Reproduced from: sci-hub.tw/10.1097/00003727-198511000-00002
The mandala of health: a model of the human ecosystem
FCH, 1985, 8(3), 1-10
© 1985 Aspen Systems Corporation
IN RECENT years a major transformation in the understanding of health and disease has taken place. The emphasis has shifted from a simplistic, reductionist cause-and-effect view of the medical model to a complex, holistic, interactive, hierarchic systems view known as an ecologic model. That shift may be so profound as to constitute a paradigm shift or a change in the collective mind set and world view regarding what the rules are and what is possible.1
An ecologic model of human health is consistent with the broad field of human ecology, which is “the study of the interactions of man and human society with the environment. It is concerned with the philosophy and quality of life in relation to the development of biological and geological resources, of urban and rural settlements, of industry and technology and of education and culture.”2(p1)
To paraphrase Pierre Dansereau,3 human ecology is the study of the issues that lie at the intersection of environment and culture. Public health lies within the broad field of human ecology.4 A public health model of the human ecosystem, such as the one that follows, helps greatly to clarify the interaction of culture with environment within the context of the holistic, interactive, and hierarchic nature of health.
THE MANDALA OF PUBLIC HEALTH
The mandala of public health (Fig 1) was developed by the Department of Public Health, City of Toronto, to conceptualize and explain public health at a time when the Department was undergoing reorganization and revising its role and priorities.5-7 The tool is useful in teaching health science students and the general public, as well as in raising a number of contemporary public health issues.
In the mandala, a circular symbol of the universe, the individual – comprising body, mind, and spirit – is seen as the center or focus but is seldom viewed in isolation. Rather, he or she exists within a family that plays a vital role in establishing health values, attitudes, and habits and continuously influences the health of its members. In buffering people and sheltering them from the effects of the community and the culture, the family acts as perhaps the most important mediating structure between persons and social institutions.8
Fig. 1. A model of the mandala of health. Source: Department of Public Health, City of Toronto.
Four factors affect the health of individuals and of the family. These factors are based on the health-field concept originally described in the Lalonde report.9 These factors as modified for the purposes of the mandala of health are
- human biology: the genetic traits and predispositions; the competence of the immune system; and the biochemical, physiologic, and anatomic state of the person and the family;
- personal behavior: dietary habits, including smoking and drinking; driving habits, including use of seatbelts; general risk-taking and preventive behaviors;
- psychosocial environment: socioeconomic status, peer pressure, exposure to advertising, social support systems, and related factors; and
- physical environment: adequacy of housing and the physical state of the work place and the immediate environment.
The model emphasizes that life style is not the same as personal behavior but rather is personal behavior as influenced, modified, and constrained by a lifelong socialization process, as well as by the psychosocial environment, including family, community, cultural values, and standards. One’s life style, then, is chosen from a fairly narrow range of options.
The medical care system exists within a community of which it is a part and to which it is accountable; this system is concerned almost exclusively with human biology and personal behavior. Hence, medical care tends to be a less important determinant of health than many of the other elements in the model.
Work (or its absence) is an important determinant of health. Both physical and mental health are influenced by the physical state of the work site and the psychosocial aspects of work, including the work role, social relations, and the quality of work life.
Each community has its own values, standards, support systems, and networks and is therefore a major influence on health. Additionally, the community and human-made environment exist within a broader frame of reference that includes the biosphere and a Western, democratic, technologic, science-based, Judea-Christian culture. Cultural values, attitudes, and beliefs influence health, how people perceive health, and how they react to illness; however, the biosphere, of which the person is but one small and interdependent part, is the ultimate determinant of health.
KEY ISSUES ILLUSTRATED BY THE MANDALA
The mandala can be viewed as a model of the human health ecosystem. Such a view of health is compatible with a systems hierarchy of health10 and is a holistic model of health. Holistic models of health such as the mandala differ from holistic medicine. The latter refers to an expanded medical model that recognizes that health involves body, mind, and spirit; this model often fails to recognize the influence of family, community, society, and the planet. Holistic medicine often assumes an individualistic and even victim-blaming approach, thereby failing to recognize the need for social and political action to deal with problems in the physical and social environments.11 Holistic medicine, while clearly an improvement over traditional allopathic medicine, simply does not go far enough. In contrast, the mandala implies that the health of individuals is intimately bound up with their physical and social environments and that actions within the community and a broader culture are important determinants of health.
The model also integrates the natural sciences with the social sciences. Health, then, is dependent on the judicious application of human knowledge in a complete range of social and natural sciences. By so uniting the sciences, the model conforms to the notion that there are two fundamental principles of public health: (1) ecological sanity and (2) social justice.12 The former states that human health is dependent on a healthy, stable, and safe ecosystem, and activities that impair the health of the ecosystem are viewed as ecologically insane and a threat to human health. The latter principle states that health depends on a just and equitable distribution of wealth and thus of health. It purports that health care must be distributed on the basis of social justice rather than market justice and that the disadvantaged must be protected from those who seek to exploit them at the cost of their health.
This model, then, is dynamic and interactive. It is dynamic in that the effects within the model act in two directions: (1) the health of individuals is influenced by any or all factors in the model and (2) each factor can be influenced by the person acting alone or in concert with other people. Interactive means that the various components of the model act on and interact with each other. They either reinforce or cancel out one another.
THE MANDALA AND HIGH-RISK POPULATIONS
This model of health has several important implications for those who work with high-risk populations. First, being at high risk can result from one or more of a variety of different factors. Frequently these factors (such as cigarette smoking) interact. While smoking is a personal behavior, it is influenced by whether family members smoke, by peer pressure, and by advertising. Some groups are at high risk for adopting this habit by virtue of their sex. Women have, for the past two decades, been targeted for advertising by the tobacco industry. Additionally, smoking is more acceptable in some communities and socioeconomic groups than in others. The medical care system has clearly played a role in educating the general public and individual patients about the dangers of smoking, although it has comparatively little to offer to those who develop such smoking-related diseases as lung cancer or emphysema. Some populations are clearly high risk in biologic terms, including the fetuses, infants, and people with preexisting diseases or disorders (eg, a-1-antitrypsin deficiency) that are exacerbated by tobacco smoke. For these persons, their work place may place them at undue risk because of secondhand smoke.
Finally, some societies are at greater risk than others because their cultural, political, or economic institutions do not protect them from hazards. This is particularly true of many developing nations to which the tobacco companies are now turning their attention. On the other hand, citizens of countries such as Norway, Sweden and Finland are at less risk because of the strong antismoking policies that have been adopted at the national level. The issues raised here are not unique to smoking but are true of many of the major health issues of our day. The determinants of health are complex, interactive, and hierarchic.
The second important implication of the ecosystem model of health is that health problems cannot be solved through simplistic approaches that ignore the complex reality of the human ecosystem. This is particularly true of the individualistic “life style” approach to health problems that purports that all one has to do is teach people to behave sensibly and then all will be well. Such victim-blaming approaches have not worked in the past and will not work in the future. Furthermore, blaming the victim ignores the determinants of healthy (or unhealthy) behavior and thus excuses the community, society, and environment within which the individual lives. Any attempts to help those at high risk must be multifaceted and must take into account the full range of determinants of health at the personal, community, and societal level.
This leads to a third implication: the human ecology approach to health problems, to the identification of those at high risk, and to the means of helping those at high risk, inevitably must confront the social and political nature of health at the personal, community, and societal level. This should not come as a surprise. Even in viewing the science of ecology itself (in the usual biologic sense of the word), Sears13 saw it as a potentially subversive science and wondered whether “if taken seriously as an instrument of the long-run welfare of mankind would it endanger the assumptions and practices accepted by modern societies, whatever their doctrinal commitments.”13(p11)
If that can be said of the science of ecology as a whole, how much more must it be true of human ecology (and thus public health), which deals with the cultural, social, political, and economic aspects of man’s social ecosystem. In such circumstances, as Bookchin14 has noted, “Ecology is intrinsically a critical science – in fact critical on a scale that most radical systems of political economy failed to attain.”14(p6)
Thus it is important to identify and examine the many political issues involved at the various levels of the human ecosystem hierarchy identified in the mandala – personal and family, community, and society/ culture – if effective action with and on behalf of high-risk populations is to be undertaken.
HIGH-RISK POPULATIONS AND THE POLITICS OF HEALTH
The politics of health as they affect the individual, the mediating structures of family and community, and the wider society or culture merit attention here. In all these areas (which, it should be noted, are the major levels of the mandala), issues of power, relationships, differing values, and their impact on resource allocations abound, as do issues dealing with the structure and functioning of communities and society as a whole.
Health politics of the individual
The individual is at the center of the ecosystem model of health. What are the circumstances that put an individual at high risk? Since human biology is an important determinant, our task is to identify those at high risk through genetic, prenatal, and other forms of screening and counseling. But beyond the merely biologic is the individual’s ability to handle life events in a healthy way. As Antonovsky15 noted, the real miracle is why and how anyone at all is healthy, given the myriad threats to good health. He concluded that health is to a great extent dependent on a good sense of coherence – a sense that life is comprehensible (makes sense and has some order and organization), manageable (predictable and controllable by oneself or others that one trusts), and meaningful.16
The question then becomes how one creates a sense of coherence for people, or helps them to attain a sense of coherence. The answers must include imbuing people with a sense of personal self-worth, a sense of being needed or loved, an ability to influence and control their own environment, and an ability to manage their own problems. The importance of a positive self-concept for physical and mental health cannot be understated, and it is necessary to devise ways of maximizing the coping skills and the sense of self-worth that is given to children by their parents, their immediate associates, and the school system. This concept of self-worth must be reinforced by school, work and social situations, and support systems that ensure that people have some meaningful control over the circumstances of their lives. Mindless schooling, meaningless work, and disempowered communities are antithetical to good health.17
One of the crucial areas of concern with respect to an individual’s coping ability and sense of self-worth is the nature of his or her interaction with the “helping system,” which includes health care professionals. Often, an individual’s innate ability (and need) to cope is destroyed by a domineering and “passivating” system and by individual “helpers” who take over and run the client’s life. The impacts of such a system are not limited simply to the individual (clinical iatrogenesis) but have widespread impact on social processes and indeed the entire culture (social and cultural iatrogenesis).18
One approach that can be taken by public health care professionals is to see themselves as “guides” rather than doers, helpers, or even teachers. A guide is someone who knows an area, or a part of the journey, well. (We hire them when we need them and let them go when we have finished that part of the journey or when we have learned our own way.) The concept of guided self-management is a powerful one and is important in helping to free the individual from the shackles of the health care system (Malcolm Weinstein, Director of Health Planning, Vancouver Health Department, 1982).
Thus, at the level of the individual, it is necessary to ensure that families, schools, work places, and communities strengthen and empower the individual, constantly adding to and reinforcing each individual’s sense of self-worth and ability to influence his or her own life.
Health politics of the community
In addition to the many community issues mentioned above, there is a host of other community issues that affect health. These include air and water quality, adequacy of food and housing, income levels, the safety of the work place and the quality of working life, the educational system, the community support network, and the adequacy and quality of health and social services. However, in terms of a community and its functioning, perhaps the most important determinant of health is the extent to which the community is organized. A well-organized and empowered community can cope with any of the above issues and many others that have an impact on health, whereas a disorganized and disempowered community cannot, or at least not nearly as effectively.
To a great extent, the ability of a community to organize effectively is dependent on the strength of the mediating structures.8 These are the structures that intervene between the individual and the institutions of the larger society. They include family, churches, voluntary associations, and neighborhood community groups. According to McKnight,19 the relationship between institutional strength and community strength is inverse. Strong institutions result in weak associational life, and, therefore, strong associational life and empowered communities require that institutions deliberately give power back to the mediating structures. In health terms, McKnight and his colleagues have developed a health action model, the goal of which is to strengthen communities through actions around health issues. The goal is not to improve the health of the community per se; that is considered to be an inevitable consequence of strengthening the community. The health action model involves identifying health problems in the community that have their root causes in social and environmental factors and are amenable to community action to modify or remove the health-threatening factor. By identifying these factors and exploring with the community ways in which the community can deal with these factors, the community is empowered, and at the same time some action is undertaken with respect to the adverse factors.19-20 Those who live within disempowered communities are at high risk, and their sense of personal and community coherence can be expected to be low.
Another important aspect of the politics of health at the community level as it relates to high-risk groups is the politics of work. Work is a vitally important part of the lives of many if not all of us. The politics of work have to do with three major issues: (1) the availability of work, (2) the hazards of the work place, and (3) the quality and meaningfulness of the work life.
Unemployment is perhaps one of the most devastating things that can happen to an individual in our society. It takes a severe toll on the individual’s and the family’s physical and mental health. Clearly, unemployed persons and their families are at high risk, as are communities where unemployment is high or chronic. The availability of work within the community is thus an important health issue, both at the community level and at the societal level.21
The organization and nature of work and the presence in the work environment of health-threatening situations has long been the source of political friction. Occupation-related illness and injury are far more widespread than is usually recognized, and more days are lost to sickness and injury each year than are lost because of strikes. The provision of safe and healthy working places is an important and intensely political issue at both the community and the societal level. The right of workers to safe and healthy working conditions is increasingly recognized. Nonetheless, there is still much that needs to be done. Those particularly at risk include workers in small and unorganized working places, farm workers, migrant workers, and those in the mining, forestry, and construction industries.
The third aspect of the politics of work has to do with the meaningfulness of work and the quality of working life. One important study22 has suggested that work satisfaction (maintaining a useful and satisfying role in society) is the best overall predictor of longevity, especially in older males. The issues of work satisfaction, quality of work life, the meaningfulness of work, and other related issues have received little attention to date; they surely deserve more attention in the future. They raise important points related to the nature of power in the work place, the democratization of work, the sharing of profits, and other political issues. Emery23 has suggested that one of the most “toxic” aspects of work is the shame to which workers are often subjected by being treated as mindless, child-like automatons with no useful ideas and with little or no control over their own work. Clearly, those working in such conditions are also at high risk for developing health problems, perhaps as a result of the low sense of coherence that their jobs engender.
The health politics of society
As the mandala of health indicates, the medical care system is only a comparatively small component in the totality of issues affecting health. The Lalonde9 report, and much preceding and subsequent work, has stressed that environment and life style are the major determinants of health. Nonetheless, it is impossible to ignore the fact that for much of the public, for most of the politicians, and for most health care professionals, it is the medical care system and the economics of that system that occupy most if not all of their attention. In a sense, everyone is at high risk if society continues to misallocate scarce resources to ever more expensive and less humanistic means of adding a few weeks or months to life, instead of to effective health promotion and disease prevention measures intended to add both years to life, health to life, and life to years.
Many of the factors that will lead to improved health do not even fall within traditional health policy fields.24-25 For example, two of the more effective methods of reducing motor vehicle accident mortality have been the imposition of the 55 mph speed limit (an energy policy) and the introduction of seatbelt legislation (a transport policy). Consumption of health damaging products such as alcohol and tobacco can be reduced by increasing the price (a fiscal policy) or by altering the subsidies, incentives, and other policy measures that influence the crops that are grown (an agricultural policy). Similarly, a switch from a high-meat diet to the sort of prudent diet advocated by the American Cancer Society and the American Heart Foundation would require dramatic changes in agricultural policy. Clearly, while the high-risk populations are substantial, there is little that health care professionals can do other than in the areas of advocacy and education.
One extremely important high-risk group is, of course, the poor. Inequalities in health care are particularly dramatic when viewed by income category. For example, in 1978 life expectancy among Canadian males was estimated to be roughly seven years lower for those in the lowest-income quintile compared to those in the highest-income quintile. Not only was their life expectancy lower, but their disability expectancy was greater. As a result, Canadian males in the lowest-income quintile had a disability-free life expectancy of 50 years compared to 64 years for males from the highest-income quintile.26 While the high-risk group is easy to recognize, the role of health care professionals, at least through the health care system, is limited. Clearly, most if not all of the major determinants of health identified in the mandala are acting together in this instance: low self-esteem, poor education, poor housing, disempowered communities, unemployment or bad working conditions, family and peer pressure to adopt unhealthy and risk-taking behaviors. As recent experience from the United Kingdom shows, inequalities in health are not readily remedied by providing more health care services.27 Instead, it seems that a more equitable distribution of society’s resources is called for.27
If this unequal distribution of health is true at the national level amongst developed nations, it is even more dramatically true at the global level. Here, the high-risk populations are those of the developing nations in general and in particular those who live in the rural areas or in the burgeoning slums of the world’s overpopulated cities. Improving the health of this huge high-risk population calls for herculean efforts centered around the World Health Organization’s (WHO’s) primary health care strategy, if the target of “Health for All by the Year 2000” is to be attained.28
Finally, one cannot leave the topic of global health without noting that the largest high-risk group of all is Homo sapiens. Faced by the specter of full-scale nuclear war and the subsequent nuclear winter,29 all other health hazards pale by comparison. Unless everyone acts now to stop the senseless arms race, there may be no human ecosystem, no high-risk population, no population at all.
- Kuhn T: The Structure of Scientific Revolutions. Chicago, University of Chicago Press, 1970.
- Commonwealth Human Ecology Council, London, England.
- Dansereau P: cited in Human Ecology in the Commonwealth (occasional paper No 14) London, The Commonwealth Foundation, 1972, pp 33-34.
- Kartmann L: Human ecology and public health. Am J Pub Health 1967;57(5):737- 749.
- Public Health in the 1980s. Department of Public Health, Toronto, Ontario, Canada, 1978.
- Hancock T: Public health planning in Toronto: 1. Conceptual planning. Can J Public Health, to be published.
- Baxter D: Public health planning in Toronto: 2. Program planning. Can J Public Health, to be published.
- Berger, P, Neuhaus R: To Empower People: The Role of Mediating Structures in Public Policy. Washington, DC, American Enterprise Institute, 1977.
- A New Perspective on the Health of Canadians. Ottawa, Department of Health and Welfare, Canada, 1974.
- Brody H: The systems view of man. Perspect Biol Med 1973;17(1):71-92.
- Guttmacher S: Whole in body, mind and spirit: Holistic health and the limits of medicine. Hastings Cent Rep 1979;9(2): 16-21.
- Hancock T: Ecological sanity and social justice: Public health in the Age of Osiris. Alternatives 1981;(9)4: 11-18.
- Sears P: Ecology: A subversive subject. Bioscience 1964;14(7):11-13.
- Bookchin M: Ecology and Revolutionary Thought. New York, Times Change Press, 1970.
- Antonovsky A: Health, Stress, and Coping. San Francisco, Jossey-Bass, 1979.
- Antonovsky A: The sense of coherence as a determinant of health. Advances 1984; 1(3):36-50.
- Albee G: Preventing psychopathology and promoting human potential. Am Psychol 1982;37:1043-1050.
- Illich I: Limits to Medicine (Medical Nemesis). Lon-don, Marion Soyars, 1976.
- McKnight J: Politicising health care. Social Policy 1978;9:36-39.
- Coonley R: A Model for Community-based Health Action and Primary Prevention: A Demonstration Project. Evanston, Ill, Center for Urban Affairs, Northwestern University, 1978.
- Kirsh S: Unemployment: Its Impact on Body and Soul. Toronto, Canadian Mental Health Association, 1983.
- Palmore E: The relative importance of social factors in predicting longevity, in Palmore E, Jeffers F (eds) Prediction of Life Span. Lexington, Mass, DC Heath, 1971.
- Emery F: Public policies for healthy workplaces, beyond health care: Proceedings of a conference on healthy public policy. Can J Public Health 1985;76(Supp 1):46-50.
- Hancock T: Beyond health care: Creating a healthier future. Futurist 1982; 16(4):4-13.
- Beyond health care: Proceedings of a conference on healthy public policy. Can J Public Health 1985;76(Supp 1): 1-104.
- Wilkins R, Adams 0: The Healthfulness of Life. Montreal, Institute for Research on Public Policy, 1983.
- Townsend P, Davidson N: Inequalities in Health. Markham, Ontario, Penguin Books, 1982.
- Mahler H: The meaning of “Health for All by the Year 2000.” World Health Forum 1981;2(1):5-22.
- The Effects of Nuclear War on Health and Health Services. Geneva, World Health Organization, 1984.