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Health Promotion International, Vol. 24 No. 1doi:10.1093/heapro/danO44

D he Author (2009). Published by Oxford University Press. All rights reseFor Permissions, please email: journals.permissions@oxfordjournals

Water, ecology and health: ecosystems as settingsfor promoting health and sustainabilityMARGOT W. PARKES1,2* and PIERRE HORWITZ 31Departmentof Family Practice,University of British Columbia, Vancouver, BC, Canada,2College of Health Disciplines,Institutefor AboriginalHealth, Vancouver, BC, Canadaand 3Consortfo r Health and Ecology, Edith Cowan University,Joondalup,WA, Australia*Correspondingauthor.E-mail: [email protected]

SUMMARYDespite the proposed ecological and systems-based per-spectives of the settings-based approach to health pro-motion, most initiatives have tended to overlook thefundamental nature of ecosystems. This paper responds tothis oversight by proposing an explicit re-integration ofecosystems within the healthy settings approach.We makethis case by focusing on water as an integrating unit ofanalysis. Water, on which all life depends, is not only anintegral consideration for the existing healthy settings(schools, hospitals, workplaces) but also highlights theecosystem context of health and sustainability.A focus oncatchments (also know as watersheds and river basins)exemplifies the scaled and upstream/downstream nature ofecosystems and draws into sharp focus the cross-sectoraland transdisciplinarycontext of the social and environ-mental determinants of health. We position this work inrelation to the converging agendas of health promotion

and ecosystem management at the local, regionalglobal scales-and draw on evidence from internatinitiatives as diverse as the WHO Commission on SoDeterminants of Health, and the Millennium EcosysAssessment. Using water as a vehicle for understanthe systemic context for human wellbeing, healthmotion and disease prevention draws inevitable attento key challenges of scale, intersectoral governancethe complementary themes of promoting resiliencepreventing vulnerability. We conclude by highlightingimportance of building individual and instituticapacity for this kind of integration equipping ageneration of researchers, practitioners and decismakers to be conversant with the language of ecosystcapable of systemic thought and focused on settingscan promote both health and sustainability.

Key words: healthy settings; ecosystem; water; health and sustainability

INTRODUCTION

The settings approach to health promotion ischaracterized by 'ecological' and systemic per-spectives (Green et al., 1996; Poland et al., 2000;Dooris, 2006). Despite this orientation, healthysettings initiatives, such as healthy cities, schools,workplaces and hospitals, often overlook the situ-ated and contextual specifics of the ecosystem.This results in the incongruous situation ofinitiatives that are place-based and conceptually'ecological', but blind to the processes, functions

and populations of local ecosystems. This discnect is inconsistent with the socio-ecologapproach of the Ottawa Charter (WHO, 19and recognition of ecosystems as a basis framing and informing health promotion (Cet al., 1999; Butler, 2006). It is also out of swith growing awareness of the supporting, prosioning, regulating and cultural role of ecotems, and recognition that ecosystem disrupthas both direct an d indirect implicationshealth that tend to exacerbate existing heainequities--whether through exposure to phys


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Ecosystems as settings for health and sustainability 95Table 1: Applications of systems theory relevant to-but not explicit in-the healthy settings agendaField of endeavour Systems theory (and application) ReferencesEpidemiology -a social-ecological perspective; (McMichael 1999)

-an ecosocial approach to health (Krieger, 2001)Environmental health -environment as ecosystem, ecoystem services support (Corvalan et al., 2005)health and wellbeing, ecosystem impairment leads to'direct'; 'ecosystem mediated' and 'indirect, deferred,displaced' health impacts.Ecosystem approaches to -ecosystem approaches to health (Lebel. 2003)human health, and Ecohealth -ecosystem sustainability and health (Waltner-Toews, 2004)Infectious disease ecology -social ecology, coupled human-natural systems, linked (Wilcox and Colwell, 2005;social and ecological systems Parkes et al., 2005)Natural resource management, -social-ecological systems, resilience, adaptive (Berkes et al. 2003; Ostrom

ecosystem management management, governance of common pool resources 1990)Business and organizational -open systems theory, participative strategic planning. (Emery, 2000)behaviourCommunity development -soft systems methodology, process of inquiry; purposeful (Checkland, 1999)

participative action

hazards or loss of livelihoods (Corvalan et al.,2005; Marmot, 2007). The failure to embedhealthy settings within ecosystems is also amissed opportunity to enable more integratedapproaches to promoting the commonalitiesbetween health promotion and sustainable devel-opment (Dooris, 1999). Ecosystems can intui-tively be recognized where boundaries areobvious, for instance, urban ecosystems, islandecosystems or water catchments.The aims of this paper are to draw attentionto the importance of ecosystems as contexts forhealthy settings initiatives; to introduce water asa physical, literal and figurative vehicle forunderstanding the systemic context for healthand wellbeing; and to examine the potentialcontributions of catchments as a setting forachieving health promotion. We argue that suchan approach not only provides direction for thegreening of health settings, but also offers atimely platform for integrated and cross-sectoralapproaches to improving health by addressingboth its social and environmental determinants(Parkes et al., 2003).CONCEPTS: RE-INTEGRATINGSETTINGS, ECOSYSTEMS, WATERAND HEALTHSettings and ecosystemsWhile the evolution of the healthy settingsapproach is characterized by debate regardingdefinition and evaluation (Whitelaw et al., 2001),an overarching conceptual consistency has beenproposed for a settings approach-based on an

ecological model of health promotion, a systemsperspective and a focus on whole system organiz-ation development and change (Dooris, 2006).Despite this conceptual coherence, we notesome practical concerns and dilemmas abouthow the 'ecological' approach to health settingshas manifested. One of these is the relative lackof cross-reference and exchange with otherhealth, environment and development fields thathave been heavily informed by ecological andsystems-based thinking (Table 1). Arguably,each of these fields is equally guilty of imple-menting their 'systemic' approach in territorialsilos of 'health protection/promotion', 'environ-ment', 'community development' and so on .Another related concern is that core health pro-motion practices often fail to reflect systembehaviours or to incorporate the fundamentalsof ecosystems in their design and approach (seeTable 2). We see this oversight as a manifes-tation of what James Kay describes as the unsur-prising challenges of (eco)systemic thinking.'Generally these [dynamics of complex systems]are not intuitive to people. They do not conformto the Newtonian notion of linear causalitymode of reasoning that is cornerstone to...culture' (Kay and Schneider, 1995).Water, catchments and systemsJames Kay's quote raises the question of how tointegrate genuinely ecological and (eco)systemicthinking to the mainstream health sectorwithout surrendering such an endeavour to thedomain of specialists and isolationist language.We claim that a focus on water can respond to


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that distribution. The local an d regional appropri-ateness of development, particularly where itaffects natural resources, land use and climate, isbest determined by foregrounding water and itscatchment supply. This argument is best exempli-fied by new integrated catchment management(ICM) (Bellamy et al., 1999) (although it is rarelypractised as such).Third, the cultural, social, biophysical and pol-itical nature of water is universal over time an dculture. Catchments, river basins and watersources are often important sources of cultural orcommunity identity and sense of place (Horwitzet al., 2001; Parkes and Panelli, 2001)--a contem-

porary reality that reflects long-standing connec-tions between waterways an d Indigenous cultures(Townsend et al., 2004; Kaneshiro et al., 2005).The forecasts of global climate change, includingchanging seasons and distributions of rainfall(IPCC, 2007), will only intensify the politicalecology of water (Postel, 2000). In sum, 'wherewe are an d who we are' is related to wateraccess, flows and cycles in a manner thatembraces both environmental and social deter-minants of health and demands socio-ecologicalperspective. A reciprocity then holds, that'...sustainable and regenerated water catchmentsare the emergent property of social processes,and not the technical property of an ecosystem... That is, desirable water catchment propertiesarise out of interaction.., among multiple, inter-dependent, stakeholders...' [(Ison et al., 2007)p. 500]. The biophysical and social processes ofwater are intertwined in complex ways.

Together, these understandings of water arerepresented by our metaphorical use of water-related terms to express more complex phenom-ena, like the upstream (causal) determinants of(downstream) health consequences. Concepts offlows, cycles, springs, floods, droughts and so onall have meaning in other contexts. Such meta-phors are powerful in indigenous languages too,an d in proverbs, sayings and other wise utter-ances. For instance,Nothing in the world is more flexible and yieldingthan water. Yet when it attacks the firm and thestrong, none can withstand it, because they have noway to change it. So the flexible overcome theadamant, the yielding overcome the forceful.Everyone knows this, but no one can do it. (Lao Tzu,translated by Cleary [(Cleary, 1993), p. 66].This quote, attributed to the Chinese TaoistLao Tzu, helps us to see the systemic properties

Ecosystems as settings for health and sustainability 97of water and draws attention to the linksbetween general laws of ecology, systems think-ing, and the properties and behaviours of wateras presented in Table 2.

The systems thinking outlined in Table 2reminds us that nature, societies or organizationsare not best understood by relatively simple,linear, equilibrium-based models. Systemic prin-ciples implore us to think about alternatives tocontrolling a system. Similarly, predicting asystem's behaviour without attending to uncer-tainties (unforeseen or unforeseeable conse-quences) or complexities becomes part of theproblem. Perhaps most importantly, attending tosystems principles redresses a dysfunction inwestern thinking and policy-making that separ-ates people or their institutions from their sur-roundings, their context.

CONTEXT: CATCHMENTS AS SETTINGSFOR HEALTH AND SUSTAINABILITY'Locating' ourselves-and our settings for healthpromotion-in relation to water is both adescription of and a means to understand'context' and reciprocity. Here, we draw on thesocio-ecological features of water, ecosystemsand health to examine the proposal of catch-ments as context, and settings, for promotinghealth and sustainability. We propose catch-ments as a tangible context within which to fulfilthe Ottawa Charter's (WHO, 1986) call for reci-procal maintenance 'to take care of each other,our communities and our natural environment'.Table 3 summarizes this potential in relation toa series of mutually reinforcing arguments span-ning ICM, the determinants of health and healthpromotion.

More reciprocity: health promotion andecosystem managementThe increased recognition of the life--andhealth--supporting qualities of ecosystems indi-cated by the Millennium Ecosystem Assessment(Corvalan et al., 2005) is extended and supportedby a range of international initiatives. The WHOCommission on the Social Determinants ofHealth is explicit about links between ecosys-tems and social determinants of health notingthat 'addressing the intersection between socialdeterminants of environmental change an dthe effect of environmental change on health


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98 M.W. Parkes and P. HorwitzTable 3: Simple arguments for complex relationships -catchments as settings for health and sustainabilityaIntegrated catchment management Connection with determinants of health Implications for healthy settings(ICM)Calls for ecosystem-based approaches to Our understanding of environmental Catchments provide anintegrated water resources hazards (microbiological and ecosystem-based setting to

management have led to the field of chemical) is enhanced by understand and respond to1CM. understanding of ecosystems water-based environmental hazardattributes (see Table 2) . and water-related disease.ICM is recognized as an important Socioeconomic context has far-reaching Through its influence on

influence on socioeconomic context implications for social determinants of socio-economic factors, ICM can bin rural and urban settings (including health and health inequalities, viewed as a strategy to improve thlivelihoods, equity of access, poverty), social determinants of health.

ICM is a multi-stakeholder process that Multi-stakeholder processes that involve ICM provides a setting and a processinvolves social learning and social learning and collaboration are with the capacity to promote bothcollaboration within the context of a characteristic of-and consistent health and sustainability.particular (catchment) ecosystem. with-both settings approaches to

health promotion and ecosystemmanagement.

aSource: Parkes et al. (Parkes et al., 2008). Catchments are also referred to as river basins (especially in Europe) orwatersheds (especially in North America).

inequities will benefit sustainable ecological andpopulation health alike' [(Marmot, 2007)p. 1156]. Likewise, the Millennium DevelopmentGoal to 'Ensure environmental sustainability'(MDG7) has implications for most otherMDG's-not least the provision of ecosystemservices required to 'Eradicate extreme povertyand hunger (MDG1)' (United NationsDevelopment Programme, 2008). There is also ashift from global-scale concerns such as climatechange (Confalonieri et al., 2007) to the specificimplications of place-based ecosystem manage-ment and conservation policies for health andwellbeing (including poverty reduction). Forinstance, the intergovernmental RamsarConvention on Wetlands has resolved to under-take an extensive review of the interactionsbetween wetlands and human health, andadopted the theme 'Healthy Wetlands, HealthyPeople' for its Conference of parties in 2008.Another example is the increasing attention topublic health implications of water resourcesmanagement (Parkes et al., 2008).

These international developments represent aconverging, cross-sectoral recognition the needfor integration of (eco)system approaches andecological context into strategies to improvehealth and wellbeing. They add weight to thecalls for 'health in all policies' (Kickbusch et al.,2008) and recognition that climate change andfood-security are health promotion concerns aswell as economic and environmental issues(Catford, 2008). An important consequence of

this convergence is a demand for reciprocexchange between different modes of thinkinand a flow of new ideas into areas where suthinking ha s been non-traditional--includingrowing awareness of the cross-cutting reevance of (eco)systemic approaches and thining (see Table 1). We see this as a direreflection of complex systems, and discuss theimplications briefly here in relation to the thrchallenges of scale, intersectoral governancand the complementary themes of promotinresilience and preventing vulnerability.Scale issues: from local settings to globalconcernsConsidering catchments as settings for health prmotion, draws attention to issues of scale ahierarchical nestedness (see Table 2). In particlar, the catchment scale demands recognition ofmiddle (meso) ground that is smaller than a focon global context for health promotion (Le2007), but larger and more complex than a singinstitution or jurisdiction such as healthy schoohospitals or cities. Perhaps, the closest precedein the healthy settings repertoire is the scale'Healthy Island' (Nutbeam, 1996).An informative contribution to understandincatchments as a mesoscale 'setting' is providby one of the four future scenari6s examinedthe Millennium Ecosystem Assessment. T'Adapting Mosaic' scenario is characterizedintegrated management, local adaptation an


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learning, and explicitly refers to socio-ecologicalsystems. Under this scenario, confidence in theability of humans to better manage thesesystems is balanced by humility and an activepreparation for ecological surprises; politicaland economic power devolves to regions withgreat regional variation; and 'learning whilemanaging' is widely acclaimed as an approachto good governance, management and problem-solving (Corvalan et al., 2005).Predictions for the 'Adapting Mosaic' scen-ario include (inter alia, and compared withother scenarios developed in the MillenniumEcosystem Assessment (Millennium EcosystemAssessment, 2005): greater regional pride andmore cultural and social diversity, an improve-ment in mental health (including that of min-ority populations), a reduction in alcoholism,domestic violence, depression and intravenousdrug use, better preservation of knowledge andpractices of traditional health systems (withspin-off benefits in relation to new pharmaceuti-cals). These proposed improvements appear tobe based on a heightened sense of place andsense of community -echoing proposed saluto-genic effects of healthy settings that strengthen'both sense of place and sense of self'(Kickbusch, 1996) and reflecting the health-promoting benefits of participatory, empower-ing, multi-stakeholder processes.

At the same time, the 'Adapting Mosaic' scen-ario draws attention to the need for explicit atten-tion to cross-scale phenomena. The scenariopredicted decline in food supplies per capita(partly compensated for by a more equal distri-bution), as well as system failures in dealing with:(i) the global commons, (ii) global capacity toprovide emergency relief, (iii) an inability todevelop critical masses of expertise or economiesof scale an d (iv) a dearth of global leadership.Collectively, these mean inadequate response tolarge scale environmental problems like climatechange (Corvalan et al., 2005).Rather than dealing a definitive blow to themesoscale settings approach, these predicted fail-ures emphasize the need for proactive engage-ment with other fields already grappling with themethodological challenges- including attentionto cross-scale and intersectoral dynamics-that ischaracteristic of work on social-ecologicalsystems (Gunderson and Holling, 2002). It has,for example, been noted that community-basednatural resource management programmes thatsucceeded in solving complex problems of

Ecosystems as settings for health and sustainability 99collective action in an enduring way had beenorganized in multiple layers of nested enterprises(Ostrom, 1990). These kinds of lessons offerimportant and tangible insights for health pro-motion in the twenty-first century if the vision ofa socio-ecological context for health is to berealized.GovernanceViewing 'settings' at different scales highlightsgeneric concerns that transcend sectoral, thematicor regional boundaries and reflects the fact that'... many people, individually and collectively,contribute, often inadvertently, to the suffering ofothers while improving their ow n well-being. Thiscan result from environmental changes which arelinked across scales and between geographicalregions through both biophysical an d social pro-cesses.' [(UNEP, 2007), p. 301].Whether or not it is an easy or convenient fitwith our existing templates for sectoral govern-ance and action, the rate and scale of change inboth society and ecosystems means that anysettings-based approach should eventually inter-sect with the sectors and stakeholders representa-tive of the ecosystem context fo r health. Drawingon experiences of community-based conservationin watersheds in Thailand, Lebel et al. observethat 'A multi-level perspective also helps exploremore deeply the institutional possibilities inherentin a multi-layered, networked and dynamicworld.' [(Lebel et al., 2008) p. 1461.

The linkage between human health and waterin catchment settings exposes human health aspart of a 'resource dilemma' (sensu Ison et al.,2007), applicable when the externalities ofrational choices of one set of actors spoil theiruse by another set--in other words situations ofcomplexity, uncertainty, interdependence, mul-tiple perspectives and controversy. We concurthat such situations tend to be inappropriatelycoordinated and governed by either hierarchicalcommand and control mechanisms that fail dueto loss of legitimation and information, ormarket-based mechanisms subject to marketfailure. Ison proposes a third approach to sup-plement these tw o others; drawing on 'network'mechanisms for governance--and a languagenotable for its 'echo' of equity-focused healthpromotion--with the following properties:"* using equity to resolve resource dilemmas;"* using exchange of meaning, sense making

and interdependence as dynamics;


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100 M. W. Parkesand P.Horwitz"* prioritizing learning processes communi-

cation, cooperation, negotiated agreementand reciprocity;"* intervention mechanisms characterized byprocess facilitation;"* welfare characterized by social capital, trust,community and concerted action;

"* failure characterized as inequality in powerrelations; an d"* criteria for success centre around commonmeanings, concerted action and institutionalchange (Ison et al., 2007).

Resilience, vulnerability and healthCatchments provide tangible contexts withinwhich to fulfil overlapping objectives across fieldswith a preventive and pro-active orientation.Water resources have important implications fo r arange of fields with converging interests in 'redu-cing vulnerability' and 'increasing resilience',including community development, ecosystemsmanagement, disaster preparedness, sustainabilityand public health (Woodward, et al., 1998; Ryffand Singer, 2003; Turner et al., 2003; ISDR, 2007;Berkes et al., 2003; Tobin, 1999). These fields echoa duality familiar to public health, where vulner-ability is viewed as a 'hazard' to be avoided,whereas resilience focuses on an 'asset' to beenhanced, but which is also much harder to evalu-ate. The focus on 'resilience' that is emerging incontexts as varied as agro-ecosystem health(Waltner-Toews and Wall, 1997), rural commu-nities responding to drought, hailstorms and bush-fire (Hegney et al., 2007) and disaster prepared-ness and recovery (Masten and Obradovi6, 2008)has considerable overlap with, and implicationsfor, settings-based health promotion.In the catchment context, promotion ofhealth and resilience converge towards acommon goal: to cultivate enduring capacity torespond positively to change and challenges.We acknowledge that this proposal is, in manyways, a re-integration and re-contextualizationof how indigenous and place-based cultures an dcommunities have envisioned the relationshipamong health, ecosystems and communitiesover millennia [see, for example, Panelli an dTipa (Panelli and Tipa, 2007)].LESSONS AND CONCLUSIONSA central lesson from this analysis is the import-ant overlaps and overlooked commonalities

between the aims of health promotion aecosystem management (also natural resourmanagement). At the mesoscale settingriver catchments, health promotion couleverage off the community engagemeinherent in participatory catchment initiativ(Hinchcliffe et al., 1999), and also mobilize tcapacity for proactive engagement in commnity design, land-use decision-making aimpact assessments (Bhatia, 2007; Wernha2007; Dannenberg et al., 2003). Water acatchment-based initiatives provide opportnities for both 'creating supportive enviroments' and 'strengthening community actio(WHO, 1986). Recognition is increasing of tpotential to both promote health and reduinequities through water resources manageme(Parkes et al., 2008).

The opportunities and challenges of the stemic context for health promotion are obviounot new-in terms of intersectoral, collaboratior multi-stakeholder processes (Sindall, 19WHO, 2007). Building on conceptual, methodlogical and operational strengths, we see heapromotion as making an important contributito the collective thinking and action that wcharacterize the converging terrain betwepublic health, sustainability governance and ecsystem management (Brown, 2007). Yet, t'rising tide' of interest in these issues has mtiple origins and outlets. There will thereforea need for careful navigation, especially sinissues of territoriality an d funding can becomexaggerated in proactive, preventive--and undvalued-fields such as public health and sustaability. In summary, recognizing ecosystemssettings for health promotion provides nreminders of the need for the health sector'share power with other sectors, other disciplinand most importantly with people themselv(WHO, 1986).

Beyond the specific implications for the fieof health promotion, a critical implicationour argument is the challenge of building invidual and institutional capacity- equippingnew generation of researchers, practitioners adecision-makers to be promoters of both heaand sustainability. In this context, we see catcments as not only a context for future collaboation and actions, but as real, ecosystem-bassettings for individuals and society to (re)leaand (re)integrate the fundamental relationshibetween water, ecology and the determinantshealth.


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ACKNOWLEDGEMENTSThis paper is the result of learning and exchangethat has articulated with peers and companions inmany settings. Particular recognition goes to PhilWeinstein, Ruth Panelli and the TAIERI Trust(New Zealand), Bruce Wilcox and Hiki NoAssociates (Hawaii), Ute Goeft and RobCampbell (Australia) and Karen Morrison,Martin Bunch, Henry Venema (Network forEcosystem Sustainability and Health, Canada).

FUNDINGDuring the period this paper was finalized,M.W.P. was a recipient of a Fellowship from theCanadian Institutes of Health Research'Initiative in Global Health Research'.

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