SOCIAL JUSTICE THROUGH HEALTH CARE

We hardly come across a person who may be fully satisfied with the health care delivery system run by either the government or the private sector. This is true not only for developing but for all the developed countries as well. Every law abiding, contributing individual has some legitimate expectations from the state. Disenchantment with present dispensation of health care compels people to seek better options across the borders. Even the present flow rate of patients from developed to developing countries has assumed the proportions of Medical tourism. Medical tourism is not a one-way traffic. Poor from India are known to visit Rashid Hospital at Lahore for kidney transplants. Medical tourism will definitely bring in world class equipment and services in our corporate hospitals. These corporate tertiary care hospitals can act as excellent referral hospitals. Lack of enough clinical material, as the patients are often referred to in medical parleyences is prompting the doctors from developed world into medical adventurism. Very recently two NGO’s headed by renowned plastic surgeons of Indian origin were in India, claiming to their credit hundreds of cleft lip and palate surgeries conducted in one week. During my brief interaction when I asked them one basic question that how do you justify single step surgery by a single specialist for a clinical entity that require 3-5 set up surgeries by 10 specialists over a period of 20 years, there was no answer. On record local doctors conduct all these surgeries. These NGO’s bring in a battery of trainee resident doctors for hands on training. Dumping of questionable services and drugs continues unabated in the absence of stringent regulations. Clear-cut up to date guidelines by health authorities have yet to be issued to safe guard the health interests of this nation. Most of the drugs banned in developed countries are still being dumped in the Indian market. Commerce alone dictates the policies of multinational companies in health sector of developing countries. State and national medical councils, the watch dogs of our national health interests are controlled by elected representatives from among the doctors. Competitive populism for being elected to these high offices takes away the very sting off these regulators. In this ‘market forces’ driven health sector, apart from other factors, size of the population, economic prosperity and literacy levels dictate the out look of key players. Subjective as well as objective assessments of the health care operations leave people confused with huge piles of data and endless interpretations. At the tail end of govt. health care delivery system is the rural dispensary or the slum revamping center, and the end user an illiterate or semi literate villager or a slum dweller. Dispensary is the humane face, the welfare state can present to its people. In yesteryears the service providers were from among the same social class they used to serve. Doctor can be a friend, philosopher and guide to the locals. Unfortunately the economic and social disparity between the service providing doctors and the service user population has grown enormously. Ad-hocism in health care delivery should be done away with immediate effect. Doctors and paramedical staff appointed on yearly contract basis are not showing any interest in the national programmes. Established private health care providers also have not shown any meaningful commitment for national programmes. Middle class itself has fragmented. Now it is fashionable to assign economic values to any issue like gender, but for social responsibility and justice. In this era of fast paced growth, the unorganized, silently suffering millions can not be wished away. Once reading on biodiversity I stumbled upon a very interesting quote, “only the species with economic importance will survive”. In our active pursuit for magnetizing economy, we assigned economic values to any thing except for morals. Commercialization of education has produced a new breed of professionals who have scant regard for professional ethics. Privatization is the buzzword with governments, because it takes away government responsibility. Private sector players are eyeing many ‘viable’ health institutions. There are no takers for commercially non-viable rural institutions. Rural health institutions dispense social medicine. Very recently one of the key players from private sector health care quoted the cost of developing one bed in corporate hospital at Rs. 30-60 lacs. These corporate health services are definitely out of each of the common man. These type of hospitals are definitely required for a nation with the present rate of growth but ‘bharat’ definitely needs different kind of hospitals. There are very strong social under currents against the exploitive private healthcare, inadequate government sector health care resources and the indifferent approach of welfare state. Health for all is a very lofty but expensive proposition. There are ways and means to reduce the pressure from government institutions. Private-public partnership, health insurance, monitoring and regulation of private sector health care can all make the things bit easy. Preventive health care education can go a long way in improving the public health. Community participation in health care has produced few but wonderful examples. Complementary community participation can make up for minor but critical deficiencies in the government run health care system. Setting up of health system corporations with World Bank assistance has already improved the working of govt. sector health care institutions considerably. Community participation through NGO’s can still improve the system, but most of the meaningful NGO’s turn their back on govt. run health care institutions because of their doubts on the integrity of government officers. Government health care institution are increasingly seen not as caring hospitals but like police stations, where medico legal reports are written and postmortems conducted. Most of the government doctors’ time is spent in courts appearing as medico legal experts witnesses. Emergency, post mortem, and then the VIP duties in addition hardly leave the doctors free for any meaningful job at government hospitals. There is an urgent need to have separate curative, preventive, legal, administrate and health intelligence wings. Government hospitals attract the poorest of the poor, mostly people from the unorganized sector. Their contribution to national GDP is by no means small. With the present growth rate, upward social mobility is seen in every strata of society. Many segments of this unorganized sector can be organised so that they also enjoy the patronage of welfare state in the form of health insurance policies. Apart from direct benefit to these segments of society, the state will benefit from the ‘off loading’ of burden from government run health care system and loading it on insurance driven private sector health care institutions. Poorest of the poor will repose faith in welfare state. Sanjivini, health insurance policy with the Punjab Milkmen Cooperative Societies is already a big success. ECHS (Ex servicemen Contributory Health Scheme) is an other success story. These success stories can be replicated with countless groups like, panwallas, dhabewallas, autorikshaw drivers etc. Simply organize the unorganized sector. There is no dearth of role models from among government doctors also. Their inclusion rather than drift after dissent from the present dispensation of health care will immensely improve the system. Stability of tenure is an excellent incentive government can give to its doctors without costing anything to exchequer. Yet tenure beyond decades should be discouraged as it leads to development of vested interests of the old incumbents and denial of chance to the youngsters. Resource mismatching is a major problem in the govt. run health care system. There are dispensaries where specialists are posted and still many more civil hospitals where non-specialist are posted. These mismatching result in defective and inefficient health care. Nodal Hospitals can be created for round the clock emergency services by cannibalizing defunct and sick institutions where equipment worth crores is lying unused and salary bills are bleeding the exchequer white. Most of the medical officers retire in the same administrate rank. This undue stagnation has forced many a brilliant doctors out of service. By simply seeking options for place of posting, honestly implementing with minimum displacement on merit can also revitalize the govt. doctors’ cadres. Private sector health care delivery system is a totally market driven commercial enterprise. So called ‘market forces’ have least respect for ethical and moral value systems. Multi level marketing chains have evolved in the name of referral systems. End result is exploitation of the unsuspecting common man, who still regards his healer a holy person. This ‘incentive’ system is strengthening the hold of unqualified, unscrupulous and unregistered medical practitioners on illiterate masses. Not many qualified doctors are unscrupulous. A large section of private health care providers feel genuinely threatened by blackmailers of all sorts. Consumer protection act is a very convenient beating stick in the hands of their tormentors.

Under the constant threat of being blackmailed, the private health care providers are becoming more defensive in attitude. More patients are being referred to tertiary care institutions for this reason only, thereby flooding the referral institutions. People have a common feeling that sickness is an invitation for exploitation at the hands of private health care providers. Even the charitable hospitals are charging as heavily as fully private hospitals. Medical profession is fully responsible and capable of self-correction. Medical councils and associations can jointly evolve a fail-safe mechanism to keep their black sheep under check even without government help, but the buck stops with the government. Welfare state is duty bound not only in providing health care delivery system but also proper health care administration and social justice through its health care delivery mechanism.

Name : Dr. Pardeep Kumar Sharma

Email-ID : omfspardeep@yahoo.com.

(M) : 0988456296

Date of Birth : 12.02.1962

Education Qualifications : BDS (Bachelor of Dental Surgery)

MDS (Master of Dental Surgery in Oral and Maxillofacial Surgery)

Educational Institutes Attended

Govt. High School Bargari : Matriculation (1969-1977)

Distt. Faridkot, Punjab, India

DAV College Chandigarh : Pre-University (1973-79)

(Punjab University)

Barjindra College Faridkot : Pre-Medical (1980)

Dental Wing, Medical College : BDS (1981-1986)

Patiala

Dental College and Hospital : MDS (2003-2006)

Amritsar

Professional Experience

House Officer, Christian : 1987-1988

Medical College & Hospital,

Ludhiana

Research Officer, All India : Jan. 1989 to June 1989

Institute of Medical Science

AIIIMS, New Delhi

Dental Officer, Indian Armed : July 1989 to August 1994.

Forces in the Rank of Capt.

3

Medical Officer (Dental) : w.e.f. Nov. 1995 till date

in Punjab Civil Medical Service

(PCMS)

Research papers Published

“Role of Programmed cell death in dental anomalies associated with cleft lip and Palate”. “Medical Hypotheses” Churchil Living Stone Publishers London-1991

Post traumatic polatoglossal adhesion, a case report stomatologica India (1990).

Research Project Undertakes

“Malocclusion and associated Factors among Delhi Children” a study sponsored by Indian Council of Medical Research (ICMR).

Areas of Interest : Environment, Health, Defence, International Affairs and Rationalism

Healthy children are easier on the household budget unfortunately not everyone is so blessed so what do you do? When considering the family budget and being a good parent, providing quality healthcare at a reasonable price is right up there with the mortgage payment, car payments and college tuition.

Health Savings Accounts can be simple and easy to understand. A Health Savings Account is a tax-favored savings account combined with a qualifying high-deductible health insurance plan. Health Savings Accounts allow you to legally avoid federal income tax by depositing 100% of the health plan’s deductible, up to $2,850 for singles or $5,650 for families, into your Health Savings Account. Health Savings Accounts, (HSA) touted as a way to lower health-insurance costs and broaden coverage, have fallen short of their promise. They are gaining popularity because they allow individuals, rather than an HMO or the government, to take charge of their health care. Also, they’re an excellent option for individuals and families without employer-sponsored health insurance. Health Savings Accounts are becoming quite popular for people who are generally healthy and they’re leading the way in this transition.

Savings can be used to help pay the deductible and for non-covered medical expenses, such as dental and vision. Savings reduce or eliminate annual out-of-pocket exposure. Savings not spent remain in the HSA tax-deferred. Savings and investments unlike premiums, unused HSA dollars remain in the HSA until you use them later. Day-to-day expenses come out of the health savings account, while catastrophic expenses are covered by insurance. Health Savings Accounts are gaining popularity because they allow individuals, rather than an HMO or the government, to take charge of their health care. A Health Savings Account combined with a High Deductible Health Insurance Plan gives individuals an economic incentive to become better consumers of health care services because they are now spending their own money up to the level of their high deductible. Health Savings Accounts are an excellent option for individuals and families without employer-sponsored health insurance.

If your employer offers a high-deductible health insurance policy, you may be able to make pretax contributions, like you would with a flexible-spending account. Legislation passed by Congress December 9, 2006, will let you make a one-time transfer of funds tax free from a flexible-spending account to an HSA. You cannot have an HSA if you use a flexible-spending account to pay health-care costs or if you have other medical coverage (say, through a spouse’s policy). You can keep the money in an HSA account even after you leave that job, similar to a 401(k). Keep in mind that you can continue to withdraw money from the account tax-free for qualified medical expenses after age 65. You can’t make new HSA contributions after age 65, but you can still use the money in your account tax-free for medical expenses at any age.

Deposits to an HSA may be made by any policyholder of a qualified High Deductible Health Plan (HDHP), by an employer on behalf of a policyholder, or any other person. Previously, the annual maximum deposit to an HSA was the lesser of the HDHP deductible or specified IRS limits. As of 2007 plan years, Congress has abolished the lower limit based on the deductible, and the maximum contribution will simply be the statutory limit. These include deductibles and coinsurance as well as many other expenses not covered under medical plans, such as dental, vision and chiropractic care; durable medical equipment such as eyeglasses and hearing aids; purchase and use of qualifying over-the-counter medications; and transportation expenses related to medical care. Contributions are deductible, the account accumulates tax-free, and withdrawals used for medical expenses are tax-free. Contributions and gains can be rolled from year to year – there’s no “use it or lose it”. Contributions to the HSAs are tax-deductible at the federal and state level.

Healthcare is the number one issue facing many individuals and companies in America. Now with the release of Michael Moore’s new movie, SICKO, the debate on healthcare in the USA in on. Many well-meaning people believe that a government take-over of healthcare coverage, called a “single-payer” system, is the answer. Health Savings Accounts are combined with a High Deductible Health Plan (HDHP) to offer a more affordable approach to healthcare. They were created to help give control back to consumers and lower healthcare costs. While most healthcare insurance clients say they are satisfied with their current plans, the landscape changes when major illnesses start. Alternatively, your HSA balance can be used to cover your post-age-65 healthcare costs including Medicare Part A and B premiums, Medicare HMO premiums, garden-variety health premiums, insurance deductibles and co-payments, prescriptions, long-term care insurance premiums, and so forth. But what about the person who lives pay check to pay check or the single parent trying to provide healthcare for themselves and children. Combine a tax-favored Health Savings Account (HSA) and an HSA-eligible health insurance plan to save money tax-free for healthcare costs.

Health Savings Account Plans help you take control of your health care expenses with a tax-favored savings account and quality medical coverage. Health Savings Account (HSA) Plans are an excellent choice for individuals and families who want to control their health insurance costs by combining a lower cost high deductible health insurance plan with a tax advantaged savings account and network discounts. Learn how to take advantage of the money-saving benefits of a Health Savings Account. By allowing you to deposit tax-deductible funds into a health savings account that you can use to cover medical costs, Health Savings Accounts enable you to take control of your own health care decisions. Once your insurance policy has become effective, you may begin to fund your Health Savings Account. Please note: To obtain the maximum tax benefit from your Health Savings Account in 2008 as well as lock in 2007 rates, you must have your HSA-qualified insurance plan effective no later than December 31. There are about 10 million people enrolled in “consumer-driven health plans,” and about 6 million of those are Health Savings Accounts. To really maximize your savings pair up a Discount Health Plan, for the everyday savings on you health care, with your HSA and HDHP. You may want to read my other article on Healthcare and the Family Budget – How to Get the Biggest Bang for Your Buck!

New York Health Insurance

Health insurance is insurance that pays for all or part of a person’s health care bills. A health insurance policy is an annually renewable contract between an insurance company and an individual. With health insurance claims, the individual policy-holder pays a deductible plus co-payment (for instance, a hospital stay might require the first 1000 dollar of fees to be paid by the policy-holder plus 100 dollar per night stayed in hospital). Usually there is a maximum out-of-pocket payment for any single year, and there can be a lifetime maximum.

The purpose of health insurance is to help people cover their health care costs which usually include doctor visits, hospital stays, surgery, procedures, tests, home care, and other treatments and services.

According to the latest United States Census Bureau figures, around 85% of citizens have health insurance. 59.5% of these people receive their health insurance coverage through an employer, and about 9% purchase it directly from the market. Government sources cover 27.3% of the population. Those without health insurance coverage are expected to pay privately for medical services.

Types of New York Health Insurance (http://new-york.ixs.net/General/New-York-Health-Insurance/index.aspx ) The types of health insurance in New York are group health plans, individual plans, and government health plans such as Medicare and Medicaid. In the United States, government-funded Medicare programs help to insure the elderly and end stage renal disease patients.

Group Health Plans

A group health plan offers health care coverage for employers, student organizations, professional associations, religious organizations, and other groups. The employer may pay for part or all of the insurance cost (premium).

Individual and Family Health Insurance

Individual and family health insurance is a type of health insurance coverage that is made available to individuals and families, rather than to employer groups or organizations. These types of health care plans are sold directly to individuals. For those of you who are unemployed or self-employed, an individual health insurance policy is always an option. Unfortunately rates for these policies are high and the coverage is usually less comprehensive than a managed care plan. The good news is that, in many cases, your insurance premium will be tax deductible. Of course, if you’re married, you can always try to catch a ride on your spouse’s group health insurance benefits plan.

Health insurance can be further classified into fee-for-service or indemnity (traditional insurance) and managed care. Both group and individual insurance plans can be either fee-for-service or managed care plans.

Managed Care Health Insurance

These include HMO, PPO, and POS plans. Managed-care plans typically make use of healthcare provider networks. Healthcare providers within a network agree to perform services for managed-care plan patients at pre-negotiated rates and will usually submit the claim to the insurance company for you. In general, you’ll have less paperwork and lower out-of-pocket costs with a managed care health insurance plan and a broader choice of healthcare providers with an indemnity plan.

There are three main types of managed care plans:

• Health Maintenance Organizations (HMO)

• Point-of-Service (POS)

• Preferred Provider Organizations (PPO)

All of these plans offer substantial health insurance benefits to members and their families. If you’re fortunate enough to have a choice of plan, consider the advantages, and disadvantages, of each. Compare the cost of care, the difference in premiums, deductible amounts and your freedom to choose a doctor outside the plan. There are numerous other coverages to compare as well — from prescription drugs to dental to alternative therapies. Be sure you understand the fine points of each.

Indemnity or Fee-For-Service Plan

Normally it covers the same expenses as managed care. The difference is your doctor is paid for each visit with the claim filed by either the patient or the medical provider. A big advantage– unlike some managed care plans, Fee-for-Service allows the patient a great deal of freedom in choosing which doctors and hospitals to use, but will probably involve higher out-of-pocket costs and more paperwork.

However, you’ll likely be required to pay an annual deductible before the insurance company begins to pay on your claims. An Indemnity plan may also require that you pay up front for services and then submit a claim to the insurance company for reimbursement.

Short-Term Health Insurance

Short-term health insurance plans are designed to protect against unforeseen accidents or illnesses, rather than to provide comprehensive coverage, and, as such, typically do not include coverage for preventive care, physicals, immunizations, dental or vision care. It covers for a limited period of time, and may be an ideal solution for those between jobs or those waiting for other health insurance to start. Typically, short-term plans offer coverage up to six months, although some plans may offer coverage up to 12 months. Purchasing a short-term medical insurance plan will make you ineligible for any guaranteed issue individual health plans commonly referred to as HIPAA (Health Insurance Portability and Accountability Act) Plans. HIPAA plans are usually very expensive and are generally intended for people with pre-existing medical conditions who would have trouble getting health insurance otherwise.

Medical Savings Account (MSA)

Medical savings account (MSA) is the most recent development in the area of health insurance. The principle behind the MSA is to take the bulk of the financial risk, and premium payments, away from the managed care and indemnity insurers, and allow individuals to save money, tax free, in a savings account for use for medical expenses. Individuals or their employers purchase major-medical policies, medical insurance policies with no coverage for medical expenses until the amount paid by the patient exceeds a predetermined maximum amount, such as 2500 dollar per year. These policies have extremely high deductibles and correspondingly low monthly premiums and the participants take the money that they would have spent on higher premiums and deposit it in an MSA. This money accrues through monthly deposits and also earns interest, and can be spent only to pay for medical care

What’s The Best Health Insurance Plan?

There is no one “best” plan for everyone. The best match for you and your family may be different than the best match for someone else. In order to help you answer this question, here are a few things to consider:

1. Are you going to need long-term coverage or just something for the short-term?

If you’re between jobs for 1-6 months, you may want to go for short-term coverage options. Alternatively, if you have no prospects of receiving group health insurance coverage through an employer, you may value the stability and increased benefits offered through an individual and family health insurance plan which will provide longer term coverage.

2. Are you looking for basic coverage or more comprehensive coverage?

Some insurance plans offer basic coverage (i.e., primarily inpatient hospitalization and outpatient surgery coverage) to cover you in case of a major accident or illness. These insurance plans typically have a lower monthly premium than plans with more comprehensive coverage, and may be appropriate for people who intend to use their insurance primarily in the event of a serious accident or illness. Other insurance plans that offer more comprehensive coverage may include benefits such as preventative care, physician services, prescription drug benefits and routine office visits. These insurance plans typically have a higher monthly premium than plans that only offer basic coverage, and may be appropriate for people who intend to use their insurance on a regular basis.

3. Would you pay for your services before you use them or when you use them?

If you choose a health insurance plan with a low monthly premium, you’re likely to have a higher co-payment or deductible. If you don’t anticipate making frequent use of your health insurance coverage, a higher-deductible plan with a lower monthly premium may suit you best.

4. How important to you is easy access to specialists?

Health insurance plans that require you to coordinate your care through a primary care physician typically require that you obtain a referral before seeing a specialist. So, if you prefer easier access to specialists, you may wish to consider a different type of plan.

5. Do you have a specific doctor or hospital that you would like to visit for healthcare?

Some insurance plans utilize provider networks. Pay special attention to the network of doctors or facilities that each health insurance plan utilizes. Also note that networks utilized by health insurance plans can change, so there is no guarantee that your doctor will always be contracted with your chosen health insurance plan.

6. What is the most you could pay out in case of a serious illness or injury?

Health insurance plans typically place limits on how much a member is required to pay out per year for his or her healthcare. This limit is often referred to as an out-of-pocket maximum. Once you’ve contributed this maximum amount toward your healthcare, the health insurance company typically covers all other costs for the remainder of the benefit year. If you’re concerned about what may happen to you in case of a serious illness or injury, you may wish to pay special attention to the out-of-pocket maximums for the health insurance plans you’re considering.

No matter what insurance plan you may choose, educate yourself and understand all the basics of the health insurance before finalizing anything.

For more information about New York Health Insurance visit: http://new-york.ixs.net

Imbalance of Ecosystems and Its effect on Public and Livestock health

Dr.Kedar Karki M.V.St. (Preventive veterinary Medicine)

Central Veterinary Laboratory Tripureshwor

The health of humans, like all living organisms, is dependent on an ecosystem that sustains life. Healthy ecosystems are the sine qua non for healthy organisms. Yet there is abundant evidence that many life-support systems are far from healthy, placing an increased burden on human health. In some areas of the world, gains in life expectancy and quality of life made during the twentieth century are at risk of being reversed in the twenty-first century. The consequences of ecosystem degradation to human health are numerous, and include health risks from unsafe drinking water, polluted air, climate change, emerging new diseases, and the resurgence of old diseases owing to ecological imbalances. Reversing this damage is possible in some cases, but not in others. Prevention of ecological damage is by far the most efficient strategy.

DEFINING ECOSYSTEMS

An ecological system may be defined as a community of plants and animals interacting with each other and their abiotic, or natural, environment. Typically, ecosystems are differentiated on the basis of dominant vegetation, topography, climate, or some other criteria. Boreal forests, for example, are characterized by the predominance of coniferous trees; prairies are characterized by the predominance of grasses; the Arctic tundra is determined partly by the harsh climatic zone. In most areas of the world, the human community is an important and often dominant component of the ecosystem. Ecosystems include not only natural areas (e.g., forests, lakes, marine coastal systems) but also human-constructed systems (e.g., urban ecosystems, agro-ecosystems, impoundments). Human populations are increasingly concentrated in urban ecosystems, and it is estimated that, by the year 2010, 50 percent of the world’s population will be living in urban areas.

A landscape comprises a mosaic of ecosystems, including towns, rivers, lakes, agricultural systems, and so on. Precise boundaries between ecosystems are often difficult to establish. Often regions slide into one another gradually, over a protracted “transition” zone, as for example between the boreal forest and the Taiga regions of Canada.

ECOSYSTEM HEALTH

It is important to recognize the inherent difficulties in defining “health,” whether at the level of the individual, population, or ecosystem. The concept of health is somewhat of an enigma, being easier to define in its absence (sickness) than in its presence. Perhaps partially for that reason, ecologists have resisted applying the notion of “health” to ecosystems. Yet, ecosystems can become dysfunctional, particularly under chronic stress from human activity.Example for this can be cited the discharge of nutrients from sewage, industrial waste, or agricultural runoff into lakes or rivers affects the normal functioning of the ecosystem, and can result in severe impairment. Excessive nutrient inputs from human activity was one of the major factors that severely compromised the health of the lower Laurentian Great Lakes (Lake Erie and Lake Ontario) and regions of the upper Great Lakes (Lake Michigan). Unfortunately, degraded ecosystems are becoming more the rule than the exception.

The study of the features of degraded systems, and comparisons with systems that have not been altered by human activity, makes it possible to identify the characteristics of healthy ecosystems. Healthy ecosystems may be characterized not only by the absence of signs of pathology, but also by signs of health, including measures of vigor (productivity), organization, and resilience.

Vigor can be assessed in terms of the metabolism (activity and productivity) of the system. Ecosystems differ greatly in their normal ranges of productivity. Estuaries are far more productive than open oceans, and marshes have higher productivity than deserts. Health is not evaluated by applying one standard to all systems. Organization can be assessed by the structure of the biotic community that forms an ecosystem and by the nature of the interactions between the species (both plants and animals). Invariably, healthy ecosystems have more diversity of biota than ecologically compromised systems. Resilience is the capacity of an ecosystem to maintain its structure and functions in the face of natural disturbances. Systems with a history of chronic stress are less likely to recover from normal perturbations such as drought than those systems that have been relatively less stressed.

Healthy ecosystems can also be characterized in economic, social, and human health terms. Healthy ecosystems support a certain level of economic activity. This is not to say that the ecosystem is necessarily self-sufficient, but rather that it supports economic productivity to enable the human community to meet reasonable needs. Inevitably, ecosystem degradation impinges on the long-term sustainability of the human economy that is associated with it, although in the short-term this may not be evident, as natural capital (e.g., soils, renewable resources) may be overexploited and temporarily enhance economic returns. Similarly, with respect to social well-being, healthy ecosystems provide a basis for and encourage community integration. Historically, for example, native Hawaiian groups managed their ecosystem through a well-developed social cohesiveness that provided a high degree of cooperation in fishing and farming activity.

Another reflection of ecosystem health lies directly in the public health domain. In spring 2000, a deadly strain of the bacterium E-coli (0157:H7) entered the public water supply in Walkerton, Ontario, Canada, causing seven deaths and making thousands sick. This small town, with a population of five thousand, is in a farming community. Inadequate manure management from cattle operations was the likely source of this tragedy.

HOW HEALTHY ECOSYSTEMS BECOME PATHOLOGICAL

Stress from human activity is a major factor in transforming healthy ecosystems to sick ecosystems. Chronic stress from human activity differs from natural disturbances. Natural disturbances (fires, floods, periodic insect infestations) are part of the dynamics of most ecosystems. These processes help to “reset” ecosystems by recycling nutrients and clearing space for recolonization by biota that may be better adapted to changing environments. Thus, natural perturbations help keep ecosystems healthy. In contrast, chronic and acute stress on ecosystems resulting from human activity (e.g., construction of large dams, release of nutrients and toxic substances into the air, water, and land) generally results in long-term ecological dysfunction.

Five major sources of human-induced (anthropogenic) stresses have been identified by D. J. Rapport and A. M. Friend (1979): physical restructuring, overharvesting, waste residuals, introduction of exotic species, and global change.

Physical Restructuring. Activities such as wetland drainage, removal of shoals in lakes, damming of rivers, and road construction fragment the landscape and alter and damage critical habitat. These activities also disrupt nutrient cycling, and cause the loss of biodiversity.

Overharvesting. Overexploitation is commonplace when it comes to harvesting of wildlife, fisheries, and forests. Over long periods of time, stocks of preferred species are reduced. For example, the giant redwoods that once thrived along the California coast now exist only in remnant patches because of overharvesting. When dominant species like the giant redwoods (arguably the world’s tallest tree—one specimen was recorded at 110 meters tall with a circumference of 13.4 meters) are lost, the entire ecosystem becomes transformed. Overharvesting often results in reduced biodiversity of endemic species, while facilitating the invasion of opportunistic species.

Waste Residuals. Discharges from municipal, industrial, and agricultural sources into the air, water, and land have severely compromised many of the earth’s ecosystems. The effects are particularly apparent in aquatic ecosystems. In some lakes that lack a natural buffering capacity, acid precipitation has eliminated most of the fish and other organisms. While the visual effect appears beneficial (water clarity goes up) the impact on ecosystem health is devastating. Systems that once contained a variety of organisms and were highly productive (biologically) become devoid of most lifeforms except for a few acid-tolerant bacteria and sediment-dwelling organisms.

Introduction of Exotic Species. The spread of exotics has become a problem in almost every ecosystem of the world. Transporting species from their native habitat to entirely new ecosystems can wreck havoc, as the new environments are often without natural checks and balances for the new species. In the Great Lakes Basin, the accidental introduction of two small pelagic fishes, the alewife and the rainbow smelt, combined with the simultaneous overharvesting of natural predators, such as the lake trout, led to a significant decline in native fish species. The introduction of the sea lamprey, an eel-like predacious fish that attacks larger fish, into Lake Erie and the upper Great Lakes further destabilized the native fish community. The sea lamprey contributed to the demise of the deepwater benthic fish community by preying on lake trout, whitefish, and burbot. This contributed to a shift in the fish community from one that had been dominated by large benthics to one dominated by small pelagics (fish found in the upper layers of the lake profile). This shift from bottom-dwelling fish (benthic) to surface-dwelling fish (pelagic) has now been partially reversed by yet another accidental introduction of an exotic: the zebra mussel. As the zebra mussel is a highly efficient filter of both phtyoplankton and zooplankton, its presence has reduced the available food in the surface waters for pelagic fish. However, while the benthic fish community has gained back its dominance, the preferred benthic fish species have not yet recovered owing to the degree of initial degradation. Overall, the increasing dominance by exotics not only altered the ecology, but also reduced significantly the commercial value of the fisheries.

Global Change. Rapid climate change (or climate warming) is an emerging potential global stress on all of the earth’s ecosystems. In evolutionary time, there have of course been large fluctuations in climate. However, for the most part these fluctuations have occurred gradually over long periods of time. Rapid climate change is an entirely different matter. By altering both averages and extremes in precipitation, temperature, and storm events, and by destabilizing the El Niño Southern Oscillation (ENSO), which controls weather patterns over much of the southern Pacific region, many ecosystem processes can become significantly altered. Excessive periods of drought or unusually heavy rains and flooding will exceed the tolerance for many species, thus changing the biotic composition. Flooding and unusually high winds contribute to soil erosion, and at the same time add to nutrient load in rivers and coastal waters.

These anthropogenic stresses have compromised ecosystem function in most regions of the world, resulting in ecosystem distress syndrome (EDS). EDS is characterized by a group of signs, including abnormalities in nutrient cycling, productivity, species diversity and richness, biotic structure, disease prevalence, soil fertility, and so on. The consequences of these changes for human health are not inconsiderable. Impoverished biotic communities are natural harbors for pathogens that affect humans and other species.

ECOSYSTEM HEALTH AND HUMAN HEALTH

An important aspect of ecosystem degradation is the associated increased risk to human health. Traditionally, the concern has been with contaminants, particularly industrial chemicals that can have adverse impacts on human development, neurological functions, reproductive functions, and that appear to be causative agents in a variety of carcinomas. In addition to these serious environmental concerns (where the remedies are often technological, including engineering solutions to reduce the release of contaminants), there are a large number of other risks to human health stemming from ecological imbalance.

Ecosystem distress syndrome results in the loss of valued ecosystem services, including flood control, water quality, air quality, fish and wildlife diversity, and recreation. One of the major signs of EDS is increased disease incidence, both in humans and other species. Human population health should thus be viewed within an ecological context as an expression of the integrity and health of the life-supporting capacity of the environment.

Ecological imbalances triggered by global climate change and other causes are responsible for increased human health risks.

Climate Change and Vector-Borne Diseases. The global infectious disease burden is on the order of several hundred million cases per year. Many vector-borne diseases are climate sensitive. Malaria, dengue fever, hantavirus pulmonary syndrome, and various forms of viral encephalitis are all in this category. All these diseases are the result of arthropod-borne viruses (arboviruses) which are transmitted to humans as a result of bites from blood-sucking arthropods.

Global climate change—particularly as it impacts both temperatures and precipitation—is highly correlated with the prevalence of vector-borne diseases. For example, viruses carried by mosquitoes, ticks, and other blood-sucking arthropods generally have increased transmission rates with rising temperatures. St. Louis encephalitis (SLE) serves as an example. The mosquito Culex tarsalis carries this virus. The percentage of bites that results in transmission of SLE is dependent on temperature, with greater transmission at higher temperatures.

The temperature dependence of vector-borne diseases is also well illustrated with malaria. Malaria is endemic throughout the tropics, with a high prevalence in Africa, the Indian subcontinent, Southeast Asia, and parts of South and Central America and Mexico. Approximately 2.4 billion people live in areas of risk, with some 350 million new infections occurring annually, resulting in approximately 2 million deaths, predominantly in young children. Untreated malaria can become a life-long affliction—general symptoms include fever, headache, and malaise.

The climate sensitivity of malaria arises owing to the nature of the interactions of parasites, vectors, and hosts, all of which impact the ultimate transmission rates to humans. The gestation time required for the parasite to become fully developed within the mosquito host (a process termed sporogony) is from eight to thirty-five days. When temperatures are in the range of 20°C to 27°C, the gestation time is reduced. Rainfall and humidity also have an influence. Both drought and heavy rains tend to reduce the population of mosquitoes that serve as vectors for malaria. In drier regions of the tropics, low rainfall and humidity restricts the survival of mosquitoes. Severe flooding can result in scouring of rivers and destruction of the breeding habitats for the mosquito vector, while intermediate rainfall enhances vector production.

Ecological Imbalances. Cholera is a serious and potentially fatal disease that is caused by the bacterium Vibrio cholerae. While not nearly so prevalent as malaria, cases are nonetheless numerous. In 1993, there were 296,206 new cases of cholera reported in South America; 9,280 cases were reported in Mexico; 62,964 cases in Africa; and 64,599 cases in Asia. Most outbreaks in Asia, Africa, and South America have originated in coastal areas. Symptoms of cholera include explosive watery diarrhea, vomiting, and abdominal pain. The most recent pandemic of cholera involved more regions than at any previous time in the twentieth century. The disease remains endemic in India, Bangladesh, and Africa. Vibrio cholerae has also been found in the United States—in the Gulf Coast region of Texas, Louisiana, and Florida; the Chesapeake Bay area; and the California coast.

The increase in prevalence of V. cholerae has been strongly linked to degraded coastal marine environments. Nutrient-enriched warmer coastal waters, resulting from a combination of climate change and the use of fertilizers, provides an ideal environment for reproduction and dissemination of V. cholerae. Recent outbreaks of cholera in Bangladesh, for example, are closely correlated with higher sea surface temperatures. V. cholerae attach to the surface of both freshwater and marine copepods (crustaceans), as well as to roots and exposed surfaces of macrophytes (aquatic plants) such as the water hyacinth, the most abundant aquatic plant in Bangladesh. Nutrient enrichment and warmer temperatures give rise to algae blooms and an abundance of macrophytes. The algae blooms provide abundant food for copepods, and the increasing copepod and macrophyte populations provide V. cholerae with habitat. Subsequent dispersal of V. cholerae into estuaries and fresh water bodies allows contact with humans who use these waters for drinking and bathing. Global distribution of marine pathogens such as V. cholerae is further facilitated by ballast water discharged from vessels. Ballast water contains a virtual cocktail of pathogens, including V. cholerae.

Two other examples of how ecological imbalances lead to human health burdens concern the increased prevalence of Lyme disease and hantavirus pulmonary disease. Lyme disease, sonamed because it was first positively identified in Lyme, Connecticut, is a crippling arthritic-type disease that is transmitted by spirochete-infected Ixodes ticks (deer ticks). Ticks acquire the infection from rodents, and spend part of their life cycle on deer. Three factors have combined to increase the risk to humans of contracting Lyme disease, particularly in North America: (1) the elimination of natural deer predators, particularly wolves; (2) reforestation of abandoned farmland has created more favorable habitat for deer; and (3) the creation of suburban estates, which the deer find ideal habitat for browsing. The net result is a rising deer population, which increases the chances of humans coming into more contact with ticks.

By 1995, in the southwestern United States, hantavirus infection was confirmed in ninety-four persons in twenty states, with 48 percent mortality. Variants of the strain that causes hantavirus pulmonary syndrome have also been found in other areas of the country, as well as in Asia and Europe. The virus is apparently asymptomatic in rodents, and it is transmitted in their saliva and excreta. In humans it has a flu-like presentation, which is followed by acute respiratory distress syndrome. The primary reservoir in the Four Corners area of the southwestern United States is the deer mouse. Climatic disturbances, which in recent years are thought to be exacerbated by human activity (e.g., global warming), appear to set up conditions that trigger outbreaks. In the early 1990s, ENSO events initially caused drought conditions to develop in the southwestern United States. This led to a decline in plant and animal populations, including natural predators of the deer mouse. Heavy rains followed the drought in 1993, resulting in a bumper crop of piñon nuts, a major food supply for the deer mouse. Subsequently the deer mouse population greatly increased, bringing about increased contact with humans and triggering the outbreak of hantavirus.

Antibiotic Resistance and Agricultural Practice Antibiotic resistance is a growing threat to public health. Antibiotic resistant strains of Streptococcus pneumoniae, a common bacterial pathogen in humans and a leading cause of many infections, including chronic bronchitis, pneumonia, and meningitis, have greatly increased in prevalence since the mid-1970s. In some regions of the world, up to 70 percent of bacterial isolates taken from patients proved resistant to penicillin and other b-lactam antibiotics. The use of large quantities of antibiotics in agriculture and aquaculture appears to have been a key factor in the development of antibiotic resistance by pathogens in farm animals that subsequently may also infect humans. One of the most serious risks to human health from such practices is vancomycin-resistant enterococci. The use of avoparcin, an animal growth promoter, appears to have compromised the utility of vancomycin, the last antibiotic effective against multi-drug-resistant bacteria. In areas where avoparcin has been used, such as on farms in Denmark and Germany, vancomycin-resistant bacteria have been detected in meat sold in supermarkets. Avoparcin was subsequently banned by the European Union. Another example is the use of ofloxacin to protect chickens from infection and thereby enhance their growth. This drug is closely related to ciprofloxacin, one of the most widely used antibiotics in the year 2000. There have been cases of resistance to ciprofloxacin directly related to its veterinary use. In the United Kingdom, ciprofloxacin resistance developed in strains of campylobacter, a common cause of diarrhea. Multi-drug-resistant strains of salmonella have been traced to European egg production.

Food and Water Security. Agricultural practices are also responsible for a growing number of threats to public health. Some of these are related to inadequate waste management, which has resulted in parasites and bacteria entering water supplies. Others are of entirely different origins and involve apparent transfer across species of pathogens that affect both animals and humans. The most recent and spectacular example is mad cow disease, known as variant Creutzfeldt-Jakob disease in humans, a neuro-degenerative condition that, in humans, is ultimately fatal. The first case of Bovine Spongiform Encephalopathy (BSE), the animal form of the disease, was identified in Southern England in November 1981. By the fall of 2000, an outbreak had also occurred in France, and isolated cases appeared in Germany, Switzerland, and Spain. More than one hundred deaths in Europe were attributed to what has come to be commonly called mad cow disease.

Improper manure management was the likely source of the outbreak of E. coli 0157:H7 in Walkerton, Ontario, Canada. Other health risks associated with malfunctioning agroecosystems include periodic outbreaks of cryptosporidiosis, a parasitic disease that is spread by surface runoff contaminated by feces of infected cattle. This parasite causes fever and diarrhea in immunocompetent individuals and severe diarrhea and even death in immunocompromised individuals.

ECOSYSTEM RESTORATION

Ecosystem pathology in some cases can be reversed simply by removing the source of stress. In cases, for example, where ecosystem degradation is the result of point-source additions of nutrients or toxic chemicals, removal of these stresses may result in considerable recovery of ecosystem health. A classic case is Lake Washington (near Seattle, Washington). This lake had become highly anoxic (oxygen-depleted) owing to a sewage outfall entering the lake. Redirecting the sewage outfall away from the lake reversed many of the signs of pathology.

In cases where it is not feasible to remove the source of stress, more innovative engineering solutions have been tried. For example, in the Kyrönjoki and Lestijoki Rivers in western Finland, spring and fall runoff leads to sharp pulses of acidity. Spring runoff from snowmelt, which releases acid from tilled or dug soils, has been particularly damaging to fish, during the critical time of year for spawning. Fish reproduction is severely curtailed, if not all together eliminated in highly acidic water. Further there have been massive fish kills resulting from the highly acidic waters. One possible remedy is to replace the original drains which take runoff from the land to the rivers with new limed drains that can neutralize the acidity. This solution has been implemented on an experimental basis and appears to substantially reduce acidic runoff.

More radical treatments for damaged ecosystems involve “ecosystem surgery.” In some cases, invading exotic vegetation (such as mangroves in Hawaii) have been removed from regions, and native vegetation has been replanted. In areas of North America where wetlands have been severely depleted owing to farming, urbanization, and industrial activity, efforts have been made to establish new wetlands.

More often than not, however, reversing ecosystem pathology is not possible. Efforts to restore the indigenous grasslands in the Jornada Experimental Range in the southwestern United States provide an example. Overgrazing by cattle has severely degraded the landscape and has lead to replacement of the native grasses by largely inedible shrubs, dominated by mesquite. Erosion by wind and episodic heavy rains have left areas between shrubs largely bare, and subsequently underlying sands have developed in dune-like fashion over a large part of the area. The resulting mesquite dunes have proven highly resistant to efforts to restore the native grasslands, although almost every intervention has been tried, including highly toxic defoliants (Agent Orange), fire, and bulldozing.

Even where it has been possible to restore some of the ecological functions of degraded ecosystems, and thus improve ecosystem health, the restoration seldom results in reestablishment of the pristine biotic community. The best that can be achieved in most cases is reestablishment of the key ecological functions that provide the required ecosystem services, such as the regulation of water, primary and secondary productivity, nutrient cycling, and pollination. In all such efforts, key indicators of ecosystem health (vigor, productivity, and resilience) are essential to monitor progress. Standard ecological indicators can be used for this purpose (e.g., measures of productivity, species composition, nutrient flows, soil fertility) along with socioeconomic and human health indicators.

Experience in efforts to restore highly damaged ecosystems suggests that ecosystem-health prevention is far more effective than restoration. For marine ecosystems, setting aside protective zones that afford a sanctuary for fish and wildlife has considerable promise. Many countries are adopting policies to establish such areas with the prospect that these healthy regions can serve as a reservoir for biota that have become depleted in the unprotected areas. Yet this remedy is not without its limits. Restoring ecosystem health is not simply a matter of replenishing lost or damaged biota. It is also a matter of reestablishing the complex interactions among ecosystem lifeforms. Having a ready source of healthy biota that could potentially recolonize damaged ecosystems is important, but it is only part of the solution.

PREVENTION OF ECOSYSTEM DISRUPTIONS

Given the difficulties in reversing ecosystem degradation, and the many associated human health risks that arise with the loss of ecosystem health, the most effective approach is simply the prevention of ecosystem disruption. However, like many common-sense approaches, this is easier said than done. In both developed and developing countries there is a strong inclination to continue economic growth, even at the cost of severe environmental damage. Apart from selfish motivations, the argument is made that economic growth has many obvious health benefits, such as providing more efficient means of distributing food supplies, providing more plentiful food, and providing better health services and funding for research to improve standards of living. These are indeed benefits of economic development, and have led to substantial increases in health status worldwide.

However, at the dawn of the twenty-first century, the past is not necessarily the best guide to the future. The human population is at an all-time high, and associated pressures of human activity have led to increasing degradation of the earth’s ecosystems. As ultimately healthy ecosystems are essential for life of all biota, including humans, current global and regional trends are ominous. Under these circumstances, a tradeoff between immediate material gains and long-term sustainability of humans on the planet may be the only option. If so, the solution to sustaining human health and ecosystem health becomes one of devising a new politic that places sustaining life support systems as a precondition for betterment of the human condition.

BIBLIOGRAPHY

Aldhous, P. (2000). “Inquiry Blames Missed Warnings for Scale of Britain’s BSE Crisis.” Nature 408:3–5.

Baquero, R., and Blazquez, J. (1997). “Evolution of Antibiotic Resistance.” Trends in Ecology and Evolution 12:482–487.

Bright, C. (1998). Life Out of Bounds: Bioinvasion in a Borderless World. New York: W. W. Norton.

Colwell, R. R. (1996). “Global Climate and Infectious Disease: The Cholera Paradigm.” Science 274:2025–2031.

Colwell, R. R., and Patz, J. A. (1998). Climate, Infectious Disease and Health: An Interdisciplinary Perspective. Washington, DC: American Academy of Microbiology.

Epstein, P. R. (1995). “Emerging Diseases and Ecosystem Instability: New Threats to Public Health.” American Journal of Public Health 85(2):168–172.

Huq, A., and Colwell, R. R. (1996). “Vibrios in the Marine and Estuarine Environment: Tracking Vibrio Cholerae.” Ecosystem Health 2:198–214.

Mageau, M. T.; Costanza, R.; and Ulanowicz, R. E. (1995). “The Development and Initial Testing of a Quantitative Assessment of Ecosystem Health.” Ecosystem Health 1:201–213.

Rapport, D. J. (1989). “What Constitutes Ecosystem Health?” Perspectives in Biology and Medicine 33:120–132.

Rapport, D. J., and Friend, A. M. (1979). Towards a Comprehensive Framework for Environmental Statistics: A Stress-Response Approach. Ottawa: Statistics Canada.

Rapport, D. J., and Regier, H. A. (1980). “An Ecological Approach to Environmental Information.” Ambio 9:22–27.

—— (1995). “Disturbance and Stress Effects on Ecological Systems.” In Complex Ecology: The Part-Whole Relation in Ecosystems, ed. B. C. Patten and S. E. Jorgensen. Englewood Cliffs, NJ: Prentice Hall.

Rapport, D. J.; Costanza, R.; and McMichael, A. J. (1998). “Assessing Ecosystem Health: Challenges at the Interface of Social, Natural, and Health Sciences.” Trends in Ecology and Evolution 13(10):397–401.

Rapport, D. J.; Christensen, N.; Karr, J. R.; and Patil, G. P. (1998). “The Centrality of Ecosystem Health in Achieving Sustainability in the Twenty-First Century: Concepts and Approaches to Environmental Management.” In Human Survivability in the Twenty-First Century, ed. D. M. Hayne. Toronto: University of Toronto Press.

Rapport, D. J.; Costanza, R.; Epstein, P. R.; Gaudet, R.; and Levins, R., eds. (1998). Ecosystem Health. Malden, MA: Blackwell Science.

Rapport, D. J., and Whitford, W. (1999). “How Ecosystems Respond to Stress: Common Properties of Arid and Aquatic Systems.” Bio Science 49(3):193–203.

Rapport, D. J.; Regier, H. A.; and Hutchinson, T. C. (1985). “Ecosystem Behavior under Stress.” American Naturalist 125:617–640.

Reeves, W. C.; Hardy, J. L.; Reisen, W. K.; and Milby, M. M. (1994). “The Potential Effect of Global Warming on Mosquito-Borne Arboviruses.” Journal of Medical Entomology 31(3):323–332.

Ruiz, G. M.; Rawlings, T. K.; Dobbs, F. C.; Drake, L. A.; Mullady, T.; Huq, A.; and Colwell, R. R.. (2000). “Global Spread of Microorganisms by Ships.” Nature 408:49–50.

Watson R. T.; Zinyowera, M. C.; and Moss, R. H., eds. (1996). Second Assessment Report of the Intergovernmental Panel on Climate Change. Cambridge, UK: Cambridge University Press.