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ARTIGO ARTICLE 31

Social ecosystem health:


confronting the complexity and emergence
of infectious diseases

Saúde no ecossistema social:


enfrentando a complexidade e a emergência
de doenças infecciosas

Cristina de Albuquerque Possas 1

1 Vice-presidência de Abstract The emergence and re-emergence of infectious diseases and their rapid dissemination
Tecnologia, Fundação
worldwide are challenging national health systems, particularly in developing countries affected
Oswaldo Cruz. Av. Brasil
4365, Rio de Janeiro, RJ by extreme poverty and environmental degradation. The expectations that new vaccines and
21045-900, Brasil. drugs and global surveillance would help reverse these trends have been frustrated thus far by
cpossas@netra.castelo.fiocruz.br
the complexity of the epidemiological transition, despite promising prospects for the near future
in biomolecular research and genetic engineering. This impasse raises crucial issues concerning
conceptual frameworks supporting priority-setting, risk anticipation, and the transfer of science
and technology’s results to society. This article discusses these issues and the limitations of social
and economic sciences on the one hand and ecology on the other as the main theoretical refer-
ences of the health sciences in confronting the complexity of these issues on their own. The ten-
sion between these historically dissociated paradigms is discussed and a transdisciplinary ap-
proach is proposed, that of social ecosystem health, incorporating these distinct perspectives into
a comprehensive framework.
Key words Ecosystem; Infectious Diseases; World Health; Ecology

Resumo A emergência e reemergência de doenças infecciosas e sua rápida disseminação em es-


cala global estão desafiando os sistemas nacionais de saúde, em particular nos países em desen-
volvimento afetados pela pobreza extrema e pela degradação ambiental. As expectativas de que
novas vacinas e medicamentos e a vigilância global contribuiriam para impedir essas tendên-
cias têm sido até aqui frustradas pela complexidade da transição epidemiológica, em que pese
às perspectivas promissoras da biologia molecular e da engenharia genética. Esse impasse levan-
ta questões cruciais relacionadas às estruturas conceituais que embasam a definição de priori-
dades, a antecipação de riscos e a transferência dos resultados da ciência e da tecnologia para a
sociedade. Este artigo discute essas questões e as limitações das ciências sociais e econômicas, de
um lado, e da ecologia, de outro, como principais referências teóricas das ciências da saúde, para
enfrentar sozinhas a complexidade desses cenários. A tensão entre esses paradigmas historica-
mente dissociados é discutida, e uma abordagem transdisciplinar é proposta – ecossistema so-
cial e saúde –, incorporando essas distintas perspectivas em um referencial teórico abrangente.
Palavras-chave Ecossistema; Doenças Infecciosas; Saúde Mundial; Ecologia

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32 POSSAS, C. A.

Introduction Atlantic Forest, and the cerrado (savanna) are


evident. Various development projects have
In the contemporary world, infectious diseases stimulated deforestation, erosion, floods, and
are still the main causes of death, killing more population flows into these ecosystems, creat-
people than heart disease or cancer. Their inci- ing new villages in forest areas. Such changes
dence and spread have increased in the last have involved the introduction of humans into
two decades, although scientists and policy- ecological niches, amplifying the risks of expo-
makers in the 1960s believed they could be sure to pathogens formerly confined to ani-
kept “under control” by development, sanita- mals, such as yellow fever flavivirus (monkeys)
tion, new medical technologies, and advances and hantavirus (rodents).
in the pharmaceutical industry. The unexpect- Global warming, only recently an accepted
ed phenomena of emergence and re-emer- hypothesis, despite evidence of the environ-
gence of infectious diseases and drug-resistant mental impact of human intervention and pol-
diseases, whose incidence is increasing rapidly, lution, also amplifies the risks brought about
will certainly change the global epidemiologi- by these social and ecological changes result-
cal scenario in the near future. ing from deforestation. It stimulates the flow of
Various social and ecological processes, such disease vectors (mosquitoes, ticks, and others)
as extreme poverty, population movements, ur- from tropical to temperate zones. These new
banization, and deforestation, favor the emer- scenarios increasingly concern developed na-
gence and resurgence of infectious syndromes tions, which had previously played down the
and diseases and increase their epidemiologi- importance of “tropical” infectious diseases, as-
cal complexity. The intensification of interna- sumed to be restricted to the poorest countries.
tional travel and migration has also helped am- This article examines the possible epidemi-
plify these processes, accelerating the movement ological scenarios resulting from these phe-
of humans, animals, and plants and the global nomena and the limitations of the social and
proliferation of viruses, bacteria, and fungi. economic sciences and ecology to deal with
Globalization, resulting in the rapid incor- their complexity. The tension between these
poration of new technologies and amplifying historically dissociated paradigms is discussed
the impacts of urbanization, unemployment, and a transdisciplinary approach is proposed,
social exclusion, and poverty, aggravates the i.e., social ecosystem health, in order to incor-
consequences of these social and ecological porate them into a comprehensive theoretical
changes in ways never before imagined (Levins framework, supporting alternative strategies to
et al., 1986). anticipate risks and prevent the amplification
These changing conditions favor the global of risk conditions (Levins et al., 1994, 1995; Pos-
emergence and resurgence of various infectious sas & Marques, 1994; Levins & Lopez, 1999).
diseases with complex and dynamic cycles, such In this approach, anticipation of risks and
as HIV/AIDS, tuberculosis, dengue, yellow fever, interventions should be examined simultane-
malaria, leishmaniasis, leptospirosis, hantavirus ously from a social sciences perspective, as so-
pulmonary syndrome, and many others. The cial and political processes, and from an eco-
rapid spread of these diseases worldwide chal- logical perspective, as an evolutionary force in
lenges national health systems, particularly af- ecosystems. Contrary to common sense, evolu-
fecting developing countries like Brazil, a nation tion can be affected by social and health poli-
plagued by social exclusion and environmental cies, since the time scales in evolutionary
degradation and with a rapidly aging population. processes are not necessarily large or even sec-
In these developing countries, social and ular. Natural selection can be fast, as an expres-
ecological processes are often interconnect- sion of evolutionary plasticity in the evolution
ed. In the early 20th century, developing coun- among pathogens, and can be influenced by
tries harbored a large proportion of the world’s intervention (Levins, 1994; Levins et al., 1994,
preserved forest ecosystems, i.e., the tropical 1995).
forests. Nevertheless, as a consequence of vari-
ous predatory interventions, large areas of these
preserved forests have become complex urban Emergence: epidemiological complexity
ecosystems, affected by a broad range of social
and economic processes related to the indus- The notion of emergence is crucial to under-
trialization and modernization of agriculture standing biological phenomena and requires
in the agro-industries. an adequate theoretical framework. Emergence
In Brazil, the detrimental impacts of these results from possible new properties in a com-
economic activities on the Amazon Forest, the plex system which are not reducible to the sys-

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SOCIAL ECOSYSTEM HEALTH 33

tem’s simple constituent elements. Recognition Nevertheless, in order to avoid unaccept-


of emerging properties in complex systems al- able mistakes, it is important to stress at the
lows scientists to overcome the reductionism conceptual level that these definitions should
in simplistic and stereotyped approaches to not be restrictive.
the scientific method. On the one hand, concerning new or emerg-
As Prigogine & Stengers (1984) and Kauff- ing diseases, as we have noted in previous pub-
man (1993) have pointed out in discussing the lications (Levins et al., 1995), most bacteria are
phenomenon of order emerging from chaos, the not pathogenic, most arthropods are not dis-
notion of self-organization in complex systems ease vectors, and most mammals do not cause
is related to the concept of emergence. This con- disease in humans. If they emerge as a cause
cept highlights the limitations of a certain view of disease, this often results from environmen-
of science, supported by predictive capacity and tal change and human activity favoring the am-
reductionism. In the particular case of models plification of risk conditions. Practically all
called chaotic, in non-linear systems of equa- pathogens defined as “new” existed previously
tions, small changes in parameters and/or in in nature and in most cases have not changed
initial conditions can result in dramatic conse- their genetic structure. Their emergence as
quences in the final outcomes, including unpre- “new” agents has resulted from significant
dictability. In previous publications, in a model changes in social and environmental condi-
we developed to examine the Brazilian epidemi- tions favoring their access to new host popula-
ological profile (Possas, 1989, 1992; Levins et al. tions or the increase of their virulence in im-
1993), small changes in social and economic mune-compromised hosts. Pathogens previ-
conditions led to dramatic changes in the final ously confined to monkeys (yellow fever) or ro-
outcome, i.e., the population’s health profile. dents (hantavirus) moved into human popula-
The notion of complexity is thus at the core tions because human activities created the op-
of modern biology and is crucial for under- portunity for them to do so.
standing phenomena related to the emergence On the other hand, concerning re-emerging
of pathogens and diseases. However, since most diseases, it is important to note that endemic
biological processes related to emergence and diseases or pathogenic agents not defined as
re-emergence of pathogens and diseases are new, emerging, or re-emerging, which persist
triggered by environmental change and human without significant changes in their behavior,
activity, in order to approach their complexity should not be viewed as “stable” or labeled as
it is necessary to deal with complexity in other “persistent”, “unchangeable”, or “remaining”.
areas of knowledge: complex social and eco- Such a view would mean to assume a stability
nomic systems, as shown by Hodgson (G. M. of viruses, bacteria, and fungi that does not ex-
Hodson: personal communication) and White- ist in nature.
head (1993), and complex ecosystem health On the contrary, these microbes are ex-
(Rapport, 1989; Levins et al., 1994, 1995; Walt- posed to selective pressure that does not always
ner-Toews, 1996). occur in the long term. Contradicting intuitive
However, the main challenge here is how to arguments, the time scales in evolutionary
bridge the disciplinary gaps between social processes are not necessarily large or even sec-
and economic sciences and ecology in order to ular. The development of multidrug resistant
provide a better understanding of the complex bacteria in hospitals is a good example. Natur-
interactions linking human populations, social al selection can happen very rapidly, as an ex-
organizations, and the environment. pression of evolutionary plasticity in the evolu-
Emerging and re-emerging infectious dis- tion among pathogens. For this reason, diseases
eases have been defined (Lederberg et al., 1992) assumed to be endemic or “stable” are rapidly
as diseases whose pathogenic agents are un- changing their pattern of dissemination.
known or unexpected or whose incidence has Therefore, a disease now assumed to be
increased in the last two decades. Re-emergence “endemic” or “remaining” can escape control
has been defined as the resurgence of a known and become a re-emerging disease in the near
disease after a significant decline in its inci- future. A good example is yellow fever, eradi-
dence. Despite some differences in labeling cated from Brazilian urban areas since 1942
pathogenic agents, syndromes, or diseases as and confined to its sylvatic pattern of dissemi-
new, emerging, or re-emerging, there is a rea- nation in ecological niches by Haemagogus
sonable consensus among international agen- mosquitoes circulating the Flavivirus arbovirus
cies (World Health Organization – WHO –, Pan- among monkeys. Recently, penetration of hu-
American Health Organization – PAHO) and mans into these niches by deforestation, farm-
national governments in this area. ing, and ecological tours has introduced sylvat-

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34 POSSAS, C. A.

ic yellow fever patients into the main Brazilian ditions of ecological balance into account, we
urban areas, already exposed to the Aedes ae- may favor the survival and reproduction of
gypti mosquitoes transmitting dengue. There- more resistant strains and populations. When
fore, there is a significant risk of urbanization we kill mosquitoes with larvicides we can cre-
of yellow fever in Brazil – according to Silveira ate more resistant species, increasing their vec-
(1998), estimated number of cases is ten times torial capacity (Levins et al., 1993, 1994, 1995;
that of reported cases –, despite the availability Levins, 1994). We may also kill frogs feeding on
of a high quality vaccine – Brazil’s Fundação mosquito larvae and favor the proliferation of
Oswaldo Cruz (FIOCRUZ) produces 70% of the more resistant mosquitoes in new areas. When
world’s yellow fever vaccine – and lasting im- we kill one rodent species in an area without
munity, estimated at ten years. Another exam- eliminating the waste on which rodents feed, a
ple is dengue, formerly eradicated and now new species can take the place of the former
disseminated and a major public health con- and continue to transmit the disease.
cern in Brazil, since there is no vaccine avail- Therefore, social response to epidemics
able and there is a real risk of hemorrhagic and public health interventions should be un-
dengue fever epidemics. Finally, malaria has derstood not only from a social sciences per-
become resistant to several drugs and poses an spective, as social and political processes, but
important challenge in the Amazon region. as suggested by Levins (1994), from an ecologi-
Social and economic changes have aggra- cal perspective, as an evolutionary force and a
vated this epidemiological complexity and fa- component of the evolutionary process, inter-
vored the resurgence of these infectious dis- fering directly in it. When the prevalence or in-
eases. On the one hand, there has been mass cidence of a disease increases in a society, di-
migration to urban areas lacking adequate in- verse behavioral and institutional changes in
frastructure. On the other, urban populations, public health are usually triggered. Such new
especially the poor, are crowded into peripher- behaviors and intervention patterns often help
al metropolitan areas and are increasingly pen- change the conditions of contagion and accel-
etrating into previously preserved ecosystems erate diagnosis and treatment. This social re-
to eke out a living. Consequently, ecosystems sponse affects vector populations and habitats,
like the Amazon, the Atlantic Forests, and the since it expresses crucial behavioral and inter-
cerrado (savanna) are increasingly being inte- vention patterns in society that can be consid-
grated into complex urban ecosystems by so- ered, according to the author, as “co-parame-
cial and economic processes in both metropol- ters in the same sense of the reproduction rates
itan areas and nearby small urban villages. of pathogens or rates of frequency of mosquito
We have discussed in previous publications bites or the duration of immunity”.
how changes in society and in ecosystems that Political issues and equity are thus not only
lead to population mobility and environmental issues of social justice. As proposed by Levins
degradation can exert selective pressure on (1994), they interfere directly in the evolution-
pathogenic agents, increasing the plasticity of ary process, since they refer to the specific con-
known strains of bacteria and viruses, favoring ditions of social response to pathogens. Multi-
the emergence and resurgence of infectious dis- ple interactions between variables in the con-
eases worldwide. We have examined how mul- texts of variation, selection, and the impact of
tiple infections from diverse origins, recombin- selection on diverse species communities and
ing and producing new strains of pathogens, health intervention should be considered. The
also contribute to increased plasticity by creat- epidemiological complexity requires a trans-
ing conditions for recombination and produc- disciplinary approach that transcends common
tion of new strains of pathogens (Epstein et al., sense and reductionism. Therefore, in order to
1994; Levins, 1994; Levins et al. 1994, 1995). understand and confront the evolution of path-
The impact of intervention can also favor ogenic systems it is necessary to conceive a
the emergence or resurgence of infectious dis- new social ecosystem health perspective.
eases. Antibiotics can increase infection and
resistance. Extensive use of pesticides and oth-
er chemical products against vectors of infec- Ecosystem and society:
tious diseases may change patterns in the in- disciplinary boundaries
teractions between predator and prey. When
we eliminate the natural enemies, we are creat- The limitations of each respective disciplinary
ing new ecological niches for the animals we field in confronting, by itself, the complexity
intend to eliminate. When we kill vectors of and emergence of pathogens and diseases are
diseases without taking the specific local con- evident and result from the historical dissocia-

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SOCIAL ECOSYSTEM HEALTH 35

tion of different paradigms, building separate As Lakoff & Johnson (1980) pointed out in
theoretical frameworks and methodologies and their classic book, most abstract thoughts are
thus restricting future scientific and technolog- metaphorical, since they use concrete ideas to
ical development in this area. reason about less concrete ones, often uncon-
Besides this difficulty in integrating diverse sciously. Their book on cognitive science, ap-
conceptual references into a common academ- proaching linguistics and philosophy of sci-
ic structure, it should be noted that both fields ences, was the first organized exploration on
have developed their frameworks in more sta- metaphors and how they affect both our world
ble settings: the rapid changes resulting from view and our unconscious thought processes.
globalization have spawned perplexity and ad- As indicated by Habermas (1991), the split
herence to tradition, contributing to the per- between an omnipresent “system” and “life-
sistence of the gap, despite several important world” (everyday social knowledge) indicates
transdisciplinary initiatives. On the one hand, why it is so difficult for philosophers and scien-
social and economy theories tend to minimize tists to assume a broad and transcendent episte-
the environment and the biosphere, focusing mological perspective and bridge the gaps be-
on health care reforms; on the other, ecologists tween “system”, “society”, “health”, and “ecology”.
tend to misunderstand the social and econom- Morin (1983) noted this problem in his at-
ic forces driving or restraining their actions, fo- tempt to articulate man/animal and nature/
cusing on local sustainability and the ecologi- culture, not by reduction of the former to the
cal impacts of interventions. latter, but by complexifying both. But, accord-
The complexity of the phenomena resulting ing to him, this demonstration had little effect:
in emergence and re-emergence of infectious “the great disjunction (bios/anthropos) and the
diseases requires a new transdiciplinary ap- great reduction (from complex to simple) con-
proach – social ecosystem health. In a recent tinue to reign undisturbed in our universities”
publication, Levins & Lopez (1999) provide im- (Morin, 1983:385).
portant insights in this direction, emphasizing Another epistemological constraint is that
the need for an ecosocial view of health. postmodernists – and many ecologists and so-
cial scientists share this view – emphasize
postindustrial information or knowledge society
Ecosystem health and emergence: as the new societal formation, and their theo-
metaphorical thought retical formulations are based on incredulity to-
ward the possibility of metadiscourses or meta-
Several authors have debated the status of narratives, which have lost their credibility (Ly-
ecosystem health: concept, notion, or metaphor? otard, 1984). In this sense, postmodernism tends
Gallopín (1994), in his article on the status of to reject comprehensive social theories or broad
ecosystem health in agriculture (agro-ecosys- epistemological perspectives. This context has
tem health), comments that it is not so clear if favored the hegemony of relativism in the sociol-
this approach can become the much-needed ogy of science and of a social constructivism op-
framework for “an accepted research model posing “social” and “natural” and overestimat-
which embraces the physical, biological, and ing the cultural and cognitive aspects of science.
human dimensions of long-term sustainability” As noted by Cole (1992), “nature poses some
(CGIAR, 1993:8). He calls attention to the ambi- strict limits on what the content of a solution
guity of the concept of ecosystem health, which adopted by the scientific community can be. By
according to him “gives it some of its richness” leaving nature out, the social constructivists
and concludes that “it might well be that the make it more difficult to understand the way in
concept is more useful as a metaphor suggesting which the external world and social processes
more systematic approaches to the diagnosis interact in the development of scientific knowl-
and treatment of agrecosystems ills, underscor- edge” (Cole, 1992:26).
ing the importance of validation of remedial ac- In this widespread postmodern perspec-
tion interventions…” (Gallopin, 1994:59). tive, reality “…intrinsically cannot make sense
Various authors have discussed whether or else only makes sense when remythologized
ecosystem health in socioecological systems on the basis of illusion and/or power struggles
can be understood in this metaphorical sense. (…). Our only legitimate options are to simply
Ecosystems are often viewed as concrete repre- accept disorder and uninterpretalibility (of life
sentations of food chains, where system ele- and culture) or to make highly contingent, lo-
ments evolve and co-evolve and species collab- cal, and ultimately only weakly defensible ef-
orate and compete in complex cycles: preda- forts to bring order to a small part of the world”
tors, prey, hosts, and parasites. (Calhoun, 1995:112).

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36 POSSAS, C. A.

The increasing yearning, in academic com- ative and destructive potential, producing in
munities, for all forms of empirical representa- spiraling and increasing speed both “more cre-
tion, undervaluing theory, certainly reflects ation and more destruction, more efficiency and
these recent trends. Hence, local geographic more inequality” (Luttwak, 1999:187).
representation of reality and corresponding According to this approach, the main con-
technologies (Geographical Information Sys- sequence of this new form of capitalism in the
tem – GIS –, mapping, spatial analysis) or local political sphere is the shift of power from pub-
representation of perceptions or cultural val- lic authorities to private and institutional eco-
ues of specific communities (psychological and nomic interests. Inevitably, these processes
anthropological empirical studies) often be- have drastically reduced the sphere of democ-
come more important for scientists than un- ratic control and regulation by society – and
derstanding structural processes. particularly by more vulnerable populations in
Concerning this increasing emphasis on developing countries – over destructive eco-
representation, Calhoun (1995) notes that “in nomic processes, thereby hindering the reduc-
such a postmodern society the sign becomes the tion of their traumatic impact on the lives of in-
autonomous source and form of value, the sig- dividuals, families, neighborhoods, cities, and
nifier is detached from the signified. The struc- nations. The natural environment and the so-
ture of relations that now matters is not that by cial environment both become more vulnera-
which capital dominates labor, or centers of pow- ble with the acceleration of these destructive
er grow and eliminate the territorial organiza- impacts.
tion of power. Rather, the structure of relations In fact, the indicators provided by the recent
which now matters is among signs” (Calhoun, UNDP Human Development Report (UNDP,
1995:102). 1999) highlighted the social and economic im-
It is in this postmodern context of reval- pacts of globalization in terms of the inequity
orization of the local, of perceptions, and of and vulnerability resulting from lack of social
culture in everyday life that the emergence and control and adequate regulation over concen-
reconstruction of metaphors – health promo- tration trends, which are rapidly aggravating
tion, prevention, community health, sustain- social disparities worldwide. The report’s main
ability, and ecosystem health – should be un- conclusion is that competitive markets can
derstood. provide efficient production but cannot pro-
Discussions on the possibilities and limita- vide human development. Therefore, a new ap-
tions of the “ecosystem health” metaphor proach to global institutions and government
should take into account this debate concern- is necessary.
ing postmodern relativism and social construc- Globalization has also accelerated detri-
tivism, since they refer to an attempt to under- mental impacts on the environment. The latest
stand complexity, emergence, and human dis- United Nations report, Global Environment Out-
eases in their ecological and social contexts. look 2000, indicates that since the Earth Sum-
mit in Rio eight years ago the same environ-
mental trends have continued in most coun-
Society, globalization, and emergence: tries of the world and indicators have gotten
structural thought even worse (UNEP, 2000). Significant increas-
es in land degradation, forest loss, biodiversity
Contrasting with postmodern relativism, sev- loss, degradation of marine and coastal zones,
eral authors have pointed out the new forms atmospheric and water pollution, urban and
assumed by capitalism and their impacts on industrial contamination, and waste were ob-
social organizations, on natural environments, served.
and on social life worldwide. They have dis- These drastic changes in the global scenario
cussed the spiraling of the globalization process raise several issues concerning the nature of
and its increasing complexity and noted that health reforms, particularly in more vulnerable
capitalism in its recent form is quite distinct developing countries, affected by the changing
from the strictly regulated form that flourished role of the state and shifting of power from the
worldwide from 1945 to 1980. Luttwak (1999), public sector to private and institutional eco-
in his concept of “geo-economy”, called these nomic interests. The reduction of democratic
new features “turbo capitalism”. In his view, the control and regulation by society over destruc-
main characteristic distinguishing “turbo capi- tive economic processes is making it difficult
talism” from the formerly regulated capitalism to minimize the traumatic impact on the lives
is the global introduction of an accelerated of individuals, families, and neighborhoods, af-
structural change and its simultaneously cre- fecting both society and the environment.

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SOCIAL ECOSYSTEM HEALTH 37

Social ecosystem health environment and the social, economic, environ-


mental, and political factors of a group of peo-
A social ecology of health (Levins & Lopez, 1999) ple living in a urban area (e.g., a city or neigh-
assumes that ecosystems are social ecosys- borhood)” (McMullan, 1998:1).
tems, increasingly transformed by human ac- In Brazil, diseases transmitted by insect and
tivity. This statement may sound obvious, and rodent vectors are being amplified by the chang-
most ecologists would easily accept it. Never- ing social and ecological conditions in cities, in
theless, it is not sufficient to introduce social complex urban ecosystems. Leptospirosis is a
and economic variables into the system or to good example. While in developed nations lep-
involve local communities in system “manage- tospirosis is a disease affecting mostly animals,
ment”. Social and environmental interventions in the main Brazilian cities approximately 3,600
by ecologists as political actors are part of the patients are treated in hospitals every year
system and interfere in its evolution. for leptospirosis (annual average from 1991 to
Constanza (1994) properly synthesizes the 1999) and a new pulmonary form of severe lep-
need for an alternative approach: “The funda- tospirosis is emerging (Possas, 2000). The dis-
mental reason why we are so interested in ease used to be a medical curiosity but is now
ecosystem health is that we have got ourselves disseminated as a result of faulty sanitation,
stuck or painted into a corner in managing waste, floods, and proliferation of the rodent
ecosystems by the default criterion of having no transmitting the disease. In some areas, where
human impact…What we are trying to do is to local governments have succeeded in killing the
truly integrate science, policy, and management rodent Rattus norvegicus transmitting ictero-
in dealing with ecosystems and moving beyond hemorrhagic leptospirosis, other species of ro-
the no impact paradigm…We have to consider dents, such as Rattus rattus, often take the for-
humans as components of ecosystems and we mer’s place, since the lack of proper sanitation
can no longer look for pristineness as the major and waste disposal usually persist.
criterion” (Constanza, 1994:29). These theoretical and methodological diffi-
This debate raises issues concerning sus- culties in confronting a complex new reality
tainability and sustainable development. Ac- certainly affect policy and decision-making to
cording to some authors, the concepts of ecosys- deal with emerging and re-emerging infectious
tem health and sustainability are so closely re- diseases, particularly in developing countries
lated that for practical purposes they are essen- suffering the consequences of globalization.
tially the same (Smit & Smithers, 1994). Social These challenges can be examined from two
and economic sciences have historically been different perspectives: risk anticipation and
incorporated into medicine and public health. policy implementation. The first refers to the
However, there is an important gap in under- conditions for creating the necessary scientific
standing the social and economic phenomena and technological capacity to anticipate risk
leading to emergence and re-emergence of conditions and project scenarios for the future
pathogens and diseases. concerning emergence and re-emergence of
In Latin America, important developments pathogens, syndromes, and diseases in these
occurred in the last three decades in the fields countries. The second, based on adequate in-
of social epidemiology and social sciences in formation on risk conditions, concerns the abil-
health, but few studies have focused on the ity to implement effective intersectoral inter-
complex conditions of emergence of specific ventions, transferring existing knowledge and
diseases and pathogens. technologies to society. These issues are espe-
Correspondingly, incorporation of new de- cially crucial for developing countries where
velopments in contemporary ecology into pub- structures for funding sciences and technology
lic health and medicine is still limited. Several are often dissociated from health policy and
authors have contributed to this effort, but decision-making.
their contributions have still not been orga-
nized into a comprehensive framework.
Challenging these theoretical gaps, in many Eco-social models and future scenarios
developing nations ecosystems are increasing-
ly changing into complex urban ecosystems. The incorporation of social and ecological vari-
McMullan (1998), extending the concept of re- ables into epidemiological models as a tool for
searchers at the International Development anticipating and assessing impacts of environ-
Research Centre (IDRC) to the city, suggests mental and social change on human popula-
that urban ecosystem health “is a concept en- tions has been widely recommended by inter-
compassing the complex interplay among the national organizations and national govern-

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38 POSSAS, C. A.

ments. Various quantitative and qualitative dures, as an alternative approach to current bio-
models have been developed with this purpose. statistical methods.
Nevertheless, several factors have restricted These six tables (population tables, risk ta-
the utilization of population-based epidemio- bles, and epidemiological profile tables) are re-
logical models in policy and decision-making, lated to each other in such a way that the final
especially in developing countries. outcome is the population’s epidemiological
Such obstacles relate basically to three dif- profile. The scope of its extension can be de-
ferent issues: difficult access to information, fined at different levels: from local population
since most of these countries lack adequate da- studies to national ones.
ta on disease incidence and prevalence; lack of The six tables are organized in two distinct
knowledge concerning population-based in- sets: Tables 1, 2, and 3, where Table 3 is the re-
struments and methodologies for epidemio- sult of Table 1 multiplied by Table 2, and Tables
logical analysis; and inadequate conditions at 4, 5, and 6, where Table 6 is the result of Table 4
the national and local levels to operate epi- multiplied by Table 5. Table 1 is a given popula-
demiological analysis in the health and social tion’s distribution according to each specific
planning processes. risk condition. Table 2 is the distribution of dis-
Despite these constraints, predictive mod- eases according to each specific risk condition.
els can overcome the limitations of existing da- Table 3 displays the population’s epidemiologi-
ta and simulate scenarios for the future. Eco- cal profile according to specific risk conditions.
social models can provide valuable tools for According to available data, it shows how inci-
these future scenarios, simulating alternatives dence (or prevalence) and the respective time
to risk conditions and assessing the impacts of span are distributed in the total population and
alternative environmental and social policies how they relate to each specific risk condition.
both at the national and local levels. Table 4 is the population distribution ac-
Eco-social models for emergence have cording to all possible combinations of discrete
been conceived from diverse approaches using levels/categories of risk conditions. It is an n
both quantitative and qualitative mathematics dimension matrix, where n is the number of
(Puccia & Levins, 1986; Puccia et al., 1994). risk conditions considered. Table 5 is also a
In former publications, some elements for matrix of n dimensions, where combined risk
an eco-social approach to epidemiological conditions are simultaneously related to a dis-
analysis were suggested. In a model developed ease or diseases related to different conditions.
to examine the epidemiological profile of the Table 6, the total profile table, is the final prod-
Brazilian population (Possas, 1989, 1992; Levins uct of Tables 4 and 5 and displays the total pop-
et al., 1993), we found that small changes in so- ulation’s epidemiological profile as related to
cial and economic conditions lead to dramatic all possible combinations of risk conditions.
changes in the final outcome, i.e., the popula- Further analysis of these combinations should
tion’s health profile. These results indicated an consider a specific hypothesis of cumulative
outcome similar to those produced by models effects, controlling confounding factors.
of complexity called chaotic, in non-linear sys- Since for most diseases there is no consen-
tems of equations, where small changes in pa- sus on the effect of joint risk exposure, Spasof
rameters and/or in initial conditions can result & McDowell (1987) conclude that except for ac-
in dramatic consequences in the final out- cidents (which experts assumed were best de-
comes, including unpredictability. scribed by an additive model) and ischemic
This model proposed a non-conventional heart disease, for which they applied a logistic
methodology, incorporating environmental model, all other diseases were best described
and socioeconomic information related to risk by a multiplicative model. A useful discussion
factors for diseases. Risk conditions were iden- of this methodological problem can be found in
tified from a review of the international litera- Gunning-Schepers (1989) resulting from her re-
ture on clinical epidemiology on risk factors for search on a simulation approach to prevention.
specific diseases. Information on socioeco- Finally, Table 6 is the final product of Tables
nomic and environmental conditions was ob- 4 and 5 and displays the total population’s epi-
tained from national surveys for Brazil, which demiological profile as related to all possible
was selected as a country study for model sim- combinations of risk conditions.
ulation. To understand how these diverse risk con-
A predictive model for future studies on so- ditions and diseases interact over a population
cial and environmental impacts on health was demands a population-based approach rather
conceived. It consists basically of six tables that than the disease-based approach characteristi-
do not require sophisticated statistical proce- cally used in clinical epidemiology. Neverthe-

Cad. Saúde Pública, Rio de Janeiro, 17(1):31-41, jan-fev, 2001


SOCIAL ECOSYSTEM HEALTH 39

less, population-based eco-social models need tion, the causal and non-causal determinants,
the input of clinical epidemiology research to favor multiple conditions of vulnerability to
provide realistic prediction. the pathogens, affecting their biology in ecosys-
Eco-social models can indicate that in het- tems increasingly transformed by human ac-
erogeneous societies exposed to rapid social tivity.
and ecological change it is often impossible to From the social sciences perspective, epi-
demarcate the diverse geographic and econom- demiological complexity resulting from these
ic spaces where populations are now exposed new conditions requires a critical review of so-
to risks as “rural”, “urban”, or “sylvatic” areas or cial and economic processes intensified by
as either “archaic” or “modern” conditions. globalization and urbanization, which have
Rather, these life conditions overlap and have blurred the traditional boundaries between
multiple effects. As a consequence, the same global and local, urban and rural, with impor-
population is often exposed to diverse risk con- tant theoretical and methodological implica-
ditions, leading to complex epidemiological tions.
profiles as a result of the epidemiological tran- The limitations of each disciplinary field to
sition. deal alone with the complexity and emergence
of pathogens and diseases are evident and re-
sult from the historical dissociation of different
Conclusions paradigms, building separate theoretical frame-
works and methodologies and thus constrain-
The increasingly complex conditions of human ing future scientific and technological develop-
populations’ exposure and tolerance to the ments in this area.
emergence and resurgence of pathogens and Besides this difficulty in integrating diverse
infectious diseases in the global context and conceptual references into a common academ-
the limitations of social and economic sciences ic structure, it should be noted that both fields
on the one hand and ecology on the other to have developed their frameworks in more sta-
confront these new epidemiological scenarios ble settings: the rapid changes resulting from
by themselves highlight the urgent need for an globalization has led to perplexity and adher-
alternative framework. ence to tradition, contributing to the persis-
The expectations that new vaccines and tence of the gap, despite several important
drugs and global surveillance would help re- transdisciplinary initiatives. On the one hand,
verse the new epidemiological trends have social and economic theories tend to minimize
been frustrated thus far by the increasing com- the environment and the biosphere, focusing
plexity of the epidemiological transition, de- on health care reforms; on the other, ecologists
spite promising prospects for the near future in tend to misunderstand the social and econom-
biomolecular research and genetic engineer- ic forces driving or restraining their actions, fo-
ing. As for new vaccines, the heavy social im- cusing on local sustainability and the ecologi-
pact that these new developments (powerful cal impacts of interventions.
new techniques such as DNA vaccines, pep- A social ecosystem health approach sup-
tides, new combinations of antigens, and con- ported by a strong and continuous transdisci-
jugate vaccines) could have on human health plinary effort can provide an alternative basis
contrasts with the enormous burden of vac- for a new theoretical framework and new
cine-preventable diseases worldwide (Possas, methodologies, supporting eco-social strate-
1996), aggravated by extreme poverty and envi- gies for specific surveillance of emerging and
ronmental degradation. This impasse raises re-emerging infectious pathogens, syndromes,
crucial issues concerning conceptual refer- and diseases. These strategies, such as risk an-
ences for priority-setting, risk anticipation, and ticipation, modeling future scenarios, preven-
the transfer of science and technology’s results tion, and health promotion, will require ade-
to society. quate priority-setting from governments and
This article has discussed the increasing societies, along with the necessary investments
tension between these historically dissociated in social policies, environmental policies, and
paradigms and identified the need for a new science and technology, based on health infor-
transdisciplinary approach – social ecosystem mation systems oriented to emergence.
health – incorporating these distinct perspec-
tives into a comprehensive framework.
From the ecosystem perspective, the chang-
ing patterns of exposure, favoring new connec-
tions between the diverse chains of determina-

Cad. Saúde Pública, Rio de Janeiro, 17(1):31-41, jan-fev, 2001


40 POSSAS, C. A.

Acknowledgments

This article is an outcome of a research project on


Emerging Diseases and Policy Strategies, in collabo-
ration with Profs. Richard Levins and Tamara Awer-
buch of the Harvard New Diseases Group, Depart-
ment of Population and International Health, Har-
vard University School of Public Health. The Brazilian
component of the research was funded by the Na-
tional Research Council (CNPq) and by Fiocruz PAPES
II Project. I thank Dr. Akira Homma, Fiocruz Vice-
President for Technology, for the support provided to
this project.

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