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Оглавление5 Towards a Healthy Concept of Health
HENRIK LERNER1* AND JAKOB ZINSSTAG23
1 Ersta Sköndal Bräcke University College, Stockholm, Sweden; 2 Swiss Tropical and Public Health Institute, Basel, Switzerland; 3 University of Basel, Basel, Switzerland
One Health as an Interdisciplinary Multispecies Health Approach
Two distinct ways of using One Health
The term ‘One Health’ is used in two distinct ways. First, it has been used as denominating a specific approach with origins in the 19th century combining veterinary and human medicine (Lerner, 2013). Through time this approach has widened substantially (Bresalier et al., Chapter 1, this volume). In a second way, the term is nowadays used as an umbrella for many approaches with a strong multispecies and multi- or interdisciplinary scope such as One Health, ecohealth (Rapport et al., 1999), health in social-ecological systems (Zinsstag et al., 2011), planetary health (Whitmee et al., 2015) and others. In order to avoid confusion and the risk of losing particular features of the specific One Health approach, one needs to separate between these two usages. One simple solution is to strictly use ‘One Health approaches’ when referring to the second sense and ‘One Health’ or ‘the One Health approach’ when referring to the first sense.
This chapter will focus on the One Health approach, its definition as well as implications of the definition. In order to aim for a ‘healthy’ concept one always needs to analyse how the concept is defined and where the boundaries to other concepts are. In everyday work, many crucial concepts such as health are not explicitly defined, rather one uses an implicit working definition. However, in dilemmas when one needs to think whether a certain state belongs to health or not, one needs to start thinking of the explicit definition of the concept of health. Here, our concept analysis will focus on different definitions of the One Health approach, what ‘One’ implies in terms of trans- and interdisciplinarity, and how to define ‘Health’ within the One Health approach.
Definitions of the One Health approach
There are several ways to define the One Health approach. The choice of definition influences where the boundaries for the approach are. One could distinguish a narrow and a wide approach of One Health (Lerner and Berg, 2017). In the narrow approach, One Health research is mainly constituted by collaborations between veterinary medicine and human medicine. In the wide approach, biological sciences, health economy and social sciences are also contributing to the research. Nowadays, the narrow approach is more or less abandoned in favour of the wide approach.
There are several wide definitions of One Health. In this book, Zinsstag et al. (Chapter 2, this volume) propose the following definition:
One Health [can thus be defined] as any added value in terms of health of humans and animals, financial savings, social resilience or environmental sustainability achievable by the cooperation of human and veterinary medicine and other disciplines when compared to the two medicines and other disciplines working separately.
(Zinsstag et al., Chapter 2, this volume, p. 16)
This approach is narrow in the emphasis on human and veterinary medicine. However, it is also wide in considering economical and biological sciences. Crucial for this definition is that there needs to be inter- or transdisciplinarity in order to achieve a One Health approach, because one cannot talk about One Health if there is no added value from transdisciplinarity.
Let us now compare this definition with some other definitions of the One Health approach. Gibbs (2014, 2018) has earlier gathered and compared different descriptions of One Health, but these three discussed below are present at the moment on their organizations’ homepages.
The One Health Initiative defines One Health as:
Recognizing that human health (including mental health via the human-animal bond phenomenon), animal health, and ecosystem health are inextricably linked, One Health seeks to promote, improve, and defend the health and well-being of all species by enhancing cooperation and collaboration between physicians, veterinarians, other scientific health and environmental professionals and by promoting strengths in leadership and management to achieve these goals.
(One Health Initiative, 2008)
The One Health Initiative definition focuses on interdisciplinarity. This is similar in one aspect to the definition used in this book, but the added value by transdisciplinarity is not recognized. The One Health Initiative definition is wide in recognizing all aspects of health care for humans, animals and the environment.
The World Health Organization (WHO) defines One Health as: ‘an approach to designing and implementing programmes, policies, legislation and research in which multiple sectors communicate and work together to achieve better public health outcomes’ (WHO, 2017). This definition focuses on the collaborative multidisciplinarity. Here, a more narrow view on health occurs due to focusing on better public health outcomes.
The One Health Commission defines One Health as: ‘a collaborative, multisectoral, and transdisciplinary approach – working at local, regional, national, and global levels – to achieve optimal health and well-being outcomes recognizing the interconnections between people, animals, plants and their shared environment’ (One Health Commission, 2009). The One Health Commission definition focuses, as does the definition in this book, on transdisciplinarity. There is an emphasis on health that is a connection between human, animal and plants in their environment.
To summarize, when one looks at collaboration, the definition in this book and that of the One Health Commission demand a transdisciplinary approach giving added value to, for example, research. The other two definitions are focused on multi- or interdisciplinary work. If one instead looks at which organisms are covered, the definition in this book is narrower than the One Health Commission (which explicitly also includes plant health) and the One Health Initiative (which includes ecosystem health) definitions. However, it is wider than the definition elaborated on the WHO homepage (referring to public health).
The Demarcation of ‘One’ in One Health
‘One’ in One Health refers to several sciences working together towards the same goal. To work together could imply different things, and the One Health approach in this book is not aiming for multidisciplinary science, which is when several disciplines work in parallel with each other while studying a subject. Rather it aims for trans- and interdisciplinarity (Berger-González et al., Chapter 6, this volume). To be able to call something a One Health research study, there needs to be trans- and interdisciplinarity involved, otherwise the research is public health, human medicine, veterinary medicine, health economics or social science. Also, a transdisciplinary approach aims for including more than science, thus, collaboration between researchers, policy makers (e.g. politicians, non-governmental organizations (NGOs)) and practitioners is needed in One Health.
The added value from inter- and transdisciplinary science has also been addressed in other studies. Manlove et al. (2016) found in a literature survey that many of the One Health publications could be clustered in three different silos and although more overlap between the silos occurred through time, this was still the case. In order to benefit inter- and transdisciplinary science, crucial for One Health, Rüegg et al. (2018) created a One Health index (OHI) to evaluate whether research is One Health or only focused on one discipline. The authors suggest that it might be less beneficial if the OHI is too high or too low, but the optimal range of the OHI index is still unclear. That could be used either to visualize how to make research more inter- or transdisciplinary, to show how the index changes over time, or as a tool to use in the distribution of funding.
Fig. 5.1 attempts to illustrate a Boolean depiction of the different terms and concepts relevant to different One Health approaches. One Health is at the intersection of human (public) health and animal health. Global health extends public health to an international level but does not include animal health. Ecosystem approaches to health (ecohealth) have a stronger emphasis on ecology and more sciences from the arts and humanities are included and thus clearly encompass One Health (Lerner and Berg, 2017). Planetary health is more anthropocentric and attempts to relate health with global change phenomena such as climate change (Lerner and Berg, 2017). This has also been found in a scientometric analysis of scientific papers within the field of planetary health (Falceto de Barros et al., 2019).
Fig. 5.1. Boolean depiction of health concepts and approaches to health. All these terms and concepts are relevant to One Health approaches. Green, animal health; red, human (public) health; yellow, global health; black, ecosystem approaches to health (ecohealth) or health in social-ecological systems (HSES); blue, planetary health.
The Demarcation of ‘Health’ in One Health
The concept of health is crucial to define for the One Health approach. To promote health, one needs to have a clear idea of what kind of health one aims for. Policy work as well as how to allocate resources are dependent on what is included in health. However, there is a lack of theoretical discussion on how to define the concept within the One Health approaches. Health is much more complicated in One Health approaches than, for example, in global health, where only human health is considered. In One Health approaches, at the least both human and animal health need to be considered (Lerner and Berg, 2015, 2017). There are also claims that plant health should be included in the considerations (Fletcher et al., 2009). Also important is to consider how many aspects of life need to be covered. Should the definition apply only to physical aspects or also to mental, social and even spiritual aspects?
Health could also be considered on different levels, such as individual, population and ecosystem levels of health (Lerner and Berg, 2015). The first two are familiar to the disciplines of human and veterinary medicine and public health, but the third level, ecosystem health, is seldom recognized, and this makes One Health a more holistic transdisciplinary approach. In order to work with ecosystem health, biologists, environmentalists and others must be included in the approach. Sometimes, as in the One Health Commission and the One Health Initiative definitions, the term ‘environmental’ is used in the same manner as ‘ecosystem’.
There are claims that the concept of health should be clearly defined for at least animals and humans (Stephen, 2014). Could there be a universal definition of health for, at least, both animals and humans? This might imply that the definition of health should be non-speciesist. In order to reach such a definition, one can follow two routes, either start from a human concept of health (top-down) and widen it to include animals, or one can find a common basic level for animals and humans (bottom-up) and define this as health. The first route might be too anthropocentric as well as not including enough species. The second route might be too basic for all aspects of human, and some species of animal, health (Lerner, 2019).
To define health bottom-up one starts by finding a common denominator. Mainly, these definitions are based on biology. A pioneer of One Health approaches, Rudolf Virchow, who defined health in terms of vital cells is an example of this. In Virchow’s definition, health is considered present when enough cells are vital (Virchow, 1881). Species in all biological kingdoms consist of cells, and the definition of health could therefore easily be applied to all organisms. A more modern bottom-up version of health is Christopher Boorse’s biostatistical theory of health, where health is regarded as species-specific functioning of biological organs (Boorse, 1997).
Top-down health definitions, on the other hand, start with definitions of human health and are expanded to other species if they share characteristics that are the foundation of these particular health definitions. These definitions are more holistic and encompass physical, mental and social aspects of an individual. An example of this is the WHO definition of health, covering physical, mental and social aspects of well-being. Nowadays, this definition has expanded to cover mammals and birds, at least in some fields of veterinary medicine (Lerner, 2017).
Is it possible to have a universal concept of health for all levels? A couple of aspects make this difficult. One should decide whether health should be defined as a state or as a process. Both ways exist. Health at the individual level is often defined as a state (Nordenfelt, 2006), while processes might be more important at population and ecosystem level. There might also be potential conflicts between these three levels. This is a similar problem as in ethics when individuals are compared to species or to ecosystems. Where should health apply? In the individual or outside the individual at an aggregated level such as the individual’s population or the individual’s ecosystem? In ethics, simplified, this question created the divide between animal ethics and environmental ethics (Lerner and Berg, 2015). Here, further discussions are needed.
There are many definitions of health present, and no consensus exists on what definition to choose. Recently, a thorough analysis of the idea that health should be a kind of balance was performed with a One Health perspective (Lerner, 2019). This study analysed which definitions based on an idea of balance could be suitable for One Health. Both bottom-up and top-down definitions were analysed. The conclusion was that there were promising aspects with some definitions, but there were also obstacles that made current definitions not fully applicable in One Health without some adjustments.
Despite the problems there are also other fruitful attempts to find universal non-speciesist definitions of health (Lerner, 2017). Lerner (2019) suggested criteria for what such a definition must fulfil to be suitable for the One Health approach. However, this area needs to be expanded and could be helped by a transdisciplinary merging of scientists from, for example, philosophy of medicine, sociology, animal welfare research, plant science and ecosystem science.
Summary
This chapter analyses the concept of One Health and focuses on the two words in the concept with the aim to better explain what the terms ‘one’ and ‘health’ refer to. First, making a distinction between the usage of the terms ‘One Health approaches’, which refers to all appraoches with a multispecies and multi- or interdisciplinary scope, and ‘One Health’, which refers to a specific kind of approach being made. Second, the One Health definition set forth in this book was compared to three other definitions of One Health, and pros and cons were identified. Additionally, the meaning of ‘one’ was discussed, showing the need for an interdisciplinary approach. Finally, the meaning of ‘health’ was shown to be complex, both regarding which definition of health to choose and on which level (individual, population or ecosystem) to apply it. A non-speciesist definition of health is needed, which could be either a bottom-up or top-down definition. Further discussions within the One Health approaches are needed.
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