Chapter 27: Environmental & Ecological Determinants of Health

Welcome to Last Minute Lecture.

This free chapter overview is designed to help students review and understand key concepts.

These summaries supplement not replaced the original textbook and may not be redistributed or resold.

For complete coverage, always consult the official text.

Welcome back to the Deep Dive.

It is great to have you here with us.

Today, we are doing something a little different.

We're changing the focal length.

We are.

But usually when you think about nursing or just healthcare in general, the mental image is pretty specific, right?

You're picturing a hospital room, maybe a clinic, a stethoscope, a patient in a bed.

It's very immediate, very one -on -one.

Exactly.

That's the traditional view, the bedside view, and it's where most of us start when we think about the profession.

For sure.

But the material we're covering today takes that camera lens and just zooms out, way out.

We're zooming out past the hospital walls, past the city limits, until that hospital bed is just a dot and the patient,

well, the patient is actually the planet.

Which brings us to Chapter 27 of Community Health Nursing,

a Canadian perspective.

The chapter is titled Ecological Determinants of Health and Environmental Health and Equities, and it's written by Andrea Terkop.

And you're right, this is a massive shift in perspective for a nursing student.

We are moving from the bedside to the biosphere.

And it feels incredibly timely.

I mean, you can't turn on the news without seeing something about the environment, but this text uses a specific term to describe the era we're living in, the Anthropocene.

Yes, the Anthropocene.

It's a really powerful concept to start with.

And leading scholars, they agree we've entered this new geological age.

So what does that actually mean?

Essentially, it means that human activity has become the dominant influence on the climate and the environment.

We aren't just living in the environment anymore, we are actively shaping it and often, well, damaging it to the point where the very systems we need to survive are threatened.

That is a heavy way to start a shift.

So our mission today is to walk through this chapter step by step.

We need to decode the link between the environment and our health, understand why, and this is a big one, why some people get sick from the environment while others don't, and finally, figure out what a nurse is supposed to do about it.

Right.

Because it's so easy to feel helpless when you're talking about global warming, but this text argues nurses have a huge role to play.

They absolutely do.

And it all starts with understanding the basics.

We have to define ecological determinants of health.

Okay, let's unpack this.

We talk all the time about the social determinants of health, you know, housing, income, education.

But what are the ecological determinants?

Think of them as the non -negotiable necessities for life.

The text is very, very clear on this.

Without these, no life is viable.

So we're talking about the obvious things like oxygen.

Yes, oxygen, clean water and soil to grow food.

But it goes deeper.

It includes the ozone layer that protects us from UV rays.

It includes the natural systems that detoxify our waste.

It includes a stable climate.

It's the hardware of existence.

That's a great way to put it.

It's the fundamental hardware.

And the text contrasts our dependency on these systems with a very dangerous mindset that it calls the logic of domination.

The logic of domination.

That sounds ominous.

It is a critical concept in the chapter.

It refers to a mindset that falsely legitimizes the oppression and exploitation of nature.

It's this idea that humans are separate from and superior to nature, which then justifies using it up, polluting it, destroying it.

Okay, I see.

But the text makes a crucial connection here.

This logic doesn't just apply to nature.

It also justifies the marginalization of people.

It links the exploitation of the earth with the political and economic marginalization of vulnerable groups.

So the same thinking that says it's okay to pollute this river is often the same thinking that says it's okay to exploit the people who live by this river.

Precisely.

It's a pattern of thought.

And the chapter offers a counter model to this, which is indigenous traditional knowledge.

Here in Canada, we have these really inspiring models of relationship with the non -human world that are respectful and sustainable.

We're definitely going to dive deeper into that indigenous wisdom later, but I want to stick with this idea of the foundation.

The text mentions the Lancet Commission.

What's the connection they draw here?

Right.

So the Lancet Commission on Pollution and Health made a very strong statement.

They explicitly connected pollution control with poverty alleviation.

I guess so.

They argue that you cannot achieve the United Nations Sustainable Development Goals, things like ending poverty, ensuring good health without addressing pollution.

The two are completely intertwined.

Because, as we're going to see, pollution loves poverty.

It absolutely does.

And that brings us to the concept of traditional ecological knowledge and wisdom, which is often abbreviated as TKW.

TKW.

Okay.

So what does that actually look like in practice?

Is it just, you know, knowledge about plants?

It's so much more than that.

It's knowledge that is embodied.

It's not just read in a book.

It's handed down through oral tradition for generations.

It comes from being part of the ecosystem, observing, feeling, tasting, breathing, listening.

It's a deep ancestral relationship with the land.

So it's holistic.

Deeply holistic.

But the text warns us that this wisdom is under threat.

A threat from what?

Global change.

Displacement.

If you displace indigenous peoples from their traditional lands, or if climate change alters the Arctic so drastically that the old signs and patterns in the ice and snow don't work anymore, that wisdom is threatened.

And the text is clear that this is a loss for everyone.

That seems like the perfect bridge to the next section of the chapter, which is all about that inequality.

We establish that we all need air and water.

But the central argument here is that while the environment surrounds everyone, it doesn't affect everyone equally.

That is the absolute core of environmental health inequity.

And to talk about that, we have to talk about environmental injustice.

The text defines this as the inequitable exposure of poor, minority, and disenfranchised populations to toxic chemicals and contaminated environments.

And in the Canadian context, who are we talking about specifically?

Who's most at risk?

The text lists three main groups.

Children, older adults, and First Nations, Metis, and Inuit communities.

OK, so let's break down why.

The chapter lists three big factors that determine this risk.

Geographic location,

social location, and developmental stage.

Let's start with geography, you know, location, location, location.

Right.

It matters where you live.

Living in the Arctic is physically climatically different from living in the Niagara region or a coastal community in B .C.

But it's not just about the weather.

It's about geopolitics.

This is where it gets really interesting to me.

The text points out that political borders, the lines we draw on our maps, they don't match ecosystem borders.

They almost never do.

The text uses the example of the North Atlantic right whale.

This is a species that has a habitat spanning across the Canada -U .S.

border.

The whales don't care about the 49th parallel.

Exactly.

The whales don't know where the border is, but the environmental policies protecting them might change completely once they cross that invisible line.

And that mismatch has huge implications.

And that mismatch applies to pollution, too.

Tragically, yes.

And this is a key example of geopolitical inequity.

The text discusses the Inuit in the Arctic.

Now, think about this for a second.

The Arctic has very little industry to the south.

The local emissions are low.

Right.

It's considered pristine.

Exactly.

And yet, Inuit communities are negatively affected by pollutants generated thousands of kilometers away in the industrial south.

So it travels.

It travels.

The text specifically highlights something called persistent organic pollutants, or POPs.

These are chemicals produced by industries, often in the Great Lakes region or even further south,

and they travel on air currents and water currents all the way up to the Arctic.

Then they accumulate in the food chain.

And the text notes, they have been found in the breast milk of Inuit women.

That is a devastating detail.

So you have a population that didn't produce the pollution living in what looks like a pristine environment.

And yet the industrial waste of the south is ending up in the breast milk of mothers.

It creates a situation of profound injustice.

And there's another aspect to this geographic factor that the text calls the boomerang effect.

The boomerang effect.

What's that?

It describes how industrial nations, like the G7 countries and Canada is one of them, might pat themselves on the back for reducing local emissions.

Maybe the air in our cities is clinger than it was in the 1970s.

Sure.

We have stricter regulations now.

We do.

But often that's because the dirty industries were just moved.

They were exported to developing nations with looser regulations and cheaper labor.

So we didn't solve the problem.

We just sent the factory somewhere else.

Exactly.

And because the ecosystem is global, those pollutants eventually come back to haunt us.

Through the food we import, through the global air currents, they boomerang.

Let's move to the second factor, social location.

This is about intersectionality, where you stand in society based on your gender, your race, your socioeconomic status.

And the text has a lot to say about gender here.

It really does.

It highlights that women and men often have different exposures simply because of societal roles.

Globally, women are often responsible for domestic work.

In resource poor settings, that might mean cooking over open wood stoves with poor ventilation, which leads to massive exposure to indoor air pollutants or the physical labor of carrying water for miles.

But it's not just traditional domestic roles, right?

The text mentions pink collar risks.

Yes, this is about risks in the paid workforce.

So consider the cosmetic industry.

Women working in nail salons or hair salons, they're exposed daily to endocrine disruptors in nail polish, hair dye, shampoos.

What are endocrine disruptors?

They're chemicals that can mimic or interfere with our body's hormones, and they can cause serious reproductive issues.

And the text also mentions a biological vulnerability for women as well.

Correct.

Biologically, women on average have more adipose tissue, that's fat tissue, than men.

Many of these synthetic chemicals are what we call lipophilic, meaning they love fat.

They dissolve in it.

So they build up in fat tissue.

They build up there over a lifetime.

And because of the biological roles of pregnancy and breastfeeding,

those accumulated toxins can be transferred directly to the fetus or the infant.

Which connects gender directly to the health of the next generation.

Now, what about the intersection of poverty and race?

This is where we really see the concentration of risk.

Poverty isn't spread out evenly.

In Canada, poverty is often concentrated in specific neighborhoods, and these neighborhoods are more likely to be near industrial sites, waste dumps, or major highways.

The residents are exposed to more lead, more mold, more noise pollution.

And the text specifically calls out structural racism in Canada regarding indigenous peoples.

It does.

It points to the long term, and I mean decades long, lack of clean drinking water in many First Nation communities.

That is a clear, undeniable example of environmental injustice.

Absolutely.

And it brings up a heartbreaking dilemma regarding food for Inuit communities, which we touched on with the POPs.

This is the choice between traditional food and imported food.

Yes.

Traditional food seal, whale, fish,

is culturally significant.

It's spiritually important and it's nutritionally dense.

It's what has kept people healthy for millennia.

Right.

But as we mentioned, it's now contaminated with these POPs from the South.

So the choice becomes eat your traditional food and risk exposure to toxins or eat processed imported food from the South, which is incredibly expensive and often leads to malnutrition, obesity, and diabetes.

That's an impossible choice.

It's a choice that no one should have to make.

And it illustrates how environmental issues are never just about nature.

They are about justice, culture, and survival.

The third factor is developmental stage.

We talked about this briefly, but why are children and older adults specifically listed as being so vulnerable?

Children are not just small adults.

Their protective mechanisms, their blood brain barrier, their metabolic systems are still developing.

The text highlights these windows of vulnerability.

What does that mean, a window of vulnerability?

It means that if a child is exposed to a neurotoxicant like lead or certain pesticides during a critical window of brain development,

the damage can be permanent.

It can lead to learning disabilities, ADHD or cognitive impairment for the rest of their life.

And what about older adults?

Well, it's sort of the other end of the spectrum.

Defense mechanisms are weakening.

The immune system isn't as robust.

But there's also the factor of bioaccumulation.

If you've been exposed to low levels of toxins for 70 or 80 years, that body burden adds up.

Right.

It's the cumulative effect.

Exactly.

Plus, older adults are physically more vulnerable to extreme events like the heatwaves we're seeing more frequently, which can be deadly.

That segues perfectly into section three of our deep dive.

Global change.

The text identifies the big three issues.

And number one, inevitably, is climate change.

We can't avoid it.

The text identifies the driver very clearly.

Carbon dioxide, CO2 from the burning of fossil fuels.

And the impacts aren't just it gets a little warmer.

No, not at all.

It's rising sea levels threatening coastal communities.

It's melting permafrost.

And that permafrost issue is critical for northern infrastructure houses and Inuit communities are literally sinking as the ground thaws and becomes unstable.

It's extreme weather, the floods in B .C., the fires in Alberta.

I was really surprised by the health connection regarding diseases that the chapter points out.

Vector borne diseases.

It's a huge issue.

As the planet warms, insects like mosquitoes and ticks that carry diseases are expanding their range and moving north.

So things we used to think of as tropical diseases.

They're not just tropical anymore.

The text mentions the Zika virus as an example of a disease moving into regions that were previously too cold for the mosquito that carries it.

We're seeing the same with Lyme disease here in Canada.

And there's a mental health component to climate change too, isn't there?

The text mentions that specifically.

Yes.

This is a profound point.

For indigenous people specifically, whose identity is so deeply tied to the land, watching that environment disappear or change beyond recognition takes a massive psychological toll.

It's a loss of culture, a loss of identity.

It's a form of grief.

Issue number two is pollution.

And the stat here just floored me.

The mortality statistic.

Yeah.

In 2015, diseases caused by pollution were responsible for an estimated nine million premature deaths.

Nine million in one year in one year.

And to put that in perspective, the text notes that is three times more deaths than from AIDS, tuberculosis and malaria combined.

Wow.

It is 15 times more than from all wars and other forms of violence.

That is staggering.

And yet we so often treat pollution as a side issue, as an environmental problem, not a health problem.

We do.

And we need to talk about ecotoxicity.

This is the study of how synthetic chemicals enter the ecosystem and move up the food chain.

We mentioned the biological vulnerability of women earlier, but the text also highlights a major issue for men.

Male infertility.

Right.

The sperm count issue.

Yes,

there's growing evidence linking Xenoestrogens.

These are human -made chemicals that mimic the hormone estrogen to declining sperm counts in men across the industrialized world.

We're altering the reproductive capability of our own species.

The text has a specific feature box in this section.

It's a yes, but why box on plastic and health.

I feel like plastic is the topic everyone's talking about.

But what does the text really emphasize for a nursing student?

It moves beyond just the litter problem.

You know, the images of plastic bags in the ocean.

It talks about microplastics.

These plastics break down into microscopic particles that are now being found in seafood, in salt,

in our drinking water globally.

So we are literally eating and drinking plastic.

We are.

And it's not just the plastic itself, but the chemicals in the plastic, things like PCBs, cadmium, lead, which are known to be toxic.

So the text calls on nurses to be advocates here.

In what way?

It's not just about telling people to recycle.

It's about advocating for systemic change, for bans on single use plastics like straws and cutlery, not just to save a turtle, which is important, but to protect human health from microplastic ingestion.

The third big issue the text covers is socio -political trends.

This is about how we live.

Urbanization is the big one here.

Humanity is shifting to megacities.

More and more people are living in massive urban centers.

And what are the specific health risks of a megacity?

Well, there are several.

Heat islands, all that concrete and asphalt holds heat, making heat waves much more deadly.

Sedentary lifestyles leading to obesity and chronic disease,

higher concentrations of air pollution.

And interesting to note, the text points out that higher population density can correlate with increased rates of sexually transmitted infections.

The text also mentions displacement.

Yes, or climate refugees.

The text estimates that 26 million people have already been displaced for their homes globally.

These are people forced to leave because of drought, crop failures, floods or conflict over shrinking resources.

But there is a little glimmer of hope in this section regarding municipalities.

Yes, there is.

While nations often get bogged down in political debates and move slowly on climate agreements,

cities can often act much faster.

Mayors have direct control over things like public transit, waste management, building codes.

The text suggests that municipal action is a real sweet spot for meaningful change.

Okay, we've covered a lot of heavy, somewhat depressing stuff, pollution, disease, displacement, but section four of the chapter pivots, and I think this is so important.

It talks about the salutogenic effects of nature.

This is a vital shift.

Salutogenesis comes from the Latin salus for health.

It's the opposite of pathogenesis, which is the study of disease.

Salutogenesis asks, what causes health?

What creates well -being?

And the answer, at least in this context, is nature.

The evidence is incredibly strong.

Green spaces reduce stress, they improve birth weights in newborns, they lower cardiovascular mortality.

Even just looking at trees from a hospital window has a measurable positive effect on patient recovery.

And it mentions animal companionship too.

Absolutely.

From service dogs helping veterans with PTSD to the general human animal bond.

It connects us to the other, to the living world outside of ourselves.

There's a specific research highlight in the text.

It's little at all.

This is a project from 2015, the school garden study.

Can you tell us about the green team?

I love this example.

It shows how community health nursing actually works on the ground.

This is a project involving students, nurses, and the community that created a school vegetable garden.

Okay.

But the key here is that it wasn't just adults telling kids to dig.

It was youth driven.

The green team of students made the decisions about what to plant, how to care for it.

So what was the outcome?

What was the benefit?

Well, aside from the delicious vegetables, it created access to healthy food in the community.

It fostered intergenerational learning.

You had older adults from the community coming in to teach the kids how to grow things.

It built community resilience and social connection.

It's a perfect example of what the chapter calls a co -benefit.

Exactly.

You help the environment with local food and composting, and you help the people with better nutrition, mental health, and social connection.

It's a win -win.

Speaking of personal connection, the text challenges the reader with a little case study box that involves an ecological footprint calculator.

Yes.

It basically asks you, the listener or the student, to go online and use one of these tools to calculate how many Earths would be required if everyone on the planet lived your lifestyle.

It's a humbling exercise.

I can tell you that.

It really is.

It confronts us with our own consumption.

But the goal isn't guilt, it's awareness.

It asks, okay, now you know this, what are you going to do about it?

Moving on to section five, the text says that complex problems need robust frameworks.

You can't just wing it when you're dealing with something this big.

It introduces three specific frameworks to help nurses think about this.

Right.

If you try to tackle planetary health without a map, you'll just get lost.

These are the maps.

The first map is indigenous perspectives.

We touched on this, but here the text formalizes it.

The core values are respect, humility, and a responsibility to future generations, the seven generations principle.

And it highlights a very specific and powerful concept, two -eyed seeing.

And this is attributed to Micmac elder Albert Marshall.

That's right.

Two -eyed seeing is a beautiful and practical concept.

It means learning to see from one eye with the strengths of indigenous ways of knowing, and from the other eye with the strengths of Western scientific ways of knowing.

And using them both together, not choosing one over the other.

Simultaneously, you use both eyes at the same time.

It's about overcoming that Western dualism that separates us from nature.

That separates the spiritual from the scientific.

It integrates them.

The second framework is intersectional ecological feminist approaches.

That is a mouthful.

It is, but the core idea is actually pretty accessible.

It critiques what it calls value dualism.

In Western thought, we often set up these opposing pairs, reason versus emotion, culture versus nature, man versus woman.

And crucially, we tend to assign more value to the first one in each pair.

So reason is seen as better or more valid than emotion.

Exactly.

And ecofeminism argues that this value hierarchical thinking is used to justify domination.

If reason is better than emotion and man is superior to nature, then it's logically okay to dominate nature.

This framework challenges that entire structure of thinking.

It also talks about emotional intelligence, which I thought was interesting.

Yes.

It argues that empathy is a valid and necessary tool for policy and practice.

Valuing caring work like child care, nursing and environmental stewardship is essential.

We shouldn't dismiss emotion as irrational.

We need it to make ethical, compassionate decisions.

Okay.

The third framework is planetary health approaches.

There's a visual for this one.

Figure 27 .2.

Can you walk us through the flow of it?

It looks a bit like a flow chart.

It is.

Imagine it moving from left to right.

On the far left, you have the underlying drivers.

These are the big root causes, our consumption habits, population growth.

Okay.

The deep stuff.

Right.

These drivers then push the ecological drivers, things we've talked about like climate change, biodiversity loss, and land use change.

So our consumption causes climate change.

Makes sense.

And then those ecological drivers create the proximate causes of ill health things like poor air quality, reduced food production, contaminated water.

Okay.

But, and this is a really key part of the model, there are mediating factors in the middle of all this.

And what are those?

Things like governance, wealth, and technology.

These are the factors that can make the impact of those proximate causes better or worse.

Good governance can protect people from bad air quality through regulation.

Personal wealth often buffers people from food shortages.

So they act like a filter or an amplifier.

Perfect analogy.

And finally, on the far right side of the chart, you have the health effects,

malnutrition, infectious diseases, mental health issues.

The message of the framework is linear, but complex.

Human health depends entirely on the health of Earth's systems.

You cannot break that chain.

Okay, so we have the definitions, the inequities, the global issues, and now the frameworks to think about them.

For the nursing students listening, this is the part where we need to land the plane.

Section six is community health nursing practice.

What do we actually do?

The text breaks us down by the five levels of prevention.

This is the so what section.

This is the application and throughout it, the text emphasizes co -benefits, actions that help the planet and people at the same time.

Let's start with the biggest one.

Primordial prevention.

This is the big picture stuff, right?

Policy.

Exactly.

Primordial prevention targets the underlying conditions that create risk in the first place.

So here, the focus is on international and national laws and treaties.

The text highlights a key concept, the precautionary principle.

And what is the precautionary principle?

It's the duty to prevent harm before full scientific certainty exists.

Basically, if we have good reason to suspect a chemical causes cancer, we shouldn't wait for a thousand people to get cancer and prove it beyond all doubt before we ban it.

We should err on the side of caution.

Don't wait for the body count.

That's a blunt way to put it.

But yes, an example given is the Stockholm convention on POPs.

Nurses can and should advocate for these kinds of powerful preventative treaties.

Next is primary prevention.

Risk reduction.

This is more on the community and individual level.

It's about education and creating healthy environments.

For a nurse, this might mean talking to new parents about toxins in the home service, in cleaning products, in plastics, in furniture.

There's a great feature example here called the One Health Model from Ontario.

I love this story.

It's brilliant.

It's a collaboration between public health nurses and veterinarians.

They targeted homeless pet owners.

Now, homeless populations are often very hard to reach with traditional health services.

There can be a lot of mistrust, but they love their dogs, their pets or family.

So what did the program do?

They provided free vet care for the dogs.

By caring for the animal, they built trust and rapport with the owner.

And that engagement, that relationship allowed them to then offer human healthcare vaccinations, checkups, referrals to the owners.

It recognizes that the health of the human and the animal and the environment are all linked.

That is such a creative and compassionate solution.

Third level, secondary prevention,

screening.

And usually we think of screening patients for disease, like a blood pressure check, but here the text suggests screening policies.

How does a nurse screen a policy?

By getting involved, by sitting on boards, urban planning boards, for example.

If a developer proposes a new subdivision, a nurse on that board can screen the proposal for its health impacts.

Does it have green space?

Is it walkable?

Will it be built near a pollution source?

So it's detecting the potential for harm in the plan before it becomes harm in a patient.

Precisely.

It's proactive and upstream thinking.

Fourth level, tertiary prevention.

This is treatment and restoration.

All right, this is for people who are already sick.

The text mentions the environmental health clinic in Fall River, Nova Scotia.

This is a specialized clinic for people who are suffering from environmental sensitivities.

So they're treating the immediate symptoms, but also trying to understand the environmental cause.

Yes.

An interprofessional team helps patients manage their conditions, which are often complex and caused by the very toxins and pollutants we've been discussing.

And finally, the fifth level, quaternary prevention.

This is a term not everyone might know.

Quaternary prevention is about ethics, specifically about protecting patients from over -medicalization.

But the environmental link here is fascinating.

It's all about pharmaceutical pollution.

You mean drugs getting into the water supply?

When we take medications, antibiotics, hormones, chemotherapy drugs, our bodies don't freely metabolize them.

We excrete residues in our urine.

They go into the wastewater system and often wastewater treatment plants can't filter them out.

They end up in our rivers and lakes.

And what's the effect?

Fish are being found with antidepressants and birth control hormones in their systems, which disrupts their endocrine systems.

We are seeing antibiotic resistance develop in the environment.

Wow.

So the nursing action here is advocating for prudent prescribing.

It's about not throwing medication at every single problem if it isn't necessary.

Reducing the chemical load on the patient also reduces the chemical load on the ecosystem.

That is a connection I genuinely never would have made.

My prescription affects the fish.

It's all connected.

That's the core message of the entire chapter.

So we've reached the end of the chapter.

How does the text wrap all of this up?

It concludes with an ethical imperative.

It reminds us that nursing is consistently ranked as the most trusted profession,

that trust is a superpower.

And with that trust comes a responsibility to use our voice to advocate for ecological justice.

And it's not just for us.

It's about intergenerational justice.

Exactly.

We're holding the world in trust for the children of the future.

The chapter ends with a provocative question.

And I think it's the perfect place for us to leave our listeners.

What is the question?

What can I do today to contribute?

It's so easy to feel overwhelmed by the sheer scale of the Anthropocene, but the text urges us to move beyond that feeling and find one small, tangible action.

Maybe it's checking your own ecological footprint online.

Maybe it's joining a green team at your school or workplace.

Maybe it's just asking a question about a local policy.

But do something.

That's the challenge.

Thank you so much for taking this deep dive with us into the ecological determinants of health.

This was incredibly insightful.

It was a real pleasure.

It's such an important topic.

And a big thank you from the last minute lecture team for listening.

Good luck with your studies and we'll see you on the next deep dive.

Goodbye.