Concepts associated with health from the perspective of sustainable development
Conceptos asociados a la salud desde la perspectiva del desarrollo sostenible
Leonardo Alberto Ríos-OsorioI; Walter Alfredo Salas-ZapataII; Manuel Ortiz-LobatoIII
IPhD in Sustainability, Universidad Politécnica de Catalunya; Specialist in Biomedical Basic Sciences Parasitology, Assistant Professor, Head of Health and Sustainability Research Group, School of Microbiology, University of Antioquia, Medellín Colombia. Dirección: Calle 67 # 53 108, Bloque 5. Oficina 5-134, AA 1226, Medellín, Colombia. E-mail: email@example.com
IIPhD in Sustainability, Bacteriologist, Auxiliar Professor, Health and Sustainability Research Group, School of Microbiology, University of Antioquia. Medellín Colombia. Dirección: Calle 67 # 53 108, Bloque 5. Oficina 5-103, AA 1226, Medellín, Colombia. E-mail: firstname.lastname@example.org
IIIPhD Candidate in the Doctorate Program in Language and Technology at the Polytechnic University of Valencia, Spain. Linguist, M.A. in English and Spanish by the University of Valencia and UNED, Spain. Associate Professor at the Polytechnic University of Valencia, Spain, at the College of Agricultural Engineering. Dirección: Calle Cristo de la Fe, 23, Esc.2, Pta.16, 46980 Paterna-Valencia-España. E-mail: email@example.com
The concept of health is a social construction defined by the historical-cultural contexts of societies. At the moment, this context is characterized by global challenges such as climate change, energy crisis, the north-south divide, and poverty, among others. In view of these challenges, sustainable development has emerged as a proposal to cope with these drawbacks of the Western development model. In this sense, it is plausible to suppose, in accordance with a new global scenario of sustainable development, that a new conception of health is also emerging. For that reason, this paper aims at identifying this renewed concept of health, together with related concepts which are mentioned in the official documents on sustainable development originated in the world summits. Despite the fact that the concepts of health and sustainable development have been understood as being equivalent, none of the aforementioned official documents has provided societies with an explicit concept of health. It was verified that the concept of health has been associated with that of need satisfaction and preservation of ecosystems, whereas the construct of illness is associated with the concepts of poverty and high consumption levels. Finally, it is concluded that health is an intermediate goal of sustainable development and not an end in itself.
Keywords: Sustainable Development; Health; Poverty; Social Welfare; Consumption Levels; Ecosystem.
El concepto de salud es una construcción social definida por los contextos histórico-culturales de las sociedades. Actualmente, dicho contexto está caracterizado por problemas como el cambio climático, la crisis energética, los desequilibrios norte-sur, y la pobreza, entre otros, que llevaron al surgimiento del desarrollo sostenible como una propuesta para afrontar estos defectos del modelo de desarrollo occidental. En ese sentido, es plausible suponer que en el marco de este escenario global con el surgimiento del desarrollo sostenible también esté emergiendo una nueva concepción de la salud. Por esa razón, en este trabajo nos propusimos identificar el concepto de salud, y los conceptos asociados a ésta, que se encuentran en los documentos oficiales del desarrollo sostenible que han surgido en las diferentes cumbres mundiales. Aunque se pudo inferir que los conceptos de salud y desarrollo sostenible son equivalentes, en ninguno de estos documentos se encontró un concepto explícito de salud. Así mismo, se observó que el concepto de salud está asociado con el de satisfacción de necesidades y cuidado de los ecosistemas, mientras que el de enfermedad está asociado a los conceptos de pobreza y elevados niveles de consumo. Finalmente, se concluye que la salud es un objetivo intermedio del desarrollo sostenible y no un fin en sí mismo.
Keywords: Desarrollo Sostenible; Salud; Pobreza; Bienestar Social; Niveles de Consumo; Ecosistema.
The Health-illness phenomenon can be conceived as a historical-cultural construct that transcends the specialized concepts that storm of the pathological phenomena; it embraces the understanding of the entirety of the social, cultural events and the worldview in which those pathological phenomena show up (Ríos et al., 2009). For that reason, throughout the history of the Western world the conceptions of health and illness have evolved according to the historical worldview (Quevedo, 1991) to the point that diseases that were known with a name X at a definite time in the past, are known today as X' (Arrizabalaga, 1987).
In particular, the Modern era showed the emergence of four paradigms in the field of health, which in turn reflect different modes of the relationship between health and illness. Firstly, the axiological and political paradigm confers to the norms and the social powers the capacity to serve as the borderline between health and illness; secondly, the clinical paradigm attributes full validity to the interpretation of signs and symptoms in order to distinguish what is healthy from what is not; thirdly, the technological modern paradigm establishes the limits between health and disease on the basis of the application of technologies and devices available in the market; finally, the statistical paradigm separates the normal from the pathological as a function of positions and mathematical suppositions (Gómez, p. 7, 2000). These last three paradigms have configured what is known today as the biomedical model of health, which has become the dominant and hegemonic ideology, and is characterized by its positivist conceptual and procedural foundations (Capra, 1984).
During the XX century, new social conditions appeared which justified the need of building a new concept of health. This new concept was distanced from the dominant model in the fact that it reflected multi-causation and a diversity of factors socio-ecological, cultural, political and economic related to it. This view was adopted in 1948 by the World Health Organization (WHO) and led to its definition of health as "a state of complete physical, social and mental well-being, and not merely the absence of disease or infirmity (WHO, 1998). Nevertheless, although this posture was formally adopted by most States at an international scale, the biomedical model is still dominant in health practices; therefore, the pathological thing is still privileged over the normal thing, the illness over the well-being, the assistance and therapeutics over prevention and development of health, and the institutional thing comes first, before the community thing (Gómez, p. 8, 2000).
In the last years of the 20th century, a revision of the concept of Health as defined in 1948 was deemed as necessary, since new social conditions had arisen. The existence of a number of problematic issues, such as climate change, high consumption levels in the industrialized world, in a dramatic contrast to famine in poor countries, the exhaustion of the water sources, the North-South division in the accumulation of wealth, droughts and the energy crisis, can be listed among other global events that happen in the world today (Jiménez, 2008). To this respect, the report published by the Club of Rome "The limits to the growth" (Meadows, 1972) shed light on a number of connections at a planetary level which did not exist before, as well as gave a significant warning regarding the pattern of development in the West, which would pose a risk to the existence of life on earth in case the same tendencies were to continue. For that reason, it revealed the need for a new model of development which included these concerns within its conceptual and methodological foundations.
In fact, sustainable development may be understood in different ways according to the context in which it is debated (Ríos et al., 2005). One of these contexts is the political-institutional framework, which involves the celebration of world conferences in which states, institutions and other international organisms have reached agreements to make decisions and to undertake actions to face the challenges aforementioned. From that point of view, it can be affirmed that the political-institutional context of sustainable development is configured by the initiatives promoted by the General Assembly of the United Nations. The three most relevant actions are: the creation of the World Commission on Environment and Development, with the objective of elaborating of a 'world program for change', which finally led to the Bruntland Report (WCED, 1987); the realization of the Earth Summit, or Rio Summit, which produced a declaration of principles and the Agenda 21 program; and the realization of the Summit of Johannesburg, or Rio+10. In this political context, sustainable development is conceived as one that "meets the needs of the present without compromising the ability of future generations to meet their own needs" (WCED, 1987). Subsequently, this is the concept which has guided institutional and governmental decisions and actions and served as the basis for the formulation of the Millennium Development Goals.
The challenges which gave origin to the concept of sustainable development, in our view, represent the arrival of humanity into a new stage of its history. In this new era, sociopolitical and economic organization, culture and ecology configure a reality that implies a change in our worldview. Therefore, if we bear in mind that the concept of health is a historical-cultural construction, it seems logical to suppose that a new paradigm of the health-illness phenomenon is to emerge in the light of sustainable development.
For this reason, this paper has the purpose of identifying the concept of health that underlies the political-institutional discourse on sustainable development. A documental research from a historical-hermeneutics perspective was made. This was based on the analysis of four official documents on the subject: the Brundtland Report; the Declaration of Principles of the Rio Summit; the Agenda 21; and the Plan of Application of the Decisions of the World Summit on Sustainable Development, which was a resolution of the Johannesburg Summit. These documents were chosen because they are the reference marks that convey the official and institutional understanding of the basis of sustainable development with a global, political purpose. Thus, they allow for in-depth critical analysis of the viewpoints and processes underlying politicians' actions implemented so as they achieve the intended goals.
Likewise, the analysis was carried out by means of a three-level interpretation of the texts: firstly, as for the concept of health which may be inferred from the documents; secondly, on the role which health plays within sustainable development discourse; thirdly, regarding the concepts associated to health from the perspective of the sustainable development.
Reference Documents of the Political-institutional Discourse on Sustainable Development
The Brundtland Report
In principle, the Bruntland Report argues for the existence of a close link between human health and Earth's integrity as a space where human life takes place. In explicit terms, the Report states that: "throughout much of the world, children born today can expect to live longer and be better educated than their parents. In many parts, the new-born can also expect to attain a higher standard of living in a wider sense. Such progress provides hope as we contemplate the improvements still needed, and also as we face our failures to make this Earth a safer and sounder home for us and for those who are to come... The Earth is one but the world is not. We all depend on one biosphere for sustaining our lives. Yet each community, each country, strives for survival and prosperity with little regard for its impact on others. Some consume the Earth's resources at a rate that would leave little for future generations. Others, many more in number, consume far too little and live with the prospect of hunger, squalor, disease, and early death" (WCED, p. 39, 1987)
The Report assumes that an improvement in human health, as indicated by an increase in life expectancy, has been possible to a great extent thanks to the availability and use of Earth resources in order to meet human needs. From this fact, it is essential, then, to maintain Earth's integrity and welfare. Two main ideas may be inferred from this: on the one hand, the protection of ecosystems is clearly justified because of their essential role in the availability of resources for human life; thus, the welfare of the population which shows in fact an anthropocentric approach to sustainable development-. On the other hand, the availability of resources is associated to health and, as a consequence, its absence is related to disease and human suffering.
From that point of view, the phenomenon of disease is therefore conceived as the pressure placed on the environment. In particular, the Report describes several ways in which this may happen: "Environmental stress has often been seen as the result of the growing demand on scarce resources and the pollution generated by the rising living standards of the relatively affluent. But poverty itself pollutes the environment, creating environmental stress in a different way. Those who are poor and hungry will often destroy their immediate environment in order to survive: They will cut down forests; their livestock will overgraze grasslands; they will overuse marginal land; and in growing numbers they will crowd into congested cities. The cumulative effect of these changes is so far-reaching as to make poverty itself a major global scourge" (WCED, p. 40, 1987).
According to the text, the two concepts associated to the emergence of disease are high consumption levels and poverty, because both are responsible for the environmental destruction and the resources undermining. Nevertheless, it is difficult to establish the underlying concept of health from the report alone, so from the report's perspective high levels of life, as a consequence of resource availability, would be associated to health because resource consumption has allowed an improvement in life expectancy.
Alternatively, independently from consumption levels, health as it is conceived in the Brundtland Report can also be understood as Earth and its ecosystems' ecological integrity. However, the emphasis it puts on solving the threat of poverty through economic growth so as to improve the population's ability to use the resources allows us to understand that it is only partially correct. The report says: "a development that is sustainable has to address the problem of the large number of people who live in absolute poverty - that is, who are unable to satisfy even the most basic of their needs. Poverty reduces people's capacity to it uses resources in a sustainable manner; it intensifies pressure on the environment. Most such absolute poverty is in developing countries; in many, it has been aggravated by the economic stagnation of the 1980s" (WCED, p. 60, 1987)
For that reason, the text continues: "...growth must be revived in developing countries because that is where the links between economic growth, the alleviation of poverty, and environmental conditions operate most directly. Yet developing countries are part of an interdependent world economy; their prospects also depend on the levels and patterns of growth in industrialized nations" (WCED, p. 60, 1987)... "requires a change in the content of growth, to make it less material and energy-intensive and more equitable..." (WCED, p. 62, 1987).
In general, it may be argued that the Bruntland Report poses two clearly defined views on the concept of health in the context of the sustainable development: on one hand, human health as the ideal state of well-being, which is reached when there is availability of material goods at a level which allows for satisfaction of its needs. On the other hand, the well-being of the Earth and its ecosystems is essential for the sustainability of human health, as it both directly guarantees the availability of resources and, indirectly, does not pose a danger for it.
Rio Declaration on Environment and Development
Due to the alarming situation denounced in the Brundtland Report, in 1992 the General Assembly of the United Nations decided to hold the World Conference of the United Nations for the Environment and Development in the Brazilian city of Rio de Janeiro, also known as the Summit of the Earth (Foundation Heinrich Böll, p. 3, 2002). In this event, sustainable development became a concept that binds the purposes of environmental protection to world development as one single idea. The outcome of the final consensus among the participant countries became a final declaration known as the Rio Declaration.
The Rio Declaration contains the fundamental principles on which sustainable development is conceived within the frame of the political-institutional context. Consequently, all the underlying philosophy and the basic elements of strategies, programs, projects and other kinds of activities on the matter are to be found in this proposal for world development.
This declaration is a manifesto of 27 principles, four of which show some relationship with the concept of health. Two aspects related to the health concept are also present in the Bruntland Report. The first aspect is that the concept of health can be assumed in two senses: the human health and the ecosystems health. As mentioned above, the search for healthy ecosystems is justified by its contribution to human health. To this respect, principle 7 say that " States shall cooperate in a spirit of global partnership to conserve, protect and restore the health and integrity of the Earth's ecosystem", and principle 14 say that "States should effectively cooperate to discourage or prevent the relocation and transfer to other States of any activities and substances that cause severe environmental degradation or are found to be harmful to human health" (United Nations, p. 46, 1992)
These principles reflect the anthropocentric standpoint of sustainable development, since, in the nature-society relationship, nature is important in the measure that it is useful for the society; the first is important in the measure that it is useful for the latter. This viewpoint had already been stated from the very beginning, in principle 1: "Human beings are at the centre of concerns for sustainable development. They are entitled to a healthy and productive life in harmony with nature" (United Nations, p. 3, 1992).
The second aspect is that, in this document, health seems to be indirectly associated with the possibilities of using the natural resources for the satisfaction of basic human needs, and disease with the lack of those. In the same way, the declaration places stronger emphasis on the eradication of poverty, rather than in the reduction of the high levels of consumption of the most affluent. For instance, principle 5 affirms that "all States and all people shall cooperate in the essential task of eradicating poverty as an indispensable requirement for sustainable development, in order to decrease the disparities in standards of living and better meet the needs of the majority of the people of the world" (p. 4, 1992).
In the same line of the Bruntland Report, from these principles we may infer that health is an ideal state of human well-being, which results from the satisfaction of their needs and of the possibilities of carrying out a productive life, based on the use of environmental resources.
The Program or Agenda 21
The program or Agenda 21 was arguably the most representative result of the Summit of Rio. It is a strategic plan organized around four programmatic areas or sections: 'Social and economic Dimensions', 'Conservation and management of the resources'; 'Strengthening of the role of major groups'; and 'Means for implementation' (United Nations, 1992).
In particular, section 1 shows the understanding and the relevance of health inside the context of sustainable development.
Health and sustainable development: equivalent concepts in Agenda 21
Following the track of the Bruntland Report and the Rio Declaration, the Agenda 21 points out two causes for environmental degradation and, consequently, two phenomena associated to disease. Specifically this document claims that "Both insufficient development leading to poverty and inappropriate development resulting in overconsumption, coupled with an expanding world population, can result in severe environmental health problems in both developing and developed nation... most developmental activities affect the environment to some degree, which in turn causes or exacerbates many health problems. Conversely, it is the very lack of development that adversely affects the health condition of many people, which can be alleviated only through development" (United Nations, p. 51, 1992).
Agenda 21, thus, clearly associates the concept of poverty 'Lack of development' and high consumption levels,'an inadequate development', to the phenomenon of disease, because both of them put at risk the availability of resources for the satisfaction of needs, while the protection of ecosystems and the availability of resources is associated to human health.
Nevertheless, the document also suggests an interdependent relationship between health and development when it points out that "Health ultimately depends on the ability to manage successfully the interaction between the physical, spiritual, biological and economic/social environment. Sound development is not possible without a healthy population... The health sector cannot meet basic needs and objectives on its own; it is dependent on social, economic and spiritual development, while directly contributing to such development" (United Nations, p. 51, 1992). For that reason, within this context the concept of health and sustainable development can be assumed as equivalent.
The following excerpts of the Agenda 21 document do also reinforce this idea when they claim that to achieve better levels of health an entire process of social, economic and political development is necessary. In parallel, better levels of health contribute to this development. In fact, the content of these quotes of Agenda 21 are strikingly similar to the Ottawa Charter for Health Promotion (WHO, 1986), to the extent that Agenda 21 seems to propose a strategy of promotion of health along the lines previously suggested by the Charter.
Agenda 21: "The linkage of health, environmental and socio-economic improvements requires intersectorial efforts. Such efforts, involving education, housing, public works and community groups, including businesses, schools and universities and religious, civic and cultural organizations are aimed at enabling people in their communities to ensure sustainable development. Particularly relevant is the inclusion of prevention programs rather than relying solely on remediation and treatment. Countries ought to develop plans for priority actions, drawing on the program areas in this chapter, which are based on cooperative planning by the various levels of government, non-governmental organizations and local communities. An appropriate international organization, such as WHO, should coordinate these activities". This coordination involves not only those sectors within the field of health, but also some unrelated areas, so as to "meet the basic health needs of rural peri-urban and urban populations; to provide the necessary specialized environmental health services; and to coordinate the involvement of citizens in solutions to health problems" (United Nations, p. 51, 1992).
According to Agenda 21, the route towards better levels of health is more focused on the reduction of poverty than on the reduction of the high consumption levels. Particularly, Agenda 21 suggests that the achievement of better levels of health entails an entire intersectorial strategy that combines the use of socioeconomic and environmental instruments tending to meet the needs of populations. That means that health improvements should be achieved by proposing a 'deeper degree of development' rather than by an 'appropriate development'.
Environmental protection: a medium for the population's health
Since the elaboration of Agenda 21, sustainable development apparently follows a development-health-development cycle, in the sense that, as mentioned in the previous section, sustainable development is a condition for healthy populations, by means of the improvement of the conditions of their lives and of the protection of its environment, because the sustainable development implies both.
In particular, the importance of the intervention on the environment is that the risk factors for disease among the population lie within it. For instance, when dealing with the fight against communicable diseases, Agenda 21 emphasizes the need to take measures of control of diseases such as "cholera, diarrheal diseases, leishmaniasis, malaria and schistosomiasis. In all such instances, the environmental measures, either as an integral part of primary health care or undertaken outside the health sector, form an indispensable component of overall disease control strategies, together with health and hygiene education, and in some cases, are the only component" (United Nations, p. 54, 1992).
This orientation to intervene on the environment is not only present when the text refers to the fight against communicable diseases, but also when dealing with the 'solution for the problem of urban health.' To this respect, Agenda 21 argues that "All too often, urban development is associated with destructive effect on the physical environment and the resource bases needed for sustainable development. Environmental pollution in urban areas is associated with excess morbidity and mortality. Overcrowding and inadequate housing contribute to respiratory diseases, tuberculosis, meningitis and other diseases. In urban environments, many factors that affect human health are outside the health sector" (United Nations, p. 62, 1992).
This quote from Agenda 21 highlights the problems of health related to high density of urban population, which not only limits the benefit of social services, but also hinders the possibilities of cities welcoming new inhabitants with decent and healthy standards of living. In fact, it is also around these cities that most industrial activity is concentrated, which contributes to the environmental crisis, particularly the contamination of the air and of water sources.
Health: an instrument for sustainable development
Nevertheless, beyond achieving a healthier standard of living for populations, interventions on the environment aim to reach certain levels of development or sustainable development. Agenda 21 reiterates this in some of its sections: the overall objective is to minimize hazards and maintain the environment to a degree that human health and safety is not impaired or endangered and yet encourage development to proceed" (United Nations, p. 65, 1992). "The health and well-being of all urban dwellers must be improved so that they can contribute to economic and social development" (United Nations, p. 63, 1992).
Likewise, as far as the protection of vulnerable groups is concerned, the Agenda 21 claims that "In addition to meeting basic health needs, specific emphasis has to be given to protecting and educating vulnerable groups, particularly infants, youth, women, indigenous people and the very poor as a prerequisite for sustainable development" (United Nations, p. 59, 1992). Finally, in the case of communicable diseases, and particularly on AIDS, it sustains that "...the socio-economic impact of the pandemic is expected to be devastating for all countries, and increasingly for women and children. While direct health costs will be substantial, they will be dwarfed by the indirect costs of the pandemic mainly costs associated with the loss of income and decreased productivity of the workforce" (United Nations, p. 55, 1992).
From these statements, it may be inferred that within the discourse on sustainable development health is perceived as both an instrument and as a requirement to achieve it.
As regarding the ways in which Agenda 21 understands the concept of health, several remarks may be emphasized: firstly, there is no specific definition of the health-disease phenomenon; in contrast, allusions to an adaptation of the concept to different elements of the discourse may be found along the document. Thus, there appear references to human health, Earth's health, ecosystem's health, environmental health, health systems, public health, community health, urban sanitation, rural health, etc.
Nevertheless, the conception of health underlying Agenda 21 may be inferred starting from the special attention devoted to health problems along the document. For example, the emphasis placed on environmental sanitation against communicable diseases allows us to identify a conception of the Health-Disease phenomenon which may be considered as reductionist, as it omits a number of elements which are equally relevant, such as cultural, ecological, psychological and sociological factors related to these diseases, among others.
Secondly, in what seems to be an incoherent approach, Agenda 21 seems to provide a more integral vision on health when it recognizes the need to carry out intersectorial actions in order to achieve better levels of health and well-being, involving the participation of governments, non-governmental organizations and communities. Nevertheless, this viewpoint can be accounted for on the fact the end goal pursued by these actions is not health, but development. In that sense, it can be stated that there is a sort of developmentalism in the view of health, in which it is conceived as the ideal state of well-being, allowing for the satisfaction of needs. According to this definition, it can be measured in terms of level of development.
Plan of Application of the Decisions of the World Summit on Sustainable Development
Ten years after the Rio Summit, the implementation of the objectives proposed in the summit was being carried out at a slower pace than expected. In fact, in a certain sense, the previous conditions had even worsened (United Nations, 2001). For that reason, the Summit of Johannesburg was hosted with the goal of renewing the reached agreements signed in Rio 92 and of elaborating new proposals that supplemented the existing plan of action (United Nations, p. 116, 2002).
These new proposals were put on paper in the Plan of Application of the Decisions of the World Summit on Sustainable Development. In general, the document ratifies the conceptual tenets of the previous summits; this stance may be observed in the following excerpt: "The Rio Declaration on Environment and Development states that human beings are at the centre of concerns for sustainable development, and that they are entitled to healthy and productive life, in harmony with nature. The goals of sustainable development can only be achieved in the absence of a high prevalence of debilitating diseases, while obtaining health gains for the whole population requires poverty eradication. There is an urgent need to address the causes of ill health, including environmental causes, and their impact on development, with particular emphasis on women and children, as well as vulnerable groups of society, such as people with disabilities, elderly persons and indigenous people" (United Nations, p. 39, 2002)
According to these words, some of the conclusions reached and ratified in this summit are; firstly, an anthropocentric vision of sustainable development, as it places humankind as the center around which revolve the concerns of sustainable development; second, health is an intermediate objective of sustainable development; and third, it is necessary to eradicate poverty and to eliminate the causes of ill health, including the environmental ones, if we want populations to be healthy.
For that reason, one of the sections of this Plan is dedicated to the eradication of poverty. This is, according to the Plan, the main goal at a world level: "Eradicating poverty is the greatest global challenge facing the world today and an indispensable requirement for sustainable development, particularly for developing countries. Although each country has the primary responsibility for its own sustainable development and poverty eradication and the role of national policies and development strategies cannot be overemphasized, concerted and concrete measures are required at all levels to enable developing countries to achieve their sustainable development goals as related to the internationally agreed poverty-related targets and goals, including those contained in Agenda 21, the relevant outcomes of other United Nations conferences and the United Nations Millennium Declaration" (United Nations, p. 9, 2002)
Similarly, the second section deals with the 'Modification of the unsustainable Modalities of Consumption and Production.', and it affirms that "Fundamental changes in the way societies produces and it consumes are indispensable for achieving global sustainable development. All countries should promote sustainable consumption and production patterns, with the developed countries taking the lead and with all countries benefiting from the process, taking into account the Rio principles, including, inter alia, the principle of common but differentiated responsibilities as set out in principle 7 of the Rio Declaration on Environment and Development. Governments, relevant international organizations, the deprives you sector and all major groups should play an active role in changing unsustainable consumption and production patterns" (United Nations, p. 13, 2002)
Like previous documents, poverty and high consumption levels are identified as the two major causes of environmental degradation. Nevertheless, the eradication of poverty is placed at a higher level of importance, considering the modification of unsustainable models of consumption on a secondary position, in the search for healthy populations and of sustainable development.
Concepts, Roles and Ideas Associated to Health-Disease Within the Sustainable Development Discourse
As the review of the official documents has made explicit, the concept of health in the political-institutional discourse on sustainable development is characterized by its ambiguity and by its indiscriminate use to refer to the health of individuals, of ecosystems, as well as the earth's well-being, among others. Nevertheless, in our opinion, the concept of health which receives more emphasis is that one which understands health as a state of well-being to be achieved through the availability of resources offered by the environment. In turn, these resources may satisfy basic human needs.
Indeed, a concept of health that incorporates elements like environmental protection and satisfaction of needs, from the Ottawa Charter perspective, generally shows an integral approach to the concept. Notwithstanding, the treatment of health challenges, in the sense proposed in these documents, paradoxically reflects a biologist-reductionist tendency in the understanding of health, particularly evident in the emphasis placed on environmental sanitation in the fight against diseases.
This apparent contradiction, which simultaneously combines an integral conception of health and a reductionist treatment of disease, or of health problems, may be accounted for by the fact that, at a certain point in the political-institutional discourse, health and sustainable development are seen as equivalent, since the process of meeting basic human needs without affecting the availability of natural resources, on which well-being depends, is essentially what we understand as sustainable development, and it is also health.
Nevertheless, the equivalence between the concept of health and the concept of sustainable development is transitory; in fact, throughout these documents, it is explicit that health is a means to achieve sustainable development. Consequently, the place that it occupies within the political-institutional context of sustainable development is secondary, instrumental and practical.
On the other hand, when health is alluded to in these documents, we frequently find two related concepts: first, the care and protection of ecosystems and the satisfaction of basic human necessities. However, as indicated, environmental protection is only justified as far as it guarantees the availability of resources for the satisfaction of human needs. In this sense, it would be more appropriate to state that the concept associated to health is that of the satisfaction of basic needs. This does not imply that, in the political-institutional context of sustainable development, the environmental protection is not important for achieving better standards of living but that its role may be labeled as secondary.
In the case of the illness concept the two definitions that emerged were those of poverty and high consumption levels because both are causes of the environmental degradation, and in turn means, to put in danger the satisfaction of the basic human needs, the health.
It is interesting to point out that when establishing these conceptual associations, the satisfaction of basic necessities arises as an implicit and core association related with the health-illness process. It is as if in this context of the sustainable development health is understood as well-having, rather than well-being: (Latouche, p. 286, 2010) "The standard of living measures itself by the level of consumption, including the amount of waste produced." If we accept this view as such, then the political-institutional perspective on sustainable development does not suggest any significant changes with regard to the pattern of western development, which has been characterized as a model of society based on the abundance of objects, to the point that "Abundance carries with it the loss of its proper meaning. In this deluge of objects, it has become almost impossible to desire something for itself, if it is not already the envied possession or object of desire of others" (Latouche, p. 286, 2010).
It is remarkable that throughout the texts no allusion whatsoever was made to the concept of health understood as a good life standard, happiness, the human beings' capacity to carry out their day-to-day activities or to fulfill their aspirations in life. Indeed, these are important cultural categories in the construction of the concept of health, despite not being necessarily bound to the productive potential of persons.
Added to the above-mentioned absence, the fact that the development model and the high consumption levels are not explicitly questioned may lead us to believe that these documents assumed the concepts associated to health in the perspective of the western development model rather than in the frame of a sustainable development model. The problem, in our view, is not that the documents propose 'more development' in order to eradicate poverty, but that they do not indicate the most suitable kind of development to achieve its eradication, since development processes themselves have contributed to the generation of poverty (Goldsmith et al., 1992). Likewise, it is absolutely legitimate to think that an 'appropriate development' and the 'modification of unsustainable modes of consumption and production' are valid strategies against the high levels of consumption of the most opulent societies; however, in a planet where about 20% of the population consumes nearly 80% of the resources, it does not seem enough (Jiménez, 2008).
According to Daniel Wagman, the wild career toward the current man's material abundance follows three main axes: the ecological crisis and the North-South Divide, already mentioned previously, and the social and individual crisis. This latter element is becoming more and more dramatic, as the current pattern of production and consumption does not only change the face of the earth, but also destroys social structures and human values (Wagman, 2000). The pattern of current consumption separates production from consumers more and more, and stimulates individual self-destructing values. These phenomena lead to the increasing appearance of mental problems and behavior disorders in citizens, and a sense of solitude that oppresses mass populations, in spite of being physically closer in vertical cities. Violence and indifference for anyone else's problems hamper the possibility to achieve that ideal world in which we all fight side by side to achieve improvements in the conditions of our co-citizens. Finally, the only values that the economic system requires for its sustainability are individualism and the increase in economic benefits, rather than any kind of interpersonal relationship.
The pattern of western development is based on the fact that basic human necessities are accounted for thanks to the consumption of market-provided goods and services (Stahel, 2002). Thus, as long as the political-institutional discourse on sustainable development does not question essential elements as the abovementioned, it will only contribute to the reproduction of the same model which originated the problems justifying the emergence of sustainable development movements. For that reason, in this particular context, sustainable development can be considered as a contradictory concept (Parayil, 1998)
As a result, the political-institutional discourse on sustainable development does not represent substantial changes in the pattern of western development and it continues to be framed within the same worldview of this model of development. Consequently, this context of sustainable development does not offer any new elements to conceive health in a different light from the prior approach, established during the modern era.
In the referred texts, the conception of health within the frame of sustainable development is understood essentially as a phenomenon of global transcendence and as a key factor to achieve the objectives of the development pattern. In this context, it may be seen in three conceptual axes: biological health, operationalized and instrumentalized according to the needs of adaptation to the pro-sustainable development Western discourse. This approach limits health to the biological theories of disease, and inserts it within the environmental context, considering it a key factor both for the analysis of its problems and for the search of solutions.
In the second place, the institutional point of view on health, according to which it is an establishment or institution, whether public or private, local or regional, national or international, which should uphold / veil for people's health. In accordance with the political-institutional discourse, the problem of health is dependent of the access to and the quality of the health services offered and regulated by these institutions. In the third place, health may also be perceived in a formal sense, associated to cultural factors of both of individual and collective transcendence. This meaning is associated to the idea of well-being as understood in Western lifestyle and quality of life.
The theoretical hypothesis that the paradigm of the sustainable development, despite all the challenges which account for it , gives shape to a new social-historical context for mankind, from which a new conception of health can emerge, remains valid to date. Although from the political-institutional perspective of sustainable development the conception of health and disease is similar to that present in the mindset of the pattern of western development, in our opinion if would be possible to find a new conception if the analysis is made from a different perspective: instead of the political-institutional one, an epistemological stance, to mention just one.
In any case, we currently face the evidence of a radical change of perception of reality, and that fact requires change in its worldview leading to a readjustment of all the conceptual macro-structures on which it is based. Amid this process, the concept of health must suffer a paradigm transition which is not to be found in the political-institutional discourse on sustainable development, even though it does not mean that it is not happening at the moment.
The debate about the definition of the health-disease phenomenon, at present, is crowded with uncertainties and contradictions. No definite formula has been found to create a specific definition for these two concepts which may include all the thinking styles that coexist at our time. One of the best ways of understanding these two phenomena is to conceive them as socio-cultural, historical and temporary constructs, influenced by diverse areas, including knowledge which does not proceed from the medical and biomedical sciences that have been in charge of their research. In this way, contributions from psychology, anthropology, ecology, economics, politics can be admitted, as well as any other areas which give structure to the worldview of each society at a specific time in their history; in turn, these disciplines are directly related to the view human beings have of their own condition, of other living beings and their natural environment.
Following Gadamer (1996), health is the harmony of life, a harmony in the chaos that reflects what we are, what we assume as normal and abnormal, the historical being together with a cultural concept which is the product of the historical relation between humans and nature. From that point of view, to assume health as an intermediate goal in the search for sustainable development, measured by means of indicators such as morbimortality, access to health services, environmental risk factors for health and Gross Domestic Product per capita would be a mistake; in fact, it would be a denial of the very concept, which emerged from the immeasurability of cultural, social, political and psychological elements. And that is, precisely, another great challenge out there.
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Recebido em: 01/02/2011
Aprovado em: 20/09/2011