One Health and EcoHealth in Ontario: a qualitative study exploring how holistic and integrative approaches are shaping public health practice in Ontario

Health, the environment and systems

The role of governance

Making connections, forming bridges and closing gaps

Challenging next steps

On health, the environment and systemsBoth One Health and EcoHealth critically re-examine and redefine our conceptualizations of health and the environment, especially through a broad systems lens. These approaches encourage reflective thinking that greatly expands on the traditional biomedical definition of health. In doing so, we begin to consider ideas around the health of animals and ecosystems, sustainability (in all its diverse forms), transdisciplinarity and other knowledge cultures, equity and social justice [13]. Further exploration of these ideas inevitably leads to reflections on the types of values embedded in our definitions of health, and encourages asking questions such as “Whose idea of health?”, “Health for whom?” and “Health for all or health for some?”.Similarly, our notion of the environment begins to look a little bit differently under a holistic systems lens. This is perhaps where EcoHealth most significantly distinguishes itself from environmental health, an important field in its own right. Where the latter focuses heavily on the traditional biophysical definition of the environment, a holistic systems discourse includes, among others, socioecological, economic, cultural and policy-framed conceptualizations of the environment. These are all complex academic concepts grounded in philosophy, epistemology, ethics and the systems sciences, and as such, do not lend themselves easily towards providing concise and neatly packaged concepts or definitions. Indeed, the challenge of developing an understanding of these seemingly simple concepts such as health and the environment was evident in many of the interviews. When asked to define health, many participants struggled to provide a clear definition without any afterthoughts or concessions.Similarly, our notion of the environment begins to look a little bit differently under a holistic systems lens. This is perhaps where EcoHealth most significantly distinguishes itself from environmental health, an important field in its own right. Where the latter focuses heavily on the traditional biophysical definition of the environment, a holistic systems discourse includes, among others, socioecological, economic, cultural and policy-framed conceptualizations of the environment. These are all complex academic concepts grounded in philosophy, epistemology, ethics and the systems sciences, and as such, do not lend themselves easily towards providing concise and neatly packaged concepts or definitions. Indeed, the challenge of developing an understanding of these seemingly simple concepts such as health and the environment was evident in many of the interviews. When asked to define health, many participants struggled to provide a clear definition without any afterthoughts or concessions.The definition of health as conceived by the World Health Organization [18] was a common starting point for many participants. However participants expanded on this definition to include discussions of equity, access to resources, socioeconomic disparities, community health and economic health.Additionally, the majority of the participants found the traditional biomedical definition of health to be lacking on a number of fronts. For example one participant observed that:Some participants did away with the idea that health had to be a singular, definable concept and importantly, discussed the role of context – an argument heavily couched in EcoHealth and One Health thinking. EcoHealth researchers often stress the importance of perspective and context in framing and understanding health and disease. These scientists grapple with the difficulty of answering deceptively simple questions when working in systems such as: “how do we define the ‘patient’ – not just its boundaries but also its internal dynamics” [19]? For example, Waltner-Toews et al. use an example of a simple patch of grass to illustrate this challenge. [19] In trying to define the health of this ‘patient’, Waltner-Toews et al. first struggled to understand the purpose and value of this plot of land: Was the plot of land more important as fertile land for agricultural development or was it a vibrant space for community recreational activities [19]? Perhaps this patch of green space represented something else entirely.Furthermore, expanding upon traditional biomedical concepts to include other perspectives, leads to the emergence of even more challenging issues: Who claims ownership or bears responsibility for the system? How do we even define what the problem is and consequently, how do we define the solution?The answers to these questions fundamentally dictate our understanding of our ‘patient’, its state of health and subsequently, our response to this system. As eloquently stated by Waltner-Toews et al. [19], “perspective changes everything”.These ideas were evident in several interviews with participants describing health as a constantly shifting and highly contextual concept. Health was not seen as something that could be imported unchanged across disciplines, communities or time scales. Furthermore, a commonly expressed point was the importance of adaptability and being able to shift one’s perspective on health to adapt to local contexts and understandings.The challenges of definitions and the importance of contextualization also emerged during discussions around the environment. Multiple concepts of the environment were discussed during the interviews, with participants discussing the built, social, economic, urban, policy and food environment. Moreover, one participant stressed the importance of working with the community to better understand how other groups in the population understood and valued the environment. This type of community engagement was stressed to be a core part of the participant’s programming.Some participants also viewed environments as existing within nested systems of other environments. Using a holistic lens as a contextual tool helped participants to navigate these complex systems and understand the multiple downstream and upstream connections between the health of their community and the multiple conceptualizations of the environment. For example, in considering the role of food systems in their community, one participant “saw food as having a direct effect on the local economy, the local environment and our local health of the community in the sense of its connectivity and social capital and relationships”. In the words of another participant, “It’s kind of a systems focus on how changing one piece changes all of those nested hierarchies of environments that are sitting within each other”.The inextricable links and interconnections between health and the environment was another common discussion which emerged from the interviews. Certainly this is not a new idea. Within the environmental health field, environmental factors have been long documented as causative agents of disease and illness. What is perhaps unique about these discussions however is that participants described the environment as more than just a determinant for health. Rather, participants viewed health and the environment as fundamental and necessary components of each other. For example, in discussing this connection, one participant stated, “I think they’re completely integrated. I mean, you can’t get out of it”. For another participant, the environment was an essential component of their definition of health: “you have to look at the environment, how healthy is the air? Is it good to breathe? And how much can you get out and about?…That’s all to me, part of health”. Finally, one participant defined a healthy environment as “one that does not negatively affect the physical, mental or social well-being of people…and which even promotes physical, social or mental well-being, good health”.These ideas which link the health of people with the environment were found to be significant not only from an academic standpoint, but also a practical perspective because participants could view holistic and sustainable practices as creating a “double-dividend” [20] for both health and for the environment. For one participant, this was evident in their discussion on the importance of the built environment for health:Although many of these holistic reflections on health were seen as intuitive by the participants in this study, they were not commonly shared among their partners or other actors within the larger public health system. Many participants identified these incongruent perspectives as major obstacles towards healthy collaboration with their stakeholders.This lack of shared understanding was identified across a range of stakeholders, from bureaucrats (“we’ve been consistently educating the government, the bureaucracy, in terms of where we’re coming from”), to the general public (“yeah people [the public] don’t even get it. And people you’d think would get it. And if you think, if they’re not getting it… how are we ever going to sell this”), and even to other actors within the public health sphere (“It’s not their mandate. They don’t have to think that way, it’s not required”).Overall holistic and systemic perspectives about health and the environment were commonly discussed by participants. Participants’ perspectives were diverse and far-reaching, with health and the environment commonly seen as contextual, shifting, nebulous and inextricably linked with each other. Applying a holistic or systems lens towards these concepts allowed some participants to make sense of their inherent complexity and to better understand their importance in various contexts at the community level. Finally, participants identified major challenges in creating a shared understanding about health, the environment and systems thinking. These barriers speak to larger issues of working with different partners and stakeholders. Thus various governance structures and models of stakeholder collaboration emerged as a key theme from the interviews. These discussions are profiled in the next section.

The Role of GovernanceThere is no single way to teach EcoHealth or One Health, or to understand how these may be practiced - their pluralistic nature creates an inclusive space for multiple perspectives and approaches. In considering the role of governance, however, one useful heuristic may be to conceptualize these holistic practices as having two main arms or branches: the first considers the complex, systems-based interconnections between health and the larger environment, and the myriad issues which emerge from that line of thinking; the second focuses on the process by which these connections are understood and acted upon. It is in this second branch that models of governance and working with different stakeholders becomes crucial to the conversation.This idea is echoed in the fact that governance and engaging stakeholders in the larger system were major themes discussed by study participants. Interestingly, governance was seen as an important structural force that could have both stifling and supportive effects towards holistic approaches to public health practice.Governance was found to act as a barrier towards holistic practices in a number of ways. For example, participants identified navigating the complex web of mandates and jurisdictions as a major challenge towards working within a larger system of stakeholders and partners:When considering how to work with multiple stakeholders on a particular issue, there was a great deal of confusion and uncertainty on a number of different levels: What were the mandates and responsibilities of the stakeholders involved? How did their mandates fit with the issue in question? Whose responsibility did that issue fall under the direct purview of? Who needed to assume responsibility?And finally, how does one reconcile issues of overlapping or conflicting mandates and jurisdictions?Better methods of communication were identified as one way to improve collaboration between multiple stakeholders and overcome some of these jurisdictional issues. For example, one participant stressed the need to learn each other’s ‘languages’ – how to speak and interact with different groups, disciplines, sectors and knowledge cultures. Doing so could lead to a shared understanding of each others’ perspectives and their individual roles in the larger system.Challenging relationships with management and other political forces were identified as another important obstacle faced by participants. This was manifested through: communication barriers between scientists and decision makers (“as a scientist, it becomes really hard, you know a lot of the work that we do to inform policy has to be put into a very politic way to move forward”); political or jurisdictional barriers limiting the powers of public health practitioners (“So sometimes we can’t do anything because of bureaucracy”); and finally, the difficulties in negotiating the role of public health practitioners in policy development while under a governing political framework (“but we are public servants, so we are going to help facilitate that process, we can’t articulate that policy ourselves”).Working in this highly political environment was seen as challenging to one participant’s ideals of value-neutral scientific objectivity.By contrast, other participants were much more comfortable with this intersection between science and politics. Organizational mandates and working practices were thought to be greatly strengthened by the influence of leaders and champions of particular causes. Strong political voices could help to advance ideas and push forward agendas on holistic working practices. Interestingly, one participant even planned a healthy communities advocacy campaign around a local political election. This innovative form of community engagement was a way to encourage community members to connect the health of their community with the local political environment.Despite creating some major barriers, models of governance were also found to be an important support system for several participants. For example, one participant said of a particular governance arrangement:Additionally, top-down governance mechanisms were seen as one way to promote holistic and systems perspectives around health and the environment. One participant pointed to the importance of the Ottawa Charter as “a guiding model for everything that we do”. Another participant discussed how the Ontario Public Health Program Standards have brought issues such as air quality, climate change and built environment to the forefront of the public health discourse:The emergence of governance as an important theme arising from these key informant interviews is not surprising. Governance as a driving force for the health and sustainability of natural systems has long been a core tenet of the natural resource management sphere. This holds true when shifting our perspective towards the intersection of the environment with human systems, also known as socio-ecological systems. In studying watersheds as a common point of conversation between health systems, ecosystems and social systems, Parkes et al. [20] illustrated the value of applying a governance lens to best link these multiple perspectives. By doing so, Parkes et al. [20] were able to “compare and contrast a range of perspectives, while highlighting gaps in knowledge and understanding…and identifying new opportunities for integration between perspectives”.There is much more to be learned about the articulation and management of governance structures and mechanisms in public health practice. Governance structures, their role in the practice of public health in Ontario, and their potential utility in facilitating holistic and systems-based approaches towards health, thus warrant further research.

Making connections, forming bridges and closing gapsThe importance of relationship-building was another key theme which emerged from the interviews. Both formal and informal relationships were found at the grassroots and community level, across disciplines and knowledge cultures, across diverse governmental and non-governmental sectors, as well as internationally. Although building these partnerships required extensive time, energy, and resources, they were seen to be valuable tools to help participants overcome a number of the challenges previously discussed in this report. For example, developing strong relationships with diverse stakeholders could help to connect disparate perspectives, break down silos and develop a shared understanding among those involved.A shared understanding of holistic perspectives around health and the environment could also be cultivated through advocacy partnerships. Collaborations between various organizations could help to push particular issues or perspectives forward. For example, one participant cited a collaborative report by the World Health Organization, the Food and Agriculture Organization of the United Nations, the World Organization for Animal Health (OIE), the World Bank, UNICEF and the United Nations System for Influenza Coordination, as helping to advocate for One Health approaches towards health [12].Participants found partnerships to be essential in understanding and applying a systems lens to their work, and in promoting longer-term health outcomes and program visions.Partnerships were also seen as fundamentally important to building capacity within communities. Working closely with stakeholders and engaging community members could lead to greater empowerment and increased ability for groups to “articulate policies and to bring them forward to key decision-makers locally”. These community engagement strategies were also seen to be essential in the creation of sustainable health outcomes that could be replicated “across neighbourhoods and communities”. In fact, one participant highlighted sustainability and replicability as key components of their programming. Healthy and empowered communities could become important models of practice and sources of learning for other communities.Closely related to the theme of partnerships, the idea of connections and acting as connectors strongly resonated with some participants. For these individuals, developing these connections within their larger network of stakeholders was a core component of their mandate and identity.Developing connections was also seen as a key step towards the creation of healthy public policy. For example, one participant discussed the importance of involving a wide range of stakeholders in policy development processes. This participant cited the knowledge translation strategy of the Canadian Institutes of Health Research (CIHR) to demonstrate the important role that community members and end-users have to play in research and policy creation.Similarly participants addressed the need for closer and healthier collaborations between scientists, policy makers and the public. In particular, one participant recognized the need to develop close working relationships with key political figures and decision makers.Although participants recognized the wide range of benefits that could arise out of partnerships and collaborations, they also identified several significant challenges to overcome. For example, although including non-traditional voices in the larger discourse could provide valuable insights from alternate points of view, some participants discussed the difficulties of engaging groups who had such different perspectives on issues such as health.Additionally issues of sensitivity may be created when bringing particular types of stakeholders to the table. Overcoming this barrier may require political finesse and manoeuvring around sensitive topics. For example, one participant noted the challenge of working with industry partners on particular issues due to their financial self-interests. However, rather than censoring these voices, the participant felt that it was incumbent upon scientists and researchers to be more reflective and more forthcoming with regard to their own biases and self-interests.Finally, a lack of resources was identified as one of the biggest challenges towards developing partnerships and collaborations. Participants identified time, finances and manpower as essential requirements for these holistic working practices. For example, engaging community members, closely working with grassroots groups, and applying a systems lens to their programming, were all seen as intensive activities that required a significant investment of resources.Certainly the importance of forming partnerships and working collaboratively with stakeholders is well recognized within public health. Participants in these interviews described the immense value of forming relationships and connections with communities and stakeholders. As stated by one participant, at its core, “public health itself is integrative”. However, the simplistic and intuitive nature of this idea belies the immense challenges in realizing this goal. Indeed, these obstacles were a major theme which consistently emerged during the key informant interviews. As will be discussed in the next section, the difficulties of operationalizing these concepts may be one of the most significant challenges to adopting holistic practices in public health.

Challenging next steps: how can we operationalize EcoHealth and One Health?A number of researchers have offered up various pillars, models and heuristics to try and best explain EcoHealth and One Health. Charron [9] suggests six core principles which may be used to frame health under a holistic and systemic lens. The sixth principle, ‘knowledge-to-action’ refers to when the “knowledge gained from research is used to improve health and well-being” [9] by considering and improving the larger ecosystem.In considering the rich information emerging from all these interviews and the lessons learned from the experiences of all the participants, it is unclear as to where all this knowledge will eventually lead. Certainly, this is a reflexive issue that was not only struggled by the primary researcher of this study but also by the participants themselves. Despite recognizing the merits of holistic approaches to public health practice, some participants were challenged to in translating these ideas into tangible programs and policies for their organization.Other participants were able to identify a number of key steps that will first need to be taken in order for holistic and systems thinking to better inform the practice of public health in Ontario. These steps will require effective engagement of actors from across disciplines, organizations and knowledge cultures. There must also be change occurring at varying scales and magnitudes of the system - from the broad societal level down to the individual, from the federal government down to the local community, and from the top of a political-management structure down to the scientist.As previously discussed, greater investments of time, money and human resources are required, in order for these changes to materialize. Change can also be cultivated by greater championing of these ideas within public health. Political and organizational leaders were seen to be highly valuable in several ways. Not only could they promote a change in the way that society and organizations perceive and think about our health and well-being in the context of the larger ecosystem, but they could change the way that we think about our own roles and mandates as actors within the public health sphere.One of the biggest barriers preventing participants from broadly adopting holistic principles into their work was the lack of indicators and measures of health in the larger system. Many participants found current metrics to be inadequate for measuring and understanding broader public health issues. For example, it was recognized that traditional health outcomes such as rates of disease and illness only presented one facet of the overall health of communities. Extending participants’ discussions on holistic definitions of health, well-being and the environment, into specific and measurable markers were challenging to say the least.Additionally, there is a lack of evaluative tools to measure the success of programs that applied holistic and systems-framed approaches towards health. This became especially problematic when participants redefined their role as public health actors: not just as defenders against disease and sickness, but as capacity builders, connectors of systems, and promoters of health and well-being. In this new role, definitions and measures of success were ambiguous. How does one measure the intangibles of their work? This challenge becomes increasingly complicated when multiple stakeholders and partners are involved.In contrast, one participant seemed to find some success in transforming these broader holistic goals into specific objectives of their work. For example, issues of social equity were seen not just as lofty, feel-good ideals, but as specific targets that could be measured and evaluated within their programming.Certainly a key step in the advancement of holistic and systems thinking in public health, is to develop better ways to reflect upon and evaluate the impact that public health actors are having on their communities.Lastly, there needs to be organizational changes to the way that public health actors work with each other. As discussed previously, participants in these interviews consistently stressed the need to build working relationships across organizations, disciplines and sectors. In order for these healthy collaborations to manifest and for partners to effectively collaborate, the way that we share and integrate each other’s knowledge needs to be better articulated. Thus agreements on data sharing, data ownership, accountability and other standard operating procedures will need to be carefully constructed, as the structural foundations for these collaborative relationships. The importance of these data agreements was highlighted by one participant’s observation that:As mentioned by one participant, the concepts which form EcoHealth and One Health are intuitive and “easy to sell”. And as seen by some of the themes emerging from these interviews, these ideas are generally accepted by study participants and at least by some of their partners. For these participants, the greater task at hand seemed to be, ‘how do they translate this knowledge into action’?Understanding how these concepts can be transformed into tangible actions is no simple task and certainly merits much more research and reflection. In fact both the Public Health Agency of Canada [11] and the Centre for Disease Control and Prevention [21] have recently held working meetings that tried to understand how to solve this challenge: how can EcoHealth and One Health be operationalized in the public health sphere? Interestingly, many of the key themes and findings from this current study echo several of the conclusions described in the two reports arising from these meetings [11, 21]. Both reports emphasize the importance of better cross-sectoral collaborations and working relationships, incorporating community and non-traditional stakeholders into partnerships, improving methods of data sharing, and harnessing political forces as a means to advocate for and push forward EcoHealth and One Health ideas.How can the ‘knowledge-to-action’ pillar of EcoHealth be achieved? How might the lessons and insights gleaned from these interviews be used to shape the practice of public health in Ontario? Simple and easy answers to these questions are lacking. However the participants in this study did identify some key steps and processes which must occur before these holistic approaches can become commonplace and standard working practices in the public health sphere.For example, one area which merits more research is the study of models of collaboration and partnerships - especially those which engage multiple sectors, perspectives and knowledge communities. Develop a clear understanding of the critical success factors of sustainable cross-sectoral partnerships could have important lessons for public health actors. One organization researching concepts in integrated governance within public health is the National Collaborating Centre for Healthy Public Policy (NCCHPP). For example, a recent NCCHPP report profiled two Canadian initiatives which centred on integrated governance – ActNow BC and Section 54 of Quebec’s Public Health Act [22]. In their preliminary analysis of these initiatives, the authors were able to compare two governance approaches used in these initiatives for developing healthy public policy: horizontal management and a whole-of-government approach. Neither of the initiatives studied by the NCCHPP specifically focus on the connection between health and the environment. Thus there is a need to identify and evaluate additional integrated governance initiatives in the area of health and the environment, and the role of strategies such as horizontal management or a whole-of-government approach in the success of these initiatives.Certainly, focusing on the gritty details of organizational structures and policies, and the processes by which public health work is performed, seems far removed from the broad issues of health within a larger ecosystem. However, as underscored by the previous discussions, tackling these next steps are necessary tasks before public health can move towards a practice that is integrative, holistic and inclusive of systems perspectives.