Different facets, one hard problem: Health, environment, energy, sustainability

We who have made our careers in environmental and occupational health are proud of the progress we have made in managing difficult problems and understanding complexity and interdependent relationships. And so we should be proud, as the situation for local pollution issues is generally better than it was 20 years ago, especially in developed countries; we know much more, and we have better management tools than we did just a few years ago. However, we should be humble. We are only skating on the surface of what can best be described as the ultimate “wicked problem,”¹ sticky, refractory, contradictory, and darkly opaque at the center, with no path to resolution obvious or feasible at the beginning of the effort to resolve it.

Wicked problems, as they have come to be known, are typically issues with both technical and social dimensions that appear refractory to resolution because developments have to happen in both. These developments have to be structural, irreversible, and together or in sequence to make progress. Because the drivers of technical innovation and of social behavior and acceptance are so different, coordinating progress in the two dimensions is nearly impossible; either can be derailed at any time, and the two can intermesh and jam each other at any point because of unintended consequences, economics, and personal interest (since many people inevitably have a stake in the status quo). Wicked problems, also called “sociotechnical problems,” include the biggest issues of our time, such as climate change globalization and world economic development, and some of the narrowest, such as liberty and governance of the Internet.

Health, “environment,” energy, and sustainability are so closely connected that they may be thought of as different aspects of one super problem, a wicked problem that at its core contains the existential issue of climate change. I am here using “environment” for the huge cluster of themselves interrelated issues that are related to the natural and the built, or artificial, environment, including toxics and ecosystem change, in the shorthand style of policy wonks in Washington, DC, where I currently have the ill fortune to live. (It is not pleasant.) In the environmental health sciences, we chip away at individual problems, and sometimes we even solve them; but the big sticky mess remains.

The connections are obvious to any of us who have studied the problem,¹ and probably almost all of the readers of this journal have thought about many these issues deeply.

Human health is determined by many factors, importantly including environmental quality and integrity. We as a society require environmental protection to protect human health and the integrity of ecosystems that support human communities and economic activity. Much of the pressure on the environment can be traced to energy extraction, production, and utilization, making energy use one of the most powerful determinants of environmental quality. Sustainability, defined as a means of achieving ecological, economic, and social balance by achieving “development that meets the needs of the present without compromising the ability of future generations to meet their own needs,” has become a major business value and corporate strategy. These 4 sectors are therefore interlinked, often in ways that are complicated and indirect. For example, good health is associated with economic productivity. Access to sufficient energy is associated with better health (although depending in part on the energy technology) and sustainable prosperity, and employment is associated with good health.

Addressing the health facets of this super problem is complicated enough. Human beings are actually well protected from extreme environmental conditions, beyond physiological adaptation, by cultural responses and the built environment, which provides a sheltering microenvironment in which most people spend most of their time. Given these biological and social protection mechanisms, people tend to be vulnerable in specific ways and not simply as an extrapolation of the predictions of toxicology or physiology. There are also disciplinary obstacles to seeing the true outlines of health in relation to “environment.” Health status can be assessed at the level of individuals (personal health, which is the domain of medicine and dominated by access to health care) and has many determinants that shape health risks for individuals and families, including genetics, individual lifestyle, and unpredictable encounters with pathogens. Health can also be assessed at the level of communities or countries (population health, which is the domain of prevention and public health). Collective health status and the distribution of health risks are not simply the sum of all individual health risks. Population health status has its own determinants, such as income and its distribution, that shape general, baseline, or average health risk for entire communities and determine the magnitude of extremes.

The interface between health and environment goes beyond traditional public health measures to include significant and large effects from modifiable determinants of health at the population level: exposure to particulate air pollution, toxic environmental hazards, ecosystem change promoting infectious disease, economic insecurity resulting from ecosystem disruption or resource depletion, climate change and weather instability, and aggravated natural disasters. Foremost among the health risks at the interface of health and environment are the health risks that arise from microbial water pollution and inadequate sanitation, but in developed countries we rarely talk about this because obvious outbreaks are rare. Day to day, except for egregious situations where neglect, injustice, and incompetence often distract our attention, we tend to focus on the residual risks and those that arise from technology, such as cancer. As a result, in rich countries we tend to focus on small hazards and precaution without realizing that breaches in public health infrastructure can still have devastating consequences.

Energy production, consumption, and utilization is a key driver of environmental and ecosystem risk, the most important single driver not only because of its role in fossil fuels, climate change, and air pollution but because it quite literally powers the economy and people's lives. Energy choices dictate land use patterns, opportunity at the community level, and the dependency of our economy on the fuels we use. Energy use,² like income,^3,4 correlates to a point with health status overall, reflecting quality of life and infrastructure, but this relationship plateaus, as it does in the more familiar “Preston curve” of GDP and mortality. The effect is in part dependent on the predominant fuel, reliance on coal being associated with reduced health indicators.² Some energy technologies result in significant health risks such as air pollution, vehicular traffic, occupational injury and disease, social injustice and limited opportunity in communities, and resource extraction that compromises future economically productive use of land and that has indirect effects on health.⁵

Sustainability, taken as the general policy of extracting only so much of any resource as the current generation needs for a decent life and leaving enough for future generations, is a unifying principle that incorporates environmental protection and efficient and restrained resource utilization, including energy resources. Sustainability has emerged as an effective corporate policy as well as a popular public value because of its return on investment and cost savings. The beauty of sustainability as an approach is that, taken seriously, it aligns interests among all parties, and in so doing sidesteps the confrontational aspect that inevitably comes with an emphasis on environmental protection (which naturally sets up a counter-position by implying “protection from whom?”).⁵ Progress in sustainability can result in health gains, especially through ecosystem preservation, pollution prevention, and well-managed built or artificial ecosystems, which in turn add additional benefit that motivates society to progress further in sustainability policies. The approach of making and keeping sustainability popular and a public value therefore represents an important path forward in resolving the wicked problem.

Ideally, our governments should be deliberating and ultimately setting public policy in ways that consider health, environmental protection, energy, and sustainability as interrelated in complicated and sometimes ways, requiring analysis for policy effects, opportunities for gains, and prevention of unintended consequences. To do so, we need robust but suitably refined models for use in analysis, coordination among responsible agencies, and multivalent policy proposals for achieving progress in reaching goals of health, environmental protection, energy supply, and sustainability as a coordinated strategy. Such modeling goes far beyond econometrics and the models economists use to predict economic behavior. As in climate modeling, the uncertainties are vast and there is an element of randomness. The future cannot be mapped with smooth curves and predictions, as it was in the blockbuster book of the 1970s, Limits to Growth, with its debt to Jay W. Forrester, whose pioneering models made such problems seem so simple.⁶

However, a call for modeling and policy guidance can also be an invitation to naiveté, is a minefield of complications in itself, and is fraught with ideological danger. To some, such thinking may smack of central planning, with arbitrary constraint on free enterprise, and expresses a lack of trust in markets. To others, it does not go nearly far enough because the unfolding of the ultimate existential problem, climate change, is a physical process that will not wait for deliberation and persuasion.

For us in environmental and occupational health, solving one problem at a time is an incremental way of helping people and protecting the environment. Solving big problems leaves a legacy and frees society to tackle the next problem in turn with concentration and confidence. However, solving the wickedest problems of them all requires commitment and competence far beyond the capacity of technical experts. Solving wicked problems ultimately requires judgment and power, effectively used. Lest they sacrifice human rights and freedoms in pursuit of an objective, judgment and power must at the same time be tempered with humane guidance and democratic controls and focused on urgent problems when needed, while kept distributed and only concentrated to the extent absolutely required. The responsible exercise of judgment and power has been in short supply of late, and the future remains deeply uncertain. A wicked problem indeed.