Rethinking Public Health as Sustainability and Environmental Health as Environmental Justice

Environmental health has been the cornerstone of modern public health since the Public Health Revolution of the 1850s. The editorial “Addressing Gaps in Public Health Education to Advance Environmental Justice: Time for Action” by Levy et al. (p. 69) points out that the Council on Education for Public Health has minimized its role as a result of the redefinition of public health competencies in 2016, effectively withdrawing recognition for environmental health as central to public health.

This marginalization is not necessarily obvious because, in 2019, 91% of schools of public health continued to offer environmental health concentrations. However, this was down from 100% before 2016, a drop of almost 10% in three years.¹ Concentration availability does not speak to the subordination of competencies to interdisciplinary educational objectives, which atomizes and diffuses what should be an integrated curriculum of environmental health in master of public health (MPH) programs. Environmental health has a defined body of knowledge and experience² that is technically complicated, involves unfamiliar domains of knowledge (such as toxicology), and must be taught as distinct theory and practice with coherency.

Public health, preventive medicine, and health promotion largely emphasize individual behavior and program management. Environmental health rests mainly on collective actions in primary prevention in line with Rose’s “population health strategy” model of intervention.³ The “source–exposure–effect” (SEE) model that resides at the heart of environmental health demonstrates the impracticality of individual behavioral change as the primary strategy for protection from environmental hazards.² When key environmental health concepts and content are generalized to fit the paradigms of other concentrations, students lose the opportunity to master the skills they need to address some of the most important, interrelated, and rapidly emerging exposure-related challenges we face: emerging infectious disease hazards, primary and interactive effects of pollutants, and local effects of toxic exposures.

Borrowed and incomplete paradigms are even less well suited to environmental health problems of a complex, interdisciplinary, and emergent nature, including climate change, disaster response and emergency management, local ecosystem viability, global health and development, and urbanization. Without an integrated framework for environmental health, there is no place to tie the loose ends.

The current discussion does open an opportunity for rethinking environmental health for a new era. Climate change is the most critical of a large set of problems involving ecosystem change and long chains of causation. These issues are not easily analyzed with the SEE model. They are more amenable to methods of analysis that arise from decision-making models and risk science than to classical epidemiology, and they require tools that are more versatile. One way forward would be to reach out to the community of scholars in environmental studies, environmental sciences,⁴ social epidemiology,⁵ and the emerging field of sustainability research,⁶ who are potential expert collaborators and are motivated by environmental justice as a core organizing principle.

Environmental health does need to incorporate more social and behavioral science^5,6 but in the specific applications of risk communication, motivating concerted action at a societal level, and root cause analysis,⁷ not in motivating individual behavioral change. Public health education at the MPH level needs to promote recognition of the importance of multidisciplinary models in imagining solutions to so-called “wicked problems,” which are by definition complex, intertwined, system driven, and refractory.⁷

The common wrap-around for all of these issues should be sustainability. Sustainability, ensuring continuity and sufficiency for future generations, means protecting the health of individuals and the community, mitigating the health impact of catastrophic global change, ensuring the viability of communities and the services that support them, and advocating for environmental justice through the right of all people to live a decent life in the face of existential threats. Sustainability is a unifying concept for all public health and a better strategy than redefining environmental health within the domains of other disciplines.