. Towards this, we have developed the four big pattern knowledge understandings (with visuals) as tools that are presented later in this chapter.

   



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Two-Eyed Seeing (in that it speaks directly to the setting of collaborative, cross-cultural work) intentionally seeks to avoid the situation becoming a clash between knowledges, domination by one worldview, or assimilation by one worldview of the knowledge of another. At the same time, we acknowledge what Ermine et al. (2004) referred to as the precarious relationship between Indigenous peoples and the Western world. In the combined understandings and words of Elders Murdena and Albert, “we recognize that the Indigenous Sciences draw upon Tribal Consciousnesses, while we also recognize that the latter tend to be negated by too much formal education and that our times place an overwhelming emphasis on formal education. We must, therefore, be diligent in taking the best from our two worlds: Indigenous and Western. We recognize that Western Science privileges objectivity and de-emphasizes the human element, yet we depend heavily upon it and its technologies in our modern lives. Nevertheless, for the benefit of all humans, our times need to learn to factor the human element into science and to rediscover our humility as but one species on the planet” (see also A. Marshall [2005] and M. Marshall [2005] for elaboration). The Healing Tense As mentioned previously, Ermine (2007, 201) indicates that “recognizing that the Indigenous-West encounter is about thought worlds may also remind us that frameworks or paradigms are required to reconcile these solitudes.” In this regard, we believe that the “healing tense” within the Mi’kmaw language provides insightful guidance. This tense has been brought forward by Elder Murdena who explains that it requires a person to put his/her deeds out in front of him/herself like an object, to take ownership over them, to be able to say “that’s me” within a consciousness of transformation. The healing tense is explored and explained in Iwama et al. (2007; 2009) wherein Murdena’s words are found, including: You have to take full responsibility of your actions. See, in the Mi’kmaw world you have to give recognition to everything. Misdeeds good deeds past deeds. You know? Anything. You have to give that acknowledgment. Everything that you do, you have to acknowledge it. And the listener, if he’s a Mi’kmaw speaker, will understand at which state of reality are you in. Healed in a way

   

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that you’re back. Reinstated into the family. If you don’t go into that tense you cannot heal, you will not have healed. Murdena’s understandings as to what the Mi’kmaw language requires and provides via the healing tense resonate profoundly with what Ermine (2007) indicates is urgently required if reconciliation is to occur via intercultural dialogue and what he suggests can be provided by the concept of ethical space.

O u r C u l t u r a l ly I n c l u s i v e V i e w o f Science: Telling Dynamic Pattern-Based Stories Michell et al. (2008) discuss various ways the view of science has been broadened within Indigenous science educational initiatives. They refer to Integrative Science as welcoming the holistic sciences, although the approach we have developed is that and more. We have heeded the suggestion of Battiste (2002, 11) that “focussing on the similarities between the two systems of knowledge [Indigenous and Western] rather than on their differences may be a more useful place to start when considering how best to introduce educational reform.” In doing so, we recognized that the question “What is your view of the nature of science?” is immediately raised by any vision to bring together Indigenous and Western scientific knowledges and ways of knowing. Thus, we have chosen to emphasize that both Indigenous and Western scientific knowledges are based in observations and other experiences of the natural world and we have worked to develop the view of science as dynamic patternbased knowledges about our interactions with and within nature (Bartlett 2011). We suggest that a culturally inclusive view of science can then be developed. By “culturally inclusive” we mean including both the Indigenous sciences and the Western sciences and dealing with the “mutually irreconcilable beliefs” that Winder (2005) identified as a challenge for integrative research and the “cultural mismatch” that ccl (2007) identified as the challenge in Aboriginal science education. In other words, being “culturally inclusive” means we acknowledge and understand that the Indigenous and Western sciences have different ontologies, epistemologies, methodologies, and goals. Moreover, we choose to understand: (1) that our pattern-based knowledges take

   



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the form of “stories”; and (2) that variety in our stories emerges as different cultures assemble and transmit (i.e. shape and share) their stories in different ways depending upon which “human pattern smarts” are being privileged. The Native Knowledge Network of the University of Alaska – Fairbanks has worked for many years to develop culturally responsive science curricula. Within that initiative, Stephens (2000) created a concept map depicting the Indigenous and Western sciences in which “pattern recognition” is similarly considered as common ground between (i.e. similarities in) the knowledges. We suggest that to view science as dynamic, pattern-based knowledges assembled and transmitted as stories is a conceptual innovation that broadens (not misleads) educational understanding and therefore can also help address the concerns about cognitive imperialism forefronted by Battiste (2000, 2005, 2008).

“Pattern Smarts” and “Pattern View of Science” With respect to the culturally inclusive view of science developed within Integrative Science, we emphasize that our pattern-based knowledges draw upon “human pattern smarts.” These smarts are the “multiple intelligences” in Gardner’s (1983, 1993, 1998, 1999) Multiple Intelligences (mi) Theory. We acknowledge that mi Theory has been critiqued by authors who were initially drawn to it but then became disillusioned with the theory’s evolution (Kincheloe 2004). In responding to other critiques, Gardner (2006, 503) reminds us that it “is a synthesis of work in a number of disciplines, ranging from neuroscience to anthropology  ... wherein each of the intelligences is seen as a computational capacity – the ability to process certain kinds of information in the process of solving problems or fashioning products.” We feel comfortable in using “pattern smarts” for the multiple intelligences, in that mi Theory is a brain-based theory and that an overall understanding within cognitive neuroscience is that the human brain is a highly specialized, pattern-seeking organ (e.g. Wolfe 2006). “Science” as viewed by Integrative Science involves pattern recognition and pattern expression and also pattern transformation, given that we further attribute dynamism (adaptability and change) to these knowledge processes. Kavanagh et al. (2006) and Lefort et al. (2006) provide examples of Integrative Science work in this regard.

   

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We readily acknowledge that our consideration of “pattern” should include a companion reference in Indigenous worldviews to that in cognitive neuroscience. The latter, although increasingly advocated to address issues of learning and instruction (e.g. Varma et al. 2008), does not include the spiritual along with the cognitive, emotional, and physical domains of being human. Thus, for a richer view towards the use of “pattern” as encouraged by Integrative Science, we recommend understandings in Sheridan and Longboat (2006). These authors speak to the sacred ecology of mind within the Haudenosaunee/Mohawk tradition. They explain that such is a consequence of long residence in traditional territory and enduring spiritual and intellectual relationships between people, clans, and landscape wherein animal and spiritual helpers manifest their presence in one’s life. Our pattern-based view of science has been inspired and supported by many additional sources. For example, Douglas J. Cardinal (one of the world’s foremost architects who grew up in Alberta and who draws insights from both his Blackfoot First Nation and European ancestry) indicates that a sensibility to the patterns of other creatures and the environments in which they lived was essential in the great challenge of survival for the Aboriginal hunters and gatherers on the Great Plains of North America (Cardinal, in Doyle 2001). Indeed, Cardinal indicates that the Aboriginal “Spiritual Warrior” has to render his/her spirit pattern-less in order to be receptive to these patterns. Integrative Science refers to this receptivity as being “pattern-able.” Doyle’s (2001) overall report from the Millennium Conferences on Creativity in the Arts and Sciences emphasized the great need for new encouragement towards original thinking, innovation, and creativity in Canada while pointing to the importance of pattern recognition and pattern breaking. Rupert Ross (who spent many years interacting closely with First Nations people in northwestern Ontario while working as a crown attorney) felt that “pattern-thought” was the way of thinking that hunter-gatherers in that remote area used in “doing their shopping in the natural world” (Ross 1992, 81). ­Gerald Gloade (a Mi’kmaw artist, storyteller, and scientist who once worked with the Department of Natural Resources in Nova Scotia and who now works with the Mi’kmawey Debert Cultural Centre of the Confederacy of Mainland Mi’kmaq and interacts frequently with Integrative Science personnel) states that “pattern r­ ecognition”

   



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is a traditional Mi’kmaw way of knowing with respect to ecological knowledge (personal communication, 2008). Paula Underwood Spencer (a genealogist and writer with Oneida ancestry who lived in Virginia and California in the United States) wrote several works designed for educational use, basing them on Native American oral traditions. She (Underwood Spencer 1990) accords pattern a key role in her description of the Western and Indigenous sciences as Hawk and Eagle, respectively. Thater-Braan (2001) talks of a “pattern for understanding” in her article on Native American educational values, diversity, and the need for cognitive pluralism. Further relevant to the consideration of a pattern-based view of science is the fact that mathematics, which is assigned a significant role in Western science (and a role that has roots dating to at least 500 bc [Wolfram 2002]), has long been referred to as the “language of science” and often today as a “science of patterns” (Devlin 1994). The Atlas of Science Literacy (Project 2061 2001, 27) states that “mathematics is the study of any patterns or relationships, whereas natural science is concerned only with those patterns that are relevant to the observable world.” Finally, it is increasingly being realized that non-Eurocentric mathematical expressions of pattern abound in the world’s cultures (e.g. Zaslavsky 1973; Powell and Frankenstein 1997; Eglash 1999). Pattern is the primary concern of science within the Western worldview of the nature of science referred to as conventionalism, according to Wisdom (1971, 273) who portrayed it as fairly simple: “Conventionalism does not deny reality but is, so to speak, agnostic about it; that is to say, all one can do is to make usable conventions about concepts. Its primary concern is pattern-making.” Wisdom argued that truth-value is indispensable to science and, regarding the conventionalist notion of truth, pointed to the early writings of Henri Poincaré in indicating that it is “a more sophisticated notion of truth than the prevailing one (which was of a realistic character or was a correspondence notion)” (1971, 273). Wisdom (1971) further indicates that the conventionalist theory of truth is the representative of pragmatism in the philosophy of science. The interested reader is referred to further work on conventionalism by Wisdom (1975) plus the analysis of conventionalism by Ben-­ Menahem (2006) who, unfortunately, does not include the work of Wisdom nor mention “pattern-making” per se. Ben-­ Menahem (2006, 1) maintains “that conventionalism does not purport to base truth on

   

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convention, but rather, seeks to forestall the conflation of truth and convention.” Within Integrative Science, Elder Murdena encourages the understanding that for mainstream academic researchers, “to prove [the truth] is desirable and skepticism is a virtue,” whereas in the living knowledge that is Mi’kmaw Traditional Knowledge, “to know is ok and trust is a gift.” She also teaches that trust (which associates with truth) joins love, honesty, humility, respect, patience, and wisdom to become the Seven Sacred Mi’kmaw Gifts (Teachings) that one is offered over the course of his/her life journey. These seven are also found in the teachings held by many other Aboriginal peoples in Canada (courage sometimes replaces patience) and are to be understood within the larger understanding that Aboriginal epistemology is grounded in the self, the spirit, the unknown (Ermine 1999). Elder Murdena indicates that in the Mi’kmaw understanding, “unknown” means “spiritual interconnectiveness and interdependence.” That Aboriginal peoples have been present in Canada for millennia indicates that such knowledge systems worked exceedingly well in the great challenge of survival, wherein pattern sensibilities would have been vital. In addition, Mi’kmaw Elders who form the advisory group for the Mi’kmawey Debert Cultural Centre (under development by the Confederacy of Mainland Mi’kmaq, a First Nation Tribal Council in Nova Scotia) adamantly, passionately, and quite correctly indicate “we are still here; our communities are living places” in an assertion against the misconception in the dominant society that Mi’kmaw and other First Nation peoples are part of the distant past in Canadian history (Confederacy of Mainland Mi’kmaq 2007). Indeed, this is one of the eight anchoring themes for the proposed Centre. Moreover, the Elders also say, “we did more than just survive, my dear; we lived” (where survival might otherwise be interpreted to mean simply “a one dimensional existence of gathering food and making it through February [the winter])” (Confederacy of Mainland Mi’kmaq 2007, 13). As the co-authors of this chapter, we maintain that in the above are found rich understandings for healthy communities today.

“ S t o ry ” f o r P a t t e r n - B a s e d K n ow l e d g e s With respect to the culturally inclusive view of science developed within Integrative Science, we emphasize that our pattern-based

   



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knowledges take the form of “stories.” This is found as Part 1 within our simple, four-part “integrative framework” (Bartlett 2011; also see iish website); Part 1 points to the key role of the individual knower (“me”; “you”) in the generation of knowledge, i.e. the “agency” (the human consciousness) within knowledge. It further involves learning that this agency becomes contextualized within a larger community of knowers – the knowledge collective – eventually becoming the knowledge system, its stories. In this sense, agency is recognized as including that originating in subjects but also (and very importantly) that originating in relationships; such “relative being” is explored at length in Hoffmeyer (2008a). Parts 2, 3, and 4 in the integrative framework are, respectively, our common ground, our differences (and respect for them), and our co-learning journey. Parts 2 and 3 promote “Two-Eyed Seeing” but they can also help strengthen and feed Indigenous knowledge, this being what Ermine (eeah Dialogue Circle 2007) indicates would most benefit Aboriginal peoples with respect to the relationship between Indigenous knowledge and the Western scientific paradigm. As indicated, we prefer “stories” because they embed acknowledgment of the agency within our knowledges. Integrative Science recognizes how Western sciences’ stories evolve into a claimed context-free objectivity. Integrative Science also recognizes how Indigenous sciences retain the evidence of lived experience. Watson and Huntington (2008, 274), for example, show “how stories are embedded into the places and practices of hunting [as practiced by Koyukon Athabascans in northwestern Alaska] – and thus all part of the assemblage that informs ik [Indigenous Knowledge].” They emphasize how these assemblages become known within epistemic spaces and they discuss the differences this represents with respect to Western science, thereby also illustrating what is pointed to by Part 3 in our integrative framework, namely our differences and respect for them. Our choice of “stories” was/is both inspired and supported by many other contexts and sources of understanding, a select few of which are shared below. Indigenous scholar Jo-ann Archibald’s (2008) book “Indigenous Storywork; Educating the Heart, Mind, Body and Spirit” explains that she worked with Coast Salish and Stó:l ˉo Elders in British Columbia to learn how Indigenous oral stories both nourish knowledge systems and are knowledge systems. She explores seven principles (respect, responsibility, reciprocity, reverence, holism,

   

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i­nterrelatedness, and synergy) of “storywork” in her effort to find a respectful place for stories and storytelling in contemporary education. In Integrative Science, we recognized from the outset the need for an educational component for ourselves within our co-learning journey, and we have used Archibald’s (2001) work to inform our “big picture” with respect to Indigenous epistemology for Two-Eyed Seeing, as explained later. Smylie (2004) indicates: “In Indigenous knowledge systems, generation of knowledge starts with ‘stories’ as the base units of knowledge, then proceeds to ‘knowledge’ as integration of the values and processes described in the stories and finally culminates in ‘wisdom’, a distillation of experiential knowledge. This process can be viewed as cyclical, since keepers of ‘wisdom’ in turn generate new ‘stories’ as a way of disseminating what they know.” “The truth about stories is that’s all we are,” says the Canadian writer Thomas King, whose father was Cherokee and mother Greek and German. In his 2003 book “The Truth About Stories; A Native Narrative” he attributes the line “I will tell you something about stories” to Laguna storyteller Leslie Silko (1997) and then also “They aren’t just entertainment / Don’t be fooled / They are all we have, you see / All we have to fight off / Illness and death. You don’t have anything / If you don’t have the stories.” Elder Albert encourages us to understand that when we work with Indigenous Sciences and Aboriginal Traditional Knowledges, it is essential to seek review by knowledgeable Elders and other Knowledge Holders (review, that is, of the stories being brought forward), as only they (the Elders) are able to speak to the validity and authenticity of such stories. This is akin to the peer-review process required of Western knowledges. It is what can address the concern that stories “might otherwise be simply made up and sold,” which, Albert indicates, happens all too easily when the only roles afforded by the mainstream to Aboriginal peoples and their knowledges are those of “Hollywood Indians,” wherein someone else is providing your life script and/or relegating your understandings to entertainment status. Similarly, Chamberlin’s (2003) book If This Is Your Land, Where Are Your Stories? Finding Common Ground encourages the broad understanding that it is not until we’ve come to understand each other’s stories that we can reimagine the “them” and “us” to find our common ground in a modern world beset with misunderstandings.

   



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We acknowledge that Western science is not generally portrayed, especially in its educational and application arenas, as involving stories. Hoffmeyer (2008b, 2), for example, indicates: “In the post-postmodernist times of today the very term story may perhaps appear suspicious as it certainly was inside the natural sciences in Bateson’s own time  – and still is of course.” Nevertheless, a peer-reviewed, natural sciences research paper with its subsections of introduction, materials and methods, results, and discussion is but a highly standardized, highly specialized format for telling a particular type of story for an audience expected to have in-depth background. And yet, from a different perspective, E.O. Wilson, the renowned biologist and Professor Emeritus at Harvard University, has frequently spoken and written (e.g. Wilson 1998) of the scientist (involved in discovery research) as being more of a storyteller and a mythmaker than most scientists realize or at least care to admit.

O u r K e y V i s ua l s a n d M o r e : E x p l a i n i n g t h e V i s i o n a n d E x pa n d i n g t h e J o u r n e y From its origins in post-secondary education, Integrative Science expanded into the broad science arenas of research, applications, and outreach to Aboriginal youth and community (iish website; Bartlett 2005; Bartlett 2011; Bartlett et al. 2012). This broader (i.e. beyond the science educational arena) dimension for the IndigenousWest encounter has been the subject of considerable and increasing work since the 1999 World Conference on Science called for a new commitment by science to society for the twenty-first century (unesco 1999, 2000; icsu 2002). The challenge is huge in the societal nexus where academic expert knowledges come together with community knowledges and where partners bring different lifeworld perceptions and perspectives. Moreover, there can be reluctance on the part of experts to become open to the new, to learn, and to transform. As Anuik (2008, 121) points out, in the natural and applied sciences “professional associations and their close counterparts ... steadfastly adhere to what they perceive as unbiased standards.” We believe Ermine’s (2007) suggestion of ethical space and thought frameworks for reconciliation are relevant in all science contexts and arenas. On the basis of our experience, we also point to the great utility of approaches beyond thought frameworks, such as performative inquiry (Fels and McGivern 2002; Iwama et al. 2009;

   

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Figure 10.6 Integrative Science Vision, painting by Basma Kavanagh

Bartlett 2011) and lyric inquiry (Neilsen 2008; Iwama et al. 2007) and we suggest Four Arrows (2008), Knowles and Cole (2008), and Frodeman (2010) as excellent sources for additional consideration. Given the uniqueness of Integrative Science and its breadth of relevancy, we frequently are called to explain the Integrative Science vision to bring together scientific knowledges and ways of knowing from Indigenous and Western worldviews to many and diverse audiences (see iish website). We have found that a second commissioned painting (Figure 10.6) by Basma Kavanagh helps readily convey the understanding that “only when knowledge is conditioned by respect can it be truly shared” (in Mi’kmaq: “Ta’n tujiw kjijitaqn tela’tasik kepne’ktn ketloqo kisiktpi’tasitew”) (Mi’kmawey 1997). Ms Kavanagh’s painting depicts a sacred fire beside which two people are kneeling, one directly across from the other. Kneeling places a person in a position that offers and invites trust because it is a position of extreme vulnerability. Trust, in turn, enables sharing and co-learning of deep-level thoughts about actions, values, and knowledges.

   



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Through these mindful intentions, the two spheres of the respective worldviews of Indigenous and Western sciences are brought together to generate an expanding ground of common understanding and a deepening respect for differences. The whole of this effort may be seen as being held in the talons of Eagle, a spiritual messenger of great traditional significance for many Aboriginal peoples and a guide for the journey of Integrative Science. We note that the “-ive” in “integrative” helpfully indicates the ongoing (indeed, never-ending) nature of this co-learning journey and our mindful (indeed, spiritual) intent to talk and walk together in mutual respect to develop a living knowledge of collaboration for the twenty-first century. In this sense one might think of two great rivers coming together – though they are a combined flow, their water molecules come from different watershed sources and although these same molecules freely and readily intermix, one molecule does not merge into another. Given escalating needs and desires for multicultural collaborations in community settings, we wish to emphasize that Integrative Science has always considered mindful attention to the role of human consciousness as a fundamental part of our co-learning journey. This is a contributing reason to why the word integrative was originally chosen and why “Sense of Place, Emergence and Participation” was the title given many years ago to one of the entry-level courses in the new Integrative Science post-secondary degree program. As Iwama et al. (2009) point out, citing Webster’s Third International English Dictionary: “the three letters, -ive, introduce the idea of action, of tending toward a state, especially in a regular or lasting way.” Further, with respect to consciousness and cognition, Maturana and Varela (1987) wrote The Tree of Knowledge; The Biological Roots of Human Understanding, a publication solicited by the Organization of American States as it sought ways to address the many difficulties confronted in social communication and knowledge transfer. These authors view human cognition as an ongoing bringing-forth of a world through the process of living itself (i.e. not cognition as a representation of the world “out there”), a view compatible with Aboriginal knowledge given the understanding that consciousness, spirituality, interconnectiveness, and interdependence are at the heart of Indigenous epistemology. This understanding is evidenced in the statement about Aboriginal epistemology by Ermine (1999, 108) that we pointed to earlier. Ermine (eeah Dialogue Circle 2007, 4)

   

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Figure 10.7 “Two-Eyed Seeing – Big Pic #1, Ontologies,” computer graphic by Integrative Science

further indicates that “ancestral knowledge contained the awareness that everything is energy, that everything is interconnected and that everything possesses consciousness.” Our Integrative Science emphasis on mindful attention to consciousness is also one reason why “living knowledge” is one of the hoped-for outcomes for students in the Integrative Science academic program. Another reason is that “living knowledge” also embraces the understanding put forward by Elder Albert that knowledge from the Aboriginal perspective “is not a tool but rather it is spirit. It is a gift passed on through many people. It transforms the holder. It also reminds us that we Elders have responsibilities to the spirit of that knowledge. We must pass it on.” Blackstock (2007, 2011) presents an excellent visual that depicts this key understanding of passing on ancestral knowledge. Her articles challenge us to examine Aboriginal and Western knowledges towards respectful coexistence; her context of concern is the disproportionate numbers of Aboriginal children who are either in government care or in the care of non-Aboriginal families.

   



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Our Tools: Patterns ... Seeing “Big Pictures” and Using “Organics” In contemporary Canada, the words “healing” and “reconciliation” are words that frequently travel together in discussions configured by Aboriginal perspectives and contexts. Elder Murdena offers a key insight with respect to healing; Willie Ermine offers a key insight with respect to reconciliation. Integrative Science has adopted and adapted both. For Murdena’s insight, we realize that participants in the co-learning journey need to be able to place the actions, values, and knowledges of their own culture out in front of themselves like an object, to take ownership over them and to be able to say “that’s me.” Furthermore, as guided by Two-Eyed Seeing, we need these “objects” for both the Indigenous and Western worldviews. In this way, participants can learn both “that’s me” and “that’s you” to foster working together. Thus, we have developed simple responses (in text and visual form) to four “big picture” philosophical questions. These depictions enable us to put these philosophical considerations for our knowledge systems out in front of ourselves like an object (tool). In the Spirit of the East, we believe such can help encourage “our place of beginnings” towards the thought frameworks that Ermine’s (2007) insight indicates are required to reconcile the solitudes of Indigenous and Western cultures. That is, we suggest herein that the first phase of entering ethical space for the purpose of reconciling our scientific knowledges and ways of knowing – the ethical space conceived within Ermine’s insight – includes learning to appropriately, correctly, and respectfully acknowledge the “that’s me” and the “that’s you” of our worldviews, as they configure our sciences. Furthermore, in the overall Integrative Science co-learning journey we talk about “growing” rather than “going” forward, and knowledge “gardening” more than knowledge translation or transfer (Bartlett 2011). In the words of journey participant Marilyn Iwama: “We are learning to weave back and forth between our knowledges, our worldviews and our stories. We are learning to navigate that weaving by recognizing patterns that help us do that. Call those patterns knowledge orientations. Call them maps – maps for the garden. We have learned the importance of making our knowledges, our stories, visual.” In regards to this desire to “make our knowledges, our stories, visual,” we have developed four “big picture” understandings (which are

   

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Figure 10.8 “Two Eyed Seeing – Big Pic #2, Epistemologies,” computer graphic by Integrative Science

patterns in their own right) that can be put, as “objects” of ourselves, in front of us, congruent with Murdena’s explanation of the healing tense. These are explained below. In sharing them herein, we reiterate that our approach is intended to help orient within “our place of beginnings” and we also reiterate our concurrence with Watson and Huntington (2008, 276) that the “intellectual traditions we assemble, ‘Western’ and ‘Indigenous,’ are not entirely separable into our individual selves, who are instead a ‘multiplicity of multiplicities.’” 1 . O u r W o r l d This relates to ontologies, as we share a desire for our knowledges to have an overarching understanding of “how our world is,” albeit with differences as to what we deem these to be. The “big pattern” question here is: What do we believe the natural world to be? A possible response from within Indigenous science is: beings ... interconnective and animate  ... spirit + energy + matter  ... with constant change (flux) within balance and wholeness.

•

   



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A possible response from within Western science is: objects  ... composed of parts and wholes characterized by systems and emergences ... energy + matter ... with evolution. • A visual that complements these words is provided in Figure 10.7. •

2 . O u r K e y C o n c e p t s a n d A c t i o n s This relates to epistemologies, as we share a desire for our knowledges to observe key values, albeit with differences as to what we deem these to be. The “big pattern” question here is: What do we value as “ways of coming to know” the natural world, i.e. what are our key concepts and actions? A possible response from within Indigenous science is: respect, relationship, reverence, reciprocity, ritual (ceremony), repetition, responsibility (after Archibald 2001). • A possible response from within Western science is: hypothesis (making and testing), data collection, data analysis, model and theory construction. • A visual that complements these words is provided in Figure 10.8. •

3 . O u r L a n g ua g e s a n d M e t h o d o l o g i e s We can focus on core concepts for the languages and methodologies that structure our knowledges, as we share a tendency to want such, albeit with differences as to what we deem these to be. The “big pattern” question here is: What can remind us of the complexity within our ways of knowing? A possible response from within Indigenous science is: weaving of patterns within nature’s patterns via creative relationships and reciprocities among love, land, and life (vigour) that are constantly reinforced and nourished by Aboriginal languages. • A possible response from within Western science is: un- ­weaving of nature’s patterns (especially via analytic logic and the use of instruments) to cognitively reconstruct them, especially using mathematical language (rigour) and computer models. • A visual that complements these words is provided in Figure 10.9. •

4 . O u r O v e r a l l K n ow l e d g e O b j e c t i v e s : We can focus on objectives, as we share a desire for our knowledges to have overall purpose, albeit with differences as to what we deem these to be.

   

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Figure 10.9 “Two-Eyed Seeing – Big Pic #3, Methodologies,” computer graphic by Integrative Science

The “big pattern” question here is: What overall goals do we have for our ways of knowing? A possible response from within the Indigenous sciences is: collective, living knowledge to enable nourishment of one’s journey within an expanding sense of “place, emergence and participation” for collective consciousness and interconnectiveness  ... towards resonance of understanding within the environment  ... towards long-term sustainability for the people and natural environment (tested and found to work by the vigorous challenges of survival over millennia). • A possible response from within the Western sciences is: dynamic, testable, published knowledge independent of personal experience that can enable prediction and control (and “progress”) ... towards construction of understanding of environment ... towards eventual understanding of how the cosmos works (tested and found to work by the rigorous challenges of experimental design). • A visual that complements these words is provided in Figure 10.10. •

   

Figure 10.10 “Two-Eyed Seeing – Big Pic #4, Knowledge Objectives,” computer graphic by Integrative Science, including part of the “First Nations Holistic Lifelong Learning Model” from the Canadian Council on Learning, Aboriginal Learning Knowledge Centre (http://www.ccl-cca/CCL)

   

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Conclusion We believe that our “big picture” or “big pattern” understandings for the dimensions of knowledge systems are representative of the kind of work that is essential in order to expand the discussion framework for healthy communities. They can help render the complexity and magnitude of issues into readily graspable (and remember-able) form and help ensure space for different worldviews. This facilitates partner empowerment, participation, and engagement, all of which are undoubtedly needed in cross- and transcultural research, as well as that which is integrative (e.g. Tress et al. 2006), interdisciplinary (e.g. Schmidt 2008; Frodeman 2010), or transdisciplinary (e.g. ­Hadorn et al. 2008; Pohl 2010). We further suggest this is particularly true when, as in Integrative Science, a co-learning journey is used (Bartlett 2011; Bartlett et al. 2012), an approach we believe is congruent with “common group learning” which Pohl et al. (2008) identified as one of the three basic ways (the other two being deliberation among experts and via a subgroup or individual) that transdisciplinary research teams organize collaboration in order to reach integration. Pohl and Hadorn (2008) and Wiesmann et al. (2008, 433), respectively, emphasize common understandings of core terms and insightful propositions to enhance transdisciplinarity, with the latter authors indicating that the “debate is still fairly young and the processes still being developed.” Yet this field is much advanced in comparison to that for the reconciliation of the Indigenous-West encounter (to use the words of Ermine [2007]). Finally, our experience also suggests the utility  – for work that is integrative, transdisciplinary, and transcultural and that seeks to encourage human reconnections with the Earth – of organic (naturebased) and visual models rather than (or in addition to) the highly compartmentalized flowcharts so commonly used in collaborative initiatives (Bartlett et al. 2012). We similarly (Bartlett et al. 2012) encourage organic metaphors and language (when English is being used) rather than mechanistic ones. Such “organics” can help remind us of our biological kinships with other species and the Earth, as do Aboriginal languages and the animal characters in many Aboriginal stories. This can further help us begin to reverse the intellectual techniques, theories, and stories that Western people have used to distance, even remove, themselves from nature (for example discussions

   



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of this distancing and removal see Louv 2005; Johnson and Murton 2007; Watson and Huntington 2008). In addition, “organics” are naturally holistic and thus encourage innovative thinking and enriched understandings from the outset. Examples within Integrative Science include those for the guiding principles of Trees Holding Hands and Two-Eyed Seeing. We have also mentioned knowledge gardening, learning about success from the ash tree, and learning about knowledges coming together from a river. An excellent organic example outside of Integrative Science (and one that we promote extensively) is the tree model developed for First Nations’ Life Long Learning by the “Aboriginal Learning Knowledge Centre” within the Canadian Council on Learning – the model and explanation are available online (see ccl website); the model is also partially included in Figure 10.10.

A c k n ow l e d g m e n t s We acknowledge and thank Cape Breton University for being the academic home for Integrative Science for many years. We also extend our sincere appreciation and thanks to the various other organizations that have provided support and to the many individuals who have been or continue to be participants within (or, in other ways, supporters of) the co-learning journey of Integrative Science guided by Two-Eyed Seeing. This includes numerous Elders, community members, university science students, school students, educators, scientists, and others from Mi’kmaw First Nations and organizations in Atlantic Canada, plus key people from other Aboriginal communities and organizations elsewhere in Canada. Similarly, there have been many non-Aboriginal Elders and other people: research scientists, professors, students, research assistants, associates, and fellows, and individuals in government and elsewhere outside academia. We offer a special thanks to artist Basma Kavanagh and graphic designer Kristy Read for their enriching visual contributions. We are particularly grateful to Sable Offshore Energy, Inc., which provided our first financial support, and to the Canada Research Chairs program, which provided the essential longer-term funding that enabled research flexibility and creativity. We further wish to acknowledge research project, workshop, or infrastructure funding from sshrc (Social Sciences and Humanities Research Council) of Canada, cihr – iaph (Canadian Institutes of Health Research –

   

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Institute of Aboriginal Peoples’ Health), nserc (Natural Sciences and Engineering Research Council) of Canada, iwk Health Centre Foundation, Nova Scotia Health Research Foundation, Atlantic Aboriginal Health Research Program, Mounted Police Foundation, Canadian Foundation for Innovation, and Nova Scotia Research Innovation Trust Fund. We offer thanks to our Earth Mother and all our relations. Ms−i t No’kmaq.

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Contributors

Walter F. Baber is an associate professor in the Graduate Center for Public Policy and Administration at California State University – Long Beach. Professor Baber’s primary areas of research are environmental politics and policy and adaptive organizations of governance. His teaching interests lie in the areas of public law, public policy, and organization theory. Cheryl Bartlett is professor emerita at Cape Breton University, after retiring from her position as professor of biology and Tier 1 Canada Research Chair in Integrative Science in December 2012. In recognition of her work, Bartlett was appointed a Member of the Order of Canada in December 2011. Robert V. Bartlett is the Gund Professor of Liberal Arts in the Political Science Department at the University of Vermont. His research focuses on environmental democracy – namely, the applicability of theories of deliberative democracy to environmental policy and politics and, in turn, the implications of practical policy considerations for theorizing about deliberative democracy. Anne Marie Dalton is a professor in the Department of Religious Studies at Saint Mary’s University. Her research focuses on religion and its relationship with ecology, gender, culture, and international development. Colleen Davison is a research scientist and adjunct assistant professor in the Department of Community Heath and ­Epidemiology at

   

328 Contributors

Queen’s University and the Clinical Research Centre at Kingston General Hospital. Nancy Edwards is a full professor in the School of Nursing and the Department of Epidemiology and Community Medicine at the University of Ottawa, director of the Community Health Research Unit, principal scientist at the Institute of Population Health, senior scientist at the Élisabeth Bruyère Research Institute, and academic consultant for the City of Ottawa (Public Health Services). The focus of her research is multiple interventions in community health nursing care. John Fitzgibbon is professor of rural planning and development in the School of Environmental Design and Rural Development at the University of Guelph. His primary areas of academic interest include source water protection, environmental management, community-based natural resource management, environmental farm planning, and nutrient management planning. Nicholas P. Guehlstorf is an associate professor in the Department of Political Science at Southern Illinois University Edwardsville. His research focuses on the integration of democratic values into environmental policy and considers the theoretical problems with citizen involvement, economic development, and scientific information in decision-making. Lars K. HallstrÖm is a professor of political studies (Augustana faculty) and is joint-appointed to the Department of Resource Economics and Environmental Sociology in the Faculty of Agricultural, Life, and Environmental Sciences at the University of Alberta. His research focuses on environmental policy, rural development, and comparative public policy. Patti Hansen-Ketchum is an associate professor with the School of Nursing at St Francis Xavier University. Her research program aims to explore and examine interventions that integrate nature and ecological thinking into health systems for the equitable promotion of health across all age groups and vulnerable populations in diverse contexts.

   



Contributors 329

Marilyn Iwama is a poet and adjunct professor of English and First Nations studies at the University of Northern British Columbia. Traci Lichtenberg is a supervisor of water quality and environmental compliance at Missouri American Water. Patricia Marck is a professor and director in the School of Nursing and an associate dean of the Faculty of Health and Social Development at the University of British Columbia – Okanagan. She works with students, clinical practitioners, care recipients, managers, educators, and policy-makers to adapt knowledge and methods from the field of ecological restoration (the study and repair of damaged ecosystems) to study safety and quality issues across the continuum of care. Elder Albert Marshall is from the Bear Clan of the Mi’kmaw Nation. He lives in the community of Eskasoni in Unama’ki, Cape Breton, Nova Scotia. Marshall is a spiritual leader, and a fluent speaker of the Mi’kmaw language. Elder Murdena Marshall is from the Bear Clan of the Mi’kmaw Nation. She lives in the community of Eskasoni in Unama’ki, Cape Breton, Nova Scotia. Marshall is a spiritual leader, a fluent speaker of the Mi’kmaw language, and an associate professor (retired) of Mi’kmaq studies at Cape Breton University. Karen Morrison is vice-president of the International Association for Ecology and Health and an adjunct professor in the Faculty of Environmental Studies at York University. Her work is largely concerned with issues related to environmental change and human health and well-being, and in particular with questions related to water governance, transdisciplinary research, and public policy. Margot W. Parkes is a Canada Research Chair in Health, Ecosystems, and Society and an associate professor in the School of Health Sciences at the University of Northern British Columbia. Her research focuses on impacts of ecosystem change on social determinants of health, especially in the context of watersheds in rural, remote, and Indigenous communities.

   

330 Contributors

David Waltner-Toews is a veterinarian, epidemiologist, scientist, and author. He specializes in diseases other animals share with people, international development, and ecosystem approaches to health. He is also a professor emeritus at the University of Guelph.

   

Index

1999 World Conference on Science, 307 Aboriginal Peoples: definition, 283–4; Elders, 225, 280–3, 293, 296–7, 317; Aboriginal Education Research Centre (aerc), 287; Aboriginal Learning Knowledge Centre, 292, 315, 317; ecological citizenship, 116, 269–71; education, problems in, 43–4, 290–1; and health care, 78; Indigenous sciences, 290–1; pattern view of science, 304–6; ­traditional ecological knowledge, 78; “Trees Holding Hands,” 294–6; Two-Eyed Seeing, 283–4, 294–9, 310. See also Eskasoni; M ˉaori; Mi’kmaq; Tlicho Acterberg, Jean, 270 activity settings theory, 40, 43 Adaptive Methodology for Ecosystem Sustainability and Health (amesh), 12, 195, 228 administrative discretion: decisionmaking, 137; deliberative rulemaking, 135, 147–9; general-

izations about, 145; living with, 139; and modern governance, 147–9; negotiated regulations and hybrid rule-making, 146; regulations, 138, 154–5; “Rule of Law,” 140; rule-making, 141–3; safe for democracy, 131–2, 144 Administrative Procedures Act (1941), 143, 160; amendments to, 161 Alberta Health Services Board, 77 Alma Ata Declaration, 11 Anderson, Kathryn, 266, 268 Anderson, Winslow, 270 Anglicans. See under Christians anthropocentrism, 113, 153, 263, 271 Atlas of Science Literacy, the, 303 Baracoa River (Cuba), 328 Bauta (Cuba), 230, 236, 238 Behchoko (Northwest Territories), 43–4 Berry, Thomas, 256, 270–2, 275n4 Bertalanffy, Ludwig von, 36 Bouchard, Luc, 273–4

   

332 Index

Bronfenbrenner, Urie: convergence and diversity, 10; prominent models, 36–7; strengthening communities, 37–8, 41 Cajete, Gregory, 291–2 Canada’s International Development Research Centre, 11, 47, 213 Canada’s Social Science and Humanities Research Council (sshrc): advances in integration, 8; managing health systems, 72; sshrc study, 90n1: policy-­makers, 74; research, 75; fostering place ethics, 79; conducting citizen science, 82; restoration and emancipation, 84 Canadian Aboriginal Science and Technology Society, 284 Canadian Coalition for Global Health Research (ccghr), 46 Canadian Council on Learning, 315, 317 Canadian Extractives Sector in Developing Countries, National Roundtable on the, 267 Canadian Institutes of Health Research (cihr), 46, 47; ­cihr– Institute of Aboriginal Peoples’ Health, 294 Canadian International Development Agency, 44 Canadian Network for Corporate Responsibility, 267 Canadian Task Force on Central America, 265 Cape Breton: University, 289, 317 Caputo, John, 263 Cardinal, Douglas J., 302

Carson, Rachel, 269 Catholics. See under Christians Center for Watershed Protection, 162 Chesapeake Bay Program, 161 Chiapas (Mexico), 265–6 China: Cultural Revolution, 45; Yunnan Province, 44–6; government, 45 Christians: Anglicans, 257; Canadian Christian groups, 265–8, 273–4; Catholics, 257, 260, 266, 273–4; Protestants, 256–7, 260, 275n3; stewardship vs. domination, 262, 263, 270–1 chronosystem, 37–8, 44, 53. See also Bronfenbrenner, Urie Churchman, C.W. See “wicked problems” ciguatera fish poisoning (cfp): in algal vs. coral ecosystems, 237, 241–2, 244–5, 246, 248; ciguatoxic species, 232; folk beliefs about, 238; possible causes of, 232, 245; symptoms of, 231, 233; toxins associated with, 231–2; tracking of cases, in Cuba, 232–3, 236–7, 238–9, 241 citizen science, 81–2 Clean Air Amendments (1997), 143 Clean Water Action Plan, 162 Cobb, John, 256 “cognition in practice,” 234 co-learning, 282–3, 284–7, 309. See also Integrative Science collective moral imagination, 31, 70–1 colonization of the imagination, 31, 70, 72

   



Index 333

Communities of Practice (cop): definition, 235; knowledge dissemination in, 234–5, 237, 238– 41, 245–6, 247–8; and situated learning theory, 243, 246 Communities of Practice for Ecosystem Approaches to Health, 11 community health: in Aboriginal communities, 73, 78, 79; in China, 44–6; and hospitals, 74–5, 76; and local health services, 77; in Mongolia, 46–9; multilevel approaches to, 76, 83, 86; and natural settings, 99–120, 239; and pollution, 241–2. See also place ethics Community Oriented Participatory Action Research (copar), 191, 195 Corporate Social Responsibility, National Roundtable on, 267 critical realism, 103 cross-cultural understanding, 284, 299 Cuban Ministry of Industrial Fishing (Ministerio de la Industría Pesquería), 233; Decree-Law 164, 233, 239 Cuban Special Period in Peacetime, 227–8 Cuban Sports Fishing Federation (Federación Cubana de Pesca Deportiva), 233 Cyclone Lily, 237 Cypher, Jennifer, and Eric Higgs, 70 Dahlgren, Goran, and Margaret Whitehead, 38–9 Daley, Dorothy M., 161

Davis, Kenneth Culp, 138, 144–9 deliberative democratic theory, 10, 132 Department of Natural Resources: Missouri, 175; Nova Scotia, 302 Donnelly, Gabrielle, 266–7 ecohealth: definition, 11, 229; development, 10, 11–12, 153, 187, 198, 212–13 ecological citizenship, 69–71, 86–9, 99–101, 108–9, 115–20 ecological literacy, 69, 71–2 ecological restoration: definition, 73; and adaptation, 72, 83–4; and health systems, 72–9, 84–7, 88–9; and place ethics, 79–81 ecologically emancipated communities. See ecological citizenship Ecosystem-based Community Oriented Participatory Action Research (eco-par), 191 Ehrenfeld, D., 9, 113 engaged practice, 79, 82–3 Environmental Law Institute, 165, 170, 175, 177 Environmental Protection Agency (epa): guidelines on pollutant levels, 170, 171; and legislation, 162, 165; programs, 161–2, 165, 171, 175, 177, 178–9 epistemologies, 280, 284, 300, 312–13 Ermine, Willie, 286–7, 299, 300, 305, 307, 316 Eskasoni First Nation, 290, 294 ethical space, 286, 300, 307, 311 Evans, Robert, and Greg Stoddart, 39–40, 41

   

334 Index

Federal Guidelines on Mitigation Banking (1995), 176–7. See also epa feedback loops, 34–6, 51 First Nations’ Life Long Learning (program), 315, 317 First Nations University, 286 Fisher, Frank, 9 Flanagan, Owen, 264–5 Frankfurt School, 10 Gambierdiscus toxicus. See ciguatera fish poisoning General Systems Theory. See ­Bertalanffy, Ludwig von Gloade, Gerald, 302 globalization, 10; of politics, 136, 151–3; of risk, 136, 154; and wealth inequality, 53 Gross-Stein, J., 191, 194, 201 Havana (Cuba), 229, 237–8, 243 health equity: international approaches, 11, 46–7; and risk exposure, 136, 154; who Commission on Social Determinants of Health, 10 health promotion, nature-based, 99–120. See also ecological restoration “health society,” 10, 17, 132, 153 Heller, Chaia, 272–3 Hippocrates, 9 homeostasis, 36 Hughes, Ken, 77 humanism, 113 Hurricane Michelle, 237 Indigenous Peoples. See Aboriginal Peoples

Integrative Science: definition, 284–9; co-learning, 282–3, 309; healing tense, 299–300; origins, 289–92, 307; pattern and story, 301–7, 311–15; and trust, 308; Two-Eyed Seeing, 294–9, 310, 311–315; words of Elders, 288, 293–4, 296, 299–300, 310. See also citizen science “Integrity of Creation and the Athabasca Oil Sands.” See ­Bouchard, Luc Intermodal Surface Transportation Equity Act, 165 International Association for ­Ecology and Health (iaeh), 11, 153 International City/County Management Association, 162 International Joint Commission of the Great Lakes, 11 Janes, Craig, 46–9 Jibacoa-Bacuanyagua coastal and marine protected area (Cuba), 237 Jim Crow segregation laws, 54–5 kairos Canada, 266–8 Kinast, Robert L., 268 Kowalchuk, Lisa, and Jennifer Pierce, 268 La Habana (province) (Cuba), 224, 228–9, 236, 242 Labrador, Charles, 294 Lave, John, 234–5 Leopold, Aldo, 270 local knowledge. See Aboriginal Peoples, traditional ecological

   

Index 335



knowledge; Communities of Practice; ecological citizenship macrosystem. See Bronfenbrenner, Urie M ˉaori, 192, 196, 197 Mariel (Cuba): ciguatera fish poisoning in, 230, 236, 241, 243, 244–5; demographics, ­228–9, 243; fishing community in, ­240–1, 246; pollution in, 241–2, 245 Maritimes-Guatemala Network, 265–6 mesosystem. See Bronfenbrenner, Urie microsystem. See Bronfenbrenner, Urie Mi’kmaq / Mi’kmaw First Nation: epistemologies, 304, 308, 310, 313; interconnectedness, 289, 304; language, 289, 290, ­299–300; Mi’kmawey Debert Cultural Centre, 302, 304; Seven Sacred Gifts, 288, 304; territory, 281, 290; traditional knowledge, 303, 304 Millennium Conferences on Creativity in the Arts and Sciences, 302 Millennium Ecosystem Assessment, 13, 14, 185, 244 Missouri Wetland Project. See watershed management Mongolia, mining and health equity in, 46–9 Multiple Intelligences (mi) Theory, 301 National Estuary Program, 161

Native Knowledge Network of the University of Alaska-Fairbanks, 301 negotiated rule-making, 142–3, 145–6, 148 nested influences, 34, 46, 51 Network for Ecosystems, Sustainability and Health (nesh), 11 New Mexico, University of, 291 New Zealand: Ministry of Agriculture and Forestry, 211; Landcare Trust, 212; Ministry for Environment, 208, 211. See also Taieri Catchment and Community Health (TCandCH) Project Nova Scotia. See Mi’kmaq one health, 8, 10–12. See also ecohealth ontologies. See epistemologies Onyx, Jenny, 259 Organization of American States, 309 Ottawa Charter for Health Promotion, 6, 11–12, 102, 185–6 Our Common Future, 11 Parra y Callado, Antonio, 233 participatory research. See citizen science; Taieri Catchment and Community Health (TCandCH) philosophy of technology, 113–14, 118 place ethics, 69, 71–2, 75, 78–81, 82, 84, 88–9, 101–3, 105, ­106–8, 110–14, 119–20, 282, 288–9, 302 Playa Baracoa (Cuba): Ciguatera Fish Poisoning in, 230, 236, 238–9, 247; cyclone damage to,

   

336 Index

230; demographics, 228–9, 243; fishing community in, 238–40, 245, 247, 248 Poey y Aloy, Felipe, 233, 238 Poincaré, Henri, 303 politics of expertise, 9 precautionary principle, 137, 154 Project Accompaniment, 265–6 Protestants. See under Christians public participation: in ­legislation, 141–4, 146; in place ethics, 71–2, 79–83, 87–8; on policy juries, 149–54; on watershed issues, 159–65, 169, 174, 1 ­ 75–80, ­184–213. See also Communities of Practice Radford Ruether, Rosemary, 256, 271 reciprocal interactions. See feedback loops reciprocal maintenance, 6, 14, 103 restorative approach to healthcare issues, 31, 70, 72–3, 78, 85–8 Rio Declaration, 11 Rio+20 Conference, 14 Rosen, Stanley, 263 Ross, Rupert, 302 Santa Cruz del Norte (Cuba): ciguatera fish poisoning in, 230, 236–8, 247; demographics, ­228–9, 243; fishing community in, 237–8, 247; marine protected area, 237, 246; pollution in, 241; storm damage to, 237 St Paul’s Diocese, 273 Second World War, 9 ser International Indigenous Peoples Restoration Network, 78

Silent Spring. See Carson, Rachel Sirianni, Carmen, 161–2 Situated Learning Theory (slt): definition, 233–5; and adaptation, 242–5, 249; “reified” information, 244–9. See also Communities of Practice social capital: definition, 259; and local knowledge, 234–5, 237, 249–50; and reciprocal interaction, 51; and religion, 257–8, 259–65, 274; spiritual capital, 257, 275n1 social determinants of health: and ecohealth, 8, 10, 99–103; and health care, 69–90; multilevel, 35; research into, 34–40; who Commission on, 10, 12–15, 17, 185. See also activity settings theory; community health; socioecological theory socio-ecological theory: definition, 35; application, Canadian, 40–4; application, international, 44–9; limitations of approach, 49–56; models, 36–40 Species at Risk Act, 284 spirituality: definition, 258–9; and ecology, 270, 271–2; Indigenous, 270, 271–2, 288–9, 291, 292, 296, 302, 304, 310; neo-pagan and Wiccan, 258–9; as religion, 9, 258–9. See also place ethic Stoddart, Greg. See Evans, Robert, and Greg Stoddart Stokols, Daniel, 38 structural adjustment policies, 53 Subcommittee on Human Rights and International Development of the Standing Committee on

   



Index 337

Foreign Affairs and International Trade, 267 Swan, James A., 269–71 systems theory, 36; application to health, 40–1 Taieri Catchment and Community Health (TCandCH) Project, 190–213; copar process in, 191, 192–3, 195, 203; horizontal and vertical connections, 205, 209; local participation in, 202–4, 206–10; and M ˉaori, 192, 196; taieri Trust, 201–3, ­205–6, 208–12; Upper Taieri Water Management Steering Group, 211–12 Targeted Watershed Initiative, 162 technocracy, 9, 113–14 technological colonization of the imagination, 69, 72, 89 theological reflection, 268 Tlicho First Nation, 43–4 transculturalism. See cross-cultural understanding Turin, Polytechnic Institute of, 151–2 Two-Eyed Seeing. See under Integrative Science Underwood Spencer, Paula, 303 Unidad Municipal de Higiene y Epidemiología (umhe), 238–9, 241, 245 United States Fish and Wildlife Service, 165 Vaught, Karl, 264

Vermont, University of, 151–2 Waihola-Waipori Lake-Wetland Complex, 207. See also Taieri Watershed Assistance Grants (wag) Program, 162 watershed management: in Missouri, 159–180; mitigation banking, 164–5, 169, 175, 176–80; in New Zealand (see Taieri Catchment and Community Health (TCandCH) Project); public awareness of, 160–1, 163, 165; public participation in, ­159–65, 169, 174, 175–80, ­184–213; urban vs. rural, 166, 174, ­178–80. See also epa Weislogel, Eric, 263–4, 274 wellness, as holistic concept, 258 wetland mitigation banking, 164, 169, 175, 176–80 Wetland Reserve Program, 170 Whitehead, Margaret. See ­Dahlgren, Goran, and Margaret Whitehead White House Office of Environmental Policy’s Federal Wetlands Plan, 165 wholeness, 264–5 “wicked problems”: definition, 6–7; approaches to, 17–18; examples, 15–16 World Health Organization (who): Alliance for Health Policy and Systems Research, 40, 46; Commission on Social Determinants of Health, 10, 12–15, 17, 185